Improving versus maintaining nuclear safety

International Nuclear Information System (INIS)

2002-01-01

The concept of improving nuclear safety versus maintaining it has been discussed at a number of nuclear regulators meetings in recent years. National reports have indicated that there are philosophical differences between NEA member countries about whether their regulatory approaches require licensees to continuously improve nuclear safety or to continuously maintain it. It has been concluded that, while the actual level of safety achieved in all member countries is probably much the same, this is difficult to prove in a quantitative way. In practice, all regulatory approaches require improvements to be made to correct deficiencies and when otherwise warranted. Based on contributions from members of the NEA Committee on Nuclear Regulatory Activities (CNRA), this publication provides an overview of current nuclear regulatory philosophies and approaches, as well as insights into a selection of public perception issues. This publication's intended audience is primarily nuclear safety regulators, but government authorities, nuclear power plant operators and the general public may also be interested. (author)

Planned activities to improve safety

International Nuclear Information System (INIS)

1998-01-01

This document presents the fulfilling of the Brazilian obligations under the Convention on Nuclear Safety. The Chapter 6 of the document contains some details about the planed activities to safety improvements

Improving safety on rural local and tribal roads safety toolkit.

Science.gov (United States)

2014-08-01

Rural roadway safety is an important issue for communities throughout the country and presents a challenge for state, local, and Tribal agencies. The Improving Safety on Rural Local and Tribal Roads Safety Toolkit was created to help rural local ...

PROPOSAL OF VOIVODESHIP ROAD SAFETY IMPROVEMENT PROGRAMME

Directory of Open Access Journals (Sweden)

Tomasz SZCZURASZEK

2016-07-01

Full Text Available The article presents a proposal of the ‘GAMBIT KUJAWSKO-POMORSKI’ Road Safety Improvement Programme. The main idea of the Programme is to establish and initiate systems that will be responsible for the most important areas of activity within road safety, including road safety control, supervision, and management systems in the whole Voivodeship. In total, the creation and start of nine such systems has been proposed, namely: the Road Safety Management, the Integrated Road Rescue Service, the Personnel Continuing Education, the Hazardous Road Behaviour Monitoring, the Social Education for Safe Behaviour on Road, the Teaching Personnel Improvement, the Area Development and Planning Process Improvement, the Road Infrastructure Design Quality Improvement, and the Road and Traffic Management Process Efficiency Improvement. The basic aim of each system has been discussed as well as the most important tasks implemented as its part. The Road Safety Improvement Programme for the Kujawsko-Pomorskie Voivodeship presented in this article is a part of the National Road Safety Programme 2013-2020. Moreover, it is not only an original programme in Poland, but also a universal project that may be adapted for other voivodeships as well.

Research on the improvement of nuclear safety

International Nuclear Information System (INIS)

Yoo, Keon Joong; Kim, Dong Soo; Kim, Hui Dong; Park, Chang Kyu

1993-06-01

To improve the nuclear safety, this project is divided into three areas which are the development of safety analysis technology, the development of severe accident analysis technology and the development of integrated safety assessment technology. 1. The development of safety analysis technology. The present research aims at the development of necessary technologies for nuclear safety analysis in Korea. Establishment of the safety analysis technologies enables to reduce the expenditure both by eliminating excessive conservatisms incorporated in nuclear reactor design and by increasing safety margins in operation. It also contributes to improving plant safety through realistic analyses of the Emergency Operating Procedures (EOP). 2. The development of severe accident analysis technology. By the computer codes (MELCOR and CONTAIN), the in-vessel and the ex-vessel severe accident phenomena are simulated. 3. The development of integrated safety assessment technology. In the development of integrated safety assessment techniques, the included research areas are the improvement of PSA computer codes, the basic study on the methodology for human reliability analysis (HRA) and common cause failure (CCF). For the development of the level 2 PSA computer code, the basic research for the interface between level 1 and 2 PSA, the methodology for the treatment of containment event tree are performed. Also the new technologies such as artificial intelligence, object-oriented programming techniques are used for the improvement of computer code and the assessment techniques

Mochovce NPP safety improvement and completion

International Nuclear Information System (INIS)

1997-01-01

6th Nuclear society information meeting dealt with the completion of the Mochovce NPP with regard to implementation of safety measures. It was aimed to next problems: I. 'Survey' presentation on the situation of the nuclear power industry in partner countries; II. Basic technical presentations; III. Presentations of operators of the other VVER 440/213 NPPs on their activities in the field of safety improvement in relation to IAEA recommendations; IV. Technical solutions of safety improvements ranked with IAEA degree 3 (Report SC 108 VVER); V: Technical solutions of selected Safety Measures ranked with IAEA degree 2 and 1 (Report SC 108 VVER)

Current activities on safety improvement at Ukrainian NPPs

International Nuclear Information System (INIS)

Stovbun, V.V.

2000-01-01

This report describes general development status of the national programs on safety improvement of the Ukrainian NPPs, basic approaches adopted for planning and implementation of safety improvement works, and state of implementation of principal technical activities aimed at safety improvement of Ukrainian NPPs. (author)

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

Science.gov (United States)

McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R

2014-10-01

Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.

Methods for safety culture improvement

International Nuclear Information System (INIS)

Sivintsev, Yu.V.

1998-01-01

New IAEA publication concerning the problems of safety assurance covering different aspects beginning from terminology applied and up to concrete examples of well and poor safety culture development at nuclear facilities is discussed. The safety culture is defined as such set of characteristics and specific activities of institutions and individual persons which states that safety problems of a nuclear facility are given the attention determined by their importance as being of highest priority. The statements of the new document have recommended, not mandatory character. It is emphasized that the process of safety culture improvement at nuclear facilities should be integral component of management procedure, not a bolt on extra

Improving patient safety: lessons from rock climbing.

Science.gov (United States)

Robertson, Nic

2012-02-01

How to improve patient safety remains an intractable problem, despite large investment and some successes. Academics have argued that the root of the problem is a lack of a comprehensive 'safety culture' in hospitals. Other safety-critical industries such as commercial aviation invest heavily in staff training to develop such a culture, but comparable programmes are almost entirely absent from the health care sector. In rock climbing and many other dangerous activities, the 'buddy system' is used to ensure that safety systems are adhered to despite adverse circumstances. This system involves two or more people using simple checks and clear communication to prevent problems causing harm. Using this system as an example could provide a simple, original and entertaining way of introducing medical students to the idea that human factors are central to ensuring patient safety. Teaching the buddy system may improve understanding and acceptance of other patient safety initiatives, and could also be used by junior doctors as a tool to improve the safety of their practice. © Blackwell Publishing Ltd 2012.

Safety improvement of Paks nuclear power plant

International Nuclear Information System (INIS)

Vamos, G.

1999-01-01

Safety upgrading completed in the early nineties at the Paks NPP include: replacement of steam generator safety valves and control valves; reliability improvement of the electrical supply system; modification of protection logic; enhancement of the fire protection; construction of full scope Training Simulator. Design safety upgrading measures achieved in recent years were concerned with: relocation of steam generator emergency feed-water supply; emergency gas removal from the primary coolant system; hydrogen management in the containment; protection against sumps; preventing of emergency core cooling system tanks from refilling. Increasing seismic resistance, containment assessment, refurbishment of reactor protection system, improving reliability of emergency electrical supply, analysis of internal hazards are now being implemented. Safety upgrading measures which are being prepared include: bleed and feed procedures; reactor over-pressurisation protection in cold state; treatment of steam generator primary to secondary leak accidents. Operational safety improvements are dealing with safety culture, training measures and facilities; symptom based emergency operating procedures; in-service inspection; fire protection. The significance of international cooperation is emphasised in view of achieving nuclear safety standards recognised in EU

Safety culture improvement. An adaptive management framework

International Nuclear Information System (INIS)

Obadia, Isaac Jose

2005-01-01

After the Chernobyl nuclear accident in 1986, the International Atomic Energy Agency (IAEA) established the safety culture concept as a proactive mean to contribute to safety improvement, starting a worldwide safety culture enhancement program within nuclear organizations mainly focused on nuclear power plants. More recently, the safety culture concept has been extended to non-power applications such as nuclear research reactors and nuclear technological research and development organizations. In 1999, the Nuclear Engineering Institute (IEN), a research and technological development unit of the Brazilian Nuclear Energy Commission (CNEN), started a management change program aiming at improving its performance level of excellence. This change program has been developed assuming the occurrence of complex causal inter-relationships between the organizational culture and the implementation of the management process. A systematic and adaptive management framework comprised of a safety culture improvement practice integrated to a management process based on the Criteria for Excellence of the Brazilian Quality Award Model, has been developed and implemented at IEN. The case study has demonstrated that the developed framework makes possible an effective safety culture improvement and simultaneously facilitates an effective implementation of the management process, thus providing some governance to the change program. (author)

Emulating a crowded intracellular environment in vitro dramatically improves RT-PCR performance

International Nuclear Information System (INIS)

Lareu, Ricky R.; Harve, Karthik S.; Raghunath, Michael

2007-01-01

The polymerase chain reaction's (PCR) phenomenal success in advancing fields as diverse as Medicine, Agriculture, Conservation, or Paleontology is based on the ability of using isolated prokaryotic thermostable DNA polymerases in vitro to copy DNA irrespective of origin. This process occurs intracellularly and has evolved to function efficiently under crowded conditions, namely in an environment packed with macromolecules. However, current in vitro practice ignores this important biophysical parameter of life. In order to more closely emulate conditions of intracellular biochemistry in vitro we added inert macromolecules into reverse transcription (RT) and PCR. We show dramatic improvements in all parameters of RT-PCR including 8- to 10-fold greater sensitivity, enhanced polymerase processivity, higher specific amplicon yield, greater primer annealing and specificity, and enhanced DNA polymerase thermal stability. The faster and more efficient reaction kinetics was a consequence of the cumulative molecular and thermodynamic effects of the excluded volume effect created by macromolecular crowding

EC6 safety design improvements

Energy Technology Data Exchange (ETDEWEB)

Yu, S.; Lee, A.G.; Soulard, M. [Candu Energy Inc., Mississauga, ON (Canada)

2014-07-01

The Enhanced CANDU 6 (EC6) builds on the proven high performance design such as the Qinshan CANDU 6 reactor, and has made improvements to safety, operational performance, and has incorporated extensive operational feedback. Completion of all three phases of the pre-licensing design review by the Canadian Regulator - the Canadian Nuclear Safety Commission has provided a higher level of assurance that the EC6 reference design has taken modern regulatory requirements and expectations into account and further confirmed that there are no fundamental barriers to licensing the EC6 design in Canada. The EC6 design is based on the defence-in-depth principles in INSAG-10 and provides further safety features that address the lessons learned from Fukushima. With these safety features, the EC6 design has strengthened accident prevention as the first priority in the defence-in-depth strategy, as outlined in INSAG-10. As well, the EC6 design has incorporated further mitigation measures to provide additional protection of the public and the environment if the preventive measures fail. The EC6 design has an appropriate combination of inherent, passive safety characteristics, engineered features and administrative safety measures to effectively prevent and mitigate severe accident progressions. A strong contributor to the robustness and redundancy of CANDU design is the two-group separation philosophy. This ensures a high degree of independence between safety systems as well as physical separation and functional independence in how fundamental safety functions are provided. This paper will describe the following safety features based on the application of defence-in-depth and design approach to prevent beyond design basis events progressing to severe accidents and to mitigate the consequences if it occurs: Improved steam generator heat sink via a more reliable emergency heat removal system; Increased time before manual field actions are required via enhanced capacity of

Study of system safety evaluation on LTO of national project. NISA safety research project on system safety of nuclear power plants

International Nuclear Information System (INIS)

Takizawa, Masayuki; Sekimura, Naoto; Miyano, Hiroshi; Aoyama, Katsunobu

2012-01-01

Japanese safety regulatory body, that is, Nuclear and Industrial Safety Agency (NISA) started a 5-year national safety research project as 'the first stage' from 2006 FY to 2010 FY whose objective is 'Improve the technical information basis in order to utilize knowledge as well as information related to ageing management and maintenance of NPPs. Fukushima disaster happened in March 2011, and the priority of research needs for ageing management dramatically changed in Japan. The second-stage national project started in October 2011 with the concept of 'system safety' of NNPs where not only ageing management on degradation phenomena of important components but also safety management on total plant systems are paid attention to. The second-stage project is so called 'Japanese Ageing Management Program for System Safety (JAMPSS)'. (author)

The mathematics of dam safety

Energy Technology Data Exchange (ETDEWEB)

Widmann, R. [Osterreichische Gesellschaft fuer Geomechanik, Salzburg (Austria)

1997-05-01

The safety of a dam is determined by its design, construction and supervision during operation. High arch dam failures have dropped dramatically since the early part of this century. An essential part of the success story relates to improved measurement techniques that can detect earlier unexpected behaviour that may lead to failure. (UK)

A tool for safety evaluations of road improvements.

Science.gov (United States)

Peltola, Harri; Rajamäki, Riikka; Luoma, Juha

2013-11-01

Road safety impact assessments are requested in general, and the directive on road infrastructure safety management makes them compulsory for Member States of the European Union. However, there is no widely used, science-based safety evaluation tool available. We demonstrate a safety evaluation tool called TARVA. It uses EB safety predictions as the basis for selecting locations for implementing road-safety improvements and provides estimates of safety benefits of selected improvements. Comparing different road accident prediction methods, we demonstrate that the most accurate estimates are produced by EB models, followed by simple accident prediction models, the same average number of accidents for every entity and accident record only. Consequently, advanced model-based estimates should be used. Furthermore, we demonstrate regional comparisons that benefit substantially from such tools. Comparisons between districts have revealed significant differences. However, comparisons like these produce useful improvement ideas only after taking into account the differences in road characteristics between areas. Estimates on crash modification factors can be transferred from other countries but their benefit is greatly limited if the number of target accidents is not properly predicted. Our experience suggests that making predictions and evaluations using the same principle and tools will remarkably improve the quality and comparability of safety estimations. Copyright © 2013 Elsevier Ltd. All rights reserved.

An integrated approach for improving occupational health and safety management: the voluntary protection program in Taiwan.

Science.gov (United States)

Su, Teh-Sheng; Tsai, Way-Yi; Yu, Yi-Chun

2005-05-01

A voluntary compliance program for occupational health and safety management, Voluntary Protection Programs (VPP), was implemented with a strategy of cooperation and encouragement in Taiwan. Due to limitations on increasing the human forces of inspection, a regulatory-based guideline addressing the essence of Occupational Health and Safety Management Systems (OHSMS) was promulgated, which combined the resources of third parties and insurance providers to accredit a self-improving worksite with the benefits of waived general inspection and a merit contributing to insurance premium payment reduction. A designated institute accepts enterprise's applications, performs document review and organizes the onsite inspection. A final review committee of Council of Labor Affairs (CLA) confers a two-year certificate on an approved site. After ten years, the efforts have shown a dramatic reduction of occupational injuries and illness in the total number of 724 worksites granted certification. VPP worksites, in comparison with all industries, had 49% lower frequency rate in the past three years. The severity rate reduction was 80% in the same period. The characteristics of Taiwan VPP program and international occupational safety and health management programs are provided. A Plan-Do-Check-Act management cycle was employed for pursuing continual improvements to the culture fostered. The use of a quantitative measurement for assessing the performance of enterprises' occupational safety and health management showed the efficiency of the rating. The results demonstrate that an employer voluntary protection program is a promising strategy for a developing country.

Total safety management: An approach to improving safety culture

International Nuclear Information System (INIS)

Blush, S.M.

1993-01-01

A little over 4 yr ago, Admiral James D. Watkins became Secretary of Energy. President Bush, who had appointed him, informed Watkins that his principal task would be to clean up the nuclear weapons complex and put the US Department of Energy (DOE) back in the business of producing tritium for the nation's nuclear deterrent. Watkins recognized that in order to achieve these objectives, he would have to substantially improve the DOE's safety culture. Safety culture is a relatively new term. The International Atomic Energy Agency (IAEA) used it in a 1986 report on the root causes of the Chernobyl nuclear accident. In 1990, the IAEA's International Nuclear Safety Advisory Group issued a document focusing directly on safety culture. It provides guidelines to the international nuclear community for measuring the effectiveness of safety culture in nuclear organizations. Safety culture has two principal aspects: an organizational framework conducive to safety and the necessary organizational and individual attitudes that promote safety. These obviously go hand in hand. An organization must create the right framework to foster the right attitudes, but individuals must have the right attitudes to create the organizational framework that will support a good safety culture. The difficulty in developing such a synergistic relationship suggests that achieving and sustaining a strong safety culture is not easy, particularly in an organization whose safety culture is in serious disrepair

Patient safety--worker safety: building a culture of safety to improve healthcare worker and patient well-being.

Science.gov (United States)

Yassi, Annalee; Hancock, Tina

2005-01-01

Patient safety within the Canadian healthcare system is currently a high national priority, which merits a comprehensive understanding of the underlying causes of adverse events. Not least among these is worker health and safety, which is linked to patient outcomes. Healthcare workers have a high risk of workplace injuries and more mental health problems than most other occupational groups. Many healthcare professionals feel fatigued, stressed, in pain, or at risk of illness or injury-factors they feel impede their ability to provide consistent quality care. With this background, the Occupational Health and Safety Agency for Healthcare (OHSAH) in British Columbia, jointly governed by healthcare unions and healthcare employers, launched several major initiatives to improve the healthcare workplace. These included the promotion of safe patient handling, adaptive clothing, scheduled toileting, stroke management training, measures to improve management of aggressive behaviour and, of course, infection control-all intended to improve the safety of workers, but also to improve patient safety and quality of care. Other projects also explicitly promoting physical and mental health at work, as well as patient safety are also underway. Results of the projects are at various stages of completion, but ample evidence has already been obtained to indicate that looking after the well-being of healthcare workers results in safer and better quality patient care. While more research is needed, our work to date suggests that a comprehensive systems approach to promoting a climate of safety, which includes taking into account workplace organizational factors and physical and psychological hazards for workers, is the best way to improve the healthcare workplace and thereby patient safety.

Research reactor management. Safety improvement activities in HANARO

International Nuclear Information System (INIS)

Wu, Jong-Sup; Jung, Hoan-Sung; Hong, Sung Taek; Ahn, Guk-Hoon

2012-01-01

Safety activities in HANARO have been continuously conducted to enhance its safe operation. Great effort has been placed on a normalization and improvement of the safety attitude of the regular staff and other employees working at the reactor and other experimental facilities. This paper introduces the activities on safety improvement that were performed over the last few years. (author)

Improving patient safety culture in Saudi Arabia (2012-2015): trending, improvement and benchmarking.

Science.gov (United States)

Alswat, Khalid; Abdalla, Rawia Ahmad Mustafa; Titi, Maher Abdelraheim; Bakash, Maram; Mehmood, Faiza; Zubairi, Beena; Jamal, Diana; El-Jardali, Fadi

2017-08-02

Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans. This paper also explored the association between patient safety culture predictors and patient safety grade, perception of patient safety, frequency of events reported and number of events reported. We utilized a customized version of the patient safety culture survey developed by the Agency for Healthcare Research and Quality. The Medical City is a tertiary care teaching facility composed of two sites (total capacity of 904 beds). Data was analyzed using SPSS 24 at a significance level of 0.05. A t-Test was used to compare results from the 2012 survey to that conducted in 2015. Two adopted Generalized Estimating Equations in addition to two linear models were used to assess the association between composites and patient safety culture outcomes. Results were also benchmarked against similar initiatives in Lebanon, Palestine and USA. Areas of strength in 2015 included Teamwork within units, and Organizational Learning-Continuous Improvement; areas requiring improvement included Non-Punitive Response to Error, and Staffing. Comparing results to the 2012 survey revealed improvement on some areas but non-punitive response to error and Staffing remained the lowest scoring composites in 2015. Regression highlighted significant association between managerial support, organizational learning and feedback and improved survey outcomes. Comparison to international benchmarks revealed that the hospital is performing at or

[Does simulator-based team training improve patient safety?].

Science.gov (United States)

Trentzsch, H; Urban, B; Sandmeyer, B; Hammer, T; Strohm, P C; Lazarovici, M

2013-10-01

Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

Safety goals and safety culture opening plenary. 1. WANO's Role in Maintaining and Improving Safety Culture

International Nuclear Information System (INIS)

Tsutsumi, Ryosuke

2001-01-01

Over the past several years, operators of the world's nuclear plants have compiled an increasingly impressive record of operational performance. Among the many factors that have led to this improvement are the unprecedented cooperation and information exchange among the world's nuclear operators. This paper presents the World Association of Nuclear Operators (WANO) operating experience program and WANO peer review program as examples of the kinds of interaction that are occurring around the globe to maintain and improve the nuclear safety culture. In addition, some unique features of WANO are discussed. WANO has established four programs to help its members communicate effectively with each other. These include the exchange of operating experiences, voluntary peer reviews, professional and technical development, and technical support and exchange. The operating experience program alerts members to events that have occurred at other NPPs and enables members to take appropriate actions to prevent event recurrence. When an event occurs at a plant, management at that plant analyses the event and completes an event report, which is then sent to the WANO regional center to which the plant belongs. After a regional center review and necessary iteration, the report is posted onto the WANO Web site to make it available to all WANO members. By the end of 2000, more than 1500 event reports had been posted. The WANO Peer Review Program is a unique opportunity for members to learn and share the best worldwide insights into safe and reliable nuclear operations. The peer review program has become one of WANO's most important activities containing all essential elements of WANO's mission. A WANO peer review team consists of 15 to 16 people with NPP experience; most team members are from countries outside the one that they are visiting. These teams of peers from plants around the world visit host plants upon request to identify strengths and areas for improvement, with a strong

Improving the safety of future nuclear fission power plants

International Nuclear Information System (INIS)

Frisch, W.; Gros, G.

2001-01-01

The main objectives and principles in nuclear fission reactor safety are presented, e.g. the defence in depth strategy and technical principles such as redundancy, diversity and physical separation. After a brief historical review of the continuous development of safety improvement, the most recent international discussion is presented. This includes mainly the international activities within IAEA and its International Nuclear Safety Advisory Group (INSAG). The safety improvement, presented in recommendations of IAEA and INSAG is expressed as an improvement of all elements and all levels of the defence in depth concept. Special emphasis is put on improvement of the highest level, which requires the implementation of means to mitigate consequences of accidents with severe core damage. The different future concepts are briefly characterised. Some examples from the French-German safety approach are taken to demonstrate how requirements for safety improvement by means of an enhancement of the defence in depth principle are developed

Improving the safety and reliability of Monju

International Nuclear Information System (INIS)

Itou, Kazumoto; Maeda, Hiroshi; Moriyama, Masatoshi

1998-01-01

Comprehensive safety review has been performed at Monju to determine why the Monju secondary sodium leakage accident occurred. We investigated how to improve the situation based on the results of the safety review. The safety review focused on five aspects of whether the facilities for dealing with the sodium leakage accident were adequate: the reliability of the detection method, the reliability of the method for preventing the spread of the sodium leakage accident, whether the documented operating procedures are adequate, whether the quality assurance system, program, and actions were properly performed and so on. As a result, we established for Monju a better method of dealing with sodium leakage accidents, rapid detection of sodium leakage, improvement of sodium drain facilities, and way to reduce damage to Monju systems after an accident. We also improve the operation procedures and quality assurance actions to increase the safety and reliability of Monju. (author)

The awareness of employees in safety culture through the improved nuclear safety culture evaluation method

Energy Technology Data Exchange (ETDEWEB)

Kim, Young Ga; Sung, Chan Ho; Jung, Yeon Sub [KHNP Central Research Institute, Daejeon (Korea, Republic of)

2012-10-15

After the Chernobyl nuclear accident in 1986, nuclear safety culture terminology was at first introduced emphasizing the importance of employees' attitude and organizational safety. The concept of safety culture was spread by INSAG 4 published in 1991. From that time, IAEA had provided the service of ASCOT for the safety culture assessment. However, many people still are thinking that safety culture is abstract and is not clear. It is why the systematic and reliable assessment methodology was not developed. Assessing safety culture is to identify what is the basic assumption for any organization to accept unconsciously. Therefore, it is very difficult to reach a meaningful conclusion by a superficial investigation alone. KHNP had been doing the safety culture assessment which was based on ASCOT methodology every 2 years. And this result had contributed to improving safety culture. But this result could not represent the level of organization's safety culture due to the limitation of method. So, KHNP has improved the safety culture method by benchmarking the over sea assessment techniques in 2011. The effectiveness of this improved methodology was validated through a pilot assessment. In this paper, the level of employees' safety culture awareness was analyzed by the improved method and reviewed what is necessary for the completeness and objectivity of the nuclear safety culture assessment methodology.

The awareness of employees in safety culture through the improved nuclear safety culture evaluation method

International Nuclear Information System (INIS)

Kim, Young Ga; Sung, Chan Ho; Jung, Yeon Sub

2012-01-01

After the Chernobyl nuclear accident in 1986, nuclear safety culture terminology was at first introduced emphasizing the importance of employees' attitude and organizational safety. The concept of safety culture was spread by INSAG 4 published in 1991. From that time, IAEA had provided the service of ASCOT for the safety culture assessment. However, many people still are thinking that safety culture is abstract and is not clear. It is why the systematic and reliable assessment methodology was not developed. Assessing safety culture is to identify what is the basic assumption for any organization to accept unconsciously. Therefore, it is very difficult to reach a meaningful conclusion by a superficial investigation alone. KHNP had been doing the safety culture assessment which was based on ASCOT methodology every 2 years. And this result had contributed to improving safety culture. But this result could not represent the level of organization's safety culture due to the limitation of method. So, KHNP has improved the safety culture method by benchmarking the over sea assessment techniques in 2011. The effectiveness of this improved methodology was validated through a pilot assessment. In this paper, the level of employees' safety culture awareness was analyzed by the improved method and reviewed what is necessary for the completeness and objectivity of the nuclear safety culture assessment methodology

EUROSAFE Forum for nuclear safety. Towards Convergence of Technical Nuclear Safety Practices in Europe. Safety Improvements - Reasons, Strategies, Implementation

Energy Technology Data Exchange (ETDEWEB)

Erven, Ulrich (ed.) [Gesellschaft fuer Anlagen- und Reaktorsicherheit, GRS mbH, Schwertnergasse 1, 50667 Koeln (Germany); Cherie, Jean-Bernard (ed.) [Institut de Radioprotection et de Surete Nucleaire, IRSN, BP 17, 92262 Fontenay-aux-Roses Cedex (France); Boeck, Benoit De (ed.) [Association Vincotte Nuclear, AVN, Rue Walcourt 148, 1070 Bruxelles (Belgium)

2005-07-01

The EUROSAFE Forum for Nuclear Safety is part of the EUROSAFE approach, which consists of two further elements: the EUROSAFE Tribune and the EUROSAFE Web site. The general aim of EUROSAFE is to contribute to fostering the convergence of technical nuclear safety practices in a broad European context. This is done by providing technical safety and research organisations, safety authorities, power utilities, the rest of the industry and non-governmental organisations mainly from the European Union and East-European countries, and international organisations with a platform for the presentation of recent analyses and R and D in the field of nuclear safety. The goal is to share experiences, to exchange technical and scientific opinions, and to conduct debates on key issues in the fields of nuclear safety and radiation protection. The EUROSAFE Forum on 2005 focused on Safety Improvements, Reasons - Strategies - Implementation, from the point of view of the authorities, TSOs and industry. Latest work in nuclear installation safety and research, waste management, radiation safety as well as nuclear material and nuclear facilities security carried out by GRS, IRSN, AVN and their partners in the European Union, Switzerland and Eastern Europe are presented. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety and safety management, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge, and the need for greater transparency - these are all issues where the value of an international approach is gaining

EUROSAFE Forum for nuclear safety. Towards Convergence of Technical Nuclear Safety Practices in Europe. Safety Improvements - Reasons, Strategies, Implementation

Energy Technology Data Exchange (ETDEWEB)

Erven, Ulrich [Gesellschaft fuer Anlagen- und Reaktorsicherheit, GRS mbH, Schwertnergasse 1, 50667 Koeln (Germany); Cherie, Jean-Bernard [Institut de Radioprotection et de Surete Nucleaire, IRSN, BP 17, 92262 Fontenay-aux-Roses Cedex (France); Boeck, Benoit De [Association Vincotte Nuclear, AVN, Rue Walcourt 148, 1070 Bruxelles (Belgium)

2005-07-01

The EUROSAFE Forum for Nuclear Safety is part of the EUROSAFE approach, which consists of two further elements: the EUROSAFE Tribune and the EUROSAFE Web site. The general aim of EUROSAFE is to contribute to fostering the convergence of technical nuclear safety practices in a broad European context. This is done by providing technical safety and research organisations, safety authorities, power utilities, the rest of the industry and non-governmental organisations mainly from the European Union and East-European countries, and international organisations with a platform for the presentation of recent analyses and R and D in the field of nuclear safety. The goal is to share experiences, to exchange technical and scientific opinions, and to conduct debates on key issues in the fields of nuclear safety and radiation protection. The EUROSAFE Forum on 2005 focused on Safety Improvements, Reasons - Strategies - Implementation, from the point of view of the authorities, TSOs and industry. Latest work in nuclear installation safety and research, waste management, radiation safety as well as nuclear material and nuclear facilities security carried out by GRS, IRSN, AVN and their partners in the European Union, Switzerland and Eastern Europe are presented. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety and safety management, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge, and the need for greater transparency - these are all issues where the value of an international approach is gaining

Twenty years of improvements in LWR safety

International Nuclear Information System (INIS)

Franks, S. III; Mulkey, J.P.; Moonka, A.

1996-01-01

Substantial improvements have been made in the safety of light-water reactors in the US during the past two decades, making currently operating reactors safer than ever before. Safety improvements have resulted both from regulatory and operational changes and from new knowledge and technology. The US Nuclear Regulatory Commission, the US Department of Energy, and the American nuclear power industry have worked together and with the international community to enhance the safety of existing plants and to incorporate lessons learned from prior operation into designs for a new generation of advanced, inherently safer reactors

A BWR Safety and Operability Improvements

International Nuclear Information System (INIS)

Sawyer, Craig D.

1993-01-01

The A BWR is the culmination of 30 years of design, development and operating experience of BWRs around the world. It represents across the board improvements is safety, operation and maintenance practices (O and M), economics, radiation exposure and rad waste generation. More than ten years and $20m5 went into the design and development of its new features, and it is now under construction in Japan. This paper concentrates on the safety and operability improvements. In the safety area, more than a decade improvement in core damage frequency (CDFR) has been assessed by formal PIRA techniques, with CDFR less than 10 -6 /year. Severe accident mitigation has also been formally addressed in the design. Plant operations were simplified by incorporation of better materials, optimum use of redundancy in mechanical and electrical equipment so that on-line maintenance can be performed, by better arrangements which account for required maintenance practices, and by an advanced control room

78 FR 48029 - Improving Chemical Facility Safety and Security

Science.gov (United States)

2013-08-07

... Improving Chemical Facility Safety and Security By the authority vested in me as President by the... at reducing the safety risks and security risks associated with hazardous chemicals. However... to further improve chemical facility safety and security in coordination with owners and operators...

Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.

Science.gov (United States)

Simons, Pascale A M; Houben, Ruud; Vlayen, Annemie; Hellings, Johan; Pijls-Johannesma, Madelon; Marneffe, Wim; Vandijck, Dominique

2015-02-01

The importance of a safety culture to maximize safety is no longer questioned. However, achieving sustainable culture improvements are less evident. Evidence is growing for a multifaceted approach, where multiple safety interventions are combined. Lean management is such an integral approach to improve safety, quality and efficiency and therefore, could be expected to improve the safety culture. This paper presents the effects of lean management activities on the patient safety culture in a radiotherapy institute. Patient safety culture was evaluated over a three year period using triangulation of methodologies. Two surveys were distributed three times, workshops were performed twice, data from an incident reporting system (IRS) was monitored and results were explored using structured interviews with professionals. Averages, chi-square, logistical and multi-level regression were used for analysis. The workshops showed no changes in safety culture, whereas the surveys showed improvements on six out of twelve dimensions of safety climate. The intention to report incidents not reaching patient-level decreased in accordance with the decreasing number of reports in the IRS. However, the intention to take action in order to prevent future incidents improved (factorial survey presented β: 1.19 with p: 0.01). Due to increased problem solving and improvements in equipment, the number of incidents decreased. Although the intention to report incidents not reaching patient-level decreased, employees experienced sustained safety awareness and an increased intention to structurally improve. The patient safety culture improved due to the lean activities combined with an organizational restructure, and actual patient safety outcomes might have improved as well. Copyright © 2014 Elsevier Ltd. All rights reserved.

Technical specification improvement through safety margin considerations

International Nuclear Information System (INIS)

Howard, R.C.; Jansen, R.L.

1986-01-01

Westinghouse has developed an approach for utilizing safety analysis margin considerations to improve plant operability through technical specification revision. This approach relies on the identification and use of parameter interrelations and sensitivities to identify acceptable operating envelopes. This paper summarizes technical specification activities to date and presents the use of safety margin considerations as another viable method to obtain technical specification improvement

Confidence improvement of disosal safety bydevelopement of a safety case for high-level radioactive waste disposal

Energy Technology Data Exchange (ETDEWEB)

Baik, Min Hoon; Ko, Nak Youl; Jeong, Jong Tae; Kim, Kyung Su [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2016-12-15

Many countries have developed a safety case suitable to their own countries in order to improve the confidence of disposal safety in deep geological disposal of high-level radioactive waste as well as to develop a disposal program and obtain its license. This study introduces and summarizes the meaning, necessity, and development process of the safety case for radioactive waste disposal. The disposal safety is also discussed in various aspects of the safety case. In addition, the status of safety case development in the foreign countries is briefly introduced for Switzerland, Japan, the United States of America, Sweden, and Finland. The strategy for the safety case development that is being developed by KAERI is also briefly introduced. Based on the safety case, we analyze the efforts necessary to improve confidence in disposal safety for high-level radioactive waste. Considering domestic situations, we propose and discuss some implementing methods for the improvement of disposal safety, such as construction of a reliable information database, understanding of processes related to safety, reduction of uncertainties in safety assessment, communication with stakeholders, and ensuring justice and transparency. This study will contribute to the understanding of the safety case for deep geological disposal and to improving confidence in disposal safety through the development of the safety case in Korea for the disposal of high-level radioactive waste.

Safety culture improvements in a nuclear laboratory setting

International Nuclear Information System (INIS)

Smith, K.L.; McKenna, J.

2014-01-01

In 2008, AECL performed a comprehensive safety culture assessment using recognized, industry-proven methodologies. Main observations were grouped into several key areas including standards, procedures, error-free work, and leadership fundamentals. Shortly thereafter, in 2009 May, the National Research Universal (NRU) reactor was shut down following discovery of a small leak of heavy water. Extensive repairs were required to return the reactor to service and a root cause investigation was conducted to determine the organizational and programmatic causes that led to the event. Taken together, these presented management with insights into common areas of weaknesses in performance and behaviours. A Corrective Action Plan (CAP) to address both the findings of the root cause analysis and safety culture assessment was captured in a comprehensive improvement plan issued in 2010 March, entitled the Voyageur Program Phase II (Voyageur II). The CAP addresses six key areas: Improve equipment reliability; Drive desired behaviours; Improve problem identification and resolution; Improve use of industry Operating Experience (OPEX) and reduce isolationism; Improve standards of operation; and, Improve management oversight. AECL's safety culture has been monitored regularly using quarterly surveys. A detailed safety culture assessment was executed in 2012 September. Compared with previous results, improvements for AECL were noted in the following areas: Use of Operating Experience, specifically in work planning, pre job briefs and training; Procedure quality; Availability of safety equipment; Control of temporary changes; and, Improved operational standards. (author)

Safety culture improvements in a nuclear laboratory setting

Energy Technology Data Exchange (ETDEWEB)

Smith, K.L.; McKenna, J. [Atomic Energy of Canada Limited, Chalk River, ON (Canada)

2014-07-01

In 2008, AECL performed a comprehensive safety culture assessment using recognized, industry-proven methodologies. Main observations were grouped into several key areas including standards, procedures, error-free work, and leadership fundamentals. Shortly thereafter, in 2009 May, the National Research Universal (NRU) reactor was shut down following discovery of a small leak of heavy water. Extensive repairs were required to return the reactor to service and a root cause investigation was conducted to determine the organizational and programmatic causes that led to the event. Taken together, these presented management with insights into common areas of weaknesses in performance and behaviours. A Corrective Action Plan (CAP) to address both the findings of the root cause analysis and safety culture assessment was captured in a comprehensive improvement plan issued in 2010 March, entitled the Voyageur Program Phase II (Voyageur II). The CAP addresses six key areas: Improve equipment reliability; Drive desired behaviours; Improve problem identification and resolution; Improve use of industry Operating Experience (OPEX) and reduce isolationism; Improve standards of operation; and, Improve management oversight. AECL's safety culture has been monitored regularly using quarterly surveys. A detailed safety culture assessment was executed in 2012 September. Compared with previous results, improvements for AECL were noted in the following areas: Use of Operating Experience, specifically in work planning, pre job briefs and training; Procedure quality; Availability of safety equipment; Control of temporary changes; and, Improved operational standards. (author)

Creative Dramatics. Beginnings Workshop.

Science.gov (United States)

Gabriel, Julia; Sidlovskaya, Olga; Stotter, Ruth; Haugen, Kirsten; Leithold, Naomi

2000-01-01

Presents five articles on using creative dramatics in early childhood education: (1) "Drama: A Rehearsal for Life" (Julia Gabriel); (2) "Fairy Tales Enhance Imagination and Creative Thinking" (Olga Sidlovskaya); (3) "Starting with a Story" (Ruth Stotter); (4) "Using Creative Dramatics to Include All…

Research notes : are safety corridors really safe? Evaluation of the corridor safety improvement program.

Science.gov (United States)

1998-08-26

High accident frequencies on Oregons highway corridors are of concern to the Oregon Department of Transportation (ODOT). : ODOT adopted the Corridor Safety Improvement Program as part of an overall program of safety improvements using federal and ...

Radiotherapy professionals faced with the obligation of treatments safety improvement

International Nuclear Information System (INIS)

2011-01-01

The occurrence of a major accident in Epinal (2006), followed by one in Toulouse (2007), led the Ministry of Health to mobilize the whole actors in radiotherapy in order to define national measures intended to improve health care security. Compiled in the so-called 'road map', these measures were presented in November 2007, and implemented in the 2009-2013 cancer programme. The French Institute for Radiological Protection and Nuclear Safety (IRSN) undertook a study aiming at assessing the effects of the above-mentioned measures on organization and safety management of radiotherapy facilities, but also on treatment achievement procedures and health professionals. More specifically, IRSN sought to examine the ability of health professionals to take into account new safety demands and to adapt their practices accordingly. With these purposes objectives, a qualitative study using the methods of ergonomics and sociology of organizations was completed in 2009-2010. The results of the study presented in this report show an effective improvement of health care safety along with a variable integration of safety measures depending on radiotherapy facilities and units. In particular, integration depends on 1) the governance mode of the health care facility, more or less conducive to promoting safety, 2) the pre-existence of a safety culture and safety organization, and 3) the facility commitment to health care safety improvement actions. The study also reveals that the implementation of new safety demands and the changes they involve create new constraints, which put pressure on health professionals and may threaten the durability of the improvements made. In order to facilitate the appropriation and implementation by radiotherapy units of the measures meant to improve health care safety, IRSN identifies 6 lines of thought: - strengthen coordination between institutional actors in order to ensure the consistency of the requests addressed to the facilities and limit their

Gap Analysis Approach for Construction Safety Program Improvement

Directory of Open Access Journals (Sweden)

Thanet Aksorn

2007-06-01

Full Text Available To improve construction site safety, emphasis has been placed on the implementation of safety programs. In order to successfully gain from safety programs, factors that affect their improvement need to be studied. Sixteen critical success factors of safety programs were identified from safety literature, and these were validated by safety experts. This study was undertaken by surveying 70 respondents from medium- and large-scale construction projects. It explored the importance and the actual status of critical success factors (CSFs. Gap analysis was used to examine the differences between the importance of these CSFs and their actual status. This study found that the most critical problems characterized by the largest gaps were management support, appropriate supervision, sufficient resource allocation, teamwork, and effective enforcement. Raising these priority factors to satisfactory levels would lead to successful safety programs, thereby minimizing accidents.

Measuring and improving patient safety through health information technology: The Health IT Safety Framework.

Science.gov (United States)

Singh, Hardeep; Sittig, Dean F

2016-04-01

Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety

ELECTRICAL SAFETY IMPROVEMENT PROJECT A COMPLEX WIDE TEAMING INITIATIVE

Energy Technology Data Exchange (ETDEWEB)

GRAY BJ

2007-11-26

This paper describes the results of a year-long project, sponsored by the Energy Facility Contractors Group (EFCOG) and designed to improve overall electrical safety performance throughout Department of Energy (DOE)-owned sites and laboratories. As evidenced by focused metrics, the Project was successful primarily due to the joint commitment of contractor and DOE electrical safety experts, as well as significant support from DOE and contractor senior management. The effort was managed by an assigned project manager, using classical project-management principles that included execution of key deliverables and regular status reports to the Project sponsor. At the conclusion of the Project, the DOE not only realized measurable improvement in the safety of their workers, but also had access to valuable resources that will enable them to do the following: evaluate and improve electrical safety programs; analyze and trend electrical safety events; increase electrical safety awareness for both electrical and non-electrical workers; and participate in ongoing processes dedicated to continued improvement.

Improving nuclear safety of VVER-440 units

International Nuclear Information System (INIS)

Nochev, T.; Sabinov, S.

2001-01-01

In this paper authors deals with improvement of nuclear safety of WWER-440 units in Kozloduy NPP. Main directions for improving nuclear safety of WWER-440 units were: - to expand number of the design accident; - to increase reliability of equipment important for the safety; - to decrease the probability of initiating events; - improvements the integrity of the primary circuit (application LBB concept, qualification of the pressure safety valves to avoid pressurized thermal shock); - improvement of the fire protection; - improvement of the operation including upgrading and improvement of operational documents, implementation of new system for training the operators and etc.; - reassessment of the seismic response of the plant. Main actions were made at NPP Kozloduy to increase nuclear safety of VVER-440 units. 1. Modernization of Emergency High Pressure Safety Injection System. The modernization includes dividing of independent channels with reservation of active elements. Pumps were exchanged with more effective and reliable ones. HPSIS was increased reliability in general through decrease number of active elements and exchanged with passive. 2. For the purpose of avoiding fast cooling at the primary circuit and obtaining thermal shock of reactor vessel, Main Safety Insulation Valves are installed at NPP Kozloduy. 3. Modernization of Emergency power supplies AC. Oil breakers VMP-10 are exchanged with gas FS-4. 4. Generator breakers are installed to decrease probability of loss power supply and blackout. They provide reliable power supply to the system important for the safety in case of failure on generator. 5. I and C system has been qualified and optimized. 6. Reassessments of Limiting Conditions of Operation and new scram signals have been introduced. 7. An operators-oriented Informational System has been developed. It includes ensuring and updating of equipment data, new informational support of operator and etc. 8. A new auxiliary independent system for

Leadership Actions to Improve Nuclear Safety Culture

International Nuclear Information System (INIS)

Clewett, L.K.

2016-01-01

The challenge many leaders face is how to effectively implement and then utilise the results of Safety Culture surveys. Bruce Power has recently successfully implemented changes to the Safety Culture survey process including how corrective actions were identified and implemented. The actions taken in response to the latest survey have proven effective with step change performance noted. Nuclear Safety is a core value for Bruce Power. Nuclear Safety at Bruce Power is based on the following four pillars: reactor safety, industrial safety, radiological safety and environmental safety. Processes and practices are in place to achieve a healthy Nuclear Safety Culture within Bruce Power such that nuclear safety is the overriding priority. This governance is based on industry leading practices which monitor, asses and take action to drive continual improvements in the Nuclear Safety Culture within Bruce Power.

