Professional Documents
Culture Documents
DOI 10.1007/s00769-016-1239-3
Received: 16 August 2016 / Accepted: 21 September 2016 / Published online: 15 October 2016
Springer-Verlag Berlin Heidelberg 2016
Abstract The role of human being as a part of a measuring errors in a chemical analytical laboratory and how to take
system in a chemical analytical laboratory is discussed. It is into account the error residual risk, is important. Human
argued that a measuring system in chemical analysis errors and their metrological implications are suggested for
includes not only measuring instruments and other devices, consideration in future editions of the relevant documents,
reagents and supplies, but also a sampling inspector and/or such as the International Vocabulary of Metrology (VIM)
analyst performing a number of important operations. and the Guide to the Expression of Uncertainty in Mea-
Without this human contribution, a measurement cannot be surement (GUM).
carried out. Human errors, therefore, influence the mea-
surement result, i.e., the measurand estimate and the Keywords Human error Measuring system
associated uncertainty. Consequently, chemical analytical Measurement uncertainty Method validation
and metrological communities should devote more atten- Chemical analysis
tion to the topic of human errors, in particular at the design
and development of a chemical analytical/test method and
measurement procedure. Also, mapping human errors Introduction
ought to be included in the program of validation of the
measurement procedure (method). Teaching specialists in The International Union of Pure and Applied Chemistry
analytical chemistry and students how to reduce human (IUPAC) and the Cooperation on International Traceability
in Analytical Chemistry (CITAC) have published recently
the joint IUPAC/CITAC Guide: Classification, modeling
The author Walter Bich is Convener of the Joint Committee for and quantification of human errors in a chemical analytical
Guides in Metrology (JCGM) Working Group 1 (Guide to the
Expression of Uncertainty in Measurement—GUM). The opinion laboratory (IUPAC Technical Report) [1]. The classifica-
expressed in this paper does not necessarily represent the view of this tion includes commission errors (mistakes and violations)
Working Group. and omission errors (lapses and slips) under different sce-
narios at different steps of the chemical analysis. A ‘‘Swiss
Papers published in this section do not necessarily reflect the opinion
of the Editors, the Editorial Board and the Publisher. cheese’’ model is used for characterizing the interaction of
A critical and constructive debate in the Discussion Forum or a Letter such errors with a laboratory quality system including
to the Editor is strongly encouraged! different components, whose weak points are represented
by holes in slices of the Swiss cheese. Quantification of
& Ilya Kuselman
ilya.kuselman@bezeqint.net
human errors in chemical analysis, based on expert judg-
ments, i.e., on the expert’s knowledge and experience, is
1
Independent Consultant on Metrology, 4/6 Yarehim St., applied. Scores related to the error quantification are
7176419 Modiin, Israel defined. They concern the likelihood and severity of the
2
Istituto Nazionale di Ricerca Metrologica (INRIM), 91 Strada human errors, and the effectiveness of a laboratory quality
delle Cacce, 10135 Turin, Italy system against these errors. Monte Carlo simulation is used
3
School of Chemistry, UNSW, Sydney, NSW 2052, Australia to propagate variability of the expert judgments,
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422 Accred Qual Assur (2016) 21:421–424
represented by appropriate probability mass functions. The represent. When the composition of a batch is tested, the
residual risk of human errors, remaining after the error sampling target should have the analyte concentration close
reduction by the laboratory quality system, and conse- as possible to the mean concentration value in the whole
quences of this risk for the quality of the laboratory batch. When the spatial or temporal variation of the material
measurement results are discussed in this Guide. It is composition is under study, separate sampling targets are
shown also that the measurement uncertainty budget is not necessary for obtaining information about analyte concen-
complete without taking into account such residual risk of trations in each specific location or time. Any sampling target
human errors [1, 2]. is analyzed according to the analytical/measurement proce-
For a few fully automated systems, such as a spacecraft dure to obtain the measurement results of the analyte
robotic laboratory [3, 4] which samples and analyzes concentrations, i.e., measurand estimates and associated
without human participation, only latent human errors (in uncertainty [13]. Sampling needs not necessarily be included
development and construction of the system) are possible in a measurement. In such case, it would not contribute to
[5]. In general, they can be revealed and eliminated during uncertainty. Whether or not sampling is included in the
the system validation for the intended use. There is a rise of measurement is reflected in the definition of the measurand.
