Radiation Physics and Chemistry 116 (2015) 262–266

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Radiation Physics and Chemistry

journal homepage: www.elsevier.com/locate/radphyschem

THERP and HEART integrated methodology for human error

assessment
Francesco Castiglia, Mariarosa Giardina, Elio Tomarchio n
Department of Energy, Information Engineering and Mathematical Models, University of Palermo, Viale delle Scienze, 90128 Palermo, Italy

H I G H L I G H T S

THERP and HEART integrated methodology is proposed to investigate operator errors during high-dose-rate treatment.

The new approach is based on fuzzy set concept to rank an exhaustive list of erroneous tasks.

The results allow to achieve a better understanding of health hazards in the radiotherapy treatment process.

art ic l e i nf o a b s t r a c t

Article history: THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve
Received 1 October 2014 operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the
Accepted 23 December 2014 basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead
Available online 24 December 2014
to patient radiological overexposures. The results allow for the identification of human errors that are
Keywords: necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so
HDR brachytherapy that it can be properly monitored and appropriately managed.
Human errors & 2014 Elsevier Ltd. All rights reserved.
THERP
HEART
Fuzzy

1. Introduction known tool based on event-tree approach for evaluating human

Until now clinical records have showed that erroneous tasks
due to deficient medical staff training, lack of independent checks,
lack of quality control procedures, absence of overall supervision
are the leading causes of injury in radiation therapy administration
(ICRP, 2000, 2005, 2008). Frequently, the training generally ad-
dresses only normal situations and does not prepare radiotherapy
staff for unusual situations, so the result is a lack of a ‘safety
culture’.
In this filed, the safety concerns in high-dose-rate (HDR) ther-
apy arise from the fact that failures of safety devices or mistakes in
the use of automated remote techniques can involve large doses
applied over a short period of time. These events result in adverse
clinical effects, including death.
In this paper the THERP and HEART integrated methodology is
proposed to investigate accident scenarios that involve operator
errors during HDR treatments.
THERP (technique for human error rate prediction) is a well-
n
Corresponding author. Fax: þ39 091232202.
E-mail address: elio.tomarchio@unipa.it (E. Tomarchio).
errors alone or in connection with equipment functioning, op-
erational procedures and practices, or other system and human
characteristics that influence system behavior. HEART (human
error assessment and reduction technique) is a technique, derived
from a wide range of findings in the ergonomics literature, which
assumes that the probability of a human error may be modified
according to the presence and strength of the identified error-
promoting conditions (EPCs). The method considers the human
error as an isolated entity, unaffected by any other task.
In the proposed approach, the probability of medical personnel
error or misjudgment during the treatment process is evaluated by
using the fuzzy HEART method as proposed in (Castiglia et al.,
2010; Castiglia and Giardina, 2011, 2013) and the fuzzy interval of
the error probability is employed in the event-tree obtained by the
THERP technique.
Accidental events leading to potential radiological over-ex-
posure of patients during HDR brachytherapy treatments are ex-
amined by using the proposed methodology in order to test the
validity of the approach over a whole range of possible
circumstances.
The obtained results allow for the identification of human er-
rors that are necessary to achieve a better understanding of the