A dramatic, objective antiandrogen withdrawal response: case report and review of the literature

Directory of Open Access Journals (Sweden)

Litwin Alan

2008-11-01

Full Text Available Abstract Antiandrogen withdrawal response is an increasingly recognized entity in patients with metastatic prostate cancer. To our knowledge, there have been no reports describing a durable radiologic improvement along with prostate-specific antigen (PSA with discontinuation of the antiandrogen agent bicalutamide. We report a case in which a dramatic decline of serum PSA levels associated with a dramatic improvement in radiologic disease was achieved with bicalutamide discontinuation.

PROPOSAL OF VOIVODESHIP ROAD SAFETY IMPROVEMENT PROGRAMME

OpenAIRE

Tomasz SZCZURASZEK; Jan KEMPA

2016-01-01

The article presents a proposal of the ‘GAMBIT KUJAWSKO-POMORSKI’ Road Safety Improvement Programme. The main idea of the Programme is to establish and initiate systems that will be responsible for the most important areas of activity within road safety, including road safety control, supervision, and management systems in the whole Voivodeship. In total, the creation and start of nine such systems has been proposed, namely: the Road Safety Management, the Integrated Road Rescue Service, the ...

Improving Employees' Safety Awareness in Healthcare Organizations Using the DMAIC Quality Improvement Approach.

Science.gov (United States)

Momani, Amer; Hirzallah, Muʼath; Mumani, Ahmad

Occupational injuries and illnesses in healthcare can cause great human suffering, incur high cost, and have an adverse impact on the quality of patient care. One of the most effective solutions for addressing health and safety issues and improving decisions at the point of care rests in raising employees' safety awareness to recognize, avoid, or respond to potential problems before they arise. In this article, the DMAIC Six Sigma model (Define, Measure, Analyze, Improve, Control) is used as a systematic program to measure, improve, and sustain employees' safety awareness in healthcare organizations. We report on a case study using the model, which was implemented and validated at a local hospital. First, the occupational health and safety knowledge that each job requires was identified. Next, the degree of competence of jobholders to meet these requirements was assessed. Based on the assessment, different awareness-raising efforts were proposed and implemented. The results showed significant improvement in the overall safety awareness compliance assessed: from 74.2% to 84.4% (p < .001) after the intervention. The proposed model ensures that the organization's awareness-raising efforts serve its actual needs and produce optimized and sustained results that eventually lead to safer healthcare service.

Improving the safety of LWR power plants. Final report

International Nuclear Information System (INIS)

1980-04-01

This report documents the results of the Study to identify current, potential research issues and efforts for improving the safety of Light Water Reactor (LWR) power plants. This final report describes the work accomplished, the results obtained, the problem areas, and the recommended solutions. Specifically, for each of the issues identified in this report for improving the safety of LWR power plants, a description is provided in detail of the safety significance, the current status (including information sources, status of technical knowledge, problem solution and current activities), and the suggestions for further research and development. Further, the issues are ranked for action into high, medium, and low priority with respect to primarily (a) improved safety (e.g. potential reduction in public risk and occupational exposure), and secondly (b) reduction in safety-related costs

Health IT for Patient Safety and Improving the Safety of Health IT.

Science.gov (United States)

Magrabi, Farah; Ong, Mei-Sing; Coiera, Enrico

2016-01-01

Alongside their benefits health IT applications can pose new risks to patient safety. Problems with IT have been linked to many different types of clinical errors including prescribing and administration of medications; as well as wrong-patient, wrong-site errors, and delays in procedures. There is also growing concern about the risks of data breach and cyber-security. IT-related clinical errors have their origins in processes undertaken to design, build, implement and use software systems in a broader sociotechnical context. Safety can be improved with greater standardization of clinical software and by improving the quality of processes at different points in the technology life cycle, spanning design, build, implementation and use in clinical settings. Oversight processes can be set up at a regional or national level to ensure that clinical software systems meet specific standards. Certification and regulation are two mechanisms to improve oversight. In the absence of clear standards, guidelines are useful to promote safe design and implementation practices. Processes to identify and mitigate hazards can be formalised via a safety management system. Minimizing new patient safety risks is critical to realizing the benefits of IT.

Steam Pressure-Reducing Station Safety and Energy Efficiency Improvement Project

Energy Technology Data Exchange (ETDEWEB)

Lower, Mark D [ORNL; Christopher, Timothy W [ORNL; Oland, C Barry [ORNL

2011-06-01

The Facilities and Operations (F&O) Directorate is sponsoring a continuous process improvement (CPI) program. Its purpose is to stimulate, promote, and sustain a culture of improvement throughout all levels of the organization. The CPI program ensures that a scientific and repeatable process exists for improving the delivery of F&O products and services in support of Oak Ridge National Laboratory (ORNL) Management Systems. Strategic objectives of the CPI program include achieving excellence in laboratory operations in the areas of safety, health, and the environment. Identifying and promoting opportunities for achieving the following critical outcomes are important business goals of the CPI program: improved safety performance; process focused on consumer needs; modern and secure campus; flexibility to respond to changing laboratory needs; bench strength for the future; and elimination of legacy issues. The Steam Pressure-Reducing Station (SPRS) Safety and Energy Efficiency Improvement Project, which is under the CPI program, focuses on maintaining and upgrading SPRSs that are part of the ORNL steam distribution network. This steam pipe network transports steam produced at the ORNL steam plant to many buildings in the main campus site. The SPRS Safety and Energy Efficiency Improvement Project promotes excellence in laboratory operations by (1) improving personnel safety, (2) decreasing fuel consumption through improved steam system energy efficiency, and (3) achieving compliance with applicable worker health and safety requirements. The SPRS Safety and Energy Efficiency Improvement Project being performed by F&O is helping ORNL improve both energy efficiency and worker safety by modifying, maintaining, and repairing SPRSs. Since work began in 2006, numerous energy-wasting steam leaks have been eliminated, heat losses from uninsulated steam pipe surfaces have been reduced, and deficient pressure retaining components have been replaced. These improvements helped ORNL

THE FLUORBOARD A STATISTICALLY BASED DASHBOARD METHOD FOR IMPROVING SAFETY

International Nuclear Information System (INIS)

PREVETTE, S.S.

2005-01-01

The FluorBoard is a statistically based dashboard method for improving safety. Fluor Hanford has achieved significant safety improvements--including more than a 80% reduction in OSHA cases per 200,000 hours, during its work at the US Department of Energy's Hanford Site in Washington state. The massive project on the former nuclear materials production site is considered one of the largest environmental cleanup projects in the world. Fluor Hanford's safety improvements were achieved by a committed partnering of workers, managers, and statistical methodology. Safety achievements at the site have been due to a systematic approach to safety. This includes excellent cooperation between the field workers, the safety professionals, and management through OSHA Voluntary Protection Program principles. Fluor corporate values are centered around safety, and safety excellence is important for every manager in every project. In addition, Fluor Hanford has utilized a rigorous approach to using its safety statistics, based upon Dr. Shewhart's control charts, and Dr. Deming's management and quality methods

Use of microsecond current prepulse for dramatic improvements of wire array Z-pinch implosion

International Nuclear Information System (INIS)

Calamy, H.; Lassalle, F.; Loyen, A.; Zucchini, F.; Chittenden, J. P.; Hamann, F.; Maury, P.; Georges, A.; Bedoch, J. P.; Morell, A.

2008-01-01

The Sphinx machine [F. Lassalle et al., 'Status on the SPHINX machine based on the 1microsecond LTD technology'] based on microsecond linear transformer driver (LTD) technology is used to implode an aluminium wire array with an outer diameter up to 140 mm and maximum current from 3.5 to 5 MA. 700 to 800 ns implosion Z-pinch experiments are performed on this driver essentially with aluminium. Best results obtained before the improvement described in this paper were 1-3 TW radial total power, 100-300 kJ total yield, and 20-30 kJ energy above 1 keV. An auxiliary generator was added to the Sphinx machine in order to allow a multi microsecond current to be injected through the wire array load before the start of the main current. Amplitude and duration of this current prepulse are adjustable, with maxima ∼10 kA and 50 μs. This prepulse dramatically changes the ablation phase leading to an improvement of the axial homogeneity of both the implosion and the final radiating column. Total power was multiplied by a factor of 6, total yield by a factor of 2.5 with a reproducible behavior. This paper presents experimental results, magnetohydrodynamic simulations, and analysis of the effect of such a long current prepulse

A word from the DG: Improved safety at CERN

CERN Multimedia

2006-01-01

One of the important objectives of my term of office is improving safety at CERN. My consideration of safety issues over the last few months, in conjunction with the Safety Commission and the Heads of Department, has led me to define a new approach for the implementation of safety policy at CERN. It is not a question of changing the safety policy and the basic safety rules laid down in document 'Safety Policy at CERN' (SAPOCO 42) but, rather, of improving the way they are applied by clarifying the roles of everyone concerned. The existing safety policy and rules have yet to be fully implemented. Some people continue to think, for example, that safety implementation only concerns the Safety Commission (SC). In reality, as SAPOCO 42 clearly specifies, safety is the responsibility of each and every individual. This means that each person in charge of a task is also responsible for guaranteeing its safe completion by implementing all the necessary measures. To enhance the awareness of this responsibility and t...

NPP Temelin. Status of safety improvements

International Nuclear Information System (INIS)

1999-01-01

The WWER-1000 Temelin NPP under construction has been subjected as other NPPs of the same type to numerous project reviews resulting in quite a number of recommendations for design changes. Results of the IAEA mission to review the resolution of WWER-1000 safety issues at Temelin NPP are cited in this paper. The main conclusions emphasize that a combination of eastern and western technology and practices led to safety improvements in comparison with the international practices. Plant managers are clearly committed to implementation of operational programs which are consistent with effective western operational safety practices. Considerable effort remains to bring planned programs to successful implementation, in particular in meeting the need to foster strong safety culture among all personnel

Recipe Modification Improves Food Safety Practices during Cooking of Poultry.

Science.gov (United States)

Maughan, Curtis; Godwin, Sandria; Chambers, Delores; Chambers, Edgar

2016-08-01

Many consumers do not practice proper food safety behaviors when preparing food in the home. Several approaches have been taken to improve food safety behaviors among consumers, but there still is a deficit in actual practice of these behaviors. The objective of this study was to assess whether the introduction of food safety instructions in recipes for chicken breasts and ground turkey patties would improve consumers' food safety behaviors during preparation. In total, 155 consumers in two locations (Manhattan, KS, and Nashville, TN) were asked to prepare a baked chicken breast and a ground turkey patty following recipes that either did or did not contain food safety instructions. They were observed to track hand washing and thermometer use. Participants who received recipes with food safety instructions (n = 73) demonstrated significantly improved food safety preparation behaviors compared with those who did not have food safety instructions in the recipe (n = 82). In addition, the majority of consumers stated that they thought the recipes with instructions were easy to use and that they would be likely to use similar recipes at home. This study demonstrates that recipes could be a good source of food safety information for consumers and that they have the potential to improve behaviors to reduce foodborne illness.

Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.

Science.gov (United States)

Singer, Sara J; Rosen, Amy; Zhao, Shibei; Ciavarelli, Anthony P; Gaba, David M

2010-01-01

Evidence of variation in safety climate suggests the need for improvement among at least some hospitals. However, comparisons only among hospitals may underestimate the improvement required. Comparison of hospitals with analogous industries may provide a broader perspective on the safety status of our nation's hospitals. The purpose of this study was to compare safety climate among hospital workers with personnel from naval aviation, an organization that operates with high reliability despite intrinsically hazardous conditions. We surveyed a random sample of health care workers in 67 U.S. hospitals and, for generalizability, 30 veterans affairs hospitals using questions comparable with those posed at approximately the same time (2007) to a census of personnel from 35 squadrons of U.S. naval aviators. We received 13,841 (41%) completed surveys in U.S. hospitals, 5,511 (50%) in veterans affairs hospitals, and 14,854 (82%) among naval aviators. We examined differences in respondents' perceptions of safety climate at their institution overall and for 16 individual items. Safety climate was three times better on average among naval aviators than among hospital personnel. Naval aviators perceived a safer climate (up to seven times safer) than hospital personnel with respect to each of the 16 survey items. Compared with hospital managers, naval commanders perceived climate more like frontline personnel did. When contrasting naval aviators with hospital personnel working in comparably hazardous areas, safety climate discrepancies increased rather than decreased. One individual hospital performed as well as naval aviation on average, and at least one hospital outperformed the Navy benchmark for all but three individual survey items. Results suggest that hospitals have not sufficiently created a uniform priority of safety. However, if each hospital performed as well as the top-performing hospital in each area measured, hospitals could achieve safety climate levels comparable

Dramatically improve the Safety Performance of Li ion Battery Separators and Reduce the Manufacturing Cost Using Ultraviolet Curing and High Precision Coating Technologies

Energy Technology Data Exchange (ETDEWEB)

Voelker, Gary [Miltec UV International, LLC, Stevensville, MD (United States); Arnold, John [Miltec UV International, LLC, Stevensville, MD (United States)

2017-06-30

The objective of this project was to improve the safety of operation of Lithium ion batteries (LIB)and at the same time significantly reduce the manufacturing cost of LIB separators. The project was very successful in demonstrating the improved performance and reduced cost attributed to using UV curable binder and high speed printing technology to place a very thin and precisely controlled ceramic layer on the surface of base separators made of polyolefins such as Polyethylene, Polypropylene and combinations of the two as well as cellulosic base separators. The underlying need for this new technology is the recently identified potential of fire in large format Lithium ion batteries used in hybrid, plug-in hybrid and electric vehicles. The primary potential cause of battery fire is thermal runaway caused by several different electrical or mechanical mechanisms; such as, overcharge, puncture, overheating, compaction, and internal short circuit. During thermal runaway, the ideal separator prevents ion flow and continues to physically separate the anode from the cathode. If the temperature of the battery gets higher, the separator may melt and partially clog the pores and help prevent ion flows but it also can shrink which can result in physical contact of the electrodes and accelerate thermal run-away even further. Ceramic coated separators eliminate many of the problems related to the usage of traditional separators. The ceramic coating provides an electrically insulating layer that retains its physical integrity at high temperature, allows for more efficient thermal heat transfer, helps reduce thermal shrinkage, and inhibits dendrite growth that could create a potential short circuit. The use of Ultraviolet (UV) chemistry to bind fine ceramic particles on separators is a unique and innovative approach primarily because of the instant curing of the UV curable binder upon exposure to UV light. This significant reduction in drying/curing time significantly reduces the

To improve the safety of treatments in radiotherapy by developing a safety culture

International Nuclear Information System (INIS)

2008-01-01

Following the radiotherapy accidents between 2004 and 2006, the I.R.S.N. deemed necessary to lead a study on the safety of treatments in radiotherapy and on the use and the adaptation to the medical domain of safety analysis approach developed for the nuclear installations. Of this study, six mains lines of investigation appear: Endow the radiotherapy services with real referential of safety, reinforce the robustness of the organization of radiotherapy services, improve the safety of the equipment and software at the design and operating stages, improve the management of the expertise and reinforce the operating feed back on incidents and accidents. The main learning from this study is the benefit that could be gained by fitting the safety analysis concepts and methods to the specificities of radiotherapy considering the organization of it collective work, the cooperation between actors stemming from different jobs as well as the interactions between actors and technical systems in the process of the treatments, when they are put into service and during their periodic checks. (author)

Experience of safety and performance improvement for fuel handling equipment

International Nuclear Information System (INIS)

Gyoon Chang, Sang; Hee Lee, Dae

2014-01-01

The purpose of this study is to provide experience of safety and performance improvement of fuel handling equipment for nuclear power plants in Korea. The fuel handling equipment, which is used as an important part of critical processes during the refueling outage, has been improved to enhance safety and to optimize fuel handling procedures. Results of data measured during the fuel reloading are incorporated into design changes. The safety and performance improvement for fuel handling equipment could be achieved by simply modifying the components and improving the interlock system. The experience provided in this study can be useful lessons for further improvement of the fuel handling equipment. (authors)

Improvement of Managers’ Safety Knowledge through Scientifically Reasonable Interviews

Directory of Open Access Journals (Sweden)

Paas Õnnela

2015-11-01

Full Text Available The safety management system has been analysed in 16 Estonian enterprises using the MISHA method (Method for Industrial Safety and Health Activity Assessment. The factor analysis (principal component analysis and varimax with Kaiser analysis has been implemented for the interpretation of the results on safety performance at the enterprises implementing OHSAS 18001 and the ones that do not implement OHSAS 18001. The division of the safety areas into four parts for a better understanding of the safety level and its improvement possibilities has been proven through the statistical analysis. The connections between the questions aimed to clarify the safety level and performance at the enterprises have been set based on the statistics. New learning package “training through the questionnaires” has been worked out in the current paper for the top and middle-level managers to improve their safety knowledge, where the MISHA questionnaire has been taken as the basis.

Operational safety improvement in OPR 1000

International Nuclear Information System (INIS)

Jung, Y.-E.

2005-01-01

Nuclear power operating experience management might be an important factor for the operational safety improvement. KHNP's nuclear information management system, called KONIS receives, distributes and manages all nuclear information from domestic and foreign, especially operating experience. Ulchin 3 and 4, the first units of OPR 1000 series operates several organizations regarding management of operating experience e.g. specialist group program, various task forces, equipment specialist system for operator, etc. Peer review is another contribution for nuclear safety. (author)

Organizational factors influencing improvements in safety

International Nuclear Information System (INIS)

Marcus, A.; Nichols, M.L.; Olson, J.; Osborn, R.; Thurber, J.

1992-01-01

Research reported here seeks to identify the key organizational factors that influence safety-related performance indicators in nuclear power plants over time. It builds upon organizational factors identified in NUREG/CR-5437, and begins to develop a theory of safety-related performance and performance improvement based on economic and behavioral theories of the firm. Central to the theory are concepts of past performance, problem recognition, resource availability, resource allocation, and business strategies that focus attention. Variables which reflect those concepts are combined in statistical models and tested for their ability to explain scrams, safety system actuations, significant events, safety system failures, radiation exposure, and critical hours. Results show the performance indicators differ with respect to the sets of variables which serve as the best predictors of future performance, and past performance is the most consistent predictor of future performance

Can we improve patient safety?

Science.gov (United States)

Corbally, Martin Thomas

2014-01-01

Despite greater awareness of patient safety issues especially in the operating room and the widespread implementation of surgical time out World Health Organization (WHO), errors, especially wrong site surgery, continue. Most such errors are due to lapses in communication where decision makers fail to consult or confirm operative findings but worryingly where parental concerns over the planned procedure are ignored or not followed through. The WHO Surgical Pause/Time Out aims to capture these errors and prevent them, but the combination of human error and complex hospital environments can overwhelm even robust safety structures and simple common sense. Parents are the ultimate repository of information on their child's condition and planned surgery but are traditionally excluded from the process of Surgical Pause and Time Out, perhaps to avoid additional stress. In addition, surgeons, like pilots, are subject to the phenomenon of "plan-continue-fail" with potentially disastrous outcomes. If we wish to improve patient safety during surgery and avoid wrong site errors then we must include parents in the Surgical Pause/Time Out. A recent pilot study has shown that neither staff nor parents found it added to their stress, but, moreover, 100% of parents considered that it should be a mandatory component of the Surgical Pause nor does it add to the stress of surgery. Surgeons should be required to confirm that the planned procedure is in keeping with the operative findings especially in extirpative surgery and this "step back" should be incorporated into the standard Surgical Pause. It is clear that we must improve patient safety further and these simple measures should add to that potential.

Applying principles from safety science to improve child protection.

Science.gov (United States)

Cull, Michael J; Rzepnicki, Tina L; O'Day, Kathryn; Epstein, Richard A

2013-01-01

Child Protective Services Agencies (CPSAs) share many characteristics with other organizations operating in high-risk, high-profile industries. Over the past 50 years, industries as diverse as aviation, nuclear power, and healthcare have applied principles from safety science to improve practice. The current paper describes the rationale, characteristics, and challenges of applying concepts from the safety culture literature to CPSAs. Preliminary efforts to apply key principles aimed at improving child safety and well-being in two states are also presented.

Dramatic weight loss associated with commencing clozapine

OpenAIRE

Lally, John; McDonald, Colm

2011-01-01

The authors report the case of a 44-year-old man with a long history of chronic enduring schizophrenia who experienced dramatic weight loss after commencing treatment with clozapine, an antipsychotic medication characteristically associated with the greatest degree of weight gain among medical treatments for schizophrenia. He was obese with a body mass index (BMI) of 41.5 kg/m2, but after commencing clozapine therapy he experienced an improvement in psychotic symptoms and 40% loss of his body...

Improving patient safety in radiology: a work in progress

International Nuclear Information System (INIS)

Sze, Raymond W.

2008-01-01

The purpose of this paper is to share the experiences, including successes and failures, as well as the ongoing process of developing and implementing a safety program in a large pediatric radiology department. Building a multidisciplinary pediatric radiology safety team requires successful recruitment of team members, selection of a team leader, and proper and ongoing training and tools, and protected time. Challenges, including thorough examples, are presented on improving pediatric radiology safety intradepartmentally, interdepartmentally, and institutionally. Finally, some major challenges to improving safety in pediatric radiology, and healthcare in general, are presented along with strategies to overcome these challenges. Our safety program is a work in progress; this article is a personal account and the reader is asked for tolerance of its occasional subjective tone and contents. (orig.)

The role of individual diligence in improving safety.

Science.gov (United States)

Corbett, Angus; Travaglia, Jo; Braithwaite, Jeffrey

2011-01-01

This paper aims to be a theoretical examination of the role of individuals in sponsoring and facilitating effective, systemic change in organisations. Using reports of a number of high-profile initiatives to improve patient safety, it seeks to analyse the role of individual health care professionals in developing and facilitating new systems of care that improve safety and quality. The paper uses recent work in sociology that is concerned with the phenomenon of "sociological citizenship". The authors test whether successful initiators of change in health care can be described as sociological citizens. This notion of sociological citizens is applied to a number of highly successful initiatives to improve safety and quality to extrapolate the factors associated with individual clinician leadership, which may have affected the success of such endeavours. In each of the examples analysed the initiators of change can be characterised as sociological citizens. In reviewing the roles of these charismatic individuals it is evident that they see the relational interdependence between the individuals and organisations and that they use this information to achieve both professional and organisational objectives. The paper uses a case study method to investigate the usefulness of the role of sociological citizenship in interventions that aim to improve patient safety. The paper reviews the key concepts and uses of the concept of sociological citizenship to produce a framework against which the case studies were assessed. The authors suggest that a goal of policy for improving patient safety should be directed to the problem of how hospitals and health care organisations can create the conditions for encouraging the individual diligence and care that is needed to support reliable, safe health care practices. Improving the safety and quality of health care is an important public health initiative. It has also proven to be difficult to achieve sustained reductions in the harm

Patient handover in orthopaedics, improving safety using Information Technology.

Science.gov (United States)

Pearkes, Tim

2015-01-01

Good inpatient handover ensures patient safety and continuity of care. An adjunct to this is the patient list which is routinely managed by junior doctors. These lists are routinely created and managed within Microsoft Excel or Word. Following the merger of two orthopaedic departments into a single service in a new hospital, it was felt that a number of safety issues within the handover process needed to be addressed. This quality improvement project addressed these issues through the creation and implementation of a new patient database which spanned the department, allowing trouble free, safe, and comprehensive handover. Feedback demonstrated an improved user experience, greater reliability, continuity within the lists and a subsequent improvement in patient safety.

Safety improvement and results of commissioning of Mochovce NPP WWER 440/213

International Nuclear Information System (INIS)

Lipar, M.

1998-01-01

Mochovce NPP is the last one of this kind and compared to its predecessors, it is characterized by several modifications which contribute to the improvement of the safety level. In addition based on Nuclear Regulatory Authority requirements and based on documents: - IAEA - Safety Issues and their ranking for NPP WWER 440/213, - IAEA - Safety Improvement of Mochovce NPP Project Review Mission, - Riskaudit - Evaluation of the Mochovce NPP Safety Improvements. Additional safety measures have been implemented before commissioning. The consortium EUCOM (FRAMATOME - SIEMENS), SKODA Praha, ENERGOPROJEKT Praha, Russian organizations and VUJE Trnava Nuclear Power Plants research institute were selected for design and implementation of the safety measures. The papers summarized, safety requirements, safety measures implemented, results of commissioning and results of safety analysis report evaluation. (author)

Improving staff perception of a safety climate with crew resource management training.

Science.gov (United States)

Kuy, SreyRam; Romero, Ramon A L

2017-06-01

Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate. Published by Elsevier Inc.

Use of a Surgical Safety Checklist to Improve Team Communication.

Science.gov (United States)

Cabral, Richard A; Eggenberger, Terry; Keller, Kathryn; Gallison, Barry S; Newman, David

2016-09-01

To improve surgical team communication, a team at Broward Health Imperial Point Hospital, Ft Lauderdale, Florida, implemented a program for process improvement using a locally adapted World Health Organization Surgical Safety Checklist. This program included a standardized, comprehensive time out and a briefing/debriefing process. Postimplementation responses to the Safety Attitudes Questionnaire revealed a significant increase in the surgical team's perception of communication compared with that reported on the pretest (6% improvement resulting in t79 = -1.72, P improved surgical teamwork behaviors and an enhanced culture of safety in the OR. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Using game theory to improve safety within chemical industrial parks

CERN Document Server

Reniers, Genserik

2013-01-01

Though the game-theoretic approach has been vastly studied and utilized in relation to economics of industrial organizations, it has hardly been used to tackle safety management in multi-plant chemical industrial settings. Using Game Theory for Improving Safety within Chemical Industrial Parks presents an in-depth discussion of game-theoretic modelling which may be applied to improve cross-company prevention and -safety management in a chemical industrial park.   By systematically analyzing game-theoretic models and approaches in relation to managing safety in chemical industrial parks, Using Game Theory for Improving Safety within Chemical Industrial Parks explores the ways game theory can predict the outcome of complex strategic investment decision making processes involving several adjacent chemical plants. A number of game-theoretic decision models are discussed to provide strategic tools for decision-making situations.   Offering clear and straightforward explanations of methodologies, Using Game Theor...

How to improve safety of laparoscopic cholecystectomy

Directory of Open Access Journals (Sweden)

ZHANG Yong

2013-06-01

Full Text Available Laparoscopic cholecystectomy (LC has become the "gold standard" of treatment for benign gallbladder disease. This paper summarizes various surgical safety measures used in recent years, and suggests an emphasis on perioperative imaging examination, preoperative prevention of risk factors, training of surgical skills, and introduction of fast-track surgery concept, so as to avoid the incidence of complications and improve the safety of LC.

Improving patient safety through quality assurance.

Science.gov (United States)

Raab, Stephen S

2006-05-01

Anatomic pathology laboratories use several quality assurance tools to detect errors and to improve patient safety. To review some of the anatomic pathology laboratory patient safety quality assurance practices. Different standards and measures in anatomic pathology quality assurance and patient safety were reviewed. Frequency of anatomic pathology laboratory error, variability in the use of specific quality assurance practices, and use of data for error reduction initiatives. Anatomic pathology error frequencies vary according to the detection method used. Based on secondary review, a College of American Pathologists Q-Probes study showed that the mean laboratory error frequency was 6.7%. A College of American Pathologists Q-Tracks study measuring frozen section discrepancy found that laboratories improved the longer they monitored and shared data. There is a lack of standardization across laboratories even for governmentally mandated quality assurance practices, such as cytologic-histologic correlation. The National Institutes of Health funded a consortium of laboratories to benchmark laboratory error frequencies, perform root cause analysis, and design error reduction initiatives, using quality assurance data. Based on the cytologic-histologic correlation process, these laboratories found an aggregate nongynecologic error frequency of 10.8%. Based on gynecologic error data, the laboratory at my institution used Toyota production system processes to lower gynecologic error frequencies and to improve Papanicolaou test metrics. Laboratory quality assurance practices have been used to track error rates, and laboratories are starting to use these data for error reduction initiatives.

La dramatúrgia docent

OpenAIRE

Comelles, Salvador

2009-01-01

La vida és un teatre. Una dita que lluny de semblar despectiva, resumeix la realitat humana diària. Perquè la vida és dramatúrgia. Un concepte menys agressiu que evoca les diferents situacions comunicatives que les persones enfronten al llarg de la seva vida per tal de complir els seus objectius. I ho fan assumint rols i actituds que una situació concreta requereix, com ara, la vida del docent i l’àmbit professional i social on es desenvolupa. Identificar l’ombra dramatúrgica que és desprèn d...

Alternative off-site power supply improves nuclear power plant safety

International Nuclear Information System (INIS)

Gjorgiev, Blaže; Volkanovski, Andrija; Kančev, Duško; Čepin, Marko

2014-01-01

Highlights: • Additional power supply for mitigation of the station blackout event in NPP is used. • A hydro power plant is considered as an off-site alternative power supply. • An upgrade of the probabilistic safety assessment from its traditional use is made. • The obtained results show improvement of nuclear power plant safety. - Abstract: A reliable power system is important for safe operation of the nuclear power plants. The station blackout event is of great importance for nuclear power plant safety. This event is caused by the loss of all alternating current power supply to the safety and non-safety buses of the nuclear power plant. In this study an independent electrical connection between a pumped-storage hydro power plant and a nuclear power plant is assumed as a standpoint for safety and reliability analysis. The pumped-storage hydro power plant is considered as an alternative power supply. The connection with conventional accumulation type of hydro power plant is analysed in addition. The objective of this paper is to investigate the improvement of nuclear power plant safety resulting from the consideration of the alternative power supplies. The safety of the nuclear power plant is analysed through the core damage frequency, a risk measure assess by the probabilistic safety assessment. The presented method upgrades the probabilistic safety assessment from its common traditional use in sense that it considers non-plant sited systems. The obtained results show significant decrease of the core damage frequency, indicating improvement of nuclear safety if hydro power plant is introduced as an alternative off-site power source

Improving health care quality and safety: the role of collective learning.

Science.gov (United States)

Singer, Sara J; Benzer, Justin K; Hamdan, Sami U

2015-01-01

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through

Socio-Dramatic Affective-Relational Intervention for Adolescents with Asperger Syndrome & High Functioning Autism: Pilot Study

Science.gov (United States)

Lerner, Matthew D.; Mikami, Amori Yee; Levine, Karen

2011-01-01

This study examined the effectiveness of a novel intervention called "socio-dramatic affective-relational intervention" (SDARI), intended to improve social skills among adolescents with Asperger syndrome and high functioning autism diagnoses. SDARI adapts dramatic training activities to focus on in vivo practice of areas of social skill…

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

DEFF Research Database (Denmark)

Kristensen, Solvejg; Mainz, Jan; Bartels, Paul

2009-01-01

such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas. CONCLUSION: The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators...... for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety....

Improving patient safety in Libya: insights from a British health system perspective.

Science.gov (United States)

Elmontsri, Mustafa; Almashrafi, Ahmed; Dubois, Elizabeth; Banarsee, Ricky; Majeed, Azeem

2018-04-16

Purpose Patient safety programmes aim to make healthcare safe for both patients and health professionals. The purpose of this paper is to explore the UK's patient safety improvement programmes over the past 15 years and explore what lessons can be learnt to improve Libyan healthcare patient safety. Design/methodology/approach Publications focusing on UK patient safety were searched in academic databases and content analysed. Findings Several initiatives have been undertaken over the past 15 years to improve British healthcare patient safety. Many stakeholders are involved, including regulatory and professional bodies, educational providers and non-governmental organisations. Lessons can be learnt from the British journey. Practical implications Developing a national patient safety strategy for Libya, which reflects context and needs is paramount. Above all, Libyan patient safety programmes should reference internationally approved guidelines, evidence, policy and learning from Britain's unique experience. Originality/value This review examines patient safety improvement strategies adopted in Britain to help developing country managers to progress local strategies based on lessons learnt from Britain's unique experience.

Modelling of safety barriers including human and organisational factors to improve process safety

DEFF Research Database (Denmark)

Markert, Frank; Duijm, Nijs Jan; Thommesen, Jacob

2013-01-01

It is believed that traditional safety management needs to be improved on the aspect of preparedness for coping with expected and unexpected deviations, avoiding an overly optimistic reliance on safety systems. Remembering recent major accidents, such as the Deep Water Horizon, the Texas City....... A valuable approach is the inclusion of human and organisational factors into the simulation of the reliability of the technical system using event trees and fault trees and the concept of safety barriers. This has been demonstrated e.g. in the former European research project ARAMIS (Accidental Risk...

Patient Education May Improve Perioperative Safety.

NARCIS (Netherlands)

de Haan, L.S.; Calsbeek, H; Wolff, André

2016-01-01

Importance: There is a growing interest in enabling ways for patients to participate in their own care to improve perioperative safety, but little is known about the effectiveness of interventions enhancing an active patient role. Objective: To evaluate the effect of patient participation on

Safety implications of standardized continuous quality improvement programs in community pharmacy.

Science.gov (United States)

Boyle, Todd A; Ho, Certina; Mackinnon, Neil J; Mahaffey, Thomas; Taylor, Jeffrey M

2013-06-01

Standardized continuous quality improvement (CQI) programs combine Web-based technologies and standardized improvement processes, tools, and expectations to enable quality-related events (QREs) occurring in individual pharmacies to be shared with pharmacies in other jurisdictions. Because standardized CQI programs are still new to community pharmacy, little is known about how they impact medication safety. This research identifies key aspects of medication safety that change as a result of implementing a standardized CQI program. Fifty-three community pharmacies in Nova Scotia, Canada, adopted the SafetyNET-Rx standardized CQI program in April 2010. The Institute for Safe Medication Practices (ISMP) Canada's Medication Safety Self-Assessment (MSSA) survey was administered to these pharmacies before and 1 year into their use of the SafetyNET-Rx program. The nonparametric Wilcoxon signed-rank test was used to explore where changes in patient safety occurred as a result of SafetyNETRx use. Significant improvements occurred with quality processes and risk management, staff competence, and education, and communication of drug orders and other information. Patient education, environmental factors, and the use of devices did not show statistically significant changes. As CQI programs are designed to share learning from QREs, it is reassuring to see that the largest improvements are related to quality processes, risk management, staff competence, and education.

[Improving patient safety through voluntary peer review].

Science.gov (United States)

Kluge, S; Bause, H

2015-01-01

The intensive care unit (ICU) is one area of the hospital in which processes and communication are of primary importance. Errors in intensive care units can lead to serious adverse events with significant consequences for patients. Therefore quality and risk-management are important measures when treating critically ill patients. A pragmatic approach to support quality and safety in intensive care is peer review. This approach has gained significant acceptance over the past years. It consists of mutual visits by colleagues who conduct standardised peer reviews. These reviews focus on the systematic evaluation of the quality of an ICU's structure, its processes and outcome. Together with different associations, the State Chambers of Physicians and the German Medical Association have developed peer review as a standardized tool for quality improvement. The common goal of all stakeholders is the continuous and sustainable improvement in intensive care with peer reviews significantly increasing and improving communication between professions and disciplines. Peer reviews secure the sustainability of planned change processes and consequently lead the way to an improved culture of quality and safety.

Quantifying the effectiveness of ITS in improving safety of VRUs

NARCIS (Netherlands)

Silla, A.; Rämä, P.; Leden, L.; Noort, M. van; Kruijff, J. de; Bell, D.; Morris, A.; Hancox, G.; Scholliers, J.

2017-01-01

This paper presents the results of a safety impact assessment, providing quantitative estimates of the safety impacts of ten intelligent transport systems (ITS) which were designed to improve safety, mobility and comfort of vulnerable road users (VRUs). The evaluation method originally developed to

PNRA: Practically Improving Safety Culture within the Regulatory Body

International Nuclear Information System (INIS)

Bhatti, S.A.N.; Habib, M.A.

2016-01-01

were carried out in order to prepare the organization for the cultural assessment activity. After completion of safety culture self assessment at PNRA, the communication strategy was defined to share outcome of this assessment in the organization with the focus on developing dialogue and shared understanding. The safety culture improvement activities were designed to maintain and enhance strong areas of safety culture at PNRA and to address those areas that need attention in order to enhance safety consciousness. This paper presents PNRA’s experience of using IAEA emerging methodology for safety culture self assessment, challenges faced during the process and lessons learnt for further improvement in order to implement it more effectively in future. The paper also highlights strategy utilised for conveying outcomes of SCSA in the organization at different levels along with safety culture improvement activities. (author)

Nuclear safety improvement activities related to WWER-440 units in Bulgaria

International Nuclear Information System (INIS)

Gantchev, T.

1998-01-01

The systematic evaluation of the deficiencies of the original design of the WWER reactors brought to the development of a Short Term Programme for Safety Upgrading and Modernisation of Kozloduy WWER-440 units. The implementation of this Programme was completed in 1997. The strive for continuos improvement of Kozloduy Nuclear Power Plant (NPP) safety level, the new requirements of the Bulgarian Nuclear Safety Authority and the public concern initiated the development of new Complex Programme for Safety Improvement (PRG'97), now in a process of implementation. (author)

Driving forces behind the Chinese public's demand for improved environmental safety.

Science.gov (United States)

Wen, Ting; Wang, Jigan; Ma, Zongwei; Bi, Jun

2017-12-15

Over the past decades, the public demand for improved environmental safety keeps increasing in China. This study aims to assess the driving forces behind the increasing public demand for improved environmental safety using a provincial and multi-year (1995, 2000, 2005, 2010, and 2014) panel data and the Stochastic Impacts by Regression on Population, Affluence, and Technology (STIRPAT) model. The potential driving forces investigated included population size, income levels, degrees of urbanization, and educational levels. Results show that population size and educational level are positively (Pdemand for improved environmental safety. No significant impact on demand was found due to the degree of urbanization. For the impact due to income level, an inverted U-shaped curve effect with the turning point of ~140,000 CNY GDP per capita is indicated. Since per capita GDP of 2015 in China was approximately 50,000 CNY and far from the turning point, the public demand for improved environmental safety will continue rising in the near future. To meet the increasing public demand for improved environmental safety, proactive and risk prevention based environmental management systems coupled with effective environmental risk communication should be established. Copyright © 2017 Elsevier B.V. All rights reserved.

A new system to reduce formaldehyde levels improves safety conditions during gross veterinary anatomy learning.

Science.gov (United States)

Nacher, Víctor; Llombart, Cristina; Carretero, Ana; Navarro, Marc; Ysern, Pere; Calero, Sebastián; Fígols, Enric; Ruberte, Jesús

2007-01-01

Dissection is a very useful method of learning veterinary anatomy. However, formaldehyde, which is widely used to preserve cadavers, is an irritant, and it has recently been classified as a carcinogen. In 1997, the Instituto Nacional de Seguridad e Higiene en el Trabajo [National Institute of Workplace Security and Hygiene] found that the levels of formaldehyde in our dissection room were above the threshold limit values. Unfortunately, no optimal substitute for formaldehyde is currently available. Therefore, we designed a new ventilation system that combines slow propulsion of fresh air from above the dissection table and rapid aspiration of polluted air from the perimeter. Formaldehyde measurements performed in 2004, after the introduction of this new system into our dissection laboratory, showed a dramatic reduction (about tenfold, or 0.03 ppm). A suitable propelling/aspirating air system successfully reduces the concentration of formaldehyde in the dissection room, significantly improving safety conditions for students, instructors, and technical staff during gross anatomy learning.

A Scholarly Pathway in Quality Improvement and Patient Safety.

Science.gov (United States)

Ferguson, Catherine C; Lamb, Geoffrey

2015-10-01

There are several challenges to teaching quality improvement (QI) and patient safety material to medical students, as successful programs should combine didactic and experiential teaching methods, integrate the material into the preclinical and clinical years, and tailor the material to the schools' existing curriculum. The authors describe the development, implementation, and assessment of the Quality Improvement and Patient Safety (QuIPS) Scholarly Pathway-a faculty-mentored, three-year experience for students interested in gaining exposure to QI and patient safety concepts at the Medical College of Wisconsin (MCW). The QuIPS pathway capitalized on the existing structure of scholarly pathways for MCW medical students, allowing QI and patient safety to be incorporated into the existing curriculum using didactic and experiential instruction and spanning preclinical and clinical education. Student reaction to the QuIPS pathway has been favorable. Preliminary data demonstrate that student knowledge as measured by the Quality Improvement Knowledge Assessment Tool significantly increased after the first year of implementation. A novel curriculum such as the QuIPS pathway provides an important opportunity to develop and test new assessment tools for curricula in systems-based practice and practice-based learning and improvement. The authors also hope that by bringing together local QI and patient safety experts and stakeholders during the curricular development process, they have laid the groundwork for the creation of a more pervasive curriculum that will reach all MCW students in the future. The model may be generalizable to other U.S. medical schools with scholarly pathways as well.

Improving patient safety in radiation oncology

International Nuclear Information System (INIS)

Hendee, William R.; Herman, Michael G.

2011-01-01

Beginning in the 1990s, and emphasized in 2000 with the release of an Institute of Medicine report, healthcare providers and institutions have dedicated time and resources to reducing errors that impact the safety and well-being of patients. But in January 2010 the first of a series of articles appeared in the New York Times that described errors in radiation oncology that grievously impacted patients. In response, the American Association of Physicists in Medicine and the American Society of Radiation Oncology sponsored a working meeting entitled ''Safety in Radiation Therapy: A Call to Action''. The meeting attracted 400 attendees, including medical physicists, radiation oncologists, medical dosimetrists, radiation therapists, hospital administrators, regulators, and representatives of equipment manufacturers. The meeting was cohosted by 14 organizations in the United States and Canada. The meeting yielded 20 recommendations that provide a pathway to reducing errors and improving patient safety in radiation therapy facilities everywhere.

Improved obstetric safety through programmatic collaboration.

Science.gov (United States)

Goffman, Dena; Brodman, Michael; Friedman, Arnold J; Minkoff, Howard; Merkatz, Irwin R

2014-01-01

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p Risk Management of the American Hospital Association.

Transportation Safety Excellence in Operations Through Improved Transportation Safety Document

International Nuclear Information System (INIS)

Dr. Michael A. Lehto; MAL

2007-01-01

A recent accomplishment of the Idaho National Laboratory (INL) Materials and Fuels Complex (MFC) Nuclear Safety analysis group was to obtain DOE-ID approval for the inter-facility transfer of greater-than-Hazard-Category-3 quantity radioactive/fissionable waste in Department of Transportation (DOT) Type A drums at MFC. This accomplishment supported excellence in operations through safety analysis by better integrating nuclear safety requirements with waste requirements in the Transportation Safety Document (TSD); reducing container and transport costs; and making facility operations more efficient. The MFC TSD governs and controls the inter-facility transfer of greater-than-Hazard-Category-3 radioactive and/or fissionable materials in non-DOT approved containers. Previously, the TSD did not include the capability to transfer payloads of greater-than-Hazard-Category-3 radioactive and/or fissionable materials using DOT Type A drums. Previous practice was to package the waste materials to less-than-Hazard-Category-3 quantities when loading DOT Type A drums for transfer out of facilities to reduce facility waste accumulations. This practice allowed operations to proceed, but resulted in drums being loaded to less than the Waste Isolation Pilot Plant (WIPP) waste acceptance criteria (WAC) waste limits, which was not cost effective or operations friendly. An improved and revised safety analysis was used to gain DOE-ID approval for adding this container configuration to the MFC TSD safety basis. In the process of obtaining approval of the revised safety basis, safety analysis practices were used effectively to directly support excellence in operations. Several factors contributed to the success of MFC's effort to obtain approval for the use of DOT Type A drums, including two practices that could help in future safety basis changes at other facilities. (1) The process of incorporating the DOT Type A drums into the TSD at MFC helped to better integrate nuclear safety

Speech Recognition Interfaces Improve Flight Safety

Science.gov (United States)

2013-01-01

"Alpha, Golf, November, Echo, Zulu." "Sierra, Alpha, Golf, Echo, Sierra." "Lima, Hotel, Yankee." It looks like some strange word game, but the combinations of words above actually communicate the first three points of a flight plan from Albany, New York to Florence, South Carolina. Spoken by air traffic controllers and pilots, the aviation industry s standard International Civil Aviation Organization phonetic alphabet uses words to represent letters. The first letter of each word in the series is combined to spell waypoints, or reference points, used in flight navigation. The first waypoint above is AGNEZ (alpha for A, golf for G, etc.). The second is SAGES, and the third is LHY. For pilots of general aviation aircraft, the traditional method of entering the letters of each waypoint into a GPS device is a time-consuming process. For each of the 16 waypoints required for the complete flight plan from Albany to Florence, the pilot uses a knob to scroll through each letter of the alphabet. It takes approximately 5 minutes of the pilot s focused attention to complete this particular plan. Entering such a long flight plan into a GPS can pose a safety hazard because it can take the pilot s attention from other critical tasks like scanning gauges or avoiding other aircraft. For more than five decades, NASA has supported research and development in aviation safety, including through its Vehicle Systems Safety Technology (VSST) program, which works to advance safer and more capable flight decks (cockpits) in aircraft. Randy Bailey, a lead aerospace engineer in the VSST program at Langley Research Center, says the technology in cockpits is directly related to flight safety. For example, "GPS navigation systems are wonderful as far as improving a pilot s ability to navigate, but if you can find ways to reduce the draw of the pilot s attention into the cockpit while using the GPS, it could potentially improve safety," he says.