autonomous robots having an ability to perform different For example, measuring ‘‘the mass concentration of chro-
steps of testing, such as sample preparation in analytical mium VI in the material delivered to the laboratory’’ does not
laboratories serving uranium industry [6, 7], or some kinds involve sampling, whereas ‘‘the mean mass concentration of
of blood and urine analysis in clinical laboratories [8]. chromium VI in Sydney Harbor’’ does.
Nevertheless, using these robots by the laboratory staff Sample preparation includes selection of the test por-
may also provoke a number of scenarios of human errors. tion, drying (or freezing, e.g., grapes), sieving, milling,
Moreover, in routine laboratories having lower level of splitting, homogenization and decomposition (e.g., geo-
automation, human errors may happen quite easily and logical samples).
should be taken into proper account. Analysis of a test portion may start from an analyte
Therefore, the role of human being in chemical analysis, extraction from a test portion and separation of the analyte
still essential in most measurement methods and proce- from other components of the extract. After that, a quali-
dures, is discussed in the present article. It is suggested to tative analysis is possible, including identification and
include human being in the updated definition of measuring confirmation of the analyte. Then, a quantitative part of the
system in the International Vocabulary of Metrology analysis consists of calibration of a measuring system and
(VIM) [9]. Such update would probably impact also on measurement of the analyte property—usually concentra-
other metrological definitions, as well as on the measure- tion or mass fraction.
ment uncertainty evaluation in the Guide to the Expression The measurement procedure documents human partici-
of Uncertainty in Measurement (GUM) [10]. pation at each step of the analysis/testing. Detailed
examples of human error scenarios at such steps, from
sampling to reporting results, are provided in the Guide [1]
Measurement method, procedure and measuring for pH measurement of groundwater, multi-residue pesti-
system cide analysis of fruits and vegetables, and ICP-MS analysis
of geological samples.
According to the VIM, measurement method [9–2.5] is a In the VIM, measuring system [9–3.2] is a ‘‘set of one
‘‘generic description of a logical organization of operations or more measuring instruments and often other devices,
used in a measurement,’’ while measurement procedure including any reagent and supply, assembled and adap-
[9–2.6] is a ‘‘detailed description of a measurement ted to give information used to generate measured
according to one or more measurement principles and to a quantity values within specified intervals for quantities
given measurement method, based on a measurement of specified kinds.’’ Human beings are not included in
model and including any calculation to obtain a measure- this definition. However, no system of this kind can
ment result.’’ However, this distinction is not universally provide alone the necessary information unless it is a
recognized, since the term ‘‘method’’ is often used as part of a fully robotic laboratory. In a routine chemical
including ‘‘procedure’’ [11], especially in chemical ana- analytical laboratory, a measuring system without a
lytical practice [12]. sampling inspector and/or an analyst is not complete.
The main steps of a measurement procedure in chemical Furthermore, in the case of qualitative testing (e.g.,
analysis include sampling, sample preparation, analysis of a organoleptic testing), a measuring system for nominal
test portion and calculation of test results and reporting. and ordinal property values [14–16] may consist of just
Sampling means taking at a particular time a sample/portion an analyst (expert), for example, an expert for testing
(sampling target) of material, which the sample is intended to color of freshwater cultured pearls [17].