http://dx.doi.org/10.1016/j.radphyschem.2014.12.012
0969-806X/& 2014 Elsevier Ltd. All rights reserved.
 F. Castiglia et al. / Radiation Physics and Chemistry 116 (2015) 262–266
radiotherapy treatment process so that it can be properly mon-
itored and appropriately managed. Therefore, the method seems
able to improve the safety and quality of processes where failure
modes and human factors are the most important causes of acci-
dental events.
2. Human error evaluation methodologies
In large and complex industrial systems, the human error has
been cited as a cause or contributing factor in a lot of disasters and
accidents. Thus the need for improved Human Reliability Analysis
(HRA) methodologies for application to Probabilistic Safety As-
sessments (PSA) has motivated a number of major activities in
research and development worldwide, at since early 1990s.
As well known, the first generation approaches in Human Re-
liability Analysis tend to break a task into component parts and
then consider the potential impact of modifying factors such as
time pressure, equipment design and stress. By combining these
elements a nominal Human Error Potential (HEP) is determined.
The HEP can be modified taking into account the context-related
Performance Shaping Factors (PSFs) which consider the state and
importance of various factors that will determine the task per-
formance. This classification includes tools like HEART and THERP
techniques.
2.1. THERP technique
THERP technique, developed in the Sandia Laboratories for the
US Nuclear Regulatory Commission, is the well-known tool based
on event-tree approach for evaluating the probability of a human
error, in a similar way to an engineering risk assessment (Swain,
1964; Swain and Guttman, 1983). In this method, the individual is
treated in a manner similar to technical components and the re-
sultant tree portrays step by step of the stages involved in a task,
in a logical order.
An example is provided in Fig. 1 where capital letter “A” re-
presents the fact that the technician has incorrectly performed a
task with probability P(A); the lower case letter “a” represents the
fact that this task has been correctly performed and the prob-
ability is P(a)¼1  P(A).
The following relationship should also be required:
P(a)P(b|a) + P(a)P(B|a) + P(A)P(b|A) + P(A)P(B|A) = 1.0
The HEP that the operator will unsuccessfully complete the task
is a complex conditional probability involving much possible
combinations of errors, however if these errors just happen to be
independent the conditional probabilities are just the same as the
simple ones and the failure probability can be calculates as fol-
lows:
P(F) = P(a)P(B|a) + P(A)P(b|A) + P(A)P(B|A)
= P(a)P(B) + P(A)P(b) + P(A)P(B)
The primary source of guidance for the quantification of the
Fig. 1. THERP event-tree.
263
HEP relevant to each subtask is the THERP handbook (Humphreys,
1995). The HEP entered into the tree is modified by assessor using
the Performance Shaping Factors (PSFs), which consider the
training or stress level and other factors that may influence the
task fault.
The probability that an error will occur is given by Pi, the joint
probability that an error will occur and that the error will lead to
system failure is given by (PSFi Pi), the probability that an opera-
tion will be performed and that does not lead to system failure is
given by (1  PSFi Pi). The probability that a class of errors will lead
to system failure is given by Σi PSFi Pi
2.2. Fuzzy HEART technique
The HEART technique assumes that any predicted reliability of
task performance may be modified according to the presence of
the identified EPCs. The method identifies nine generic task types
and proposes nominal human unreliability values, in addition to
17 EPCs whose influence on task performance is considered to
have a maximum effect.
The failure rate is estimated by using the empirical expression
⎧ ⎫
P=P0⎨ ∏ ⎡⎣(EPCi − 1)Api + 1⎤⎦⎬
⎪ ⎪
⎪ ⎪
⎩ i ⎭ (3)
where P is the probability of human error, P0 is the nominal
human unreliability, EPCi is the ith error-promoting condition and
Api is the engineer's assessment of the proportion effect (from 0
to 1) for each ith EPC (Castiglia et al., 2010).
Castiglia et al. (2010) proposed to modify the technique by
using the concept of fuzzy linguistic expressions in the re-
presentation of the proportion assessment factor, Api. This ap-
proach is taken because in the HEART model this parameter is the
one most characterized as subjective and imprecise.
The concept of the linguistic variable (LV), consisting in a
variable with values defined as words, phrases or sentences in a
natural or artificial language, is very useful when one deals with
situations too complex or ill-defined to be reasonably described in
conventional quantitative expressions. These linguistic values can
be represented by the approximate reasoning of fuzzy numbers.
(1)
For example, for Very Low (VL), Low (L), Medium (M), High
(H) and Very High (VH), the fuzzy number of these linguistic va-
lues can be described as reported in (Castiglia et al., 2010). The
linguistic variables, so represented, can be used to estimate the Api
and Eq. (3) is written as follows:
P(x)=P0 ∏i ⎡⎣(EPCi − 1)Ap LVi (x) − 1⎤⎦ with
LV = VL, L, M, H,VH (4)
(2)
where ApLVi is the fuzzy proportion assessment factor as reported
in (Castiglia et al., 2010).
264 F. Castiglia et al. / Radiation Physics and Chemistry 116 (2015) 262–266