More safety by improving the safety culture

International Nuclear Information System (INIS)

Laaksonen, J.

1993-01-01

In its meeting in 1986, after Chernobyl accident, the INSAG group concluded, that the most important reason for the accident was lack of safety culture. Later the group realized that the safety culture, if it is well enough, can be used as a powerful tool to assess and develop practices affecting safety in any country. A comprehensive view on the various aspects of safety culture was presented in the INSAG-4 report published in 1991. Finland was among the first nations include the concept of safety culture in its regulations. This article describes the roles of government and the regulatory body in creating a national safety culture. How safety culture is seen in the operation of a nuclear power plant is also discussed. (orig.)

Proposal for the improvement of IRD safety culture based on risk analysis

International Nuclear Information System (INIS)

Aguiar, L.A.; Ferreira, P.R.R.; Silveira, C.S.

2017-01-01

The Safety Culture (SC) is a concept about the relationship of individuals and organizations towards the safety in a specific activity. Any organization that carries out activities with risks has a SC, even at minimum levels. People perceive different types of radiation risks in very different ways, therefore, to identify and to analysis of the possible radiation risks resulting from normal operation or accident conditions is an important issue in order to improve the SC in organization. The main is to present guidelines for the improvement of the safety culture in the Institute of Radiation Protection and Dosimetry - IRD through on risk-based approach. The methodology proposed here is: A) select a division of the IRD for case study; B) assess the level of the 10 culture safety basic elements of the IRD division selected; C) conduct a survey of the hazards and risks associated with the various activities developed by the division; D) reassess the level of the 10 basic elements of CS; And E) analyze the results and correlate the impact of risk knowledge on safety culture improvement. The expected result is improvement the safety and of safety culture by understanding of radiation risks and hazards relating to work and to the working environment; and thus enforce a collective commitment to safety by teams and individuals and raise the safety culture to higher levels. (author)

Proposal for the improvement of IRD safety culture based on risk analysis

Energy Technology Data Exchange (ETDEWEB)

Aguiar, L.A.; Ferreira, P.R.R. [Instituto de Radioproteção e Dosimetria (DIRAD/IRD/CNEN-RJ), Rio de Janeiro, RJ (Brazil); Silveira, C.S., E-mail: laguiar@ird.gov.br [Comissão Nacional de Energia Nuclear (DRS/CGMI/CNEN), Rio de Janeiro, RJ (Brazil)

2017-07-01

The Safety Culture (SC) is a concept about the relationship of individuals and organizations towards the safety in a specific activity. Any organization that carries out activities with risks has a SC, even at minimum levels. People perceive different types of radiation risks in very different ways, therefore, to identify and to analysis of the possible radiation risks resulting from normal operation or accident conditions is an important issue in order to improve the SC in organization. The main is to present guidelines for the improvement of the safety culture in the Institute of Radiation Protection and Dosimetry - IRD through on risk-based approach. The methodology proposed here is: A) select a division of the IRD for case study; B) assess the level of the 10 culture safety basic elements of the IRD division selected; C) conduct a survey of the hazards and risks associated with the various activities developed by the division; D) reassess the level of the 10 basic elements of CS; And E) analyze the results and correlate the impact of risk knowledge on safety culture improvement. The expected result is improvement the safety and of safety culture by understanding of radiation risks and hazards relating to work and to the working environment; and thus enforce a collective commitment to safety by teams and individuals and raise the safety culture to higher levels. (author)

A chief safety officer as the driver and guardian of a great safety rating.

Science.gov (United States)

Steck, Oliver; Zenker, Daniel; Beatty, Tom

2013-02-01

If the Pharmaceutical Industry were to align to broad metrics that objectively state each product's "Safety Rating" two things would happen. First, Life Sciences companies would refocus dramatically on safety (followed by outcomes). Second, companies that have the highest aggregate "Safety Rating" would enjoy a significant competitive advantage. To achieve and maintain a high safety rating, the role of Safety officer needs to be elevated to the C-Suite.

Advanced power reactors with improved safety characteristics

International Nuclear Information System (INIS)

Birkhofer, A.

1994-01-01

The primary objective of nuclear safety is the protection of individuals, society and environment against radiological hazards from accidental releases of radioactive materials contained in nuclear reactors. Hereto, these materials are enclosed by several successive barriers and the barriers protected against mishaps and accidents by a multi-level system of safety precautions. The evolution of reactor technology continuously improves this concept and its implementation. At a world-wide scale, several advanced reactor concepts are currently being considered, some of them already at a design stage. Essential safety objectives include both further strengthening the prevention of accidents and improving the containment of fission products should an accident occur. The proposed solutions differ considerably with regard to technical principles, plant size and time scales considered for industrial application. Two typical approaches can be distinguished: The first approach basically aims at an evolution of power reactors currently in use, taking into account the findings from safety research and from operation of current plants. This approach makes maximum use of proven technology and operating experience but may nevertheless include new safety features. The corresponding designs are often termed 'large evolutionary'. The second approach consists in more fundamental changes compared to present designs, often with strong emphasis on specific passive features protecting the fuel and fuel cladding barriers. Owing to the nature and capability of those passive features such 'innovative designs' are mostly smaller in power output. The paper describes the basic objectives of such developments and illustrates important technical concepts focusing on next generation plants, i.e. designs to be available for industrial application until the end of this decade. 1 tab. (author)

Dramatic weight loss associated with commencing clozapine.

Science.gov (United States)

Lally, John; McDonald, Colm

2011-11-08

The authors report the case of a 44-year-old man with a long history of chronic enduring schizophrenia who experienced dramatic weight loss after commencing treatment with clozapine, an antipsychotic medication characteristically associated with the greatest degree of weight gain among medical treatments for schizophrenia. He was obese with a body mass index (BMI) of 41.5 kg/m(2), but after commencing clozapine therapy he experienced an improvement in psychotic symptoms and 40% loss of his body weight attained through an altered diet and exercise regime, which resulted in him attaining a normal BMI of 24.8 kg/m(2).

Measurable improvement in patient safety culture: A departmental experience with incident learning.

Science.gov (United States)

Kusano, Aaron S; Nyflot, Matthew J; Zeng, Jing; Sponseller, Patricia A; Ermoian, Ralph; Jordan, Loucille; Carlson, Joshua; Novak, Avrey; Kane, Gabrielle; Ford, Eric C

2015-01-01

Rigorous use of departmental incident learning is integral to improving patient safety and quality of care. The goal of this study was to quantify the impact of a high-volume, departmental incident learning system on patient safety culture. A prospective, voluntary, electronic incident learning system was implemented in February 2012 with the intent of tracking near-miss/no-harm incidents. All incident reports were reviewed weekly by a multiprofessional team with regular department-wide feedback. Patient safety culture was measured at baseline with validated patient safety culture survey questions. A repeat survey was conducted after 1 and 2 years of departmental incident learning. Proportional changes were compared by χ(2) or Fisher exact test, where appropriate. Between 2012 and 2014, a total of 1897 error/near-miss incidents were reported, representing an average of 1 near-miss report per patient treated. Reports were filed by a cross section of staff, with the majority of incidents reported by therapists, dosimetrists, and physicists. Survey response rates at baseline and 1 and 2 years were 78%, 80%, and 80%, respectively. Statistically significant and sustained improvements were noted in several safety metrics, including belief that the department was openly discussing ways to improve safety, the sense that reports were being used for safety improvement, and the sense that changes were being evaluated for effectiveness. None of the surveyed dimensions of patient safety culture worsened. Fewer punitive concerns were noted, with statistically significant decreases in the worry of embarrassment in front of colleagues and fear of getting colleagues in trouble. A comprehensive incident learning system can identify many areas for improvement and is associated with significant and sustained improvements in patient safety culture. These data provide valuable guidance as incident learning systems become more widely used in radiation oncology. Copyright © 2015

Characterization and improvement of the nuclear safety culture through self-assessment

International Nuclear Information System (INIS)

Levin, H.A.; McGehee, R.B.; Cottle, W.T.

1996-01-01

Organizational culture has a powerful influence on overall corporate performance. The ability to sustain superior results in ensuring the public's health and safety is predicated on an organization's deeply embedded values and behavioral norms and how these affect the ability to change and seek continuous improvement. The nuclear industry is developing increased recognition of the relationship of culture to nuclear safety performance as a critical element of corporate strategy. This paper describes a self-assessment methodology designed to characterize and improve the nuclear safety culture, including processes for addressing employee concerns. This methodology has been successfully applied on more than 30 occasions in the last several years, resulting in measurable improvements in safety performance and quality and employee motivation, productivity, and morale. Benefits and lessons learned are also presented

Development of effective means of propaganda of safety techniques for coal mines

Energy Technology Data Exchange (ETDEWEB)

Galushko, A.L.; Brusilovskiy, V.I.; Popov, I.I.

1979-01-01

Information letters about accidents in coal mines are systematically developed and sent to enterprises and organizations of the branch for practical use in preventive work on work protection and work safety. Information materials on advanced experience in prevention of accidents and traumatism are published in large quantities. Principal measures which have dramatically affected the reduction of the level of production traumatism are listed which merit dissemination in the branch. It is noted that the use of these means of propaganda of work safety makes it possible to improve preventive work on work safety and production sanitation in enterprises of the coal industry.

Poly(2,5-dimercapto-1,3,4-thiadiazole) as a Cathode for Rechargeable Lithium Batteries with Dramatically Improved Performance

KAUST Repository

Gao, Jie

2012-05-29

Organosulfur compounds with multiple thiol groups are promising for high gravimetric energy density electrochemical energy storage. We have synthesized a poly(2,5-dimercapto-1,3,4-thiadiazole) (PDMcT)/poly(3,4-ethylenedioxythiophene) (PEDOT) composite cathode for lithium-ion batteries with a new method and investigated its electrochemical behavior by charge/discharge cycles and cyclic voltammetry (CV) in an ether-based electrolyte. Based on a comparison of the electrochemical performance with a carbonate-based electrolyte, we found a much higher discharge capacity, but also a very attractive cycling performance of PDMcT by using a tetra(ethylene glycol) dimethyl ether (TEGDME)-based electrolyte. The first discharge capacity of the as-synthesized PDMcT/PEDOT composite approached 210 mAh g -1 in the TEGDME-based electrolyte. CV results clearly show that the redox reactions of PDMcT are highly reversible in this TEGDME-based electrolyte. The reversible capacity remained around 120 mAh g -1 after 20 charge/discharge cycles. With improved cycling performance and very low cost, PDMcT could become a very promising cathode material when combined with a TEGDME-based electrolyte. The poor capacity in the carbonate-based electrolyte is a consequence of the irreversible reaction of the DMcT monomer and dimer with the solvent, emphasizing the importance of electrolyte chemistry when studying molecular-based battery materials. The nature of the electrolyte has a dramatic effect on the performance of poly(2,5-dimercapto-1,3,4-thiadiazole) (PDMcT) as a cathode material in lithium-ion batteries. Whereas the use of an ethylene/diethyl carbonate (EC/DEC)-based electrolyte resulted in very poor performance, the use of a tetra(ethylene glycol) dimethyl ether (TEGDME)-based electrolyte dramatically improved the performance in terms of both the discharge capacity and capacity retention (see scheme). Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Improving health care quality and safety: the role of collective learning

Directory of Open Access Journals (Sweden)

Singer SJ

2015-11-01

Full Text Available Sara J Singer,1–4 Justin K Benzer,4–6 Sami U Hamdan4,6 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; 2Department of Medicine, Harvard Medical School, Boston, MA, USA; 3Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA; 4Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA; 5VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; 6Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA Abstract: Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation, internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological

Using dramatic role-play to develop emotional aptitude

Directory of Open Access Journals (Sweden)

Russell Dinapoli

2009-12-01

Full Text Available As university educators, we need to prepare students for the transition from the information age to what Daniel H. Pink (2005 calls the conceptual age, which is governed by artistry, empathy and emotion, by including in the curricula activities that stimulate both hemispheres of the brain. This can be done by promoting activities that energize what Daniel Goleman (1995 refers to as emotional intelligence, and it further maintains that, as Paul Ekman (2003 suggests, the ability to detect feelings improves communication. Recognizing the need to include in the curricula procedures that help develop students’ right brain aptitudes and enhance their communication skills, I have endeavoured to introduce dramatic scene study as a sustained activity in my English for Specific Purposes courses at the Universidad de Valencia. My aim was to energize the students’ creative and emotional aptitudes, as well as to dynamize effective teamwork. This article sustains that dramatic role-play, based on scripted scene study and related improvisational activities, is one way of achieving this.

Patient Safety Based Knowledge Management SECI to Improve Nusrsing Students Competency

Directory of Open Access Journals (Sweden)

Joanggi Wiriatarina Harianto

2015-10-01

Full Text Available Introduction: Patient safety is an important component of health services quality,and  basic principles of patient care. Nursing students also have a great potential to make an action that could endanger the patient, because hospital is one of student practice area. The purpose of this study was to improve the nursing students competency in patient safety by using knowledge management SECI approached. Method: The study used exploratory survey, and quasy experiment. The samples were some of nursing students of STIKes Muhammadiyah Samarinda who were on internship programme that selected using simple random sampling technique, in total of 54 students. This research’s variables were the knowledge management SECI based-patient safety and nursing student’s competency. The data were collected by using questionnaires and observation. The data were analyze by using Partial Least Square (PLS. Result: The result showed that there were significant influence the implementation of a model patient safety based knowledge management seci on increased competence nursing students. Discussion: Improved student competency in patient safety using SECI knowledge management was carried out in four phases, that is Socialization, Externalization, Combination, and Internalization. The result was a new knowledge related to patient safety that able to improve the student’s competency.. Keywords: Patient safety, Knowledge management, SECI, competency

Improving patient safety: patient-focused, high-reliability team training.

Science.gov (United States)

McKeon, Leslie M; Cunningham, Patricia D; Oswaks, Jill S Detty

2009-01-01

Healthcare systems are recognizing "human factor" flaws that result in adverse outcomes. Nurses work around system failures, although increasing healthcare complexity makes this harder to do without risk of error. Aviation and military organizations achieve ultrasafe outcomes through high-reliability practice. We describe how reliability principles were used to teach nurses to improve patient safety at the front line of care. Outcomes include safety-oriented, teamwork communication competency; reflections on safety culture and clinical leadership are discussed.

International conference on the strengthening of nuclear safety in Eastern Europe. Keynote papers. Regulatory aspects of NPP safety, status of safety improvements, status of safety analysis report

International Nuclear Information System (INIS)

1999-06-01

The Objective of the Conference was to assess the past decade of nuclear safety efforts in countries operating WWER and RBMK nuclear reactors and to address remaining safety issues which require further work. A particular focus of the Conference was on international co-operation and assistance and where such efforts should be focused in the future. All Eastern European countries that operate RBMK or WWER reactors participated in the Conference, and presented papers on three key areas of nuclear safety: Regulatory Aspects of Nuclear Power Plant Safety; Status of Safety Improvements; and Status of Safety Analysis Reports. In addition, representatives from 18 additional countries that provide financial and/or technical assistance and co-operation in the area of WWER and RBMK safety offered the most extensive commentary. Key international (IAEA, World Association of Nuclear Operators, the Nuclear Energy Agency, the G-24 NUSAC, the European Commission, and the EBRD) organizations that provide nuclear safety assistance for WWER and RBMK reactors also made presentations. There is no question that considerable progress on nuclear safety has been made in Eastern Europe. Special mention should be made of successful efforts to strengthen the independence and technical competence of the nuclear regulatory authorities. Efforts should now concentrate on improving the depth and scope of the technical abilities of the regulatory authorities. More attention by governments is needed to ensure that the regulatory authorities have the financial resources and enforcement authority to fully execute their missions. In respect to the operators of the nuclear power plants, they have demonstrated clear progress in operational safety improvements. Significant additional efforts are required to maintain and enhance an effective safety culture. Design safety improvement programmes are in place in all countries. Implementation of these programmes has varied and is particularly affected by

Effect of generic issues program on improving safety

International Nuclear Information System (INIS)

Fard, M. R.; Kauffman, J. V.

2010-01-01

The U.S. Nuclear Regulatory Commission (NRC) identifies (by its assessment of plant operation) certain issues involving public health and safety, the common defense and security, or the environment that could affect multiple entities under NRC jurisdiction. The Generic Issues Program (GIP) addresses the resolution of these Generic Issues (GIs). The resolution of these issues may involve new or revised rules, new or revised guidance, or revised interpretation of rules or guidance that affect nuclear power plant licensees, nuclear material certificate holders, or holders of other regulatory approvals. U.S. NRC provides information related to the past and ongoing GIP activities to the general public by the use of three main resources, namely NUREG-0933, 'Resolution of Generic Safety Issues, ' Generic Issues Management Control System (GIMCS), and GIP public web page. GIP information resources provide information such as historical information on resolved GIs, current status of the open GIs, policy documents, program procedures, GIP annual and quarterly reports and the process to contact GIP and propose a GI This paper provides an overview of the GIP and several examples of safety improvements resulting from the resolution of GIs. In addition, the paper provides a brief discussion of a few recent GIs to illustrate how the program functions to improve safety. (authors)

The Power of Collaboration for Improving Safety in Complex Systems

International Nuclear Information System (INIS)

Hart, C. A.

2016-01-01

Many potentially hazardous industries involve systems that consist of a complex array of subsystems that must work together effectively in order for the entire system to perform. Often the subsystems are coupled, such that changes in any one subsystem can affect other subsystems. “System Think” refers to an awareness of the impacts throughout a system of changes in any subsystem. The U.S. commercial aviation industry, in its continuing endeavor to improve safety, uses a collaborative approach to accomplish System Think— bringing all of the key parts of the industry together to work in a collaborative manner to identify and address potential safety concerns. The collaborative approach resulted in an 83% reduction in the fatal accident rate in only 10 years. It also demonstrated that, contrary to conventional wisdom that safety improvements usually hurt productivity, safety improvements that result from a collaborative approach can simultaneously improve productivity. Last but not least, it minimised one of the continuing challenges of making changes in complex systems, which is unintended consequences. The purpose of this presentation is to describe the collaborative approach and to discuss its transferability to other potentially hazardous industries that are seeking to manage their risks more efficiently and effectively. (author)

Assistance of Foreign Countries and International Organizations to Support Safety Improvements at Ignalina NPP

International Nuclear Information System (INIS)

Shevaldin, V.

1997-01-01

International cooperation and assistance for the improving safety of Ignalina NPP is described. Sweden was among the first countries which supported safety improvements at Ignalina NPP. The first project in the cooperation was BARSELINA, Probabilistic Safety Analysis of Ignalina NPP. The cooperation is still bringing significant support to the plant, including improvements in the fire protection, communications system, physical protection, and many other areas. Another one very important source of assistance was Nuclear Safety Account, administered by the EBRD. In 1993 experts of the plant, together with representatives of VATESI and SKI (Sweden) have worked out a short-term safety improvement program SIP-1, which was financed by the EBRD . Eighteen safety related projects were selected, expensive and reliable equipment was procured and installed

Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Esmail, Aneez; Wensing, Michel

2015-01-01

ABSTRACT Background: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts. Objective: This paper provides a broad overview with practical guidance on how to improve patient safety. Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident. Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care. Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis. PMID:26339837

Improvement programme of safety performance indicators (SPIs) in Korea

International Nuclear Information System (INIS)

Lee, S.Y.

2001-01-01

KINS has developed and used Safety Performance Indicators (SPIs), which are count based and composed of 10 indicators in 8 areas, to monitor the trend of performance of NPPs in Korea since 1997. However, the limited usage of SPIs and the increasing worldwide interest on SPIs became the motivation of the SPI improvement programme in Korea. Korea is planning to establish plant performance evaluation programme through analysis of SPI and result of inspection. The SPI improvement programme is a part of the plant performance evaluation programme and includes study on performance evaluation areas, indicator categories, selection and development of indicators, redefinition of indicators and introduction of graphical display system. The selected performance evaluation areas are general performance, reactor safety and radiation safety. Each area will have categories as sub-areas and a total of six categories are selected. One or two indicators for each category are determined or will be developed to make a set of Safety Performance Indicators. Also, a graphic display system will be introduced to extend the usage of SPIs. (author)

[An approach to care indicators benchmarking. Learning to improve patient safety].

Science.gov (United States)

de Andrés Gimeno, B; Salazar de la Guerra, R M; Ferrer Arnedo, C; Revuelta Zamorano, M; Ayuso Murillo, D; González Soria, J

2014-01-01

Improvements in clinical safety can be achieved by promoting a safety culture, professional training, and learning through benchmarking. The aim of this study was to identify areas for improvement after analysing the safety indicators in two public Hospitals in North-West Madrid Region. Descriptive study performed during 2011 in Hospital Universitario Puerta de Hierro Majadahonda (HUPHM) and Hospital de Guadarrama (HG). The variables under study were 40 indicators on nursing care related to patient safety. Nineteen of them were defined in the SENECA project as care quality standards in order to improve patient safety in the hospitals. The data collected were clinical history, Madrid Health Service assessment reports, care procedures, and direct observation Within the 40 indicators: 22 of them were structured (procedures), HUPHM had 86%, and HG 95% 14 process indicators (training and protocols compliance) with similar results in both hospitals, apart from the care continuity reports and training in hand hygiene. The 4 results indicators (pressure ulcer, falls and pain) showed different results. The analysis of the indicators allowed the following actions to be taken: to identify improvements to be made in each hospital, to develop joint safety recommendations in nursing care protocols in prevention and treatment of chronic wound, to establish systematic pain assessments, and to prepare continuity care reports on all patients transferred from HUPHM to HG. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.

Improved safety at CERN

CERN Multimedia

2006-01-01

As announced in Weekly Bulletin No. 43/2006, a new approach to the implementation of Safety at CERN has been decided, which required taking some managerial decisions. The guidelines of the new approach are described in the document 'New approach to Safety implementation at CERN', which also summarizes the main managerial decisions I have taken to strengthen compliance with the CERN Safety policy and Rules. To this end I have also reviewed the mandates of the Safety Commission and the Safety Policy Committee (SAPOCO). Some details of the document 'Safety Policy at CERN' (also known as SAPOCO42) have been modified accordingly; its essential principles, unchanged, remain the basis for the safety policy of the Organisation. I would also like to inform you that I have appointed Dr M. Bona as the new Head of the Safety Commission until 31.12.2008, and that I will proceed soon to the appointment of the members of the new Safety Policy Committee. All members of the personnel are deemed to have taken note of the d...

International conference on the strengthening of nuclear safety in Eastern Europe. Keynote papers. Regulatory aspects of NPP safety, status of safety improvements, status of safety analysis report

Energy Technology Data Exchange (ETDEWEB)

NONE

1999-06-01

The Objective of the Conference was to assess the past decade of nuclear safety efforts in countries operating WWER and RBMK nuclear reactors and to address remaining safety issues which require further work. A particular focus of the Conference was on international co-operation and assistance and where such efforts should be focused in the future. All Eastern European countries that operate RBMK or WWER reactors participated in the Conference, and presented papers on three key areas of nuclear safety: Regulatory Aspects of Nuclear Power Plant Safety; Status of Safety Improvements; and Status of Safety Analysis Reports. In addition, representatives from 18 additional countries that provide financial and/or technical assistance and co-operation in the area of WWER and RBMK safety offered the most extensive commentary. Key international (IAEA, World Association of Nuclear Operators, the Nuclear Energy Agency, the G-24 NUSAC, the European Commission, and the EBRD) organizations that provide nuclear safety assistance for WWER and RBMK reactors also made presentations. There is no question that considerable progress on nuclear safety has been made in Eastern Europe. Special mention should be made of successful efforts to strengthen the independence and technical competence of the nuclear regulatory authorities. Efforts should now concentrate on improving the depth and scope of the technical abilities of the regulatory authorities. More attention by governments is needed to ensure that the regulatory authorities have the financial resources and enforcement authority to fully execute their missions. In respect to the operators of the nuclear power plants, they have demonstrated clear progress in operational safety improvements. Significant additional efforts are required to maintain and enhance an effective safety culture. Design safety improvement programmes are in place in all countries. Implementation of these programmes has varied and is particularly affected by

Improving safety through quality management system: SINAGAMA experience

International Nuclear Information System (INIS)

Muhammad Lebai Juri

2000-01-01

This paper discussed critically the policies and measures adopted during preoperational and operational stages to improve safety of workers, public, the environment as well as the products treated at SINAGAMA. (author)

Improving occupational safety in Kuzbass mines

Energy Technology Data Exchange (ETDEWEB)

Evseev, V S

1986-08-01

Some achievements of VostNII are listed in improving occupational safety in Kuzbass mines. Methane is a major problem: 90.6% of mines is in category III or supercategory; over 21% has an absolute methane emission of 30 m/sup 3//min or more. Another problem is spontaneous fires, which cost 2 million t of coal per year. One method of preventing these is injection of antipyrogens (urea and diammonium phosphate); another is the creation of gel (water glass, ammonium chloride and water) barriers in goaf areas. High pressure water jets are also used. Various methods of improving ventilation systems to match increased coal output are proposed, including drilling large diameter ventilation boreholes from the surface. In Leninskugol' mines the useful air is only 55.8% of the total delivered. More attention should be given to degassing (currently producing 130 million m/sup 3//y of methane). Dust levels are increasing due to the advent of narrow web cutter loaders (100% of coal cutter loaders in Kuzbass mines in 1984). Water injection and spraying are partially effective at dust suppression. Some electrical safety devices developed by VostNII are described.

Near-peers improve patient safety training in the preclinical curriculum.

Science.gov (United States)

Raty, Sally R; Teal, Cayla R; Nelson, Elizabeth A; Gill, Anne C

2017-01-01

Accrediting bodies require medical schools to teach patient safety and residents to develop teaching skills in patient safety. We created a patient safety course in the preclinical curriculum and used continuous quality improvement to make changes over time. To assess the impact of resident teaching on student perceptions of a Patient Safety course. Using the Institute for Healthcare Improvement patient safety curriculum as a frame, the course included the seven IHI modules, large group lectures and small group facilitated discussions. Applying a social action methodology, we evaluated the course for four years (Y1-Y4). In Y1, Y2, Y3 and Y4, we distributed a course evaluation to each student (n = 184, 189, 191, and 184, respectively) and the response rate was 96, 97, 95 and 100%, respectively. Overall course quality, clarity of course goals and value of small group discussions increased in Y2 after the introduction of residents as small group facilitators. The value of residents and the overall value of the course increased in Y3 after we provided residents with small group facilitation training. Preclinical students value the interaction with residents and may perceive the overall value of a course to be improved based on near-peer involvement. Residents gain valuable experience in small group facilitation and leadership.

Lord Byron's dramatic work

Directory of Open Access Journals (Sweden)

Andrejević Ana

2009-01-01

Full Text Available All of Byron's six finished dramas aspire to display conflict between the individual will and the strength of the universal and omnipresent inevitability. Although he accentuated classical dramatic rules or three dramatic unities as the way to construct a good drama, he couldn't escape from the deep rooted romantic feeling of his genius. His plays are thus pictures of existing existential revolt with the protagonists true to their feelings, always consistent, active and devoted to one general idea. They are estranged from the meaningless world that leads them to rebellion and death, but prometheously constructed are the most successful and memorable element of his plays. Byron as a dramatist always tries to find an everlasting dimension and virtue in the meaningless world through the construction of personal myth and thus the main subject of all his dramas is freedom in all its aspects.

Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements In Post Arthroplasty Surgical Outcomes

Science.gov (United States)

Paxton, Elizabeth W.; Fisher, David; Li, Robert A.; Barber, Thomas C.; Singh, Jasvinder A.

2014-01-01

This study compared the total joint arthroplasty (TJA) surgical outcomes of patients who had bariatric surgery prior to TJA to TJA patients who were candidates but did not have bariatric surgery. Patients were retrospectively grouped into: Group 1 (n=69), those with bariatric surgery >2 years prior to TJA, Group 2 (n=102), those with surgery within 2 years of TJA, and Group 3 (n=11,032), those without bariatric surgery. In Group 1, 2.9% (95%CI 0.0–6.9%) had complications within 1 year compared to 5.9% (95%CI 1.3–10.4%) in Group 2, and 4.1% (95%CI 3.8–4.5%) in Group 3. 90-day readmission (7.2%, 95%CI 1.1–13.4%) and revision density (3.4/100 years of observation) was highest in Group 1. Bariatric surgery prior to TJA may not provide dramatic improvements in post-operative TJA surgical outcomes. PMID:24674730

How to Improve Patient Safety Culture in Croatian Hospitals?

Science.gov (United States)

Šklebar, Ivan; Mustajbegović, Jadranka; Šklebar, Duška; Cesarik, Marijan; Milošević, Milan; Brborović, Hana; Šporčić, Krunoslav; Petrić, Petar; Husedžinović, Ino

2016-09-01

Patient safety culture (PCS) has a crucial impact on the safety practices of healthcare delivery systems. The purpose of this study was to assess the state of PSC in Croatian hospitals and compare it with hospitals in the United States. The study was conducted in three public general hospitals in Croatia using the Croatian translation of the Hospital Survey of Patient Safety Culture (HSOPSC). A comparison of the results from Croatian and American hospitals was performed using a T-square test. We found statistically significant differences in all 12 PSC dimensions. Croatian responses were more positive in the two dimensions of Handoff s and Transitions and Overall Perceptions of Patient Safety. In the remaining ten dimensions, Croatian responses were less positive than in US hospitals, with the most prominent areas being Nonpunitive Response to Error, Frequency of Events Reported, Communication Openness, Teamwork within Units, Feedback & Communication about Error, Management Support for Patient Safety, and Staffing. Our findings show that PSC is significantly lower in Croatian than in American hospitals, particularly in the areas of Nonpunitive Response to Error, Leadership, Teamwork, Communication Openness and Staffing. This suggests that a more comprehensive system for the improvement of patient safety within the framework of the Croatian healthcare system needs to be developed. Our findings also help confirm that HSOPSC is a useful and appropriate tool for the assessment of PSC. HSOPSC highlights the PSC components in need of improvement and should be considered for use in national and international benchmarking.

Ways of improving safety for future PWRs in France

International Nuclear Information System (INIS)

Gros, G.; Jalouneix, J.; Manesse, D.; Mattei, J.M.

1994-06-01

Results of thinkings and studies, conducted within the Institute for Nuclear Safety and Protection (IPSN) on various fields of nuclear power plant safety, on the definition of safety objectives and principles for future PWRs. The aim of the studies is to identify ways of improving the design of future plants in France and Germany, with the main following objectives: significant reduction of the global probability of core damage, significant reduction of radioactive releases, mainly for severe accident conditions, and reduction of individual and collective doses received by workers. (R.P.) 3 refs., 1 tab

Improved safety of the system 80+TM standard plants design through increased diversity and redundancy of safety systems

International Nuclear Information System (INIS)

Matzie, Regis A.; Carpentino, Frederick L.; Robertson, James E.

1996-01-01

Safely systems in the System 80+ TM Standard Plant are designed with more redundancy, diversity and simplicity than earlier nuclear power plant designs. These gains were accomplished by an evolutionary process that preserved the desirable and proven features in currently operating nuclear plants, while improving reliability and defense-in-depth. The System 80+ safety systems are the primary contributors to a core damage frequency that is more than 100 times lower than 1980's vintage U. S. designs, including the predecessor System 80 R standard nuclear steam supply system (NSSS) design. The System 80+ design includes significant improvements to the safety injection system, emergency feedwater system, shutdown cooling system, containment spray system, reactor coolant gas vent system, and to their vital support systems. These improvements enhance performance for traditional design basis events and significantly reduce the probability of a severe accident. The System 80+ design also incorporates safety systems to mitigate a severe accident. The added systems include the rapid depressurization system, the in-containment refueling water storage tank, the cavity flooding system. These systems fully address the U. S. Nuclear Regulatory Commission's (US NRC) severe accident policy. The System 80+ safety systems are integrated with the System 80+ Nuclear Island (NI) design. The NI general arrangement provides quadrant separation of the safety systems for protection from fire and flooding, and large equipment pull spaces and lay down areas for maintenance. This paper will describe the System 80+ safety systems advanced design features, the improved accident prevention and mitigation capabilities, and startup, operating and maintenance benefits

Nature-based strategies for improving urban health and safety

Science.gov (United States)

Michelle C. Kondo; Eugenia C. South; Charles C. Branas

2015-01-01

Place-based programs are being noticed as key opportunities to prevent disease and promote public health and safety for populations at-large. As one key type of place-based intervention, nature-based and green space strategies can play an especially large role in improving health and safety for dwellers in urban environments such as US legacy cities that lack nature...

Training and Action for Patient Safety: Embedding Interprofessional Education for Patient Safety within an Improvement Methodology

Science.gov (United States)

Slater, Beverley L.; Lawton, Rebecca; Armitage, Gerry; Bibby, John; Wright, John

2012-01-01

Introduction: Despite an explosion of interest in improving safety and reducing error in health care, one important aspect of patient safety that has received little attention is a systematic approach to education and training for the whole health care workforce. This article describes an evaluation of an innovative multiprofessional, team-based…

Improvement critical care patient safety: using nursing staff development strategies, at Saudi Arabia.

Science.gov (United States)

Basuni, Enas M; Bayoumi, Magda M

2015-01-13

Intensive care units (ICUs) provide lifesaving care for the critically ill patients and are associated with significant risks. Moreover complexity of care within ICUs requires that the health care professionals exhibit a trans-disciplinary level of competency to improve patient safety. This study aimed at using staff development strategies through implementing patient safety educational program that may minimize the medical errors and improve patient outcome in hospital. The study was carried out using a quasi experimental design. The settings included the intensive care units at General Mohail Hospital and National Mohail Hospital, King Khalid University, Saudi Arabia. The study was conducted from March to June 2012. A convenience sample of all prevalent nurses at three shifts in the aforementioned settings during the study period was recruited. The program was implemented on 50 staff nurses in different ICUs. Their age ranged between 25-40 years. Statistically significant relation was revealed between safety climate and job satisfaction among nurses in the study sample (p=0.001). The years of experiences in ICU ranged between one year 11 (16.4) to 10 years 20 (29.8), most of them (68%) were working in variable shift, while 32% were day shift only. Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on ICUs after implementing a safety program. On the heels of this improvement; nurses' total knowledge, skills and attitude were enhanced regarding patient safety dimensions. Continuous educational program for ICUs nursing staff through organized in-service training is needed to increase their knowledge and skills about the importance of improving patient safety measure. Emphasizing on effective collaborative system also will improve patient safety measures in ICUS.

A report on developing a checklist to assess company plans focused on improving safety awareness, safe behaviour and safety culture: final report

NARCIS (Netherlands)

Steijger, N.; Starren, H.; Keus, M.; Gort, J.; Vervoort, M.

2003-01-01

This report describes the process of developing a checklist to asses company plans focused on improving safety awareness, safe behaviour and safety culture. These plans are part of a programme initiated by the Ministry of Social Affairs and Employment aiming at improving the safety performance of

USSR orders computers to improve nuclear safety

International Nuclear Information System (INIS)

Anon.

1990-01-01

Control Data Corp (CDC) has received an order valued at $32-million from the Soviet Union for six Cyber 962 mainframe computer systems to be used to increase the safety of civilian nuclear powerplants. The firm is now waiting for approval of the contract by the US government and Western Allies. The computers, ordered by the Soviet Research and Development Institute of Power Engineering (RDIPE), will analyze safety factors in the operation of nuclear reactors over a wide range of conditions. The Soviet Union's civilian nuclear program is one of the largest in the world, with over 50 plants in operation. Types of safety analyses the computers perform include: neutron-physics calculations, radiation-protection studies, stress analysis, reliability analysis of equipment and systems, ecological-impact calculations, transient analysis, and support activities for emergency response. They also include a simulator with realistic mathematical models of Soviet nuclear powerplants to improve operator training

Safety Culture Improvement Activities of YGN 3 and 4

International Nuclear Information System (INIS)

Cho, Il Hoon

2006-01-01

In nuclear power industry all over the world, we can never overemphasize the importance of nuclear safety. After the Chernobyl accident occurred in 1986, Korean nuclear energy industry had made every effort to enhance nuclear safety culture further. And, as a result of the efforts, Korean government declared the five principles for the nuclear energy safety regulation, which were included in the Nuclear Energy Safety Policy Statement published in 1994. In 2001, through the announcement of Nuclear Safety Charter for the peaceful use of nuclear energy, the Ministry of Science and Technology proclaimed at home and abroad that the protection of citizens and environment by securing nuclear safety should be the highest priority in nuclear energy industry. Occupying almost 40% share of domestic electricity generation, Korea Hydro and Nuclear Power Co. decided 'Safety Top Priority Management' as president's management policy, and clearly presented the safety goal to the personnel. By this, the management can effectively place stress on securing safety, which is our highest priority and the only way to win public confidence toward nuclear energy industry. This is prepared to shortly introduce the activities for improving safety culture in Yonggwang Nuclear Power unit 3 and 4 (YGN 3 and 4)

Continuous improvement of the MHTGR safety and competitive performance

International Nuclear Information System (INIS)

Eichenberg, T.W.; Etzel, K.T.; Mascaro, L.L.; Rucker, R.A.

1992-05-01

An increase in reactor module power from 350 to 450 MW(t) would markedly improve the economics of the Modular High Temperature Gas-Cooled Reactor (MHTGR). The higher power level was recommended as the result of an in-depth cost reduction study undertaken to compete with the declining price of fossil fuel. The safety assessment confirms that the high level of safety, which relies on inherent characteristics and passive features, is maintained at the elevated power level. Preliminary systems, nuclear, and safety performance results are discussed for the recommended 450 MW(t) design. Optimization of plant parameters and design modifications accommodated the operation of the steam generator and circulator at the higher power level. Events in which forced cooling is lost, designated as conduction cooldowns are described in detail. For the depressurized conduction cooldown, without full helium inventory, peak fuel temperatures are significantly lowered. A more negative temperature coefficient of reactivity was achieved while maintaining an adequate fuel cycle and reactivity control. Continual improvement of the MHTGR delivers competitive performance without relinquishing the high safety margins demanded of the next generation of power plants

Improving Aviation Safety in Indonesia: How Many More Accidents?

Directory of Open Access Journals (Sweden)

Ridha Aditya Nugraha

2016-12-01

Full Text Available Numerous and consecutive aircraft accidents combined with a consistent failure to meet international safety standards in Indonesia, namely from the International Civil Aviation Organization and the European Aviation Safety Agency have proven a nightmare for the country’s aviation safety reputation. There is an urgent need for bureaucracy reform, harmonization of legislation, and especially ensuring legal enforcement, to bring Indonesian aviation safety back to world standards. The Indonesian Aviation Law of 2009 was enacted to reform the situation in Indonesia. The law has become the ground for drafting legal framework under decrees of the Minister of Transportation, which have allowed the government to perform follow-up actions such as establishing a single air navigation service provider and guaranteeing the independency of the Indonesian National Transportation Safety Committee. A comparison with Thailand is made to enrich the perspective. Finally, foreign aviation entities have a role to assist states, in this case Indonesia, in improving its aviation safety, considering the global nature of air travel.

Design safety improvements of Kozloduy NPP to meet the modern safety requirements towards the old generation PWR

International Nuclear Information System (INIS)

Hinovski, M.P.; Sabinov, S.

2001-01-01

Activities related to safety improvement of Kozloduy NPP units, started at the end of 1970s included seismic resistance upgrading, fire safety improvement, reliable heat final absorber etc. During the last 10 years the approach was systematized and improved. Units 1 to 4 are of great interest; therefore here we will discuss these units only. As a result of studies and analyses performed at the end of the 1980s and the beginning of the 1990s, problems related to the safety were identified and complex of technical measures was developed and planned. A considerable part of these measures has already been implemented, and the rest will be performed during the next years. Activities were performed by stages, and at the moment the last stage is under way. It shall be finished by the year 2003. The number of the measures is quite large to describe them here in full scope -- during the first stage of the safety program (1991-1993) were developed and analyzed more than 4200 documents and more than 160 measures were executed. During the second and third stages more than 300 important improvements were realized. In the frame of the program, financed by EBRD, 10 new systems with great importance were implemented and 8 systems were significantly modified. The main measures are described below. (author)

A performance improvement plan to increase nurse adherence to use of medication safety software.

Science.gov (United States)

Gavriloff, Carrie

2012-08-01

Nurses can protect patients receiving intravenous (IV) medication by using medication safety software to program "smart" pumps to administer IV medications. After a patient safety event identified inconsistent use of medication safety software by nurses, a performance improvement team implemented the Deming Cycle performance improvement methodology. The combined use of improved direct care nurse communication, programming strategies, staff education, medication safety champions, adherence monitoring, and technology acquisition resulted in a statistically significant (p < .001) increase in nurse adherence to using medication safety software from 28% to above 85%, exceeding national benchmark adherence rates (Cohen, Cooke, Husch & Woodley, 2007; Carefusion, 2011). Copyright © 2012 Elsevier Inc. All rights reserved.

Application of VR and HF technologies for improving industrial safety

NARCIS (Netherlands)

Loupos, K.; Christopoulos, D.; Vezzadini, L.; Hoekstra, W.; Salem, W.; Chung, P.W.H.

2007-01-01

Safety in industrial environments can nowadays be regarded as an issue of major importance. Large amounts of money are spent by industries on this matter in order to improve safety in all levels, by reducing risks of causing damages to equipment, human injuries or even fatalities. Virtual Reality

Improving Patient Safety Culture in Primary Care: A Systematic Review

NARCIS (Netherlands)

Verbakel, Natasha J.; Langelaan, Maaike; Verheij, Theo J. M.; Wagner, Cordula; Zwart, Dorien L. M.

Background: Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which

Federal Aviation Administration weather program to improve aviation safety

Science.gov (United States)

Wedan, R. W.

1983-01-01

The implementation of the National Airspace System (NAS) will improve safety services to aviation. These services include collision avoidance, improved landing systems and better weather data acquisition and dissemination. The program to improve the quality of weather information includes the following: Radar Remote Weather Display System; Flight Service Automation System; Automatic Weather Observation System; Center Weather Processor, and Next Generation Weather Radar Development.

The Role of the Master in Improving Safety Culture Onboard Ships

Directory of Open Access Journals (Sweden)

T. Bielic

2017-03-01

Full Text Available As a complex socio-technical system marine transportation is open to risks. Due to the efforts of international organisations, flag and port administrations, classification societies and ship-owners the safety record has steadily improved. However, marine accidents resulting from inadequate safety culture still occur. In this paper examples of recent accidents related to different dimensions of safety culture are provided. The role of the master in achieving an enhanced safety is emphasised.