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Validation of measuring instrument vs method Thus, in general, a method validation is validation of the
validation measurement procedure for operating a measuring system
including not only instrument(s), devices and reagents, but
According to VIM, validation is ‘‘verification, where the human being(s) as well.
specified requirements are adequate for an intended use’’
[9–2.45], whereas verification is ‘‘provision of objective
evidence that a given item fulfills specified requirements’’ Measuring system and measurement uncertainty
[9–2.44]. When a purchased measuring instrument has
been installed in a laboratory, an experiment should be The measurement result obtained with a measuring sys-
designed to obtain objective evidence (experimental data) tem ‘‘…is generally expressed as a single measured
that the instrument performance meets the manufacturer quantity value and a measurement uncertainty’’ [9–2.9].
specification [12]. For example, the experiment design for Identifying uncertainty sources is vital for correct evalu-
verification of a high-performance liquid chromatograph ation of the uncertainty associated with the measurand
(HPLC) intended for analysis of pesticide residues in estimate. It may be useful to consider discrete operations
drinking water, includes qualification of (1) pump gradient of the measuring system at different steps of the analysis
and precision, flow rate and online vacuum degasser; (2) and to assess each operation separately to evaluate the
ultraviolet/visible (UV/Vis) diode array detector with hol- associated uncertainty. Then, the uncertainty contributions
mium oxide filter for automated wavelength calibration, of the operations are suitably summarized in the com-
detector baseline noise and wavelength accuracy; (3) bined uncertainty [22].
autosampler with necessary number of samples, variable When human beings are involved in some of the oper-
volume of test portions without hardware change, needle ations, a risk of human error remains after the error
flush and wash to minimize sample carryover; (4) chro- reduction by the laboratory quality system. This residual
matographic column compartment and its temperature risk is also a source of a contribution to the measurement
precision; (5) instrument ability to detect leaks in each uncertainty. As such, it should be included in the uncer-
module and to switch the pump off in the case when a leak tainty budget and taken into account in the appropriate way
is detected; and (6) computer and software [18]. [1, 2].
If the data confirm that the instrument performance is At the same time, for the sake of justice, one should note
satisfactory, it may be used in a specific procedure that the most successful way of solving problems arising in
according to the appropriate analytical/measurement an analysis is human as well [23]. Therefore, it is important
method. Note, a measuring instrument performance (abil- that specialists in analytical chemistry and students would
ity) is provided by its manufacturer and does not depend on be educated and trained on how to reduce human errors in a
sampling inspector and/or analyst/operator in the analytical laboratory and how to take into account the residual risk of
laboratory that purchased the instrument. human error.
The performance characteristics for the method validation The reference document in the field of measurement
and their limits (criteria) are set by the laboratory upon uncertainty, the GUM gives little attention to human errors.
agreement with the customer as fit for the intended use [19]. According to it, ‘‘Blunders in recording or analyzing data
Commonly evaluated characteristics are: selectivity; limit of can introduce a significant unknown error in the result of a
detection (LOD) and limit of quantification (LOQ); working measurement. Large blunders can usually be identified by a
range; analytical sensitivity; trueness (bias and recovery); proper review of the data; small ones could be masked by,
precision (repeatability, intermediate precision and repro- or even appear as, random variations. Measures of uncer-
ducibility); ruggedness (robustness); and measurement tainty are not intended to account for such mistakes’’
uncertainty [19–21]. Their choice is a balance between costs, [10–3.4.7]. Thus, in the GUM, only some among the pos-
risks and technical possibilities [11]. Then, evaluation of sible human errors are recognized, and anyway, they are
these characteristics is performed using measurement results not included as a source of uncertainty.
obtained by a specified experiment design. We think that a reliable evaluation of uncertainty should
When a method prescribes human participation, it is in principle account for human errors. To this purpose, the
necessary to consider possible human errors during design scope of the GUM should be broadened to include uncer-
and development of the method, since further measure- tainties caused by human errors when appropriate, for
ment/analytical results may be influenced by these errors. example, in the field of analytical chemistry. Suitable tools
Therefore, mapping possible human errors at different are now available that can probably be adapted to and
steps of analysis/testing should be required also as one of incorporated in the procedures described in the GUM or in
the validation characteristics of the method [1]. its Supplements 1 and 2 [24, 25].
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