3. THERP and HEART integrated methodology

Fuzzy linguist variable, ApLVi Triangular fuzzy probability P(x1; x2; x3)
Compared to some other HRA methodologies, THERP analysis
requires a large amount of effort to produce HEP values (Hum-
phreys, 1995). Moreover, this tool has the range of PSFs considered
generally low and the underlying psychological causes of errors

(0.0025; 0.0043; 0.0067)

(0.0031; 0.0054; 0.0084)
(0.0055; 0.0130; 0.0253)

(0.0010; 0.0018; 0.0028)

(0.0015;0.0024;0.0035)
are not identified (Kirwan, 1996, 1997).
To enhance the performance of the THERP method, in this
paper it is proposed that each subtask in the THERP event-tree is
considered independent from all others, so the error probability
can be calculated by using Eq. (4). This approach allow to take into
account the state and importance of various factors that determine
the task performance.

4. Description of brachytherapy procedures

The HDR device consists of a motor-driven source transport

system that automatically transfers radioactive material between a

Medium (M)

Medium (M)
Medium (M)
shielded safe and the treatment applicator. The medical team has

Low (VL)
High (H)
High (H)

High (H)

High (H)

High (H)

High (H)
Low (L)
radiation oncologists, medical physicists, and specialty-trained
therapists who work within the treatment preparation area to
simulate and plan treatment. Moreover further physicians work
with the oncologists and medical physicists to design and deliver

Ambiguity in the required performance standard, EPC11 ¼ 5

radiation therapy (RT) to patients.

Transfer knowledge from one task to another, EPC10¼ 5

Little or no independent checking or testing of output,

Little or no independent checking or testing of output,

Typically, the dose is calculated in the treatment planning

Poor, ambiguous or ill-matched feedback, EPC13 ¼ 4

Poor, ambiguous or ill-matched feedback, EPC13 ¼ 4

Poor, ambiguous or ill-matched feedback, EPC13¼ 4

Poor, ambiguous or ill-matched feedback EPC13¼ 4
system (TPS), and the therapy is then performed using the treat-
ment control system (TCS), which enables an operator to remotely
insert a radionuclide source into the body.
The TPS is carried out by a special dosimetry group and in-
volves several steps such as the definition of the dose distribution
geometry, the calculation of dose distribution using dose-volume
Information overload, EPC8 ¼6

Information overload, EPC8 ¼6

Information overload, EPC8 ¼6

histograms, treatment plan optimization to deliver uniform dose
EPC description and value

to the target volume, and machine parameters set up. Every

treatment plan is approved and verify by an oncologist.
A medical physicist uses key parameters specific to a radio-
nuclide and source model or select parameters from an existing
data sheets and tables; moreover a physicist reviews the proposed EPC17¼ 3

EPC17¼ 3
treatment delivery process, check the treatment unit program,
monitor the treatment progress, and review the emergency
procedures.
Use of incorrect basic data (tables, files, radionuclide and source model,

Incorrect calculation of treatments times, source dwell positions, etc.,

4.1. Human error probability in HDR procedures

For the sake of brevity, samples of obtained results, concerning

errors in “computation of dose distribution” and “textual doc-
umentation of dosimetry details” during TPS, are reported.
Each task is divided into subtasks, moreover there is a man-
Incorrect setup field parameters (area, size, etc.)

Mistakes in dose-volume histograms calculation

datory secondary check of every task before the task is considered

complete.
For “computation of dose distribution”, named Task1, the sub-
tasks are:

Use of incorrect basic data (tables, files, radionuclide and

source model, etc.), A1;

Incorrect setup field parameters (area, size, etc.), B1;
Fuzzy HEART probabilities in Task1.