CORPORATE CULTURE AS A TOOL TO IMPROVE SAFETY CULTURE

Directory of Open Access Journals (Sweden)

Erika SUJOVÁ

2013-07-01

Full Text Available The aim of the article is to explain interconnectivity between corporate culture and safety culture, which aim to utilize motivation to prevent work accidents and other unwanted events in an enterprise. The article deals with ways how to improve approaches to Occupational Health & Safety, OH&S, at work place through proper direction of corporate culture. It introduces internal and external determinants of corporate culture, which have a significant effect. The article introduces common features of corporate culture and safety culture as an element of the OH&S management system with emphasis on system effectiveness. The final portion of the article presents the hierarchy of needs model, which may serve as a basis motivating employees to follow safety and health rules at work place.

Kozloduy nuclear power plant. Units 1-4. Status of safety improvements. Rev. 2

International Nuclear Information System (INIS)

1999-01-01

This paper presents the results of the safety improvements activities carried out by the Kozloduy Nuclear Power Plant (KNPP) within the period 1990-1998. The steam supply system of this units is based of the reactor WWER-440/ B-230, which is a PWR of russian design developed according to the safety standards in force in USSR in late sixties. Up to now 10 reactor units of this type are in operation in four NPPs. Despite of efforts of the different plants to implement safety improvements measures during first 10-15 years of operation of this type of reactor its major safety problems were not eliminated and were a subject of international concern. The systematic evaluation of the deficiencies of the original design of this type of reactors have been initiated by IAEA in the beginning of 1990 and brought to developing a comprehensive list of safety problems which required urgent implementation of safety measures in all plants. To solve this problems in 1991 KNPP initiated implementation of so called 'short term' safety improvement program, developed with the help of WANO under agreement with Bulgarian Nuclear Safety Authority (BNSA) and consortium RISKAUDIT. The program was based on a stage approach and was foreseen to be implemented by tree stages in very tight time schedule in order to achieve significant and rapid improvements of the level of safety in operation of the units. The Short term program was implemented between from 1991 to 1997 owing to strong safety commitment of NEC and KNPP staff as well as broad international cooperation and financial support. Important part of resources were supplied under PHARE program of CEC, EBRD grant agreement and EDF support. In parallel a special assessment process started in 1995 in order to evaluate the level of safety, achieved by Short Term Program, according to current safety standards and to define the measures, which should be implemented by the Utility to complete the process of improving the safety in future

BRICS: opportunities to improve road safety.

Science.gov (United States)

Hyder, Adnan A; Vecino-Ortiz, Andres I

2014-06-01

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--are currently undergoing a deep epidemiological transition that is mainly driven by rapid economic growth and technological change. The changes being observed in the distribution of the burden of diseases and injuries--such as recent increases in the incidence of road traffic injuries--are matters of concern. BRICS may need stronger institutional capacity to address such changes in a timely way. In this paper, we present data on road traffic injuries in BRICS and illustrate the enormous challenge that these countries currently face in reducing the incidence of such injuries. There is an urgent need to improve road safety indicators in every country constituting BRICS. It is imperative for BRICS to invest in system-wide road safety interventions and reduce the mortality and morbidity from road traffic injuries.

Improving ICU risk management and patient safety.

Science.gov (United States)

Kielty, Lucy Ann

2017-06-12

Purpose The purpose of this paper is to describe a study which aimed to develop and validate an assessment method for the International Electrotechnical Commission (IEC) 80001-1 (IEC, 2010) standard (the Standard); raise awareness; improve medical IT-network project risk management processes; and improve intensive care unit patient safety. Design/methodology/approach An assessment method was developed and piloted. A healthcare IT-network project assessment was undertaken using a semi-structured group interview with risk management stakeholders. Participants provided feedback via a questionnaire. Descriptive statistics and thematic analysis was undertaken. Findings The assessment method was validated as fit for purpose. Participants agreed (63 per cent, n=7) that assessment questions were clear and easy to understand, and participants agreed (82 per cent, n=9) that the assessment method was appropriate. Participant's knowledge of the Standard increased and non-compliance was identified. Medical IT-network project strengths, weaknesses, opportunities and threats in the risk management processes were identified. Practical implications The study raised awareness of the Standard and enhanced risk management processes that led to improved patient safety. Study participants confirmed they would use the assessment method in future projects. Originality/value Findings add to knowledge relating to IEC 80001-1 implementation.

Improvements in operational safety performance of the Magnox power stations

Energy Technology Data Exchange (ETDEWEB)

Marchese, C.J. [BNFL Magnox Generation, Berkeley (United Kingdom)

2000-10-01

In the 43 years since commencement of operation of Calder Hall, the first Magnox power station, there remain eight Magnox stations and 20 reactors still in operation, owned by BNFL Magnox Generation. This paper describes how the operational safety performance of these stations has significantly improved over the last ten years. This has been achieved against a background of commercial competition introduced by privatization and despite the fact that the Magnox base design belongs to the past. Finally, the company's future plans for continued improvements in operational safety performance are discussed. (author)

The Challenges and Prospects of Teaching and Learning Dramatic ...

African Journals Online (AJOL)

Dramatic education is an all-inclusive academic discipline which uses as tools branches of learning that bear upon the dramatic impulse. It utilizes eclectically each and every single discipline into one unified body of knowledge, so that it can help man to comprehend the nature of experience. Educational drama or Dramatic ...

Five Topics Health Care Simulation Can Address to Improve Patient Safety

DEFF Research Database (Denmark)

Sollid, Stephen J M; Dieckman, Peter; Aase, Karina

2017-01-01

OBJECTIVES: There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore...... initiated to define priorities in health care simulation that contribute the most to improve patient safety.  METHODS: An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2......-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies...

Does external evaluation of laboratories improve patient safety?

Science.gov (United States)

Noble, Michael A

2007-01-01

Laboratory accreditation and External Quality Assessment (also called proficiency testing) are mainstays of laboratory quality assessment and performance. Both practices are associated with examples of improved laboratory performance. The relationship between laboratory performance and improved patient safety is more difficult to assess because of the many variables that are involved with patient outcome. Despite this difficulty, the argument to continue external evaluation of laboratories is too compelling to consider the alternative.

Optimization of safety equipment outages improves safety

International Nuclear Information System (INIS)

Cepin, Marko

2002-01-01

Testing and maintenance activities of safety equipment in nuclear power plants are an important potential for risk and cost reduction. An optimization method is presented based on the simulated annealing algorithm. The method determines the optimal schedule of safety equipment outages due to testing and maintenance based on minimization of selected risk measure. The mean value of the selected time dependent risk measure represents the objective function of the optimization. The time dependent function of the selected risk measure is obtained from probabilistic safety assessment, i.e. the fault tree analysis at the system level and the fault tree/event tree analysis at the plant level, both extended with inclusion of time requirements. Results of several examples showed that it is possible to reduce risk by application of the proposed method. Because of large uncertainties in the probabilistic safety assessment, the most important result of the method may not be a selection of the most suitable schedule of safety equipment outages among those, which results in similarly low risk. But, it may be a prevention of such schedules of safety equipment outages, which result in high risk. Such finding increases the importance of evaluation speed versus the requirement of getting always the global optimum no matter if it is only slightly better that certain local one

Discussion on establishment and improvement of the nuclear safety culture system

International Nuclear Information System (INIS)

Lu Weiqiang; Na Fuli

2010-01-01

By discussion of the problems in the manufacture process of nuclear power equipment enterprisers, puts forwards the tentative idea of establishment the nuclear safety culture system, meanwhile, gives some suggestions in order to improving the nuclear safety culture system. (authors)

Organizational factors influencing improvements in safety

International Nuclear Information System (INIS)

Marcus, A.; Nichols, M.L.; Olson, J.; Osborn, R.; Thurber, J.

1991-01-01

Results of conceptual and empirical research conducted by this research team, and published in NUREG-CR 5437, suggested that processes of organizational problem solving and learning provide a promising area for understanding improvement in safety-related performance in nuclear power plants. In this paper the authors describe the way in which they have built upon that work and gone much further in empirically examining a range of potentially important organizational factors related to safety. The paper describes (1) overall trends in plant performance over time on the Nuclear Regulatory Commission performance indicators, (2) the major elements in the conceptual framework guiding the current work, which seeks among other things to explain those trends, (3) the specific variables used as measures of the central concepts, (4) the results to date of the quantitative empirical work and qualitative work in progress, and (5) conclusions from the research

Processing and storage of blood components: strategies to improve patient safety

Directory of Open Access Journals (Sweden)

Pietersz RNI

2015-08-01

Full Text Available Ruby NI Pietersz, Pieter F van der Meer Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands Abstract: This review focuses on safety improvements of blood processing of various blood components and their respective storage. A solid quality system to ensure safe and effective blood components that are traceable from a donor to the patient is the foundation of a safe blood supply. To stimulate and guide this process, National Health Authorities should develop guidelines for blood transfusion, including establishment of a quality system. Blood component therapy enabled treatment of patients with blood constituents that were missing, only thus preventing reactions to unnecessarily transfused elements. Leukoreduction prevents many adverse reactions and also improves the quality of the blood components during storage. The safety of red cells and platelets is improved by replacement of plasma with preservative solutions, which results in the reduction of isoantibodies and plasma proteins. Automation of blood collection, separation of whole blood into components, and consecutive processing steps, such as preparation of platelet concentrate from multiple donations, improves the consistent composition of blood components. Physicians can better prescribe the number of transfusions and therewith reduce donor exposure and/or the risk of pathogen transmission. Pathogen reduction in cellular blood components is the latest development in improving the safety of blood transfusions for patients. Keywords: blood components, red cell concentrates, platelet concentrates, plasma, transfusion, safety 

Improvement of Safety Assessment Methodologies for Near Surface Disposal Facilities

International Nuclear Information System (INIS)

Batandjieva, B.; Torres-Vidal, C.

2002-01-01

The International Atomic Energy Agency (IAEA) Coordinated research program ''Improvement of Safety Assessment Methodologies for Near Surface Disposal Facilities'' (ISAM) has developed improved safety assessment methodology for near surface disposal facilities. The program has been underway for three years and has included around 75 active participants from 40 countries. It has also provided examples for application to three safety cases--vault, Radon type and borehole radioactive waste disposal facilities. The program has served as an excellent forum for exchange of information and good practices on safety assessment approaches and methodologies used worldwide. It also provided an opportunity for reaching broad consensus on the safety assessment methodologies to be applied to near surface low and intermediate level waste repositories. The methodology has found widespread acceptance and the need for its application on real waste disposal facilities has been clearly identified. The ISAM was finalized by the end of 2000, working material documents are available and an IAEA report will be published in 2002 summarizing the work performed during the three years of the program. The outcome of the ISAM program provides a sound basis for moving forward to a new IAEA program, which will focus on practical application of the safety assessment methodologies to different purposes, such as licensing radioactive waste repositories, development of design concepts, upgrading existing facilities, reassessment of operating repositories, etc. The new program will also provide an opportunity for development of guidance on application of the methodology that will be of assistance to both safety assessors and regulators

Innovative Patient Safety Curriculum Using iPAD Game (PASSED) Improved Patient Safety Concepts in Undergraduate Medical Students.

Science.gov (United States)

Kow, A W C; Ang, B L S; Chong, C S; Tan, W B; Menon, K R

2016-11-01

While healthcare outcomes have improved significantly, the complex management of diseases in the hospitals has also escalated the risks in patient safety. Therefore, in the process of training medical students to be proficient in medical knowledge and skills, the importance of patient safety cannot be neglected. A new innovation using mobile apps gaming system (PAtient Safety in Surgical EDucation-PASSED) to teach medical students on patient safety was created. Students were taught concepts of patient safety followed by a gaming session using iPad games created by us. This study aims to evaluate the outcome of patient safety perception using the PASSED games created. An interactive iPad game focusing on patient safety issues was created by the undergraduate education team in the Department of Surgery, Yong Loo Lin School of Medicine at the National University of Singapore. The game employed the unique touched-screen feature with clinical scenarios extracted from the hospital sentinel events. Some of the questions were time sensitive, with extra bonus marks awarded if the student provided the correct answer within 10 s. Students could reattempt the questions if the initial answer was wrong. However, this entailed demerit points. Third-year medical students posted to the Department of Surgery experienced this gaming system in a cohort of 55-60 students. Baseline understanding of the students on patient safety was evaluated using Attitudes to Patient Safety Questionnaire III (APSQ-III) prior to the game. A 20 min talk on concept of patient safety using the WHO Patient Safety Guidelines was conducted. Following this, students downloaded the apps from ITune store and played with the game for 20-30 min. The session ended with the students completing the postintervention questionnaire. A total of 221 3rd year medical students responded to the survey during the PASSED session. Majority of the students felt that the PASSED game had trained them to understand the

Improving Patient Safety in Anesthesia: A Success Story?

International Nuclear Information System (INIS)

Botney, Richard

2008-01-01

Anesthesia is necessary for surgery; however, it does not deliver any direct therapeutic benefit. The risks of anesthesia must therefore be as low as possible. Anesthesiology has been identified as a leader in improving patient safety. Anesthetic mortality has decreased, and in healthy patients can be as low as 1:250,000. Trends in anesthetic morbidity have not been as well defined, but it appears that the risk of injury is decreasing. Studies of error during anesthesia and Closed Claims studies have identified sources of risk and methods to reduce the risks associated with anesthesia. These include changes in technology, such as anesthetic delivery systems and monitors, the application of human factors, the use of simulation, and the establishment of reporting systems. A review of the important events in the past 50 years illustrates the many steps that have contributed to the improvements in anesthesia safety

Feedback from incident reporting: information and action to improve patient safety.

Science.gov (United States)

Benn, J; Koutantji, M; Wallace, L; Spurgeon, P; Rejman, M; Healey, A; Vincent, C

2009-02-01

Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. The research comprised a mixed methods review to investigate mechanisms of effective feedback for healthcare, drawing upon experience within established reporting programmes in high-risk industry and transport domains. Systematic searches of published literature were undertaken, and 23 case studies describing incident reporting programmes with feedback were identified for analysis from the international healthcare literature. Semistructured interviews were undertaken with 19 subject matter experts across a range of domains, including: civil aviation, maritime, energy, rail, offshore production and healthcare. In analysis, qualitative information from several sources was synthesised into practical requirements for developing effective feedback in healthcare. Both action and information feedback mechanisms were identified, serving safety awareness, improvement and motivational functions. The provision of actionable feedback that visibly improved systems was highlighted as important in promoting future reporting. Fifteen requirements for the design of effective feedback systems were identified, concerning: the role of leadership, the credibility and content of information, effective dissemination channels, the capacity for rapid action and the need for feedback at all levels of the organisation, among others. Above all, the safety-feedback cycle must be closed by ensuring that reporting, analysis and

Multi-approach model for improving agrochemical safety among rice farmers in Pathumthani, Thailand

Directory of Open Access Journals (Sweden)

Siriwong W

2012-07-01

Full Text Available Buppha Raksanam,1,2 Surasak Taneepanichskul,2 Wattasit Siriwong,2 Mark Robson3,41Sirindhorn College of Public Health, Trang, 2College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand; 3School of Environmental and Biological Sciences, Rutgers University, 4School of Public Health, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ, USAAbstract: The large-scale use of agrochemicals has raised environmental and human health concerns. A comprehensive intervention strategy for improving agrochemical safety among rice farmers in Thailand is lacking. The objective of this study is to develop a model in order to improve farmers’ health and prevent them from being exposed to agrochemical hazards, in addition to evaluating the effectiveness of the intervention in terms of agrochemical safety. This study was conducted between October 2009 and January 2011. It measures changes in the mean scores of agrochemical knowledge, health beliefs, agrochemical use behaviors, and in-home pesticide safety. Knowledge of agrochemical use constitutes a basic knowledge of agrochemicals and agrochemical safety behaviors. Health beliefs constitute perceived susceptibility, severity, benefits, and barriers to using agrochemicals. Agrochemical use behaviors include self-care practices in terms of personal health at specific times including before spraying, while spraying, during storage, transportation, waste management, and health risk management. Fifty rice farmers from Khlong Seven Community (study group and 51 rice farmers from Bueng Ka Sam community (control group were randomly recruited with support from community leaders. The participants were involved in a combination of home visits (ie, pesticide safety assessments at home and community participatory activities regarding agrochemical safety. This study reveals that health risk behaviors regarding agrochemical exposure in the study area are mainly caused by lack of attention to

Improving Patient Safety With the Military Electronic Health Record

National Research Council Canada - National Science Library

Charles, Marie-Jocelyne; Harmon, Bart J; Jordan, Pamela S

2005-01-01

The United States Department of Defense (DoD) has transformed health care delivery in its use of information technology to automate patient data documentation, leading to improvements in patient safety...

Therapeutic doll play in the treatment of a severely impaired psychiatric inpatient: dramatic clinical improvements with a nontraditional nursing intervention.

Science.gov (United States)

Birnbaum, Shira; Hanchuk, Hilary; Nelson, Marjorie

2015-05-01

Interest has grown in the use of doll therapy, particularly in geropsychiatric and dementia care settings. In a long-term state psychiatric hospital, a dollhouse-play activity was implemented in an effort to engage an acutely disturbed, middle-aged woman undergoing medication trials and whose symptoms had been refractory to conventional treatments. A schedule of nondirective dollhouse-play activities was implemented over an 8-week period. Measures of behavioral change were tracked. Dramatic clinical improvements were seen, including significant reductions in verbal and physical aggression, use of as-needed medications, and need for close one-to-one monitoring. Improvements were seen prior to achievement of therapeutic drug levels. The patient was successfully discharged from the hospital. Doll play has recently been associated with clinical benefits in the care of patients with dementia and has long been deployed in childhood mental health treatment. The current findings suggest doll play may have applications as a time-limited intervention in the treatment of major psychiatric disorders in adults and warrants consideration when achieving therapeutic alliance has proven particularly challenging. Copyright 2015, SLACK Incorporated.

Opportunities for Using Building Information Modeling to Improve Worker Safety Performance

Directory of Open Access Journals (Sweden)

Kasim Alomari

2017-02-01

Full Text Available Building information modelling (BIM enables the creation of a digital representation of a designed facility combined with additional information about the project attributes, performance criteria, and construction process. Users of BIM tools point to the ability to visualize the final design along with the construction process as a beneficial feature of using BIM. Knowing the construction process in relationship to a facility’s design benefits both safety professionals when planning worker safety measures for a project and designers when creating a project’s design. Success in using BIM to enhance safety partly depends on the familiarity of project personnel with BIM tools and the extent to which the tools can be used to identify and eliminate safety hazards. In a separate, ongoing study, the authors investigated the connection between BIM and safety to document the opportunities, barriers, and impacts. Utilizing an on-line survey of project engineers who work for construction firms together with a comprehensive literature review, the study found those who use BIM feel that it aids in communication of project information and project delivery, both of which have been found to have positive impacts on construction site safety. Further, utilizing the survey results, the authors apply the binary logistic regression econometric framework to better understand the factors that lead to safety professionals believing that BIM increases safety in the work place. In addition, according to the survey results, a large percentage of the engineers who use BIM feel that ultimately it helps to eliminate safety hazards and improve worker safety. The study findings suggest that improvements in safety performance across the construction industry may be due in part to increased use of BIM in the construction industry.

NPP Krsko core calculations to improve operational safety

International Nuclear Information System (INIS)

Ivekovic, I.; Grgic, D.; Nemec, T.

2007-01-01

Calculation tools and methodology used to perform independent calculations of cumulative influence of different changes related to fuel and core operation of NPP Krsko were described. Some examples of steady state and transient results are used to illustrate potential improvements to understanding and reviewing plant safety. (author)

Thermal-hydraulics technological strategy roadmap for LWR safety improvement and development

International Nuclear Information System (INIS)

Nakamura, Hideo; Arai, Kenji; Oikawa, Hirohide

2015-01-01

New version of the Thermal-Hydraulics Safety Evaluation Fundamental Technology Enhancement Strategy Roadmap (TH-RM) was developed by the Atomic Energy Society of Japan (AESJ) for LWR safety improvement and development. The 1st version of TH-RM was prepared in 2009 under collaboration of utilities, vendors, universities, research institutes and technical support organizations (TSO) for regulatory body. The revision was made by three sub-working groups (SWGs) by considering the lessons learned from the Fukushima Daiichi Accident. The 'safety assessment' SWG pursued development of computer codes for safety assessment. The 'fundamental technology' SWG pursued safety improvement and risk reduction via accident management (AM) measures by referring the technical map for severe accident (SA) established by the 'severe accident' SWG. Phenomena and components for counter-measures and/or proper prediction are identified by going through SA progression in both reactor and spent-fuel pool of PWR and BWR. Twelve important technology development subjects were identified, which include melt coolability enhancement to maintain integrity of containment vessel. Fact Sheet was developed to describe each of identified and selected R and D subjects. External hazards are also considered how to cope with from thermal-hydraulic safety point of view. This paper summarizes the revised TH-RM with several examples and future perspectives. (author)

Constructing a Bayesian network model for improving safety behavior of employees at workplaces.

Science.gov (United States)

Mohammadfam, Iraj; Ghasemi, Fakhradin; Kalatpour, Omid; Moghimbeigi, Abbas

2017-01-01

Unsafe behavior increases the risk of accident at workplaces and needs to be managed properly. The aim of the present study was to provide a model for managing and improving safety behavior of employees using the Bayesian networks approach. The study was conducted in several power plant construction projects in Iran. The data were collected using a questionnaire composed of nine factors, including management commitment, supporting environment, safety management system, employees' participation, safety knowledge, safety attitude, motivation, resource allocation, and work pressure. In order for measuring the score of each factor assigned by a responder, a measurement model was constructed for each of them. The Bayesian network was constructed using experts' opinions and Dempster-Shafer theory. Using belief updating, the best intervention strategies for improving safety behavior also were selected. The result of the present study demonstrated that the majority of employees do not tend to consider safety rules, regulation, procedures and norms in their behavior at the workplace. Safety attitude, safety knowledge, and supporting environment were the best predictor of safety behavior. Moreover, it was determined that instantaneous improvement of supporting environment and employee participation is the best strategy to reach a high proportion of safety behavior at the workplace. The lack of a comprehensive model that can be used for explaining safety behavior was one of the most problematic issues of the study. Furthermore, it can be concluded that belief updating is a unique feature of Bayesian networks that is very useful in comparing various intervention strategies and selecting the best one form them. Copyright © 2016 Elsevier Ltd. All rights reserved.

Theodramatic Rehearsal: Fighting Self-Deception through the Dramatic Imagination

Directory of Open Access Journals (Sweden)

Brett Vaden

2014-03-01

Full Text Available This paper seeks to appropriate the insights of dramatic theology for Christian psychology and soul care. According to Kevin Vanhoozer, Scripture is the ‘script’ for human beings’ fitting participation in the acts and deeds of God in the world (i.e., ‘theodrama’. Keeping with this dramatic paradigm, the author will explore what ‘rehearsal’ might entail by drawing from a branch of psychotherapy called ‘psychodrama.’ The main question to be addressed in this appropriation of dramatic theology is, “How might dramatic rehearsal combat self-deception?” The author will only begin to answer this question, but in the attempt it is hoped that further reflection and clarity will be induced.

Improvement of safety by analysis of costs and benefits of the system

OpenAIRE

T. Karkoszka; M. Andraczke

2011-01-01

Purpose: of the paper has been the assessment of the dependence between improvement of the implemented occupational health and safety management system and both minimization of costs connected with occupational health and safety assurance and optimization of real work conditions.Design/methodology/approach: used for the analysis has included definition of the occupational health and safety system with regard to the rules and tool allowing for occupational safety assurance in the organisationa...

Improving the safety of fresh fruit and vegetables

NARCIS (Netherlands)

Jongen, W.M.F.

2005-01-01

Fresh fruit and vegetables have been identified as a significant source of pathogens and chemical contaminants. As a result, there has been a wealth of research on identifying and controlling hazards at all stages in the supply chain. Improving the safety of fresh fruit and vegetables reviews this

Improving the safety of Ukrainian NPP to reach an internationally accepted level

International Nuclear Information System (INIS)

Bozhko, S.; Helske, J.; Janke, R.; Mayoral, C.

2013-01-01

This paper summarizes the safety status and the modernization progress of Ukrainian NPPs towards an internationally accepted level of safety. After a brief discussion of the concept of what is called an 'international accepted level' for new and operating NPPs, the status of Russian type WWER and in particular the Ukrainian NPPs is presented. Then, the performed investigations of the gaps between international accepted level and the original status of Ukrainian NPPs are presented. The safety objectives of the modernization programs, some examples of defence in depth improvements, and an overall view of the modernization programs of Ukrainian NPPs are produced. Then, few important safety improvements implemented at the oldest Ukrainian WWER-1000 South Ukraine-1 are given in more detail. Finally, a conclusion presents the current status on the way to fulfill the national safety targets and to reach an internationally accepted level for all the Ukrainian NPPs. The paper is followed by the slides of the presentation. (authors)

Patient Safety Culture and the Ability to Improve: A Proof of Concept Study on Hand Hygiene.

Science.gov (United States)

Caris, Martine G; Kamphuis, Pim G A; Dekker, Mireille; de Bruijne, Martine C; van Agtmael, Michiel A; Vandenbroucke-Grauls, Christina M J E

2017-11-01

OBJECTIVE To investigate whether the safety culture of a hospital unit is associated with the ability to improve. DESIGN Qualitative investigation of safety culture on hospital units following a before-and-after trial on hand hygiene. SETTING VU University Medical Center, a tertiary-care hospital in the Netherlands. METHODS With support from hospital management, we implemented a hospital-wide program to improve compliance. Over 2 years, compliance was measured through direct observation, twice before, and 4 times after interventions. We analyzed changes in compliance from baseline, and selected units to evaluate safety culture using a positive deviance approach: the hospital unit with the highest hand hygiene compliance and 2 units that showed significant improvement (21% and 16%, respectively) were selected as high performing. Another 2 units showed no improvement and were selected as low performing. A blinded, independent observer conducted interviews with unit management, physicians, and nurses, based on the Hospital Survey on Patient Safety Culture. Safety culture was categorized as pathological (lowest level), reactive, bureaucratic, proactive, or generative (highest level). RESULTS Overall, 3 units showed a proactive or generative safety culture and 2 units had bureaucratic or pathological safety cultures. When comparing compliance and interview results, high-performing units showed high levels of safety culture, while low-performing units showed low levels of safety culture. CONCLUSIONS Safety culture is associated with the ability to improve hand hygiene. Interventions may not be effective when applied in units with low levels of safety culture. Although additional research is needed to corroborate our findings, the safety culture on a unit can benefit from enhancement strategies such as team-building exercises. Strengthening the safety culture before implementing interventions could aid improvement and prevent nonproductive interventions. Infect Control

Progress toward international agreement to improve reactor safety

International Nuclear Information System (INIS)

Lieberman, J.I.; Graham, B.

1993-01-01

Representatives of nearly one-half of the 114 member states of the International Atomic Energy Agency (IAEA), including the United States, have participated in the development of an international nuclear safety conventions proposed multilateral treaty to improve civil nuclear power reactor safety. A preliminary draft of the convention has been developed (referred to as the draft convention for this report), but discussions are continuing, and when the final convention text will be completed and presented to IAEA member states for signature is uncertain. This report responds to the former and current Chairman's request that we provide information on the development of the nuclear safety convention, including a discussion of (1) the draft convention's scope and objectives, (2) how the convention will be implemented and monitored, (3) the views of selected country representatives on what provisions should be included in the draft convention, and (4) the convention's potential benefits and limitations

Do clinical safety charts improve paramedic key performance indicator results? (A clinical improvement programme evaluation).

Science.gov (United States)

Ebbs, Phillip; Middleton, Paul M; Bonner, Ann; Loudfoot, Allan; Elliott, Peter

2012-07-01

Is the Clinical Safety Chart clinical improvement programme (CIP) effective at improving paramedic key performance indicator (KPI) results within the Ambulance Service of New South Wales? The CIP intervention area was compared with the non-intervention area in order to determine whether there was a statistically significant improvement in KPI results. The CIP was associated with a statistically significant improvement in paramedic KPI results within the intervention area. The strategies used within this CIP are recommended for further consideration.

Improvement of Safety Features in Standard Operation Procedure of Tc-99m Generator

International Nuclear Information System (INIS)

Manisah Saedon; Mohd Khairul Hakimi; Shyen, A.K.S.

2011-01-01

This paper describes the improvements proposed to the original production procedures for Tc-99m generators. Improvements are intended to add safety and health features for workers into the existing procedures. The difference between the new safe work procedures from the original work procedures; is the concern about the safety and health of employees other than the product safety. One of the suggested safety characteristics is by using the visual aid so that the workers can easily see and read the procedures when they perform their duties, whereas the previous procedures are kept in the manual and difficult to access. The purpose of this paper is to share information about the importance of safety and health features for the workers in the procedures established in addition to provide awareness to all parties involved. (author)

Intravenous immunoglobulin therapy leading to dramatic improvement in a patient with systemic juvenile idiopathic arthritis and severe pericarditis resistant to steroid pulse therapy.

Science.gov (United States)

Aizawa-Yashiro, Tomomi; Oki, Eishin; Tsuruga, Kazushi; Nakahata, Tohru; Ito, Etsuro; Tanaka, Hiroshi

2012-05-01

A 7-year-old Japanese boy with a 4-month history of systemic juvenile idiopathic arthritis (s-JIA) experienced disease flare with spiking fever, exanthema and arthralgia. He then developed progressive dyspnea due to severe pericarditis, and proinflammatory hypercytokinemia was suspected. Methylprednisolone pulse therapy was ineffective and echocardiography showed massive pericardial effusion had persisted. Alternatively, subsequent intravenous immunoglobulin (IVIG) therapy resulted in dramatic resolution of the pericardial effusion, and his general condition significantly improved within a few days. This case report may lend further support the use of IVIG for selected patients with s-JIA and severe pericarditis.

Organisational learning and continuous improvement of health and safety in certified manufacturers

DEFF Research Database (Denmark)

Granerud, Lise; Rocha, Robson Sø

2011-01-01

and raise goals within health and safety on a continuous basis. The article examines how certified occupational and health management systems influence this process to evaluate how far they hinder or support learning. It presents a model with which it is possible to identify and analyse improvement......Certified management systems have increasingly been applied by firms in recent decades and now cover the management of health and safety, principally through the OHSAS 18001 standard. In order to become certified, firms must not only observe the relevant legislation, but also improve performance...... processes. The model is applied to five cases from a qualitative study of Danish manufacturers with certified health and safety management systems. The cases illustrate the wide variation in health and safety management among certified firms. Certification is found to support lower levels of continuous...

Design of marine structures with improved safety for environment

International Nuclear Information System (INIS)

Klanac, Alan; Varsta, Petri

2011-01-01

The paper describes a method for design of marine structures with increased safety for environment, considering also the required investment costs as well as the aspects of risk distribution onto the maritime stakeholders. Practically, the paper seeks to answer what is the optimal amount that should be invested into certain safety measure for any given vessel. Due to the uneven distribution of risk, as well as the differing impact of costs emerging from safety improvements, stakeholders experience conflicting ranking of alternatives. To solve this multi-stakeholder decision-making problem, in which each stakeholder is a decision-maker, the method applies concepts of group decision-making theory, namely the Game Theory. The method fosters axiomatic definition of the optimum solution, arguing that the solution, or the final selected design, should satisfy the non-dominance, efficiency, and fairness. These three are thoroughly discussed in terms of structural design, especially the latter. Considering the coupling of environmental risk and structural design, the method also builds on the preference structure of four maritime stakeholders: yards, owners, oil receivers and the public, who either share the risks or directly influence structural design. Method is presented on a practical study of structural design of a tanker with a crashworthy side structure that is capable of reducing the risk of collision. The outcome of this study outlines a number of possibilities for successful improvement of tanker safety that can benefit, concurrently, all maritime stakeholders.

Taking up national safety alerts to improve patient safety in hospitals: The perspective of healthcare quality and risk managers.

Science.gov (United States)

Pfeiffer, Yvonne; Schwappach, David

2016-01-01

National safety alert systems publish relevant information to improve patient safety in hospitals. However, the information has to be transformed into local action to have an effect on patient safety. We studied three research questions: How do Swiss healthcare quality and risk managers (qm/rm(1)) see their own role in learning from safety alerts issued by the Swiss national voluntary reporting and analysis system? What are their attitudes towards and evaluations of the alerts, and which types of improvement actions were fostered by the safety alerts? A survey was developed and applied to Swiss healthcare risk and quality managers, with a response rate of 39 % (n=116). Descriptive statistics are presented. The qm/rm disseminate and communicate with a broad variety of professional groups about the alerts. While most respondents felt that they should know the alerts and their contents, only a part of them felt responsible for driving organizational change based on the recommendations. However, most respondents used safety alerts to back up their own patient safety goals. The alerts were evaluated positively on various dimensions such as usefulness and were considered as standards of good practice by the majority of the respondents. A range of organizational responses was applied, with disseminating information being the most common. An active role is related to using safety alerts for backing up own patient safety goals. To support an active role of qm/rm in their hospital's learning from safety alerts, appropriate organizational structures should be developed. Furthermore, they could be given special information or training to act as an information hub on the issues discussed in the alerts. Copyright © 2016. Published by Elsevier GmbH.

Danish initiatives to improve the safety of meat products

DEFF Research Database (Denmark)

Wegener, Henrik Caspar

2010-01-01

and Campylobacter, and to a lesser extent Yersinia, Escherichia coli O157 and Listeria. Danish initiatives to improve the safety of meat products have focused on the entire production chain from the farm to the consumer, with a special emphasis on the pre-harvest stage of production. The control of bacterial......During the last two decades the major food safety problems in Denmark, as determined by the number of human patients, has been associated with bacterial infections stemming from meat products and eggs. The bacterial pathogens causing the majority of human infections has been Salmonella...

The association between event learning and continuous quality improvement programs and culture of patient safety.

Science.gov (United States)

Mazur, Lukasz; Chera, Bhishamjit; Mosaly, Prithima; Taylor, Kinley; Tracton, Gregg; Johnson, Kendra; Comitz, Elizabeth; Adams, Robert; Pooya, Pegah; Ivy, Julie; Rockwell, John; Marks, Lawrence B

2015-01-01

To present our approach and results from our quality and safety program and to report their possible impact on our culture of patient safety. We created an event learning system (termed a "good catch" program) and encouraged staff to report any quality or safety concerns in real time. Events were analyzed to assess the utility of safety barriers. A formal continuous quality improvement program was created to address these reported events and make improvements. Data on perceptions of the culture of patient safety were collected using the Agency for Health Care Research and Quality survey administered before, during, and after the initiatives. Of 560 good catches reported, 367 could be ascribed to a specific step on our process map. The calculated utility of safety barriers was highest for those embedded into the pretreatment quality assurance checks performed by physicists and dosimetrists (utility score 0.53; 93 of 174) and routine checks done by therapists on the initial day of therapy. Therapists and physicists reported the highest number of good catches (24% each). Sixty-four percent of events were caused by performance issues (eg, not following standardized processes, including suboptimal communications). Of 31 initiated formal improvement events, 26 were successfully implemented and sustained, 4 were discontinued, and 1 was not implemented. Most of the continuous quality improvement program was conducted by nurses (14) and therapists (7). Percentages of positive responses in the patient safety culture survey appear to have increased on all dimensions (p continuous quality improvement programs can be successfully implemented and that there are contemporaneous improvements in the culture of safety. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Assessment of freeway work zone safety with improved cellular automata model

Directory of Open Access Journals (Sweden)

Guohua Liang

2014-08-01

Full Text Available To accurately assess the safety of freeway work zones, this paper investigates the safety of vehicle lane change maneuvers with improved cellular automata model. Taking the traffic conflict and standard deviation of operating speed as the evaluation indexes, the study evaluates the freeway work zone safety. With improved deceleration probability in car-following raies and the addition of lanechanging rules under critical state, the lane-changing behavior under critical state is defined as a conflict count. Through 72 schemes of simulation runs, the possible states of the traffic flow are carefully studied. The results show that under the condition of constant saturation traffic conflict count and vehicle speed standard deviation reach their maximums when the mixed rate of heave vehicles is 40%. Meanwhile, in the case of constant heavy vehicles mix, traffic conflict count and vehicle speed standard deviation reach maximum values when saturation rate is 0. 75. Integrating ail simulation results, it is known the traffic safety in freeway work zones is classified into four levels : safe, relatively safe, relatively dangerous, and dangerous.

Development and improvement of safety analysis code for geological disposal

Energy Technology Data Exchange (ETDEWEB)

NONE

2013-08-15

In order to confirm the long-term safety concerning geological disposal, probabilistic safety assessment code and other analysis codes, which can evaluate possibility of each event and influence on engineered barrier and natural barrier by the event, were introduced. We confirmed basic functions of those codes and studied the relation between those functions and FEP/PID which should be taken into consideration in safety assessment. We are planning to develop 'Nuclide Migration Assessment System' for the purpose of realizing improvement in efficiency of assessment work, human error prevention for analysis, and quality assurance of the analysis environment and analysis work for safety assessment by using it. As the first step, we defined the system requirements and decided the system composition and functions which should be mounted in them based on those requirements. (author)

Continuous restraint control systems: safety improvement for various occupants

NARCIS (Netherlands)

Laan, E. van der; Jager, B. de; Veldpaus, F.; Steinbuch, M.; Nunen, E. van; Willemsen, D.

2009-01-01

Occupant safety can be significantly improved by continuous restraint control systems. These restraint systems adjust their configuration during the impact according to the actual operating conditions, such as occupant size, weight, occupant position, belt usage and crash severity. In this study,

Plan for research to improve the safety of light-water nuclear power plants

International Nuclear Information System (INIS)

1978-03-01

This is the U.S. Nuclear Regulatory Commission's first annual report to Congress on recommendations for research on improving the safety of light-water nuclear power plants. Suggestions for reactor safety research were identified in, or received from, various sources, including the Advisory Committee on Reactor Safeguards, the NRC regulatory staff, and the consultants to the Research Review Group. After an initial screening to eliminate those not related to improved reactor safety, all the suggestions were consolidated into research topics. It is recommended that the following research projects be carried out: alternate containment concepts, especially vented containments; alternate decay heat removal concepts, especially add-on bunkered systems; alternate emergency core cooling concepts; improved in-plant accident response; and advanced seismic designs

Learning through Dramatic Story Presentation

Science.gov (United States)

Tindall, Evie

2012-01-01

The use of story with dramatic presentation approaches produces an engaging and powerful instructional choice for today's adult ESL educators. Two engaging and timed-tested approaches are Reader's Theater and Tableau Vivant. Both provide English language learners with content tailored to their abilities in addition to numerable opportunities to…

The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement, Research, Training, and Practice.

Science.gov (United States)

Pronovost, Peter J; Holzmueller, Christine G; Molello, Nancy E; Paine, Lori; Winner, Laura; Marsteller, Jill A; Berenholtz, Sean M; Aboumatar, Hanan J; Demski, Renee; Armstrong, C Michael

2015-10-01

Academic medical centers (AMCs) could advance the science of health care delivery, improve patient safety and quality improvement, and enhance value, but many centers have fragmented efforts with little accountability. Johns Hopkins Medicine, the AMC under which the Johns Hopkins University School of Medicine and the Johns Hopkins Health System are organized, experienced similar challenges, with operational patient safety and quality leadership separate from safety and quality-related research efforts. To unite efforts and establish accountability, the Armstrong Institute for Patient Safety and Quality was created in 2011.The authors describe the development, purpose, governance, function, and challenges of the institute to help other AMCs replicate it and accelerate safety and quality improvement. The purpose is to partner with patients, their loved ones, and all interested parties to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste in health care. A governance structure was created, with care mapped into seven categories, to oversee the quality and safety of all patients treated at a Johns Hopkins Medicine entity. The governance has a Patient Safety and Quality Board Committee that sets strategic goals, and the institute communicates these goals throughout the health system and supports personnel in meeting these goals. The institute is organized into 13 functional councils reflecting their behaviors and purpose. The institute works daily to build the capacity of clinicians trained in safety and quality through established programs, advance improvement science, and implement and evaluate interventions to improve the quality of care and safety of patients.

Nature-Based Strategies for Improving Urban Health and Safety.

Science.gov (United States)

Kondo, Michelle C; South, Eugenia C; Branas, Charles C

2015-10-01

Place-based programs are being noticed as key opportunities to prevent disease and promote public health and safety for populations at-large. As one key type of place-based intervention, nature-based and green space strategies can play an especially large role in improving health and safety for dwellers in urban environments such as US legacy cities that lack nature and greenery. In this paper, we describe the current understanding of place-based influences on public health and safety. We focus on nonchemical environmental factors, many of which are related to urban abandonment and blight. We then review findings from studies of nature-based interventions regarding impacts on health, perceptions of safety, and crime. Based on our findings, we suggest that further research in this area will require (1) refined measures of green space, nature, and health and safety for cities, (2) interdisciplinary science and cross-sector policy collaboration, (3) observational studies as well as randomized controlled experiments and natural experiments using appropriate spatial counterfactuals and mixed methods, and (4) return-on-investment calculations of potential economic, social, and health costs and benefits of urban greening initiatives.

Legacy data sharing to improve drug safety assessment: the eTOX project

DEFF Research Database (Denmark)

Sanz, Ferran; Pognan, François; Steger-Hartmann, Thomas

2017-01-01

The sharing of legacy preclinical safety data among pharmaceutical companies and its integration with other information sources offers unprecedented opportunities to improve the early assessment of drug safety. Here, we discuss the experience of the eTOX project, which was established through...

Improvement of operational safety: The self-assessment at the Russian NPPs

International Nuclear Information System (INIS)

Kolotov, Aleksander

2002-01-01

The operating organization has scheduled for the forthcoming year to elaborate the NPP safety self-assessment standards and to settle precise criterion for its performance. Toward this end it was decided to form a Working Team including of NPP and VNIIAES representatives to elaborate major tasks on the self-assessment improvement, development and implementation of new documentation and training the personnel in new methodology. Actions developed by R osenergoatom , one of its items is the participation of 'Rosenergoatom' and VNIIAES representatives in the workshop, contains the sequence of Russian NPP safety self-assessment improvement at the first stage

Housing improvement and home safety Effectiveness Matters

OpenAIRE

, Crd; Sphr@, L; , MrcSphsu

2014-01-01

The homes we live in impact on health, wellbeing and health inequalities. Treating illnesses directly related to living in cold, damp and dangerous homes costs the NHS £2.5 billion per year. Ensuring affordable warmth through insulation and more efficient heating can improve health and wellbeing. Home safety assessment and modification can reduce falls and risk of falling in older people. Education, promotion of exercise and wearing of appropriate footwear, environmental modifications and tra...

Safety cases for the co-ordinated research project on improvement of safety assessment methodologies for near surface radioactive waste disposal facilities (ISAM)

International Nuclear Information System (INIS)

Kozak, M.W.; Torres-Vidal, C.; Kelly, E.; Guskov, A.; Blerk, J. van

2002-01-01

A Co-ordinated Research Project (CRP) has recently been completed on the Improvement of Safety Assessment Methodologies for Near-Surface Radioactive Waste Disposal Facilities (ISAM). A major aspect of the project was the use of safety cases for the practical application of safety assessment. An overview of the ISAM safety cases is given in this paper. (author)

A Quantitative Feasibility Study on Potential Safety Improvement Effects of Advanced Safety Features in APR-1400 when Applied to OPR-1000

Energy Technology Data Exchange (ETDEWEB)

Ualikhan Zhiyenbayev [KAIST, Daejeon (Korea, Republic of); Chung, Dae Wook [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2015-10-15

This study aims to test the feasibility of the applications using Probabilistic Safety Assessment (PSA). Particularly, three of those advanced safety features are selected as follows: 1. Providing an additional Emergency Diesel Generator (EDG); 2. Increasing the capacity of Class 1E batteries; 3. Placing a Refueling Water Storage Tank (RWST) inside containment, i.e., change from RWST to IRWST. The Advanced Power Reactor 1400 (APR-1400) adopts several advanced safety features compared to its predecessor, the Optimized Power Reactor 1000 (OPR-1000), which includes an additional Emergency Diesel Generator, increase in battery capacity, in-containment refueling water storage tank (IRWST), and so on. Considering the remarkable advantages of these safety features in safety improvement and the design similarities between APR-1400 and OPR-1000, it is feasible to apply key advanced safety features of APR-1400 to OPR-1000 to enhance the safety. The selected safety features are incorporated into OPR-1000 PSA model using the Advanced Information Management System (AIMS) for PSA and CDFs are re-evaluated for each application and combination of three applications. Based on current results, it is concluded that three of key advanced safety features of APR-1400 can be effectively applied to OPR-1000, resulting in considerable safety improvement. In aggregate, three advanced safety features, which are an additional EDG, increased battery capacity and IRWST, can reduce the CDF of OPR-1000 by more than 15% when applied altogether.

A Quantitative Feasibility Study on Potential Safety Improvement Effects of Advanced Safety Features in APR-1400 when Applied to OPR-1000

International Nuclear Information System (INIS)

Ualikhan Zhiyenbayev; Chung, Dae Wook

2015-01-01

This study aims to test the feasibility of the applications using Probabilistic Safety Assessment (PSA). Particularly, three of those advanced safety features are selected as follows: 1. Providing an additional Emergency Diesel Generator (EDG); 2. Increasing the capacity of Class 1E batteries; 3. Placing a Refueling Water Storage Tank (RWST) inside containment, i.e., change from RWST to IRWST. The Advanced Power Reactor 1400 (APR-1400) adopts several advanced safety features compared to its predecessor, the Optimized Power Reactor 1000 (OPR-1000), which includes an additional Emergency Diesel Generator, increase in battery capacity, in-containment refueling water storage tank (IRWST), and so on. Considering the remarkable advantages of these safety features in safety improvement and the design similarities between APR-1400 and OPR-1000, it is feasible to apply key advanced safety features of APR-1400 to OPR-1000 to enhance the safety. The selected safety features are incorporated into OPR-1000 PSA model using the Advanced Information Management System (AIMS) for PSA and CDFs are re-evaluated for each application and combination of three applications. Based on current results, it is concluded that three of key advanced safety features of APR-1400 can be effectively applied to OPR-1000, resulting in considerable safety improvement. In aggregate, three advanced safety features, which are an additional EDG, increased battery capacity and IRWST, can reduce the CDF of OPR-1000 by more than 15% when applied altogether

Improved technical specifications and related improvements to safety in commercial Nuclear power plants

International Nuclear Information System (INIS)

Hoffman, D.R.; Demitrack, T.; Schiele, R.; Jones, J.C.

2004-01-01

Many of the commercial nuclear power plants in the United States (US) have been converting a portion of the plant operating license known as the Technical Specifications (TS) in accordance with a document published by the US Nuclear Regulatory Commission (NRC). The TS prescribe commercial nuclear power plant operating requirements. There are several types of nuclear power plants in the US, based on the technology of different vendors, and there is an NRC document that supports each of the five different vendor designs. The NRC documents are known as the Improved Standard Technical Specifications (ISTS) and are contained in a separate document (NUREG series) for each one of the designs. EXCEL Services Corporation (hereinafter EXCEL) has played a major role in the development of the ISTS and in the development, licensing, and implementation of the plant specific Improved Technical Specifications (ITS) (which is based on the ISTS) for the commercial nuclear power plants in the US that have elected to make this conversion. There are currently 103 operating commercial nuclear power plants in the US and 68 of them have successfully completed the conversion to the ITS and are now operating in accordance with their plant specific ITS. The ISTS is focused mainly on safety by ensuring the commercial nuclear reactors can safely shut down and mitigate the consequences of any postulated transient and accident. It accomplishes this function by including requirements directly associated with safety in a document structured systematically and taking into account some key human factors and technical initiatives. This paper discusses the ISTS including its format, content, and detail, the history of the ISTS, the ITS development, licensing, and implementation process, the safety improvements resulting from a plant conversion to ITS, and the importance of the ITS Project to the industry. (Author)

Improved technical specifications and related improvements to safety in commercial Nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Hoffman, D.R.; Demitrack, T.; Schiele, R.; Jones, J.C. [EXCEL Services Corporation, 11921 Rockville Pike, Suite 100, Rockville, MD 20852 (United States)]. e-mail: donaldh@excelservices.com

2004-07-01

Many of the commercial nuclear power plants in the United States (US) have been converting a portion of the plant operating license known as the Technical Specifications (TS) in accordance with a document published by the US Nuclear Regulatory Commission (NRC). The TS prescribe commercial nuclear power plant operating requirements. There are several types of nuclear power plants in the US, based on the technology of different vendors, and there is an NRC document that supports each of the five different vendor designs. The NRC documents are known as the Improved Standard Technical Specifications (ISTS) and are contained in a separate document (NUREG series) for each one of the designs. EXCEL Services Corporation (hereinafter EXCEL) has played a major role in the development of the ISTS and in the development, licensing, and implementation of the plant specific Improved Technical Specifications (ITS) (which is based on the ISTS) for the commercial nuclear power plants in the US that have elected to make this conversion. There are currently 103 operating commercial nuclear power plants in the US and 68 of them have successfully completed the conversion to the ITS and are now operating in accordance with their plant specific ITS. The ISTS is focused mainly on safety by ensuring the commercial nuclear reactors can safely shut down and mitigate the consequences of any postulated transient and accident. It accomplishes this function by including requirements directly associated with safety in a document structured systematically and taking into account some key human factors and technical initiatives. This paper discusses the ISTS including its format, content, and detail, the history of the ISTS, the ITS development, licensing, and implementation process, the safety improvements resulting from a plant conversion to ITS, and the importance of the ITS Project to the industry. (Author)

78 FR 69433 - Executive Order 13650 Improving Chemical Facility Safety and Security Listening Sessions

Science.gov (United States)

2013-11-19

... Chemical Facility Safety and Security Listening Sessions AGENCY: National Protection and Programs... from stakeholders on issues pertaining to Improving Chemical Facility Safety and Security (Executive... regulations, guidance, and policies; and identifying best practices in chemical facility safety and security...

Improving construction site safety through leader-based verbal safety communication.

Science.gov (United States)

Kines, Pete; Andersen, Lars P S; Spangenberg, Soren; Mikkelsen, Kim L; Dyreborg, Johnny; Zohar, Dov

2010-10-01

The construction industry is one of the most injury-prone industries, in which production is usually prioritized over safety in daily on-site communication. Workers have an informal and oral culture of risk, in which safety is rarely openly expressed. This paper tests the effect of increasing leader-based on-site verbal safety communication on the level of safety and safety climate at construction sites. A pre-post intervention-control design with five construction work gangs is carried out. Foremen in two intervention groups are coached and given bi-weekly feedback about their daily verbal safety communications with their workers. Foremen-worker verbal safety exchanges (experience sampling method, n=1,693 interviews), construction site safety level (correct vs. incorrect, n=22,077 single observations), and safety climate (seven dimensions, n=105 questionnaires) are measured over a period of up to 42 weeks. Baseline measurements in the two intervention and three control groups reveal that foremen speak with their workers several times a day. Workers perceive safety as part of their verbal communication with their foremen in only 6-16% of exchanges, and the levels of safety at the sites range from 70-87% (correct observations). Measurements from baseline to follow-up in the two intervention groups reveal that safety communication between foremen and workers increases significantly in one of the groups (factor 7.1 increase), and a significant yet smaller increase is found when the two intervention groups are combined (factor 4.6). Significant increases in the level of safety are seen in both intervention groups (7% and 12% increases, respectively), particularly in regards to 'access ways' and 'railings and coverings' (39% and 84% increases, respectively). Increases in safety climate are seen in only one of the intervention groups with respect to their 'attention to safety.' No significant trend changes are seen in the three control groups on any of the three measures

Performance improvement of the Annular Core Pulse Reactor for reactor safety experiments

International Nuclear Information System (INIS)

Reuscher, J.A.; Pickard, P.S.

1976-01-01

The Annular Core Pulse Reactor (ACPR) is a TRIGA type reactor which has been in operation at Sandia Laboratories since 1967. The reactor is utilized in a wide variety of experimental programs which include radiation effects, neutron radiography, activation analysis, and fast reactor safety. During the past several years, the ACPR has become an important experimental facility for the United States Fast Reactor Safety Research Program and questions of interest to the safety of the LMFBR are being addressed. In order to enhance the capabilities of the ACPR for reactor safety experiments, a project to improve the performance of the reactor was initiated. It is anticipated that the pulse fluence can be increased by a factor of 2.0 to 2.5 utilizing a two-region core concept with high heat capacity fuel elements around the central irradiation cavity. In addition, the steady-state power of the reactor will be increased by about a factor of two. The new features of the improvements are described

How to Know when Dramatic Change Is on Track: Leading Indicators of School Turnarounds

Science.gov (United States)

Kowal, Julie; Ableidinger, Joe

2011-01-01

In recent years, national policymakers have placed new emphasis on "school turnarounds" as a strategy for rapid, dramatic improvement in chronically failing schools, calling on education leaders to turn around performance in the 5,000 lowest-achieving schools nationwide. This goal may seem daunting, given the dismal success rates of…

Socio-dramatic affective-relational intervention for adolescents with asperger syndrome & high functioning autism: pilot study.

Science.gov (United States)

Lerner, Matthew D; Mikami, Amori Yee; Levine, Karen

2011-01-01

This study examined the effectiveness of a novel intervention called 'socio-dramatic affective-relational intervention' (SDARI), intended to improve social skills among adolescents with Asperger syndrome and high functioning autism diagnoses. SDARI adapts dramatic training activities to focus on in vivo practice of areas of social skill deficit among this population. SDARI was administered as a six-week summer program in a community human service agency. Nine SDARI participants and eight age- and diagnosis-group matched adolescents not receiving SDARI were compared on child- and parent-report of social functioning at three week intervals beginning six weeks prior to intervention and ending six weeks post-intervention. Hierarchical Linear Modeling (HLM) was used to estimate growth trends between groups to assess treatment outcomes and post-treatment maintenance. Results indicated significant improvement and post-treatment maintenance among SDARI participants on several measures of child social functioning. Implications for practice and research are discussed.

Evaluation of implementation an Integrated Safety and Preventive Maintenance System for Improving of Safety Indexes

Directory of Open Access Journals (Sweden)

I mohammadfam

2014-03-01

Full Text Available Accident analysis shows that one of the main reasons for accidents is non-integration of maintenance units with safety. Merging these two processes through an integrated system can reduce and or eliminate accidents, diseases, and environmental pollution. These issues lead to improvement in organizational performance, as well. The aim of this study is to design and establish an integrated system for obtaining the aforementioned goal. Integration was carried out at Nirou Moharreke Machine Tools Company via Structured System Analysis & Design Method (SSADM. In order to measure the effectiveness of the system, selected indexes were compared using statistical methods prior and after system establishment. Results show that the accident severity index reduced from 135.46 in 2010, to 43.85 in 2012. Moreover, system effectiveness improved equipment reliability and availability (e.g. reliability of the Pfeiffer Milling machine (P (t>50 increased from 0.89 in 2010, to 0.9 in 2012. This system by forecasting various failures, and planning and designing the required operations for preventing occurrence of these failures, plays an important role in improving safety conditions of equipment, and increasing organizational performance, and is capable of presenting an excellent accident prevention program.

A simple intervention to improve patient safety, save time and improve staff experience in the AMU procedure room.

Science.gov (United States)

Misselbrook, Gary Peter; Kause, Juliane; Yeoh, Su-Ann

2016-01-01

Over the last decade, operating theatres and Intensive Care Units (ICUs) have established systematic methods for performing procedures on patients that have been shown to reduce complications and improve patient safety. Whilst the use of procedure rooms on Acute Medicine Units (AMUs) is highly recommended by patient safety groups and Royal College publications, they are not universally available or appropriately utilised. In this article we discuss a quality improvement project that was undertaken on an AMU at a large university teaching hospital in the United Kingdom, highlighting its successes and challenges.

Navigating towards improved surgical safety using aviation-based strategies.

Science.gov (United States)

Kao, Lillian S; Thomas, Eric J

2008-04-01

Safety practices in the aviation industry are being increasingly adapted to healthcare in an effort to reduce medical errors and patient harm. However, caution should be applied in embracing these practices because of limited experience in surgical disciplines, lack of rigorous research linking these practices to outcome, and fundamental differences between the two industries. Surgeons should have an in-depth understanding of the principles and data supporting aviation-based safety strategies before routinely adopting them. This paper serves as a review of strategies adapted to improve surgical safety, including the following: implementation of crew resource management in training operative teams; incorporation of simulation in training of technical and nontechnical skills; and analysis of contributory factors to errors using surveys, behavioral marker systems, human factors analysis, and incident reporting. Avenues and challenges for future research are also discussed.

Using a Training Video to Improve Agricultural Workers' Knowledge of On-Farm Food Safety

Science.gov (United States)

Mathiasen, Lisa; Morley, Katija; Chapman, Benjamin; Powell, Douglas

2012-01-01

A training video was produced and evaluated to assess its impact on the food safety knowledge of agricultural workers. Increasing food safety knowledge on the farm may help to improve the safety of fresh produce. Surveys were used to measure workers' food safety knowledge before and after viewing the video. Focus groups were used to determine…

Augmented reality for improved safety

CERN Multimedia

Stefania Pandolfi

2016-01-01

Sometimes, CERN experts have to operate in low visibility conditions or in the presence of possible hazards. Minimising the duration of the operation and reducing the risk of errors is therefore crucial to ensuring the safety of personnel. The EDUSAFE project integrates different technologies to create a wearable personnel safety system based on augmented reality.    The EDUSAFE integrated safety system uses a camera mounted on the helmet to monitor the working area.  In its everyday operation of machines and facilities, CERN adopts a whole set of measures and safety equipment to ensure the safety of its personnel, including personal wearable safety devices and access control systems. However, sometimes, scheduled and emergency maintenance work needs to be done in zones with potential cryogenic hazards, in the presence of radioactive equipment or simply in demanding conditions where visibility is low and moving around is difficult. The EDUSAFE Marie Curie Innovative&...

The Psychodrama-Social Dramatics Separation.

Science.gov (United States)

Klepac, Richard L.

Social dramatics is a therapeutic and educational program that can act as a mirror to reflect images of the self in action with others. It is the modality for experiential learning to correct social dysfunction by providing models for imitation, opportunities to practice and develop individual forms from that model, and risk free environments for…

Variable Speed Limits: Strategies to Improve Safety and Traffic Parameters for a Bottleneck

Directory of Open Access Journals (Sweden)

M. Z. Hasanpour

2017-04-01

Full Text Available The primary purpose of the speed limit system is to enforce reasonable and safe speed. To reduce secondary problems such as accidents and queuing, Variable Speed Limits (VSL has been suggested. In this paper VSL is used to better safety and traffic parameters. Traffic parameters including speed, queue length and stopping time have been pondering. For VLS, an optimization decision tree algorithm with the function of microscopic simulation was used. The results in case of sub saturated, saturated and supersaturated at a bottleneck are examined and compared with the Allaby logic tree. The results show that the proposed decision tree shows an improved performance in terms of safety and comfort along the highway. The VSL pilot project is part of the Road Safety Improvement Program included in Iran’s road safety action plan that is in the research process in the BHRC Research Institute, Road and Housing & Urban Development Research that is planned for next 10-year Transportation safety view Plan.

National plan to enhance aviation safety through human factors improvements

Science.gov (United States)

Foushee, Clay

1990-01-01

The purpose of this section of the plan is to establish a development and implementation strategy plan for improving safety and efficiency in the Air Traffic Control (ATC) system. These improvements will be achieved through the proper applications of human factors considerations to the present and future systems. The program will have four basic goals: (1) prepare for the future system through proper hiring and training; (2) develop a controller work station team concept (managing human errors); (3) understand and address the human factors implications of negative system results; and (4) define the proper division of responsibilities and interactions between the human and the machine in ATC systems. This plan addresses six program elements which together address the overall purpose. The six program elements are: (1) determine principles of human-centered automation that will enhance aviation safety and the efficiency of the air traffic controller; (2) provide new and/or enhanced methods and techniques to measure, assess, and improve human performance in the ATC environment; (3) determine system needs and methods for information transfer between and within controller teams and between controller teams and the cockpit; (4) determine how new controller work station technology can optimally be applied and integrated to enhance safety and efficiency; (5) assess training needs and develop improved techniques and strategies for selection, training, and evaluation of controllers; and (6) develop standards, methods, and procedures for the certification and validation of human engineering in the design, testing, and implementation of any hardware or software system element which affects information flow to or from the human.

Dramatic improvement in genome assembly achieved using doubled-haploid genomes.

Science.gov (United States)

Zhang, Hong; Tan, Engkong; Suzuki, Yutaka; Hirose, Yusuke; Kinoshita, Shigeharu; Okano, Hideyuki; Kudoh, Jun; Shimizu, Atsushi; Saito, Kazuyoshi; Watabe, Shugo; Asakawa, Shuichi

2014-10-27

Improvement in de novo assembly of large genomes is still to be desired. Here, we improved draft genome sequence quality by employing doubled-haploid individuals. We sequenced wildtype and doubled-haploid Takifugu rubripes genomes, under the same conditions, using the Illumina platform and assembled contigs with SOAPdenovo2. We observed 5.4-fold and 2.6-fold improvement in the sizes of the N50 contig and scaffold of doubled-haploid individuals, respectively, compared to the wildtype, indicating that the use of a doubled-haploid genome aids in accurate genome analysis.

Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

Science.gov (United States)

Kuo, Calvin C; Robb, William J

2013-06-01

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

Using game technologies to improve the safety of construction plant operations.

Science.gov (United States)

Guo, Hongling; Li, Heng; Chan, Greg; Skitmore, Martin

2012-09-01

Many accidents occur world-wide in the use of construction plant and equipment, and safety training is considered by many to be one of the best approaches to their prevention. However, current safety training methods/tools are unable to provide trainees with the hands-on practice needed. Game technology-based safety training platforms have the potential to overcome this problem in a virtual environment. One such platform is described in this paper - its characteristics are analysed and its possible contribution to safety training identified. This is developed and tested by means of a case study involving three major pieces of construction plant, which successfully demonstrates that the platform can improve the process and performance of the safety training involved in their operation. This research not only presents a new and useful solution to the safety training of construction operations, but illustrates the potential use of advanced technologies in solving construction industry problems in general. Copyright © 2011 Elsevier Ltd. All rights reserved.

Evaluating the Effectiveness of Two Teaching Strategies to Improve Nursing Students' Knowledge, Skills, and Attitudes About Quality Improvement and Patient Safety.

Science.gov (United States)

Maxwell, Karen L; Wright, Vivian H

The purpose of this study was to evaluate two teaching strategies with regard to quality and safety education for nurses content on quality improvement and safety. Two groups (total of 64 students) participated in online learning or online learning in conjunction with a flipped classroom. A pretest/posttest control group design was used. The use of online modules in conjunction with the flipped classroom had a greater effect on increasing nursing students' knowledge of quality improvement than the use of online modules only. There was no statistically significant difference between the groups for safety.

Using human factors engineering to improve patient safety in the cardiovascular operating room.

Science.gov (United States)

Gurses, Ayse P; Martinez, Elizabeth A; Bauer, Laura; Kim, George; Lubomski, Lisa H; Marsteller, Jill A; Pennathur, Priyadarshini R; Goeschel, Chris; Pronovost, Peter J; Thompson, David

2012-01-01

Despite significant medical advances, cardiac surgery remains a high risk procedure. Sub-optimal work system design characteristics can contribute to the risks associated with cardiac surgery. However, hazards due to work system characteristics have not been identified in the cardiovascular operating room (CVOR) in sufficient detail to guide improvement efforts. The purpose of this study was to identify and categorize hazards (anything that has the potential to cause a preventable adverse patient safety event) in the CVOR. An interdisciplinary research team used prospective hazard identification methods including direct observations, contextual inquiry, and photographing to collect data in 5 hospitals for a total 22 cardiac surgeries. We performed thematic analysis of the qualitative data guided by a work system model. 60 categories of hazards such as practice variations, high workload, non-compliance with evidence-based guidelines, not including clinicians' in medical device purchasing decisions were found. Results indicated that hazards are common in cardiac surgery and should be eliminated or mitigated to improve patient safety. To improve patient safety in the CVOR, efforts should focus on creating a culture of safety, increasing compliance with evidence based infection control practices, improving communication and teamwork, and designing better tools and technologies through partnership among all stakeholders.

Fire safety improvement of para-aramid fiber in thermoplastic polyurethane elastomer

International Nuclear Information System (INIS)

Chen, Xilei; Wang, Wenduo; Li, Shaoxiang; Jiao, Chuanmei

2017-01-01

Highlights: • Fire safety of para-aramid fiber on TPU has been investigated. • Para-aramid fiber has excellent flame retardant abilities and smoke suppression properties on TPU. • A new technique to improve the fire safety polymer is provided in this article. - Abstract: This article mainly studied fire safety effects of para-aramid fiber (AF) in thermoplastic polyurethane (TPU). The TPU/AF composites were prepared by molten blending method, and then the fire safety effects of all TPU composites were tested using cone calorimeter test (CCT), microscale combustion colorimeter test (MCC), smoke density test (SDT), and thermogravimetric/fourier transform infrared spectroscopy (TG-IR). The CCT test showed that AF could improve the fire safety of TPU. Remarkably, the peak value of heat release rate (pHRR) and the peak value of smoke production rate (pSPR) for the sample with 1.0 wt% content of AF were decreased by 52.0% and 40.5% compared with pure TPU, respectively. The MCC test showed that the HRR value of AF-2 decreased by 27.6% compared with pure TPU. TG test showed that AF promoted the char formation in the degradation process of TPU; as a result the residual carbon was increased. The TG-IR test revealed that AF had increased the thermal stability of TPU at the beginning and reduced the release of CO_2 with the decomposition going on. Through the analysis of the results of this experiment, it will make a great influence on the study of the para-aramid fiber in the aspect of fire safety of polymer.

Fire safety improvement of para-aramid fiber in thermoplastic polyurethane elastomer

Energy Technology Data Exchange (ETDEWEB)

Chen, Xilei; Wang, Wenduo; Li, Shaoxiang; Jiao, Chuanmei, E-mail: jiaochm@qust.edu.cn

2017-02-15

Highlights: • Fire safety of para-aramid fiber on TPU has been investigated. • Para-aramid fiber has excellent flame retardant abilities and smoke suppression properties on TPU. • A new technique to improve the fire safety polymer is provided in this article. - Abstract: This article mainly studied fire safety effects of para-aramid fiber (AF) in thermoplastic polyurethane (TPU). The TPU/AF composites were prepared by molten blending method, and then the fire safety effects of all TPU composites were tested using cone calorimeter test (CCT), microscale combustion colorimeter test (MCC), smoke density test (SDT), and thermogravimetric/fourier transform infrared spectroscopy (TG-IR). The CCT test showed that AF could improve the fire safety of TPU. Remarkably, the peak value of heat release rate (pHRR) and the peak value of smoke production rate (pSPR) for the sample with 1.0 wt% content of AF were decreased by 52.0% and 40.5% compared with pure TPU, respectively. The MCC test showed that the HRR value of AF-2 decreased by 27.6% compared with pure TPU. TG test showed that AF promoted the char formation in the degradation process of TPU; as a result the residual carbon was increased. The TG-IR test revealed that AF had increased the thermal stability of TPU at the beginning and reduced the release of CO{sub 2} with the decomposition going on. Through the analysis of the results of this experiment, it will make a great influence on the study of the para-aramid fiber in the aspect of fire safety of polymer.

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice.

Science.gov (United States)

Pitts, Samantha I; Maruthur, Nisa M; Luu, Ngoc-Phuong; Curreri, Kimberly; Grimes, Renee; Nigrin, Candace; Sateia, Heather F; Sawyer, Melinda D; Pronovost, Peter J; Clark, Jeanne M; Peairs, Kimberly S

2017-11-01

While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

The basic discussion on nuclear power safety improvement based on nuclear equipment design

International Nuclear Information System (INIS)

Zhao Feiyun; Yao Yangui; Yu Hao; He Yinbiao; Gao Lei; Yao Weida

2013-01-01

The safety of strengthening nuclear power design was described based on nuclear equipment design after Fukushima nuclear accident. From these aspects, such as advanced standard system, advanced design method, suitable test means, consideration of beyond design basis event, and nuclear safety culture construction, the importance of nuclear safety improvement was emphatically presented. The enlightenment was given to nuclear power designer. (authors)

Standardization and improvement of safety for radioisotope equipped instruments

International Nuclear Information System (INIS)

Sumi, Tetsuo

1980-01-01

The safety for radioisotope-equipped instruments is considered. The one is the safety for the source assembly. The radioisotopes employed for radioisotope-equipped instruments are sealed sources which are used in the state of being contained in the enclosures. Many of the enclosures are provided with shutter mechanism for the purpose of emitting radiation only during the period required. If the possible troubles that might lead to the accidents are sampled out of the results of field operation of radiation instruments, and the safety measures for source enclosures are considered in connection with these troubles, it is no exaggeration to say that the safety for source enclosures has been maintained by preventing the critical accidents by the management of users and the cooperation of manufactures though there were the chance for investigating the safety in the common field and the establishment of JIS Z 4614 standard. Another consideration is concerned with the measures to improve the safety. No accident in the past never guarantees no accident in the future. Accumulation of experience is most effective for those measures, and the more experiences the better. It may be most effective that the manufacturers disclose their experiences each other from the wide outlook overcoming the barrier of trade secret. Fortunately, such consciousness has risen since a few years ago, and the investigation group is doing the works in the Japan Radioisotope Association. On the other hand, the reasonable revision of the radiation injury prevention law is desired. (Wakatsuki, Y.)

Review of Risk Reduction Methods using Probabilistic Safety Assessment Insights and Improved Technology

Energy Technology Data Exchange (ETDEWEB)

Lee, Eun-Chan; Choi, Byung-Pil [Korea Hydro and Nuclear Power Co., Daejeon (Korea, Republic of)

2016-10-15

As seen in the process of the periodic safety review of domestic nuclear power plants, the risk management objectives such as core damage frequency and large early release frequency are not easy to be met without continuous safety improvements and the integratoin of the improved technologies into the PSA evaluation methodologies. Because external event analyses have a protion of uncertainty factors in the current analysis methodologies, the technical efforts in various perspectives.

Safety improvements at Canadian nuclear power plants in the aftermath of Fukushima accident

International Nuclear Information System (INIS)

Rzentkowski, G.; Khouaja, H.

2014-01-01

This paper describes the safety review of operating nuclear power plants undertaken by the Canadian Nuclear Safety Commission in light of the March 11, 2011 accident at the Fukushima Daiichi Nuclear Power Plants (NPPs). The review confirmed that the Canadian NPPs are robust and have a strong design relying on multiple layers of defence to protect the public from credible external events. Nevertheless, in the spirit of continuous safety improvements, the review identified a number of recommendations to further strengthen reactor defence-in-depth in preventing and mitigating the consequences of beyond design basis accidents, enhance onsite and offsite emergency response, and improve the CNSC regulatory framework. Progress achieved to date, in implementing these measures, is described in this paper along with a summary of safety benefits for each level of the reactor defence-in-depth. (author)

Safety improvements at Canadian nuclear power plants in the aftermath of Fukushima accident

Energy Technology Data Exchange (ETDEWEB)

Rzentkowski, G.; Khouaja, H. [Canadian Nuclear Safety Commission, Ottawa, ON (Canada)

2014-07-01

This paper describes the safety review of operating nuclear power plants undertaken by the Canadian Nuclear Safety Commission in light of the March 11, 2011 accident at the Fukushima Daiichi Nuclear Power Plants (NPPs). The review confirmed that the Canadian NPPs are robust and have a strong design relying on multiple layers of defence to protect the public from credible external events. Nevertheless, in the spirit of continuous safety improvements, the review identified a number of recommendations to further strengthen reactor defence-in-depth in preventing and mitigating the consequences of beyond design basis accidents, enhance onsite and offsite emergency response, and improve the CNSC regulatory framework. Progress achieved to date, in implementing these measures, is described in this paper along with a summary of safety benefits for each level of the reactor defence-in-depth. (author)

ABB engagement in efforts to improve the safety of RBMK reactors

International Nuclear Information System (INIS)

Tiren, L.I.; Bioere, S.; Molin, J.

1993-01-01

ABB Atom is engaged in safety analysis for the Ignalinsk (RBMK) nuclear power plant. The analysis is done within the framework of two different initiatives of the Swedish Nuclear Power Inspectorate, namely: probabilistic safety assessment, i.e. the BARSELINA project, and analysis of containment safety issues. The aim is to enable decisions to be made for specific hardware modifications. The following items were considered by the Swedish Nuclear Power Inspectorate to be the most significant with regard to safety and were thus selected for further study or action: nondestructive testing of primary system components, fire and flooding protection, pressure relief from the reactor cavity in certain accident sequences, Accident Localization System improvements, and a separate auxiliary feedwater system. (Z.S.) 1 fig

Safety margins in older adults increase with improved control of a dynamic object

Science.gov (United States)

Hasson, Christopher J.; Sternad, Dagmar

2014-01-01

Older adults face decreasing motor capabilities due to pervasive neuromuscular degradations. As a consequence, errors in movement control increase. Thus, older individuals should maintain larger safety margins than younger adults. While this has been shown for object manipulation tasks, several reports on whole-body activities, such as posture and locomotion, demonstrate age-related reductions in safety margins. This is despite increased costs for control errors, such as a fall. We posit that this paradox could be explained by the dynamic challenge presented by the body or also an external object, and that age-related reductions in safety margins are in part due to a decreased ability to control dynamics. To test this conjecture we used a virtual ball-in-cup task that had challenging dynamics, yet afforded an explicit rendering of the physics and safety margin. The hypotheses were: (1) When manipulating an object with challenging dynamics, older adults have smaller safety margins than younger adults. (2) Older adults increase their safety margins with practice. Nine young and 10 healthy older adults practiced moving the virtual ball-in-cup to a target location in exactly 2 s. The accuracy and precision of the timing error quantified skill, and the ball energy relative to an escape threshold quantified the safety margin. Compared to the young adults, older adults had increased timing errors, greater variability, and decreased safety margins. With practice, both young and older adults improved their ability to control the object with decreased timing errors and variability, and increased their safety margins. These results suggest that safety margins are related to the ability to control dynamics, and may explain why in tasks with simple dynamics older adults use adequate safety margins, but in more complex tasks, safety margins may be inadequate. Further, the results indicate that task-specific training may improve safety margins in older adults. PMID:25071566

Safety Margins in Older Adults Increase with Improved Control of a Dynamic Object

Directory of Open Access Journals (Sweden)

Christopher James Hasson

2014-07-01

Full Text Available Older adults face decreasing motor capabilities due to pervasive neuromuscular degradations. As a consequence errors in movement control increase. Thus, older individuals should maintain larger safety margins than younger adults. While this has been shown for object manipulation tasks, several reports on whole-body activities, such as posture and locomotion, however demonstrate age-related reductions in safety margins. This is despite increased costs for control errors, such as a fall. We posit that this paradox could be explained by the dynamic challenge presented by the body or an external object, and that age-related reductions in safety margins are in part due to a decreased ability to control dynamics. To test this conjecture we used a virtual ball-in-cup task that had challenging dynamics, yet afforded an explicit rendering of the physics and safety margin. The hypotheses were: 1 When manipulating an object with challenging dynamics, older adults have smaller safety margins than younger adults. 2 Older adults increase their safety margins with practice. Nine young and 10 healthy older adults practiced moving the virtual ball-in-cup to a target location in exactly two seconds. The accuracy and precision of the timing error quantified skill and the ball energy relative to an escape threshold quantified the safety margin. Compared to the young adults, older adults had increased timing errors, greater variability, and decreased safety margins. With practice, both young and older adults improved their ability to control the object with decreased timing errors and variability, and increased their safety margins. These results suggest that safety margins are related to the ability to control dynamics, and may explain why in tasks with simple dynamics older adults use adequate safety margins, but in more complex tasks, safety margins may be inadequate. Further, the results indicate that task-specific training may improve safety margins in older

Implementing electronic handover: interventions to improve efficiency, safety and sustainability.

Science.gov (United States)

Alhamid, Sharifah Munirah; Lee, Desmond Xue-Yuan; Wong, Hei Man; Chuah, Matthew Bingfeng; Wong, Yu Jun; Narasimhalu, Kaavya; Tan, Thuan Tong; Low, Su Ying

2016-10-01

Effective handovers are critical for patient care and safety. Electronic handover tools are increasingly used today to provide an effective and standardized platform for information exchange. The implementation of an electronic handover system in tertiary hospitals can be a major challenge. Previous efforts in implementing an electronic handover tool failed due to poor compliance and buy-in from end-users. A new electronic handover tool was developed and incorporated into the existing electronic medical records (EMRs) for medical patients in Singapore General Hospital (SGH). There was poor compliance by on-call doctors in acknowledging electronic handovers, and lack of adherence to safety rules, raising concerns about the safety and efficiency of the electronic handover tool. Urgent measures were needed to ensure its safe and sustained use. A quality improvement group comprising stakeholders, including end-users, developed multi-faceted interventions using rapid PDSA (P-Plan, D-Do, S-Study, A-Act ) cycles to address these issues. Innovative solutions using media and online software provided cost-efficient measures to improve compliance. The percentage of unacknowledged handovers per day was used as the main outcome measure throughout all PDSA cycles. Doctors were also assessed for improvement in their knowledge of safety rules and their perception of the electronic handover tool. An electronic handover tool complementing daily clinical practice can be successfully implemented using solutions devised through close collaboration with end-users supported by the senior leadership. A combined 'bottom-up' and 'top-down' approach with regular process evaluations is crucial for its long-term sustainability. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Labor-Management Cooperation in Illinois: How a Joint Union Company Team Is Improving Facility Safety.

Science.gov (United States)

Mahan, Bruce; Maclin, Reggie; Ruttenberg, Ruth; Mundy, Keith; Frazee, Tom; Schwartzkopf, Randy; Morawetz, John

2018-01-01

This study of Afton Chemical Corporation's Sauget facility and its International Chemical Workers Union Council (ICWUC) Local 871C demonstrates how significant safety improvements can be made when committed leadership from both management and union work together, build trust, train the entire work force in U.S. Occupational Safety and Health Administration 10-hour classes, and communicate with their work force, both salaried and hourly. A key finding is that listening to the workers closest to production can lead to solutions, many of them more cost-efficient than top-down decision-making. Another is that making safety and health an authentic value is hard work, requiring time, money, and commitment. Third, union and management must both have leadership willing to take chances and learn to trust one another. Fourth, training must be for everyone and ongoing. Finally, health and safety improvements require dedicated funding. The result was resolution of more than one hundred safety concerns and an ongoing institutionalized process for continuing improvement.

Integrating Quality and Safety Competencies to Improve Outcomes: Application in Infusion Therapy Practice.

Science.gov (United States)

Sherwood, Gwen; Nickel, Barbara

Despite intense scrutiny and process improvement initiatives, patient harm continues to occur in health care with alarming frequency. The Quality and Safety Education for Nursing (QSEN) project provides a roadmap to transform nursing by integrating 6 competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. As front-line caregivers, nurses encounter inherent risks in their daily work. Infusion therapy is high risk with multiple potential risks for patient harm. This study examines individual and system application of the QSEN competencies and the Infusion Nurses Society's 2016 Infusion Therapy Standards of Practice in the improvement of patient outcomes.

Participatory approach to improving safety, health and working conditions in informal economy workplaces in Cambodia.

Science.gov (United States)

Kawakami, Tsuyoshi; Tong, Leng; Kannitha, Yi; Sophorn, Tun

2011-01-01

The present study aimed to improve safety and health in informal economy workplaces such as home workplaces, small construction sites, and rural farms in Cambodia by using "participatory" approach. The government, workers' and employers' organizations and NGOs jointly assisted informal economy workers in improving safety and health by using participatory training methodologies. The steps taken were: (1) to collect existing good practices in safety and health in Cambodia; (2) to develop new participatory training programmes for home workers and small construction sites referring to ILO's WISE training programme, and (3) to train government officers, workers, employers and NGOs as safety and health trainers. The participatory training programmes developed consisted of action-checklists associated with illustrations, good example photo sheets, and texts explaining practical, low-cost improvement measures. The established safety and health trainers reached many informal economy workers through their human networks, and trained them by using the developed participatory training programmes. More than 3,000 informal economy workers were trained and they implemented improvements by using low-cost methods. Participatory training methodologies and active cooperation between the government, workers, employers and NGOs made it possible to provide practical training for those involved in the informal economy workplaces.

Applying different quality and safety models in healthcare improvement work: Boundary objects and system thinking

International Nuclear Information System (INIS)

Wiig, Siri; Robert, Glenn; Anderson, Janet E.; Pietikainen, Elina; Reiman, Teemu; Macchi, Luigi; Aase, Karina

2014-01-01

A number of theoretical models can be applied to help guide quality improvement and patient safety interventions in hospitals. However there are often significant differences between such models and, therefore, their potential contribution when applied in diverse contexts. The aim of this paper is to explore how two such models have been applied by hospitals to improve quality and safety. We describe and compare the models: (1) The Organizing for Quality (OQ) model, and (2) the Design for Integrated Safety Culture (DISC) model. We analyze the theoretical foundations of the models, and show, by using a retrospective comparative case study approach from two European hospitals, how these models have been applied to improve quality and safety. The analysis shows that differences appear in the theoretical foundations, practical approaches and applications of the models. Nevertheless, the case studies indicate that the choice between the OQ and DISC models is of less importance for guiding the practice of quality and safety improvement work, as they are both systemic and share some important characteristics. The main contribution of the models lay in their role as boundary objects directing attention towards organizational and systems thinking, culture, and collaboration

Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.

Science.gov (United States)

Burnett, Susan; Benn, Jonathan; Pinto, Anna; Parand, Anam; Iskander, Sandra; Vincent, Charles

2010-08-01

Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding 'readiness' at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.

Using standardized insulin orders to improve patient safety in a tertiary care centre.

Science.gov (United States)

Doyle, Mary-Anne; Brez, Sharon; Sicoli, Silvana; De Sousa, Filomena; Keely, Erin; Malcom, Janine C

2014-04-01

To standardize insulin prescribing practices for inpatients, improve management of hypoglycemia, reduce reliance on sliding scales, increase use of basal-bolus insulin and improve patient safety. Patients with diabetes were admitted to 2 pilot inpatient units followed by corporate spread to all insulin-treated patients on noncritical care units in a Canadian tertiary care multicampus teaching hospital. Standardized preprinted insulin and hypoglycemia management orders, decision support tools and multidisciplinary education strategies were developed, tested and implemented by way of the Model for Improvement and The Ottawa Model for Research Process. Clinical and balance measures were evaluated through statistical process control. Patient safety was improved through a reduction in hypoglycemia and decreased dependence on correctional scales. Utilization of the preprinted orders approached the target of 70% at the end of the test period and was sustained at 89% corporately 3 years post-implementation. The implementation of a standardized, preprinted insulin order set facilitates best practices for insulin therapy, improves patient safety and is highly supported by treating practitioners. The utilization of formal quality-improvement methodology promoted efficiency, enhanced sustainability, increased support among clinicians and senior administrators, and was effective in instituting sustained practice change in a complex care centre. Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.

78 FR 55257 - Patient Safety and Quality Improvement: Civil Money Penalty Inflation Adjustment

Science.gov (United States)

2013-09-10

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Patient Safety and Quality Improvement: Civil Money... Civil Rights has determined that an adjustment to the maximum civil money penalty amount for violations... confidentiality and privilege protections of Patient Safety Work Product (PSWP), and procedures for enforcement...

TEL4Health – Mobile tools to improve patient safety

NARCIS (Netherlands)

Drachsler, Hendrik; Kalz, Marco; Specht, Marcus

2013-01-01

Drachsler, H., Kalz, M., & Specht, M. (2013, 10 October). TEL4Health – Mobile tools to improve patient safety. Presentation given at the blended learning platform of the Netherlands Organisation for Hospitals (Nederlandse Vereniging van Ziekenhuizen), Utrecht, The Netherlands.

THE INTRODUCTION OF THE METHODOLOGY TO IMPROVE ROAD SAFETY

Directory of Open Access Journals (Sweden)

D. V. Kapsky

2013-01-01

Full Text Available Recommendations for improving the road safety and quality of road traffic controlled junctions(crossings on individual parameters of traffic light control, improvement of traffic light control by optimizing the length of the transition interval in the traffic light cycle, increase awareness and early warning drivers about the upcoming change traffic lights division of transport and pedestrian traffic, road conditions , transportation planning and technical aids of road  traffic, as well as recommendations for the use of the hump in the settlements, etc.

Critical review of controlled release packaging to improve food safety and quality.

Science.gov (United States)

Chen, Xi; Chen, Mo; Xu, Chenyi; Yam, Kit L

2018-03-19

Controlled release packaging (CRP) is an innovative technology that uses the package to release active compounds in a controlled manner to improve safety and quality for a wide range of food products during storage. This paper provides a critical review of the uniqueness, design considerations, and research gaps of CRP, with a focus on the kinetics and mechanism of active compounds releasing from the package. Literature data and practical examples are presented to illustrate how CRP controls what active compounds to release, when and how to release, how much and how fast to release, in order to improve food safety and quality.

A study in improvement of administrative system in the nuclear safety regulation

International Nuclear Information System (INIS)

Yook, Dong Il; Kuk, Doe Hyeong; Lee, Seong Min; Kim, Jong Sam; Hwang, Sun Ho

2001-03-01

One of the most important tasks to improve nuclear safety regulation system is to separate nuclear regulatory institutes from public agencies which promote the development nuclear power. Moreover, nuclear safety regulation should be not only specialized but optimized to be adapted for new environments such as high-tech information age. Especially, it is necessary to reform the current nuclear safety regulation systems both to be effective under the local self-administration which began to operate in recent years and to be supported by local residents

A study in improvement of administrative system in the nuclear safety regulation

Energy Technology Data Exchange (ETDEWEB)

Yook, Dong Il; Kuk, Doe Hyeong; Lee, Seong Min; Kim, Jong Sam; Hwang, Sun Ho [Chungnam National Univ., Taejon (Korea, Republic of)

2001-03-15

One of the most important tasks to improve nuclear safety regulation system is to separate nuclear regulatory institutes from public agencies which promote the development nuclear power. Moreover, nuclear safety regulation should be not only specialized but optimized to be adapted for new environments such as high-tech information age. Especially, it is necessary to reform the current nuclear safety regulation systems both to be effective under the local self-administration which began to operate in recent years and to be supported by local residents.

Monitoring System For Improving Radiation Safety Management

International Nuclear Information System (INIS)

Osovizky, A.; Paran, J.; Tal, N.; Ankry, N.; Ashkenazi, B.; Tirosh, D.; Marziano, R.; Chisin, R.