Mistakes in dose-volume histograms calculation, C1;

Incorrect calculation of treatments times, source dwell posi-
Subtask Error description

Verification error

tions, simulator localization information, etc., D1;

Verification error, E1.
etc.)

For “textual documentation of dosimetry details”, named Task2,

the subtasks are:
Table 1

transcription errors of the setup parameters, A2;

D1
A1

B1

C1

E1

Incorrect patient identification, B2;

 F. Castiglia et al. / Radiation Physics and Chemistry 116 (2015) 262–266 265

Table 2
Fuzzy HEART probabilities in Task2.

Subtask Error description EPC description and value Fuzzy linguist variable, Triangular fuzzy probability P(x1; x2; x3)
ApLVi

A2 Transcription errors of the setup Information overload, EPC8 ¼ 6 Medium (M) (0.0039;0.0101;0.0207)
parameters Transfer knowledge from one task to another, High (H)
EPC10¼ 5
Poor, ambiguous or ill-matched feedback Low (L)
EPC13¼ 4
B2 Incorrect patient identification Ambiguity in the required performance stan- Low (L) (0.0009;0.0026;0.0055)
dard, EPC11 ¼5
Mismatch between perceived and actual risk, Very Low (VL)
EPC12¼4
Poor instruction or procedures, EPC16¼ 3 Medium (M)
C2 Verification error Poor, ambiguous or ill-matched feedback, Medium (M) (0.0015;0.0024;0.0035)
EPC13¼ 4
Little or no independent checking or testing of High (H)
output, EPC17¼ 3

PTask2(x) = F1(x1, x2 ; x3) + F2(x1, x2 ; x3)

= A2C2 + a2B2c2
= (7.3E − 06; 2.9E − 05; 8.7E − 05) (6)

5. Conclusion

In this paper an attempt to highlight the importance of the

human factor during accident scenarios relevant to HDR treat-
ments is performed. The analysis has been performed by using a
Fig. 2. Event-tree of errors in “computation of dose distribution”, Task1.
THERP and HEART integrated methodology.
The results allow for the identification of human errors that are
necessary to achieve a better understanding of health hazards in
the radiotherapy treatment process, so that it can be properly
monitored and appropriately managed.
Compared with traditional HRA methodologies, the proposed
method has the following advantages:

1. The fuzzy process allows the adoption of a linguistic expression

Fig. 3. Event-tree of errors in “textual documentation of dosimetry details”, Task2.

Verification error, C2.
The HEP probability obtained by using fuzzy HEART are re-
ported in Tables 1 and 2. In the analysis to take into account that
the operating staff is trained in operating practices, the considered
task is “Completely familiar, well-designed highly practiced, per-
formed by highly trained and experienced person” (generic task G,
with P0 ¼0.0004 in Eq. (4)). Therefore, the most pertinent EPCi
were assessed to be: “Little or no independent checking or testing
of output”, “Mismatch between perceived and actual risk”, “In-
formation overload”, “Transfer knowledge from one task to an-
other”, “Poor, ambiguous or ill-matched feedback”, “Ambiguity in
the required performance standard”.
The event-tree sequences of incorrect actions in Task1 and
Task2 are reported in Figs. 2 and 3, respectively, whereas the
failure probabilities are calculated as follows:
PTask1(x) = ∑i = 1,4 Fi(x1, x2; x3)
= A1E1 + a1B1E1 + a1b1C1E1 + a1b1c1D1E1
= (1.8E − 05; 5.8E − 05; 1.5E − 04) (5)
to define the assessment factors in Eq. (4), so it is possible to
take expert judgements into consideration in a more simple
and direct way.
2. The fuzzy HEART error probability used in the event-tree allows
to take into account the state and importance of various factors
that determine the task performance, this approach overcomes
some weakness of the THERP method.
3. The resultant tree portrays step by step of the stages involved
in a task, in a logical order, this allows a more accurate as-
sessment of the error.
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