1999-01-01

Medi SMARTS (Medical Survey Mapping Automatic Radiation Tracing System), a gamma radiation monitoring system, was installed in a nuclear medicine department. In this paper the evaluation of the system's ability to improve radiation safety management is presented. The system is based on a state of the art software that continuously collects on line radiation measurements for display, analysis and logging. Radiation is measured by GM tubes; the signal is transferred to a data processing unit and then via an RS-485 communication line to a computer. The system automatically identifies the detector type and its calibration factor, thus providing compatibility, maintainability and versatility when changing detectors. Radiation levels are displayed on the nuclear medicine department map at six locations. The system has been operating continuously for more than one year, documenting abnormal events caused by routine operation or failure incidents. In cases where abnormal working conditions were encountered, an alarm message was sent automatically to the supervisor via his tele-pager. An interesting issue observed during the system evaluation, was the inability to distinguish between high radiation levels caused by proper routine operation and those caused by safety failure incidents. The solution included examination of two parameters, radiation levels as well as their duration period. A careful analysis of the historical data, applying the appropriated combined parameters determined for each location, verified that such a system can identify abnormal events, provide alarms to warn in case of incidents and improve standard operating procedures

An interprofessional approach to improving paediatric medication safety

Directory of Open Access Journals (Sweden)

Kennedy Neil

2010-02-01

Full Text Available Abstract Background Safe drug prescribing and administration are essential elements within undergraduate healthcare curricula, but medication errors, especially in paediatric practice, continue to compromise patient safety. In this area of clinical care, collective responsibility, team working and communication between health professionals have been identified as key elements in safe clinical practice. To date, there is limited research evidence as to how best to deliver teaching and learning of these competencies to practitioners of the future. Methods An interprofessional workshop to facilitate learning of knowledge, core competencies, communication and team working skills in paediatric drug prescribing and administration at undergraduate level was developed and evaluated. The practical, ward-based workshop was delivered to 4th year medical and 3rd year nursing students and evaluated using a pre and post workshop questionnaire with open-ended response questions. Results Following the workshop, students reported an increase in their knowledge and awareness of paediatric medication safety and the causes of medication errors (p Conclusion This study has helped bridge the knowledge-skills gap, demonstrating how an interprofessional approach to drug prescribing and administration has the potential to improve quality and safety within healthcare.

Lidar and Dial application for detection and identification: a proposal to improve safety and security

International Nuclear Information System (INIS)

Gaudio, P.; Malizia, A.; Gelfusa, M.; Parracino, S.; Poggi, L.A.; Lungaroni, M.; Ciparisse, J.F.; Giovanni, D. Di; Cenciarelli, O.; Carestia, M.; Peluso, E.; Gabbarini, V.; Talebzadeh, S.; Bellecci, C.; Murari, A.

2017-01-01

Nowadays the intentional diffusion in air (both in open and confined environments) of chemical contaminants is a dramatic source of risk for the public health worldwide. The needs of a high-tech networks composed by software, diagnostics, decision support systems and cyber security tools are urging all the stakeholders (military, public, research and academic entities) to create innovative solutions to face this problem and improve both safety and security. The Quantum Electronics and Plasma Physics (QEP) Research Group of the University of Rome Tor Vergata is working since the 1960s on the development of laser-based technologies for the stand-off detection of contaminants in the air. Up to now, four demonstrators have been developed (two LIDAR-based and two DIAL-based) and have been used in experimental campaigns during all 2015. These systems and technologies can be used together to create an innovative solution to the problem of public safety and security: the creation of a network composed by detection systems: A low cost LIDAR based system has been tested in an urban area to detect pollutants coming from urban traffic, in this paper the authors show the results obtained in the city of Crotone (south of Italy). This system can be used as a first alarm and can be coupled with an identification system to investigate the nature of the threat. A laboratory dial based system has been used in order to create a database of absorption spectra of chemical substances that could be release in atmosphere, these spectra can be considered as the fingerprints of the substances that have to be identified. In order to create the database absorption measurements in cell, at different conditions, are in progress and the first results are presented in this paper.

Lidar and Dial application for detection and identification: a proposal to improve safety and security

Science.gov (United States)

Gaudio, P.; Malizia, A.; Gelfusa, M.; Murari, A.; Parracino, S.; Poggi, L. A.; Lungaroni, M.; Ciparisse, J. F.; Di Giovanni, D.; Cenciarelli, O.; Carestia, M.; Peluso, E.; Gabbarini, V.; Talebzadeh, S.; Bellecci, C.

2017-01-01

Nowadays the intentional diffusion in air (both in open and confined environments) of chemical contaminants is a dramatic source of risk for the public health worldwide. The needs of a high-tech networks composed by software, diagnostics, decision support systems and cyber security tools are urging all the stakeholders (military, public, research & academic entities) to create innovative solutions to face this problem and improve both safety and security. The Quantum Electronics and Plasma Physics (QEP) Research Group of the University of Rome Tor Vergata is working since the 1960s on the development of laser-based technologies for the stand-off detection of contaminants in the air. Up to now, four demonstrators have been developed (two LIDAR-based and two DIAL-based) and have been used in experimental campaigns during all 2015. These systems and technologies can be used together to create an innovative solution to the problem of public safety and security: the creation of a network composed by detection systems: A low cost LIDAR based system has been tested in an urban area to detect pollutants coming from urban traffic, in this paper the authors show the results obtained in the city of Crotone (south of Italy). This system can be used as a first alarm and can be coupled with an identification system to investigate the nature of the threat. A laboratory dial based system has been used in order to create a database of absorption spectra of chemical substances that could be release in atmosphere, these spectra can be considered as the fingerprints of the substances that have to be identified. In order to create the database absorption measurements in cell, at different conditions, are in progress and the first results are presented in this paper.

The state of quality improvement and patient safety teaching in health professional education in New Zealand.

Science.gov (United States)

Robb, Gillian; Stolarek, Iwona; Wells, Susan; Bohm, Gillian

2017-10-27

To investigate how quality and patient safety domains are being taught in the pre-registration curricula of health profession education programmes in New Zealand. All tertiary institutions providing training for medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, dietetics and 11 other allied health professions in New Zealand were contacted and a person with relevant curriculum knowledge was invited to participate. Interviews were conducted using a semi-structured interview guide to explore nine quality and safety domains; improvement science, patient safety, quality and safety culture, evidence-based practice, patient-centred care, teamwork and communication, leadership for change, systems thinking and use of information technology (IT). Transcribed data were extracted and categorised by discipline and domain. Two researchers independently identified and categorised themes within each domain, using a general inductive approach. Forty-nine institutions were contacted and 43 (88%) people were interviewed. The inclusion and extent of quality and safety teaching was variable. Evidence-based practice, patient-centred care and teamwork and communication were the strongest domains and well embedded in programmes, while leadership, systems thinking and the role of IT were less explicitly included. Except for two institutions, improvement science was absent from pre-registration curricula. Patient safety teaching was focused mainly around incident reporting, and to a lesser extent learning from adverse events. Although a 'no blame' culture was articulated as important, the theme of individual accountability was still apparent. While participants agreed that all domains were important, the main barriers to incorporating improvement science and patient safety concepts into existing programmes included an 'already stretched curriculum' and having faculty with limited expertise in these areas. Although the building blocks for improving the quality and safety of

Health innovation for patient safety improvement.

Science.gov (United States)

Sellappans, Renukha; Chua, Siew Siang; Tajuddin, Nur Amani Ahmad; Mei Lai, Pauline Siew

2013-01-01

Medication error has been identified as a major factor affecting patient safety. Many innovative efforts such as Computerised Physician Order Entry (CPOE), a Pharmacy Information System, automated dispensing machines and Point of Administration Systems have been carried out with the aim of improving medication safety. However, areas remain that require urgent attention. One main area will be the lack of continuity of care due to the breakdown of communication between multiple healthcare providers. Solutions may include consideration of "health smart cards" that carry vital patient medical information in the form of a "credit card" or use of the Malaysian identification card. However, costs and technical aspects associated with the implementation of this health smart card will be a significant barrier. Security and confidentiality, on the other hand, are expected to be of primary concern to patients. Challenges associated with the implementation of a health smart card might include physician buy-in for use in his or her everyday practice. Training and technical support should also be available to ensure the smooth implementation of this system. Despite these challenges, implementation of a health smart card moves us closer to seamless care in our country, thereby increasing the productivity and quality of healthcare.

Health innovation for patient safety improvement

Directory of Open Access Journals (Sweden)

Renukha Sellappans

2013-01-01

Full Text Available Medication error has been identified as a major factor affecting patient safety. Many innovative efforts such as Computerised Physician Order Entry (CPOE, a Pharmacy Information System, automated dispensing machines and Point of Administration Systems have been carried out with the aim of improving medication safety. However, areas remain that require urgent attention. One main area will be the lack of continuity of care due to the breakdown of communication between multiple healthcare providers. Solutions may include consideration of “health smart cards” that carry vital patient medical information in the form of a “credit card” or use of the Malaysian identification card. However, costs and technical aspects associated with the implementation of this health smart card will be a significant barrier. Security and confidentiality, on the other hand, are expected to be of primary concern to patients. Challenges associated with the implementation of a health smart card might include physician buy-in for use in his or her everyday practice. Training and technical support should also be available to ensure the smooth implementation of this system. Despite these challenges, implementation of a health smart card moves us closer to seamless care in our country, thereby increasing the productivity and quality of healthcare.

Intervention improves physician counseling on teen driving safety.

Science.gov (United States)

Campbell, Brendan T; Borrup, Kevin; Saleheen, Hassan; Banco, Leonard; Lapidus, Garry

2009-07-01

As part of a statewide campaign, we surveyed physician attitudes and practice regarding teen driving safety before and after a brief intervention designed to facilitate in office counseling. A 31-item self-administered survey was mailed to Connecticut physicians, and this was followed by a mailing of teen driving safety materials to physician practices in the state. A postintervention survey was mailed 8 months after the presurvey. A total of 102 physicians completed both the pre and postsurveys. Thirty-nine percent (39%) reported having had a teen in their practice die in a motor vehicle crash in the presurvey, compared with 49% in the postsurvey. Physician counseling increased significantly for a number of issues: driving while impaired from 86% to 94%; restrictions on teen driving from 53% to 64%; teen driving laws from 53% to 63%; safe vehicle from 32% to 42%; parents model safe driving from 29% to 44%; and teen-parent written contract from 15% to 37%. At baseline, the majority of physicians who provide care to teenagers in Connecticut report discussing and counseling teens on first wave teen driver safety issues (seat belts, alcohol use), but most do not discuss graduate driver licensing laws or related issues. After a brief intervention, there was a significant increase in physician counseling of teens on teen driving laws and on the use of teen-parent contracts. Additional interventions targeting physician practices can improve physician counseling to teens and their parents on issues of teen driving safety.

Improving patient safety in the radiation oncology setting through crew resource management.

Science.gov (United States)

Sundararaman, Srinath; Babbo, Angela E; Brown, John A; Doss, Richard

2014-01-01

This paper demonstrates how the communication patterns and protocol rigors of a methodology called crew resource management (CRM) can be adapted to a radiation oncology environment to create a culture of patient safety. CRM training was introduced to our comprehensive radiation oncology department in the autumn of 2009. With 34 full-time equivalent staff, we see 100-125 patients daily on 2 hospital campuses. We were assisted by a consulting group with considerable experience in helping hospitals incorporate CRM principles and practices. Implementation steps included developing change initiative skills for key leaders, providing training in teamwork and communications, creating site-specific tools for safety and efficiency, and collecting data to document results. Our goals were to improve patient safety, teamwork, communication, and efficiency through the use of tools we developed that emphasized teamwork and communication, cross-checking, and routinizing specific protocols. Our CRM plan relies on the following 4 pillars: patient identification methods; "pause for the cause"; enabling all staff to halt treatment and question decisions; and daily morning meetings. We discuss some of the hurdles to change we encountered. Our safety record has improved. Our near-miss rate before CRM implementation averaged 11 per month; our near-miss rate currently averages 1.2 per month. In the 5 years prior to CRM implementation, we experienced 1 treatment deviation per year, although none rose to the level of "mis-administration." Since implementing CRM, our current patient treatment setup and delivery process has eliminated all treatment deviations. Our practices have identified situations where ambiguity or conflicting documentation could have resulted in inappropriate treatment or treatment inefficiencies. Our staff members have developed an extraordinary sense of teamwork combined with a high degree of personal responsibility to assure patient safety and have spoken up when

16 CFR 1500.88 - Exemptions from lead limits under section 101 of the Consumer Product Safety Improvement Act for...

Science.gov (United States)

2010-01-01

... 101 of the Consumer Product Safety Improvement Act for certain electronic devices. 1500.88 Section... from lead limits under section 101 of the Consumer Product Safety Improvement Act for certain electronic devices. (a) The Consumer Product Safety Improvement Act (CPSIA) provides for specific lead limits...

Tactile display landing safety and precision improvements for the Space Shuttle

Science.gov (United States)

Olson, John M.

A tactile display belt using 24 electro-mechanical tactile transducers (tactors) was used to determine if a modified tactile display system, known as the Tactile Situation Awareness System (TSAS) improved the safety and precision of a complex spacecraft (i.e. the Space Shuttle Orbiter) in guided precision approaches and landings. The goal was to determine if tactile cues enhance safety and mission performance through reduced workload, increased situational awareness (SA), and an improved operational capability by increasing secondary cognitive workload capacity and human-machine interface efficiency and effectiveness. Using both qualitative and quantitative measures such as NASA's Justiz Numerical Measure and Synwork1 scores, an Overall Workload (OW) measure, the Cooper-Harper rating scale, and the China Lake Situational Awareness scale, plus Pre- and Post-Flight Surveys, the data show that tactile displays decrease OW, improve SA, counteract fatigue, and provide superior warning and monitoring capacity for dynamic, off-nominal, high concurrent workload scenarios involving complex, cognitive, and multi-sensory critical scenarios. Use of TSAS for maintaining guided precision approaches and landings was generally intuitive, reduced training times, and improved task learning effects. Ultimately, the use of a homogeneous, experienced, and statistically robust population of test pilots demonstrated that the use of tactile displays for Space Shuttle approaches and landings with degraded vehicle systems, weather, and environmental conditions produced substantial improvements in safety, consistency, reliability, and ease of operations under demanding conditions. Recommendations for further analysis and study are provided in order to leverage the results from this research and further explore the potential to reduce the risk of spaceflight and aerospace operations in general.

Accounting software cost management on health and safety, legal framework and areas of improvement

Directory of Open Access Journals (Sweden)

K.I. Samchuk

2017-03-01

Full Text Available Awareness of human life and health as the highest value is a sign of a civilized society. The economic activity of enterprises accompanied the influence of dangerous and harmful factors. An urgent need for society development and European integration is to create an effective mechanism by which the whole complex will be implemented measures to create conditions that meet the health care workers. The article highlighted media mouthpieces and performers interests of occupational safety, responsibilities entities regarding safety, the place and importance of your support in the management of safety measures, the necessity and directions of its improvement. Improving your security management costs of safety measures based on the determination of the legal framework, which aims to provide legal protection for employees, agencies and organizations, entities in the relationship work.

Present status and improvement approach of atomic energy laws and safety standards

International Nuclear Information System (INIS)

Oh, B. J.; An, H. J.; Kim, S. W.; Kim, C. B.; Kang, S. C.; Lee, J. I.

2000-01-01

Major revision to the atomic energy act, which is currently undergoing are introduced: increase of members of nuclear safety commission, adoption of standard design certification, periodic safety review, production license system of radioactive isotope facilities, preparation for implementation of IAEA convention. Improvement of the notice of ministry of science and technology are discussed in accordance with the new atomic energy act, enforcement detect, and enforcement regulations, whose revision were completed in May 2000. Allocation of the code number to the notice, development procedures for the safety and regulatory guides are also introduced

Preventing hospital-acquired venous thromboembolism: Improving patient safety with interdisciplinary teamwork, quality improvement analytics, and data transparency.

Science.gov (United States)

Schleyer, Anneliese M; Robinson, Ellen; Dumitru, Roxana; Taylor, Mark; Hayes, Kimberly; Pergamit, Ronald; Beingessner, Daphne M; Zaros, Mark C; Cuschieri, Joseph

2016-12-01

Hospital-acquired venous thromboembolism (HA-VTE) is a potentially preventable cause of morbidity and mortality. Despite high rates of venous thromboembolism (VTE) prophylaxis in accordance with an institutional guideline, VTE remains the most common hospital-acquired condition in our institution. To improve the safety of all hospitalized patients, examine current VTE prevention practices, identify opportunities for improvement, and decrease rates of HA-VTE. Pre/post assessment. Urban academic tertiary referral center, level 1 trauma center, safety net hospital; all patients. We formed a multidisciplinary VTE task force to review all HA-VTE events, assess prevention practices relative to evidence-based institutional guidelines, and identify improvement opportunities. The task force developed an electronic tool to facilitate efficient VTE event review and designed decision-support and reporting tools, now integrated into the electronic health record, to bring optimal VTE prevention practices to the point of care. Performance is shared transparently across the institution. Harborview benchmarks process and outcome performance, including patient safety indicators and core measures, against hospitals nationally using Hospital Compare and Vizient data. Our program has resulted in >90% guideline-adherent VTE prevention and zero preventable HA-VTEs. Initiatives have resulted in a 15% decrease in HA-VTE and a 21% reduction in postoperative VTE. Keys to success include the multidisciplinary approach, clinical roles of task force members, senior leadership support, and use of quality improvement analytics for retrospective review, prospective reporting, and performance transparency. Ongoing task force collaboration with frontline providers is critical to sustained improvements. Journal of Hospital Medicine 2016;11:S38-S43. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.

Obtaining Valid Safety Data for Software Safety Measurement and Process Improvement

Science.gov (United States)

Basili, Victor r.; Zelkowitz, Marvin V.; Layman, Lucas; Dangle, Kathleen; Diep, Madeline

2010-01-01

We report on a preliminary case study to examine software safety risk in the early design phase of the NASA Constellation spaceflight program. Our goal is to provide NASA quality assurance managers with information regarding the ongoing state of software safety across the program. We examined 154 hazard reports created during the preliminary design phase of three major flight hardware systems within the Constellation program. Our purpose was two-fold: 1) to quantify the relative importance of software with respect to system safety; and 2) to identify potential risks due to incorrect application of the safety process, deficiencies in the safety process, or the lack of a defined process. One early outcome of this work was to show that there are structural deficiencies in collecting valid safety data that make software safety different from hardware safety. In our conclusions we present some of these deficiencies.

Fall prevention and safety communication training for foremen: report of a pilot project designed to improve residential construction safety.

Science.gov (United States)

Kaskutas, Vicki; Dale, Ann Marie; Lipscomb, Hester; Evanoff, Brad

2013-02-01

Falls from heights account for 64% of residential construction worker fatalities and 20% of missed work days. We hypothesized that worker safety would improve with foremen training in fall prevention and safety communication. Training priorities identified through foreman and apprentice focus groups and surveys were integrated into an 8-hour training. We piloted the training with ten foremen employed by a residential builder. Carpenter trainers contrasted proper methods to protect workers from falls with methods observed at the foremen's worksites. Trainers presented methods to deliver toolbox talks and safety messages. Results from worksite observational audits (n=29) and foremen/crewmember surveys (n=97) administered before and after training were compared. We found that inexperienced workers are exposed to many fall hazards that they are often not prepared to negotiate. Fall protection is used inconsistently and worksite mentorship is often inadequate. Foremen feel pressured to meet productivity demands and some are unsure of the fall protection requirements. After the training, the frequency of daily mentoring and toolbox talks increased, and these talks became more interactive and focused on hazardous daily work tasks. Foremen observed their worksites for fall hazards more often. We observed increased compliance with fall protection and decreased unsafe behaviors during worksite audits. Designing the training to meet both foremen's and crewmembers' needs ensured the training was learner-centered and contextually-relevant. This pilot suggests that training residential foremen can increase use of fall protection, improve safety behaviors, and enhance on-the-job training and safety communication at their worksites. Construction workers' training should target safety communication and mentoring skills with workers who will lead work crews. Interventions at multiple levels are necessary to increase safety compliance in residential construction and decrease falls

The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation.

Science.gov (United States)

Eichhorn, John H

2012-04-01

The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

Braking Control for Improving Ride Comfort

Directory of Open Access Journals (Sweden)

Lee Jonghyup

2018-01-01

Full Text Available While many vehicle control systems focus on vehicle safety and vehicle performance at high speeds, most driving conditions are very low risk situations. In such a driving situation, the ride comfort of the vehicle is the most important performance index of the vehicle. Electro mechanical brake (EMB and other brake-by-wire (BBW systems have been actively researched. As a result, braking actuators in vehicles are more freely controllable, and research on improving ride comfort is also possible. In this study, we develop a control algorithm that dramatically improves ride comfort in low risk braking situations. A method for minimizing the inconvenience of a passenger due to a suddenly changing acceleration at the moment when the vehicle is stopped is presented. For this purpose, an acceleration trajectory is generated that minimizes the discomfort index defined by the change in acceleration, jerk. A controller is also designed to track this trajectory. The algorithm that updates the trajectory is designed considering the error due to the phase lag occurring in the controller and the plant. In order to verify the performance of this controller, simulation verification is completed using a car simulator, Carsim. As a result, it is confirmed that the ride comfort is dramatically improved.

Use of PSA for improving the safety of French PWRs

International Nuclear Information System (INIS)

Lanore, J.M.; Chambon, J.L.

1994-06-01

Two French PWR Probabilistic Safety Assessment (PSA) studies were conducted for the standardized PWR series of 900 and 1300 MWe. Both PSA 900 and PSA 1300 are level 1 PSAs, that means their objective is the evaluation of core meltdown frequency. These studies have some specific features, in particular the treatment of shutdown conditions, the treatment of long term post-accidental situations, and a wide use of French experience feedback. The PSAs are used for safety improvements of the French PWRs. Following the PSA results, several modifications to plants concerning the dominant sequences were decided. (R.P.). 2 refs., 4 figs

Development of the Continued Improvement System for Nuclear Safety Culture

International Nuclear Information System (INIS)

Park, H. C.; Park, H. G.; Park, Y. W.; Park, J. Y.

2016-01-01

It has been found that almost 80 % of the incidents and accidents occurred recently, such as the Fukushima Daiichi disaster and Domestic SBO accident etc. were analyzed to be caused from human errors. (IAEA NES NG-G-2.1) Which strongly claims the importance of the safety culture system. Accordingly, it should be away from a cursory approach like one-off field survey or Snap shop which were being conducted at present for the continued improvement of safety culture. This study introduces an analytical methodology which approaches the generic form of the safety both consciously and unconsciously expressed with behavior, thoughts, and attitude etc. This study was implemented only for open materials such as Inspection report, incidents and accidents reports, QA documents because of the limitation in accessibility to data. More effective use with securing operational data will be possible in future

Development of the Continued Improvement System for Nuclear Safety Culture

Energy Technology Data Exchange (ETDEWEB)

Park, H. C.; Park, H. G.; Park, Y. W.; Park, J. Y. [KAIST, Daejeon (Korea, Republic of)

2016-05-15

It has been found that almost 80 % of the incidents and accidents occurred recently, such as the Fukushima Daiichi disaster and Domestic SBO accident etc. were analyzed to be caused from human errors. (IAEA NES NG-G-2.1) Which strongly claims the importance of the safety culture system. Accordingly, it should be away from a cursory approach like one-off field survey or Snap shop which were being conducted at present for the continued improvement of safety culture. This study introduces an analytical methodology which approaches the generic form of the safety both consciously and unconsciously expressed with behavior, thoughts, and attitude etc. This study was implemented only for open materials such as Inspection report, incidents and accidents reports, QA documents because of the limitation in accessibility to data. More effective use with securing operational data will be possible in future.

Temperature and level measurements realized for Nuclear Safety Level Improvement of Slovak NPPs

International Nuclear Information System (INIS)

Badiar, S.; Slanina, M.; Stanc, S.; Golan, P.; Krupa, J.

2001-01-01

Process of continual safety improvement in the individual Slovak nuclear power plants has been in progress since the beginning of nineties with the objective to upgrade the safety level of units in operation up to the European standards. In the framework of these activities, safety instrumentation systems with 1E qualification for the control of WWER reactor coolant systems were built and added. Methods for implementation of safety instrumentation systems for monitoring temperature and level in reactor coolant systems in the particular plants in Slovakia are presented showing the objectives and methods of their implementation. (Authors)

Little Eyolf and dramatic tradition

Directory of Open Access Journals (Sweden)

Roland Lysell

2015-02-01

Full Text Available The article criticises an Ibsen tradition who has seen the last scene of Little Eyolf as a reconciliation. Instead, the article discusses the improbability of a happy marriage characterised by social engagement. The play is open but it is hardly probable that Rita, with her erotic desire, and Allmers, whose desire has turned into metaphysics, can be happy together. The arguments refer to inner criteria and the constantly present dramatic tradition.

Puppetry and Creative Dramatics in Storytelling.

Science.gov (United States)

Champlin, Connie

The 14 units in this book are designed to help teachers and librarians motivate children to express emotions, pantomime characters, and create a full story environment through puppetry and creative dramatics. Each unit is built around a specific piece of literature, and each provides instructions for the educator concerning the necessary…

Human-centred radiological software techniques supporting improved nuclear safety

International Nuclear Information System (INIS)

Szoeke, Istvan; Johnsen, Terje

2013-01-01

The Institute for Energy Technology (IFE) is an international research foundation for energy and nuclear technology. IFE is also the host for the international OECD Halden Reactor Project. The Software Engineering Department in the Man Technology Organisation at IFE is a leading international centre of competence for the development and evaluation of human-centred technologies, process visualisation, and the lifecycle of high integrity software important to safety. This paper is an attempt to give a general overview of the current, and some of the foreseen, research and development of human-centred radiological software technologies at the Software Engineering department to meet with the need of improved radiological safety for not only nuclear industry but also other industries around the world. (author)

Evaluating the Effectiveness of an Educational Intervention to Improve the Patient Safety Attitudes of Intern Pharmacists.

Science.gov (United States)

Walpola, Ramesh L; Fois, Romano A; McLachlan, Andrew J; Chen, Timothy F

2017-02-25

Objective. To evaluate the effectiveness of a face-to-face educational intervention in improving the patient safety attitudes of intern pharmacists. Methods. A patient safety education program was delivered to intern pharmacists undertaking The University of Sydney Intern Training Program in 2014. Their patient safety attitudes were evaluated immediately prior to, immediately after, and three-months post-intervention. Underlying attitudinal factors were identified using exploratory factor analysis. Changes in factor scores were examined using analysis of variance. Results. Of the 120 interns enrolled, 95 (78.7%) completed all three surveys. Four underlying attitudinal factors were identified: attitudes towards addressing errors, questioning behaviors, blaming individuals, and reporting errors. Improvements in all attitudinal factors were evident immediately after the intervention. However, only improvements in attitudes towards blaming individuals involved in errors were sustained at three months post-intervention. Conclusion. The educational intervention was associated with short-term improvements in pharmacist interns' patient safety attitudes. However, other factors likely influenced their attitudes in the longer term.

Improved Safety Margin Characterization of Risk from Loss of Offsite Power

Energy Technology Data Exchange (ETDEWEB)

Nelson, Paul [Texas A & M Univ., College Station, TX (United States)

2017-11-07

Original intent: The original intent of this task was “support of the Risk-Informed Safety Margin Characteristic (RISMC) methodology in order” “to address … efficiency of computation so that more accurate and cost-effective techniques can be used to address safety margin characterizations” (S. M. Hess et al., “Risk-Informed Safety Margin Characterization,” Procs. ICONE17, Brussels, July 2009, CD format). It was intended that “in Task 1 itself this improvement will be directed toward upon the very important issue of Loss of Offsite Power (LOOP) events,” more specifically toward the challenge of efficient computation of the multidimensional nonrecovery integral that has been discussed by many previous contributors to the theory of nuclear safety. It was further envisioned that “three different computational approaches will be explored,” corresponding to the three subtasks listed below; deliverables were tied to the individual subtasks.

The effect of Health, Safety and Environment Management System (HSE-MS on the improvement of safety performance indices in Urea and Ammonia Kermanshah Petrochemical Company

Directory of Open Access Journals (Sweden)

M. S. Poursoleiman

2015-09-01

.Conclusion: The implementation of Health, Safety and the Environment Management System caused a reduction in accidents and its consequences and most of the safety performance indices in the entire process cycle of Kermanshah Petrochemical Company. Overall, safety condition has been improved considerably.

Improving safety in mining

Energy Technology Data Exchange (ETDEWEB)

NONE

2007-08-15

AcuMine is a spin-out company from CRC Mining Australia and the University of Sydney's Australian Centre for Field Robotics (ACFR). Its focus is to provide safety and fatigue management in mining environments. The AcuLine Haul Check system was its first development. Of greater benefit to safety in mines will be the AcuMine Proximity System (APPS) developed to reliably detect and warn drivers when in proximity to other trucks and utility vehicles and to detect personnel near to those heavy vehicles. 6 figs.

Improving Safety, Quality and Efficiency through the Management of Emerging Processes: The TenarisDalmine Experience

Science.gov (United States)

Bonometti, Patrizia

2012-01-01

Purpose: The aim of this contribution is to describe a new complexity-science-based approach for improving safety, quality and efficiency and the way it was implemented by TenarisDalmine. Design/methodology/approach: This methodology is called "a safety-building community". It consists of a safety-behaviour social self-construction…

Dramatics in the Classroom: Making Lessons Come Alive. Fastback 70.

Science.gov (United States)

Kelly, Elizabeth Flory

The contents of this booklet focus on effective techniques for using dramatics in the classroom and are based on the premise that drama can integrate all skills and help to avoid fragmentation in learning. Chapters discuss motivating the dreamers in the classroom, curriculum dramatics--eclectic teaching, training the teacher, transforming the…

Editorial: Advances in healthcare provider and patient training to improve the quality and safety of patient care

Directory of Open Access Journals (Sweden)

Elizabeth M. Borycki

2015-09-01

Full Text Available This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic health records and mobile health applications. Such technologies can be harnessed to improve patient safety; however, if not used properly they can negatively impact on patient safety. In this issue we focus on advances in training that can improve patient safety and the optimal use of new technologies in healthcare. For example, use of clinical simulations and online computer based training can be employed both to facilitate learning about new clinical discoveries as well as to integrate technology into day to day healthcare practices. In this issue we are publishing papers that describe advances in healthcare provider and patient training to improve patient safety as it relates to the use of educational technologies, health information technology and on-line health resources. In addition, in the special issue we describe new approaches to training and patient safety including, online communities, clinical simulations, on-the-job training, computer based training and health information systems that educate about and support safer patient care in real-time (i.e. when health professionals are providing care to patients. These educational and technological initiatives can be aimed at health professionals (i.e. students and those who are currently working in the field. The outcomes of this work are significant as they lead to safer care for patients and their family members. The issue has both theoretical and applied papers that describe advances in patient

78 FR 66326 - Hazardous Materials: Rail Petitions and Recommendations To Improve the Safety of Railroad Tank...

Science.gov (United States)

2013-11-05

...: Rail Petitions and Recommendations To Improve the Safety of Railroad Tank Car Transportation (RRR) AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA), DOT. ACTION: Advance Notice of... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration 49 CFR Parts...

Behavioral Emergency Response Team: Implementation Improves Patient Safety, Staff Safety, and Staff Collaboration.

Science.gov (United States)

Zicko, Cdr Jennifer M; Schroeder, Lcdr Rebecca A; Byers, Cdr William S; Taylor, Lt Adam M; Spence, Cdr Dennis L

2017-10-01

Staff members working on our nonmental health (non-MH) units (i.e., medical-surgical [MS] units) were not educated in recognizing or deescalating behavioral emergencies. Published evidence suggests a behavioral emergency response team (BERT) composed of MH experts who assist with deescalating behavioral emergencies may be beneficial in these situations. Therefore, we sought to implement a BERT on the inpatient non-MH units at our military treatment facility. The objectives of this evidence-based practice process improvement project were to determine how implementation of a BERT affects staff and patient safety and to examine nursing staffs' level of knowledge, confidence, and support in caring for psychiatric patients and patients exhibiting behavioral emergencies. A BERT was piloted on one MS unit for 5 months and expanded to two additional units for 3 months. Pre- and postimplementation staff surveys were conducted, and the number of staff assaults and injuries, restraint usage, and security intervention were compared. The BERT responded to 17 behavioral emergencies. The number of assaults decreased from 10 (pre) to 1 (post); security intervention decreased from 14 to 1; and restraint use decreased from 8 to 1. MS staffs' level of BERT knowledge and rating of support between MH staff and their staff significantly increased. Both MS and MH nurses rated the BERT as supportive and effective. A BERT can assist with deescalating behavioral emergencies, and improve staff collaboration and patient and staff safety. © 2017 Sigma Theta Tau International.

Can cyclist safety be improved with intelligent transport systems?

Science.gov (United States)

Silla, Anne; Leden, Lars; Rämä, Pirkko; Scholliers, Johan; Van Noort, Martijn; Bell, Daniel

2017-08-01

In recent years, Intelligent Transport Systems (ITS) have assisted in the decrease of road traffic fatalities, particularly amongst passenger car occupants. Vulnerable Road Users (VRUs) such as pedestrians, cyclists, moped riders and motorcyclists, however, have not been that much in focus when developing ITS. Therefore, there is a clear need for ITS which specifically address VRUs as an integrated element of the traffic system. This paper presents the results of a quantitative safety impact assessment of five systems that were estimated to have high potential to improve the safety of cyclists, namely: Blind Spot Detection (BSD), Bicycle to Vehicle communication (B2V), Intersection safety (INS), Pedestrian and Cyclist Detection System+Emergency Braking (PCDS+EBR) and VRU Beacon System (VBS). An ex-ante assessment method proposed by Kulmala (2010) targeted to assess the effects of ITS for cars was applied and further developed in this study to assess the safety impacts of ITS specifically designed for VRUs. The main results of the assessment showed that all investigated systems affect cyclist safety in a positive way by preventing fatalities and injuries. The estimates considering 2012 accident data and full penetration showed that the highest effects could be obtained by the implementation of PCDS+EBR and B2V, whereas VBS had the lowest effect. The estimated yearly reduction in cyclist fatalities in the EU-28 varied between 77 and 286 per system. A forecast for 2030, taking into accounts the estimated accident trends and penetration rates, showed the highest effects for PCDS+EBR and BSD. Copyright © 2016 Elsevier Ltd. All rights reserved.

Improvement of the safety level of installations with the generalization of procedures

International Nuclear Information System (INIS)

Cornille, Y.; Dupraz, B.; Schektman, N.

1986-06-01

The generalization of control procedures to the largest possible spectra of accidental situations which is being developed on pressurized water reactor units will allow to increase the safety level of these installations. This improvement has been quantified for some situations pointing out an appreciable mitigation of meltdown risk which could result. A new improvement is aimed with the definition and the utilization of new procedures ''by states'' which will allow an optimized treatment of situations resulting from multiple failures, now treated in the procedures SPI - SPU - U1. The needs related to these procedures and their development led to joint research and development programs between Electricite de France and the Institute of Protection and Nuclear Safety [fr

Improving the safety of workers in the vicinity of mobile plant

Energy Technology Data Exchange (ETDEWEB)

NONE

2001-07-01

This report investigates possible approaches and technologies to improve the safety of pedestrians around mobile plant. The study has considered mobile plant in underground mining, surface mineral extraction and warehousing and materials handling. It investigates vehicle ergonomics and visual task analysis, aids to improve reversing and sight lines, direct body detection techniques, conventional transponder (RFID) and VLF magnetic dipole detection technologies. 43 refs., 5 apps.

Measures to Improve Diagnostic Safety in Clinical Practice.

Science.gov (United States)

Singh, Hardeep; Graber, Mark L; Hofer, Timothy P

2016-10-20

Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic process through better measurement of diagnostic performance. The diagnostic process is a dynamic team-based activity that involves uncertainty, plays out over time, and requires effective communication and collaboration among multiple clinicians, diagnostic services, and the patient. Thus, it poses special challenges for measurement. In this paper, we discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. We highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, we propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined. This would enable safe diagnosis to become an organizational priority and facilitate quality improvement. Health-care systems should consider measurement and evaluation of diagnostic performance as essential to timely and accurate diagnosis and to the reduction of preventable diagnostic harm.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Proactive Management of Aviation System Safety Risk

Data.gov (United States)

National Aeronautics and Space Administration — Aviation safety systems have undergone dramatic changes over the past fifty years. If you take a look at the early technology in this area, you'll see that there was...

Language in african dramatic literature: The example of Ola Rotimi's ...

African Journals Online (AJOL)

This paper discusses the use of language in African dramatic literature and identifies the controversy over the choice of a most appropriate language to be used by African playwrights and also X-rays the solution to language problem as proffered by prominent dramatic scholars. These solutions are then narrowed to Ola ...

Airline Safety Improvement Through Experience with Near-Misses: A Cautionary Tale.

Science.gov (United States)

Madsen, Peter; Dillon, Robin L; Tinsley, Catherine H

2016-05-01

In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes. Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry. Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses-those where the possible dangers are salient. Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses. © 2015 Society for Risk Analysis.

A Pilot Quality Improvement Collaborative to Improve Safety Net Dental Access for Pregnant Women and Young Children.

Science.gov (United States)

Vander Schaaf, Emily B; Quinonez, Rocio B; Cornett, Amanda C; Randolph, Greg D; Boggess, Kim; Flower, Kori B

2018-02-01

Objectives To determine acceptability and feasibility of a quality improvement (QI) collaborative in safety net dental practices, and evaluate its effects on financial stability, access, efficiency, and care for pregnant women and young children. Methods Five safety net dental practices participated in a 15-month learning collaborative utilizing business assessments, QI training, early childhood oral health training, and prenatal oral health training. Practices collected monthly data on: net revenue, no-show rates, total encounters, and number of encounters for young children and pregnant women. We analyzed quantitative data using paired t-tests before and after the collaborative and collected supplemental qualitative feedback from clinic staff through focus groups and directed email. Results All mean measures improved, including: higher monthly revenue ($28,380-$33,102, p = 0.37), decreased no-show rate (17.7-14.3%, p = 0.11), higher monthly dental health encounters (283-328, p = 0.08), and higher monthly encounters for young children (8.8-10.5, p = 0.65), and pregnant women (2.8-9.7, p = 0.29). Results varied by practice, with some demonstrating largest increases in encounters for young children and others pregnant women. Focus group participants reported that the collaborative improved access for pregnant women and young children, and that QI methods were often new and difficult. Conclusion for practice Participation by safety net dental practices in a QI collaborative is feasible and acceptable. Individual sites saw greater improvements in different outcomes areas, based on their own structures and needs. Future efforts should focus on specific needs of each dental practice and should offer additional QI training.

Improved Safety Margin Characterization of Risk from Loss of Offsite Power

International Nuclear Information System (INIS)

Nelson, Paul

2017-01-01

Original intent: The original intent of this task was ''support of the Risk-Informed Safety Margin Characteristic (RISMC) methodology in order'' ''to address ... efficiency of computation so that more accurate and cost-effective techniques can be used to address safety margin characterizations'' (S. M. Hess et al., ''Risk-Informed Safety Margin Characterization,'' Procs. ICONE17, Brussels, July 2009, CD format). It was intended that ''in Task 1 itself this improvement will be directed toward upon the very important issue of Loss of Offsite Power (LOOP) events,'' more specifically toward the challenge of efficient computation of the multidimensional nonrecovery integral that has been discussed by many previous contributors to the theory of nuclear safety. It was further envisioned that ''three different computational approaches will be explored,'' corresponding to the three subtasks listed below; deliverables were tied to the individual subtasks.

Road accident rates: strategies and programmes for improving road traffic safety.

Science.gov (United States)

Goniewicz, K; Goniewicz, M; Pawłowski, W; Fiedor, P

2016-08-01

Nowadays, the problem of road accident rates is one of the most important health and social policy issues concerning the countries in all continents. Each year, nearly 1.3 million people worldwide lose their life on roads, and 20-50 million sustain severe injuries, the majority of which require long-term treatment. The objective of the study was to identify the most frequent, constantly occurring causes of road accidents, as well as outline actions constituting a basis for the strategies and programmes aiming at improving traffic safety on local and global levels. Comparative analysis of literature concerning road safety was performed, confirming that although road accidents had a varied and frequently complex background, their causes have changed only to a small degree over the years. The causes include: lack of control and enforcement concerning implementation of traffic regulation (primarily driving at excessive speed, driving under the influence of alcohol, and not respecting the rights of other road users (mainly pedestrians and cyclists), lack of appropriate infrastructure and unroadworthy vehicles. The number of fatal accidents and severe injuries, resulting from road accidents, may be reduced through applying an integrated approach to safety on roads. The strategies and programmes for improving road traffic should include the following measures: reducing the risk of exposure to an accident, prevention of accidents, reduction in bodily injuries sustained in accidents, and reduction of the effects of injuries by improvement of post-accident medical care.

West Virginia peer exchange : streamlining highway safety improvement program project delivery.

Science.gov (United States)

2015-01-01

The West Virginia Division of Highways (WV DOH) hosted a Peer Exchange to share information and experiences : for streamlining Highway Safety Improvement Program (HSIP) project delivery. The event was held September : 22 to 23, 2014 in Charleston, We...

Occupational Safety & Health. Inspectors' Opinions on Improving OSHA Effectiveness. Fact Sheet for Subcommittee on Health and Safety, Committee on Education and Labor, House of Representatives.

Science.gov (United States)

General Accounting Office, Washington, DC. Div. of Human Resources.

Questionnaires gathered opinions of all Occupational Safety and Health Administration (OSHA) field supervisors and a randomly selected sample of one-third of the compliance officers about OSHA's approach to improving workplace safety and health. Major topics addressed were enforcement, safety and health standards, education and training, employer…

Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum.

Science.gov (United States)

Lin, Yihan; Scott, John W; Yi, Sojung; Taylor, Kathryn K; Ntakiyiruta, Georges; Ntirenganya, Faustin; Banguti, Paulin; Yule, Steven; Riviello, Robert

2017-10-23

A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety. The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety. The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda. Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%). In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, pskills would improve patient outcomes. Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global

Improving safety in small enterprises through an integrated safety management intervention.

Science.gov (United States)

Kines, Pete; Andersen, Dorte; Andersen, Lars Peter; Nielsen, Kent; Pedersen, Louise

2013-02-01

This study tests the applicability of a participatory behavior-based injury prevention approach integrated with safety culture initiatives. Sixteen small metal industry enterprises (10-19 employees) are randomly assigned to receive the intervention or not. Safety coaching of owners/managers result in the identification of 48 safety tasks, 85% of which are solved at follow-up. Owner/manager led constructive dialogue meetings with workers result in the prioritization of 29 tasks, 79% of which are accomplished at follow-up. Intervention enterprises have significant increases on six of eight safety-perception-survey factors, while comparisons increase on only one factor. Both intervention and comparison enterprises demonstrate significant increases in their safety observation scores. Interview data validate and supplement these results, providing some evidence for behavior change and the initiation of safety culture change. Given that over 95% of enterprises in most countries have less than 20 employees, there is great potential for adapting this integrated approach to other industries. Copyright © 2012 National Safety Council and Elsevier Ltd. All rights reserved.

Improving Safety through Human Factors Engineering.

Science.gov (United States)

Siewert, Bettina; Hochman, Mary G

2015-10-01

Human factors engineering (HFE) focuses on the design and analysis of interactive systems that involve people, technical equipment, and work environment. HFE is informed by knowledge of human characteristics. It complements existing patient safety efforts by specifically taking into consideration that, as humans, frontline staff will inevitably make mistakes. Therefore, the systems with which they interact should be designed for the anticipation and mitigation of human errors. The goal of HFE is to optimize the interaction of humans with their work environment and technical equipment to maximize safety and efficiency. Special safeguards include usability testing, standardization of processes, and use of checklists and forcing functions. However, the effectiveness of the safety program and resiliency of the organization depend on timely reporting of all safety events independent of patient harm, including perceived potential risks, bad outcomes that occur even when proper protocols have been followed, and episodes of "improvisation" when formal guidelines are found not to exist. Therefore, an institution must adopt a robust culture of safety, where the focus is shifted from blaming individuals for errors to preventing future errors, and where barriers to speaking up-including barriers introduced by steep authority gradients-are minimized. This requires creation of formal guidelines to address safety concerns, establishment of unified teams with open communication and shared responsibility for patient safety, and education of managers and senior physicians to perceive the reporting of safety concerns as a benefit rather than a threat. © RSNA, 2015.

Safety Challenges and Improvement Strategies of Ethnic Minority Construction Workers: A Case Study in Hong Kong.

Science.gov (United States)

Wu, Chunlin; Luo, Xiaowei; Wang, Tao; Wang, Yue; Sapkota, Bibek

2018-04-18

Due to cultural differences, ethnic minority construction workers are more difficult to manage and more vulnerable to accidents. This study aims to identify the major barriers faced by ethnic minority workers from their own perspectives and determine potential strategies to enhance safety climate of construction projects, thus ultimately improve their safety performance. A survey with modified Nordic safety climate questionnaire was conducted in a certain sub-contractor in Hong Kong. In-depth interviews, status quo description, major challenge investigation and safety knowledge tests were carried as well. The top three most important safety challenges identified are improper stereotypes from the whole industry, lack of opportunities for job assignment, and language barriers. To improve the safety performance, employers should allocate sufficient personal protective equipment and governments should organize unannounced site visits more frequently. Besides, the higher-level management should avoid giving contradictory instructions to foremen against to the standards of supervisors.

Safety assessment and improvement of Ignalina NPP against downcomer ruptures outside Accident Localisation System

International Nuclear Information System (INIS)

Rimkevicius, S.; Urbonavicius, E.

2002-01-01

Accident Localisation System (ALS) of Ignalina NPP is a pressure suppression type confinement, designed to prevent the release of contaminated steam-water mixture to the environment in case of Loss-of-Coolant Accident (LOCA). One of the peculiarities of Ignalina NPP with RBMK-1500 reactors is that not all of the reactor coolant circuit is enclosed within ALS. Some part of downcomers, that connect Drum Separator (DS) and suction header of main circulation pump is located outside ALS. In case of downcomer rupture in DS compartment the discharge is not confined, but flows to the environment through the safety panels installed in the ceiling of DS compartments. Numerous safety analyses were performed to assess the safety of Ignalina NPP against downcomer break outside ALS, and results were used for different applications in order to improve the safety of the plant. This paper presents the overview of the performed analyses, recommendations raised and safety improvements made to enhance the safety level of NPP. One of the applications is to present the recommendations for safety improvement if maximal allowable pressure limits are exceeded. The calculations results demonstrate that in the case of two downcomers rupture in drum separators compartment the maximum permissible pressure in the reactor hall could be exceeded. The knock-out panels from the reactor hall to the environment were recommended and installed for reactor hall overpressure protection. The evaluation of the drainage system efficiency from DS compartments was performed. In this case the especial attention was paid to analyse the water collection and drainage system behaviour in long term after postulated breaks. The analysis results showed that the modernization of the drainage system prevents the accumulation of the released water in the compartments even in the case of two downcomer pipes ruptures, and decreases the release of radioactive fission products (FP) to the environment.(author)

DASHBOARDS AND CONTROL CHARTS. EXPERIENCES IN IMPROVING SAFETY AT HANFORD WASHINGTON

International Nuclear Information System (INIS)

PREVETTE, S.S.

2006-01-01

The aim of this paper is to demonstrate the integration of safety methodology, quality tools, leadership, and teamwork at Hanford and their significant positive impact on safe performance of work. Dashboards, Leading Indicators, Control charts, Pareto Charts, Dr. W. Edward Deming's Red Bead Experiment, and Dr. Deming's System of Profound Knowledge have been the principal tools and theory of an integrated management system. Coupled with involved leadership and teamwork, they have led to significant improvements in worker safety and protection, and environmental restoration at one of the nation's largest nuclear cleanup sites

Alberta Environment's weir safety program : options for rehabilitation to improve public safety : a case study of the Calgary weir

Energy Technology Data Exchange (ETDEWEB)

Blakely, D [Alberta Environment, Edmonton, AB (Canada)

2009-07-01

Alberta Environment Water Management Operations (WMO) owns and operates 46 dams and 800 kilometres of canals in Alberta. The WMO consists of 120 staff and several contract operators to take care of this infrastructure. Most of the infrastructure supplies water for irrigation use, which adds 5 billion dollars to the provincial economy annually. Other water uses include stock watering, domestic use, municipal use, recreational use and habitat. Alberta Environment's weir safety program was also discussed along with options for rehabilitation to improve public safety. A case study of Calgary's Weir Dam on the Bow River was highlighted. A brief history of the dam was offered and safety programs around provincially-owned weirs were discussed. Photographs were included to illustrate some of the additional safety measures at the Calgary weir, such as suspended safety buoys upstream of the boom directing paddlers to the portage trail, and signage on the river that can be activated when the boom is out. Typical river users on the Calgary Bow River and safety history at the Calgary Weir were discussed along with other topics such as the Calgary Bow River weir project criteria; project design progress; pre-feasibility options; scale modelling; final design analysis; construction funding; and proposed changes to the safety program for the new weir configuration. figs.

Does the accreditation of private dental practices work? Time to rethink how accreditation can improve patient safety.

Science.gov (United States)

Jean, Gillian

2017-10-09

Accreditation to demonstrate engagement with the National Safety and Quality Health Service Standards (Standards) is compulsory for most hospital and healthcare settings, but to date remains voluntary for private dental practices (PDPs). The regulatory framework governing the dental profession lacks a proactive element to drive improvements in quality and safety of care, and an accreditation scheme can strengthen existing regulation. The current model of accreditation operating in accordance with the Australian Health Service Safety and Quality Accreditation Scheme (Scheme) is based on the Standards, which were written for a hospital model of healthcare service. The majority of PDPs are small office-based businesses with clear leadership structure and employing six staff or fewer. The Scheme is overly bureaucratic given the simplicity of the PDP business model. This article considers whether accreditation has a proven track record of improving quality of service and offers opinions about how a more appropriate safety management program for PDPs may look. What is known about the topic? There has been minimal research about the impact of accreditation schemes in improving patient safety in PDP. What does this paper add? This paper proposes a redesign of the Scheme to make it more relevant to PDPs. The paper offers strategies to minimise duplication of purpose between accreditation and existing legislation; and to strengthen critical elements of accreditation to improve effects on patient safety. What are the implications for practitioners? A redesigned accreditation scheme will support dental practitioners to implement a quality assurance system with improved efficiency, reduced administrative burden, and optimised patient safety.

Food Safety Instruction Improves Knowledge and Behavior Risk and Protection Factors for Foodborne Illnesses in Pregnant Populations.

Science.gov (United States)

Kendall, Patricia; Scharff, Robert; Baker, Susan; LeJeune, Jeffrey; Sofos, John; Medeiros, Lydia

2017-08-01

Objective This study compared knowledge and food-handling behavior after pathogen-specific (experimental treatment) versus basic food safety instruction (active control) presented during nutrition education classes for low-income English- and Spanish-language pregnant women. Methods Subjects (n = 550) were randomly assigned to treatment groups in two different locations in the United States. Food safety instruction was part of an 8-lesson curriculum. Food safety knowledge and behavior were measured pre/post intervention. Descriptive data were analyzed by Chi-Square or ANOVA; changes after intervention were analyzed by regression analysis. Results Knowledge improved after intervention in the pathogen-specific treatment group compared to active control, especially among Spanish-language women. Behavior change after intervention for the pathogen-specific treatment group improved for thermometer usage, refrigeration and consumption of foods at high risk for safety; however, all other improvements in behavior were accounted for by intervention regardless of treatment group. As expected, higher pre-instruction behavioral competency limited potential gain in behavior post-instruction due to a ceiling effect. This effect was more dominant among English-language women. Improvements were also linked to formal education completed, a partner at home, and other children in the home. Conclusions for Practice This study demonstrated that pathogen-specific food safety instruction leads to enhance knowledge and food handling behaviors that may improve the public health of pregnant women and their unborn children, especially among Spanish-language women. More importantly, food safety instruction, even at the most basic level, benefited pregnant women's food safety knowledge and food-handling behavior after intervention.

[Organize quality assurance as in aviation; improve patient safety in Dutch hospitals].

Science.gov (United States)

Haerkens, Marck H T M; Beekmann, Roland T A; van den Elzen, Guus J P; Lansbergen, Michael D I; Berlijn, Dick L

2009-01-01

Failing teamwork is a major cause of adverse events in hospitals in the Netherlands. Training team-skills can improve the safety standards in clinical heath care. An adapted version of Crew Resource Management (CRM) training is proving to be a usable format in the hospital environment. We emphasize that paying attention to the subject of safety has to start early in medical education in order to incorporate non-technical skills into the hospital culture.

Suggestions for an improved HRA method for use in Probabilistic Safety Assessment

International Nuclear Information System (INIS)

Parry, Gareth W.

1995-01-01

This paper discusses why an improved Human Reliability Analysis (HRA) approach for use in Probabilistic Safety Assessments (PSAs) is needed, and proposes a set of requirements on the improved HRA method. The constraints imposed by the need to embed the approach into the PSA methodology are discussed. One approach to laying the foundation for an improved method, using models from the cognitive psychology and behavioral science disciplines, is outlined

Nation, Districts Step up Safety

Science.gov (United States)

Shah, Nirvi

2013-01-01

President Barack Obama's announcement last week of a wide-ranging anti-violence plan in response to the Newtown, Connecticut, school shootings comes as many districts are adopting new and sometimes dramatic measures--including arming teachers and volunteers--intended to prevent similar tragedies in their own schools. School safety experts warn…

Relationship between general safety requirements and safety culture in the improvement of safe operation of I.N.R. TRIGA reactor facilities

International Nuclear Information System (INIS)

Ciocanescu, M.; Preda, M.; Chiritescu, M.; Dumitru, M.

1996-01-01

Acquiring of the basic principles of ''safety culture'' by a large number of profesionals in the nuclear field drew the attention of the decision factors in the INR managerial structure, who decided to promote certain practical actions at each level in order to improve nuclear safety. Starting from the ''Republican Standards for Nuclear Safety'' issued by CSEN in 1975, where general safety criteria are defined for nuclear reactors and NPPs, the specialists at the TRIGA reactor originated and implemented a coherent and secure system to ensure nuclear safety over all steps of nuclear activities: research, conception, execution, commissioning and operation. This system has been continuosly corrected so that now it is completely integrated in a modern safety system. The paper presents the way in which a modern system for nuclear safety at the TRIGA reactor has been implemented and developed, in accordance to specific criteria and requirements imposed by related National Regulations and with the principles of safety culture. Starting from the definition of specific responsabilities, there are presented the internal stipulations and practical actions at all levels in order to enhance nuclear safety. (orig.)

Assessing and improving the safety culture of non-power nuclear installations

International Nuclear Information System (INIS)

Bastin, S.J.; Cameron, R.F.; McDonald, N.R.; Adams, A.; Williamson, A.

2000-01-01

The development and application of safety culture principles has understandably focused on nuclear power plant and fuel cycle facilities and has been based on studies in Europe, North America, Japan and Korea. However, most radiation injuries and deaths have resulted from the mishandling of radioactive sources, inadvertent over-exposure to X-rays and critically incidents, unrelated to nuclear power plant. Within the Forum on Nuclear Cooperation in Asia (FNCA), Australia has been promoting initiatives to apply safety culture principles across all nuclear and radiation application activities and in a manner that is culturally appropriate for Asian countries. ANSTO initiated a Safety Culture Project in 1996 to develop methods for assessing and improving safety culture at nuclear and radiation installations other than power reactors and to trial these at ANSTO and in the Asian region. The project has sensibly drawn on experience from the nuclear power industry, particularly in Japan and Korea. There has been a positive response in the participating countries to addressing safety culture issues in non-power nuclear facilities. This paper reports on the main achievements of the project. Further goals of the project are also identified. (author)

Five Years after the Fukushima Daiichi Accident: Nuclear Safety Improvements and Lessons Learnt

International Nuclear Information System (INIS)

Magwood, William D. IV; Niel, Jean-Christophe; Fuketa, Toyoshi; Sheron, Brian; Boyd, Michael; McGarry, Ann; Dussart-Desart, Roland; Reig, Javier; Hah, Yeonhee; Nieh, Ho; Vasquez-Maignan, Ximena; Salgado, Nancy; White, Andrew; Lazo, Edward; Creswell, Len; Leeds, Eric; Gannon-Picot, Cynthia; Griffiths, Janice

2016-01-01

Countries around the world continue to implement safety improvements and corrective actions based on lessons learnt from the 11 March 2011 accident at the Fukushima Daiichi nuclear power plant. This report provides a high-level summary and update on these activities, and outlines further lessons learnt and challenges identified for future consideration. It focuses on actions taken by NEA committees and NEA member countries, and as such is complementary to reports produced by other international organisations. It is in a spirit of openness and transparency that NEA member countries share this information to illustrate that appropriate actions are being taken to maintain and enhance the level of safety at their nuclear facilities. Nuclear power plants are safer today because of these actions. High-priority follow-on items identified by NEA committees are provided to assist countries in continuously benchmarking and improving their nuclear safety practices. (authors)

Editorial: Advances in healthcare provider and patient training to improve the quality and safety of patient care

OpenAIRE

Elizabeth M. Borycki

2015-01-01

This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic ...

Improvement of the Patient Safety Culture in the Primary Health Care Corporation - Qatar.

Science.gov (United States)

El Zoghbi, Mohamad; Farooq, Saad; Abulaban, Ali; Taha, Heba; Ajanaz, Sajna; Aljasmi, Jawaher; Ahmad, Shakil; Said, Hana

2018-04-17

Primary Health Care Corporation (PHCC) is the public primary health care provider in Qatar. Having a patient safety culture (PSC) is the keystone to enabling a continuous process to improve the quality of services and to reduce errors. The objective of this study was to assess the impact of accreditation, quality improvement trainings, and patient safety (PS) trainings on the improvement of the PSC at the PHCC in Qatar. The Medical Office Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality was used in 2012 and 2015 to assess the culture of PS and health care quality in the 21 health centers. The results of the two surveys were compared using the χ test. A P value of less than 0.05 was considered significant. Out of 2689 staff working in the 21 health centers, 1810 (67.3%) completed the survey in 2012, and 2616 (70.0%) of 3735 completed the survey in 2015. The comparison between 2012 and 2015 survey's results showed a statistically significant improvement for all the 10 dimensions (P < 0.05). Although a statistically significant difference was observed between 2012 and 2015 results for work pressure and pace, three of the four questions of the work pressure and pace dimension presented nonsignificant differences. The survey was a good tool to raise awareness on PS and quality issues at PHCC. There is evidence that the implementation of accreditation program, the quality improvement trainings, and PS trainings helped the organization improve its PS culture.

Errors in laboratory medicine: practical lessons to improve patient safety.

Science.gov (United States)

Howanitz, Peter J

2005-10-01

Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification

Computerised clinical decision support systems to improve medication safety in long-term care homes: a systematic review.

Science.gov (United States)

Marasinghe, Keshini Madara

2015-05-12

Computerised clinical decision support systems (CCDSS) are used to improve the quality of care in various healthcare settings. This systematic review evaluated the impact of CCDSS on improving medication safety in long-term care homes (LTC). Medication safety in older populations is an important health concern as inappropriate medication use can elevate the risk of potentially severe outcomes (ie, adverse drug reactions, ADR). With an increasing ageing population, greater use of LTC by the growing ageing population and increasing number of medication-related health issues in LTC, strategies to improve medication safety are essential. Databases searched included MEDLINE, EMBASE, Scopus and Cochrane Library. Three groups of keywords were combined: those relating to LTC, medication safety and CCDSS. One reviewer undertook screening and quality assessment. Overall findings suggest that CCDSS in LTC improved the quality of prescribing decisions (ie, appropriate medication orders), detected ADR, triggered warning messages (ie, related to central nervous system side effects, drug-associated constipation, renal insufficiency) and reduced injury risk among older adults. CCDSS have received little attention in LTC, as attested by the limited published literature. With an increasing ageing population, greater use of LTC by the ageing population and increased workload for health professionals, merely relying on physicians' judgement on medication safety would not be sufficient. CCDSS to improve medication safety and enhance the quality of prescribing decisions are essential. Analysis of review findings indicates that CCDSS are beneficial, effective and have potential to improve medication safety in LTC; however, the use of CCDSS in LTC is scarce. Careful assessment on the impact of CCDSS on medication safety and further modifications to existing CCDSS are recommended for wider acceptance. Due to scant evidence in the current literature, further research on implementation and

Do safety checklists improve teamwork and communication in the operating room? A systematic review.

Science.gov (United States)

Russ, Stephanie; Rout, Shantanu; Sevdalis, Nick; Moorthy, Krishna; Darzi, Ara; Vincent, Charles

2013-12-01

The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. Safety checklists are beneficial for OR teamwork and

Dramatization at Extracurricular Activities as a Means to Enhance Foreign Language Teaching

Directory of Open Access Journals (Sweden)

Marina Valeryevna Kuimova

2015-02-01

Full Text Available The main purpose of foreign language teaching is to learn to communicate and overcome the language barrier. The article studies dramatization and its appropriateness in foreign language teaching, provides criteria for choosing a literary work for dramatization. The use of dramatization at extracurricular activities develops communication abilities, creativity; enhances motivation to learn a foreign language and strengthens students’ confidence in a foreign language.

To improve nuclear plant safety by learning from accident's experience

International Nuclear Information System (INIS)

Matsumoto, Hidezo; Kida, Masanori; Kato, Hiroyuki; Hara, Shin-ichi

1994-01-01

The ultimate goal of this study is to produce an expert system that enables the experience (records and information) gained from accidents to be put to use towards improving nuclear plant safety. A number of examples have been investigated, both domestic and overseas, in which experience gained from accidents was utilized by utilities in managing and operating their nuclear power stations to improve safety. The result of investigation has been used to create a general 'basic flow' to make the best use of experience. The ultimate goal is achieved by carrying out this 'basic flow' with artificial intelligence (AI). To do this, it is necessary (1) to apply language analysis to process the source information (primary data base; domestic and overseas accident's reports) into the secondary data base, and (2) to establish an expert system for selecting (screening) significant events from the secondary data base. In the processing described in item (1), a multi-lingual thesaurus for nuclear-related terms become necessary because the source information (primary data bases) itself is multi-lingual. In the work described in item (2), the utilization of probabilistic safety assessment (PSA), for example, is a candidate method for judging the significance of events. Achieving the goal thus requires developing various new techniques. As the first step of the above long-term study project, this report proposes the 'basic flow' and presents the concept of how the nuclear-related AI can be used to carry out this 'basic flow'. (author)

Systematic review and meta-analysis of behavioral interventions to improve child pedestrian safety.

Science.gov (United States)

Schwebel, David C; Barton, Benjamin K; Shen, Jiabin; Wells, Hayley L; Bogar, Ashley; Heath, Gretchen; McCullough, David

2014-09-01

Pedestrian injuries represent a pediatric public health challenge. This systematic review/meta-analysis evaluated behavioral interventions to teach children pedestrian safety. Multiple strategies derived eligible manuscripts (published before April 1, 2013, randomized design, evaluated behavioral child pedestrian safety interventions). Screening 1,951 abstracts yielded 125 full-text retrievals. 25 were retained for data extraction, and 6 were later omitted due to insufficient data. In all, 19 articles reporting 25 studies were included. Risk of bias and quality of evidence were assessed. Behavioral interventions generally improve children's pedestrian safety, both immediately after training and at follow-up several months later. Quality of the evidence was low to moderate. Available evidence suggested interventions targeting dash-out prevention, crossing at parked cars, and selecting safe routes across intersections were effective. Individualized/small-group training for children was the most effective training strategy based on available evidence. Behaviorally based interventions improve children's pedestrian safety. Efforts should continue to develop creative, cost-efficient, and effective interventions. © The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Improving teamwork, trust and safety: an ethnographic study of an interprofessional initiative.

Science.gov (United States)

Jones, Aled; Jones, Delyth

2011-05-01

This study explored the perceptions of staff in an interprofessional team based on a medical rehabilitation ward for older people, following the introduction of a service improvement programme designed to promote better teamworking. The study aimed to address a lack of in-depth qualitative research that could explain the day-to-day realities of interprofessional teamworking in healthcare. All members of the team participated, (e.g. nurses, doctors, physiotherapists, social worker, occupational therapists), and findings suggest that interprofessional teamworking improved over the 12-month period. Four themes emerged from the data offering insights into the development and effects of better interprofessional teamworking: the emergence of collegial trust within the team, the importance of team meetings and participative safety, the role of shared objectives in conflict management and the value of autonomy within the team. Reductions in staff sickness/absence levels and catastrophic/major patient safety incidents were also detected following the introduction of the service improvement programme.

Strategies to Improve Management of Shoulder Dystocia Under the AHRQ Safety Program for Perinatal Care.

Science.gov (United States)

McArdle, Jill; Sorensen, Asta; Fowler, Christina I; Sommerness, Samantha; Burson, Katrina; Kahwati, Leila

2018-03-01

To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Mixed-methods implementation evaluation. Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action. Key informants were labor and delivery unit staff who implemented SPPC safety strategies. The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation. Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation. Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances. Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights

[Process management in the hospital pharmacy for the improvement of the patient safety].

Science.gov (United States)

Govindarajan, R; Perelló-Juncá, A; Parès-Marimòn, R M; Serrais-Benavente, J; Ferrandez-Martí, D; Sala-Robinat, R; Camacho-Calvente, A; Campabanal-Prats, C; Solà-Anderiu, I; Sanchez-Caparrós, S; Gonzalez-Estrada, J; Martinez-Olalla, P; Colomer-Palomo, J; Perez-Mañosas, R; Rodríguez-Gallego, D

2013-01-01

To define a process management model for a hospital pharmacy in order to measure, analyse and make continuous improvements in patient safety and healthcare quality. In order to implement process management, Igualada Hospital was divided into different processes, one of which was the Hospital Pharmacy. A multidisciplinary management team was given responsibility for each process. For each sub-process one person was identified to be responsible, and a working group was formed under his/her leadership. With the help of each working group, a risk analysis using failure modes and effects analysis (FMEA) was performed, and the corresponding improvement actions were implemented. Sub-process indicators were also identified, and different process management mechanisms were introduced. The first risk analysis with FMEA produced more than thirty preventive actions to improve patient safety. Later, the weekly analysis of errors, as well as the monthly analysis of key process indicators, permitted us to monitor process results and, as each sub-process manager participated in these meetings, also to assume accountability and responsibility, thus consolidating the culture of excellence. The introduction of different process management mechanisms, with the participation of people responsible for each sub-process, introduces a participative management tool for the continuous improvement of patient safety and healthcare quality. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.

Improving the effectiveness of road safety campaigns : current and new practices.

NARCIS (Netherlands)

Hoekstra, A.T.G. & Wegman, F.C.M.

2015-01-01

The evaluation of campaigns aimed at improving road safety is still the exception rather than the rule. Because of this, ineffective campaigns and campaign techniques are allowed to continue to be utilised without question, while new methods of behaviour modification are often ignored. Therefore,

Improving the effectiveness of road safety campaigns : Current and new practices

NARCIS (Netherlands)

Hoekstra, T.; Wegman, F.C.M.

2011-01-01

The evaluation of campaigns aimed at improving road safety is still the exception rather than the rule. Because of this, ineffective campaigns and campaign techniques are allowed to continue to be utilised without question, while new methods of behaviour modification are often ignored. Therefore,

A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency.

Science.gov (United States)

O'Heron, Colette T; Jarman, Benjamin T

2014-01-01

To outline a structured approach for general surgery resident integration into institutional quality improvement and patient safety education and development. A strategic plan to address Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described. Gundersen Lutheran Medical Foundation is an independent academic medical center graduating three categorical residents per year within an integrated multi-specialty health system serving 19 counties over 3 states. The quality improvement and patient safety education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings. Structured education regarding and participation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data. © 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.

Learning from positively deviant wards to improve patient safety: an observational study protocol.

Science.gov (United States)

Baxter, Ruth; Taylor, Natalie; Kellar, Ian; Lawton, Rebecca

2015-12-11

Positive deviance is an asset-based approach to improvement which has recently been adopted to improve quality and safety within healthcare. The approach assumes that solutions to problems already exist within communities. Certain groups or individuals identify these solutions and succeed despite having the same resources as others. Within healthcare, positive deviance has previously been applied at individual or organisational levels to improve specific clinical outcomes or processes of care. This study explores whether the positive deviance approach can be applied to multidisciplinary ward teams to address the broad issue of patient safety among elderly patients. Preliminary work analysed National Health Service (NHS) Safety Thermometer data from 34 elderly medical wards to identify 5 'positively deviant' and 5 matched 'comparison' wards. Researchers are blinded to ward status. This protocol describes a multimethod, observational study which will (1) assess the concurrent validity of identifying positively deviant elderly medical wards using NHS Safety Thermometer data and (2) generate hypotheses about how positively deviant wards succeed. Patient and staff perceptions of safety will be assessed on each ward using validated surveys. Correlation and ranking analyses will explore whether this survey data aligns with the routinely collected NHS Safety Thermometer data. Staff focus groups and researcher fieldwork diaries will be completed and qualitative thematic content analysis will be used to generate hypotheses about the strategies, behaviours, team cultures and dynamics that facilitate the delivery of safe patient care. The acceptability and sustainability of strategies identified will also be explored. The South East Scotland Research Ethics Committee 01 approved this study (reference: 14/SS/1085) and NHS Permissions were granted from all trusts. Findings will be published in peer-reviewed, scientific journals, and presented at academic conferences. This study

Improving battery safety by early detection of internal shorting with a bifunctional separator

Science.gov (United States)

Wu, Hui; Zhuo, Denys; Kong, Desheng; Cui, Yi

2014-10-01

Lithium-based rechargeable batteries have been widely used in portable electronics and show great promise for emerging applications in transportation and wind-solar-grid energy storage, although their safety remains a practical concern. Failures in the form of fire and explosion can be initiated by internal short circuits associated with lithium dendrite formation during cycling. Here we report a new strategy for improving safety by designing a smart battery that allows internal battery health to be monitored in situ. Specifically, we achieve early detection of lithium dendrites inside batteries through a bifunctional separator, which offers a third sensing terminal in addition to the cathode and anode. The sensing terminal provides unique signals in the form of a pronounced voltage change, indicating imminent penetration of dendrites through the separator. This detection mechanism is highly sensitive, accurate and activated well in advance of shorting and can be applied to many types of batteries for improved safety.

Patient safety and quality improvement education: a cross-sectional study of medical students’ preferences and attitudes

Directory of Open Access Journals (Sweden)

Teigland Claire L

2013-02-01

Full Text Available Abstract Background Recent educational initiatives by both the World Health Organization and the American Association of Medical Colleges have endorsed integrating teaching of patient safety and quality improvement (QI to medical students. Curriculum development should take into account learners’ attitudes and preferences. We surveyed students to assess preferences and attitudes about QI and patient safety education. Methods An electronic survey was developed through focus groups, literature review, and local expert opinion and distributed via email to all medical students at a single medical school in the spring of 2012. Results A greater proportion of students reported previous exposure to patient safety than to quality improvement topics (79% vs. 47%. More than 80% of students thought patient safety was of the same or greater importance than basic science or clinical skills whereas quality improvement was rated as the same or more important by about 70% of students. Students rated real life examples of quality improvement projects and participation in these projects with actual patients as potentially the most helpful (mean scores 4.2/5 and 3.9/5 respectively. For learning about patient safety, real life examples of mistakes were again rated most highly (mean scores 4.5/5 for MD presented mistakes and 4.1/5 for patient presented mistakes. Students rated QI as very important to their future career regardless of intended specialty (mean score 4.5/5. Conclusions Teaching of patient safety and quality improvement to medical students will be best received if it is integrated into clinical education rather than solely taught in pre-clinical lectures or through independent computer modules. Students recognize that these topics are important to their careers as future physicians regardless of intended specialty.

Issues to improve the safety of 18K370 steam turbine operation

Directory of Open Access Journals (Sweden)

Bzymek Grzegorz

2017-01-01

Full Text Available The paper presents the process of improving the safety and reliability of operation the 18K370 steam turbines Opole Power Plant since the first failure in 2010 [1], up to install the on-line monitoring system [2]. It shows how the units work and how to analyse the contol stage as a critical node in designing the turbine. Selected results of the analysis of the strength of CSD (Computational Solid Dynamic and the nature of the flow in different operating regimes - thanks to CFD (Computational Fluid Dynamic analysis have been included. We have also briefly discussed the way of lifecycle management of individual elements [2,3]. The presented actions could be considered satisfactory, and improve the safety of operating steam turbines of type 18K370.

Improving patient safety in radiotherapy through error reporting and analysis

International Nuclear Information System (INIS)

Findlay, Ú.; Best, H.; Ottrey, M.

2016-01-01

Aim: To improve patient safety in radiotherapy (RT) through the analysis and publication of radiotherapy errors and near misses (RTE). Materials and methods: RTE are submitted on a voluntary basis by NHS RT departments throughout the UK to the National Reporting and Learning System (NRLS) or directly to Public Health England (PHE). RTE are analysed by PHE staff using frequency trend analysis based on the classification and pathway coding from Towards Safer Radiotherapy (TSRT). PHE in conjunction with the Patient Safety in Radiotherapy Steering Group publish learning from these events, on a triannual and summarised on a biennial basis, so their occurrence might be mitigated. Results: Since the introduction of this initiative in 2010, over 30,000 (RTE) reports have been submitted. The number of RTE reported in each biennial cycle has grown, ranging from 680 (2010) to 12,691 (2016) RTE. The vast majority of the RTE reported are lower level events, thus not affecting the outcome of patient care. Of the level 1 and 2 incidents reported, it is known the majority of them affected only one fraction of a course of treatment. This means that corrective action could be taken over the remaining treatment fractions so the incident did not have a significant impact on the patient or the outcome of their treatment. Analysis of the RTE reports demonstrates that generation of error is not confined to one professional group or to any particular point in the pathway. It also indicates that the pattern of errors is replicated across service providers in the UK. Conclusion: Use of the terminology, classification and coding of TSRT, together with implementation of the national voluntary reporting system described within this report, allows clinical departments to compare their local analysis to the national picture. Further opportunities to improve learning from this dataset must be exploited through development of the analysis and development of proactive risk management strategies

On the Major Dramatic Conftict of Shakespeare's the Merchant of Venice

Institute of Scientific and Technical Information of China (English)

蒋文

2000-01-01

"The Merchant of Venice", a master piece with humanist idea by William Shakespeare, presents readers a dramatic conflict between friendship and greediness, love and cruelty.This essay illustrates briefly how this conflict is created, developed and dramatized. At the same time, the root causes for this conflict is analysed.

Li-Ion Electrolytes with Improved Safety and Tolerance to High-Voltage Systems

Science.gov (United States)

Smart, Marshall C.; Bugga, Ratnakumar V.; Prakash, Surya; Krause, Frederick C.

2013-01-01

Given that lithium-ion (Li-ion) technology is the most viable rechargeable energy storage device for near-term applications, effort has been devoted to improving the safety characteristics of this system. Therefore, extensive effort has been devoted to developing nonflammable electrolytes to reduce the flammability of the cells/battery. A number of promising electrolytes have been developed incorporating flame-retardant additives, and have been shown to have good performance in a number of systems. However, these electrolyte formulations did not perform well when utilizing carbonaceous anodes with the high-voltage materials. Thus, further development was required to improve the compatibility. A number of Li-ion battery electrolyte formulations containing a flame-retardant additive [i.e., triphenyl phosphate (TPP)] were developed and demonstrated in high-voltage systems. These electrolytes include: (1) formulations that incorporate varying concentrations of the flame-retardant additive (from 5 to 15%), (2) the use of mono-fluoroethylene carbonate (FEC) as a co-solvent, and (3) the use of LiBOB as an electrolyte additive intended to improve the compatibility with high-voltage systems. Thus, improved safety has been provided without loss of performance in the high-voltage, high-energy system.

Improved safety culture and labor-management relations attributed to changing at-risk behavior process at Union Pacific.

Science.gov (United States)

2009-09-01

Changing At-Risk Behavior (CAB) is a safety process that is being conducted at Union Pacifics San Antonio Service Unit (SASU) with the aim of improving road and yard safety. CAB is an example of a proactive safety risk-reduction method called Clea...

Completion plug design provides improved operational efficiency and safety while minimizing environmental risks

Energy Technology Data Exchange (ETDEWEB)

Dum, Frank [T.D. Williamson, Inc., Tulsa, OK (United States)

2012-07-01

Pipeline repair standards have been raised with recent improvements for completion plugs when used with a brand new setting tool, resulting in lower environmental risks, improved operational efficiency and safety. The design changes were originally made to serve in an offshore environment in order to minimize the diver's time in the water and simplify steps by the diver to execute pipeline repair operations in cold, dark conditions. Enhancements in the design include fewer number of fittings, plugs, o-rings and gaskets isolating the pipeline product found inside the pipe. The new design is a step toward meeting strict operational and safety standards demanded in the field of pipeline maintenance and repair. (author)

Journey Toward High Reliability: A Comprehensive Safety Program to Improve Quality of Care and Safety Culture in a Large, Multisite Radiation Oncology Department.

Science.gov (United States)

Woodhouse, Kristina Demas; Volz, Edna; Maity, Amit; Gabriel, Peter E; Solberg, Timothy D; Bergendahl, Howard W; Hahn, Stephen M

2016-05-01

High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology. In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade. Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Postintervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P safety framework. Our multifaceted initiatives, focusing on culture and system changes, can be successfully implemented in a large academic radiation oncology department to yield measurable improvements in SC and outcomes. Copyright © 2016 by American Society of Clinical Oncology.

Video Taping and Abnormal Psychology: Dramatized Clinical Interviews.

Science.gov (United States)

Lyons, Michael J.; And Others

1984-01-01

Students in an abnormal psychology course worked in teams to produce dramatizations of diagnostic interviews and then presented them in class. Positive and negative aspects of the activity are discussed. (RM)

Improving occupational safety and health by integration into product development

DEFF Research Database (Denmark)

Broberg, Ole

1996-01-01

A cross-sectional case study was performed in a large company producing electro-mechanical products for industrial application. The objectives were: (i) to study the product development process and the role of key actors', (ii) to identify current practice on integrating occupational safety and h...... and studies of documents. A questionnaire regarding product development tasks and occupational safety and health were distributed to 30 design and production engineers. A total of 27 completed the questionnaire corresponding to a response rate of 90 per cent.......A cross-sectional case study was performed in a large company producing electro-mechanical products for industrial application. The objectives were: (i) to study the product development process and the role of key actors', (ii) to identify current practice on integrating occupational safety...... and health into the development process, especially the efforts and attitudes of design and production engineers', and (iii) to identify key actors'reflections on how to improve this integration. The study was based on qualitative as well as quantitative methods including interviews, questionnaires...

Pharmacist medication reviews to improve safety monitoring in primary care patients.

Science.gov (United States)

Gallimore, Casey E; Sokhal, Dimmy; Zeidler Schreiter, Elizabeth; Margolis, Amanda R

2016-06-01

Patients prescribed psychotropic medications within primary care are at risk of suboptimal monitoring. It is unknown whether pharmacists can improve medication safety through targeted monitoring of at risk populations. Access Community Health Centers implemented a quality improvement pilot project that included pharmacists on an integrated care team to provide medication reviews for patients. Aims were to determine whether inclusion of a pharmacist performing medication reviews within a primary care behavioral health (PCBH) practice is feasible and facilitates safe medication use. Pharmacists performed medication reviews of the electronic health record for patients referred for psychiatry consultation. Reviews were performed 1-3 months following consultation and focused on medications with known suboptimal monitoring rates. Reviews were documented within the EHR and routed to the primary care provider. Primary outcome measures were change in percentage up-to-date on monitoring and AIMS assessment, and at risk of experiencing drug interaction(s) between baseline and 3 months postreview. Secondary outcome was provider opinion of medication reviews collected via electronic survey. Reviews were performed for 144 patients. Three months postreview, percentage up-to-date on recommended monitoring increased 18% (p = .0001), at risk for drug interaction decreased 20% (p improved safety monitoring of psychotropic medications. Results identify key areas for improvement that other clinics considering integration of similar pharmacy services should consider. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

A multidisciplinary three-phase approach to improve the clinical utility of patient safety indicators.

Science.gov (United States)

Najjar, Peter; Kachalia, Allen; Sutherland, Tori; Beloff, Jennifer; David-Kasdan, Jo Ann; Bates, David W; Urman, Richard D

2015-01-01

The AHRQ Patient Safety Indicators (PSIs) are used for calculation of risk-adjusted postoperative rates for adverse events. The payers and quality consortiums are increasingly requiring public reporting of hospital performance on these metrics. We discuss processes designed to improve the accuracy and clinical utility of PSI reporting in practice. The study was conducted at a 793-bed tertiary care academic medical center where PSI processes have been aggressively implemented to track patient safety events at discharge. A three-phased approach to improving administrative data quality was implemented. The initiative consisted of clinical review of all PSIs, documentation improvement, and provider outreach including active querying for patient safety events. This multidisciplinary effort to develop a streamlined process for PSI calculation reduced the reporting of miscoded PSIs and increased the clinical utility of PSI monitoring. Over 4 quarters, 4 of 41 (10%) PSI-11 and 9 of 138 (7%) PSI-15 errors were identified on review of clinical documentation and appropriate adjustments were made. A multidisciplinary, phased approach leveraging existing billing infrastructure for robust metric coding, ongoing clinical review, and frontline provider outreach is a novel and effective way to reduce the reporting of false-positive outcomes and improve the clinical utility of PSIs.

Improved nuclear power plant operations through performance-based safety regulation

International Nuclear Information System (INIS)

Golay, M.W.

1998-01-01

The US Nuclear Regulatory Commission (NRC) has recently instituted use of Risk-Informed, Performance-Based Regulation (RIPBR) for protecting public safety in the use of nuclear power. This was done most importantly during June 1997 in issuance of revised Regulatory Guides and Standard Review Plan (SRP) guidance to licensees and the NRC staff. The propose of RIPBR is to replace the previously-used system of prescriptive regulation, which focuses upon what licensees must do, to a system which focuses upon what they must achieve. RIPBR is goals-oriented and the previous system is means-oriented. This regulatory change is potentially revolutionary, and offers many opportunities for improving the efficiency of improving both nuclear power operations and safety. However, it must be nurtured carefully if is to be successful. The work reported in this paper is concerned with showing how RIPBR can be implemented successfully, with benefits in both areas being attained. It is also concerned with how several of the practical barriers to establishing a workable new regulatory system can be overcome. This work, sponsored by the US Dept. of Energy, is being performed in collaboration with Northeast Utilities Services Crop. and the Idaho National Engineering Laboratory. In our work we have examined a practical safety-related example at the Millstone 3 nuclear power station for implementation of RIPBR. In this examination we have formulated a set of modifications to the plant's technical specifications, and are in the process of investigating their bases and refining the modifications. (author)

Flooding Experiments and Modeling for Improved Reactor Safety

International Nuclear Information System (INIS)

Solmos, M.; Hogan, K.J.; VIerow, K.

2008-01-01

Countercurrent two-phase flow and 'flooding' phenomena in light water reactor systems are being investigated experimentally and analytically to improve reactor safety of current and future reactors. The aspects that will be better clarified are the effects of condensation and tube inclination on flooding in large diameter tubes. The current project aims to improve the level of understanding of flooding mechanisms and to develop an analysis model for more accurate evaluations of flooding in the pressurizer surge line of a Pressurized Water Reactor (PWR). Interest in flooding has recently increased because Countercurrent Flow Limitation (CCFL) in the AP600 pressurizer surge line can affect the vessel refill rate following a small break LOCA and because analysis of hypothetical severe accidents with the current flooding models in reactor safety codes shows that these models represent the largest uncertainty in analysis of steam generator tube creep rupture. During a hypothetical station blackout without auxiliary feedwater recovery, should the hot leg become voided, the pressurizer liquid will drain to the hot leg and flooding may occur in the surge line. The flooding model heavily influences the pressurizer emptying rate and the potential for surge line structural failure due to overheating and creep rupture. The air-water test results in vertical tubes are presented in this paper along with a semi-empirical correlation for the onset of flooding. The unique aspects of the study include careful experimentation on large-diameter tubes and an integrated program in which air-water testing provides benchmark knowledge and visualization data from which to conduct steam-water testing

[Experience feedback committee: a method for patient safety improvement].

Science.gov (United States)

François, P; Sellier, E; Imburchia, F; Mallaret, M-R

2013-04-01

An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety.

Science.gov (United States)

Kim, Julia M; Suarez-Cuervo, Catalina; Berger, Zackary; Lee, Joy; Gayleard, Jessica; Rosenberg, Carol; Nagy, Natalia; Weeks, Kristina; Dy, Sydney

2018-04-01

Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5). We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity. Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining

Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports

International Nuclear Information System (INIS)

Jaimes, Camilo; Murcia, Diana J.; Miguel, Karen; DeFuria, Cathryn; Sagar, Pallavi; Gee, Michael S.

2018-01-01

Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population. To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors. In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects. A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%). The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention. (orig.)

Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports

Energy Technology Data Exchange (ETDEWEB)

Jaimes, Camilo [Massachusetts General Hospital, Harvard Medical School, Division of Neuroradiology, Department of Radiology, Boston, MA (United States); Murcia, Diana J. [Massachusetts General Hospital, Harvard Medical School, Division of Abdominal Imaging, Department of Radiology, Boston, MA (United States); Miguel, Karen; DeFuria, Cathryn [Massachusetts General Hospital, Harvard Medical School, Quality and Safety Office, Department of Radiology, Boston, MA (United States); Sagar, Pallavi; Gee, Michael S. [Massachusetts General Hospital for Children, Harvard Medical School, Division of Pediatric Imaging, Department of Radiology, Boston, MA (United States)

2018-01-15

Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population. To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors. In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects. A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%). The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention. (orig.)

The SHIELD (Safety & Health Improvement: Enhancing Law Enforcement Departments Study: Feasibility and Findings

Directory of Open Access Journals (Sweden)

Kerry Stephen Kuehl

2014-05-01

Full Text Available This randomized prospective trial aimed to assess the feasibility and efficacy of a team-based worksite health and safety intervention for law enforcement personnel. Four-hundred and eight subjects were enrolled and half were randomized to meet participants met for weekly, peer-led sessions delivered from a scripted team-based health and safety curriculum. Curriculum addressed: exercise, nutrition, stress, sleep, body weight, injury, and other unhealthy lifestyle behaviours such as smoking and heavy alcohol use. Health and safety questionnaires administered before and after the intervention found significant improvements for increased fruit and vegetable consumption, overall healthy eating, increased sleep quantity and sleep quality, and reduced personal stress.

Irradiation for quality improvement, microbial safety and phytosanitation of fresh produce

Science.gov (United States)

In this book we pull together research, technological advances and current trends from many disciplines to provide a single comprehensive source of information on the many uses of irradiation to improve the safety and supply of fruits and vegetables. Part 1 of the book focuses on the potential of io...

You can't improve what you don't measure: Safety climate measures available in the German-speaking countries to support safety culture development in healthcare.

Science.gov (United States)

Manser, Tanja; Brösterhaus, Mareen; Hammer, Antje

2016-01-01

Safety climate measurement is a key input into safety culture development. The aim of this review is to provide an overview of the safety climate measures that have been evaluated for their psychometric properties in a German-speaking country and to make recommendations on how to use them in quality and patient safety improvement. A systematic search strategy was implemented to obtain relevant articles. PubMed and Web of Science databases were searched, and 128 abstracts were identified. After application of limits, 33 full texts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by two reviewers. Publications were reviewed concerning healthcare setting, target group, safety culture dimensions covered and results of their psychometric evaluation. This review identified 11 instruments for safety climate assessment in different healthcare settings (i. e. hospitals, nursing homes, primary care, dental care and community pharmacy) for which acceptable to good internal consistency was reported. We observed wide variability concerning the number of dimensions (1 to 14; in some cases including outcome dimensions) and items (9 to 128) that the instruments were comprised of. Nevertheless, consistency with regard to the thematic areas covered was rather high. While there is clear evidence that we can assess safety climate in healthcare, the application of safety climate measures by quality and patient safety practitioners has so far been rather limited. This review bridges this gap between research and improvement practice by highlighting the central role of safety climate assessment in a mixed methods approach to inform safety culture development. Copyright © 2016. Published by Elsevier GmbH.

Improving Patient Safety in Hospitals through Usage of Cloud Supported Video Surveillance

Directory of Open Access Journals (Sweden)

Predrag Dašić

2017-03-01

CONCLUSION: Patient safety is a growing issue which can be improved with the usage of high-end centralised surveillance systems allowing the staff to focus more on treating health issues rather that keeping a watchful eye on potential incidents.

Evaluation of Patient Safety Culture and Organizational Culture as a Step in Patient Safety Improvement in a Hospital in Jakarta, Indonesia

Directory of Open Access Journals (Sweden)

Afrisya Iriviranty

2016-07-01

Full Text Available Introduction: Establishment of patient safety culture is the first step in the improvement of patient safety. As such, assessment of patient safety culture in hospitals is of paramount importance. Patient safety culture is an inherent component of organizational culture, so that the study of organizational culture is required in developing patient safety. This study aimed to evaluate patient safety culture among the clinical staff of a hospital in Jakarta, Indonesia and identify organizational culture profile. Materials and Methods: This cross-sectional, descriptive, qualitative study was conducted in a hospital in Jakarta, Indonesia in 2014. Sample population consisted of nurses, midwives, physicians, pediatricians, obstetrics and gynecology specialists, laboratory personnel, and pharmacy staff (n=152. Data were collected using the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality (AHRQ and Organizational Culture Assessment Instrument (OCAI. Results: Teamwork within units” was the strongest dimension of patient safety culture (91.7%, while “staffing” and “non-punitive response to error” were the weakest dimensions (22.7%. Moreover, clan culture was the most dominant type of organizational culture in the studied hospital. This culture serves as a guide for the changes in the healthcare organization, especially in the development of patient safety culture. Conclusion: According to the results of this study, healthcare providers were positively inclined toward the patient safety culture within the organization. As such, the action plan was designed through consensus decision-making and deemed effective in articulating patient safety in the vision and mission of the organization.

Learning from no-fault treatment injury claims to improve the safety of older patients.

Science.gov (United States)

Wallis, Katharine Ann

2015-09-01

New Zealand's treatment injury compensation claims data set provides an uncommon no-fault perspective of patient safety incidents. Analysis of primary care claims data confirmed medication as the leading threat to the safety of older patients in primary care and drew particular attention to the threat posed by antibiotics. For most injuries there was no suggestion of error. The no-fault perspective reveals the greatest threat to the safety of older patients in primary care to be, not error, but the risk posed by treatment itself. To improve patients' safety, in addition to reducing error, clinicians need to reduce patients' exposure to treatment risk, where appropriate. © 2015 Annals of Family Medicine, Inc.

The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records.

Science.gov (United States)

Sittig, Dean F; Ash, Joan S; Singh, Hardeep

2014-05-01

Electronic health records (EHRs) have potential to improve quality and safety of healthcare. However, EHR users have experienced safety concerns from EHR design and usability features that are not optimally adapted for the complex work flow of real-world practice. Few strategies exist to address unintended consequences from implementation of EHRs and other health information technologies. We propose that organizations equipped with EHRs should consider the strategy of "proactive risk assessment" of their EHR-enabled healthcare system to identify and address EHR-related safety concerns. In this paper, we describe the conceptual underpinning of an EHR-related self-assessment strategy to provide institutions a foundation upon which they could build their safety efforts. With support from the Office of the National Coordinator for Health Information Technology (ONC), we used a rigorous, iterative process to develop a set of 9 self-assessment tools to optimize the safety and safe use of EHRs. These tools, referred to as the Safety Assurance Factors for EHR Resilience (SAFER) guides, could be used to self-assess safety and effectiveness of EHR implementations, identify specific areas of vulnerability, and create solutions and culture change to mitigate risks. A variety of audiences could conduct these assessments, including frontline clinicians or care teams in different practices, or clinical, quality, or administrative leaders within larger institutions. The guides use a multifaceted systems-based approach to assess risk and empower organizations to work with internal or external stakeholders (eg, EHR developers) on optimizing EHR functionality and using EHRs to drive improvements in the quality and safety of healthcare.

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

Science.gov (United States)

Goeschel, Christine A; Wachter, Robert M; Pronovost, Peter J

2010-07-01

Concern about the quality and safety of health care persists, 10 years after the 1999 Institute of Medicine report To Err is Human. Despite growing awareness of quality and safety risks, and significant efforts to improve, progress is difficult to measure. Hospital leaders, including boards and medical staffs, are accountable to improve care, yet they often address this duty independently. Shared responsibility for quality and patient safety improvement presents unique challenges and unprecedented opportunities for boards and medical staffs. To capitalize on the pressure to improve, both groups may benefit from a better understanding of their synergistic potential. Boards should be educated about the quality of care provided in their institutions and about the challenges of valid measurement and accurate reporting. Boards strengthen their quality oversight capacity by recruiting physicians for vacant board seats. Medical staff members strengthen their role as hospital leaders when they understand the unique duties of the governing board. A quality improvement strategy rooted in synergistic efforts by the board and the medical staff may offer the greatest potential for safer care. Such a mutually advantageous approach requires a clear appreciation of roles and responsibilities and respect for differences. In this article, we review these responsibilities, describe opportunities for boards and medical staffs to collaborate as leaders, and offer recommendations for how boards and medical staff members can address the challenges of shared responsibility for quality of care.

Integrating natural language processing expertise with patient safety event review committees to improve the analysis of medication events.

Science.gov (United States)

Fong, Allan; Harriott, Nicole; Walters, Donna M; Foley, Hanan; Morrissey, Richard; Ratwani, Raj R

2017-08-01

Many healthcare providers have implemented patient safety event reporting systems to better understand and improve patient safety. Reviewing and analyzing these reports is often time consuming and resource intensive because of both the quantity of reports and length of free-text descriptions in the reports. Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication related patient safety events. Different NLP algorithmic approaches were developed to identify four types of medication related patient safety events and the models were compared. Well performing NLP models were generated to categorize medication related events into pharmacy delivery delays, dispensing errors, Pyxis discrepancies, and prescriber errors with receiver operating characteristic areas under the curve of 0.96, 0.87, 0.96, and 0.81 respectively. We also found that modeling the brief without the resolution text generally improved model performance. These models were integrated into a dashboard visualization to support the patient safety committee review process. We demonstrate the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication related patient safety events. The NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis. Copyright © 2017 Elsevier B.V. All rights reserved.

Operational safety and reactor life improvements of Kyoto University Reactor

International Nuclear Information System (INIS)

Utsuro, M.; Fujita, Y.; Nishihara, H.

1990-01-01

Recent important experience in improving the operational safety and life of a reactor are described. The Kyoto University Reactor (KUR) is a 25-year-old 5 MW light water reactor provided with two thermal columns of graphite and heavy water as well as other kinds of experimental facilities. In the graphite thermal column, noticeable amounts of neutron irradiation effects had accumulated in the graphite blocks near the core. Before the possible release of the stored energy, all the graphite blocks in the column were successfully replaced with new blocks using the opportunity provided by the installation of a liquid deuterium cold neutron source in the column. At the same time, special seal mechanisms were provided for essential improvements to the problem of radioactive argon production in the column. In the heavy-water thermal column we have accomplished the successful repair of a slow leak of heavy water through a thin instrumentation tube failure. The repair work included the removal and reconstructions of the lead and graphite shielding layers and welding of the instrumentation tube under radiation fields. Several mechanical components in the reactor cooling system were also exchanged for new components with improved designs and materials. On-line data logging of almost all instrumentation signals is continuously performed with a high speed data analysis system to diagnose operational conditions of the reactor. Furthermore, through detailed investigations on critical components, operational safety during further extended reactor life will be supported by well scheduled maintenance programs

Application of visualization and simulation program to improve work zone safety and mobility.

Science.gov (United States)

2010-01-01

"A previous study sponsored by the Smart Work Zone Deployment Initiative, Feasibility of Visualization and Simulation Applications to Improve Work Zone Safety and Mobility, demonstrated the feasibility of combining readily available, inexpensiv...

How Safe is Vehicle Safety? The Contribution of Vehicle Technologies to the Reduction in Road Casualties in France from 2000 to 2010

Science.gov (United States)

Page, Yves; Hermitte, Thierry; Cuny, Sophie

2011-01-01

In France, over the last 10 years, road fatalities have decreased dramatically by 48%. This reduction is somewhat close to the target fixed by the European Commision in 2001 for the whole of Europe (−50 %). According to the French govnerment, 75% of this reduction was due to the implementation of automatic speed cameras on the roadsides from 2003 onwards. Yet, during this period, there was also a significantly increase in safety technology, new regulations in front and side impacts, and developments in Euro NCAP to improve passive safety in the vehicles. This paper set out to estimate the extent that vehicle safety technologies contributed to the road safety benefits over this decade. Using a combination of databases and fitment rates, the number of fatalities and hospitalized injuries saved in passenger car crashes was estimated for a number of safety technologies, individually and as a package including a 5 star EuroNCAP rating. The additional benefits from other public safety measures were also similarly estimated. The results showed that overall safety measures during this decade saved 240,676 fatalities + serious injuries, of which 173,663 were car occupants. Of these, 27,365 car occupants and 1,083 pedestrian savings could be attributed directly to vehicle safety improvements (11% overall). It was concluded that while public safety measures were responsible for the majority of the savings, enhanced vehicle safety technologies also made a significant improvement in the road toll in France during the last decade. As the take-up rate for these technologies improves, is expected to continue to provide even more benefits in the next 10-year period. PMID:22105388

How Safe is Vehicle Safety? The Contribution of Vehicle Technologies to the Reduction in Road Casualties in France from 2000 to 2010.

Science.gov (United States)

Page, Yves; Hermitte, Thierry; Cuny, Sophie

2011-01-01

In France, over the last 10 years, road fatalities have decreased dramatically by 48%. This reduction is somewhat close to the target fixed by the European Commision in 2001 for the whole of Europe (-50 %). According to the French govnerment, 75% of this reduction was due to the implementation of automatic speed cameras on the roadsides from 2003 onwards. Yet, during this period, there was also a significantly increase in safety technology, new regulations in front and side impacts, and developments in Euro NCAP to improve passive safety in the vehicles. This paper set out to estimate the extent that vehicle safety technologies contributed to the road safety benefits over this decade. Using a combination of databases and fitment rates, the number of fatalities and hospitalized injuries saved in passenger car crashes was estimated for a number of safety technologies, individually and as a package including a 5 star EuroNCAP rating. The additional benefits from other public safety measures were also similarly estimated. The results showed that overall safety measures during this decade saved 240,676 fatalities + serious injuries, of which 173,663 were car occupants. Of these, 27,365 car occupants and 1,083 pedestrian savings could be attributed directly to vehicle safety improvements (11% overall). It was concluded that while public safety measures were responsible for the majority of the savings, enhanced vehicle safety technologies also made a significant improvement in the road toll in France during the last decade. As the take-up rate for these technologies improves, is expected to continue to provide even more benefits in the next 10-year period.

SafetyAnalyst : software tools for safety management of specific highway sites

Science.gov (United States)

2010-07-01

SafetyAnalyst provides a set of software tools for use by state and local highway agencies for highway safety management. SafetyAnalyst can be used by highway agencies to improve their programming of site-specific highway safety improvements. SafetyA...

The use of probabilistic safety assessments for improving nuclear safety in Europe

International Nuclear Information System (INIS)

Birkhofer, A.

1992-01-01

The political changes in Europe broadened the scope of international nuclear safety matters considerably. The Western world started to receive reliable and increasingly detailed information on Eastern European nuclear technology and took note of a broad range of technical and administrative problems relevant for nuclear safety in these countries. Reunification made Germany a focus of information exchange on these matters. Here, cooperation with the former German Democratic Republic and with other Eastern European countries as well as safety analyses of Soviet-built nuclear power plants started rather early. Meanwhile, these activities are progressing toward all-European cooperation in the nuclear safety sector. This cooperation includes the use of probabilistic safety assessments (PSAs) addressing applications in both Western and Eastern Europe as well as the further development of this methodology in a converging Europe

Development of an adhesive surgical ward round checklist: a technique to improve patient safety.

LENUS (Irish Health Repository)

Dhillon, P

2012-02-01

Checklists have been shown to improve patient outcomes. Checklist use is seen in the pre-operative to post-operative phases of the patient pathway. An adhesive checklist was developed for ward rounds due to the positive impact it could have on improving patient safety. Over an eight day period data were collected from five consultant-led teams that were randomly selected from the surgical department and divided into sticker groups and control groups. Across the board percentage adherence to the Good Surgical Practice Guidelines (GSPG) was markedly higher in the sticker study group, 1186 (91%) in comparison with the control group 718 (55%). There was significant improvement of documentation across all areas measured. An adhesive checklist for ward round note taking is a simple and cost-effective way to improve documentation, communication, hand-over, and patient safety. Successfully implemented in a tertiary level centre in Dublin, Ireland it is easily transferable to other surgical departments globally.

Memorandum on the use of information technology to improve medication safety.

Science.gov (United States)

Ammenwerth, E; Aly, A-F; Bürkle, T; Christ, P; Dormann, H; Friesdorf, W; Haas, C; Haefeli, W E; Jeske, M; Kaltschmidt, J; Menges, K; Möller, H; Neubert, A; Rascher, W; Reichert, H; Schuler, J; Schreier, G; Schulz, S; Seidling, H M; Stühlinger, W; Criegee-Rieck, M

2014-01-01

Information technology in health care has a clear potential to improve the quality and efficiency of health care, especially in the area of medication processes. On the other hand, existing studies show possible adverse effects on patient safety when IT for medication-related processes is developed, introduced or used inappropriately. To summarize definitions and observations on IT usage in pharmacotherapy and to derive recommendations and future research priorities for decision makers and domain experts. This memorandum was developed in a consensus-based iterative process that included workshops and e-mail discussions among 21 experts coordinated by the Drug Information Systems Working Group of the German Society for Medical Informatics, Biometry and Epidemiology (GMDS). The recommendations address, among other things, a stepwise and comprehensive strategy for IT usage in medication processes, the integration of contextual information for alert generation, the involvement of patients, the semantic integration of information resources, usability and adaptability of IT solutions, and the need for their continuous evaluation. Information technology can help to improve medication safety. However, challenges remain regarding access to information, quality of information, and measurable benefits.

Improvement suggestions on license extension management for civil nuclear safety equipment activities

International Nuclear Information System (INIS)

Sun Xingjian; Liu Hongji; Han Guoli; Jia Fengcai

2013-01-01

Based on the concepts of Clear Requirements, Comprehensive Review, Objective Assessment, Dynamic Management, this paper gives improvement suggestions on license extension management for civil nuclear safety equipment design, manufacture, installation and non-destructive examination activities, which include establishing a relatively unified license extension review standard, combining multi-views and close linking license review and supervision, full utilizing the daily supervision and inspection results, as well as further improving motivation and elimination mechanism. (authors)

Learning from Aviation to Improve Safety in the Operating Room - a Systematic Literature Review

Directory of Open Access Journals (Sweden)

Linda S. G. L. Wauben

2012-01-01

Full Text Available Lessons learned from other high-risk industries could improve patient safety in the operating room (OR. This review describes similarities and differences between high-risk industries and describes current methods and solutions within a system approach to reduce errors in the OR. PubMed and Scopus databases were systematically searched for relevant articles written in the English language published between 2000 and 2011. In total, 25 articles were included, all within the medical domain focusing on the comparison between surgery and aviation. In order to improve safety in the OR, multiple interventions have to be implemented. Additionally, the healthcare organization has to become a ‘learning organization’ and the OR team has to become a team with shared responsibilities and flat hierarchies. Interpersonal and technical skills can be trained by means of simulation and can be supported by implementing team briefings, debriefings and cross-checks. However, further development and research is needed to prove if these solutions are useful, practical, and actually increase safety.

The improvement of nuclear safety regulation : American, European, Japanese, and South Korean experiences

International Nuclear Information System (INIS)

Cho, Byung Sun

2005-01-01

Key concepts in South Korean nuclear safety regulation are safety and risk. Nuclear regulation in South Korea has required reactor designs and safeguards that reduce the risk of a major accident to less than one in a million reactor-years-a risk supposedly low enough to be acceptable. To data, in South Korean nuclear safety regulation has involved the establishment of many technical standards to enable administration enforcement. In scientific lawsuits in which the legal issue is the validity of specialized technical standards that are used for judge whether a particular nuclear power plant is to be licensed, the concept of uncertainty law is often raised with regard to what extent the examination and judgement by the judicial power affects a discretion made by the administrative office. In other words, the safety standards for nuclear power plants has been adapted as a form of the scientific technical standards widely under the idea of uncertainty law. Thus, the improvement of nuclear safety regulation in South Korea seems to depend on the rational lawmaking and a reasonable, judicial examination of the scientific standards on nuclear safety

Analysis of the Convention on Nuclear Safety and Suggestions for Improvement

International Nuclear Information System (INIS)

Choi, K. S.; Viet, Phuong Nguyen

2013-01-01

The innovative approach of the Convention, which is based on incentive after than legal binding, had been considered successful in strengthening the nuclear safety worldwide. However, the nuclear accident at the Fukushima Dai-ichi Nuclear Power Plant (Japan) in March 2011 has exposed a number of weaknesses of the Convention. Given that context, this paper will analyse the characteristics of the CNS in order to understand the advantages and disadvantages of the Convention, and finally to suggest some possible improvements. The analysis in this paper shows that the incentive approach of the CNS has succeeded in facilitating the active roles of its Contracting Parties in making the National Reports and participating in the peer review of these reports. However, the incoherent quality of the National Reports, the different level of participation in the peer review process by different Contracting Parties, and the lack of transparency of the peer review have undermined the effectiveness of the Convention in strengthening the international safety regime as well as preventing serious regulatory errors that had happened in Japan before the Fukushima accident. Therefore, the peer review process should be reformed into a more transparent and independent direction, while an advisory group of regulators within the CNS might also be useful in improving the effectiveness of the Convention as already proven by the good practice in the European Union. Only with such effective change, the CNS can maintain its pivotal role in the international safety regime

On Dramatic Instruction: Towards a Taxonomy of Methods.

Science.gov (United States)

Courtney, Richard

1987-01-01

Examines the many possible methods used by instructors who work with dramatic action: in educational drama, drama therapy, social drama, and theater. Discusses an emergent taxonomy whereby instructors choose either spontaneous/formal, overt/covert/, or intrinsic/extrinsic methods. (JC)

Improving food safety within the dairy chain: an application of conjoint analysis

NARCIS (Netherlands)

Valeeva, N.I.; Meuwissen, M.P.M.; Oude Lansink, A.G.J.M.; Huirne, R.B.M.

2005-01-01

This study determined the relative importance of attributes of food safety improvement in the production chain of fluid pasteurized milk. The chain was divided into 4 blocks: "feed" (compound feed production and its transport), "farm" (dairy farm), "dairy processing" (transport and processing of raw

Adaptive control of 5 DOF upper-limb exoskeleton robot with improved safety.

Science.gov (United States)

Kang, Hao-Bo; Wang, Jian-Hui

2013-11-01

This paper studies an adaptive control strategy for a class of 5 DOF upper-limb exoskeleton robot with a special safety consideration. The safety requirement plays a critical role in the clinical treatment when assisting patients with shoulder, elbow and wrist joint movements. With the objective of assuring the tracking performance of the pre-specified operations, the proposed adaptive controller is firstly designed to be robust to the model uncertainties. To further improve the safety and fault-tolerance in the presence of unknown large parameter variances or even actuator faults, the adaptive controller is on-line updated according to the information provided by an adaptive observer without additional sensors. An output tracking performance is well achieved with a tunable error bound. The experimental example also verifies the effectiveness of the proposed control scheme. © 2013 ISA. Published by ISA. All rights reserved.

Care initiation area yields dramatic results.

Science.gov (United States)

2009-03-01

The ED at Gaston Memorial Hospital in Gastonia, NC, has achieved dramatic results in key department metrics with a Care Initiation Area (CIA) and a physician in triage. Here's how the ED arrived at this winning solution: Leadership was trained in and implemented the Kaizen method, which eliminates redundant or inefficient process steps. Simulation software helped determine additional space needed by analyzing arrival patterns and other key data. After only two days of meetings, new ideas were implemented and tested.

RADON-type disposal facility safety case for the co-ordinated research project on improvement of safety assessment methodologies for near surface radioactive waste disposal facilities (ISAM)

International Nuclear Information System (INIS)

Guskov, A.; Batanjieva, B.; Kozak, M.W.; Torres-Vidal, C.

2002-01-01

The ISAM safety assessment methodology was applied to RADON-type facilities. The assessments conducted through the ISAM project were among the first conducted for these kinds of facilities. These assessments are anticipated to lead to significantly improved levels of safety in countries with such facilities. Experience gained though this RADON-type Safety Case was already used in Russia while developing national regulatory documents. (author)

[Improving patient safety: Usefulness of safety checklists in a neonatal unit].

Science.gov (United States)

Arriaga Redondo, María; Sanz López, Ester; Rodríguez Sánchez de la Blanca, Ana; Marsinyach Ros, Itziar; Collados Gómez, Laura; Díaz Redondo, Alicia; Sánchez Luna, Manuel

2017-10-01

Due to the complexity and characteristics of their patients, neonatal units are risk areas for the development of adverse events (AE). For this reason, there is a need to introduce and implement some tools and strategies that will help to improve the safety of the neonatal patient. Safety check-lists have shown to be a useful tool in other health areas but they are not sufficiently developed in Neonatal Units. A quasi-experimental prospective study was conducted on the design and implementation of the use of a checklist and evaluation of its usefulness for detecting incidents. The satisfaction of the health professionals on using the checklist tool was also assessed. The compliance rate in the neonatal intensive care unit (NICU) was 56.5%, with 4.03 incidents per patient being detected. One incident was detected for every 5.3 checklists used. The most frequent detected incidents were those related to medication, followed by inadequate alarm thresholds, adjustments of the monitors, and medication pumps. The large majority (75%) of the NICU health professionals considered the checklist useful or very useful, and 68.75% considered that its use had managed to avoid an AE. The overall satisfaction was 83.33% for the professionals with less than 5 years working experience, and 44.4% of the professionals with more than 5 years of experience were pleased or very pleased. The checklists have shown to be a useful tool for the detection of incidents, especially in NICU, with a positive assessment from the health professionals of the unit. Copyright © 2016 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Applying Toyota production system techniques for medication delivery: improving hospital safety and efficiency.

Science.gov (United States)

Newell, Terry L; Steinmetz-Malato, Laura L; Van Dyke, Deborah L

2011-01-01

The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital. © 2010 National Association for Healthcare Quality.

Elevating standards, improving safety.

Science.gov (United States)

Clarke, Richard

2014-08-01

In our latest 'technical guidance' article, Richard Clarke, sales and marketing director at one of the UK's leading lift and escalator specialists, Schindler, examines some of the key issues surrounding the specification, maintenance, and operation of lifts in hospitals to help ensure the highest standards of safety and reliability.

Codifying knowledge to improve patient safety: a qualitative study of practice-based interventions.

Science.gov (United States)

Turner, Simon; Higginson, Juliet; Oborne, C Alice; Thomas, Rebecca E; Ramsay, Angus I G; Fulop, Naomi J

2014-07-01

Although it is well established that health care professionals use tacit and codified knowledge to provide front-line care, less is known about how these two forms of knowledge can be combined to support improvement related to patient safety. Patient safety interventions involving the codification of knowledge were co-designed by university and hospital-based staff in two English National Health Service (NHS) hospitals to support the governance of medication safety and mortality and morbidity (M&M) meetings. At hospital A, a structured mortality review process was introduced into three clinical specialities from January to December 2010. A qualitative approach of observing M&M meetings (n = 30) and conducting interviews (n = 40) was used to examine the impact on meetings and on front-line clinicians and hospital managers. At hospital B, a medication safety 'scorecard' was administered on a general medicine and elderly care ward from September to November 2011. Weekly feedback meetings were observed (n = 18) and interviews with front-line staff conducted (n = 10) to examine how knowledge codification influenced behaviour. Codification was shown to support learning related to patient safety at the micro (front-line service) level by structuring the sharing of tacit knowledge, but the presence of professional and managerial boundaries at the organisational level affected the codification initiatives' implementation. The findings suggest that codifying knowledge to support improvement presents distinct challenges at the group and organisational level; translating knowledge across these levels is contingent on the presence of enabling organisational factors, including the alignment of learning from clinical practice with its governance. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Alberta Environment's weir safety program : options for rehabilitation to improve public safety : a case study of the Calgary weir

Energy Technology Data Exchange (ETDEWEB)

Blakely, D. [Alberta Environment, Edmonton, AB (Canada)

2009-07-01

Alberta Environment Water Management Operations (WMO) owns and operates 46 dams and 800 kilometres of canals in Alberta. The WMO consists of 120 staff and several contract operators to take care of this infrastructure. Most of the infrastructure supplies water for irrigation use, which adds 5 billion dollars to the provincial economy annually. Other water uses include stock watering, domestic use, municipal use, recreational use and habitat. Alberta Environment's weir safety program was also discussed along with options for rehabilitation to improve public safety. A case study of Calgary's Weir Dam on the Bow River was highlighted. A brief history of the dam was offered and safety programs around provincially-owned weirs were discussed. Photographs were included to illustrate some of the additional safety measures at the Calgary weir, such as suspended safety buoys upstream of the boom directing paddlers to the portage trail, and signage on the river that can be activated when the boom is out. Typical river users on the Calgary Bow River and safety history at the Calgary Weir were discussed along with other topics such as the Calgary Bow River weir project criteria; project design progress; pre-feasibility options; scale modelling; final design analysis; construction funding; and proposed changes to the safety program for the new weir configuration. figs.

Patient safety is not enough: targeting quality improvements to optimize the health of the population.

Science.gov (United States)

Woolf, Steven H

2004-01-06

Ensuring patient safety is essential for better health care, but preoccupation with niches of medicine, such as patient safety, can inadvertently compromise outcomes if it distracts from other problems that pose a greater threat to health. The greatest benefit for the population comes from a comprehensive view of population needs and making improvements in proportion with their potential effect on public health; anything less subjects an excess of people to morbidity and death. Patient safety, in context, is a subset of health problems affecting Americans. Safety is a subcategory of medical errors, which also includes mistakes in health promotion and chronic disease management that cost lives but do not affect "safety." These errors are a subset of lapses in quality, which result not only from errors but also from systemic problems, such as lack of access, inequity, and flawed system designs. Lapses in quality are a subset of deficient caring, which encompasses gaps in therapeutics, respect, and compassion that are undetected by normative quality indicators. These larger problems arguably cost hundreds of thousands more lives than do lapses in safety, and the system redesigns to correct them should receive proportionately greater emphasis. Ensuring such rational prioritization requires policy and medical leaders to eschew parochialism and take a global perspective in gauging health problems. The public's well-being requires policymakers to view the system as a whole and consider the potential effect on overall population health when prioritizing care improvements and system redesigns.

Improved safety in advanced control complexes, without side effects

International Nuclear Information System (INIS)

Harmon, D.L.

1997-01-01

If we only look for a moment at the world around us, it is obvious that advances in digital electronic equipment and Human-System Interface (HSI) technology are occurring at a phenomenal pace. This is evidenced from our home entertainment systems to the dashboard and computer-based operation of our new cars. Though the nuclear industry has less vigorously embraced these advances, their application is being implemented through individual upgrades to current generation nuclear plants and as plant-wide control complexes for advanced plants. In both venues modem technology possesses widely touted advantages for improving plant availability as well as safety. The well-documented safety benefits of digital Instrumentation and Controls (I ampersand C) include higher reliability resulting from redundancy and fault tolerance, inherent self-test and self-diagnostic capabilities which have replaced error-prone human tasks, resistance to setpoint drift increasing available operating margins, and the ability to run complex, real-time, computer-based algorithms directly supporting an operator's monitoring and control task requirements. 22 refs., 3 figs., 5 tabs

Improving Quality and Occupational Safety on Automated Casting Lines

Directory of Open Access Journals (Sweden)

Kukla S.

2017-09-01

Full Text Available The paper presents a practical example of improving quality and occupational safety on automated casting lines. Working conditions on the line of box moulding with horizontal mould split were analysed due to low degree of automation at the stage of cores or filters installation as well as spheroidizing mortar dosing. A simulation analysis was carried out, which was related to the grounds of introducing an automatic mortar dispenser to the mould. To carry out the research, a simulation model of a line in universal Arena software for modelling and simulation of manufacturing systems by Rockwell Software Inc. was created. A simulation experiment was carried out on a model in order to determine basic parameters of the working system. Organization and working conditions in other sections of the line were also analysed, paying particular attention to quality, ergonomics and occupational safety. Ergonomics analysis was carried out on manual cores installation workplace and filters installation workplace, and changes to these workplaces were suggested in order to eliminate actions being unnecessary and onerous for employees.

78 FR 42701 - Improving Public Safety Communications in the 800 MHz Band

Science.gov (United States)

2013-07-17

...] Improving Public Safety Communications in the 800 MHz Band AGENCY: Federal Communications Commission. ACTION...-901 MHz/935- 940 MHz band (900 MHz B/ILT Band) to allow a qualified entity to file an application for..., manufacturing, energy) to non-commercial (e.g., clerical, educational, philanthropic, medical). In 2004, the...

Integrated risk reduction framework to improve railway hazardous materials transportation safety.

Science.gov (United States)

Liu, Xiang; Saat, M Rapik; Barkan, Christopher P L

2013-09-15

Rail transportation plays a critical role to safely and efficiently transport hazardous materials. A number of strategies have been implemented or are being developed to reduce the risk of hazardous materials release from train accidents. Each of these risk reduction strategies has its safety benefit and corresponding implementation cost. However, the cost effectiveness of the integration of different risk reduction strategies is not well understood. Meanwhile, there has been growing interest in the U.S. rail industry and government to best allocate resources for improving hazardous materials transportation safety. This paper presents an optimization model that considers the combination of two types of risk reduction strategies, broken rail prevention and tank car safety design enhancement. A Pareto-optimality technique is used to maximize risk reduction at a given level of investment. The framework presented in this paper can be adapted to address a broader set of risk reduction strategies and is intended to assist decision makers for local, regional and system-wide risk management of rail hazardous materials transportation. Copyright © 2013 Elsevier B.V. All rights reserved.

Current collectors for improved safety

Science.gov (United States)

Abdelmalak, Michael Naguib; Allu, Srikanth; Dudney, Nancy J.; Li, Jianlin; Simunovic, Srdjan; Wang, Hsin

2017-12-19

A battery electrode assembly includes a current collector with conduction barrier regions having a conductive state in which electrical conductivity through the conduction barrier region is permitted, and a safety state in which electrical conductivity through the conduction barrier regions is reduced. The conduction barrier regions change from the conductive state to the safety state when the current collector receives a short-threatening event. An electrode material can be connected to the current collector. The conduction barrier regions can define electrical isolation subregions. A battery is also disclosed, and methods for making the electrode assembly, methods for making a battery, and methods for operating a battery.

Improving mine safety technology and training: establishing US global leadership

Energy Technology Data Exchange (ETDEWEB)

NONE

2006-12-15

In 2006, the USA's record of mine safety was interrupted by fatalities that rocked the industry and caused the National Mining Association and its members to recommit to returning the US underground coal mining industry to a global mine safety leadership role. This report details a comprehensive approach to increase the odds of survival for miners in emergency situations and to create a culture of prevention of accidents. Among its 75 recommendations are a need to improve communications, mine rescue training, and escape and protection of miners. Section headings of the report are: Introduction; Review of mine emergency situations in the past 25 years: identifying and addressing the issues and complexities; Risk-based design and management; Communications technology; Escape and protection strategies; Emergency response and mine rescue procedures; Training for preparedness; Summary of recommendations; and Conclusions. 37 refs., 3 figs., 5 apps.

Grieg: Songs and dramatic works with orchestra. / Alan Blyth

Index Scriptorium Estoniae

Blyth, Alan

1993-01-01

Uuest heliplaadist "Grieg: Songs and dramatic works with orchestra. Barbara Bonney, Randi Stene, Hakan Hagegard, Ruth Tellefsen, Gothenburg Symphony Chorus and Orchestra, Neeme Järvi." CD 437 519 - 2GH

An electronic intervention to improve safety for pain patients co-prescribed chronic opioids and benzodiazepines.

Science.gov (United States)

Zaman, Tauheed; Rife, Tessa L; Batki, Steven L; Pennington, David L

2018-03-29

Co-prescribing opioids and benzodiazepines increases overdose risk. A paucity of literature exists evaluating strategies to improve safety of co-prescribing. This study evaluated an electronic intervention to improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines at 3 and 6 months. A prospective cohort study was conducted from December 2015 through May 2016 at San Francisco Veterans Affairs Health Care System. A clinical dashboard identified 145 eligible patients prescribed chronic opioids and benzodiazepines. Individualized taper and safety recommendations were communicated to prescribers via electronic medical record progress note and encrypted e-mail at baseline. Primary outcome was number of patients co-prescribed chronic opioids and benzodiazepines. Secondary outcomes included daily dose of opioids and benzodiazepines and number prescribed ≥100 mg morphine equivalent daily dose. Safety outcomes included number with opioid overdose education and naloxone distribution, annual urine drug screening, annual prescription drug monitoring program review, and signed opioid informed consent. Linear mixed models and generalized estimating equations were used to examine within-group change in outcomes between baseline and 3 and 6 months. Among the 145 patients, mean (standard deviation) age was 62 (11) years and 91.7% (133/145) were male. Number co-prescribed significantly decreased from 145/145 (100%) at baseline to 93/139 (67%) at 6-month follow-up (odds ratio [OR] = 0.53, 95% confidence interval [CI]: 0.34-0.81, P = .003). Mean opioid and benzodiazepine doses significantly decreased from 84.61 to 65.63 mg (95% CI: 8.32-27.86, P improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines.

Dramatically enhanced electrical breakdown strength in cellulose nanopaper

Directory of Open Access Journals (Sweden)

Jianwen Huang

2016-09-01

Full Text Available Electrical breakdown behaviors of nanopaper prepared from nanofibrillated cellulose (NFC were investigated. Compared to conventional insulating paper made from micro softwood fibers, nanopaper has a dramatically enhanced breakdown strength. Breakdown field of nanopaper is 67.7 kV/mm, whereas that of conventional paper is only 20 kV/mm. Air voids in the surface of conventional paper are observed by scanning electron microscope (SEM. Further analyses using mercury intrusion show that pore diameter of conventional paper is around 1.7 μm, while that of nanopaper is below 3 nm. Specific pore size of nanopaper is determined to be approximately 2.8 nm by the gas adsorption technique. In addition, theoretical breakdown strengths of nanopaper and conventional paper are also calculated to evaluate the effect of pore size. It turns out that theoretical values agree well with experimental data, indicating that the improved strength in nanopaper is mainly attributed to the decreased pore size. Due to its outstanding breakdown strength, this study indicates the suitability of nanopaper for electrical insulation in ultra-high voltage convert transformers and other electrical devices.

Self-powered remotely controlled machines and tools for safety improvement in mining

Energy Technology Data Exchange (ETDEWEB)

Mirzaeva, G. [University of Newcastle, Callaghan, NSW (Australia)

2005-07-01

This paper addresses the problem of meeting the safety requirements of mining industry for implementation of control and monitoring equipment without external wiring. Local power generation and accumulation combined with remote control and wireless data transmission are suggested as an appropriate way to make the implementation of such device safe and convenient, which in its turn would facilitate their wider application for automation and safety improvement. A rope shovel dipper trip system is discussed in detail as an example of a self-powered remotely-controlled system. Other possible applications of the concept are also identified, such as Armoured Face Conveyor (AFC) and water jet drilling operation monitoring. 5 refs., 6 figs.

QUEST®: A Data-Driven Collaboration to Improve Quality, Efficiency, Safety, and Transparency in Acute Care.

Science.gov (United States)

Crimmins, Mary M; Lowe, Timothy J; Barrington, Monica; Kaylor, Courtney; Phipps, Terri; Le-Roy, Charlene; Brooks, Tammy; Jones, Mashekia; Martin, John

2016-06-01

In 2008 Premier (Premier, Inc., Charlotte, North Carolina) began its Quality, Efficiency, and Safety with Transparency (QUEST®) collaborative, which is an acute health care organization program focused on improving quality and reducing patient harm. Retrospective performance data for QUEST hospitals were used to establish trends from the third quarter (Q3; July–September) of 2006 through Q3 2015. The study population included past and present members of the QUEST collaborative (N = 356), with each participating hospital considered a member. The QUEST program engages with member hospitals through a routine-coaching structure, sprints, minicollaboratives, and face-to-face meetings. Cost and efficiency data showed reductions in adjusted cost per discharge for hospitals between Q3 2013 (mean, $8,296; median, $8,459) and Q3 2015 (mean, $8,217; median, $7,895). Evidence-based care (EBC) measures showed improvement from baseline (Q3 2006; mean, 77%; median, 79%) to Q3 2015 (mean, 95%; median, 96%). Observed-to-expected (O/E) mortality improved from 1% to 22% better-than-expected outcomes on average. The QUEST safety harm composite score showed moderate reduction from Q1 2009 to Q3 2015, as did the O/E readmission rates--from Q1 2010 to Q3 2015--with improvement from a 5% to an 8% better-than-expected score. Quantitative and qualitative evaluation of QUEST collaborative hospitals indicated that for the 2006-2015 period, QUEST facilities reduced cost per discharge, improved adherence with evidence-based practice, reduced safety harm composite score, improved patient experience, and reduced unplanned readmissions.

Patient safety: Safety culture and patient safety ethics

DEFF Research Database (Denmark)

Madsen, Marlene Dyrløv

2006-01-01

,demonstrating significant, consistent and sometimes large differences in terms of safety culture factors across the units participating in the survey. Paper 5 is the results of a study of the relation between safety culture, occupational health andpatient safety using a safety culture questionnaire survey......Patient safety - the prevention of medical error and adverse events - and the initiative of developing safety cultures to assure patients from harm have become one of the central concerns in quality improvement in healthcare both nationally andinternationally. This subject raises numerous...... challenging issues of systemic, organisational, cultural and ethical relevance, which this dissertation seeks to address through the application of different disciplinary approaches. The main focus of researchis safety culture; through empirical and theoretical studies to comprehend the phenomenon, address...

[Team Care for Patient Safety, TeamSTEPPS to Improve Nontechnical Skills and Teamwork--Actions to Become an HRO].

Science.gov (United States)

Kaito, Ken

2015-07-01

It is important to develop safer medical systems and follow manuals of medical procedures for patient safety. However, these approaches do not always result in satisfactory results because of many human factors. It is known that defects of nontechnical skills are more important than those of technical skills regarding medical accidents and incidents. So, it is necessary to improve personal nontechnical skills and compensate for each other's defects based on a team approach. For such purposes, we have implemented TeamSTEPPS to enhance performance and patient safety in our hospital. TeamSTEPPS (team strategies and tools to enhance performance and patient safety) is a useful method to improve the nontechnical skills of each member and the team. In TeamSTEPPS, leadership to share mental models among the team, continuous monitoring and awareness for team activities, mutual support for workload and knowledge, and approaches to complete communication are summarized to enhance teamwork and patient safety. Other than improving nontechnical skills and teamwork, TeamSTEPPS is also very important as a High Reliability Organization (HRO). TeamSTEPPS is worth implementing in every hospital to decrease medical errors and improve patient outcomes and satisfaction.

The NPPR Trnava participation in the NPP V-2 modernisation and safety improvement project

International Nuclear Information System (INIS)

Michal, V.; Losonsky, B.; Magdolen, J.

1999-01-01

The presented contribution deals with form, present state and results of Nuclear Power Plants Research Inst.e participation in the NPP V-2 Jaslovske Bohunice Modernization and Safety Improvement Project.(author)

Model extension and improvement for simulator-based software safety analysis

Energy Technology Data Exchange (ETDEWEB)

Huang, H.-W. [Department of Engineering and System Science, National Tsing Hua University (NTHU), 101 Section 2 Kuang Fu Road, Hsinchu, Taiwan (China) and Institute of Nuclear Energy Research (INER), No. 1000 Wenhua Road, Chiaan Village, Longtan Township, Taoyuan County 32546, Taiwan (China)]. E-mail: hwhwang@iner.gov.tw; Shih Chunkuan [Department of Engineering and System Science, National Tsing Hua University (NTHU), 101 Section 2 Kuang Fu Road, Hsinchu, Taiwan (China); Yih Swu [Department of Computer Science and Information Engineering, Ching Yun University, 229 Chien-Hsin Road, Jung-Li, Taoyuan County 320, Taiwan (China); Chen, M.-H. [Institute of Nuclear Energy Research (INER), No. 1000Wenhua Road, Chiaan Village, Longtan Township, Taoyuan County 32546, Taiwan (China); Lin, J.-M. [Taiwan Power Company (TPC), 242 Roosevelt Road, Section 3, Taipei 100, Taiwan (China)

2007-05-15

One of the major concerns when employing digital I and C system in nuclear power plant is digital system may introduce new failure mode, which differs with previous analog I and C system. Various techniques are under developing to analyze the hazard originated from software faults in digital systems. Preliminary hazard analysis, failure modes and effects analysis, and fault tree analysis are the most extensive used techniques. However, these techniques are static analysis methods, cannot perform dynamic analysis and the interactions among systems. This research utilizes 'simulator/plant model testing' technique classified in (IEEE Std 7-4.3.2-2003, 2003. IEEE Standard for Digital Computers in Safety Systems of Nuclear Power Generating Stations) to identify hazards which might be induced by nuclear I and C software defects. The recirculation flow system, control rod system, feedwater system, steam line model, dynamic power-core flow map, and related control systems of PCTran-ABWR model were successfully extended and improved. The benchmark against ABWR SAR proves this modified model is capable to accomplish dynamic system level software safety analysis and better than the static methods. This improved plant simulation can then further be applied to hazard analysis for operator/digital I and C interface interaction failure study, and the hardware-in-the-loop fault injection study.

International effects on safety and performance improvement for increasing the share of nuclear power in supply of the world energy demand

International Nuclear Information System (INIS)

Rouhanifard, A.; Hosseini Toudeshki, S.

2008-01-01

Perhaps the biggest challenge in launching atomic energy projects will be common public perception that it is a dangerous energy source. In fact, there have only ever been two nuclear accidents - one was Chernobyl (Ukraine) and the other was Three Mile Island (US) where there was an encased explosion and no one was hurt. Undoubtedly, and for good reason, it has had a lasting negative effect on public opinion over the safety of nuclear energy. However, the technology behind nuclear energy has improved in recent years. People have to be aware that new nuclear is not old nuclear. Nuclear is a safe technology and plants are much safer now. In terms of air pollution, developing a nuclear power program can actually have a positive effect on the environment. So today, two thirds of the world's population live in an environment where nuclear power plants are an essential part of energy production and industrial infrastructure. World countries are moving steadily forward with plans for much expanded role of nuclear energy. Efficiency of nuclear generation has increased dramatically over thc last decades. Lessons learned from accidents, advances in nuclear technology and implementation of projects for design of future safer and more economical nuclear reactors, will lead to grow of installed global nuclear capacity from about 369 G We net at the beginning of 2005 to about 553 G We net by 2025. In this paper, we present the results of a study on international efforts to improve safety of nuclear power plants. We focus on the current state of technology and the technology which will be employed for future built reactors to strengthen the role of nuclear power plants for supply of electrical energy in next decades. Finally, based on our studies on past, present and future of the world nuclear technology, we mention the issues to be taken into consideration while preparing the program for development of nuclear power plants in Iran

Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized?