Analysis of Aviation Safety Reporting System Incident Data Associated With the Technical Challenges of the Vehicle Systems Safety Technology Project

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

This analysis was conducted to support the Vehicle Systems Safety Technology (VSST) Project of the Aviation Safety Program (AVsP) milestone VSST4.2.1.01, "Identification of VSST-Related Trends." In particular, this is a review of incident data from the NASA Aviation Safety Reporting System (ASRS). The following three VSST-related technical challenges (TCs) were the focus of the incidents searched in the ASRS database: (1) Vechicle health assurance, (2) Effective crew-system interactions and decisions in all conditions; and (3) Aircraft loss of control prevention, mitigation, and recovery.

Reporter Concerns in 300 Mode-Related Incident Reports from NASA's Aviation Safety Reporting System

Science.gov (United States)

McGreevy, Michael W.

1996-01-01

A model has been developed which represents prominent reporter concerns expressed in the narratives of 300 mode-related incident reports from NASA's Aviation Safety Reporting System (ASRS). The model objectively quantifies the structure of concerns which persist across situations and reporters. These concerns are described and illustrated using verbatim sentences from the original narratives. Report accession numbers are included with each sentence so that concerns can be traced back to the original reports. The results also include an inventory of mode names mentioned in the narratives, and a comparison of individual and joint concerns. The method is based on a proximity-weighted co-occurrence metric and object-oriented complexity reduction.

78 FR 14877 - Pipeline Safety: Incident and Accident Reports

Science.gov (United States)

2013-03-07

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket ID PHMSA-2013-0028] Pipeline Safety: Incident and Accident Reports AGENCY: Pipeline and Hazardous Materials... PHMSA F 7100.2--Incident Report--Natural and Other Gas Transmission and Gathering Pipeline Systems and...

Safety-related occurrences at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Reponen, H.; Viitasaari, O.

1985-04-01

This report contains detailed descriptions of operating incidents and other safety-related matters at the Finnish nuclear power plants regarded as significant by the regulatory authority, the Finnish Centre for Radiation and Nuclear Safety. In this connection, an account is given of the practical actions caused by the incidents, and their significance to reactor safety is evaluated. The main features of the incidents are also described in the general Quartely Report for this period, Operation of Finnish Nuclear Power Plants (STUK-B-YTO 7), which is supplemented by this report intended for experts. (author)

Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study.

Science.gov (United States)

Panagioti, Maria; Blakeman, Thomas; Hann, Mark; Bower, Peter

2017-05-30

Increasing evidence suggests that patient safety is a serious concern for older patients with long-term conditions. Despite this, there is a lack of research on safety incidents encountered by this patient group. In this study, we sought to examine patient reports of safety incidents and factors associated with reports of safety incidents in older patients with long-term conditions. The baseline cross-sectional data from a longitudinal cohort study were analysed. Older patients (n=3378 aged 65 years and over) with a long-term condition registered in general practices were included in the study. The main outcome was patient-reported safety incidents including availability and appropriateness of medical tests and prescription of wrong types or doses of medication. Binary univariate and multivariate logistic regression analyses were undertaken to examine factors associated with patient-reported safety incidents. Safety incidents were reported by 11% of the patients. Four factors were significantly associated with patient-reported safety incidents in multivariate analyses. The experience of multiple long-term conditions (OR=1.09, 95% CI 1.05 to 1.13), a probable diagnosis of depression (OR=1.36, 95% CI 1.06 to 1.74) and greater relational continuity of care (OR=1.28, 95% CI 1.08 to 1.52) were associated with increased odds for patient-reported safety incidents. Perceived greater support and involvement in self-management was associated with lower odds for patient-reported safety incidents (OR=0.95, 95% CI 0.93 to 0.97). We found that older patients with multimorbidity and depression are more likely to report experiences of patient safety incidents. Improving perceived support and involvement of patients in their care may help prevent patient-reported safety incidents. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Safety-related occurrences at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Viitasaari, O.; Rantavaara, A.

1984-03-01

This report contains detailed descriptions of operating incidents and other safety-related matters at the Finnish nuclear power plants regarded as significant by the regulatory authority, the Finnish Centre for Radiation and Nuclear Safety. In this connection, an account is given of the practical actions caused by the incidents, and their significance to reactor safety is evaluated. The main features of the incidents are also described in the general Quartely Report for this period, Operation of Finnish Nuclear Power Plants (STL-B-RTO-83/7), which is supplemented by this report intended principally for experts. (author)

[Regional Study of Patient Safety Incidents (ERIDA) in the Emergency Services].

Science.gov (United States)

Alcaraz-Martínez, J; Aranaz-Andrés, J M; Martínez-Ros, C; Moreno-Reina, S; Escobar-Álvaro, L; Ortega-Liarte, J V

2016-01-01

Evaluate the patient safety incidents that occur in the emergency departments of our region. Observational study conducted in all the hospital emergency departments in the Regional Health Service of Murcia. After systematic random sampling, data were collected during care and a week later by telephone survey. Health professionals of each service were trained and collected the information, following the methodology of the National Study of Adverse Events Related to Hospitalization -ENEAS- and the Adverse Events Related to Spanish Hospital Emergency Department Care -EVADUR-. A total of 393 samples were collected, proportional to the cases treated in each hospital. In 10 cases (3.1%) the complaint was a previous safety incident. At least one incident was detected in 47 patients (11.95%; 8.7 to 15.1%). In 3 cases there were 2 incidents, bringing the number of incidents to 50. Regarding the impact, the 51% of incidents caused harm to the patients. The effects more frequent in patients were the need for repeat visits (9 cases), and mismanagement of pain (8 cases). In 24 cases (51.1%) health care was not affected, although 3 cases required an additional test, 11 cases required further consultation, and led to hospitalisation in 2 cases. The most frequent causal factors of these incidents were medication (14) and care (12). The incidents were considered preventable in 60% of cases. A rate of incidents in the emergency departments, representative of the region, has been obtained. The implications of the results for the population means that 12 out of every 100 patients treated in emergency departments have an adverse event, and 7 of these are avoidable. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

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

Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

International Nuclear Information System (INIS)

Novak, Avrey; Nyflot, Matthew J.; Ermoian, Ralph P.; Jordan, Loucille E.; Sponseller, Patricia A.; Kane, Gabrielle M.; Ford, Eric C.; Zeng, Jing

2016-01-01

Purpose: Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. Methods: From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Results: Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically

Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

Energy Technology Data Exchange (ETDEWEB)

Novak, Avrey; Nyflot, Matthew J.; Ermoian, Ralph P.; Jordan, Loucille E.; Sponseller, Patricia A.; Kane, Gabrielle M.; Ford, Eric C.; Zeng, Jing, E-mail: jzeng13@uw.edu [Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195 (United States)

2016-05-15

Purpose: Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. Methods: From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Results: Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically

Demonstrating a correlation between the maturity of road safety practices and road safety incidents.

Science.gov (United States)

Amador, Luis; Willis, Christopher Joseph

2014-01-01

The objective of this study is to demonstrate a correlation between the maturity of a country's road safety practices and road safety incidents. Firstly, data on a number of road injuries and fatalities for 129 countries were extracted from the United Nations Global Status on Road Safety database. These data were subdivided according to road safety incident and accident causation factors and normalized based on vehicular fleet (per 1000 vehicles) and road network (per meter of paved road). Secondly, a road safety maturity model was developed based on an adaptation of the concept of process maturity modeling. The maturity of countries with respect to 10 road safety practices was determined through the identification of indicators recorded in the United Nations Global Status of Road Safety Database. Plots of normalized road safety performance of the 129 countries against their maturity scores for each road safety practice as well as an aggregation of the road safety practices were developed. An analysis of variance was done to determine the extent of the correlation between the road safety maturity of the countries and their performance. In addition, a full Bayesian analysis was done to confirm the correlation of each of the road safety practices with injuries and fatalities. Regression analysis for fatalities, injuries, and combined accidents identified maturity with respect to road safety practices associated with speed limits and use of alternative modes as being the most significant predictors of traffic fatalities. A full Bayesian regression confirms that there is a correlation between the maturity of road safety practices and road safety incidents. Road safety practices associated with enforcement of speed limits and promotion of alternative modes are the most significant road safety practices toward which mature countries have concentrated their efforts, resulting in a lower frequency of fatalities, injury rates, and property damage accidents. The authors

Extracting South African safety and security incident patterns from social media

CSIR Research Space (South Africa)

Marivate, Vukoxi N

2015-11-01

Full Text Available and potentially feed into an automated incident detection application. We collected a size-able dataset of Twitter posts (more than 60,000) over a 3 month period by monitoring crime and public safety related keywords linked to accounts. By splitting the data...

Assessing propensity to learn from safety-related events

NARCIS (Netherlands)

Drupsteen, L.; Wybo, J.L.

2015-01-01

Most organisations aim to use experience from the past to improve safety, for instance through learning from safety-related incidents and accidents. Whether an organisation is able to learn successfully can however only be determined afterwards. So far, there are no proactive measures to assess

IAEA/NEA incident reporting system (IRS). Reporting guidelines. Feedback from safety related operating experience for nuclear power plants

International Nuclear Information System (INIS)

1998-01-01

The Incident Reporting System (IRS) is an international system jointly operated by the International Atomic Energy Agency (IAEA) and the Nuclear Energy Agency of the Organisation for Economic Cooperation and Development (OECD/NEA). The fundamental objective of the IRS is to contribute to improving the safety of commercial nuclear power plants (NPPs) which are operated worldwide. This objective can be achieved by providing timely and detailed information on both technical and human factors related to events of safety significance which occur at these plants. The purpose of these guidelines, which supersede the previous IAEA Safety Series No. 93 (Part II) and the NEA IRS guidelines, is to describe the system and to give users the necessary background and guidance to enable them to produce IRS reports meeting a high standard of quality while retaining the high efficiency of the system expected by all Member States operating nuclear power plants. These guidelines have been jointly developed and approved by the NEA/IAEA

Development of several data bases related to reactor safety research including probabilistic safety assessment and incident analysis at JAERI

International Nuclear Information System (INIS)

Kobayashi, Kensuke; Oikawa, Tetsukuni; Watanabe, Norio; Izumi, Fumio; Higuchi, Suminori

1986-01-01

Presented are several databases developed at JAERI for reactor safety research including probabilistic safety assessment and incident analysis. First described are the recent developments of the databases such as 1) the component failure rate database, 2) the OECD/NEA/IRS information retrieval system, 3) the nuclear power plant database and so on. Then several issues are discussed referring mostly to the operation of the database (data input and transcoding) and to the retrieval and utilization of the information. Finally, emphasis is given to the increasing role which artifitial intelligence techniques such as natural language treatment and expert systems may play in improving the future capabilities of the databases. (author)

Hospital-related incidents; causes and its impact on disaster preparedness and prehospital organisations

Directory of Open Access Journals (Sweden)

Khorram-Manesh Amir

2009-06-01

Full Text Available Abstract Background A hospital's capacity and preparedness is one of the important parts of disaster planning. Hospital-related incidents, a new phenomenon in Swedish healthcare, may lead to ambulance diversions, increased waiting time at emergency departments and treatment delay along with deterioration of disaster management and surge capacity. We aimed to identify the causes and impacts of hospital-related incidents in Region Västra Götaland (western region of Sweden. Methods The regional registry at the Prehospital and Disaster Medicine Center was reviewed (2006–2008. The number of hospital-related incidents and its causes were analyzed. Results There were an increasing number of hospital-related incidents mainly caused by emergency department's overcrowdings, the lack of beds at ordinary wards and/or intensive care units and technical problems at the radiology departments. These incidents resulted in ambulance diversions and reduced the prehospital capacity as well as endangering the patient safety. Conclusion Besides emergency department overcrowdings, ambulance diversions, endangering patient s safety and increasing risk for in-hospital mortality, hospital-related incidents reduces and limits the regional preparedness by minimizing the surge capacity. In order to prevent a future irreversible disaster, this problem should be avoided and addressed properly by further regional studies.

Safety in the operating room during orthopedic trauma surgery-incidence of adverse events related to technical equipment and logistics

NARCIS (Netherlands)

van Delft, E. A. K.; Schepers, T.; Bonjer, H. J.; Kerkhoffs, G. M. M. J.; Goslings, J. C.; Schep, N. W. L.

2017-01-01

Safety in the operating room is widely debated. Adverse events during surgery are potentially dangerous for the patient and staff. The incidence of adverse events during orthopedic trauma surgery is unknown. Therefore, we performed a study to quantify the incidence of these adverse events. Primary

Aviation Trends Related to Atmospheric Environment Safety Technologies Project Technical Challenges

Science.gov (United States)

Reveley, Mary S.; Withrow, Colleen A.; Barr, Lawrence C.; Evans, Joni K.; Leone, Karen M.; Jones, Sharon M.

2014-01-01

Current and future aviation safety trends related to the National Aeronautics and Space Administration's Atmospheric Environment Safety Technologies Project's three technical challenges (engine icing characterization and simulation capability; airframe icing simulation and engineering tool capability; and atmospheric hazard sensing and mitigation technology capability) were assessed by examining the National Transportation Safety Board (NTSB) accident database (1989 to 2008), incidents from the Federal Aviation Administration (FAA) accident/incident database (1989 to 2006), and literature from various industry and government sources. The accident and incident data were examined for events involving fixed-wing airplanes operating under Federal Aviation Regulation (FAR) Parts 121, 135, and 91 for atmospheric conditions related to airframe icing, ice-crystal engine icing, turbulence, clear air turbulence, wake vortex, lightning, and low visibility (fog, low ceiling, clouds, precipitation, and low lighting). Five future aviation safety risk areas associated with the three AEST technical challenges were identified after an exhaustive survey of a variety of sources and include: approach and landing accident reduction, icing/ice detection, loss of control in flight, super density operations, and runway safety.

Analysis of general aviation single-pilot IFR incident data obtained from the NASA Aviation Safety Reporting System

Science.gov (United States)

Bergeron, H. P.

1983-01-01

An analysis of incident data obtained from the NASA Aviation Safety Reporting System (ASRS) has been made to determine the problem areas in general aviation single-pilot IFR (SPIFR) operations. The Aviation Safety Reporting System data base is a compilation of voluntary reports of incidents from any person who has observed or been involved in an occurrence which was believed to have posed a threat to flight safety. This paper examines only those reported incidents specifically related to general aviation single-pilot IFR operations. The frequency of occurrence of factors related to the incidents was the criterion used to define significant problem areas and, hence, to suggest where research is needed. The data was cataloged into one of five major problem areas: (1) controller judgment and response problems, (2) pilot judgment and response problems, (3) air traffic control (ATC) intrafacility and interfacility conflicts, (4) ATC and pilot communication problems, and (5) IFR-VFR conflicts. In addition, several points common to all or most of the problems were observed and reported. These included human error, communications, procedures and rules, and work load.

Reducing the Probability of Incidents Through Behavior-Based Safety -- An Anomaly or Not?

International Nuclear Information System (INIS)

Turek, John A

2002-01-01

Reducing the probability of incidents through Behavior-Based Safety--an anomaly or not? Can a Behavior-Based Safety (BBS) process reduce the probability of an employee sustaining a work-related injury or illness? This presentation describes the actions taken to implement a sustainable BBS process and evaluates its effectiveness. The BBS process at the Stanford Linear Accelerator Center used a pilot population of national laboratory employees to: Achieve employee and management support; Reduce the probability of employees' sustaining work-related injuries and illnesses; and Provide support for additional funding to expand within the laboratory

Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

Science.gov (United States)

Panagioti, Maria; Stokes, Jonathan; Esmail, Aneez; Coventry, Peter; Cheraghi-Sohi, Sudeh; Alam, Rahul; Bower, Peter

2015-01-01

Background Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care. Methods We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: ‘active patient safety incidents’ (such as adverse drug events and medical complications) and ‘precursors of safety incidents’ (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken. Results Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for ‘active patient safety incidents’ (OR = 2.39, 95% CI = 1.40 to 3.38) and ‘precursors of safety incidents’ (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low. Conclusions The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity

Automated Safety Incident Surveillance and Tracking System (ASISTS)

Data.gov (United States)

Department of Veterans Affairs — The Automated Safety Incident Surveillance and Tracking System (ASISTS) is a repository of Veterans Health Administration (VHA) employee accident data. Many types of...

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database.

Science.gov (United States)

Cooper, Jennifer; Edwards, Adrian; Williams, Huw; Sheikh, Aziz; Parry, Gareth; Hibbert, Peter; Butlin, Amy; Donaldson, Liam; Carson-Stevens, Andrew

2017-09-01

A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports. We characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame. Health care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%-47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated. The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others' behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture. © 2017 Annals of Family Medicine, Inc.

How Organisations Learn from Safety Incidents: A Multifaceted Problem

Science.gov (United States)

Lukic, Dane; Margaryan, Anoush; Littlejohn, Allison

2010-01-01

Purpose: This paper seeks to review current approaches to learning from health and safety incidents in the workplace. The aim of the paper is to identify the diversity of approaches and analyse them in terms of learning aspects. Design/methodology/approach: A literature review was conducted searching for terms incident/accident/near…

Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory cohort study?

Science.gov (United States)

van Dulmen, Simone A; Tacken, Margot A J B; Staal, J Bart; Gaal, Sander; Wensing, Michel; Nijhuis-van der Sanden, Maria W G

2011-12-01

Research on patient safety in allied healthcare is scarce. Our aim was to document patient safety in primary allied healthcare in the Netherlands and to identify factors associated with incidents. DESIGN AND SUBJECT: A retrospective study of 1000 patient records in a representative sample of 20 allied healthcare practices was combined with a prospective incident-reporting study. All records were reviewed by trained researchers to identify patient safety incidents. The incidents were classified and analyzed, using the Prevention and Recovery Information System for Monitoring and Analysis method. Factors associated with incidents were examined in a logistic regression analysis. In 18 out of 1000 (1.8%; 95% confidence interval: 1.0-2.6) records an incident was detected. The main causes of incidents were related to errors in clinical decisions (89%), communication with other healthcare providers (67%), and monitoring (56%). The probability of incidents was higher if more care providers had been involved and if patient records were incomplete (37% of the records). No incidents were reported in the prospective study. The absolute number of incidents was low, which could imply a low risk of harm in Dutch primary allied healthcare. Nevertheless, incompleteness of the patient records and the fact that incidents were mainly caused through human actions suggest that a focus on clinical reasoning and record keeping is needed to further enhance patient safety. Improvements in record keeping will be necessary before accurate incident reporting will be feasible and valid.

Effect of snowboard-related concussion safety education for recognizing possible concussions.

Science.gov (United States)

Koh, J O

2011-12-01

The aim of this study was to examine the understanding of snowboard-related concussion and to measure the recognition of possible concussion occurrence after an intervention of snowboard-related concussion safety education in snowboarding. Incidence cohort design. 2008-2009 season Gangwon-do Ski resorts, South Korea. A total of 208 university students (female-72; male-136; age-18 to 32) who registered for a snowboarding class and received credit participated in this project. Snowboard-related concussion safety education class was administered for 30 minutes before the snowboard class began. The knowledge of snowboard-related concussion before and after the safety education was evaluated. Concussion data were collected via a self-report case form at the last day of snowboarding class. The incidence of possible concussion and factors associated with concussions were analyzed by χ2 test. The mean score of snowboard-related concussion knowledge improved from fifteen points to eighteen points out of 20 total points possible. Overall the incidence of concussion was 10 per 100 snowboarder-exposures. χ2 tests showed concussion rates to be significantly different in female snowboarders (P=0.00) and in helmet users (P=0.02). The incidence of possible concussion is high among snowboarding class participants. Emphasis should be given for instituting pre-participation balance training, especially for females to reduce falling in snowboarding. To verify the effects of pre-participation balance training and falling results in a concussion, more research is needed in the future.

Exploring the Influence of Nurse Work Environment and Patient Safety Culture on Attitudes Toward Incident Reporting.

Science.gov (United States)

Yoo, Moon Sook; Kim, Kyoung Ja

2017-09-01

The aim of this study was to explore the influence of nurse work environments and patient safety culture on attitudes toward incident reporting. Patient safety culture had been known as a factor of incident reporting by nurses. Positive work environment could be an important influencing factor for the safety behavior of nurses. A cross-sectional survey design was used. The structured questionnaire was administered to 191 nurses working at a tertiary university hospital in South Korea. Nurses' perception of work environment and patient safety culture were positively correlated with attitudes toward incident reporting. A regression model with clinical career, work area and nurse work environment, and patient safety culture against attitudes toward incident reporting was statistically significant. The model explained approximately 50.7% of attitudes toward incident reporting. Improving nurses' attitudes toward incident reporting can be achieved with a broad approach that includes improvements in work environment and patient safety culture.

Food Safety Incidents, Collateral Damage and Trade Policy Responses: China-Canada Agri-Food Trade

OpenAIRE

Liu, Huanan; Hobbs, Jill E.; Kerr, William A.

2008-01-01

As markets become globalized, food safety policy and international trade policy are increasingly intertwined. Globalization also means that food safety incidents are widely reported internationally. One result is that food safety incidents can negatively impact products where no food safety issue exists as consumers lose trust in both foreign and domestic food safety institutions. While the policy framework for dealing with directly effected imported foods is well understood, how to deal with...

Summary of Auger-Related Entanglement Incidents Occurring Inside Agricultural Confined Spaces.

Science.gov (United States)

Cheng, Y H; Field, W E

2016-04-01

Entanglements in energized equipment, including augers found in agricultural workplaces, have historically been a significant cause of traumatic injury. Incidents involving augers located inside agricultural confined spaces (primarily grain storage structures and forage silos), although relatively rare events, are a widely recognized problem due to the relative severity of the resulting injuries and the complexities of victim extrication. However, this problem is neither well documented nor elucidated in the research literature, other than anecdotal observations relating to medical treatment of auger-related injuries and citations for non-compliance with federal and state workplace safety regulations. A review of nearly 1,650 cases documented in the Purdue Agricultural Confined Spaces Incident Database from 1964 to 2013 identified 167 incidents involving entanglement in an energized auger that occurred while the victim was working inside an agricultural confined space. These incidents primarily included in-floor unloading augers, sweep augers, stirring augers, and auger components found on silo unloaders. Cases involving portable tube augers used to handle grain outside grain storage structures were not included. Based on analysis of the data, approximately 98% of known victims were male, with the 21-45 age group reporting the largest number of incidents. Nearly one-third (32.3%) of incidents were fatal, and lower limb amputation was the most frequently reported injury type. (It is believed that non-fatal incidents are grossly under-reported in the data set due to a lack of comprehensive reporting requirements, especially for most farms, feedlots, and seed processing operations, which are generally exempt from compliance with OSHA machine guarding, confined-space, and grain-handling standards.) The type of auger identified most frequently as the agent of injury was the exposed in-floor auger (48), which frequently resulted in amputation of one or more lower limbs

Presentation of a method for the sequential analysis of incidents - NPP safety

Energy Technology Data Exchange (ETDEWEB)

Delage, M; Giroux, C; Quentin, P

1989-04-01

This paper presents a method which is designed to assist in the analysis of safety and based on the graphic representation of the occurrence of incidents significant for safety in 900-MWe PWR units. The graphs obtained are linked together to produce a general tree of events. With this tool, and on the basis of operating experience, it is then possible to imagine complex incident scenarios, to evaluate the potential consequences of a particular incident, or to seed out the causes which could lead to a given event. Interactions between systems or common mode faults can also be evidenced with this method.

Validating the Danish adaptation of the World Health Organization's International Classification for Patient Safety classification of patient safety incident types

DEFF Research Database (Denmark)

Mikkelsen, Kim Lyngby; Thommesen, Jacob; Andersen, Henning Boje

2013-01-01

Objectives Validation of a Danish patient safety incident classification adapted from the World Health Organizaton's International Classification for Patient Safety (ICPS-WHO). Design Thirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types.......513 (range: 0.193–0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity...

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process.

Science.gov (United States)

Howell, Ann-Marie; Burns, Elaine M; Hull, Louise; Mayer, Erik; Sevdalis, Nick; Darzi, Ara

2017-02-01

Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Medication Incidents Related to Automated Dose Dispensing in Community Pharmacies and Hospitals - A Reporting System Study

Science.gov (United States)

Cheung, Ka-Chun; van den Bemt, Patricia M. L. A.; Bouvy, Marcel L.; Wensing, Michel; De Smet, Peter A. G. M.

2014-01-01

Introduction Automated dose dispensing (ADD) is being introduced in several countries and the use of this technology is expected to increase as a growing number of elderly people need to manage their medication at home. ADD aims to improve medication safety and treatment adherence, but it may introduce new safety issues. This descriptive study provides insight into the nature and consequences of medication incidents related to ADD, as reported by healthcare professionals in community pharmacies and hospitals. Methods The medication incidents that were submitted to the Dutch Central Medication incidents Registration (CMR) reporting system were selected and characterized independently by two researchers. Main Outcome Measures Person discovering the incident, phase of the medication process in which the incident occurred, immediate cause of the incident, nature of incident from the healthcare provider's perspective, nature of incident from the patient's perspective, and consequent harm to the patient caused by the incident. Results From January 2012 to February 2013 the CMR received 15,113 incidents: 3,685 (24.4%) incidents from community pharmacies and 11,428 (75.6%) incidents from hospitals. Eventually 1 of 50 reported incidents (268/15,113 = 1.8%) were related to ADD; in community pharmacies more incidents (227/3,685 = 6.2%) were related to ADD than in hospitals (41/11,428 = 0.4%). The immediate cause of an incident was often a change in the patient's medicine regimen or relocation. Most reported incidents occurred in two phases: entering the prescription into the pharmacy information system and filling the ADD bag. Conclusion A proportion of incidents was related to ADD and is reported regularly, especially by community pharmacies. In two phases, entering the prescription into the pharmacy information system and filling the ADD bag, most incidents occurred. A change in the patient's medicine regimen or relocation was the immediate causes of an incident

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

Patient Safety Incidents and Nursing Workload

Directory of Open Access Journals (Sweden)

Katya Cuadros Carlesi

Full Text Available ABSTRACT Objective: to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile. Method: quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs was performed using the Therapeutic Interventions Scoring System (TISS-28 and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation. Results: 879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919 and rate of falls (r = 0.8770. The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload. Conclusions: the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload.

National Incidence of Patient Safety Indicators in the Total Hip Arthroplasty Population.

Science.gov (United States)

Tanenbaum, Joseph E; Knapik, Derrick M; Wera, Glenn D; Fitzgerald, Steven J

2017-09-01

The Centers for Medicare & Medicaid Services use the incidence of patient safety indicators (PSIs) to determine health care value and hospital reimbursement. The national incidence of PSI has not been quantified in the total hip arthroplasty (THA) population, and it is unknown if patient insurance status is associated with PSI incidence after THA. All patients in the Nationwide Inpatient Sample (NIS) who underwent THA in 2013 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Diseases, Ninth Revision, diagnosis code algorithms published by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. The association of insurance status and the incidence of PSI during the inpatient episode was determined by comparing privately insured and Medicare patients with Medicaid/self-pay patients using a logistic regression model that controlled for patient demographics, patient comorbidities, and hospital characteristics. In 2013, the NIS included 68,644 hospitalizations with primary THA performed during the inpatient episode. During this period, 429 surgically relevant PSI were recorded in the NIS. The estimated national incidence rate of PSI after primary THA was 0.63%. In our secondary analysis, the privately insured cohort had significantly lower odds of experiencing one or more PSIs relative to the Medicaid/self-pay cohort (odds ratio, 0.47; 95% confidence interval, 0.29-0.76). The national incidence of PSI among THA patients is relatively low. However, primary insurance status is associated with the incidence of one or more PSIs after THA. As value-based payment becomes more widely adopted in the United States, quality benchmarks and penalty thresholds need to account for these differences in risk-adjustment models to promote and maintain access to care in the underinsured population. Copyright �

EDA activities related to safety

International Nuclear Information System (INIS)

Gordon, C.; Raeder, J.

2001-01-01

This article reviews the accomplishments in ITER safety analysis during the course of the Engineering Design Activities (EDA). The key aspects of ITER safety analysis are: effluents and emissions from normal operation, including planned maintenance activities; occupational safety for workers at the facility; radioactive materials and wastes generated during operation and from decommissioning ; potential incidents and accidents and the resulting transients. As a result of the work during the EDA it is concluded that ITER is safe

Critical Incident Stress Management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare.

Science.gov (United States)

Müller-Leonhardt, Alice; Mitchell, Shannon G; Vogt, Joachim; Schürmann, Tim

2014-07-01

In complex systems, such as hospitals or air traffic control operations, critical incidents (CIs) are unavoidable. These incidents can not only become critical for victims but also for professionals working at the "sharp end" who may have to deal with critical incident stress (CIS) reactions that may be severe and impede emotional, physical, cognitive and social functioning. These CIS reactions may occur not only under exceptional conditions but also during every-day work and become an important safety issue. In contrast to air traffic management (ATM) operations in Europe, which have readily adopted critical incident stress management (CISM), most hospitals have not yet implemented comprehensive peer support programs. This survey was conducted in 2010 at the only European general hospital setting which implemented CISM program since 2004. The aim of the article is to describe possible contribution of CISM in hospital settings framed from the perspective of organizational safety and individual health for healthcare professionals. Findings affirm that daily work related incidents also can become critical for healthcare professionals. Program efficiency appears to be influenced by the professional culture, as well as organizational structure and policies. Overall, findings demonstrate that the adaptation of the CISM program in general hospitals takes time but, once established, it may serve as a mechanism for changing professional culture, thereby permitting the framing of even small incidents or near misses as an opportunity to provide valuable feedback to the system. Copyright © 2014 Elsevier Ltd. All rights reserved.

Food risk management quality: Consumer evaluations of past and emerging food safety incidents

NARCIS (Netherlands)

Kleef, van E.; Ueland, O.; Theodoridis, G.; Rowe, G.; Pfenning, U.; Houghton, J.R.; Dijk, van H.; Chryssochoidis, G.; Frewer, L.J.

2009-01-01

In European countries, there has been growing consumer distrust regarding the motives of food safety regulators and other actors in the food chain, partly as a result of recent food safety incidents. If consumer confidence in food safety is to be improved, a systematic understanding of what

Comparing non-safety with safety device sharps injury incidence data from two different occupational surveillance systems.

Science.gov (United States)

Mitchell, A H; Parker, G B; Kanamori, H; Rutala, W A; Weber, D J

2017-06-01

The United States Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard as amended by the Needlestick Safety and Prevention Act requiring the use of safety-engineered medical devices to prevent needlesticks and sharps injuries has been in place since 2001. Injury changes over time include differences between those from non-safety compared with safety-engineered medical devices. This research compares two US occupational incident surveillance systems to determine whether these data can be generalized to other facilities and other countries either with legislation in place or considering developing national policies for the prevention of sharps injuries among healthcare personnel. Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Patient Safety Incidents and Nursing Workload 1

Science.gov (United States)

Carlesi, Katya Cuadros; Padilha, Kátia Grillo; Toffoletto, Maria Cecília; Henriquez-Roldán, Carlos; Juan, Monica Andrea Canales

2017-01-01

ABSTRACT Objective: to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile. Method: quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation. Results: 879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload. Conclusions: the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload. PMID:28403334

Patient involvement in patient safety: Protocol for developing an intervention using patient reports of organisational safety and patient incident reporting

Directory of Open Access Journals (Sweden)

Armitage Gerry

2011-05-01

Full Text Available Abstract Background Patients have the potential to provide a rich source of information on both organisational aspects of safety and patient safety incidents. This project aims to develop two patient safety interventions to promote organisational learning about safety - a patient measure of organisational safety (PMOS, and a patient incident reporting tool (PIRT - to help the NHS prevent patient safety incidents by learning more about when and why they occur. Methods To develop the PMOS 1 literature will be reviewed to identify similar measures and key contributory factors to error; 2 four patient focus groups will ascertain practicality and feasibility; 3 25 patient interviews will elicit approximately 60 items across 10 domains; 4 10 patient and clinician interviews will test acceptability and understanding. Qualitative data will be analysed using thematic content analysis. To develop the PIRT 1 individual and then combined patient and clinician focus groups will provide guidance for the development of three potential reporting tools; 2 nine wards across three hospital directorates will pilot each of the tools for three months. The best performing tool will be identified from the frequency, volume and quality of reports. The validity of both measures will be tested. 300 patients will be asked to complete the PMOS and PIRT during their stay in hospital. A sub-sample (N = 50 will complete the PMOS again one week later. Health professionals in participating wards will also be asked to complete the AHRQ safety culture questionnaire. Case notes for all patients will be reviewed. The psychometric properties of the PMOS will be assessed and a final valid and reliable version developed. Concurrent validity for the PIRT will be assessed by comparing reported incidents with those identified from case note review and the existing staff reporting scheme. In a subsequent study these tools will be used to provide information to wards/units about their

Forklift safety a practical guide to preventing powered industrial truck incidents and injuries

CERN Document Server

Swartz, George

1999-01-01

Written for the more than 1.5 million powered industrial truck operators and supervisors in general industry, as well as those in the construction and marine industries, this Second Edition provides an updated guide to training operators in safety and complying with OSHA's 1999 forklift standard. This edition of Forklift Safety includes a new chapter devoted to the new OSHA 1910.178 standard and new information regarding dock safety, narrow aisle trucks, off-dock incidents, tip-over safety, pallet safety, and carbon monoxide.

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

Science.gov (United States)

Pham, Julius Cuong; Williams, Tamara L; Sparnon, Erin M; Cillie, Tam K; Scharen, Hilda F; Marella, William M

2016-05-01

In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

Science.gov (United States)

Pham, Julius Cuong; Williams, Tamara L; Sparnon, Erin M; Cillie, Tam K; Scharen, Hilda F; Marella, William M

2016-01-01

BACKGROUND: In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. METHODS: We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. RESULTS: A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. CONCLUSIONS: Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of

An analysis of electronic health record-related patient safety concerns

Science.gov (United States)

Meeks, Derek W; Smith, Michael W; Taylor, Lesley; Sittig, Dean F; Scott, Jean M; Singh, Hardeep

2014-01-01

Objective A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system. Methods The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports. Results We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR. Discussion EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA. Conclusions Because EHR-related safety concerns have complex

Functional analysis of controbloc incidents

International Nuclear Information System (INIS)

Gouffon, A.; Jorel, M.

1992-11-01

The subject of the present paper is the survey jointly carried out in 1989 by the IPSN Safety Analysis Department and the Firm BERTIN and Co. on significant incidents related to the Controbloc system equipping the EDF 1300 MWe PWR power plants in France. This survey consisted in a general review of Controbloc operating problems, together with analysis of the safety consequences of the incidents discussed. The survey enabled improvements to be recommended in this respect and provided a basis for safety analysis

Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data.

Science.gov (United States)

Howell, Ann-Marie; Burns, Elaine M; Bouras, George; Donaldson, Liam J; Athanasiou, Thanos; Darzi, Ara

2015-01-01

The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems. This study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure. 5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were

Causal Factors and Adverse Events of Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

Science.gov (United States)

Reveley, Mary S.; Briggs, Jeffrey L.; Evans, Joni K.; Jones, Sharon M.; Kurtoglu, Tolga; Leone, Karen M.; Sandifer, Carl E.

2011-01-01

Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.

The Swiss cheese model of safety incidents: are there holes in the metaphor?

Directory of Open Access Journals (Sweden)

Perneger Thomas V

2005-11-01

Full Text Available Abstract Background Reason's Swiss cheese model has become the dominant paradigm for analysing medical errors and patient safety incidents. The aim of this study was to determine if the components of the model are understood in the same way by quality and safety professionals. Methods Survey of a volunteer sample of persons who claimed familiarity with the model, recruited at a conference on quality in health care, and on the internet through quality-related websites. The questionnaire proposed several interpretations of components of the Swiss cheese model: a slice of cheese, b hole, c arrow, d active error, e how to make the system safer. Eleven interpretations were compatible with this author's interpretation of the model, 12 were not. Results Eighty five respondents stated that they were very or quite familiar with the model. They gave on average 15.3 (SD 2.3, range 10 to 21 "correct" answers out of 23 (66.5% – significantly more than 11.5 "correct" answers that would expected by chance (p Conclusion The interpretations of specific features of the Swiss cheese model varied considerably among quality and safety professionals. Reaching consensus about concepts of patient safety requires further work.

Personal, situational and organizational aspects that influence the impact of patient safety incidents: A qualitative study.

Science.gov (United States)

Van Gerven, E; Deweer, D; Scott, S D; Panella, M; Euwema, M; Sermeus, W; Vanhaecht, K

2016-07-01

When a patient safety incident (PSI) occurs, not only the patient, but also the involved health professional can suffer. This study focused on this so-called "second victim" of a patient safety incident and aimed to examine: (1) experienced symptoms in the aftermath of a patient safety incident; (2) applied coping strategies; (3) the received versus needed support and (4) the aspects that influenced whether one becomes a second victim. Thirty-one in-depth interviews were performed with physicians, nurses and midwives who have been involved in a patient safety incident. The symptoms were categorized under personal and professional impact. Both problem focused and emotion focused coping strategies were used in the aftermath of a PSI. Problem focused strategies such as performing a root cause analysis and the opportunity to learn from what happened were the most appreciated, but negative emotional responses such as repression and flight were common. Support from colleagues and supervisors who were involved in the same event, peer supporters or professional experts were the most needed. A few individuals described emotional support from the healthcare institution as unwanted. Rendered support was largely dependent on the organizational culture, a stigma remained among healthcare professionals to openly discuss patient safety incidents. Three aspects influenced the extent to which a healthcare professional became a second victim: personal, situational and organizational aspects. These findings indicated that a multifactorial approach including individual and emotional support to second victims is crucial. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

Using naturalistic driving data to explore the association between traffic safety-related events and crash risk at driver level.

Science.gov (United States)

Wu, Kun-Feng; Aguero-Valverde, Jonathan; Jovanis, Paul P

2014-11-01

There has been considerable research conducted over the last 40 years using traffic safety-related events to support road safety analyses. Dating back to traffic conflict studies from the 1960s these observational studies of driver behavior have been criticized due to: poor quality data; lack of available and useful exposure measures linked to the observations; the incomparability of self-reported safety-related events; and, the difficulty in assessing culpability for safety-related events. This study seeks to explore the relationships between driver characteristics and traffic safety-related events, and between traffic safety-related events and crash involvement while mitigating some of those limitations. The Virginia Tech Transportation Institute 100-Car Naturalistic Driving Study dataset, in which the participants' vehicles were instrumented with various cameras and sensors during the study period, was used for this study. The study data set includes 90 drivers observed for 12-13 months driving. This study focuses on single vehicle run-off-road safety-related events only, including 14 crashes and 182 safety-related events (30 near crashes, and 152 crash-relevant incidents). Among the findings are: (1) drivers under age 25 are significantly more likely to be involved in safety-related events and crashes; and (2) significantly positive correlations exist between crashes, near crashes, and crash-relevant incidents. Although there is still much to learn about the factors affecting the positive correlation between safety-related events and crashes, a Bayesian multivariate Poisson log-normal model is shown to be useful to quantify the associations between safety-related events and crash risk while controlling for driver characteristics. Copyright © 2014 Elsevier Ltd. All rights reserved.

Which aspects of safety culture predict incident reporting behavior in neonatal intensive care units? A multilevel analysis

NARCIS (Netherlands)

Snijders, Cathelijne; Kollen, Boudewijn J.; van Lingen, Richard A.; Fetter, Willem P. F.; Molendijk, Harry; Kok, J. H.; te Pas, E.; Pas, H.; van der Starre, C.; Bloemendaal, E.; Lopes Cardozo, R. H.; Molenaar, A. M.; Giezen, A.; van Lingen, R. A.; Maat, H. E.; Molendijk, A.; Snijders, C.; Lavrijssen, S.; Mulder, A. L. M.; de Kleine, M. J. K.; Koolen, A. M. P.; Schellekens, M.; Verlaan, W.; Vrancken, S.; Fetter, W. P. F.; Schotman, L.; van der Zwaan, A.; van der Tuijn, Y.; Tibboel, D.; van der Schaaf, T. W.; Klip, H.; Kollen, B. J.

2009-01-01

OBJECTIVES: Safety culture assessments are increasingly used to evaluate patient-safety programs. However, it is not clear which aspects of safety culture are most relevant in understanding incident reporting behavior, and ultimately improving patient safety. The objective of this study was to

78 FR 38803 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

Science.gov (United States)

2013-06-27

... Reports for Gas Pipeline Operators AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... (OMB) Control No. 2137-0522, titled ``Incident and Annual Reports for Gas Pipeline Operators.'' PHMSA...

An Examination of Commercial Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

Science.gov (United States)

Reveley, Mary S.; Briggs, Jeffrey L.; Thomas, Megan A.; Evans, Joni K.; Jones, Sharon M.

2011-01-01

The Integrated Vehicle Health Management (IVHM) Project is one of the four projects within the National Aeronautics and Space Administration's (NASA) Aviation Safety Program (AvSafe). The IVHM Project conducts research to develop validated tools and technologies for automated detection, diagnosis, and prognosis that enable mitigation of adverse events during flight. Adverse events include those that arise from system, subsystem, or component failure, faults, and malfunctions due to damage, degradation, or environmental hazards that occur during flight. Determining the causal factors and adverse events related to IVHM technologies will help in the formulation of research requirements and establish a list of example adverse conditions against which IVHM technologies can be evaluated. This paper documents the results of an examination of the most recent statistical/prognostic accident and incident data that is available from the Aviation Safety Information Analysis and Sharing (ASIAS) System to determine the causal factors of system/component failures and/or malfunctions in U.S. commercial aviation accidents and incidents.

Improving transitional patient safety: research protocol of the Transitional Incident Prevention Programme

NARCIS (Netherlands)

M. van Melle (Marije); D.L.M. Zwart (Dorien); A.A. de Bont (Antoinette); I.W.M. Mol (Ineke); H.F. van Stel (Henk); N.J. de Wit (Niek)

2015-01-01

markdownabstract__Introduction:__ Patient transitions between primary and hospital care include referral, discharge, and simultaneous care by the outpatient clinic and the general practitioner (GP). Research on referrals and discharge shows that safety incidents in these transitions are common. We

Work stress and patient safety: observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses.

Science.gov (United States)

Elfering, A; Semmer, N K; Grebner, S

This study investigates the link between workplace stress and the 'non-singularity' of patient safety-related incidents in the hospital setting. Over a period of 2 working weeks 23 young nurses from 19 hospitals in Switzerland documented 314 daily stressful events using a self-observation method (pocket diaries); 62 events were related to patient safety. Familiarity of safety-related events and probability of recurrence, as indicators of non-singularity, were the dependent variables in multilevel regression analyses. Predictor variables were both situational (self-reported situational control, safety compliance) and chronic variables (job stressors such as time pressure, or concentration demands and job control). Chronic work characteristics were rated by trained observers. The most frequent safety-related stressful events included incomplete or incorrect documentation (40.3%), medication errors (near misses 21%), delays in delivery of patient care (9.7%), and violent patients (9.7%). Familiarity of events and probability of recurrence were significantly predicted by chronic job stressors and low job control in multilevel regression analyses. Job stressors and low job control were shown to be risk factors for patient safety. The results suggest that job redesign to enhance job control and decrease job stressors may be an important intervention to increase patient safety.

Public information on nuclear safety and incidents at nuclear installations in the UK

International Nuclear Information System (INIS)

Gausen, R.; Gronow, W.S.

1977-01-01

In recent years public interest in the safety aspects of the use of nuclear energy has been increasing in the UK as in other countries. The Government considers public involvement on this subject to be important and has taken action to promote and encourage public debate. As a result of a Government requirement, the Health and Safety Executive (HSE) now publish a quarterly statement which gives particulars of incidents at nuclear installations reported to the HSE under the Nuclear Installations Act 1965, Dangerous Occurrences Regulations and under conditions attached to nuclear site licences granted that Act. The range of incidents covered in the quarterly statement and the present state and background of the public debate on nuclear energy in the UK are described. (author)

Incident reporting: Its role in aviation safety and the acquisition of human error data

Science.gov (United States)

Reynard, W. D.

1983-01-01

The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

Social Relations at Work and Incident Dementia

DEFF Research Database (Denmark)

Ishtiak-Ahmed, Kazi; Hansen, Åse Marie; Garde, Anne Helene

2018-01-01

Objective: We investigated whether social relations at work were associated with incident dementia in old age. Methods: One thousand five hundred seventy-two occupationally active men from the Copenhagen Male Study Cohort were followed from 1986 to 2014. Participants underwent a clinical examinat......Objective: We investigated whether social relations at work were associated with incident dementia in old age. Methods: One thousand five hundred seventy-two occupationally active men from the Copenhagen Male Study Cohort were followed from 1986 to 2014. Participants underwent a clinical....... Conclusions: Our data partially support that social relations at work are associated with incident dementia....

A probabilistic safety analysis of incidents in nuclear research reactors.

Science.gov (United States)

Lopes, Valdir Maciel; Agostinho Angelo Sordi, Gian Maria; Moralles, Mauricio; Filho, Tufic Madi

2012-06-01

This work aims to evaluate the potential risks of incidents in nuclear research reactors. For its development, two databases of the International Atomic Energy Agency (IAEA) were used: the Research Reactor Data Base (RRDB) and the Incident Report System for Research Reactor (IRSRR). For this study, the probabilistic safety analysis (PSA) was used. To obtain the result of the probability calculations for PSA, the theory and equations in the paper IAEA TECDOC-636 were used. A specific program to analyse the probabilities was developed within the main program, Scilab 5.1.1. for two distributions, Fischer and chi-square, both with the confidence level of 90 %. Using Sordi equations, the maximum admissible doses to compare with the risk limits established by the International Commission on Radiological Protection (ICRP) were obtained. All results achieved with this probability analysis led to the conclusion that the incidents which occurred had radiation doses within the stochastic effects reference interval established by the ICRP-64.

A probabilistic safety analysis of incidents in nuclear research reactors

International Nuclear Information System (INIS)

Lopes, V. M.; Sordi, G. M. A. A.; Moralles, M.; Filho, T. M.

2012-01-01

This work aims to evaluate the potential risks of incidents in nuclear research reactors. For its development, two databases of the International Atomic Energy Agency (IAEA) were used: the Research Reactor Data Base (RRDB) and the Incident Report System for Research Reactor (IRSRR). For this study, the probabilistic safety analysis (PSA) was used. To obtain the result of the probability calculations for PSA, the theory and equations in the paper IAEA TECDOC-636 were used. A specific program to analyse the probabilities was developed within the main program, Scilab 5.1.1. for two distributions, Fischer and chi-square, both with the confidence level of 90 %. Using Sordi equations, the maximum admissible doses to compare with the risk limits established by the International Commission on Radiological Protection (ICRP) were obtained. All results achieved with this probability analysis led to the conclusion that the incidents which occurred had radiation doses within the stochastic effects reference interval established by the ICRP-64. (authors)

Surface Movement Incidents Reported to the NASA Aviation Safety Reporting System

Science.gov (United States)

Connell, Linda J.; Hubener, Simone

1997-01-01

Increasing numbers of aircraft are operating on the surface of airports throughout the world. Airport operations are forecast to grow by more that 50%, by the year 2005. Airport surface movement traffic would therefore be expected to become increasingly congested. Safety of these surface operations will become a focus as airport capacity planning efforts proceed toward the future. Several past events highlight the prevailing risks experienced while moving aircraft during ground operations on runways, taxiways, and other areas at terminal, gates, and ramps. The 1994 St. Louis accident between a taxiing Cessna crossing an active runway and colliding with a landing MD-80 emphasizes the importance of a fail-safe system for airport operations. The following study explores reports of incidents occurring on an airport surface that did not escalate to an accident event. The Aviation Safety Reporting System has collected data on surface movement incidents since 1976. This study sampled the reporting data from June, 1993 through June, 1994. The coding of the data was accomplished in several categories. The categories include location of airport, phase of ground operation, weather /lighting conditions, ground conflicts, flight crew characteristics, human factor considerations, and airport environment. These comparisons and distributions of variables contributing to surface movement incidents can be invaluable to future airport planning, accident prevention efforts, and system-wide improvements.

Using multiclass classification to automate the identification of patient safety incident reports by type and severity.

Science.gov (United States)

Wang, Ying; Coiera, Enrico; Runciman, William; Magrabi, Farah

2017-06-12

with medium risk incidents (SAC3). Binary classifier ensembles appear to be a feasible method for identifying incidents by type and severity level. Automated identification should enable safety problems to be detected and addressed in a more timely manner. Multi-label classifiers may be necessary for reports that relate to more than one incident type.

Properties of incident reporting systems in relation to statistical trend and pattern analysis

International Nuclear Information System (INIS)

Kalfsbeek, H.W.; Arsenis, S.P.

1990-01-01

This paper describes the properties deemed desirable for an incident reporting system in order to render it useful for extracting valid statistical trend and pattern information. The perspective under which a data collection system is seen in this paper is the following: data are essentially gathered on a set of variables describing an event or incident (the items featuring on a reporting format) in order to learn about (multiple) dependencies (called interactions) between these variables. Hence, the necessary features of the data source are highlighted and potential problem sources limiting the validity of the results to be obtained are identified. In this frame, important issues are the reporting completeness, related to the reporting criteria and reporting frequency, and of course the reporting contents and quality. The choice of the report items (the variables) and their categorization (code dictionary) may influence (bias) the insights gained from trend and pattern analyses, as may the presence or absence of a structure for correlating the reported issues within an incident. The issues addressed in this paper are brought in relation to some real world reporting systems on safety related events in Nuclear Power Plants, so that their possibilities and limitations with regard to statistical trend and pattern analysis become manifest

[Patient safety and errors in medicine: development, prevention and analyses of incidents].

Science.gov (United States)

Rall, M; Manser, T; Guggenberger, H; Gaba, D M; Unertl, K

2001-06-01

"Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient

The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study.

Science.gov (United States)

Tuffrey-Wijne, Irene; Goulding, Lucy; Gordon, Vanessa; Abraham, Elisabeth; Giatras, Nikoletta; Edwards, Christine; Gillard, Steve; Hollins, Sheila

2014-09-24

There has been evidence in recent years that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to failures of the healthcare services to implement the reasonable adjustments they need. The aim of this paper is to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities, to describe patient safety issues faced by patients with intellectual disabilities in NHS acute hospitals, and investigate underlying contributory factors. This was a 21-month mixed-method study involving interviews, questionnaires, observation and monitoring of incident reports to assess the implementation of recommendations designed to improve care provided for patients with intellectual disabilities and explore the factors that compromise or promote patient safety. Six acute NHS Trusts in England took part. Data collection included: questionnaires to clinical hospital staff (n = 990); questionnaires to carers (n = 88); interviews with: hospital staff including senior managers, nurses and doctors (n = 68) and carers (n = 37); observation of in-patients with intellectual disabilities (n = 8); monitoring of incident reports (n = 272) and complaints involving people with intellectual disabilities. Staff did not always readily identify patient safety issues or report them. Incident reports focused mostly around events causing immediate or potential physical harm, such as falls. Hospitals lacked effective systems for identifying patients with intellectual disabilities within their service, making monitoring safety incidents for this group difficult.The safety issues described by the participants were mostly related to delays and omissions of care, in particular: inadequate provision of basic nursing care, misdiagnosis, delayed investigations and treatment, and non-treatment decisions and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders. The events leading to avoidable harm

DOE Safety Metrics Indicator Program (SMIP) Fiscal Year 2000 Annual Report of Packaging- and Transportation-related Occurrences

International Nuclear Information System (INIS)

Dickerson, L.S.

2001-01-01

The U.S. Department of Energy (DOE) Occurrence Reporting and Processing System (ORPS) is an interactive computer system designed to support DOE-owned or -operated facilities in reporting and processing information concerning occurrences related to facility operations. The Oak Ridge National Laboratory has been charged by the DOE National Transportation Program Albuquerque (NTPA) with the responsibility of retrieving reports and information pertaining to packaging and transportation (P and T) incidents from the centralized ORPS database. These selected reports are analyzed for safety concerns, trends, potential impact on P and T operations, and ''lessons learned'' in P and T safety. To support this analysis and trending, the Safety Metrics Indicator Program (SMIP) was established by the NTPA in fiscal year (FY) 1998. Its chief goal is to augment historical reporting of occurrence-based information by providing (1) management notification of those incidents that require attention, (2) an accurate picture of contractors' P and T-related performance, and (3) meaningful statistics on occurrences at particular sites, including comparisons among different contractor sites and between DOE and the private sector. This annual report contains information on those P and T-related occurrences reported to the ORPS during the period from October 1, 1999, through September 30, 2000. Only those incidents that occur in preparation for transport, during transport, and during unloading of hazardous material are considered as packaging- or transportation-related occurrences

Statistical text classifier to detect specific type of medical incidents.

Science.gov (United States)

Wong, Zoie Shui-Yee; Akiyama, Masanori

2013-01-01

WHO Patient Safety has put focus to increase the coherence and expressiveness of patient safety classification with the foundation of International Classification for Patient Safety (ICPS). Text classification and statistical approaches has showed to be successful to identifysafety problems in the Aviation industryusing incident text information. It has been challenging to comprehend the taxonomy of medical incidents in a structured manner. Independent reporting mechanisms for patient safety incidents have been established in the UK, Canada, Australia, Japan, Hong Kong etc. This research demonstrates the potential to construct statistical text classifiers to detect specific type of medical incidents using incident text data. An illustrative example for classifying look-alike sound-alike (LASA) medication incidents using structured text from 227 advisories related to medication errors from Global Patient Safety Alerts (GPSA) is shown in this poster presentation. The classifier was built using logistic regression model. ROC curve and the AUC value indicated that this is a satisfactory good model.

Incident Reporting to Improve Patient Safety: The Effects of Process Variance on Pediatric Patient Safety in the Emergency Department.

Science.gov (United States)

OʼConnell, Karen J; Shaw, Kathy N; Ruddy, Richard M; Mahajan, Prashant V; Lichenstein, Richard; Olsen, Cody S; Funai, Tomohiko; Blumberg, Stephen; Chamberlain, James M

2018-04-01

Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care. We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics. The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008. Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels. Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to

Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'.

Science.gov (United States)

Mitchell, Imogen; Schuster, Anne; Smith, Katherine; Pronovost, Peter; Wu, Albert

2016-02-01

One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP.

Science.gov (United States)

Vallejo-Gutiérrez, Paula; Bañeres-Amella, Joaquim; Sierra, Eduardo; Casal, Jesús; Agra, Yolanda

2014-01-01

To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test. Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system. The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.

Classification of medication incidents associated with information technology.

Science.gov (United States)

Cheung, Ka-Chun; van der Veen, Willem; Bouvy, Marcel L; Wensing, Michel; van den Bemt, Patricia M L A; de Smet, Peter A G M

2014-02-01

Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals. The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary. The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process. From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital. A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

Directory of Open Access Journals (Sweden)

Tariq Amina

2012-11-01

Full Text Available Abstract Background Medication incident reporting (MIR is a key safety critical care process in residential aged care facilities (RACFs. Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a design MIR artefacts that facilitate identification of the root causes of medication incidents, b integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

Science.gov (United States)

2012-01-01

Background Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes. PMID:23122411

Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study.

Science.gov (United States)

Hernan, Andrea L; Giles, Sally J; Fuller, Jeffrey; Johnson, Julie K; Walker, Christine; Dunbar, James A

2015-09-01

Patients can have an important role in reducing harm in primary-care settings. Learning from patient experience and feedback could improve patient safety. Evidence that captures patients' views of the various contributory factors to creating safe primary care is largely absent. The aim of this study was to address this evidence gap. Four focus groups and eight semistructured interviews were conducted with 34 patients and carers from south-east Australia. Participants were asked to describe their experiences of primary care. Audio recordings were transcribed verbatim and specific factors that contribute to safety incidents were identified in the analysis using the Yorkshire Contributory Factors Framework (YCFF). Other factors emerging from the data were also ascertained and added to the analytical framework. Thirteen factors that contribute to safety incidents in primary care were ascertained. Five unique factors for the primary-care setting were discovered in conjunction with eight factors present in the YCFF from hospital settings. The five unique primary care contributing factors to safety incidents represented a range of levels within the primary-care system from local working conditions to the upstream organisational level and the external policy context. The 13 factors included communication, access, patient factors, external policy context, dignity and respect, primary-secondary interface, continuity of care, task performance, task characteristics, time in the consultation, safety culture, team factors and the physical environment. Patient and carer feedback of this type could help primary-care professionals better understand and identify potential safety concerns and make appropriate service improvements. The comprehensive range of factors identified provides the groundwork for developing tools that systematically capture the multiple contributory factors to patient safety. Published by the BMJ Publishing Group Limited. For permission to use (where not

Patient-reported experiences of patient safety incidents need to be utilized more systematically in promoting safe care.

Science.gov (United States)

Sahlström, Merja; Partanen, Pirjo; Turunen, Hannele

2018-04-16

To analyze patient safety incidents (PSIs) reported by patients and their use in Finnish healthcare organizations. Cross-sectional study. About 15 Finnish healthcare organizations ranging from specialized hospital care to home care, outpatient and inpatient clinics, and geographically diverse areas of Finland. The study population included all Finnish patients who had voluntarily reported PSI via web-based system in 2009-15. Quantitative analysis of patients' safety reports, inductive content analysis of patients' suggestions to prevent the reoccurrence incidents and how those suggestions were used in healthcare organizations. Patients reported 656 PSIs, most of which were classified by the healthcare organizations' analysts as problems associated with information flow (32.6%) and medications (18%). Most of the incidents (65%) did not cause any harm to patients. About 76% of the reports suggested ways to prevent reoccurrence of PSIs, most of which were feasible, system-based amendments of processes for reviewing or administering treatment, anticipating risks or improving diligence in patient care. However, only 6% had led to practical implementation of corrective actions in the healthcare organizations. The results indicate that patients report diverse PSIs and suggest practical systems-based solutions to prevent their reoccurrence. However, patients' reports rarely lead to corrective actions documented in the registering system, indicating that there is substantial scope to improve utilization of patients' reports. There is also a need for strong patient safety management, including willingness and commitment of HCPs and leaders to learn from safety incidents.

E-bike safety: Individual-level factors and incident characteristics

DEFF Research Database (Denmark)

Haustein, Sonja; Møller, Mette

2016-01-01

safety critical incident that they believed would not have happened on a conventional bike. The most frequent explanation offered for these situations was that other road users had underestimated the speed of the e-bike, followed by rider problems regulating e-bike speed. Older cyclists were more likely...... to report problems maintaining balance due to the weight of the e-bike. Preventive measures discussed include awareness campaigns and making it easier to distinguish e-bikes from conventional bicycles to address the problem of underestimation of speed. We also identified a need to familiarise with the e...

Development of nuclear safety issues program

Energy Technology Data Exchange (ETDEWEB)

Cho, J. C.; Yoo, S. O.; Yoon, Y. K.; Kim, H. J.; Jeong, M. J.; Noh, K. W.; Kang, D. K

2006-12-15

The nuclear safety issues are defined as the cases which affect the design and operation safety of nuclear power plants and also require the resolution action. The nuclear safety issues program (NSIP) which deals with the overall procedural requirements for the nuclear safety issues management process is developed, in accordance with the request of the scientific resolution researches and the establishment/application of the nuclear safety issues management system for the nuclear power plants under design, construction or operation. The NSIP consists of the following 4 steps; - Step 1 : Collection of candidates for nuclear safety issues - Step 2 : Identification of nuclear safety issues - Step 3 : Categorization and resolution of nuclear safety issues - Step 4 : Implementation, verification and closure The NSIP will be applied to the management directives of KINS related to the nuclear safety issues. Through the identification of the nuclear safety issues which may be related to the potential for accident/incidents at operating nuclear power plants either directly or indirectly, followed by performance of regulatory researches to resolve the safety issues, it will be possible to prevent occurrence of accidents/incidents as well as to cope with unexpected accidents/incidents by analyzing the root causes timely and scientifically and by establishing the proper flow-up or remedied regulatory actions. Moreover, the identification and resolution of the safety issues related to the new nuclear power plants completed at the design stage are also expected to make the new reactor licensing reviews effective and efficient as well as to make the possibility of accidents/incidents occurrence minimize. Therefore, the NSIP developed in this study is expected to contribute for the enhancement of the safety of nuclear power plants.

Development of nuclear safety issues program

International Nuclear Information System (INIS)

Cho, J. C.; Yoo, S. O.; Yoon, Y. K.; Kim, H. J.; Jeong, M. J.; Noh, K. W.; Kang, D. K.

2006-12-01

The nuclear safety issues are defined as the cases which affect the design and operation safety of nuclear power plants and also require the resolution action. The nuclear safety issues program (NSIP) which deals with the overall procedural requirements for the nuclear safety issues management process is developed, in accordance with the request of the scientific resolution researches and the establishment/application of the nuclear safety issues management system for the nuclear power plants under design, construction or operation. The NSIP consists of the following 4 steps; - Step 1 : Collection of candidates for nuclear safety issues - Step 2 : Identification of nuclear safety issues - Step 3 : Categorization and resolution of nuclear safety issues - Step 4 : Implementation, verification and closure The NSIP will be applied to the management directives of KINS related to the nuclear safety issues. Through the identification of the nuclear safety issues which may be related to the potential for accident/incidents at operating nuclear power plants either directly or indirectly, followed by performance of regulatory researches to resolve the safety issues, it will be possible to prevent occurrence of accidents/incidents as well as to cope with unexpected accidents/incidents by analyzing the root causes timely and scientifically and by establishing the proper flow-up or remedied regulatory actions. Moreover, the identification and resolution of the safety issues related to the new nuclear power plants completed at the design stage are also expected to make the new reactor licensing reviews effective and efficient as well as to make the possibility of accidents/incidents occurrence minimize. Therefore, the NSIP developed in this study is expected to contribute for the enhancement of the safety of nuclear power plants

Safety and Health Standard 110: Incident/accident reporting and investigation

Energy Technology Data Exchange (ETDEWEB)

Sones, K. [West Kootenay Power, BC (Canada)

1999-10-01

Incident/accident reporting requirements in effect at West Kootenay Power are discussed. Details provided include definitions of low risk, high risk, and critical events, the incidents to be reported, the nature of the reports, the timelines, the investigation to be undertaken for each type of incident/accident, counselling services available to employees involved in serious incidents, and the procedures to be followed in accidents involving serious injury to non-employees. The emphasis is on the `critical five` high risk events and the procedures relating to them.

System Safety Assessment Based on Past Incidents in Oil and Gas Industries: A Focused Approach in Forecasting of Minor, Severe, Critical, and Catastrophic Incidents, 2010–2015

Directory of Open Access Journals (Sweden)

Praveen Patel

2016-01-01

Full Text Available Accident in an occupation which occurred due to series of repetitive minor incidents within the working environment. This work demonstrates the critical system safety assessment based on various incidents that took place to the different system and subsystem of two Indian oil refineries in five years of span 2010 to 2015. The categorization of incidents and hazard rate function of each incident category were classified and calculated. The result of Weibull analysis estimators in the form of scale and shape parameters provides useful information of incidents forecasting and their patterns in a particular time.

Annual report on occupational safety 1989

International Nuclear Information System (INIS)

1990-01-01

This report presents detailed information on occupational safety relating to BNFL's employees for 1989 and data compared with the previous year. Routine monitoring, non-radiological safety and 'incidents' are discussed and 'statutory' whole-body exposures, nuclear incidents, lost-time accidents, and types of injury are tabulated. (author)

Safer travel, improved economic productivity : incident management systems

Science.gov (United States)

1999-01-01

This brochure gives an overview of how incident management technologies can be used to reduce incident-related congestion and increase road safety. It focuses on the need for interagency cooperation and the benefits that can be derived from the coope...

Energy systems evaluation of potential for incidents having health or safety impact

International Nuclear Information System (INIS)

Speas, I.G.

1986-01-01

The paper discusses the results of safety surveys of Martin Marietta Energy Systems - operated nuclear facilities. The purpose was to identify potential incidents that could cause large numbers of casualties, evaluate existing prevention/response actions, and identify possible improvements. The survey findings indicate the potential for an accident with consequences similar to those at Bhopal, India, is essentially non-existent

Effects of patient safety culture interventions on incident reporting in general practice : A cluster randomised trial a cluster randomised trial

NARCIS (Netherlands)

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

2015-01-01

Background: A constructive safety culture is essential for the successful implementation of patient safety improvements. Aim: To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture. Design and setting: A three-arm cluster randomised trial

Unmodifiable variables related to thyroid cancer incidence

Directory of Open Access Journals (Sweden)

Cornelia Nitipir

2018-04-01

Full Text Available The incidence of thyroid cancer is significantly different between male and female patients. Thyroid cancer is also the only form of cancer where age can be considered a staging variable. Identifying biological prognostic factors such as age or sex is important as it helps select an optimal personalized therapy. The present analysis is an observational, prospective study that enrolled all patients with thyroid disease who were operated upon at a single center. The study aimed to determine the most frequent age at presentation, the predominance of one sex over the other, the incidence of malignant thyroid disease, and the relative risk for each sex to develop thyroid carcinoma. The incidence of thyroid carcinoma was higher for women than for men, with a higher relative risk in the female subgroup. Incidence was also highest in the 50-60-year-old group. Given that studies show better survival for women and for younger patients, even when presenting with advanced disease, compared with older, male patients, such prognostic indicators should be a factor in the treatment decision.

MO-G-BRE-06: Metrics of Success: Measuring Participation and Attitudes Related to Near-Miss Incident Learning Systems

Energy Technology Data Exchange (ETDEWEB)

Nyflot, MJ; Kusano, AS; Zeng, J; Carlson, JC; Novak, A; Sponseller, P; Jordan, L; Kane, G; Ford, EC [University of Washington, Seattle, WA (United States)

2014-06-15

Purpose: Interest in incident learning systems (ILS) for improving safety and quality in radiation oncology is growing, as evidenced by the upcoming release of the national ILS. However, an institution implementing such a system would benefit from quantitative metrics to evaluate performance and impact. We developed metrics to measure volume of reporting, severity of reported incidents, and changes in staff attitudes over time from implementation of our institutional ILS. Methods: We analyzed 2023 incidents from our departmental ILS from 2/2012–2/2014. Incidents were prospectively assigned a near-miss severity index (NMSI) at multidisciplinary review to evaluate the potential for error ranging from 0 to 4 (no harm to critical). Total incidents reported, unique users reporting, and average NMSI were evaluated over time. Additionally, departmental safety attitudes were assessed through a 26 point survey adapted from the AHRQ Hospital Survey on Patient Safety Culture before, 12 months, and 24 months after implementation of the incident learning system. Results: Participation in the ILS increased as demonstrated by total reports (approximately 2.12 additional reports/month) and unique users reporting (0.51 additional users reporting/month). Also, the average NMSI of reports trended lower over time, significantly decreasing after 12 months of reporting (p<0.001) but with no significant change at months 18 or 24. In survey data significant improvements were noted in many dimensions, including perceived barriers to reporting incidents such as concern of embarrassment (37% to 18%; p=0.02) as well as knowledge of what incidents to report, how to report them, and confidence that these reports were used to improve safety processes. Conclusion: Over a two-year period, our departmental ILS was used more frequently, incidents became less severe, and staff confidence in the system improved. The metrics used here may be useful for other institutions seeking to create or evaluate

MO-G-BRE-06: Metrics of Success: Measuring Participation and Attitudes Related to Near-Miss Incident Learning Systems

International Nuclear Information System (INIS)

Nyflot, MJ; Kusano, AS; Zeng, J; Carlson, JC; Novak, A; Sponseller, P; Jordan, L; Kane, G; Ford, EC

2014-01-01

Purpose: Interest in incident learning systems (ILS) for improving safety and quality in radiation oncology is growing, as evidenced by the upcoming release of the national ILS. However, an institution implementing such a system would benefit from quantitative metrics to evaluate performance and impact. We developed metrics to measure volume of reporting, severity of reported incidents, and changes in staff attitudes over time from implementation of our institutional ILS. Methods: We analyzed 2023 incidents from our departmental ILS from 2/2012–2/2014. Incidents were prospectively assigned a near-miss severity index (NMSI) at multidisciplinary review to evaluate the potential for error ranging from 0 to 4 (no harm to critical). Total incidents reported, unique users reporting, and average NMSI were evaluated over time. Additionally, departmental safety attitudes were assessed through a 26 point survey adapted from the AHRQ Hospital Survey on Patient Safety Culture before, 12 months, and 24 months after implementation of the incident learning system. Results: Participation in the ILS increased as demonstrated by total reports (approximately 2.12 additional reports/month) and unique users reporting (0.51 additional users reporting/month). Also, the average NMSI of reports trended lower over time, significantly decreasing after 12 months of reporting (p<0.001) but with no significant change at months 18 or 24. In survey data significant improvements were noted in many dimensions, including perceived barriers to reporting incidents such as concern of embarrassment (37% to 18%; p=0.02) as well as knowledge of what incidents to report, how to report them, and confidence that these reports were used to improve safety processes. Conclusion: Over a two-year period, our departmental ILS was used more frequently, incidents became less severe, and staff confidence in the system improved. The metrics used here may be useful for other institutions seeking to create or evaluate

Incidence of trampoline related pediatric fractures in a large district general hospital in the United Kingdom: lessons to be learnt.

Science.gov (United States)

Bhangal, K K; Neen, D; Dodds, R

2006-04-01

To test the observation that the incidence of trampoline related pediatric fractures is increasing-both nationally and in a large district general hospital. A retrospective analysis was undertaken of patient records establishing mechanism of injury of pediatric fractures over three consecutive summers from 2000-03. Theatre records of fractures treated operatively were used as the initial data source. A statistically significant increase in trampoline related injuries was discovered. This reflects the rising incidence of injuries from national data and furthermore corresponds to the growing popularity of domestic use trampolines in the UK. The incidence of injuries is increasing. There are lessons to be learnt from existing work from countries where trampoline prevalence has been greater for longer. The authors recommend various safety measures that may reduce children's injuries.

CMS penalizes 758 hospitals for safety incidents

Directory of Open Access Journals (Sweden)

Robbins RA

2015-12-01

Full Text Available No abstract available. Article truncated after 150 words. The Centers for Medicare and Medicaid Services (CMS is penalizing 758 hospitals with higher rates of patient safety incidents, and more than half of those were also fined last year, as reported by Kaiser Health News (1. Among the hospitals being financially punished are some well-known institutions, including Yale New Haven Hospital, Medstar Washington Hospital Center in DC, Grady Memorial Hospital, Northwestern Memorial Hospital in Chicago, Indiana University Health, Brigham and Womens Hospital, Tufts Medical Center, University of North Carolina Hospital, the Cleveland Clinic, Hospital of the University of Pennsylvania, Parkland Health and Hospital, and the University of Virginia Medical Center (Complete List of Hospitals Penalized 2016. In the Southwest the list includes Banner University Medical Center in Tucson, Ronald Reagan UCLA Medical Center, Stanford Health Care, Denver Health Medical Center and the University of New Mexico Medical Center (for list of Southwest hospitals see Appendix 1. In total, CMS ...

Incidents in nuclear research reactor examined by deterministic probability and probabilistic safety analysis

International Nuclear Information System (INIS)

Lopes, Valdir Maciel

2010-01-01

This study aims to evaluate the potential risks submitted by the incidents in nuclear research reactors. For its development, two databases of the International Atomic Energy Agency, IAEA, were used, the Incident Report System for Research Reactor and Research Reactor Data Base. For this type of assessment was used the Probabilistic Safety Analysis (PSA), within a confidence level of 90% and the Deterministic Probability Analysis (DPA). To obtain the results of calculations of probabilities for PSA, were used the theory and equations in the paper IAEA TECDOC - 636. The development of the calculations of probabilities for PSA was used the program Scilab version 5.1.1, free access, executable on Windows and Linux platforms. A specific program to get the results of probability was developed within the main program Scilab 5.1.1., for two distributions Fischer and Chi-square, both with the confidence level of 90%. Using the Sordi equations and Origin 6.0 program, were obtained the maximum admissible doses related to satisfy the risk limits established by the International Commission on Radiological Protection, ICRP, and were also obtained these maximum doses graphically (figure 1) resulting from the calculations of probabilities x maximum admissible doses. It was found that the reliability of the results of probability is related to the operational experience (reactor x year and fractions) and that the larger it is, greater the confidence in the outcome. Finally, a suggested list of future work to complement this paper was gathered. (author)

MCPS School Safety & Security at a Glance 2013-2014

Science.gov (United States)

Montgomery County Public Schools, 2014

2014-01-01

"MCPS School Safety and Security at a Glance" provides, in a single document, information about the reporting of incidents related to school safety and security, school climate, local school safety program descriptions, and serious incidents. Information is presented for each Montgomery County (Maryland) public school. While much of this…

MCPS School Safety & Security at a Glance 2012-2013

Science.gov (United States)

Montgomery County Public Schools, 2013

2013-01-01

"MCPS School Safety and Security at a Glance" provides, in a single document, information about the reporting of incidents related to school safety and security, school climate, local school safety program descriptions, and serious incidents. Information is presented for each Montgomery County (Maryland) public school. While much of this…

MCPS School Safety & Security at a Glance 2011-2012

Science.gov (United States)

Montgomery County Public Schools, 2012

2012-01-01

"MCPS School Safety and Security at a Glance" provides, in a single document, information about the reporting of incidents related to school safety and security, school climate, local school safety program descriptions, and serious incidents. Information is presented for each Montgomery County (Maryland) public school. While much of this…

[Results of provisional use of a system for voluntary anonymous reporting of incidents that threaten patient safety in the emergency medical services of Asturias].

Science.gov (United States)

Galván Núñez, Pablo; Santander Barrios, María Dolores; Villa Álvarez, María Cristina; Castro Delgado, Rafael; Alonso Lorenzo, Julio C; Arcos González, Pedro

2016-06-01

To describe the reported incidents and adverse events in the emergency medical services of Asturias, Spain, and assess their consequences, delays caused, and preventability. Prospective, observational study of incidents reported by the staff of the emergency medical services of Asturias after implementation of a system devised by the researchers. Incident reports were received for 0.48% (95% CI, 0.41%-0.54%) of the emergencies attended. Patient safety was compromised in 74.7% of the reported incidents. Problems arising in the emergency response coordination center (ERCC) accounted for 37.6% of the incidents, transport problems for 13.4%, vehicular problems for 10.8%, and communication problems for 8.8%. Seventy percent of the reported incidents caused delays in care; 55% of the reported incidents that put patients at risk (according to severity assessment code ratings) corresponded to problems related to human or material resources. A total of 88.1% of the incidents reported were considered avoidable. Some type of intervention was required to attenuate the effects of 46.2% of the adverse events reported. The measures that staff members most often proposed to prevent adverse events were to increase human and material resources (28.3%), establish protocols (14.5%), and comply with quality of care recommendations (9.7%). It is important to promote a culture of safety and incident reporting among health care staff in Asturias given the number of serious adverse events. Reporting is necessary for understanding the errors made and taking steps to prevent them. The ERCC is the point in the system where incidents are particularly likely to appear and be noticed and reported.

Report on safety related occurrences and reactor trips July 1, 1977 - December 31, 1977

International Nuclear Information System (INIS)

Andermo, L.; Sundman, B.

1974-04-01

This is a systematically arranged report on all reported safety related occurrences and reactor trips in Swedish nuclear power plants in operation during July 1 to December 31, 1977 inclusive. The facilities involved are Barsebaeck 1 and 2, Oskarshamn 1 and 2 and Ringhals 1 and 2. During this period of 6 months 48 safety related occurrences and 49 reactor trips have been reported to the Nuclear Power Inspectorate. Included is also one incident June 21 in Barsebaeck 2 which was not included in the last compilation of occurrences. As earlier experiences have shown it is to the greatest extent the conventional components which bring about the safety related occurrences or occurrences leading to outages or power reductions. However, the component errors discovered in the safety related systems have not affected the function of their redundant systems and other diverse systems have not been involved. Therefore the reactor safety has been satisfactory. The total number of reactor trips have increased nearly 30% since the last period. Those occurred during power operation however, were less. More than 50% of the reactor trips happened in the shutdown condition. The fact that even small deviations from prescribed operation result in automatic and safe shut down of the reactor, does not always imply a conflict with operational availability. The greatest outages are caused by occurrences withou02068NRM 0000169 450

Operational safety evaluation for minor reactor accidents

International Nuclear Information System (INIS)

Wang, O.S.

1981-01-01

The purpose of this paper is to address a concern of applying conservatism in analysing minor reactor incidents. A so-called ''conservative'' safety analysis may exaggerate the system responses and result in a reactor scram tripped by the reactor protective system (RPS). In reality, a minor incident may lead the reactor to a new thermal hydraulic steady-state without scram, and the mitigation or termination of the incident may entirely depend on operator actions. An example on a small steamline break evaluation for a pressurized water reactor recently investigated by the staff at the Washington Public Power Supply System is presented to illustrate this point. A safety evaluation using mainly the safety-related systems to be consistent with the conservative assumptions used in the Safety Analysis Report was conducted. For comparison, a realistic analysis was also performed using both the safety- and control-related systems. The analyses were performed using the RETRAN plant simulation computer code. The ''conservative'' safety analysis predicts that the incident can be turned over by the RPS scram trips without operator intervention. However, the realistic analysis concludes that the reactor will reach a new steady-state at a different plant thermal hydraulic condition. As a result, the termination of the incident at this stage depends entirely on proper operator action. On the basis of this investigation it is concluded that, for minor incidents, ''conservative'' assumptions are not necessary, sometimes not justifiable. A realistic investigation from the operational safety point of view is more appropriate. It is essential to highlight the key transient indications for specific incident recognition in the operator training program

Safety-related control air systems

International Nuclear Information System (INIS)

Anon.

1977-01-01

This Standard applies to those portions of the control air system that furnish air required to support, control, or operate systems or portions of systems that are safety related in nuclear power plants. This Standard relates only to the air supply system(s) for safety-related air operated devices and does not apply to the safety-related air operated device or to air operated actuators for such devices. The objectives of this Standard are to provide (1) minimum system design requirements for equipment, piping, instruments, controls, and wiring that constitute the air supply system; and (2) the system and component testing and maintenance requirements

Annual report on occupational safety 1987

International Nuclear Information System (INIS)

1988-01-01

This report presents detailed information on occupational safety relating to the Company's employees for 1987. Data are quoted in tables and text, together with data from the previous year for comparison where available. The report is presented under the following headings: radiological and non-radiological safety, incidents, appendices (statutory dose limits, nuclear incident criteria for reporting to ministers). (author)

Patient safety in out-of-hours primary care: a review of patient records

Directory of Open Access Journals (Sweden)

Wensing Michel

2010-12-01

Full Text Available Abstract Background Most patients receive healthcare in primary care settings, but relatively little is known about patient safety. Out-of-hours contacts are of particular importance to patient safety. Our aim was to examine the incidence, types, causes, and consequences of patient safety incidents at general practice cooperatives for out-of-hours primary care and to examine which factors were associated with the occurrence of patient safety incidents. Methods A retrospective study of 1,145 medical records concerning patient contacts with four general practice cooperatives. Reviewers identified records with evidence of a potential patient safety incident; a physician panel determined whether a patient safety incident had indeed occurred. In addition, the panel determined the type, causes, and consequences of the incidents. Factors associated with incidents were examined in a random coefficient logistic regression analysis. Results In 1,145 patient records, 27 patient safety incidents were identified, an incident rate of 2.4% (95% CI: 1.5% to 3.2%. The most frequent incident type was treatment (56%. All incidents had at least partly been caused by failures in clinical reasoning. The majority of incidents did not result in patient harm (70%. Eight incidents had consequences for the patient, such as additional interventions or hospitalisation. The panel assessed that most incidents were unlikely to result in patient harm in the long term (89%. Logistic regression analysis showed that age was significantly related to incident occurrence: the likelihood of an incident increased with 1.03 for each year increase in age (95% CI: 1.01 to 1.04. Conclusion Patient safety incidents occur in out-of-hours primary care, but most do not result in harm to patients. As clinical reasoning played an important part in these incidents, a better understanding of clinical reasoning and guideline adherence at GP cooperatives could contribute to patient safety.

"Against the silence": Development and first results of a patient survey to assess experiences of safety-related events in hospital

Directory of Open Access Journals (Sweden)

Schwappach David LB

2008-03-01

Full Text Available Abstract Background Involvement of patients in the detection and prevention of safety related events and medical errors have been widely recommended. However, it has also been questioned whether patients at large are willing and able to identify safety-related events in their care. The aim of this study was to develop and pilot test a brief patient safety survey applicable to inpatient care in Swiss hospitals. Methods A survey instrument was developed in an iterative procedure. The instrument asks patients to report whether they have experienced specific undesirable events during their hospital stay. The preliminary version was developed together with experts and tested in focus groups with patients. The adapted survey instrument was pilot-tested in random samples of patients of two Swiss hospitals (n = 400. Responders to the survey that had reported experience of any incident were sampled for qualitative interviews (n = 18. Based on the interview, the researcher classified the reported incidents as confirmed or discarded. Results The survey was generally well accepted in the focus groups and interviews. In the quantitative pilot test, 125 patients returned the survey (response rate: 31%. The mean age of responders was 55 years (range 17–91, SD 18 years and 62.5% were female. The 125 participating patients reported 94 "definitive" and 34 "uncertain" events. 14% of the patients rated any of the experienced events as "serious". The definitive and uncertain events reported with highest frequency were phlebitis, missing hand hygiene, allergic drug reaction, unavailability of documents, and infection. 23% of patients reported some or serious concerns about their safety. The qualitative interviews indicate that both, the extent of patients' uncertainty in the classification of events and the likelihood of confirmation by the interviewer vary very much by type of incident. Unexpectedly, many patients reported problems and incidents related to food

Annual report on occupational safety

International Nuclear Information System (INIS)

1985-09-01

A report is given on the occupational safety relating to BNFL's employees for the year 1984 and the results compared to those obtained in 1983. Data are presented for each of the Company's Sites on whole body exposures, accidental deaths and major injuries and nuclear and non-nuclear incidents. The results show that the Company average body dose continues to be less than 5mSv, there were no accidental deaths but 15 major injuries. One nuclear incident and 9 non-nuclear incidents were notified to the Health and Safety Executive. (UK)

An error taxonomy system for analysis of haemodialysis incidents.

Science.gov (United States)

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Cooperation of the site and public fire and safety services in case of an incident

International Nuclear Information System (INIS)

Bauch, M.

1997-01-01

This report describes the cooperation between the site and the public fire and safety services in case of an incident. As an example, the measures and facilities of the Hoechst site of the Hoechst AG and the organisational and technical background are presented. (orig.) [de

Major food safety episodes in Taiwan: implications for the necessity of international collaboration on safety assessment and management.

Science.gov (United States)

Li, Jih-Heng; Yu, Wen-Jing; Lai, Yuan-Hui; Ko, Ying-Chin

2012-07-01

The major food safety episodes that occurred in Taiwan during the past decade are briefly reviewed in this paper. Among the nine major episodes surveyed, with the exception of a U.S. beef (associated with Creutzfeldt-Jakob disease)-related incident, all the others were associated with chemical toxicants. The general public, which has a layperson attitude of zero tolerance toward food safety, may panic over these food-safety-associated incidents. However, the health effects and impacts of most incidents, with the exception of the melamine incident, were essentially not fully evaluated. The mass media play an important role in determining whether a food safety concern becomes a major incident. A well-coordinated and harmonized system for domestic and international collaboration to set up standards and regulations is critical, as observed in the incidents of pork with ractopamine, Chinese hairy crab with nitrofuran antibiotics, and U.S. wheat with malathion. In the future, it can be anticipated that food safety issues will draw more attention from the general public. For unknown new toxicants or illicit adulteration of food, the establishment of a more proactive safety assessment system to monitor potential threats and provide real-time information exchange is imperative. Copyright © 2012. Published by Elsevier B.V.

MCPS School Safety and Security at a Glance 2009-2010

Science.gov (United States)

Montgomery County Public Schools, 2010

2010-01-01

"MCPS School Safety and Security at a Glance" provides, in a single document, information about the reporting of incidents related to school safety and security, school climate, local school safety program descriptions, and serious incidents in all Montgomery County (Maryland) public schools. The information is presented for each school.…

MCPS School Safety and Security at a Glance 2008-2009

Science.gov (United States)

Montgomery County Public Schools, 2009

2009-01-01

"MCPS School Safety and Security at a Glance" provides, in a single document, information about the reporting of incidents related to school safety and security, school climate, local school safety program descriptions, and serious incidents in all Montgomery County (Maryland) Public Schools. The information is presented for each school.…

MCPS School Safety and Security at a Glance 2010-2011

Science.gov (United States)

Montgomery County Public Schools, 2011

2011-01-01

"MCPS School Safety and Security at a Glance" provides, in a single document, information about the reporting of incidents related to school safety and security, school climate, local school safety program descriptions, and serious incidents in all Montgomery County (Maryland) Public Schools. The information is presented for each school.…

Report on safety related occurrences and reactor trips January 1 - June 30, 1985

International Nuclear Information System (INIS)

1986-01-01

This is a systematically arranged report on all safety-related occurrences and reacotr trips in Swedish nuclear power plants in operation during the period from January 1 to June 30 1985. It is based on the reports submitted by the utilities to the Swedish Nuclear power Inspectorate according to Technical Specifications. Twice a year since 1974 the Inspectorate has issued a compilation on such reported occurrences and reactor trips. Starting with the compilation of the second half of 1982 some new features have been introduced. The most important change is that the volume of information has been increased. The full test, provided by the utilities when reporting the incidents, is now attached to the codified information and also the layout has been altered to facilitate reading. As in the previous reports the occurrences and reactor trips are arranged both alphabetically by facility name and chronologically by report number for each facility. Electricity generation charts for each facility are also presented. The primary purpose of this report is thus to present all the information furnished by utlities when they submit their reports according the Technical Specifications. The only evaluation made by the Inspecotrate is the categorization on the incidents. Like the previous reports this one also presents frequency of incidents as related to affected component, cause of incident etc. The difference is that only information reported by the utilities is used. This is the reason why a considerable proportion of the incidents are categorized as 'other fault'. (author)

Modeling patient safety incidents knowledge with the Categorial Structure method.

Science.gov (United States)

Souvignet, Julien; Bousquet, Cédric; Lewalle, Pierre; Trombert-Paviot, Béatrice; Rodrigues, Jean Marie

2011-01-01

Following the WHO initiative named World Alliance for Patient Safety (PS) launched in 2004 a conceptual framework developed by PS national reporting experts has summarized the knowledge available. As a second step, the Department of Public Health of the University of Saint Etienne team elaborated a Categorial Structure (a semi formal structure not related to an upper level ontology) identifying the elements of the semantic structure underpinning the broad concepts contained in the framework for patient safety. This knowledge engineering method has been developed to enable modeling patient safety information as a prerequisite for subsequent full ontology development. The present article describes the semantic dissection of the concepts, the elicitation of the ontology requirements and the domain constraints of the conceptual framework. This ontology includes 134 concepts and 25 distinct relations and will serve as basis for an Information Model for Patient Safety.

Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents

Science.gov (United States)

Mira, José Joaquín; Vicente, Maria Asuncion; Fernandez, Cesar; Guilabert, Mercedes; Ferrús, Lena; Zavala, Elena; Silvestre, Carmen; Pérez-Pérez, Pastora

2016-01-01

Background Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. Objective The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. Methods The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA’s design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. Results BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). Conclusions BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use. PMID:27678308

Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents.

Science.gov (United States)

Carrillo, Irene; Mira, José Joaquín; Vicente, Maria Asuncion; Fernandez, Cesar; Guilabert, Mercedes; Ferrús, Lena; Zavala, Elena; Silvestre, Carmen; Pérez-Pérez, Pastora

2016-09-27

Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA's design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.

General principles of nuclear safety management related to research reactor decommissioning

International Nuclear Information System (INIS)

Banciu, Ortenzia; Vladescu, Gabriela

2003-01-01

The paper contents the general principles applicable to the decommissioning of research reactors to ensure a proper nuclear safety management, during both decommissioning activities and post decommissioning period. The main objective of decommissioning is to ensure the protection of workers, population and environment against all radiological and non-radiological hazards that could result after a reactor shutdown and dismantling. In the same time, it is necessary, by some proper provisions, to limit the effect of decommissioning for the future generation, according to the new Romanian, IAEA and EU Norms and Regulations. Assurance of nuclear safety during decommissioning process involves, in the first step, to establish of some safety principles and requirements to be taken into account during whole process. In the same time, it is necessary to perform a series of analyses to ensure that the whole process is conducted in a planned and safe manner. The general principles proposed for a proper management of safety during research reactor decommissioning are as follows: - Set-up of all operations included in a Decommissioning Plan; - Set-up and qualitative evaluation of safety problems, which could appear during normal decommissioning process, both radiological and nonradiological risks for workers and public; - Set-up of accident list related to decommissioning process the events that could appear both due to some abnormal working conditions and to some on-site and off-site events like fires, explosions, flooding, earthquake, etc.); - Development and qualitative/ quantitative evaluation of scenarios for each incidents; - Development (and evaluation) of safety indicator system. The safety indicators are the most important tools used to assess the level of nuclear safety during decommissioning process, to discover the weak points and to establish safety measures. The paper contains also, a safety case evaluation (description of facility according to the decommissioning

Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents.

Science.gov (United States)

Yardley, Iain; Yardley, Sarah; Williams, Huw; Carson-Stevens, Andrew; Donaldson, Liam J

2018-06-01

Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.

Precursor incident program at EDF

International Nuclear Information System (INIS)

Fourest, B.; Maliverney, B.; Rozenholc, M.; Piovesan, C.

1998-01-01

The precursor program was started by EDF in 1994, after an investigation of the US NRC's Accident Sequence Precursor Program. Since then, reported operational events identified as Safety Outstanding Events have been analyzed whenever possible using probabilistic methods based on PSAs. Analysis provides an estimate of the remaining protection against core damage at the time the incident occurred. Measuring the incidents' severity enables to detect incidents important regarding safety. Moreover, the most efficient feedback actions can be derived from the main accident sequences identified through the analysis. Therefore, incident probabilistic analysis provides a way to assess priorities in terms of treatment and resource allocation, and so, to implement countermeasures preventing further occurrence and development of the most significant incidents. As some incidents cannot be analyzed using this method, probabilistic analysis can only be one among the methods used to assess the nuclear power plants' safety level. Nevertheless, it provides an interesting complement to classical methods of deterministic studies. (author)

Improving patient safety: how and why incidences occur in nursing care

Directory of Open Access Journals (Sweden)

Maria Cecilia Toffoletto

2013-10-01

Full Text Available The present investigation was a cross-sectional, quantitative research study analyzing incidents associated with nursing care using a root-cause methodological analysis. The study was conducted in a public hospital intensive care unit (ICU in Santiago de Chile and investigated 18 incidents related to nursing care that occurred from January to March of 2012. The sample was composed of six cases involving medications and the self-removal of therapeutic devices. The contributing factors were related to the tasks and technology, the professional work team, the patients, and the environment. The analysis confirmed that the cases presented with similar contributing factors, thereby indicating that the vulnerable aspects of the system are primarily responsible for the incidence occurrence. We conclude that root-cause analysis facilitates the identification of these vulnerable points. Proactive management in system-error prevention is made possible by recommendations.

The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

Science.gov (United States)

Panesar, Sukhmeet S; Netuveli, Gopalakrishnan; Carson-Stevens, Andrew; Javad, Sundas; Patel, Bhavesh; Parry, Gareth; Donaldson, Liam J; Sheikh, Aziz

2013-11-21

The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery. Cross-sectional study (retrospective analysis of records in a database). The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties. We extracted all orthopaedic error reports from the system over 1 year (2009-2010). The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention. 155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively. The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.

Safety design guide for safety related systems for CANDU 9

International Nuclear Information System (INIS)

Lee, Duk Su; Chang, Woo Hyun; Lee, Nam Young; A. C. D. Wright

1996-03-01

In general, two types of safety related systems and structures exist in the nuclear plant; The one is a systems and structures which perform safety functions during the normal operation of the plant, and the other is a systems and structures which perform safety functions to mitigate events caused by failure of the normally operating systems or by naturally occurring phenomena. In this safety design guide, these systems are identified in detail, and the major events for which the safety functions are required and the major safety requirements are identified in the list. As the probabilistic safety assessments are completed during the course of the project, additions or deletions to the list may be justified. 3 tabs. (Author) .new

Safety design guide for safety related systems for CANDU 9

Energy Technology Data Exchange (ETDEWEB)

Lee, Duk Su; Chang, Woo Hyun; Lee, Nam Young [Korea Atomic Energy Research Institute, Daeduk (Korea, Republic of); Wright, A.C.D. [Atomic Energy of Canada Ltd., Toronto (Canada)

1996-03-01

In general, two types of safety related systems and structures exist in the nuclear plant; The one is a systems and structures which perform safety functions during the normal operation of the plant, and the other is a systems and structures which perform safety functions to mitigate events caused by failure of the normally operating systems or by naturally occurring phenomena. In this safety design guide, these systems are identified in detail, and the major events for which the safety functions are required and the major safety requirements are identified in the list. As the probabilistic safety assessments are completed during the course of the project, additions or deletions to the list may be justified. 3 tabs. (Author) .new.

Criteria for safety-related operator actions

International Nuclear Information System (INIS)

Gray, L.H.; Haas, P.M.

1983-01-01

The Safety-Related Operator Actions (SROA) Program was designed to provide information and data for use by NRC in assessing the performance of nuclear power plant (NPP) control room operators in responding to abnormal/emergency events. The primary effort involved collection and assessment of data from simulator training exercises and from historical records of abnormal/emergency events that have occurred in operating plants (field data). These data can be used to develop criteria for acceptability of the use of manual operator action for safety-related functions. Development of criteria for safety-related operator actions are considered

What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group.

Science.gov (United States)

Caba Barrientos, F; Rodríguez Morillo, A; Galisteo Domínguez, R; Del Nozal Nalda, M; Almeida González, C V; Echevarría Moreno, M

2018-05-01

Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS). Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed. Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken. The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Critical incident monitoring in anaesthesia.

Science.gov (United States)

Choy, Y C

2006-12-01

Critical incident monitoring in anaesthesia is an important tool for quality improvement and maintenance of high safety standards in anaesthetic services. It is now widely accepted as a useful quality improvement technique for reducing morbidity and mortality in anaesthesia and has become part of the many quality assurance programmes of many general hospitals under the Ministry of Health. Despite wide-spread reservations about its value, critical incident monitoring is a classical qualitative research technique which is particularly useful where problems are complex, contextual and influenced by the interaction of physical, psychological and social factors. Thus, it is well suited to be used in probing the complex factors behind human error and system failure. Human error has significant contributions to morbidities and mortalities in anaesthesia. Understanding the relationships between, errors, incidents and accidents is important for prevention and risk management to reduce harm to patients. Cardiac arrests in the operating theatre (OT) and prolonged stay in recovery, constituted the bulk of reported incidents. Cardiac arrests in OT resulted in significant mortality and involved mostly de-compensated patients and those with unstable cardiovascular functions, presenting for emergency operations. Prolonged-stay in the recovery extended period of observation for ill patients. Prolonged stay in recovery was justifiable in some cases, as these patients needed a longer period of post-operative observation until they were stable enough to return to the ward. The advantages of the relatively low cost, and the ability to provide a comprehensive body of detailed qualitative information, which can be used to develop strategies to prevent and manage existing problems and to plan further initiatives for patient safety makes critical incident monitoring a valuable tool in ensuring patient safety. The contribution of critical incident reporting to the issue of patient safety is

Annual report on occupational safety 1985

International Nuclear Information System (INIS)

1986-09-01

This report presents information on occupational safety relating to the Company's employees for the year 1985, and compares data with figures for the previous year. The following headings are listed: principle activities of BNFL, general policy and organisation, radiological safety, including whole body, skin and extremity, and internal organ doses, non-radiological safety, incidents reportable to the health and safety executive. (U.K.)

Research for enhancing reactor safety

International Nuclear Information System (INIS)

1989-05-01

Recent research for enhanced reactor safety covers extensive and numerous experiments and computed modelling activities designed to verify and to improve existing design requirements. The lectures presented at the meeting report GRS research results and the current status of reactor safety research in France. The GRS experts present results concerning expert systems and their perspectives in safety engineering, large-scale experiments and their significance in the development and verification of computer codes for thermohydraulic modelling of safety-related incidents, the advanced system code ATHLET for analysis of thermohydraulic processes of incidents, the analysis simulator which is a tool for fast evaluation of accident management measures, and investigations into event sequences and the required preventive emergency measures within the German Risk Study. (DG) [de

SU-C-BRD-05: Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy: The Primary Experience in a New Established Program with Advanced Techniques

Energy Technology Data Exchange (ETDEWEB)

Yang, R; Wang, J [Peking University Third Hospital, Beijing, Beijing (China)

2014-06-15

Purpose: To explore the implementation and effectiveness of incident learning for the safety and quality of radiotherapy in a new established radiotherapy program with advanced technology. Methods: Reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically designed for reporting, investigating, and learning of individual radiotherapy incidents in a new established radiotherapy program, with 4D CBCT, Ultrasound guided radiotherapy, VMAT, gated treatment delivered on two new installed linacs. The incidents occurring in external beam radiotherapy from February, 2012 to January, 2014 were reported. Results: A total of 33 reports were analyzed, including 28 near misses and 5 incidents. Among them, 5 originated in imaging for planning, 25 in planning, 1 in plan transfer, 1 in commissioning and 1 in treatment delivery. Among them, three near misses originated in the safety barrier of the radiotherapy process. In terms of error type, 1 incident was classified as wrong patient, 7 near misses/incidents as wrong site, 6 as wrong laterality, 5 as wrong dose, 7 as wrong prescription, and 7 as suboptimal plan quality. 5 incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, inadequate training, failure to develop an effective plan, and communication contributed to 19, 15, 12, 5 and 3 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4; this rate fell to 0.28% in the second year from 0.56% in the first year. The rate of near miss fell to 1.24% from 2.22%. Conclusion: Effective incident learning can reduce the occurrence of near miss/incidents, enhance the culture of safety. Incident learning is an effective proactive method for improving the quality and safety of radiotherapy.

SU-C-BRD-05: Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy: The Primary Experience in a New Established Program with Advanced Techniques

International Nuclear Information System (INIS)

Yang, R; Wang, J

2014-01-01

Purpose: To explore the implementation and effectiveness of incident learning for the safety and quality of radiotherapy in a new established radiotherapy program with advanced technology. Methods: Reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically designed for reporting, investigating, and learning of individual radiotherapy incidents in a new established radiotherapy program, with 4D CBCT, Ultrasound guided radiotherapy, VMAT, gated treatment delivered on two new installed linacs. The incidents occurring in external beam radiotherapy from February, 2012 to January, 2014 were reported. Results: A total of 33 reports were analyzed, including 28 near misses and 5 incidents. Among them, 5 originated in imaging for planning, 25 in planning, 1 in plan transfer, 1 in commissioning and 1 in treatment delivery. Among them, three near misses originated in the safety barrier of the radiotherapy process. In terms of error type, 1 incident was classified as wrong patient, 7 near misses/incidents as wrong site, 6 as wrong laterality, 5 as wrong dose, 7 as wrong prescription, and 7 as suboptimal plan quality. 5 incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, inadequate training, failure to develop an effective plan, and communication contributed to 19, 15, 12, 5 and 3 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4; this rate fell to 0.28% in the second year from 0.56% in the first year. The rate of near miss fell to 1.24% from 2.22%. Conclusion: Effective incident learning can reduce the occurrence of near miss/incidents, enhance the culture of safety. Incident learning is an effective proactive method for improving the quality and safety of radiotherapy

Using total quality management approach to improve patient safety by preventing medication error incidences*.

Science.gov (United States)

Yousef, Nadin; Yousef, Farah

2017-09-04

Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions. The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool. In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%. This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated

Safety-Related Contractor Activities at Nuclear Power Plants. New Challenges for Regulatory Oversight

International Nuclear Information System (INIS)

Chockie, Alan

2005-09-01

The use of contractors has been an integral and important part of the design, construction, operation, and maintenance of nuclear power plants. To ensure the safe and efficient completion of contracted tasks, each nuclear plant licensee has developed and refined formal contract management processes to meet their specific needs and plant requirements. Although these contract management processes have proven to be effective tools for the procurement of support and components tailored to the needs of nuclear power plants, contractor-related incidents and accidents have revealed some serious weaknesses with the implementation of these processes. Identifying and addressing implementation problems are becoming more complicated due to organizational and personnel changes affecting the nuclear power industry. The ability of regulators and licensees to effectively monitor and manage the safety-related performance of contractors will likely be affected by forthcoming organization and personnel changes due to: the aging of the workforce; the decline of the nuclear industry; and the deregulation of nuclear power. The objective of this report is to provide a review of current and potential future challenges facing safety-related contractor activities at nuclear power plants. The purpose is to assist SKI in establishing a strategy for the proactive oversight of contractor safety-related activities at Swedish nuclear power plants and facilities. The nature and role of contractors at nuclear plants is briefly reviewed in the first section of the report. The second section describes the essential elements of the contract management process. Although organizations have had decades of experience with the a contract management process, there remain a number of common implantation weaknesses that have lead to serious contractor-related incidents and accidents. These implementation weaknesses are summarized in the third section. The fourth section of the report highlights the

Safety-Related Contractor Activities at Nuclear Power Plants. New Challenges for Regulatory Oversight

Energy Technology Data Exchange (ETDEWEB)

Chockie, Alan [Chockie Group International, Inc., Seattle, WA (United States)

2005-09-15

The use of contractors has been an integral and important part of the design, construction, operation, and maintenance of nuclear power plants. To ensure the safe and efficient completion of contracted tasks, each nuclear plant licensee has developed and refined formal contract management processes to meet their specific needs and plant requirements. Although these contract management processes have proven to be effective tools for the procurement of support and components tailored to the needs of nuclear power plants, contractor-related incidents and accidents have revealed some serious weaknesses with the implementation of these processes. Identifying and addressing implementation problems are becoming more complicated due to organizational and personnel changes affecting the nuclear power industry. The ability of regulators and licensees to effectively monitor and manage the safety-related performance of contractors will likely be affected by forthcoming organization and personnel changes due to: the aging of the workforce; the decline of the nuclear industry; and the deregulation of nuclear power. The objective of this report is to provide a review of current and potential future challenges facing safety-related contractor activities at nuclear power plants. The purpose is to assist SKI in establishing a strategy for the proactive oversight of contractor safety-related activities at Swedish nuclear power plants and facilities. The nature and role of contractors at nuclear plants is briefly reviewed in the first section of the report. The second section describes the essential elements of the contract management process. Although organizations have had decades of experience with the a contract management process, there remain a number of common implantation weaknesses that have lead to serious contractor-related incidents and accidents. These implementation weaknesses are summarized in the third section. The fourth section of the report highlights the

Development of safety related technology and infrastructure for safety assessment

International Nuclear Information System (INIS)

Venkat Raj, V.

1997-01-01

Development and optimum utilisation of any technology calls for the building up of the necessary infrastructure and backup facilities. This is particularly true for a developing country like India and more so for an advanced technology like nuclear technology. Right from the inception of its nuclear power programme, the Indian approach has been to develop adequate infrastructure in various areas such as design, construction, manufacture, installation, commissioning and safety assessment of nuclear plants. This paper deals with the development of safety related technology and the relevant infrastructure for safety assessment. A number of computer codes for safety assessment have been developed or adapted in the areas of thermal hydraulics, structural dynamics etc. These codes have undergone extensive validation through data generated in the experimental facilities set up in India as well as participation in international standard problem exercises. Side by side with the development of the tools for safety assessment, the development of safety related technology was also given equal importance. Many of the technologies required for the inspection, ageing assessment and estimation of the residual life of various components and equipment, particularly those having a bearing on safety, were developed. This paper highlights, briefly, the work carried out in some of the areas mentioned above. (author)

Incident factor as a learning aspect to enhance safety culture in the experimental fuel element installation of PTBN - BATAN

International Nuclear Information System (INIS)

Heri Hardiyanti; Agus Sartono; Bambang Herutomo; AS Latief

2013-01-01

The safety of a nuclear facility depends not only on the fulfillment of all technical requirements, but also on the role of non-technical aspects. The primary causation of incidents or accidents in a nuclear facility is human error which is non-technical. Therefore, in order to enhance safety, efforts from the technical aspects are as important as efforts to deal with the human factor which can be done through the application of safety culture in the facility. Incidents that took place in the Experimental Fuel Element Installation (EFEI) of PTBN - BATAN from 2011 to 2012 were caused by aging instruments and human error. In order to prevent accidents and to enhance safety, non-technical efforts that were done in the EFEI were, interalia, the obligations on all personnel to attend the pre-lab briefing, to prepare a work proposal, to compose a HIRADC (hazard identification, risk assessment, and determining control) document, to utilize self protection devices, to perform a routine maintenance, and to practice safe behavior. All personnel were involved in all those efforts. Safety is the first priority and can always be improved in the facility. A strong commitment of and cooperation between the top management and the staff are needed. (author)

Safety Review related to Commercial Grade Digital Equipment in Safety System

International Nuclear Information System (INIS)

Yu, Yeongjin; Park, Hyunshin; Yu, Yeongjin; Lee, Jaeheung

2013-01-01

The upgrades or replacement of I and C systems on safety system typically involve digital equipment developed in accordance with non-nuclear standards. However, the use of commercial grade digital equipment could include the vulnerability for software common-mode failure, electromagnetic interference and unanticipated problems. Although guidelines and standards for dedication methods of commercial grade digital equipment are provided, there are some difficulties to apply the methods to commercial grade digital equipment for safety system. This paper focuses on regulatory guidelines and relevant documents for commercial grade digital equipment and presents safety review experiences related to commercial grade digital equipment in safety system. This paper focuses on KINS regulatory guides and relevant documents for dedication of commercial grade digital equipment and presents safety review experiences related to commercial grade digital equipment in safety system. Dedication including critical characteristics is required to use the commercial grade digital equipment on safety system in accordance with KEPIC ENB 6370 and EPRI TR-106439. The dedication process should be controlled in a configuration management process. Appropriate methods, criteria and evaluation result should be provided to verify acceptability of the commercial digital equipment used for safety function

WE-G-BRA-01: Patient Safety and Treatment Quality Improvement Through Incident Learning: Experience of a Non-Academic Proton Therapy Center

Energy Technology Data Exchange (ETDEWEB)

Zheng, Y; Johnson, R; Zhao, L; Ramirez, E; Rana, S; Singh, H; Chacko, M [Procure Proton Therapy Center, Oklahoma City, OK (United States)

2015-06-15

Purpose: Incident learning has been proven to improve patient safety and treatment quality in conventional radiation therapy. However, its application in proton therapy has not been reported yet to our knowledge. In this study, we report our experience in developing and implementation of an in-house incident learning system. Methods: An incident learning system was developed based on published principles and tailored for our clinical practice and available resource about 18 months ago. The system includes four layers of error detection and report: 1) dosimetry peer review; 2) physicist plan quality assurance (QA); 3) treatment delivery issue on call and record; and 4) other incident report. The first two layers of QA and report were mandatory for each treatment plan through easy-to-use spreadsheets that are only accessible by the dosimetry and physicist departments. The treatment delivery issues were recorded case by case by the on call physicist. All other incidents were reported through an online incident report system, which can be anonymous. The incident report includes near misses on planning and delivery, process deviation, machine issues, work flow and documentation. Periodic incident reviews were performed. Results: In total, about 116 errors were reported through dosimetry review, 137 errors through plan QA, 83 treatment issues through physics on call record, and 30 through the online incident report. Only 8 incidents (2.2%) were considered to have a clinical impact to patients, and the rest of errors were either detected before reaching patients or had negligible dosimetric impact (<5% dose variance). Personnel training & process improvements were implemented upon periodic incident review. Conclusion: An incident learning system can be helpful in personnel training, error reduction, and patient safety and treatment quality improvement. The system needs to be catered for each clinic’s practice and available resources. Incident and knowledge sharing among

WE-G-BRA-01: Patient Safety and Treatment Quality Improvement Through Incident Learning: Experience of a Non-Academic Proton Therapy Center

International Nuclear Information System (INIS)

Zheng, Y; Johnson, R; Zhao, L; Ramirez, E; Rana, S; Singh, H; Chacko, M

2015-01-01

Purpose: Incident learning has been proven to improve patient safety and treatment quality in conventional radiation therapy. However, its application in proton therapy has not been reported yet to our knowledge. In this study, we report our experience in developing and implementation of an in-house incident learning system. Methods: An incident learning system was developed based on published principles and tailored for our clinical practice and available resource about 18 months ago. The system includes four layers of error detection and report: 1) dosimetry peer review; 2) physicist plan quality assurance (QA); 3) treatment delivery issue on call and record; and 4) other incident report. The first two layers of QA and report were mandatory for each treatment plan through easy-to-use spreadsheets that are only accessible by the dosimetry and physicist departments. The treatment delivery issues were recorded case by case by the on call physicist. All other incidents were reported through an online incident report system, which can be anonymous. The incident report includes near misses on planning and delivery, process deviation, machine issues, work flow and documentation. Periodic incident reviews were performed. Results: In total, about 116 errors were reported through dosimetry review, 137 errors through plan QA, 83 treatment issues through physics on call record, and 30 through the online incident report. Only 8 incidents (2.2%) were considered to have a clinical impact to patients, and the rest of errors were either detected before reaching patients or had negligible dosimetric impact (<5% dose variance). Personnel training & process improvements were implemented upon periodic incident review. Conclusion: An incident learning system can be helpful in personnel training, error reduction, and patient safety and treatment quality improvement. The system needs to be catered for each clinic’s practice and available resources. Incident and knowledge sharing among

Safety analysis of fusion reactors pertaining to nuclear incidents and accidents. Final report

International Nuclear Information System (INIS)

Raeder, J.; Weller, A.; Wolf, R.; Jin, X.; Boccaccini, L.V.; Stieglitz, R.; Carloni, D.; Pistner, C.; Herb, J.

2013-11-01

The BfS gave the projekt partners IPP, KIT, Oeko-Institut e. V., and GRS the order to carry out a literature study on the topic of safety of fusion power plants regarding nuclear incidents and accidents. In the framework of this study the actual status of science and technology of the safety concept of fusion power plants should be determined and the applicability of the nuclear safety regulations hitherto developed for nuclear power plants checked. For future commercial fusion power plants today only conceptional designs exist. The most advanced conceptual study for a future fusion power plant is the European Power Plant Conceptual Study (PPCS) from the year 2005, which is based on the tokamak principle. In this study also fundamental aspects of the safety concept of nuclear fusion are treated. Hereby several different conceptual approaches are discussed, which differ among others also in the lay-out approaches relevant for the safety of a facility like for instance the choice of the breeding concept or the materials for the blanket/divertor structure and the coolants. The safety concept of nuclear fusion is oriented on safety concepts for facilities with radioactive inventory. It is based on the concept of tiered safety levels. In order to check whether for the nuclear fusion a safety concept comparable with the nuclear fission at all is necessary, in a first step it was considered, which consequences are possible at a postulated release o large parts of the radioactive inventory of a fusion power plant. Such a worst-case scenario was compared with a corresponding, postulated release of large parts of the radioactive inventory of a nuclear power plant. As scale hereby served the radiological criterion, at the transgression of which in the environment of the facility an evacuation would be necessary. In a next step the transferability of the safety concept of the tiered safety levels of nuclear technology to the fusion was checked. Beside events transferable from

Qualification of safety-related valve actuators

International Nuclear Information System (INIS)

Anon.

1981-01-01

This Standard describes the qualification of all types of power-driven valve actuators, including damper actuators, for safety-related functions in nuclear power generating stations. It may also be used to separately qualify actuator components. This Standard establishes the minimum requirements for, and guidance regarding, the methods and procedures for qualification of all safety-related functions of power-driven valve actuators

Highway Safety Program Manual: Volume 8: Alcohol in Relation to Highway Safety.

Science.gov (United States)

National Highway Traffic Safety Administration (DOT), Washington, DC.

Volume 8 of the 19-volume Highway Safety Program Manual (which provides guidance to State and local governments on preferred highway safety practices) concentrates on alcohol in relation to highway safety. The purpose and objectives of the alcohol program are outlined. Federal authority in the area of highway safety and general policies regarding…

A method for quantitative measurement of safety culture based on ISO 26262

NARCIS (Netherlands)

Khabbaz Saberi, A.; Benders, F.; Koch, R.; Lukkien, J.J.; van den Brand, M.G.J.; Parsons, M.; Kelly, T.

2018-01-01

Safety culture is the collective attitude of members of an organization regarding safety issues: awareness, communication, knowledge, etc. In the automotive industry, specifically in its Research and Development (R&D) environments, safety culture is relatively new. Recent incidents related to

Safety-related control air systems - approved 1977

International Nuclear Information System (INIS)

Anon.

1978-01-01

This standard applies to those portions of the control air system that furnish air required to support, control, or operate systems or portions of systems that are safety related in nuclear power plants. This standard relates only to the air supply system(s) for safety-related air operated devices and does not apply to the safety-related air operated device or to air operated actuators for such devices. The objectives of this standard are to provide (1) minimum system design requirements for equipment, piping, instruments, controls, and wiring that constitute the air supply system; and (2) the system and component testing and maintenance requirements

Incidence trends of human papillomavirus-related head and neck cancer in Taiwan, 1995-2009.

Science.gov (United States)

Hwang, Tzer-Zen; Hsiao, Jenn-Ren; Tsai, Chia-Rung; Chang, Jeffrey S

2015-07-15

Recent studies suggested that human papillomavirus (HPV) is an emerging risk factor of head and neck cancer (HNC), particularly for oropharyngeal cancer. Studies from the West showed a rising trend of HPV-related HNC despite a decrease of the overall HNC incidence. In contrast, the overall HNC incidence in Taiwan has continued to rise. It is not clear whether the incidence trends of HPV-related HNC in Taiwan have a similar pattern to those from countries with an overall decreasing incidence of HNC. This study examined the incidence trends of HPV-related and HPV-unrelated HNC in Taiwan using data from the Taiwan Cancer Registry. Our results showed that the incidence trends of HPV-related and HPV-unrelated HNC in Taiwan both rose during 1995-2009. The incidence of HPV-related HNC (1.3 per 100,000 in 1995 to 3.3 in 2009, annual percentage change (APC) = 6.9, p Taiwan has continued to increase, the most rapid rise is in the HPV-related HNC. This suggests that similar to the Western world, HPV-related HNC is becoming an important public health issue in Taiwan. © 2014 UICC.

29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

Science.gov (United States)

2010-07-01

... to OSHA. 1904.39 Section 1904.39 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY... fatalities and multiple hospitalization incidents to OSHA. (a) Basic requirement. Within eight (8) hours... Administration (OSHA), U.S. Department of Labor, that is nearest to the site of the incident. You may also use...

Report on safety related occurrences and reactor trips January 1 - June 30, 1984

International Nuclear Information System (INIS)

1984-01-01

This is a systematically arranged report on all safety-related occurrences and reactor trips in Swedish nuclear power plants in operation during the period from January 1 to June 30 1984. It is based on the reports submitted by the utilities to the Swedish Nuclear Inspectorate according to Technical Specifications. Twice a year since 1974 the Inspectorate has issued a compilation on such reported occurrences and reactor trips. Starting with the compilation of the second half of 1982 some new features have been introduced. The most important change is that the volume of information has been increased. The full text, provided by the utilities when reporting the incidents, is now attached to the codified information and also the layout has been altered to facilitate reading. As in the previous reports the occurrences and reactor trips are arranged both alphabetically by facility name and chronologically by report number for each facility. Electricity generation charts for each facility are also presented. The primary purpose of this report is thus to present all the information furnished by the utilities when they submit their reports according to Technical Specifications. The only evaluation made by the Inspectorate is the categorization on the incidents. Like the previous reports this one also presents frequency of incidents as related to affected component, cause of incident etc. The difference is that only information reported by the utilities is used. This is the reason why a considerable proportion of the incidents are categorized as other component or other fault. Sometime in the future, however, the Inspectorate plants to put out a special report containing its own analyses of the most interesting events along with processed statistics and other information. (author)

Analysis on relation between safety input and accidents

Institute of Scientific and Technical Information of China (English)

YAO Qing-guo; ZHANG Xue-mu; LI Chun-hui

2007-01-01

The number of safety input directly determines the level of safety, and there exists dialectical and unified relations between safety input and accidents. Based on the field investigation and reliable data, this paper deeply studied the dialectical relationship between safety input and accidents, and acquired the conclusions. The security situation of the coal enterprises was related to the security input rate, being effected little by the security input scale, and build the relationship model between safety input and accidents on this basis, that is the accident model.

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.

Science.gov (United States)

Schwappach, David L B; Frank, Olga; Buschmann, Ute; Babst, Reto

2013-04-01

Rationale, aims and objectives  The study aims to investigate the effects of a patient safety advisory on patients' risk perceptions, perceived behavioural control, performance of safety behaviours and experience of adverse incidents. Method  Quasi-experimental intervention study with non-equivalent group comparison was used. Patients admitted to the surgical department of a Swiss large non-university hospital were included. Patients in the intervention group received a safety advisory at their first clinical encounter. Outcomes were assessed using a questionnaire at discharge. Odds ratios for control versus intervention group were calculated. Regression analysis was used to model the effects of the intervention and safety behaviours on the experience of safety incidents. Results  Two hundred eighteen patients in the control and 202 in the intervention group completed the survey (75 and 77% response rates, respectively). Patients in the intervention group were less likely to feel poorly informed about medical errors (OR = 0.55, P = 0.043). There were 73.1% in the intervention and 84.3% in the control group who underestimated the risk for infection (OR = 0.51, CI 0.31-0.84, P = 0.009). Perceived behavioural control was lower in the control group (meanCon  = 3.2, meanInt  = 3.5, P = 0.010). Performance of safety-related behaviours was unaffected by the intervention. Patients in the intervention group were less likely to experience any safety-related incident or unsafe situation (OR for intervention group = 0.57, CI 0.38-0.87, P = 0.009). There were no differences in concerns for errors during hospitalization. There were 96% of patients (intervention) who would recommend other patients to read the advisory. Conclusions  The results suggest that the safety advisory decreases experiences of adverse events and unsafe situations. It renders awareness and perceived behavioural control without increasing concerns for safety and

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review.

Science.gov (United States)

Ock, Minsu; Lim, So Yun; Jo, Min-Woo; Lee, Sang-Il

2017-03-01

We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI). We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them. There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI. The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.

Significant incidents in nuclear fuel cycle facilities

Energy Technology Data Exchange (ETDEWEB)

NONE

1996-03-01

In contrast to nuclear power plants, events in nuclear fuel cycle facilities are not well documented. The INES database covers all the nuclear fuel cycle facilities; however, it was developed in the early 1990s and does not contain information on events prior to that. The purpose of the present report is to collect significant events and analyze them in order to give a safety related overview of nuclear fuel cycle facilities. Significant incidents were selected using the following criteria: release of radioactive material or exposure to radiation; degradation of items important to safety; and deficiencies in design, quality assurance, etc. which include criticality incidents, fire, explosion, radioactive release and contamination. This report includes an explanation, where possible, of root causes, lessons learned and action taken. 4 refs, 4 tabs.

Significant incidents in nuclear fuel cycle facilities

International Nuclear Information System (INIS)

1996-03-01

In contrast to nuclear power plants, events in nuclear fuel cycle facilities are not well documented. The INES database covers all the nuclear fuel cycle facilities; however, it was developed in the early 1990s and does not contain information on events prior to that. The purpose of the present report is to collect significant events and analyze them in order to give a safety related overview of nuclear fuel cycle facilities. Significant incidents were selected using the following criteria: release of radioactive material or exposure to radiation; degradation of items important to safety; and deficiencies in design, quality assurance, etc. which include criticality incidents, fire, explosion, radioactive release and contamination. This report includes an explanation, where possible, of root causes, lessons learned and action taken. 4 refs, 4 tabs

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature

Science.gov (United States)

Hull, Louise; Soukup, Tayana; Mayer, Erik; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara

2017-01-01

Objectives The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. Design To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. Results The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). Conclusion A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement. PMID:29284714

Assessing the general safety and tolerability of vildagliptin: value of pooled analyses from a large safety database versus evaluation of individual studies

Science.gov (United States)

Schweizer, Anja; Dejager, Sylvie; Foley, James E; Kothny, Wolfgang

2011-01-01

Aim: Analyzing safety aspects of a drug from individual studies can lead to difficult-to-interpret results. The aim of this paper is therefore to assess the general safety and tolerability, including incidences of the most common adverse events (AEs), of vildagliptin based on a large pooled database of Phase II and III clinical trials. Methods: Safety data were pooled from 38 studies of ≥12 to ≥104 weeks’ duration. AE profiles of vildagliptin (50 mg bid; N = 6116) were evaluated relative to a pool of comparators (placebo and active comparators; N = 6210). Absolute incidence rates were calculated for all AEs, serious AEs (SAEs), discontinuations due to AEs, and deaths. Results: Overall AEs, SAEs, discontinuations due to AEs, and deaths were all reported with a similar frequency in patients receiving vildagliptin (69.1%, 8.9%, 5.7%, and 0.4%, respectively) and patients receiving comparators (69.0%, 9.0%, 6.4%, and 0.4%, respectively), whereas drug-related AEs were seen with a lower frequency in vildagliptin-treated patients (15.7% vs 21.7% with comparators). The incidences of the most commonly reported specific AEs were also similar between vildagliptin and comparators, except for increased incidences of hypoglycemia, tremor, and hyperhidrosis in the comparator group related to the use of sulfonylureas. Conclusions: The present pooled analysis shows that vildagliptin was overall well tolerated in clinical trials of up to >2 years in duration. The data further emphasize the value of a pooled analysis from a large safety database versus assessing safety and tolerability from individual studies. PMID:21415917

College law enforcement and security department responses to alcohol-related incidents: a national study.

Science.gov (United States)

Bernat, Debra H; Lenk, Kathleen M; Nelson, Toben F; Winters, Ken C; Toomey, Traci L

2014-08-01

Campus police and security personnel are often the first to respond to alcohol-related incidents on campus. The purpose of this study is to examine how campus law enforcement and security respond to alcohol-related incidents, and how consequences and communication differ based on characteristics of the incident. Directors of campus police/security from 343 colleges across the United States completed a survey regarding usual practice following serious, underage, and less serious alcohol incidents on and off campus. Campus law enforcement and security most commonly reported contacting campus officials. A minority reported issuing citations and referring students to the health center. Enforcement actions were more commonly reported for serious and underage incidents than for less serious incidents. Large (vs. small) colleges, public (vs. private) colleges, and those located in small (vs. large) towns more consistently reported taking actions against drinkers. Understanding how campus police and security respond to alcohol-related incidents is essential for reducing alcohol-related problems on college campuses. Copyright © 2014 by the Research Society on Alcoholism.

[Perception of safety climate in outpatient pediatric care].

Science.gov (United States)

Baldegger, Claudia; Zeller, Adelheid

2013-02-01

In ambulant pediatric care, patients situations are becoming increasingly complex, because the lenght of hospital stay is reduced since the introduction of Diagnosis Related Groups (DRG). Consequently, the patients' safety is constantly becoming more important. The patients' safety is closely associated with the nurses' awareness of risks and the safety climate within the institution. This study is investigating how nurses of a pediatric outpatient service estimate the patients' safety and how that can be optimized, if necessary. As part of a cross-sectional study, a total of 106 nurses of the pediatric outpatient service were interviewed with a modified German version of the "Patient Safety Climate Inventory (Patientensicherheitsklima-Inventar, PaSKI)". Data was analysed by a descriptive statistical method. The return rate was 80.2 percent. The results show a very high awareness of patients' safety issues as well as a high level of satisfaction concerning team collaboration. Both results have a positive influence on the safety-climate. Problems are associated mainly with the incident reporting system, e.g. with reporting critical incidents and communicating after reporting. This indicates the importance of a useable incident reporting system, which--in combination with staff training--may be an important step towards a structured risk management. Furthermore, it clarifies the importance of transparent communication after a reported incident, as also described in the literature.

NEA incident reporting system: Three years' experience

International Nuclear Information System (INIS)

Otsuka, Y.; Haeussermann, W.

1984-01-01

The paper presents an overview of the NEA Incident Reporting System (IRS) which was set up to collect, assess and disseminate on safety-related incidents in nuclear power plants. The IRS information exchange is significant in two senses. First, it enables regulatory authorities and utilities in participating countries to take appropriate action to prevent the reported mishaps occurring again elsewhere. Secondly, the continuous collection and systematic analysis of such information allows identification of areas of concern where safety research should be strengthened. There are two stages in the IRS information exchange. First, the national IRS Co-ordinator selects information on significant incidents, in accordance with a common reporting threshold, from the abnormal occurrences reported to the regulatory body, to be distributed through the NEA Secretariat. This screening is intended to exclude minor events, so that only significant information is sent to participating countries. Secondly, a group of experts periodically reviews the incidents reported during the preceding twelve months to identify major areas of concern. To assist this process, a computer-based data retrieval system is being developed for IRS incident reports. The paper gives some details of the IRS mechanism and discusses reporting criteria and the information included in a report. Areas of concern derived from reported incidents, an outline of the data retrieval system, and examples of feedback of lessons learned and possibilities for international co-operation are also discussed. (author)

Research on consequence analysis method for probabilistic safety assessment of nuclear fuel facilities (4). Investigation of safety evaluation method for fire and explosion incidents

International Nuclear Information System (INIS)

Abe, Hitoshi; Tashiro, Shinsuke; Ueda, Yoshinori

2010-01-01

A special committee on 'Research on the analysis methods for accident consequence of nuclear fuel facilities (NFFs)' was organized by the Atomic Energy Society of Japan (AESJ) under the entrustment of Japan Atomic Energy Agency (JAEA). The committee aims to research on the state-of-the-art consequence analysis method for Probabilistic Safety Assessment (PSA) of NFFs, such as fuel reprocessing and fuel fabrication facilities. The objective of this research is to obtain the useful information related to the establishment of quantitative performance objectives and to risk-informed regulation through qualifying issues needed to be resolved for applying PSA to NFFs. The research activities of the committee were mainly focused on the analysis method of consequences for postulated accidents with potentially large consequences in NFFs, e.g., events of criticality, spill of molten glass, hydrogen explosion, boiling of radioactive solution, and fire (including rapid decomposition of TBP complexes), resulting in the release of radio active materials into the environment. The results of the research were summarized in a series of six reports, which consist of a review report and five technical ones. In this technical report, the research results about basic experimental data and the method for safety evaluation of fire and explosion incidents were summarized. (author)

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

Directory of Open Access Journals (Sweden)

Minsu Ock

2017-03-01

Full Text Available Objectives We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI. Methods We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them. Results There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI. Conclusions The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.

Qualification of FPGA-Based Safety-Related PRM System

International Nuclear Information System (INIS)

Miyazaki, Tadashi; Oda, Naotaka; Goto, Yasushi; Hayashi, Toshifumi

2011-01-01

Toshiba has developed Non-rewritable (NRW) Field Programmable Gate Array (FPGA)-based safety-related Instrumentation and Control (I and C) system. Considering application to safety-related systems, nonvolatile and non-rewritable FPGA which is impossible to be changed after once manufactured has been adopted in Toshiba FPGA-based system. FPGA is a device which consists only of basic logic circuits, and FPGA performs defined processing which is configured by connecting the basic logic circuit inside the FPGA. FPGA-based system solves issues existing both in the conventional systems operated by analog circuits (analog-based system) and the systems operated by central processing unit (CPU-based system). The advantages of applying FPGA are to keep the long-life supply of products, improving testability (verification), and to reduce the drift which may occur in analog-based system. The system which Toshiba developed this time is Power Range Neutron Monitor (PRM). Toshiba is planning to expand application of FPGA-based technology by adopting this development process to the other safety-related systems such as RPS from now on. Toshiba developed a special design process for NRW-FPGA-based safety-related I and C systems. The design process resolves issues for many years regarding testability of the digital system for nuclear safety application. Thus, Toshiba NRW-FPGA-based safety-related I and C systems has much advantage to be a would standard of the digital systems for nuclear safety application. (author)

An assessment of the impact of home safety assessments on fires and fire-related injuries: a case study of Cheshire Fire and Rescue Service.

Science.gov (United States)

Arch, B N; Thurston, M N

2013-06-01

Deaths and injuries related to fires are largely preventable events. In the UK, a plethora of community-based fire safety initiatives have been introduced over the last 25 years, often led by fire and rescue services, to address this issue. This paper focuses on one such initiative--home safety assessments (HSAs). Cheshire Fire and Rescue Service (in England) implemented a uniquely large-scale HSA intervention. This paper assesses its effectiveness. The impact of HSAs was assessed in relation to three outcomes: accidental dwelling fires (ADFs), ADFs contained and injuries arising from ADFs. A two-period comparison in fire-related rates of incidences in Cheshire between 2002 and 2011 was implemented, using Poisson regression and adjusting for the national temporal trend using a control group comprising the 37 other English non-metropolitan fire-services. Significant reductions were observed in rates of ADFs [incidence rate ratios (IRR): 0.79, 95% confidence interval (CI): 0.74-0.83, P fires contained to room of origin. There is strong evidence to suggest that the intervention was successful in reducing domestic fires and related injuries.

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.

Science.gov (United States)

Archer, Stephanie; Hull, Louise; Soukup, Tayana; Mayer, Erik; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara

2017-12-27

The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

[Breast cancer incidence related with a population-based screening program].

Science.gov (United States)

Natal, Carmen; Caicoya, Martín; Prieto, Miguel; Tardón, Adonina

2015-02-20

To compare breast cancer cumulative incidence, time evolution and stage at diagnosis between participants and non-participant women in a population-based screening program. Cohort study of breast cancer incidence in relation to participation in a population screening program. The study population included women from the target population of the screening program. The source of information for diagnostics and stages was the population-based cancer registry. The analysis period was 1999-2010. The Relative Risk for invasive, in situ, and total cancers diagnosed in participant women compared with non-participants were respectively 1.16 (0.94-1.43), 2.98 (1.16-7.62) and 1.22 (0.99-1.49). The Relative Risk for participants versus non-participants was 2.47 (1.55-3.96) for diagnosis at stagei, 2.58 (1.67-3.99) for T1 and 2.11 (1.38-3.23) for negative lymph node involvement. The cumulative incidence trend had two joint points in both arms, with an Annual Percent of Change of 92.3 (81.6-103.5) between 1999-2001, 18.2 (16.1-20.3) between 2001-2005 and 5.9 (4.0-7.8) for the last period in participants arm, and 72.6 (58.5-87.9) between 1999-2001, 12.6 (7.9-17.4) between 2001-2005, and 8.6 (6.5-10.6) in the last period in the non-participant arm. Participating in the breast cancer screening program analyzed increased the in situ cumulative cancer incidence, but not the invasive and total incidence. Diagnoses were earlier in the participant arm. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

Estimated Incident Cost Savings in Shipping Due to Inspections

NARCIS (Netherlands)

S. Knapp (Sabine); G.E. Bijwaard (Govert); C. Heij (Christiaan)

2010-01-01

textabstractThe effectiveness of safety inspections has been analysed from various angles, but until now, relatively little attention has been given to translate risk reduction into incident cost savings. This paper quantifies estimated cost savings based on port state control inspections and

Assessing the general safety and tolerability of vildagliptin: value of pooled analyses from a large safety database versus evaluation of individual studies

Directory of Open Access Journals (Sweden)

Schweizer A

2011-02-01

Full Text Available Anja Schweizer1, Sylvie Dejager2, James E Foley3, Wolfgang Kothny31Novartis Pharma AG, Basel, Switzerland; 2Novartis Pharma SAS, Rueil-Malmaison, France; 3Novartis Pharmaceuticals Corporation, East Hanover, NJ, USAAim: Analyzing safety aspects of a drug from individual studies can lead to difficult-to-interpret results. The aim of this paper is therefore to assess the general safety and tolerability, including incidences of the most common adverse events (AEs, of vildagliptin based on a large pooled database of Phase II and III clinical trials.Methods: Safety data were pooled from 38 studies of ≥12 to ≥104 weeks' duration. AE profiles of vildagliptin (50 mg bid; N = 6116 were evaluated relative to a pool of comparators (placebo and active comparators; N = 6210. Absolute incidence rates were calculated for all AEs, serious AEs (SAEs, discontinuations due to AEs, and deaths.Results: Overall AEs, SAEs, discontinuations due to AEs, and deaths were all reported with a similar frequency in patients receiving vildagliptin (69.1%, 8.9%, 5.7%, and 0.4%, respectively and patients receiving comparators (69.0%, 9.0%, 6.4%, and 0.4%, respectively, whereas drug-related AEs were seen with a lower frequency in vildagliptin-treated patients (15.7% vs 21.7% with comparators. The incidences of the most commonly reported specific AEs were also similar between vildagliptin and comparators, except for increased incidences of hypoglycemia, tremor, and hyperhidrosis in the comparator group related to the use of sulfonylureas.Conclusions: The present pooled analysis shows that vildagliptin was overall well tolerated in clinical trials of up to >2 years in duration. The data further emphasize the value of a pooled analysis from a large safety database versus assessing safety and tolerability from individual studies.Keywords: type 2 diabetes, dipeptidyl peptidase-4, edema, safety, vildagliptin

Trend analysis of incidents involving setpoint drift in safety or safety/relief valves at U.S. LWRs

International Nuclear Information System (INIS)

Watanabe, Norio

2008-01-01

Since the beginning of the 1980's, in the United States, there have been many licensee event reports (LERs) involving setpoint drift in safety or safety/relief valves. The United States Nuclear Regulatory Commission (NRC) has issued a lot of generic communications on this issue and the industry has made efforts to resolve the issue. However, the NRC staff recently highlighted that over 70 LERs involved instances where safety or safety/relief valves failed to meet the allowed setpoint tolerance from 2001 through August 2006. In the present study, we analyzed the U.S. experience with setpoint drift in safety/relief valves (SRVs) at BWRs, pressurizer safety valves (PSVs), and main steam safety valves (MSSVs) at PWRs by reviewing approximately 90 LERs from 2000 to 2006 and examined the trend focusing on causes and setpoint deviation ranges. This study indicates that for SRVs and MSSVs, disc-seat bonding is a dominant cause of the setpoint drifting high and has a tendency to result in a relatively large deviation of the setpoint. This means that disc-seat bonding might be a safety concern from the view point of overpressure protection. For PSVs, the deviation of setpoints is generally small, although its causes are not specified in many instances. (author)

Nuclear Safety. 1997

International Nuclear Information System (INIS)

1998-01-01

A quick review of the nuclear safety at EDF may be summarized as follows: - the nuclear safety at EDF maintains at a rather good standard; - none of the incidents that took place has had any direct impact upon safety; - the availability remained good; - initiation of the floor 4 reactor generation (N4 unit - 1450 MW) ensued without major difficulties (the Civaux 1 NPP has been coupled to the power network at 24 december 1997); - the analysis of the incidents interesting from the safety point of view presents many similarities with earlier ones. Significant progress has been recorded in promoting actively and directly a safe operation by making visible, evident and concrete the exertion of the nuclear operation responsibility and its control by the hierarchy. The report develops the following chapters and subjects: 1. An overview on 1997; 1.1. The technical issues of the nuclear sector; 1.2. General performances in safety; 1.3. The main incidents; 1.4. Wastes and radiation protection; 2. Nuclear safety management; 2.1. Dynamics and results; 2.2. Ameliorations to be consolidated; 3. Other important issues in safety; 3.1. Probabilistic safety studies; 3.2. Approach for safety re-evaluation; 3.3. The network safety; 3.4. Crisis management; 3.5. The Lifetime program; 3.6. PWR; 3.7. Documentation; 3.8. Competence; 4. Safety management in the future; 4.1. An open future; 4.2. The fast neutron NPP at Creys-Malville; 4.3. Stabilization of the PWR reference frame; 4.4. Implementing the EURATOM directive regarding the radiation protection standards; 4.5. Development of biomedical research and epidemiological studies; 4.6. New regulations concerning the liquid and gaseous effluents; 5. Visions of an open future; 5.1. Alternative views upon safety ay EDF; 5.2. Safety authority; 5.3. International considerations; 5.4. What happens abroad; 5.5. References from non-nuclear domain. Four appendices are added referring to policy of safety management, policy of human factors in NPPs

A decreasing trend in fall-related hip fracture incidence in Victoria, Australia.

Science.gov (United States)

Cassell, E; Clapperton, A

2013-01-01

In Victoria, Australia, the age-standardised incidence of fall-related hip fracture hospitalisations decreased significantly by 25% over the period 1998/1999-2008/2009. Significant decreases in fall-related hip fractures were observed in males and females, across all 5-year age groups, in Australian-born and overseas-born Victorians, in all socio-economic quintiles and in community-dwelling older people. The study aim was to investigate trends in the incidence of fall-related and hip fracture hospitalisations among Victorians aged 65 years and older overall and by age, gender, country of birth, socio-economic status (SES) and location of the event (home, residential care institution, etc.) over the 11-year period 1998/1999 to 2008/2009. Annual counts and age-standardised rates for fall-related hospitalisations among people aged 65 years and older were estimated using Victorian hospital admissions data. The statistical significance of changes in trends over time were analysed using a log-linear regression model of the rate data assuming a Poisson distribution of cases. Although the age-standardised incidence of fall-related hospitalisations increased significantly by 13% (95% confidence interval [CI], 9% to 18%) in Victoria, the age-standardised incidence of fall-related hip fracture hospitalisations decreased from 600/100,000 in 1998/1999 to 467/100,000 in 2008/2009 - an estimated overall reduction of 25% (95% CI, -29% to -22%). By contrast, the age-standardised incidence of fall-related hospitalisations for fractures at other body sites either increased significantly or showed no significant change. Significant decreases in fall-related hip fractures were observed in both males and females, across all 5-year age groups, in both Australian-born and overseas-born Victorians, in all socio-economic quintiles and in community-dwelling older people but not in people living in residential care facilities. Despite the downward trend in the age-standardised incidence of

Test and assessment method of Automotive Safety Systems (SSB) particularly to monitor traffic incidents

Science.gov (United States)

Pijanowski, B.; Łukjanow, S.; Burliński, R.

2016-09-01

The rapid development of telematics, particularly mobile telephony (GSM), wireless data transmission (GPRS) and satellite positioning (GPS) noticeable in the last decade, resulted in an almost unlimited growth of the possibilities for monitoring of mobile objects. These solutions are already widely used in the so-called “Intelligent Transport Systems” - ITS and affect a significant increase for road safety. The article describes a method of testing and evaluation of Car Safety Systems (Polish abbreviation - SSB) especially for monitoring traffic incidents, such as collisions and accidents. The algorithm of SSB testing process is also presented. Tests are performed on the dynamic test bench, part of which is movable platform with car security system mounted on it. Crash tests with a rigid obstacle are carried out instead of destructive attempts to crash test of the entire vehicle which is expensive. The tested system, depending on the simulated traffic conditions, is mounted in such a position and with the use of components, indicated by the manufacturer for the automotive safety system installation in a vehicle, for which it is intended. Then, the tests and assessments are carried out.

Technical Review of Law Enforcement Standards and Guides Relative to Incident Management

Energy Technology Data Exchange (ETDEWEB)

Stenner, Robert D.; Salter, R.; Stanton, J. R.; Fisher, D.

2009-03-24

In an effort to locate potential law enforcement-related standards that support incident management, a team from the Pacific Northwest National Laboratory (PNNL) contacted representatives from the National Institute of Standards-Office of Law Enforcement Standards (NIST-OLES), National Institute of Justice (NIJ), Federal Bureau of Investigation (FBI), Secret Service, ASTM International committees that have a law enforcement focus, and a variety of individuals from local and regional law enforcement organizations. Discussions were held with various state and local law enforcement organizations. The NIJ has published several specific equipment-related law enforcement standards that were included in the review, but it appears that law enforcement program and process-type standards are developed principally by organizations that operate at the state and local level. Input is provided from state regulations and codes and from external non-government organizations (NGOs) that provide national standards. The standards that are adopted from external organizations or developed independently by state authorities are available for use by local law enforcement agencies on a voluntary basis. The extent to which they are used depends on the respective jurisdictions involved. In some instances, use of state and local disseminated standards is mandatory, but in most cases, use is voluntary. Usually, the extent to which these standards are used appears to depend on whether or not jurisdictions receive certification from a “governing” entity due to their use and compliance with the standards. In some cases, these certification-based standards are used in principal but without certification or other compliance monitoring. In general, these standards appear to be routinely used for qualification, selection for employment, and training. In these standards, the term “Peace Officer” is frequently used to refer to law enforcement personnel. This technical review of national law

Nuclear safety and regulation

International Nuclear Information System (INIS)

Kim, Hho Jung

2000-03-01

This book contains 12 chapters, which are atom and radiation, nuclear reactor and kinds of nuclear power plant, safeguard actuation system and stability evaluation for rock foundation of nuclear power plant, nuclear safety and principle, safety analysis and classification of incident, probabilistic safety assessment and major incident, nuclear safety regulation, system of nuclear safety regulation, main function and subject of safety regulation in nuclear facilities, regulation of fuel cycle and a nuclear dump site, protection of radiation and, safety supervision and, safety supervision and measurement of environmental radioactivity.

Social relations, depressive symptoms, and incident type 2 diabetes mellitus

DEFF Research Database (Denmark)

Laursen, Karin Rosenkilde; Hulman, Adam; Witte, Daniel

2017-01-01

of Ageing” (3398 men) aged 50–91 years were followed until 2012/2013, after baseline assessment of depressive symptoms, social support, relational strain, and network size. Hazard ratios (HR) for incident diabetes were calculated using Cox proportional hazard models, adjusting for relevant confounders...... behaviour, and body mass index the associations were attenuated and were no longer statistically significant. Depressive symptoms were associated with higher diabetes risk. This effect was not modified by any of the social variables. Conclusions People with stronger social relations are at lower risk...... of developing T2DM; however, this effect is largely explained by known diabetes risk factors. No evidence was found that stronger social relations reduce the association between depressive symptoms and incident T2DM....

Systematic safety evaluation of old nuclear power plants

International Nuclear Information System (INIS)

Dredemis, G.; Fourest, B.

1984-01-01

The French safety authorities have undertaken a systematic evaluation of the safety of old nuclear power plants. Apart from a complete revision of safety documents (safety analysis report, general operating rules, incident and accident procedures, internal emergency plan, quality organisation manual), this examination consisted of analysing the operating experience of systems frequently challenged and a systematic examination of the safety-related systems. This paper is based on an exercise at the Ardennes Nuclear Power Plant which has been in operation for 15 years. This paper also summarizes the main surveys and modifications relating to this power plant. (orig.)

Recent declines in cancer incidence: related to the Great Recession?

Science.gov (United States)

Gomez, Scarlett Lin; Canchola, Alison J; Nelson, David O; Keegan, Theresa H M; Clarke, Christina A; Cheng, Iona; Shariff-Marco, Salma; DeRouen, Mindy; Catalano, Ralph; Satariano, William A; Davidson-Allen, Kathleen; Glaser, Sally L

2017-02-01

In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions. Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression. Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index. Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to

Advances in safety related maintenance

International Nuclear Information System (INIS)

2000-03-01

The maintenance of systems, structures and components in nuclear power plants (NPPs) plays an important role in assuring their safe and reliable operation. Worldwide, NPP maintenance managers are seeking to reduce overall maintenance costs while maintaining or improving the levels of safety and reliability. Thus, the issue of NPP maintenance is one of the most challenging aspects of nuclear power generation. There is a direct relation between safety and maintenance. While maintenance alone (apart from modifications) will not make a plant safer than its original design, deficient maintenance may result in either an increased number of transients and challenges to safety systems or reduced reliability and availability of safety systems. The confidence that NPP structures, systems and components will function as designed is ultimately based on programmes which monitor both their reliability and availability to perform their intended safety function. Because of this, approaches to monitor the effectiveness of maintenance are also necessary. An effective maintenance programme ensures that there is a balance between the improvement in component reliability to be achieved and the loss of component function due to maintenance downtime. This implies that the safety level of an NPP should not be adversely affected by maintenance performed during operation. The nuclear industry widely acknowledges the importance of maintenance in NPP safety and operation and therefore devotes great efforts to develop techniques, methods and tools to aid in maintenance planning, follow-up and optimization, and in assuring the effectiveness of maintenance

Food safety issues in China: a case study of the dairy sector.

Science.gov (United States)

Dong, Xiaoxia; Li, Zhemin

2016-01-15

Over the past 10 years, food safety incidents have occurred frequently in China. Food safety issues in the dairy sector have increasingly gained the attention of the Chinese government and the public. The objective of this research is to explore consumption changes of dairy products of different income groups after these dairy safety incidents. The research indicates that consumers' response to dairy safety risk is very intense. Dairy consumption has experienced a declining trend in recent years, and the impact of dairy safety incidents has lasted for at least 5 years. Until 2012, dairy consumption had not yet fully recovered from this influence. Using the random effects model, this study examined the relationship between food safety incident and consumption. Overall, the results show that consumers in the low-income group are more sensitive to safety risk than those in the high-income group. It can be seen from this paper that the decrease of urban residents' dairy consumption was mainly driven by changes in fresh milk consumption, while the decline of milk powder consumption, which was affected by the melamine incident, was relatively moderate, and milk powder consumption for the high-income group even increased. © 2015 Society of Chemical Industry.

Successful remediation of patient safety incidents: a tale of two medication errors.

Science.gov (United States)

Helmchen, Lorens A; Richards, Michael R; McDonald, Timothy B

2011-01-01

As patient safety acquires strategic importance for all stakeholders in the health care delivery chain, one promising mechanism centers on the proactive disclosure of medical errors to patients. Yet, disclosure and apology alone will not be effective in fully addressing patients' concerns after an adverse event unless they are paired with a remediation component. The purpose of this study was to identify key features of successful remediation efforts that accompany the proactive disclosure of medical errors to patients. We describe and contrast two recent and very similar cases of preventable medical error involving inappropriate medication at a large tertiary-care academic medical center in the Midwestern United States. Despite their similarity, the two medical errors led to very different health outcomes and remediation trajectories for the injured patients. Although one error causing no permanent harm was mismanaged to the lasting dissatisfaction of the patient, the other resulted in the death of the patient but was remediated to the point of allowing the family to come to terms with the loss and even restored a modicum of trust in the providers' sincerity. To maximize the opportunities for successful remediation, as soon as possible after the incident, providers should pledge to injured patients and their relatives that they will assist and accompany them in their recovery as long as necessary and then follow through on their pledge. As the two case studies show, it takes training and vigilance to ensure adherence to these principles and reach an optimal outcome for patients and their relatives.

WE-G-BRA-03: Developing a Culture of Patient Safety Utilizing the National Radiation Oncology Incident Learning System (ROILS)

Energy Technology Data Exchange (ETDEWEB)

Hasson, B; Workie, D; Geraghty, C [Anne Arundel Medical Center, Annapolis, MD (United States)

2015-06-15

Purpose: To transition from an in-house incident reporting system to a ROILS standards system with the intent to develop a safety focused culture in the Department and enroll in ROILS. Methods: Since the AAPM Safety Summit (2010) several safety and reporting systems have been implemented within the Department. Specific checklists and SBAR reporting systems were introduced. However, the active learning component was lost due to reporting being viewed with distrust and possible retribution.To Facilitate introducing ROILS each leader in the Department received a copy of the ROILS participation guide. Four specific tasks were assigned to each leader: develop a reporting tree, begin the ROILS based system, facilitate adopting ROILS Terminology, and educate the staff on expectations of safety culture. Next, the ROILS questions were broken down into area specific questions (10–15) per departmental area. Excel spreadsheets were developed for each area and setup for error reporting entries. The Role of the Process Improvement Committee (PI) has been modified to review and make recommendations based on the ROILS entries. Results: The ROILS based Reporting has been in place for 4 months. To date 64 reports have been entered. Since the adoption of ROILS the reporting of incidents has increased from 2/month to 18/month on average. Three reports had a dosimetric effect on the patient (<5%) dose variance. The large majority of entries have been Characterized as Processes not followed or not sure how to Characterize, and Human Behavior. Conclusion: The majority of errors are typo’s that create confusion. The introduction of the ROILS standards has provided a platform for making changes to policies that increase patient safety. The goal is to develop a culture that sees reporting at a national level as a safe and effective way to improve our safety, and to dynamically learn from other institutions reporting.

WE-G-BRA-03: Developing a Culture of Patient Safety Utilizing the National Radiation Oncology Incident Learning System (ROILS)

International Nuclear Information System (INIS)

Hasson, B; Workie, D; Geraghty, C

2015-01-01

Purpose: To transition from an in-house incident reporting system to a ROILS standards system with the intent to develop a safety focused culture in the Department and enroll in ROILS. Methods: Since the AAPM Safety Summit (2010) several safety and reporting systems have been implemented within the Department. Specific checklists and SBAR reporting systems were introduced. However, the active learning component was lost due to reporting being viewed with distrust and possible retribution.To Facilitate introducing ROILS each leader in the Department received a copy of the ROILS participation guide. Four specific tasks were assigned to each leader: develop a reporting tree, begin the ROILS based system, facilitate adopting ROILS Terminology, and educate the staff on expectations of safety culture. Next, the ROILS questions were broken down into area specific questions (10–15) per departmental area. Excel spreadsheets were developed for each area and setup for error reporting entries. The Role of the Process Improvement Committee (PI) has been modified to review and make recommendations based on the ROILS entries. Results: The ROILS based Reporting has been in place for 4 months. To date 64 reports have been entered. Since the adoption of ROILS the reporting of incidents has increased from 2/month to 18/month on average. Three reports had a dosimetric effect on the patient (<5%) dose variance. The large majority of entries have been Characterized as Processes not followed or not sure how to Characterize, and Human Behavior. Conclusion: The majority of errors are typo’s that create confusion. The introduction of the ROILS standards has provided a platform for making changes to policies that increase patient safety. The goal is to develop a culture that sees reporting at a national level as a safe and effective way to improve our safety, and to dynamically learn from other institutions reporting

Environmental tests of a digital safety channel: An investigation of stress-related vulnerabilities of computer-based safety system

International Nuclear Information System (INIS)

Korsah, K.; Wilson, T.L.; Wood, R.; Tanaka, T.

1997-01-01

This article presents the results of environmental stress tests performed on an experimental digital safety channel (EDSC) assembled at the Oak Ridge National Laboratory as part of the Qualification of Advanced Instrumentation and Controls Systems Research program, which was sponsored by the US Nuclear Regulatory Commission. The program is expected to provide recommendations for environmental qualification of digital safety systems. The purpose of the study was to investigate potential vulnerabilities of distributed computer systems used in safety applications when subjected to environmental stressors. The EDSC assembled for the tests employs technologies and digital subsystems representative of those proposed for use in advanced light-water reactors or as retrofits in existing plants. Subsystems include computers, electrical and optical serial communication links, fiber-optic network links, analog-to-digital and digital-to-analog converters, and multiplexers. The EDSC was subjected to selected stressors that are a potential risk to digital equipment in a mild environment. The selected stressors were electromagnetic and radiofrequency interferences (EMI-RFI), temperature, humidity, and smoke exposure. The stressors were applied at levels of intensity considerably higher than the safety channel is likely to experience in a normal nuclear power plant environment. Ranges of stress were selected at a sufficiently high level to induce errors so that failure modes that are characteristic of the technologies employed could be identified. On the basis of the incidence of functional errors observed during testing, EMI-RFI, smoke exposure, and high temperature coupled with high relative humidity, in that order, were found to have the greatest impact of the stressors investigated. The most prevalent stressor-induced upsets, as well as the most severe, were found to occur during the EMI-RFI tests

Current safety issues related to research reactor operation

International Nuclear Information System (INIS)

Alcala-Ruiz, F.

2000-01-01

The Agency has included activities on research reactor safety in its Programme and Budget (P and B) since its inception in 1957. Since then, these activities have traditionally been oriented to fulfil the Agency's functions and obligations. At the end of the decade of the eighties, the Agency's Research Reactor Safety Programme (RRSP) consisted of a limited number of tasks related to the preparation of safety related publications and the conduct of safety missions to research reactor facilities. It was at the beginning of the nineties when the RRSP was upgraded and expanded as a subprogramme of the Agency's P and B. This subprogramme continued including activities related to the above subjects and started addressing an increasing number of issues related to the current situation of research reactors (in operation and shut down) around the world such as reactor ageing, modifications and decommissioning. The present paper discusses some of the above issues as recognised by various external review or advisory groups (e.g., Peer Review Groups under the Agency's Performance Programme Appraisal System (PPAS) or the standing International Nuclear Safety Advisory Group (INSAG)) and the impact of their recommendations on the preparation and implementation of the part of the Agency's P and B relating to the above subject. (author)

Estimated incident cost savings in shipping due to inspections

NARCIS (Netherlands)

Knapp, S.; Bijwaard, G.E.; Heij, C.

2011-01-01

The effectiveness of safety inspections of ships has been analysed from various angles, but until now, relatively little attention has been given to translate risk reduction into incident cost savings. This paper provides a monetary quantification of the cost savings that can be attributed to port

Incidence and host determinants of work-related rhinoconjunctivitis in apprentice pastry-makers.

Science.gov (United States)

Gautrin, D; Ghezzo, H; Infante-Rivard, C; Malo, J-L

2002-10-01

The authors recently assessed the incidence and determinants of immunologic sensitization to flour in apprentice pastry-makers. The aim of this work was to determine the incidence of work-related rhinoconjunctivitis (RC) symptoms and their determinants. For this 188/230 entrants (81.7%) were evaluated before starting exposure to flour, and again 10.8 and 16.8 months after. Questionnaires and skin prick testing to common and work-related allergens were administered at each visit. Bronchial responsiveness to methacholine was assessed at baseline in all subjects and in a subgroup at follow-up. Thirty subjects (16.1%) reported new work-related RC symptoms (13.1 per 100 person-years); in three subjects (1.6%), these were accompanied by incident skin prick test reactivity to flour-derived allergens. Skin prick test reactivity to grass pollens (OR = 3.0, 95% CI, 1.3-6.7) and to pets (OR = 2.5, 95% CI, 1.1-5.9), persistent rhinitis (OR = 3.1, 95% CI, 1.1-8.4), seasonal RC (OR = 2.5, 95% CI, 1.1-5.5), RC on contact with pets (OR = 2.3, 95% CI, 1.03-5.0) and skin prick test reactivity to wheat flour (OR = 10.5, 95% CI, 2.3-46.8), assessed at baseline, were significantly associated with the incidence of work-related RC symptoms. Multivariate logistic regression analysis yielded significant OR of skin prick test reactivity to wheat flour at baseline (OR = 7.1, 95% CI, 1.7-35.1) and persistent rhinitis (OR = 3.9, 95% CI, 1.01-9.6) for the incidence of work-related RC symptoms. Increased bronchial hyperresponsiveness at follow-up was more frequent, although not significantly, in subjects positive to skin prick test to flour on entry and reporting new work-related symptoms (3/5), than in other subjects (4/17). The incidence of work-related RC symptoms among apprentice pastry-makers was high (16.1% 30/186), while a minority (3/30) also developed skin prick test reactivity to flour. Skin prick test reactivity to wheat flour and persistent allergic rhinitis on starting exposure to

Sports Related Injuries: Incidence, Management and Prevention

OpenAIRE

Stanger, Michael A.

1982-01-01

The incidence of injury related to various sports is reviewed according to sport, area of injury, number of participants and hours per week spent at the sport. Organized sports accounted for fewer injuries than unsupervised recreational activities like tree climbing, skateboarding and running. The knee is the most commonly injured site. Sensitivity to patients' commitment to their sport is necessary: sometimes instead of rest, they can substitute a less hazardous form of exercise. Principles ...

Trends in Human Papillomavirus-Related Oropharyngeal Squamous Cell Carcinoma Incidence, Vermont 1999-2013.

Science.gov (United States)

Owosho, Adepitan A; Wiley, Rashidah; Stansbury, Tessie; Gbadamosi, Semiu O; Ryder, Jon S

2018-02-09

This study examines trends in age-adjusted incidence rates of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) in comparison to oral cavity proper squamous cell carcinoma (OSCC) in the population of Vermont from 1999 to 2013. Data on cases of oral and pharynx cancers diagnosed in Vermont between 1999 and 2013 were obtained from the Vermont cancer registry. The age-adjusted incidence rates and annual percentage change of HPV-related OPSCC and OSCC were calculated using Joinpoint trend analysis. Four hundred and thirty-one cases of HPV-related OPSCC were diagnosed from 1999 to 2013. Males constituted 83% (P < 0.0001) of the cases and the 6th decade of life marked the highest incidence. The overall age-adjusted incidence rates for HPV-related OPSCC significantly increased (from 2.39 to 3.86 per 100,000, P < 0.0001). In males, it significantly increased (from 3.62 to 6.93 per 100,000, P < 0.0001), while in females it remained stable (from 1.18 to 1.02 per 100,000, P = 0.28) during 1999-2013. The average rate of HPV-related OPSCC significantly increased by 4.4% annually (P = 0.004). In males the average rate significantly increased by 5.3% annually (P = 0.001) and in females the rate increased by 0.37% annually (P = 0.87). In contrast, age-adjusted overall incidence rates for OSCC significantly decreased (from 3.99 to 3.35 per 100,000, P = 0.018). The overall rate of OSCC decreased by 0.96% annually (P = 0.37) and the highest incidence of cases was in the 7th decade of life. In conclusion, there was an increasing trend of HPV-related OPSCC, specifically in males, and there appears to be a decreasing trend of OSCC in Vermont.

Incidence of fall-related injury among old people in mainland China.

Science.gov (United States)

Jiang, Juan; Long, Jianxiong; Ling, Weijun; Huang, Guifeng; Guo, Xiaojing; Su, Li

2015-01-01

The fall-related injuries of old people have attracted increasing attention particularly because of the continuous aging of the population. In this meta-analysis, we aim to present the incidence and sub-groups of fall-related injuries among old people in mainland China. A systematic electronic literature search was performed using four Chinese and two English databases. The selected papers were cross-sectional studies in mainland China, the participants of which were recruited based on inclusion and exclusion criteria. Data were collected through face-to-face interviews using questionnaire. The risk of bias was assessed using the Reporting of Observational Studies in Epidemiology (STROBE), and the pooled rates were estimated by DerSimonian and Laird random-effects model. A total of 40 cross-sectional studies that focused on 128,691 participants who were aged 60 years were included in this review. On the one hand, 54.95 per 1000 (overall), 45.94 per 1000 (males), 78.89 per 1000 (females), 25.95 per 1000 (60 years to 69 years), 33.03 per 1000 (70 years to 79 years), and 62.74 per 1000 (≥80 years) were estimated for the pooled incidence of fall-related injury. On the other hand, 91.72 per 1000 (overall), 94.54 per 1000 (males), and 144.93 per 1000 (females) were estimated for person-time incidence of fall-related injury. Higher incidence rates were observed in females compared with males, and these rates continued to increase along with age. A moderate level of fall-related injuries was observed among old people in mainland China. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

A preliminary analysis of incident investigation reports of an integrated steel plant: some reflection.

Science.gov (United States)

Verma, A; Maiti, J; Gaikwad, V N

2018-06-01

Large integrated steel plants employ an effective safety management system and gather a significant amount of safety-related data. This research intends to explore and visualize the rich database to find out the key factors responsible for the occurrences of incidents. The study was carried out on the data in the form of investigation reports collected from a steel plant in India. The data were processed and analysed using some of the quality management tools like Pareto chart, control chart, Ishikawa diagram, etc. Analyses showed that causes of incidents differ depending on the activities performed in a department. For example, fire/explosion and process-related incidents are more common in the departments associated with coke-making and blast furnace. Similar kind of factors were obtained, and recommendations were provided for their mitigation. Finally, the limitations of the study were discussed, and the scope of the research works was identified.

Work-related ill health in doctors working in Great Britain: incidence rates and trends.

Science.gov (United States)

Zhou, Anli Yue; Carder, Melanie; Gittins, Matthew; Agius, Raymond

2017-11-01

Background Doctors have a higher prevalence of mental ill health compared with other professional occupations but incidence rates are poorly studied. Aims To determine incidence rates and trends of work-related ill health (WRIH) and work-related mental ill health (WRMIH) in doctors compared with other professions in Great Britain. Method Incidence rates were calculated using an occupational physician reporting scheme from 2005-2010. Multilevel regression was use to study incidence rates from 2001 to 2014. Results Annual incidence rates for WRIH and WRIMH in doctors were 515 and 431 per 100 000 people employed, respectively. Higher incidence rates for WRIH and WRMIH were observed for ambulance staff and nurses, respectively. Doctors demonstrated an annual average incidence rates increase for WRIH and WRMIH, especially in women, whereas the other occupations demonstrated a decreasing or static trend. The difference in trends between the occupations was statistically significant. Conclusions WRIH and WRMIH incidence rate are increasing in doctors, especially in women, warranting further research. © The Royal College of Psychiatrists 2017.

Incidence and related factors of traffic accidents among the older population in a rapidly aging society.

Science.gov (United States)

Hong, Kimyong; Lee, Kyoung-Mu; Jang, Soong-nang

2015-01-01

To estimate the incidence of traffic accidents and find related factors among the older population. We used the cross-sectional data from the Korean Community Health Survey (KCHS), which was conducted between 2008 and 2010 and completed by 680,202 adults aged 19 years or more. And we used individuals aged 60 years or above (n=210,914). The incidence of traffic accidents was estimated as number of traffic accidents experienced per thousand per year by a number of factors including age, sex, residential area, education, employment status, and diagnosis with chronic diseases. Multiple logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for each potential risk factor adjusted for the others. Incidence of traffic accidents was estimated as 11.74/1,000 per year for men, and 7.65/1,000 per year for women. It tended to decline as age increased among women; compared to the youngest old age group (60-64), the older old groups (70-74 and 80+) were at lower risk for traffic accidents. Depressive symptom was the strongest predictor for both men (OR=1.83, 95% CI=1.28-2.61) and women (1.70, 1.23-2.35). Risk of traffic accident was greater in employed men (1.76, 1.40-2.22) and women diagnosis with arthritis (1.36, 1.06-1.75). Given that the incidence of and factors associated with traffic accidents differ between men and women, preventive strategies, such as driver education and traffic safety counseling for older adults, should be modified in accordance with these differences. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

The 5-year incidence of bleb-related infection and its risk factors after filtering surgeries with adjunctive mitomycin C: collaborative bleb-related infection incidence and treatment study 2.

Science.gov (United States)

Yamamoto, Tetsuya; Sawada, Akira; Mayama, Chihiro; Araie, Makoto; Ohkubo, Shinji; Sugiyama, Kazuhisa; Kuwayama, Yasuaki

2014-05-01

To report the 5-year incidence of bleb-related infection after mitomycin C-augmented glaucoma filtering surgery and to investigate the risk factors for infections. Prospective, observational cohort study. A total of 1098 eyes of 1098 glaucoma patients who had undergone mitomycin C-augmented trabeculectomy or trabeculectomy combined with phacoemulsification and intraocular lens implantation performed at 34 clinical centers. Patients were followed up at 6-month intervals for 5 years, with special attention given to bleb-related infections. The follow-up data were analyzed via Kaplan-Meier survival analysis and the Cox proportional hazards model. Incidence of bleb-related infection over 5 years and risk factors for infections. Of the 1098 eyes, a bleb-related infection developed in 21 eyes. Kaplan-Meier survival analysis revealed that the incidence of bleb-related infection was 2.2±0.5% (cumulative incidence ± standard error) at the 5-year follow-up for all cases, whereas it was 7.9±3.1% and 1.7±0.4% for cases with and without a history of bleb leakage, respectively (P = 0.000, log-rank test). When only eyes with a well-functioning bleb were counted, it was 3.9±1.0%. No differences were found between the trabeculectomy cases and the combined surgery cases (P = 0.398, log-rank test) or between cases with a fornix-based flap and those with a limbal-based flap (P = 0.651, log-rank test). The Cox model revealed that a history of bleb leakage and younger age were risk factors for infections. The 5-year cumulative incidence of bleb-related infection was 2.2±0.5% in eyes treated with mitomycin C-augmented trabeculectomy or trabeculectomy combined with phacoemulsification and intraocular lens implantation in our prospective, multicenter study. Bleb leakage and younger age were the main risk factors for infections. Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Test to prove the resistance to incidents of components of electric and control systems in the safety containment of nuclear power plants

International Nuclear Information System (INIS)

1982-01-01

The marginal program for proving the suitability of safety-relevant components of electric and control systems in the safety containment during a loss-of-coolant incident is described. Variant test conditions are established in the component-specific test program. Special attention has been paid to the representation of the course of pressure and temperature for the performance test of the valve room of the Nuclear Power Plant Philippsburg 2. (DG) [de

Incidence of work-related musculoskeletal pain among dentists in ...

African Journals Online (AJOL)

Dentists commonly experience musculoskeletal pain during the course of their career. This study investigated the incidence and mechanism of work-related musculoskeletal pain among practising dentists in Kwa-Zulu Natal. A descriptive survey was conducted among 94 dentists, who voluntarily consented to participate in ...

Safety related terms for advanced nuclear plants

International Nuclear Information System (INIS)

1995-12-01

The terms considered in this document are in widespread current use without a universal consensus as to their meaning. Other safety related terms are already defined in national or international codes and standards as well as in IAEA's Nuclear Safety Standards Series. Most of the terms in those codes and standards have been defined and used for regulatory purposes, generally for application to present reactor designs. There is no intention to duplicate the description of such regulatory terms here, but only to clarify the terms used for advanced nuclear plants. The following terms are described in this paper: Inherent safety characteristics, passive component, active component, passive systems, active system, fail-safe, grace period, foolproof, fault-/error-tolerant, simplified safety system, transparent safety

Safety related terms for advanced nuclear plants

International Nuclear Information System (INIS)

1991-09-01

The terms considered in this document are in widespread current use without a universal consensus as to their meaning. Other safety related terms are already defined in national or international codes and standards as well as in IAEA's Nuclear Safety Standards Series. Most of the terms in those codes and standards have been defined and used for regulatory purposes, generally for application to present reactor designs. There is no intention to duplicate the description of such regulatory terms here, but only to clarify the terms used for advanced nuclear plants. The following terms are described in this paper: Inherent safety characteristics, passive component, active component, passive systems, active system, fail-safe, grace period, foolproof, fault-/error-tolerant, simplified safety system, transparent safety

Water-Related Power Plant Curtailments: An Overview of Incidents and Contributing Factors

Energy Technology Data Exchange (ETDEWEB)

McCall, James [National Renewable Energy Lab. (NREL), Golden, CO (United States); Macknick, Jordan [National Renewable Energy Lab. (NREL), Golden, CO (United States); Macknick, Jordan [National Renewable Energy Lab. (NREL), Golden, CO (United States)

2016-12-01

Water temperatures and water availability can affect the reliable operations of power plants in the United States. Data on water-related impacts on the energy sector are not consolidated and are reported by multiple agencies. This study provides an overview of historical incidents where water resources have affected power plant operations, discusses the various data sources providing information, and creates a publicly available and open access database that contains consolidated information about water-related power plant curtailment and shut-down incidents. Power plants can be affected by water resources if incoming water temperatures are too high, water discharge temperatures are too high, or if there is not enough water available to operate. Changes in climate have the potential to exacerbate uncertainty over water resource availability and temperature. Power plant impacts from water resources include curtailment of generation, plant shut-downs, and requests for regulatory variances. In addition, many power plants have developed adaptation approaches to reducing the potential risks of water-related issues by investing in new technologies or developing and implementing plans to undertake during droughts or heatwaves. This study identifies 42 incidents of water-related power plant issues from 2000-2015, drawing from a variety of different datasets. These incidents occur throughout the U.S., and affect coal and nuclear plants that use once-through, recirculating, and pond cooling systems. In addition, water temperature violations reported to the Environmental Protection Agency are also considered, with 35 temperature violations noted from 2012-2015. In addition to providing some background information on incidents, this effort has also created an open access database on the Open Energy Information platform that contains information about water-related power plant issues that can be updated by users.

Benefits of a systematic approach to maintenance for safety and safety related systems

International Nuclear Information System (INIS)

Dam, R.F.; Ayazzudin, S.; Nickerson, J.H.

2003-01-01

For safety and safety-related systems, nuclear plants have to balance the requirements of demonstrating the reliability of each system, while maintaining the system and plant availability. With the goal of demonstrating statistical reliability, these systems have extensive testing programs, which often results in system unavailability and this can impact the plant capacity. The inputs to the process are often safety and regulatory related, resulting in programs that provide a high level of scrutiny. In such cases, the value of the application of a Systematic Assessment of Maintenance (SAM) process, such as Reliability Centered Maintenance (RCM), is questioned. The special case of Standby-Safety systems was discussed in a previous paper, where it was demonstrated how SAM techniques provide useful insight into current system performance, the impact of testing on component and system reliability, and how PSA considerations can be integrated into a comprehensive Maintenance, Surveillance, and Inspection (MSI) strategy. Although the system reliability requirements are an important part of the strategy evaluation, SAM techniques provide a systematic assessment within a broader context. Testing is only one part of an overall strategy focused on ensuring that component function is maintained through a combination of monitoring technologies (including testing), predictive techniques, and intrusive maintenance strategies. Each strategy is targeted to known component degradation mechanisms. This thinking can be extended to safety and safety related systems in general. Over the past 6 years, AECL has been working with CANDU utilities in the development and implementation of a comprehensive and integrated Plant Life Management (PLiM) program. As part of developing a comprehensive plant asset management approach, SAM techniques are used to develop a technical basis that not only works towards ensuring reliable operation of plant systems, but also facilitates the optimization and

Safety Culture: Lessons Learned from the US Chemical Safety and Hazard Investigations Board

International Nuclear Information System (INIS)

Griffon, M.

2016-01-01

The U.S. Chemical Safety and Hazard Investigation Board (CSB) investigation of the 2005 BP Texas City Refinery disaster as well as the Baker Panel Report have set the stage for the consideration of human and organizational factors and safety culture as contributing causes of major accidents in the oil and gas industry. The investigation of the BP Texas City tragedy in many ways started a shift in the way the oil and chemical industry sectors looked at process safety and the importance of human and organizational factors in improving safety. Since the BP Texas City incident the CSB has investigated several incidents, including the 2010 Macondo disaster in the Gulf of Mexico, where organizational factors and safety culture, once again, were contributing causes of the incidents. In the Texas City incident the CSB found that “while most attention was focused on the injury rate, the overall safety culture and process safety management (PSM) program had serious deficiencies.” The CSB concluded that “safety campaigns, goals, and rewards focused on improving personal safety metrics and worker behaviors rather than on process safety and management safety systems.” The Baker panel, established as a result of a CSB recommendation, did a more extensive review of BPs safety culture. The Baker panel found that ‘while BP has aspirational goals of “no accidents, no harm to people” BP has not provided effective leadership in making certain it’s management and US refining workforce understand what is expected of them regarding process safety performance.’ This may have been in part due to a misinterpretation of positive trends in personal injury rates as an indicator of effective process safety. The panel also found that “at some of its US refineries BP has not established a positive, trusting and open environment with effective lines of communication between management and the workforce, including employee representatives.” In 2010 when the CSB began to

Survey of factors associated with nurses' perception of patient safety.

Science.gov (United States)

Park, Sun A; Lee, Sui Jin; Choi, Go Un

2011-01-01

To describe the nurses' perception of hospital organization related to cultural issues on the safety of the patient and reporting medical errors. In addition, to identify factors associated with the safety of the patient and the nurse. A survey conducted during December 2008-Jannuary 2009, with 126 nurses using the Korean version of the AHRQ patient safety survey, a self-report 5-point Likert scale. Stata 10.0 was used for descriptive analysis, ANOVA (Analysis of variance) and logistic regression. National Cancer Center in Korea. The means for a working environment related to patient safety was 3.4 (±0.62). The associated factors of duration were at a present hospital, a special area, and direct contact with patients. Among organizational culture factors related to patient safety, the means were 3.81(±0.54) for the boss/manager's perception of patient safety and 3.37(±0.49) for the cooperation/collaboration between units. The frequent number of errors reported by nurses were 1~2(22.2%) times over the past 12 months. For incidence reporting, the items that the 'nurses perceived for communication among clinicians as fair' had a means of 3.23(±0.40) and the 'overall evaluation of patient safety was a good' 3.34(±0.73). The nurses' perception of cooperation and collaboration between units were associated with the direct contact between the patient and the nurse. The frequency of incidence reporting was associated with the duration of working hours at the present hospital and also their work experience. The nurses' perception of hospital environment, organizational culture, and incidence reporting was above average and mostly associated with organizational culture.

Surry Power Station, Units 1 and 2. Annual operating report: January--December 1977, volume I--introduction, summary of operating experience; changes, tests, experiments, and safety-related maintenance; effluent releases; data tabulations

International Nuclear Information System (INIS)

1978-01-01

A chronological operating sequence including shutdowns and occurrences during the year which required load reductions or resulted in non-load related incidents is given. Data are presented concerning plant and procedure changes, tests, experiments, safety related maintenance, effluent releases and personnel radiation exposures

Statement of nuclear incidents: statement of incidents at nuclear installations: third quarter 1990

International Nuclear Information System (INIS)

1990-01-01

A summary of nuclear incidents occuring at nuclear installations in Britain between 1st July 1990 and 30th September 1990 is presented here, as published by the Health and Safety Executive, two occurring at Harwell Laboratory and one at Winfrith. None of the incidents caused danger to the public, and doses to site workers were not significant. (UK)

Relating coccidioidomycosis (valley fever) incidence to soil moisture conditions.

Science.gov (United States)

Coopersmith, E J; Bell, J E; Benedict, K; Shriber, J; McCotter, O; Cosh, M H

2017-04-17

Coccidioidomycosis (also called Valley fever) is caused by a soilborne fungus, Coccidioides spp. , in arid regions of the southwestern United States. Though some who develop infections from this fungus remain asymptomatic, others develop respiratory disease as a consequence. Less commonly, severe illness and death can occur when the infection spreads to other regions of the body. Previous analyses have attempted to connect the incidence of coccidioidomycosis to broadly available climatic measurements, such as precipitation or temperature. However, with the limited availability of long-term, in situ soil moisture data sets, it has not been feasible to perform a direct analysis of the relationships between soil moisture levels and coccidioidomycosis incidence on a larger temporal and spatial scale. Utilizing in situ soil moisture gauges throughout the southwest from the U.S. Climate Reference Network and a model with which to extend those estimates, this work connects periods of higher and lower soil moisture in Arizona and California between 2002 and 2014 to the reported incidence of coccidioidomycosis. The results indicate that in both states, coccidioidomycosis incidence is related to soil moisture levels from previous summers and falls. Stated differently, a higher number of coccidioidomycosis cases are likely to be reported if previous bands of months have been atypically wet or dry, depending on the location.

Evaluating internal public relations using the critical incident technique

NARCIS (Netherlands)

Koning, K.H.; de Jong, Menno D.T.; van Vuuren, Hubrecht A.

2015-01-01

Although the critical incident technique (CIT) is one of the current methods in communication audits, little is known about the way it works. The validity of the CIT in the context of internal public relations depends on 3 assumptions: that participants can describe discrete communication events,

Radiological incidents in radiotherapy

International Nuclear Information System (INIS)

Hobzova, L.; Novotny, J.

2008-01-01

In many countries a reporting system of radiological incidents to national regulatory body exists and providers of radiotherapy treatment are obliged to report all major and/or in some countries all incidents occurring in institution. State Office for Nuclear Safety (SONS) is providing a systematic guidance for radiotherapy departments from 1997 by requiring inclusion of radiation safety problems into Quality assurance manual, which is the basic document for obtaining a license of SONS for handling with sources of ionizing radiation. For that purpose SONS also issued the recommendation 'Introduction of QA system for important sources in radiotherapy-radiological incidents' in which the radiological incidents are defined and the basic guidance for their classification (category A, B, C, D), investigation and reporting are given. At regular periods the SONS in co-operation with radiotherapy centers is making a survey of all radiological incidents occurring in institutions and it is presenting obtained information in synoptic communication (2003 Motolske dny, 2005 Novy Jicin). This presentation is another summary report of radiological incidents that occurred in our radiotherapy institutions during last 3 years. Emphasis is given not only to survey and statistics, but also to analysis of reasons of the radiological incidents and to their detection and prevention. Analyses of incidents in radiotherapy have led to a much broader understanding of incident causation. Information about the error should be shared as early as possible during or after investigation by all radiotherapy centers. Learning from incidents, errors and near misses should be a part of improvement of the QA system in institutions. Generally, it is recommended that all radiotherapy facilities should participate in the reporting, analyzing and learning system to facilitate the dissemination of knowledge throughout the whole country to prevent errors in radiotherapy.(authors)

Causal Factors and Adverse Conditions of Aviation Accidents and Incidents Related to Integrated Resilient Aircraft Control

Science.gov (United States)

Reveley, Mary S.; Briggs, Jeffrey L.; Evans, Joni K.; Sandifer, Carl E.; Jones, Sharon Monica

2010-01-01

The causal factors of accidents from the National Transportation Safety Board (NTSB) database and incidents from the Federal Aviation Administration (FAA) database associated with loss of control (LOC) were examined for four types of operations (i.e., Federal Aviation Regulation Part 121, Part 135 Scheduled, Part 135 Nonscheduled, and Part 91) for the years 1988 to 2004. In-flight LOC is a serious aviation problem. Well over half of the LOC accidents included at least one fatality (80 percent in Part 121), and roughly half of all aviation fatalities in the studied time period occurred in conjunction with LOC. An adverse events table was updated to provide focus to the technology validation strategy of the Integrated Resilient Aircraft Control (IRAC) Project. The table contains three types of adverse conditions: failure, damage, and upset. Thirteen different adverse condition subtypes were gleaned from the Aviation Safety Reporting System (ASRS), the FAA Accident and Incident database, and the NTSB database. The severity and frequency of the damage conditions, initial test conditions, and milestones references are also provided.

Quality Control Activities Related to Mechanical Maintenance of Safety Related Components at Krsko NPP

International Nuclear Information System (INIS)

Djakovic, D.

2016-01-01

For successful, safe and reliable operation of nuclear power plant, maintenance processes have to be systematically controlled and procedures for quality control of maintenance activities shall be established. This is requested by the quality assurance program, which shall provide control over activities affecting the quality of structures, systems, and components, considering their importance to safety. As a part of Quality and Nuclear Oversight Division (QNOD; SKV), the Quality Control Department (QC) provides quality control activities, which are deeply involved in maintenance processes at Krsko NPP, both on safety related and non-safety related (non-nuclear safety) components. QC activities on safety related components have to fulfil all requirements, which will enable the components to perform their intended safety functions. This paper describes quality control activities related to mechanical maintenance of safety related components at Krsko NPP and significant role of the Krsko plant QC Department in three particular maintenance cases connected with safety related components. In these three specific cases, the QC has confirmed its importance in compliance with quality assurance program and presented its significant added value in providing safe and reliable operation of the plant. The first maintenance activity was installation of nozzle check valves in the scope of a modification for improving regulation of spent fuel pit pumps. The QC Department performed receipt inspection of the valves. Using non-destructive examination methods and X-ray spectrometry, it was found out that the valve diffuser was made of improper material, which could cause progressive corrosion of the valve diffuser in borated water and consequently a loss of safety function of the valves followed by long-term consequences. The second one was the receipt inspection of containment ventilation fan coolers. The coolers were claimed and sent back to the supplier because the QC Department

Experience gained from some incidents related to the shipment of radioactive materials

International Nuclear Information System (INIS)

Devillers, C.

1989-08-01

The number of accidents occurring during shipment of dangerous materials in France varies between 200 and 250 each year. Those concerning radioactive materials represent one or two events per year. Six incidents or accidents recorded these last few years have been selected as particularly significant; they include not only events on public highways but also events on nuclear sites relevant to transportation safety. These events are summarized together with corrective actions engaged after analysis of the causes of the events. Finally, more general conclusions drawn from these abnormal events are presented from the point of view of emergency preparedness

Patient Safety Incidents and Nursing Workload.

Science.gov (United States)

Carlesi, Katya Cuadros; Padilha, Kátia Grillo; Toffoletto, Maria Cecília; Henriquez-Roldán, Carlos; Juan, Monica Andrea Canales

2017-04-06

to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile. quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation. 879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload. the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload. identificar a relação entre a carga de trabalho da equipe de enfermagem e a ocorrência de incidentes de segurança dos pacientes ligados aos cuidados de enfermagem de um hospital público no Chile. pesquisa transversal analítica quantitativa através de revisão de prontuários médicos. A estimativa da carga de trabalho em Unidade de Terapia Intensiva (UTI) foi realizada utilizando o Índice de Intervenções Terapêuticas-TISS-28 e para os outros serviços, foram utilizados os cocientes enfermeira/paciente e auxiliar de enfermagem/ paciente. Foram feitas análises univariada descritiva e multivariada. Para a análise multivariada utilizou-se análise de componentes principais e correlação de Pearson. foram analisados 879 prontuáriosclínicos de pós-alta e a carga de trabalho de 85 enfermeiros e 157

TH-C-18C-01: MRI Safety

Energy Technology Data Exchange (ETDEWEB)

Pooley, R [Mayo Clinic, Jacksonville, FL (United States); Bernstein, M; Shu, Y; Gorny, K; Felmlee, J [Mayo Clinic, Rochester, MN (United States); Panda, A [Mayo Clinic, Arizona, Scottsdale, AZ (United States)

2014-06-15

Clinical diagnostic medical physicists may be responsible for implementing and maintaining a comprehensive MR safety program. Accrediting bodies including the ACR, IAC, Radsite and The Joint Commission each include aspects of MR Safety into their imaging accreditation programs; MIPPA regulations further raise the significance of non-compliance. In addition, The Joint Commission recently announced New and Revised Diagnostic Imaging Standards for accredited health care organizations which include aspects of MR Safety. Hospitals and clinics look to the physicist to understand guidelines, regulations and accreditation requirements related to MR safety. The clinical medical physicist plays a significant role in a clinical practice by understanding the physical basis for the risks and acting as a facilitator to successfully implement a safety program that provides well-planned siting, allows for the safe scanning of certain implanted devices, and helps radiologists manage specific patient exams. The MRI scanning of specific devices will be discussed including cardiac pacemakers and neurostimulators such as deep brain stimulators. Furthermore for sites involved in MR guided interventional procedures, the MR physicist plays an essential role to establish safe practices. Creating a framework for a safe MRI practice includes the review of actual safety incidents or close calls to determine methods for prevention in the future. Learning Objectives: Understand the requirements and recommendations related to MR safety from accrediting bodies and federal regulations. Understand the Medical Physicist's roles to ensure MR Safety. Identify best practices for dealing with implanted devices, including pacemakers and deep brain stimulators. Review aspects of MR safety involved in an MR guided interventional environment. Understand the important MR safety aspects in actual safety incidents or near misses.

Incidence and progression rates of age-related maculopathy: the Rotterdam Study

NARCIS (Netherlands)

J.J.M. Willemse-Assink (Jacqueline); R. van Leeuwen (Redmer); R.C.W. Wolfs (Roger); J.R. Vingerling (Hans); Th. Stijnen (Theo); P.T.V.M. de Jong (Paulus); C.C.W. Klaver (Caroline); A. Hofman (Albert)

2001-01-01

textabstractPURPOSE: To describe the incidence rate of age-related macular degeneration (AMD) and the progression rates of early stages of age-related maculopathy (ARM), and to study the hierarchy of fundus features that determine progression. METHODS: A group of 4953 subjects

The NASA Aviation Safety Reporting System

Science.gov (United States)

1983-01-01

This is the fourteenth in a series of reports based on safety-related incidents submitted to the NASA Aviation Safety Reporting System by pilots, controllers, and, occasionally, other participants in the National Aviation System (refs. 1-13). ASRS operates under a memorandum of agreement between the National Aviation and Space Administration and the Federal Aviation Administration. The report contains, first, a special study prepared by the ASRS Office Staff, of pilot- and controller-submitted reports related to the perceived operation of the ATC system since the 1981 walkout of the controllers' labor organization. Next is a research paper analyzing incidents occurring while single-pilot crews were conducting IFR flights. A third section presents a selection of Alert Bulletins issued by ASRS, with the responses they have elicited from FAA and others concerned. Finally, the report contains a list of publications produced by ASRS with instructions for obtaining them.

Categorization of safety related motor operated valve safety significance for Ulchin Unit 3

International Nuclear Information System (INIS)

Kang, D. I.; Kim, K. Y.

2002-03-01

We performed a categorization of safety related Motor Operated Valve (MOV) safety significance for Ulchin Unit 3. The safety evaluation of MOV of domestic nuclear power plants affects the generic data used for the quantification of MOV common cause failure ( CCF) events in Ulchin Units 3 PSA. Therefore, in this study, we re-estimated the MGL(Multiple Greek Letter) parameter used for the evaluation of MOV CCF probabilities in Ulchin Units 3 Probabilistic Safety Assessment (PSA) and performed a classification of the MOV safety significance. The re-estimation results of the MGL parameter show that its value is decreased by 30% compared with the current value in Ulchin Unit 3 PSA. The categorization results of MOV safety significance using the changed value of MGL parameter shows that the number of HSSCs(High Safety Significant Components) is decreased by 54.5% compared with those using the current value of it in Ulchin Units 3 PSA

Nursing involvement in risk and patient safety management in Primary Care.

Science.gov (United States)

Coronado-Vázquez, Valle; García-López, Ana; López-Sauras, Susana; Turón Alcaine, José María

Patient safety and quality of care in a highly complex healthcare system depends not only on the actions of professionals at an individual level, but also on interaction with the environment. Proactive risk management in the system to prevent incidents and activities targeting healthcare teams is crucial in establishing a culture of safety in centres. Nurses commonly lead these safety strategies. Even though safety incidents are relatively infrequent in primary care, since the majority are preventable, actions at this level of care are highly effective. Certification of services according to ISO standard 9001:2008 focuses on risk management in the system and its use in certifying healthcare centres is helping to build a safety culture amongst professionals. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Organization of public authorities in France for the event of an incident or accident involving nuclear safety: Simulation of a nuclear crisis

International Nuclear Information System (INIS)

Cartigny, J.; Majorel, Y.

1986-01-01

The French nuclear safety regulations lay down the action to be taken in the event of an incident or accident involving the types of radiological hazard that could arise in a nuclear installation or during the transport of radioactive material. The organization established for this purpose is designed to ensure that the technical measures taken by the authorities responsible for nuclear safety, radiation protection, public order and public safety are fully effective. The Interministerial Nuclear Safety Committee (Comite interministeriel de la securite nucleaire), which reports to the Prime Minister, co-ordinates the measures taken by the public authorities. The public authorities and the operators together organize exercises designed to verify the whole complex of measures foreseen in the event of an incident or accident. These exercises, which have been carried out in a systematic manner in France for some years, are based on scenarios which are as realistic as possible and enable the following objectives to be achieved: (1) analysis of the crisis apparatus (ORSECRAD plans, individual intervention plans, information conventions); (2) uncovering gaps or inadequacies; (3) arrangements for interchange of information between the various participants whose responsibilities involve them in the emergency; and (4) allowance for the information requirements of the media and the population. The information drawn from these exercises enables the various procedures to be improved step by step. (author)

Guide on a national system for collecting, assessing and disseminating information on safety-related events in nuclear power plants

International Nuclear Information System (INIS)

1983-02-01

There is a wide spectrum of safety significance in the events that can occur during nuclear power plant operations. It is important that lessons be learned from safety-related events (hereinafter referred to as unusual events) so as to improve the safety of nuclear power plants. Hence formal procedures should be established for this purpose. The purpose of this document is to provide guidance to Member States for establishing a system (hereinafter referred to as a national system) for collecting, storing, retrieving, assessing and disseminating information on unusual events in nuclear power plants. The guidance given is based on experience gained in the use of existing national and international systems. This guide covers a national system that is part of a programme to improve nuclear power plant safety using experience gained from operating plants both within and outside the country. Implementing the recommendations in this guide would render any national system compatible with other national systems and facilitate the participation in the IAEA System for Reporting Unusual Events with Safety Significance (hereinafter referred to as the IAEA Incident Reporting System, IAEA-IRS) for more widespread dissemination of lessons learned from nuclear power plant operation

Closed medical negligence claims can drive patient safety and reduce litigation.

Science.gov (United States)

Pegalis, Steven E; Bal, B Sonny

2012-05-01

Medical liability reform is viewed by many physician groups as a means of reducing medical malpractice litigation and lowering healthcare costs. However, alternative approaches such as closed medical negligence claims data may also achieve these goals. We asked whether information gleaned from closed claims related to medical negligence could promote patient safety and reduce costs related to medical liability. Specifically, we investigated whether physician groups have examined such data to identify error patterns and to then institute specific patient treatment protocols. We searched for medical societies that have systematically examined closed medical negligence claims in their specialty to develop specific standards of physician conduct. We then searched the medical literature for published evidence of the efficacy, if any, related to the patient safety measures thus developed. Anesthesia and obstetric physician societies have successfully targeted costs and related concerns arising from medical malpractice lawsuits by using data from closed claims to develop patient safety and treatment guidelines. In both specialties, after institution of safety measures derived from closed medical negligence claims, the incidence and costs related to medical malpractice decreased and physician satisfaction improved. Tort reform, in the form of legislatively prescribed limits on damages arising from lawsuits, is not the only means of addressing the incidence and costs related to medical malpractice litigation. As the experience of anesthesia and obstetric physicians has demonstrated, safety guidelines derived from analyzing past medical malpractice litigation can achieve the same goals while also promoting patient safety.

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.

Learning from incident reports in the Australian medical imaging setting: handover and communication errors.

Science.gov (United States)

Hannaford, N; Mandel, C; Crock, C; Buckley, K; Magrabi, F; Ong, M; Allen, S; Schultz, T

2013-02-01

To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings. Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

Review article: A systematic review of emergency department incident classification frameworks.

Science.gov (United States)

Murray, Matthew; McCarthy, Sally

2017-10-11

As in any part of the hospital system, safety incidents can occur in the ED. These incidents arguably have a distinct character, as the ED involves unscheduled flows of urgent patients who require disparate services. To aid understanding of safety issues and support risk management of the ED, a comparison of published ED specific incident classification frameworks was performed. A review of emergency medicine, health management and general medical publications, using Ovid SP to interrogate Medline (1976-2016) was undertaken to identify any type of taxonomy or classification-like framework for ED related incidents. These frameworks were then analysed and compared. The review identified 17 publications containing an incident classification framework. Comparison of factors and themes making up the classification constituent elements revealed some commonality, but no overall consistency, nor evolution towards an ideal framework. Inconsistency arises from differences in the evidential basis and design methodology of classifications, with design itself being an inherently subjective process. It was not possible to identify an 'ideal' incident classification framework for ED risk management, and there is significant variation in the selection of categories used by frameworks. The variation in classification could risk an unbalanced emphasis in findings through application of a particular framework. Design of an ED specific, ideal incident classification framework should be informed by a much wider range of theories of how organisations and systems work, in addition to clinical and human factors. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Poster - 27: Incident Learning Practices in Ontario

Energy Technology Data Exchange (ETDEWEB)

Angers, Crystal; Medlam, Gaylene; Liszewski, Brian; Simniceanu, Carina [The Ottawa Hospital Cancer Centre, Mississauga Halton/Central West Regional Cancer Center, Odette Cancer Centre, Cancer Care Ontario (Canada)

2016-08-15

Purpose: The Radiation Incident and Safety Committee (RISC), established and supported by Cancer Care Ontario (CCO), is responsible for advising the Provincial Head of the Radiation Treatment program on matters relating to provincial reporting of radiation incidents with the goal of improved risk mitigation. Methods: The committee is made up of Radiation Incident Leads (RILs) with representation from each of the 14 radiation medicine programs in the province. RISC routinely meets to review recent critical incidents and to discuss provincial reporting processes and future directions of the committee. Regular face to face meetings have provided an excellent venue for sharing incident learning practices. A summary of the incident learning practices across Ontario has been compiled. Results: Almost all programs in Ontario employ an incident learning committee to review incidents and identify corrective actions or process improvements. Tools used for incident reporting include: paper based reporting, a number of different commercial products and software solutions developed in-house. A wide range of classification schema (data taxonomies) are employed, although most have been influenced by national guidance documents. The majority of clinics perform root cause analyses but utilized methodologies vary significantly. Conclusions: Most programs in Ontario employ a committee approach to incident learning. However, the reporting tools and taxonomies in use vary greatly which represents a significant challenge to provincial reporting. RISC is preparing to adopt the National System for Incident Reporting – Radiation Therapy (NSIR-RT) which will standardize incident reporting and facilitate data analyses aimed at identifying targeted improvement initiatives.

Poster - 27: Incident Learning Practices in Ontario

International Nuclear Information System (INIS)

Angers, Crystal; Medlam, Gaylene; Liszewski, Brian; Simniceanu, Carina

2016-01-01

Purpose: The Radiation Incident and Safety Committee (RISC), established and supported by Cancer Care Ontario (CCO), is responsible for advising the Provincial Head of the Radiation Treatment program on matters relating to provincial reporting of radiation incidents with the goal of improved risk mitigation. Methods: The committee is made up of Radiation Incident Leads (RILs) with representation from each of the 14 radiation medicine programs in the province. RISC routinely meets to review recent critical incidents and to discuss provincial reporting processes and future directions of the committee. Regular face to face meetings have provided an excellent venue for sharing incident learning practices. A summary of the incident learning practices across Ontario has been compiled. Results: Almost all programs in Ontario employ an incident learning committee to review incidents and identify corrective actions or process improvements. Tools used for incident reporting include: paper based reporting, a number of different commercial products and software solutions developed in-house. A wide range of classification schema (data taxonomies) are employed, although most have been influenced by national guidance documents. The majority of clinics perform root cause analyses but utilized methodologies vary significantly. Conclusions: Most programs in Ontario employ a committee approach to incident learning. However, the reporting tools and taxonomies in use vary greatly which represents a significant challenge to provincial reporting. RISC is preparing to adopt the National System for Incident Reporting – Radiation Therapy (NSIR-RT) which will standardize incident reporting and facilitate data analyses aimed at identifying targeted improvement initiatives.

Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty

DEFF Research Database (Denmark)

Aasvang, E K; Laursen, M B; Madsen, J

2018-01-01

include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA....../TKA, hindering evidence-based information and potential anaesthesia stratification. METHODS: In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American...... Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia. RESULTS: In all, 1451 patients were included for analysis...

Incidence of and breed-related risk factors for gastric dilatation-volvulus in dogs.

Science.gov (United States)

Glickman, L T; Glickman, N W; Schellenberg, D B; Raghavan, M; Lee, T L

2000-01-01

To compare incidence of and breed-related risk factors for gastric dilatation-volvulus (GDV) among 11 dog breeds (Akita, Bloodhound, Collie, Great Dane, Irish Setter, Irish Wolfhound, Newfoundland, Rottweiler, Saint Bernard, Standard Poodle, and Weimaraner). Prospective cohort study. 1,914 dogs. Owners of dogs that did not have a history of GDV were recruited at dog shows, and the dog's length and height and depth and width of the thorax and abdomen were measured. Information concerning the dogs' medical history, genetic background, personality, and diet was obtained from owners, and owners were contacted by mail and telephone at approximately 1-year intervals to determine whether dogs had developed GDV or died. Incidence of GDV based on the number of dog-years at risk was calculated for each breed, and breed-related risk factors were identified. Incidence of GDV for the 7 large (23 to 45 kg [50 to 99 lb]) and 4 giant (> 45 kg [> 99 lb]) breeds was 23 and 26 cases/1,000 dog-years at risk, respectively. Of the 105 dogs that developed GDV, 30 (28.6%) died. Incidence of GDV increased with increasing age. Cumulative incidence of GDV was 5.7% for all breeds. The only breed-specific characteristic significantly associated with a decreased incidence of GDV was an owner-perceived personality trait of happiness.

Statistical evaluation of information reported to ISI and ISKO systems from a safety point of view

International Nuclear Information System (INIS)

Alonso Pallares, C.

1993-01-01

This paper describes he event percentages made by the main systems or equipment groups being the cause of incidents or directly linked to the incident. Command and protection systems, first-circuit equipment (BPC, VPC, volume compensator) safety systems, reactor installation and electrical input systems are analyzed. More over the main causes of notifies events are stressed and those where operation experience obtained in WWER-type nuclear power plants shows that and important part of incidents related to safety are due to personnel errors

Playing it safe: Patron safety strategies and experience of violence in night-time entertainment districts.

Science.gov (United States)

Zhou, Jin; Droste, Nicolas; Curtis, Ashlee; Zinkiewicz, Lucy; Miller, Peter

2018-03-01

Incidences of violence are elevated in night-time entertainment districts. Research suggests that safety-related behavioural strategies adopted while drinking can reduce negative alcohol-related outcomes. The current study investigates the use of safety strategies and its association with experiences of violence among patrons from the general population. Patron interviews (N = 3949) were conducted in and around licenced venues in Newcastle (New South Wales) and Geelong (Victoria) during peak trading hours (Friday and Saturday, 21:00-01:00 h). Participants (mean age = 24.3, SD = 5.8; male 54.4%) were asked to report what measures, if any, they used to keep safe when drinking and whether they had been involved in a violent incident in the last 12 months. After controlling for patron demographics and location, the use of multiple (more than one) safety strategies was significantly associated with reduced odds of involvement in a violent incident (odds ratio = 0.64, 95% confidence interval 0.49-0.85, P = 0.002). Significant gender differences were observed in the number and type of safety strategies reported. Increasing the number of safety-related behaviours during drinking occasions is associated with a small but significant reduction in experiencing alcohol-related harms, such as violence. [Zhou J, Droste N, Curtis A, Zinkiewicz L, Miller P. Playing it safe: Patron safety strategies and experience of violence in night-time entertainment districts. © 2017 Australasian Professional Society on Alcohol and other Drugs.

[Attitudes towards patient safety culture in a hospital setting and related variables].

Science.gov (United States)

Mir-Abellán, Ramon; Falcó-Pegueroles, Anna; de la Puente-Martorell, María Luisa

To describe attitudes towards patient safety culture among workers in a hospital setting and determine the influence of socio-demographic and professional variables. The Hospital Survey on Patient Safety Culture was distributed among a sample of professionals and nursing assistants. A dimension was considered a strength if positive responses exceeded 75% and an opportunity for improvement if more than 50% of responses were negative. 59% (n=123) of respondents rated safety between 7 and 8. 53% (n=103) stated that they had not used the notification system to report any incidents in the previous twelve months. The strength identified was "teamwork in the unit/service" and the opportunity for improvement was "staffing". A more positive attitude was observed in outpatient services and among nursing professionals and part-time staff. This study has allowed us to determine the rating of the hospital in patient safety culture. This is vital for developing improvement strategies. Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Relational stressors as predictors for repeat aggressive and self-harming incidents in child and adolescent psychiatric inpatient settings.

Science.gov (United States)

Ulke, Christine; Klein, Annette M; von Klitzing, Kai

2014-01-01

This study examined whether relational stressors such as psychosocial stressors, the therapist's absence and a change of therapist are associated with repeat aggressive or self-harming incidents in child and adolescent psychiatric inpatient care. The study data were derived from critical incident reports and chart reviews of 107 inpatients. In multinomial regression analysis, patients with repeat aggressive or self-harming incidents were compared with patients with single incidents. Results suggested that a higher number of psychosocial stressors and a change of therapist, but not the therapist's absence are predictors for repeat aggressive and self-harming incidents. There was a high prevalence of therapist's absence during both, single and repeat, incidents. Repeat aggressive incidents were common in male children and adolescents with disruptive behavior disorders. Repeat self-harming incidents were common in adolescent females with trauma-related disorders. Patients with repeat aggressive or self-harming incidents had a higher number of abnormal intrafamilial relationships and acute life events than patients with single incidents. Interventions to reduce a change of therapist should in particular target children and adolescents with a higher number of psychosocial stressors and/or a known history of traumatic relational experiences. After a first incident, patients should have a psychosocial assessment to evaluate whether additional relational support is needed.

77 FR 6411 - Training, Qualification, and Oversight for Safety-Related Railroad Employees

Science.gov (United States)

2012-02-07

... Oversight for Safety-Related Railroad Employees AGENCY: Federal Railroad Administration (FRA), Department of... establishing minimum training standards for each category and subcategory of safety-related railroad employee... or contractor that employs one or more safety-related railroad employee to develop and submit a...

Safety-related operator actions: methodology for developing criteria

International Nuclear Information System (INIS)

Kozinsky, E.J.; Gray, L.H.; Beare, A.N.; Barks, D.B.; Gomer, F.E.

1984-03-01

This report presents a methodology for developing criteria for design evaluation of safety-related actions by nuclear power plant reactor operators, and identifies a supporting data base. It is the eleventh and final NUREG/CR Report on the Safety-Related Operator Actions Program, conducted by Oak Ridge National Laboratory for the US Nuclear Regulatory Commission. The operator performance data were developed from training simulator experiments involving operator responses to simulated scenarios of plant disturbances; from field data on events with similar scenarios; and from task analytic data. A conceptual model to integrate the data was developed and a computer simulation of the model was run, using the SAINT modeling language. Proposed is a quantitative predictive model of operator performance, the Operator Personnel Performance Simulation (OPPS) Model, driven by task requirements, information presentation, and system dynamics. The model output, a probability distribution of predicted time to correctly complete safety-related operator actions, provides data for objective evaluation of quantitative design criteria

Inroads into Equestrian Safety: Rider-Reported Factors Contributing to Horse-Related Accidents and Near Misses on Australian Roads

Directory of Open Access Journals (Sweden)

Kirrilly Thompson

2015-07-01

Full Text Available Horse riding and horse-related interactions are inherently dangerous. When they occur on public roads, the risk profile of equestrian activities is complicated by interactions with other road users. Research has identified speed, proximity, visibility, conspicuity and mutual misunderstanding as factors contributing to accidents and near misses. However, little is known about their significance or incidence in Australia. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52% reported having experienced at least one accident or near miss in the 12 months prior to the survey. Whilst our findings confirm the factors identified overseas, we also identified issues around rider misunderstanding of road rules and driver misunderstanding of rider hand signals. Of particular concern, we also found reports of potentially dangerous rider-directed road rage. We identify several areas for potential safety intervention including (1 identifying equestrians as vulnerable road users and horses as sentient decision-making vehicles (2 harmonising laws regarding passing horses, (3 mandating personal protective equipment, (4 improving road signage, (5 comprehensive data collection, (6 developing mutual understanding amongst road-users, (7 safer road design and alternative riding spaces; and (8 increasing investment in horse-related safety initiatives.

Inroads into Equestrian Safety: Rider-Reported Factors Contributing to Horse-Related Accidents and Near Misses on Australian Roads.

Science.gov (United States)

Thompson, Kirrilly; Matthews, Chelsea

2015-07-22

Horse riding and horse-related interactions are inherently dangerous. When they occur on public roads, the risk profile of equestrian activities is complicated by interactions with other road users. Research has identified speed, proximity, visibility, conspicuity and mutual misunderstanding as factors contributing to accidents and near misses. However, little is known about their significance or incidence in Australia. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52%) reported having experienced at least one accident or near miss in the 12 months prior to the survey. Whilst our findings confirm the factors identified overseas, we also identified issues around rider misunderstanding of road rules and driver misunderstanding of rider hand signals. Of particular concern, we also found reports of potentially dangerous rider-directed road rage. We identify several areas for potential safety intervention including (1) identifying equestrians as vulnerable road users and horses as sentient decision-making vehicles (2) harmonising laws regarding passing horses, (3) mandating personal protective equipment, (4) improving road signage, (5) comprehensive data collection, (6) developing mutual understanding amongst road-users, (7) safer road design and alternative riding spaces; and (8) increasing investment in horse-related safety initiatives.

Safety related events at nuclear installations in 1995

DEFF Research Database (Denmark)

Korsbech, Uffe C C

1996-01-01

Nuclear safety related events of significance at least corresponding to level 2 of the International Nuclear Event Scale are described. In 1995 only two events occured at nuclear power plants, and four events occured at plants using ionizing radiation for processing or research.......Nuclear safety related events of significance at least corresponding to level 2 of the International Nuclear Event Scale are described. In 1995 only two events occured at nuclear power plants, and four events occured at plants using ionizing radiation for processing or research....

Nuclear Safety. 1997; Surete Nucleaire. 1997

Energy Technology Data Exchange (ETDEWEB)

NONE

1998-01-19

A quick review of the nuclear safety at EDF may be summarized as follows: - the nuclear safety at EDF maintains at a rather good standard; - none of the incidents that took place has had any direct impact upon safety; - the availability remained good; - initiation of the floor 4 reactor generation (N4 unit - 1450 MW) ensued without major difficulties (the Civaux 1 NPP has been coupled to the power network at 24 december 1997); - the analysis of the incidents interesting from the safety point of view presents many similarities with earlier ones. Significant progress has been recorded in promoting actively and directly a safe operation by making visible, evident and concrete the exertion of the nuclear operation responsibility and its control by the hierarchy. The report develops the following chapters and subjects: 1. An overview on 1997; 1.1. The technical issues of the nuclear sector; 1.2. General performances in safety; 1.3. The main incidents; 1.4. Wastes and radiation protection; 2. Nuclear safety management; 2.1. Dynamics and results; 2.2. Ameliorations to be consolidated; 3. Other important issues in safety; 3.1. Probabilistic safety studies; 3.2. Approach for safety re-evaluation; 3.3. The network safety; 3.4. Crisis management; 3.5. The Lifetime program; 3.6. PWR; 3.7. Documentation; 3.8. Competence; 4. Safety management in the future; 4.1. An open future; 4.2. The fast neutron NPP at Creys-Malville; 4.3. Stabilization of the PWR reference frame; 4.4. Implementing the EURATOM directive regarding the radiation protection standards; 4.5. Development of biomedical research and epidemiological studies; 4.6. New regulations concerning the liquid and gaseous effluents; 5. Visions of an open future; 5.1. Alternative views upon safety ay EDF; 5.2. Safety authority; 5.3. International considerations; 5.4. What happens abroad; 5.5. References from non-nuclear domain. Four appendices are added referring to policy of safety management, policy of human factors in NPPs

Some Subjects and Relations According to the Act about Safety at Work

Directory of Open Access Journals (Sweden)

Marino Đ. Učur

2015-01-01

Full Text Available Complex relations in the field of safety at work could not be present without the subjects which have a specific status and specific rights, obligations and responsibilities regulated by the Occupational Health and Safety Act. This paper deals with: employer’s designated employee for the implementation of occupational health and safety activities, employees’ elected representative for health and safety protection at work, occupational medicine specialist, occupational health and safety specialist and the committee for safety at work in the relations of safety at work.

[Human papillomavirus vaccine. Efficacy and safety].

Science.gov (United States)

Bruni, Laia; Serrano, Beatriz; Bosch, Xavier; Castellsagué, Xavier

2015-05-01

Human papillomavirus (HPV) related disease remains a major cause of morbidity and mortality worldwide. Prophylactic vaccines have been recognized as the most effective intervention to control for HPV-related diseases. This article reviews the major phaseii/iii trials of the bivalent (HPVs16/18), quadrivalent (HPVs6/11/16/18), and the recently approved 9-valent vaccine (HPVs6/11/16/18/31/33/45/52/58). Large trials have been conducted showing the safety, immunogenicity and high efficacy of the bivalent and quadrivalent vaccines in the prevention of pre-invasive lesions and infection, especially when administered at young ages before exposure to HPV. Trials of the 9-valent vaccine have also demonstrated the safety, immunogenicity and efficacy of the vaccine in the prevention of infection and disease associated with the vaccine types, and its potential to substantially increase the overall prevention of HPV-related diseases. Post-licensure country reports have shown the recent and early impact of these vaccines at population level after the implementation of established HPV vaccination programs, including decreases in the prevalence of vaccine HPV types, the incidence of genital warts, and the incidence of high-grade cervical abnormalities. If widely implemented, current HPV vaccines may drastically reduce the incidence of cervical cancer and other HPV-related cancers and diseases. Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Preparation of the requirements for the safety regulation related to human and organizational factors

Energy Technology Data Exchange (ETDEWEB)

NONE

2013-08-15

The outline of the project in the current fiscal year is to investigate and analyze issues associated with Human and Organizational Factors involved in incidents of nuclear facilities, and to study and develop evaluation methods of these countermeasures. The guideline to evaluate licensee's safety culture and root cause analysis (RCA) had been developed for further improving safety on nuclear power plants at 2007. These guidelines have been used at regulatory inspection since that time. Based on experience of using these existing guidelines, some activities for improving guidelines are now under investigation; these are selecting candidate quantitative indicators for safety culture evaluation and researching good practices for RCA issues. JNES implemented human factor analysis about 18 domestic events including the Fukushima Dai-ichi nuclear power plant accident. (author)

Development of Incident Report Database for Organizational Learning

Science.gov (United States)

Otsuka, Yuichi; Abe, Tomotaka; Noguchi, Hiroshi; Makinouchi, Akifumi

The necessity of an incident reporting system has recently been increasing for hospitals. Japan Council for Quality Health Care (JCQHC) started operating a national incident reporting system to which domestic hospitals would report their incidents. However, the reporting system obtained an additional problem for the hospitals. They managed their own systems which collected reports by papers. The purposes of the reporting systems was to analyze considerable causes involved in incidents to improve the quality of patient safety management. On the contrary, the national reporting system aimed at collecting a statistical tendency of normal incidents. Simultaneously operating the two systems would be too much workload for safety managers. The load may have the managers rest only a short time for summarizing occurrences, not enough for analyzing their causes. However, to the authors' knowledge, there has not been an integrating policy of the two forms to adapt them to practical situations in patient safety management. The scope of this paper is to establish the integrated form in order to use in analyzing the causes of incidents as well as reporting for the national system. We have developed new data base system using XML + XSLT and Java Servlet. The developed system is composed of three computers; DB server , DB client and Data sending server. To investigate usability of the developed system, we conducted a monitoring test by real workers in reporting workplaces. The result of subjective evaluations by examinees was so preferable for the developed system. The results of usability test and the achievement of increasing the number of reports after the introduction can demonstrate the enough effectiveness of the developed system for supporting the activity of patient safety management.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

Energy Technology Data Exchange (ETDEWEB)

Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Harris, Kendra M. [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Ford, Eric [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Department of Radiation Oncology, University of Washington, Seattle, Washington (United States); Michalski, Jeff [Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri (United States); DeWeese, Theodore [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Santanam, Lakshmi; Mutic, Sasa; Gay, Hiram [Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri (United States)

2013-03-15

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

International Nuclear Information System (INIS)

Terezakis, Stephanie A.; Harris, Kendra M.; Ford, Eric; Michalski, Jeff; DeWeese, Theodore; Santanam, Lakshmi; Mutic, Sasa; Gay, Hiram

2013-01-01

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement

Nuclear power safety

International Nuclear Information System (INIS)

1991-11-01

This paper reports that since the Chernobyl nuclear plant accident in 1986, over 70 of the International Atomic Energy Agency's 112 member states have adopted two conventions to enhance international cooperation by providing timely notification of an accident and emergency assistance. The Agency and other international organizations also developed programs to improve nuclear power plant safety and minimize dangers from radioactive contamination. Despite meaningful improvements, some of the measures have limitations, and serious nuclear safety problems remain in the design and operation of the older, Soviet-designed nuclear power plants. The Agency's ability to select reactors under its operational safety review program is limited. Also, information on the extent and seriousness of safety-related incidents at reactors in foreign countries is not publicly available. No agreements exist among nuclear power countries to make compliance with an nuclear safety standards or principles mandatory. Currently, adherence to international safety standards or principles is voluntary and nonbinding. Some states support the concept of mandatory compliance, but others, including the United States, believe that mandatory compliance infringes on national sovereignty and that the responsibility for nuclear reactor safety remains with each nation

Reducing the Incidence of Cast-related Skin Complications in Children Treated With Cast Immobilization.

Science.gov (United States)

Difazio, Rachel L; Harris, Marie; Feldman, Lanna; Mahan, Susan T

2017-12-01

Cast immobilization remains the mainstay of pediatric orthopaedic care, yet little is known about the incidence of cast-related skin complications in children treated with cast immobilization. The purposes of this quality improvement project were to: (1) establish a baseline rate of cast-related skin complications in children treated with cast immobilization, (2) identify trends in children who experienced cast-related skin complications, (3) design an intervention aimed at decreasing the rate of cast-related skin complications, and (4) determine the effectiveness of the intervention. A prospective interrupted time-series design was used to determine the incidence of cast-related skin complications overtime and compare the rates of skin complications before and after an intervention designed to decrease the incidence of cast-related heel complications. All consecutive patients who were treated with cast immobilization from September 2012 to September 2014 were included. A cast-related skin complications data collection tool was used to capture all cast-related skin complications. A high rate of heel events was noted in our preliminary analysis and an intervention was designed to decrease the rate of cast-related skin complications, including the addition of padding during casting and respective provider education. The estimated cast-related skin events rate for all patients was 8.9 per 1000 casts applied. The rate for the total preintervention sample was 13.6 per 1000 casts which decreased to 6.6 in the postintervention sample. When examining the heel-only group, the rate was 17.1 per 1000 lower extremity casts applied in the preintervention group and 6.8 in the postintervention group. Incorporating padding to the heel of lower extremity cast was an effective intervention in decreasing the incidence of cast-related skin complications in patients treated with cast immobilization. Level II.

Impact of Safety-Related Regulations on Codeine Use in Children: A Quasi-Experimental Study Using Taiwan's National Health Insurance Research Database.

Science.gov (United States)

Lin, Chih-Wan; Wang, Ching-Huan; Huang, Wei-I; Ke, Wei-Ming; Chao, Pi-Hui; Chen, Wen-Wen; Hsiao, Fei-Yuan

2017-07-01

the incidence rates of codeine-related adverse events following the safety-related regulations.

[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.

Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

Science.gov (United States)

Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

2012-12-01

Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

78 FR 29392 - Embedded Digital Devices in Safety-Related Systems, Systems Important to Safety, and Items Relied...

Science.gov (United States)

2013-05-20

... NUCLEAR REGULATORY COMMISSION [NRC-2013-0098] Embedded Digital Devices in Safety-Related Systems, Systems Important to Safety, and Items Relied on for Safety AGENCY: Nuclear Regulatory Commission. ACTION... (NRC) is issuing for public comment Draft Regulatory Issue Summary (RIS) 2013-XX, ``Embedded Digital...

Safety-related instrumentation and control systems for nuclear power plants

International Nuclear Information System (INIS)

1984-01-01

This Safety Guide deals mainly with design requirements for those I and C systems that are important to safety but are not safety systems. The Guide is intended to expand paragraphs 3.1, 3.2 and 3.3 of the Code of Practice on Design for Safety of Nuclear Power Plants (IAEA Safety Series No.50-C-D) in the area of I and C systems important to safety and refers to them as safety-related I and C systems. It also gives guidance and enumerates requirements for multiplexing and the use of the digital computers employed in this area

Impact of the effect of economic crisis and the targeted motorcycle safety programme on motorcycle-related accidents, injuries and fatalities in Malaysia.

Science.gov (United States)

Law, T H; Umar, R S Radin; Zulkaurnain, S; Kulanthayan, S

2005-03-01

In 1997, a Motorcycle Safety Programme (MSP) was introduced to address the motorcycle-related accident problem. The MSP was specifically targeted at motorcyclists. In addition to the MSP, the recent economic recession has significantly contributed to a reduction of traffic-related incidents. This paper examines the effects of the recent economic crisis and the MSP on motorcycle-related accidents, casualties and fatalities in Malaysia. The autocorrelation integrated moving average model with transfer function was used to evaluate the overall effects of the interventions. The variables used in developing the model were gross domestic product and MSPs. The analysis found a 25% reduction in the number of motorcycle-related accidents, a 27% reduction in motorcycle casualties and a 38% reduction in motorcycle fatalities after the implementation of MSP. Findings indicate that the MSP has been one of the effective measures in reducing motorcycle safety problems in Malaysia. Apart from that, the performance of the country's economy was also found to be significant in explaining the number of motorcycle-related accidents, casualties and fatalities in Malaysia.

Incidence of nephrolithiasis in relation to environmental exposure to lead and cadmium in a population study

Energy Technology Data Exchange (ETDEWEB)

Hara, Azusa; Yang, Wen-Yi; Petit, Thibault; Zhang, Zhen-Yu; Gu, Yu-Mei; Wei, Fang-Fei; Jacobs, Lotte [Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven (Belgium); Odili, Augustine N. [Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven (Belgium); Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences University of Abuja (Nigeria); Thijs, Lutgarde [Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven (Belgium); Nawrot, Tim S. [Centre for Environmental Sciences, University of Hasselt (Belgium); Staessen, Jan A., E-mail: jan.staessen@med.kuleuven.be [Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven (Belgium); R& D Group VitaK, Maastricht University, Maastricht (Netherlands)

2016-02-15

Whether environmental exposure to nephrotoxic agents that potentially interfere with calcium homeostasis, such as lead and cadmium, contribute to the incidence of nephrolithiasis needs further clarification. We investigated the relation between nephrolithiasis incidence and environmental lead and cadmium exposure in a general population. In 1302 participants randomly recruited from a Flemish population (50.9% women; mean age, 47.9 years), we obtained baseline measurements (1985–2005) of blood lead (BPb), blood cadmium (BCd), 24-h urinary cadmium (UCd) and covariables. We monitored the incidence of kidney stones until October 6, 2014. We used Cox regression to calculate multivariable-adjusted hazard ratios for nephrolithiasis. At baseline, geometric mean BPb, BCd and UCd was 0.29 µmol/L, 9.0 nmol/L, and 8.5 nmol per 24 h, respectively. Over 11.5 years (median), nephrolithiasis occurred in 40 people. Contrasting the low and top tertiles of the distributions, the sex- and age-standardized rates of nephrolithiasis expressed as events per 1000 person-years were 0.68 vs. 3.36 (p=0.0016) for BPb, 1.80 vs. 3.28 (p=0.11) for BCd, and 1.65 vs. 2.95 (p=0.28) for UCd. In continuous analysis, with adjustments applied for sex, age, serum magnesium, and 24-h urinary volume and calcium, the hazard ratios expressing the risk associated with a doubling of the exposure biomarkers were 1.35 (p=0.015) for BPb, 1.13 (p=0.22) for BCd, and 1.23 (p=0.070) for UCd. In conclusion, our results suggest that environmental lead exposure is a risk factor for nephrolithiasis in the general population. - Highlights: • Prevalence and incidence rates of nephrolithiasis are increasing worldwide. • Lead and cadmium interfere with calcium homeostasis and might cause nephrolithiasis. • Environmental exposure to lead, not cadmium, predicts nephrolithiasis in the population. • Safety standards for environmental lead exposure need to account for nephrolithiasis. • Reducing environmental

FAO/IAEA International Symposium on Food Safety and Quality: Applications of Nuclear and Related Techniques, Vienna, Austria, 10−13 November 2014

International Nuclear Information System (INIS)

2015-01-01

Ensuring food supply integrity is of the utmost importance in relation to food security, safety and quality, consumer protection and international trade. Control measures throughout the entire food production and supply chain are essential to maintain and assure this integrity. The fundamental purpose of the controls is to support food safety and quality, because both are essential and set the foundation for food security and consumer protection as well as facilitating both domestic and international trade. The need for methods to monitor and verify food safety and quality is evidenced by the ever growing list of food product recalls and incidents such as melamine, antibiotic and dioxin contamination. Food fraud (e.g. the adulteration of beef products with horse meat), the introduction of new technologies with potential food safety implications (e.g. nanotechnology) and environmental factors (e.g. climate change) further highlight the importance of continued refinement, development and innovation to improve food control measures. Effective techniques are necessary to help assess and manage risks and protect the consumer. These include food irradiation to treat food directly, as well as other nuclear and related technologies for tracing food products in order to verify their provenance or to detect and control contaminants. To explore some of these challenges experienced by many Member States, an International Symposium on Food Safety and Quality: Applications of Nuclear and Related Techniques was held in Vienna, Austria, from 10 to 13 November 2014, under the auspices of the Food and Environmental Protection Subprogramme.

Constitution of an incident database suited to statistical analysis and examples

International Nuclear Information System (INIS)

Verpeaux, J.L.

1990-01-01

The Nuclear Protection and Safety Institute (IPSN) has set up and is developing an incidents database, which is used for the management and analysis of incidents encountered in French PWR plants. IPSN has already carried out several incidents or safety important events statistical analysis, and is improving its database on the basis of the experience it gained from this various studies. A description of the analysis method and of the developed database is presented

SU-E-T-310: Targeting Safety Improvements Through Analysis of Near-Miss Error Detection Points in An Incident Learning Database

International Nuclear Information System (INIS)

Novak, A; Nyflot, M; Sponseller, P; Howard, J; Logan, W; Holland, L; Jordan, L; Carlson, J; Ermoian, R; Kane, G; Ford, E; Zeng, J

2014-01-01

Purpose: Radiation treatment planning involves a complex workflow that can make safety improvement efforts challenging. This study utilizes an incident reporting system to identify detection points of near-miss errors, in order to guide our departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or their patterns. Methods: 1377 incidents were analyzed from a departmental nearmiss error reporting system from 3/2012–10/2013. All incidents were prospectively reviewed weekly by a multi-disciplinary team, and assigned a near-miss severity score ranging from 0–4 reflecting potential harm (no harm to critical). A 98-step consensus workflow was used to determine origination and detection points of near-miss errors, categorized into 7 major steps (patient assessment/orders, simulation, contouring/treatment planning, pre-treatment plan checks, therapist/on-treatment review, post-treatment checks, and equipment issues). Categories were compared using ANOVA. Results: In the 7-step workflow, 23% of near-miss errors were detected within the same step in the workflow, while an additional 37% were detected by the next step in the workflow, and 23% were detected two steps downstream. Errors detected further from origination were more severe (p<.001; Figure 1). The most common source of near-miss errors was treatment planning/contouring, with 476 near misses (35%). Of those 476, only 72(15%) were found before leaving treatment planning, 213(45%) were found at physics plan checks, and 191(40%) were caught at the therapist pre-treatment chart review or on portal imaging. Errors that passed through physics plan checks and were detected by therapists were more severe than other errors originating in contouring/treatment planning (1.81 vs 1.33, p<0.001). Conclusion: Errors caught by radiation treatment therapists tend to be more severe than errors caught earlier in the workflow, highlighting the importance of safety

The relative incidence of diabetes mellitus in abo/rhesus blood ...

African Journals Online (AJOL)

A total of 224 diabetics and 221 non-diabetics (control) were involved in this study, to determine the relative incidence of diabetes mellitus in ABO/Rhesus blood group. The current criteria for the diagnosis f diabetes mellitus were applied in differentiating the diabetics from the non-diabetics. Blood group, fasting blood sugar ...

Usual water-related behaviour and 'near-drowning' incidents in young adults.

Science.gov (United States)

Gulliver, Pauline; Begg, Dorothy

2005-06-01

To describe usual water-related behaviour and 'near-drowning' incidents in a cohort of young New Zealand adults. This was a cross-sectional study based on data collected as part of the Dunedin Multidisciplinary Health and Development Study, which is the study of a cohort (n = 1,037) born between 1 April 1972 and 31 March 1973 in Dunedin, New Zealand. The data analysed were collected at age 21 (1993/94). Each study member was given a face-to-face interview using a structured questionnaire. Males reported a higher level of water confidence, exposure to risk behaviours, and exposure to unsafe locations, and more 'near-drowning' incidents, than the females, but protective behaviour did not differ. Males and females who were 'confident' in the water were more likely to be exposed to unsafe water locations, and water-confident males were more likely to drink alcohol before water activities, but not boating. A total of 169 'near-drowning' incidents were reported by 141 study members (63% males). 'Near-drowning' incidents were associated with unsafe swimming environments for males (p near-drowning' incidents among a high-risk age group. Larger case-control studies are required to further investigate risk factors for 'near-drowning'. IMPLICATIONS FOR PRACTITIONERS: Further investigation is required to determine the effectiveness of providing water skills acquisition in both safe and unsafe environments on 'near-drowning' experience.

Experience on environmental qualification of safety-related components for Darlington Nuclear Generating Station

International Nuclear Information System (INIS)

Yu, A.S.; Kukreti, B.M.

1987-01-01

The proliferation of Nuclear Power Plant safety concerns has lead to increasing attention over the Environmental Qualification (EQ) of Nuclear Power Plant Safety-Related Components to provide the assurance that the safety related equipment will meet their intended functions during normal operation and postulated accident conditions. The environmental qualification of these components is also a Licensing requirement for Darlington Nuclear Generating Station. This paper provides an overview of EQ and the experience of a pilot project, in the qualification of the Main Moderator System safety-related functions for the Darlington Nuclear Generating Station currently under construction. It addresses the various phases of qualification from the identification of the EQ Safety-Related Components List, definition of location specific service conditions (normal, adbnormal and accident), safety-related functions, Environmental Qualification Assessments and finally, an EQ system summary report for the Main Moderator System. The results of the pilot project are discussed and the methodology reviewed. The paper concludes that the EQ Program developed for Darlington Nuclear Generating Station, as applied to the qualification of the Main Moderator System, contained all the elements necessary in the qualification of safety-related equipment. The approach taken in the qualification of the Moderator safety-related equipment proves to provide a sound framework for the qualification of other safety-related components in the station

Analysis of inadvertent safety injection incident at Kori unit 3 on september 6, 1990

International Nuclear Information System (INIS)

Kim, Kyun Tae; Chung, Bub Dong; Kim, In Goo; Kim, Hho Jung

1992-01-01

The inadvertent safety injection incident occurred at Kori Unit 3 on September 6, 1990 is analyzed using RELAP5/MOD3 code. The event was initiated by a failure of main feedwater control valve in one of three steam generators. The actual sequence of plant transient with the proper estimations of the operator actions is investigated in the present calculation. The calculational results are compared with the plant transient data. It is shown that the results of the plant behaviors are in good agreement with the plant data. The emergency response guidelines is assessed for the time of the SI termination and the establishment of natural circulation. The changes in the time of the SI termination do not significantly affect the overall plant behaviors, and the natural circulation is established

Tram-related trauma in Melbourne, Victoria.

Science.gov (United States)

Mitra, Biswadev; Al Jubair, Jubair; Cameron, Peter A; Gabbe, Belinda J

2010-08-01

To establish the incidence and pattern of injuries in patients presenting to hospital with tram-related injuries. Data on tram-related injury pertaining to 2001-2008 calendar years were extracted from three datasets: the population-based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram-related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P = 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P = 0.006) with pedestrians accounting for most major trauma cases. Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.

BMI and obesity incidence in relation to food patterns of Polish older people

DEFF Research Database (Denmark)

Wadolowska, L.; Danowska-Oziewicz, M.; Niedzwiedzka, E.

2006-01-01

BMI differentiation and obesity incidence in relation to food patterns of Polish older people were analysed. The research included 422 people aged 65+ years. 21 food patterns were separated by the factor analysis. On the basis of the self-reported body mass and height, the BMI and percentages...... of overweight or obese people were calculated. The increase of the BMI and overweight and obesity incidence for both sexes was unequivocally connected with eating rye. The increase of the BMI and overweight and obesity incidence depended among women on consuming pork meat and alcoholic beverages. For men...

Importance of human factors on nuclear installations safety

International Nuclear Information System (INIS)

Caruso, G.J.

1990-01-01

Actually, installations safety and, in particular the nuclear installations infer a strong incidence in human factors related to the design and operation of such installations. In general, the experience aims to that the most important accidents have happened as result of the components' failures combination and human failures in the operation of safety systems. Human factors in the nuclear installations may be divided into two areas: economy and human reliability. Human factors treatments for the safety evaluation of the nuclear installations allow to diagnose the weak points of man-machine interaction. (Author) [es

IAEA activity related to safety of nuclear desalination

International Nuclear Information System (INIS)

Gasparini, M.

2000-01-01

The nuclear plants for desalination to be built in the future will have to meet the standards of safety required for the best nuclear power plants currently in operation or being designed. The current safety approach, based on the achievement of the fundamental safety functions and defence in depth strategy, has been shown to be a sound foundation for the safety and protection of public health, and gives the plant the capability of dealing with a large variety of sequences, even beyond the design basis. The Department of Nuclear Safety of the IAEA is involved in many activities, the most important of which are to establish safety standards, and to provide various safety services and technical knowledge in many Technical Co-operation assistance projects. The department is also involved in other safety areas, notably in the field of future reactors. The IAEA is carrying out a project on the safety of new generation reactors, including those used for desalination, with the objective of fostering an exchange of information on safety approaches, promoting harmonization among Member States and contributing towards the development and revision of safety standards and guidelines for nuclear power plant design. The safety, regulatory and environmental concerns in nuclear powered desalination are those related directly to nuclear power plants, with due consideration given to the coupling process. The protection of product water against radioactive contamination must be ensured. An effective infrastructure, including appropriate training, a legal framework and regulatory regime, is a prerequisite to considering use of nuclear power for desalination plants, also in those countries with limited industrial infrastructures and little experience in nuclear technology or safety. (author)

Qualitative analysis of factors leading to clinical incidents.

Science.gov (United States)

Smith, Matthew D; Birch, Julian D; Renshaw, Mark; Ottewill, Melanie

2013-01-01

The purpose of this paper is to evaluate the common themes leading or contributing to clinical incidents in a UK teaching hospital. A root-cause analysis was conducted on patient safety incidents. Commonly occurring root causes and contributing factors were collected and correlated with incident timing and severity. In total, 65 root-cause analyses were reviewed, highlighting 202 factors implicated in the clinical incidents and 69 categories were identified. The 14 most commonly occurring causes (encountered in four incidents or more) were examined as a key-root or contributory cause. Incident timing was also analysed; common factors were encountered more frequently during out-hours--occurring as contributory rather than a key-root cause. In total, 14 commonly occurring factors were identified to direct interventions that could prevent many clinical incidents. From these, an "Organisational Safety Checklist" was developed to involve departmental level clinicians to monitor practice. This study demonstrates that comprehensively investigating incidents highlights common factors that can be addressed at a local level. Resilience against clinical incidents is low during out-of-hours periods, where factors such as lower staffing levels and poor service provision allows problems to escalate and become clinical incidents, which adds to the literature regarding out-of-hours care provision and should prove useful to those organising hospital services at departmental and management levels.

Reduced Incidence of Foot-Related Hospitalisation and Amputation amongst Persons with Diabetes in Queensland, Australia.

Directory of Open Access Journals (Sweden)

Peter A Lazzarini

Full Text Available To determine trends in the incidence of foot-related hospitalisation and amputation amongst persons with diabetes in Queensland (Australia between 2005 and 2010 that coincided with changes in state-wide ambulatory diabetic foot-related complication management.All data from cases admitted for the principal reason of diabetes foot-related hospitalisation or amputation in Queensland from 2005-2010 were obtained from the Queensland Hospital Admitted Patient Data Collection dataset. Incidence rates for foot-related hospitalisation (admissions, bed days used and amputation (total, minor, major cases amongst persons with diabetes were calculated per 1,000 person-years with diabetes (diabetes population and per 100,000 person-years (general population. Age-sex standardised incidence and age-sex adjusted Poisson regression models were also calculated for the general population.There were 4,443 amputations, 24,917 hospital admissions and 260,085 bed days used for diabetes foot-related complications in Queensland. Incidence per 1,000 person-years with diabetes decreased from 2005 to 2010: 43.0% for hospital admissions (36.6 to 20.9, 40.1% bed days (391 to 234, 40.0% total amputations (6.47 to 3.88, 45.0% major amputations (2.18 to 1.20, 37.5% minor amputations (4.29 to 2.68 (p < 0.01 respectively. Age-sex standardised incidence per 100,000 person-years in the general population also decreased from 2005 to 2010: 23.3% hospital admissions (105.1 to 80.6, 19.5% bed days (1,122 to 903, 19.3% total amputations (18.57 to 14.99, 26.4% major amputations (6.26 to 4.61, 15.7% minor amputations (12.32 to 10.38 (p < 0.01 respectively. The age-sex adjusted incidence rates per calendar year decreased in the general population (rate ratio (95% CI; hospital admissions 0.949 (0.942-0.956, bed days 0.964 (0.962-0.966, total amputations 0.962 (0.946-0.979, major amputations 0.945 (0.917-0.974, minor amputations 0.970 (0.950-0.991 (p < 0.05 respectively.There were significant

[Description of contributing factors in adverse events related to patient safety and their preventability].

Science.gov (United States)

Guerra-García, María Mercedes; Campos-Rivas, Beatriz; Sanmarful-Schwarz, Alexandra; Vírseda-Sacristán, Alicia; Dorrego-López, M Aránzazu; Charle-Crespo, Ángeles

2017-11-25

To assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. Retrospective descriptive study. Porriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. Reported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP). The variables measured were: Near Incident (NI) an occurrence with no effect or harm on the patient; Adverse Event (AE) an occurrence that affects or harms a patient. The level of harm is classified as minimal, minor, moderate, critical, and catastrophic. Preventability was classified as little evidence of being preventable, 50% preventable, and sound evidence of being preventable. percentages and Chi-squared test for qualitative variables; P<.05 with SPSS.15. SiNASP. Ethical considerations: approved by the Research Ethics Committee (2016/344). There were 166 recorded AEs (50.6% in males, and 46.4% in women. The mean age was 60.80years). Almost two-thirds 62.7% of AEs affected the patient, with 45.8% causing minimal damage, while 2.4% caused critical damages. Healthcare professionals were a contributing factor in 71.7% of the AEs, with the trend showing that poor communication and lack of protocols were related to the damage caused. Degree of preventability: 96.4%. Most AEs affected the patient, and were related to medication, diagnostic tests, and laboratory errors. The level of harm was related to communication problems, lack of, or deficient, protocols and a poor safety culture. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Safety culture as an element of contact and cooperation between utilities, research and safety authorities

International Nuclear Information System (INIS)

Hoegberg, L.

1994-01-01

The safety culture approach may simply be seen as a recognition of the close interdependence between safety and organisational processes: achievement of technical safety objectives will largely depend on the quality of the implementation processes in the organisations concerned. With a slight modification of the original INSAG formulation, SKI defines safety culture as 'a consciously formulated and implemented set of values in an organisation, which establishes that, as an overriding priority, safety issues receive the attention warranted by their significance'. In practice, a high level of safety culture means the systematic organisation and implementation of a number of activities aimed at creating a high quality defence in depth against both technical and human failures that may cause accidents. An enquiring and learning attitude is a key element of such a safety culture. For example, to prevent accidents, the organisation always needs to be reactive to incidents, by performing proper root cause analysis of both technical and organisational factors, and taking appropriate corrective actions. The long term organisational objective should be to be proactive and identify deficiencies in technology and organisation that may lead to serious incidents or, at worst, accidents and take corrective action even before actual occurrence of incidents of substantial safety significance. (author) 13 refs

Relation between water chemistry and operational safety

International Nuclear Information System (INIS)

Oliveira, M.F. de.

1991-01-01

This report describes the relation between chemistry/radiochemistry and operational safety, the technics bases for chemical and radiochemical parameters and an analysis of the Annual Report of Angra I Operation and OSRAT Mission report to 1989 in this area too. Furthermore it contains the transcription of the technical Specifications related to the chemistry and radiochemistry for Angra I. (author)

The relationship between the implementation of voluntary Five-Star occupational health and safety management system and the incidence of fatal and permanently disabling injury

DEFF Research Database (Denmark)

Hedlund, Frank Huess

2014-01-01

This paper examines two properties of the South African NOSA 5-Star System, a voluntary occupational health and safety (OHS) management system. The first property is the association between system implementation and final OHS outcomes measured as incidence rates of fatal and permanently disabling...... of their positive impact on OHS. It is clear though, that such systems cannot substitute authority enforcement activities.......This paper examines two properties of the South African NOSA 5-Star System, a voluntary occupational health and safety (OHS) management system. The first property is the association between system implementation and final OHS outcomes measured as incidence rates of fatal and permanently disabling...... injury. The second is the association between the Star audit rating and rates of serious occupational injury. Although there are many uncertainties involved the paper argues that companies committed to the NOSA system experienced fewer fatal and permanently disabling injuries than the general...

Germination of several groundnut cultivars in relation to incidence of ...

African Journals Online (AJOL)

This experiment is concerned with the germination of nine cultivars of groundnut grown in Nigeria in relation to incidence of fungi. The cultivars were NHK 5V8, NUTII 288, Samnut 10, 11, 21, 22, 23, 24 and MK 373. Germination potential was assessed after 10 days of planting in petri-dishes. Parameters such as seedling ...

A practical approach to incident prevention and mitigation

Energy Technology Data Exchange (ETDEWEB)

Smith, Kevin; Williams, Pat [KBC Advanced Technologies, Surrey (United Kingdom)

2012-07-01

Our industry has taken grand interest in improving safety in the last few decades, particularly of our process operations. This has resulted in significant improvements in overall industry safety statistics. Despite this improvement in our efforts, incidents still occur where people are injured, and these tragic incidents may even be fatal. Organizations have implemented various programs to lessen the chance of these incidents occurring, three of which are most commonly: check the box, minimize legal liability, and take a practical approach. Most often it is the practical approach that proves to influence the most improvements because it is an approach focused on the employees and the organizations business needs together. The plants that show the most safety are to no surprise run by reliable individuals. Usually, the causes of incidents stem from a failure to perform and maintain basic procedures. The answers to each plant's safety dilemmas are not found in any one program, but instead lie in understanding the anatomy of what it means to be safe. Only when that is understood can a solution be constructed and catered to the entire physiology of the problem. There are three basic tenants that need to be considered in any safety improvement strategy in order for it to be effective: capability, awareness and motivation. The third is further comprised of two factors that should not be overlooked: desire and accountability. Therefore, process safety is not driven by fancy software or rigid structure programs. It is apparent that several factors come into play when implementing safer practices. The focus of these practices should be on manufacturing employees. When improvement efforts are focused on activities and behaviors whose implementation is practical in a plant environment and address the three main areas of the anatomy, the likelihood of success increases substantially. (author)

Definitions of engineered safety features and related features for nuclear power plants

International Nuclear Information System (INIS)

1986-01-01

In light water moderated, light water cooled nuclear power plants, definitions are given of engineered safety features which are designed to suppress or prevent dispersion of radioactive materials due to damage etc. of fuel at the times of power plant failures, and of related features which are designed to actuate or operate the engineered safety features. Contents are the following: scope of engineered safety features and of related features; classification of engineered safety features (direct systems and indirect systems) and of related features (auxiliaries, emergency power supply, and protective means). (Mori, K.)

Preventing construction worker injury incidents through the management of personal stress and organizational stressors.

Science.gov (United States)

Leung, Mei-yung; Chan, Isabelle Yee Shan; Yu, Jingyu

2012-09-01

Construction workers (CWs) are positioned at the lowest level of an organization and thus have limited control over their work. For this reason, they are often deprived of their due rewards and training or sometimes are even compelled to focus on production at the expense of their own safety. These organizational stressors not only cause the CWs stress but also impair their safety behaviors. The impairment of safety behaviors is the major cause of CW injury incidents. Hence, to prevent injury incidents and enhance safety behaviors of CWs, the current study aimed to identify the impact of various organizational stressors and stress on CW safety behaviors and injury incidents. To achieve this aim, we surveyed 395 CWs. Using factor analysis, we identified five organizational stressors (unfair reward and treatment, inappropriate safety equipment, provision of training, lack of goal setting, and poor physical environment), two types of stress (emotional and physical), and safety behaviors. The results of correlation and regression analyses revealed the following: (1) injury incidents were minimized by safety behaviors but escalated by a lack of goal setting, (2) safety behaviors were maximized by moderate levels of emotional stress (i.e., an inverted U-shape relationship between these two variables) and increased in line with physical stress and inappropriate safety equipment, (3) emotional stress was positively predicted by the provision of training and inappropriate safety equipment, and (4) physical stress was predicted only by inappropriate safety equipment. Based on these results, we suggest various recommendations to construction stakeholders on how to prevent CW injury incidents. Copyright © 2011 Elsevier Ltd. All rights reserved.

A review of fatal accident incidence rate trends in fishing international

DEFF Research Database (Denmark)

Jensen, Olaf; Pétursdóttir, G; Abrahamsen, Annbjørg

2014-01-01

Background. Injury prevention in fishing is one of the most important occupational health challenges. The aim was to describe and compare internationally the trends of the fatal injury incidence rates and to discuss the impact of the implemented safety programs. Methods. The review is based...... on journal articles and reports from the maritime authorities in Poland, UK, Norway, Iceland, Denmark, US and Alaska and Canada. The original incidence rates were recalculated as per 1000 person-years for international comparison of the trends. Results. The risk of fatal accidents in fishing in the northern...... countries has been reduced by around 50% to an average of about 1 per 1000 person-years. Norway and Canada keep the lowest rates with around 0.5 and 0.25 per 1000 person-years. About half of the fatal injuries are related to vessel disasters and drowning. The safety programs seem to have good effects still...

Development and test of a classification scheme for human factors in incident reports

International Nuclear Information System (INIS)

Miller, R.; Freitag, M.; Wilpert, B.

1997-01-01

The Research Center System Safety of the Berlin University of Technology conducted a research project on the analysis of Human Factors (HF) aspects in incident reported by German Nuclear Power Plants. Based on psychological theories and empirical studies a classification scheme was developed which permits the identification of human involvement in incidents. The classification scheme was applied in an epidemiological study to a selection of more than 600 HF - relevant incidents. The results allow insights into HF related problem areas. An additional study proved that the application of the classification scheme produces results which are reliable and independent from raters. (author). 13 refs, 1 fig

Creating a Culture of Prevention in Occupational Safety and Health Practice.

Science.gov (United States)

Kim, Yangho; Park, Jungsun; Park, Mijin

2016-06-01

The incidence of occupational injuries and diseases associated with industrialization has declined markedly following developments in science and technology, such as engineering controls, protective equipment, safer machinery and processes, and greater adherence to regulations and labor inspections. Although the introduction of health and safety management systems has further decreased the incidence of occupational injuries and diseases, these systems are not effective unless accompanied by a positive safety culture in the workplace. The characteristics of work in the 21(st) century have given rise to new issues related to workers' health, such as new types of work-related disorders, noncommunicable diseases, and inequality in the availability of occupational health services. Overcoming these new and emerging issues requires a culture of prevention at the national level. The present paper addresses: (1) how to change safety cultures in both theory and practice at the level of the workplace; and (2) the role of prevention culture at the national level.

Creating a Culture of Prevention in Occupational Safety and Health Practice

Directory of Open Access Journals (Sweden)

Yangho Kim

2016-06-01

Full Text Available The incidence of occupational injuries and diseases associated with industrialization has declined markedly following developments in science and technology, such as engineering controls, protective equipment, safer machinery and processes, and greater adherence to regulations and labor inspections. Although the introduction of health and safety management systems has further decreased the incidence of occupational injuries and diseases, these systems are not effective unless accompanied by a positive safety culture in the workplace. The characteristics of work in the 21st century have given rise to new issues related to workers' health, such as new types of work-related disorders, noncommunicable diseases, and inequality in the availability of occupational health services. Overcoming these new and emerging issues requires a culture of prevention at the national level. The present paper addresses: (1 how to change safety cultures in both theory and practice at the level of the workplace; and (2 the role of prevention culture at the national level.

Safety balance: Analysis of safety systems

International Nuclear Information System (INIS)

Delage, M.; Giroux, C.

1990-12-01

Safety analysis, and particularly analysis of exploitation of NPPs is constantly affected by EDF and by the safety authorities and their methodologies. Periodic safety reports ensure that important issues are not missed on daily basis, that incidents are identified and that relevant actions are undertaken. French safety analysis method consists of three principal steps. First type of safety balance is analyzed at the normal start-up phase for each unit including the final safety report. This enables analysis of behaviour of units ten years after their licensing. Second type is periodic operational safety analysis performed during a few years. Finally, the third step consists of safety analysis of the oldest units with the aim to improve the safety standards. The three steps of safety analysis are described in this presentation in detail with the aim to present the objectives and principles. Examples of most recent exercises are included in order to illustrate the importance of such analyses

Nuclear safety regulation on nuclear safety equipment activities in relation to human and organizational factors

International Nuclear Information System (INIS)

Li Tianshu

2013-01-01

Based on years of knowledge in nuclear safety supervision and experience of investigating and dealing with violation events in repair welding of DFHM, this paper analyzes major faults in manufacturing and maintaining activities of nuclear safety equipment in relation to human and organizational factors. It could be deducted that human and organizational factors has definitely become key features in the development of nuclear energy and technology. Some feasible measures to reinforce supervision on nuclear safety equipment activities have also been proposed. (author)

Effect of occupational safety and health education received during schooling on the incidence of workplace injuries in the first 2 years of occupational life: a prospective study.

Science.gov (United States)

Boini, Stephanie; Colin, Regis; Grzebyk, Michel

2017-07-18

This study aimed to determine the effect of occupational safety and health (OSH) education during formal schooling on the incidence of workplace injuries (WIs) in young people starting their careers. We hypothesised that young people who had received OSH education during their schooling would have fewer WIs than those who received no OSH education. Secondary objectives focused on the effect of 'first aid at work' training during schooling and the conditions encountered on arrival in the company (occupational hazard information, safety training and job task training) on WI occurrence. Prospective cohort study. From 2009 to 2012, French apprentices and students at the end of their schooling and starting their careers were included. Occurrence of WIs. At the time of inclusion, information about school courses and personal characteristics were collected, and subsequent half-yearly contacts gathered information relating to work and personal data. During the 2-year follow-up, WIs were directly reported by participants and were identified by searching the French National Health Insurance Funds' databases listing compulsory WI declarations. 755 participants reported holding 1290 jobs. During follow-up, 158 WIs were identified, corresponding to an incident rate of 0.12 (0.10 to 0.14) WIs per full-time worker. Subjects who reported having received OSH education at school had two times less WIs than those declaring not having received OSH education (incidence rate ratio (IRR) 0.51, 0.00 to 0.98). A lower WI risk was observed for participants who received the 'first aid at work' training (IRR=0.68, 0.00 to 0.98). The conditions on arrival in company were not associated with WIs occurrence. In France, the OSH education provided to apprentices and students is mostly broader than the specific risks related to future jobs. Our results highlight the advantages of reinforcing this approach. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article

A Descriptive Analysis of Incidents Reported by Community Aged Care Workers.

Science.gov (United States)

Tariq, Amina; Douglas, Heather E; Smith, Cheryl; Georgiou, Andrew; Osmond, Tracey; Armour, Pauline; Westbrook, Johanna I

2015-07-01

Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care. © The Author(s) 2014.

Incidence and risk factors of infections complications related to implantable venous-access ports

International Nuclear Information System (INIS)

Shim, Ji Sue; Seo, Tae Seok; Song, Myung Gyu; Cha, In Ho; Kim, Jun Suk; Choi, Chul Won; Seo, Jae Hong; Oh, Sang Cheul

2014-01-01

The purpose of this study was to determine the incidence and risk factors of infections associated with implantable venous access ports (IVAPs.) From August 2003 through November 2011, 1747 IVAPs were placed in our interventional radiology suite. One hundred forty four IVAPs were inserted in patients with hematologic malignancy and 1603 IVAPs in patients with solid tumors. Among them, 40 ports (23 women and 17 men; mean age, 57.1 years; range, 13-83) were removed to treat port-related infections. We evaluated the incidence of port-related infection, patient characteristics, bacteriologic data, and patient progress. Univariable analyses (t test, chi-square test, and Fisher's exact test) and multiple logistic regression analyses were used to determine the risk factors for IVAP related infection. Overall, 40 (2.3%) of 1747 ports were removed for symptoms of infection with an incidence rate of 0.067 events/1000 catheter-days. According to the univariable study, the incidences of infection were seemingly higher in the patients who received the procedure during inpatient treatment (p = 0.016), the patients with hematologic malignancy (p = 0.041), and the patients receiving palliative chemotherapy (p = 0.022). From the multiple binary logistic regression, the adjusted odds ratios of infection in patients with hematologic malignancies and those receiving palliative chemotherapy were 7.769 (p = 0.001) and 4.863 (p = 0.003), respectively. Microorganisms were isolated from 26 (65%) blood samples, and two of the most causative organisms were found to be Staphylococcus (n = 10) and Candida species (n = 7). The underlying hematologic malignancy and the state of receiving palliative chemotherapy were the independent risk factors of IVAP-related infection.

Incidence and risk factors of infections complications related to implantable venous-access ports

Energy Technology Data Exchange (ETDEWEB)

Shim, Ji Sue; Seo, Tae Seok; Song, Myung Gyu; Cha, In Ho; Kim, Jun Suk; Choi, Chul Won; Seo, Jae Hong; Oh, Sang Cheul [Korea University Guro Hospital, Korea University College of Medicine, Seoul (Korea, Republic of)

2014-08-15

The purpose of this study was to determine the incidence and risk factors of infections associated with implantable venous access ports (IVAPs.) From August 2003 through November 2011, 1747 IVAPs were placed in our interventional radiology suite. One hundred forty four IVAPs were inserted in patients with hematologic malignancy and 1603 IVAPs in patients with solid tumors. Among them, 40 ports (23 women and 17 men; mean age, 57.1 years; range, 13-83) were removed to treat port-related infections. We evaluated the incidence of port-related infection, patient characteristics, bacteriologic data, and patient progress. Univariable analyses (t test, chi-square test, and Fisher's exact test) and multiple logistic regression analyses were used to determine the risk factors for IVAP related infection. Overall, 40 (2.3%) of 1747 ports were removed for symptoms of infection with an incidence rate of 0.067 events/1000 catheter-days. According to the univariable study, the incidences of infection were seemingly higher in the patients who received the procedure during inpatient treatment (p = 0.016), the patients with hematologic malignancy (p = 0.041), and the patients receiving palliative chemotherapy (p = 0.022). From the multiple binary logistic regression, the adjusted odds ratios of infection in patients with hematologic malignancies and those receiving palliative chemotherapy were 7.769 (p = 0.001) and 4.863 (p = 0.003), respectively. Microorganisms were isolated from 26 (65%) blood samples, and two of the most causative organisms were found to be Staphylococcus (n = 10) and Candida species (n = 7). The underlying hematologic malignancy and the state of receiving palliative chemotherapy were the independent risk factors of IVAP-related infection.

Evaluation of Safety Culture Implementation and Socialization Results

International Nuclear Information System (INIS)

Situmorang, Johnny

2003-01-01

Evaluation of safety culture implementation and socialization results has been perform. Evaluation is carried out with specifying safety culture indicators, namely: Meeting between management and employee, system for incidents analysis, training activities related to improving safety, meeting with regulator, contractors, surveys on behavioural attitudes, and resources allocated to promote safety culture. Evaluation is based on observation and visiting the facilities to show the compliance indicator in term of good practices in the frame of safety culture implementation. For three facilities of research reactors, Kartini Yogyakarta, TRIGA Mark II Bandung and MPR-GAS Serpong, implementation of safety culture is considered good enough and progressive. Furthermore some indicator should be considered more intensive, for example the allocated resources, self assesment based on own questionnaire in the frame of improving the safety culture implementation. (author)

Using Active Learning to Identify Health Information Technology Related Patient Safety Events.

Science.gov (United States)

Fong, Allan; Howe, Jessica L; Adams, Katharine T; Ratwani, Raj M

2017-01-18

The widespread adoption of health information technology (HIT) has led to new patient safety hazards that are often difficult to identify. Patient safety event reports, which are self-reported descriptions of safety hazards, provide one view of potential HIT-related safety events. However, identifying HIT-related reports can be challenging as they are often categorized under other more predominate clinical categories. This challenge of identifying HIT-related reports is exacerbated by the increasing number and complexity of reports which pose challenges to human annotators that must manually review reports. In this paper, we apply active learning techniques to support classification of patient safety event reports as HIT-related. We evaluated different strategies and demonstrated a 30% increase in average precision of a confirmatory sampling strategy over a baseline no active learning approach after 10 learning iterations.

Safety concerns related to modular/prefabricated building construction.

Science.gov (United States)

Fard, Maryam Mirhadi; Terouhid, Seyyed Amin; Kibert, Charles J; Hakim, Hamed

2017-03-01

The US construction industry annually experiences a relatively high rate of fatalities and injuries; therefore, improving safety practices should be considered a top priority for this industry. Modular/prefabricated building construction is a construction strategy that involves manufacturing of the whole building or some of its components off-site. This research focuses on the safety performance of the modular/prefabricated building construction sector during both manufacturing and on-site processes. This safety evaluation can serve as the starting point for improving the safety performance of this sector. Research was conducted based on Occupational Safety and Health Administration investigated accidents. The study found 125 accidents related to modular/prefabricated building construction. The details of each accident were closely examined to identify the types of injury and underlying causes. Out of 125 accidents, there were 48 fatalities (38.4%), 63 hospitalized injuries (50.4%), and 14 non-hospitalized injuries (11.2%). It was found that, the most common type of injury in modular/prefabricated construction was 'fracture', and the most common cause of accidents was 'fall'. The most frequent cause of cause (underlying and root cause) was 'unstable structure'. In this research, the accidents were also examined in terms of corresponding location, occupation, equipment as well as activities during which the accidents occurred. For improving safety records of the modular/prefabricated construction sector, this study recommends that future research be conducted on stabilizing structures during their lifting, storing, and permanent installation, securing fall protection systems during on-site assembly of components while working from heights, and developing training programmes and standards focused on modular/prefabricated construction.

Work-related driver safety: A multi-level investigation

OpenAIRE

AMANDA ROSE WARMERDAM

2017-01-01

This program of research explored the organisational determinants of work-related road traffic injury in light vehicle fleets. The landscape of risk management in workplace road safety in Australia and organisational practices that influence safe driver behaviour were investigated. Key findings included that safe driving is influenced by factors at multiple levels, including senior managers, supervisors and individual fleet drivers and workplace road safety is not well integrated within curre...

Comparative analysis of safety related site characteristics

International Nuclear Information System (INIS)

Andersson, Johan

2010-12-01

This document presents a comparative analysis of site characteristics related to long-term safety for the two candidate sites for a final repository for spent nuclear fuel in Forsmark (municipality of Oesthammar) and in Laxemar (municipality of Oskarshamn) from the point of view of site selection. The analyses are based on the updated site descriptions of Forsmark /SKB 2008a/ and Laxemar /SKB 2009a/, together with associated updated repository layouts and designs /SKB 2008b and SKB 2009b/. The basis for the comparison is thus two equally and thoroughly assessed sites. However, the analyses presented here are focussed on differences between the sites rather than evaluating them in absolute terms. The document serves as a basis for the site selection, from the perspective of long-term safety, in SKB's application for a final repository. A full evaluation of safety is made for a repository at the selected site in the safety assessment SR-Site /SKB 2011/, referred to as SR-Site main report in the following

Comparative analysis of safety related site characteristics

Energy Technology Data Exchange (ETDEWEB)

Andersson, Johan (ed.)

2010-12-15

This document presents a comparative analysis of site characteristics related to long-term safety for the two candidate sites for a final repository for spent nuclear fuel in Forsmark (municipality of Oesthammar) and in Laxemar (municipality of Oskarshamn) from the point of view of site selection. The analyses are based on the updated site descriptions of Forsmark /SKB 2008a/ and Laxemar /SKB 2009a/, together with associated updated repository layouts and designs /SKB 2008b and SKB 2009b/. The basis for the comparison is thus two equally and thoroughly assessed sites. However, the analyses presented here are focussed on differences between the sites rather than evaluating them in absolute terms. The document serves as a basis for the site selection, from the perspective of long-term safety, in SKB's application for a final repository. A full evaluation of safety is made for a repository at the selected site in the safety assessment SR-Site /SKB 2011/, referred to as SR-Site main report in the following

DART - for design basis justification and safety related information management

International Nuclear Information System (INIS)

Billington, A.; Blondiaux, P.; Boucau, J.; Cantineau, B.; Doumont, C.; Mared, A.

2000-01-01

DART is the acronym for Design Analysis Re-engineering Tool. It embodies a systematic and integrated approach to NPP safety re-assessment and configuration management, that makes use of Reverse Failure Mode and Effect Analysis in conjunction with a state-of-the-art relational database and a standardized data format, to permit long-term management of plant safety related information. The plant design is reviewed in a step-by-step logical fashion by constructing fault trees that identify the link between undesired consequences and their causes. Each failure cause identified in a fault tree is addressed by defining functional requirements, which are in turn addressed by documenting the specific manner in which the plant complies with the requirement. The database can be used to generate up-to-date plant safety related documents, including: SAR, Systems Descriptions, Technical Specifications and plant procedures. The approach is open-minded by nature and therefore is not regulatory driven, however the plant licensing basis will also be reviewed and documented within the same database such that a Regulatory Conformance Program may be integrated with the other safety documentation. This methodology can thus reconstitute the plant design bases in a comprehensive and systematic way, while allowing to uncover weaknesses in design. The original feature of the DART methodology is that it links all the safety related documents together, facilitating the evaluation of the safety impact resulting from any plant modification. Due to its capability to retrieve the basic justifications of the plant design, it is also a useful tool for training the young generation of plant personnel. The DART methodology has been developed for application to units 2, 3 and 4 at Vattenfall's Ringhals site in Sweden. It may be applied to any nuclear power plant or industrial facility where public safety is a concern. (author)

DART - for design basis justification and safety related information management

International Nuclear Information System (INIS)

Billington, A.; Blondiaux, B.; Boucau, J.; Cantineau, B.; Mared, A.

2001-01-01

DART is the acronym for Design Analysis Re-Engineering Tool. It embodies a systematic and integrated approach to NPP safety re-assessment and configuration management, that makes use of Reverse Failure Mode and Effect Analysis in conjunction with a state-of-the-art relational database and a standardized data format, to permit long-term management of plant safety related information. The plant design is reviewed in a step-by-step logical fashion by constructing fault trees that identify the link between undesired consequences and their causes. Each failure cause identified in a fault tree is addressed by defining functional requirements, which are in turn addressed by documenting the specific manner in which the plant complies with the requirement. The database can then be used to generate up-to-date plant safety related documents, including: SAR, Systems Descriptions, Technical Specifications and plant procedures. The approach is open-minded by nature and therefore is not regulatory driven, however the plant licensing basis will also be reviewed and documented within the same database such that a Regulatory Conformance Program may be integrated with the other safety documentation. This methodology can thus reconstitute the plant design bases in a comprehensive and systematic way, while allowing to uncover weaknesses in design. The original feature of the DART methodology is that it links all the safety related documents together, facilitating the evaluation of the safety impact resulting from any plant modification. Due to its capability to retrieve the basic justifications of the plant design, it is also a useful tool for training the young generation of plant personnel. The DART methodology has been developed for application to units 2, 3 and 4 at Vattenfall's Ringhals site in Sweden. It may be applied to any nuclear power plant or industrial facility where public safety is a concern. (author)

A monitor for consumer confidence in the safety of food

NARCIS (Netherlands)

Jonge, de J.

2008-01-01

Despite the fact that in the developed countries food safety standards are higher than ever, food safety incidents continue to occur frequently. The accumulation of food safety incidents might affect general consumer confidence in the safety of food. Therefore, in this thesis, the concept of general

Westinghouse Hanford Company health and safety performance report. Fourth quarter calendar year 1995

Energy Technology Data Exchange (ETDEWEB)

Lansing, K.A.

1996-03-01

WHC once again achieved significant improvement in its Overall safety performance as reflected by the injury/illness incidence rates. Incidence rates with one exception (Restricted Work Cases Only Incidence Rate) reflect sharp reductions. The increase in the Restricted Work Case Incidence Rate appears to be the result of effective case management activity and the return to work in a partial duty capacity of employees who may otherwise have been off work due to a work-related injury/illness (Page 2--9).

Westinghouse Hanford Company health and safety performance report. Fourth quarter calendar year 1995

International Nuclear Information System (INIS)

Lansing, K.A.

1996-03-01

WHC once again achieved significant improvement in its Overall safety performance as reflected by the injury/illness incidence rates. Incidence rates with one exception (Restricted Work Cases Only Incidence Rate) reflect sharp reductions. The increase in the Restricted Work Case Incidence Rate appears to be the result of effective case management activity and the return to work in a partial duty capacity of employees who may otherwise have been off work due to a work-related injury/illness (Page 2--9)

Resistance ability evaluation of safety-related structures for the simulated aircraft accident

Energy Technology Data Exchange (ETDEWEB)

Kim, Young Jin; Kim, Sung Woon; Choi, Jang Kyu [Daewoo E and C Co., Ltd., Suwon (Korea, Republic of)] (and others)

2003-03-15

Aircraft accidents on nuclear safety-related structures can cause severe damage to the safety of NPP(Nuclear Power Plant)s. To assess the safety of nuclear safety-related structures, the local damage and the dynamic response of global structures should be investigated together. This study have compared several local damage assessment formulas suggested for aircraft as an impactor, and have set the assessment system of local damage for impact-proof design of NPP containment buildings. And the local damage of nuclear safety-related structures in operation in Korea for commercial aircraft as impactor have been estimated. Impact load-time functions of the aircraft crash have been decided to assessment the safety of nuclear safety-related structures against the intentional colliding of commercial aircraft. Boeing 747 and Boeing 767 is selected as target aircraft based on the operation frequencies and weights. Comparison of the fire analysis methods showed that the method considering heat convection and radiation is adequate for the temperature analysis of the aircraft fuel fire. Finally, the study covered the analysis of the major structural drawings and design drawings with which three-dimensional finite element model analysis is expected to be performed.

Nuclear safety in France in 2001

International Nuclear Information System (INIS)

2002-01-01

This press dossier summarizes the highlights of nuclear safety in France in 2001: the point-of-view of A.C. Lacoste, director of the French authority of nuclear safety (ASN), the new organisation of the control of nuclear safety and radiation protection, the ASN's policy of transparency, the evolutions of nuclear fuels and the consistency of the fuel cycle, the necessary evolutions of the nuclear crisis management, the harmonizing work of safety approaches carried out by the WENRA association. The following documents are attached in appendixes: the decrees relative to the reformation of the nuclear control in France, the missions of the ASN, the control of nuclear safety and radiation protection in France, the organization of ASN in March 2000, the incidents notified in 2001, the inspections performed in 2001, and the list of the main French nuclear sites. (J.S.)

Materials for lithium-ion battery safety.

Science.gov (United States)

Liu, Kai; Liu, Yayuan; Lin, Dingchang; Pei, Allen; Cui, Yi

2018-06-01

Lithium-ion batteries (LIBs) are considered to be one of the most important energy storage technologies. As the energy density of batteries increases, battery safety becomes even more critical if the energy is released unintentionally. Accidents related to fires and explosions of LIBs occur frequently worldwide. Some have caused serious threats to human life and health and have led to numerous product recalls by manufacturers. These incidents are reminders that safety is a prerequisite for batteries, and serious issues need to be resolved before the future application of high-energy battery systems. This Review aims to summarize the fundamentals of the origins of LIB safety issues and highlight recent key progress in materials design to improve LIB safety. We anticipate that this Review will inspire further improvement in battery safety, especially for emerging LIBs with high-energy density.

Reduced Incidence of Foot-Related Hospitalisation and Amputation amongst Persons with Diabetes in Queensland, Australia

Science.gov (United States)

Lazzarini, Peter A.; O’Rourke, Sharon R.; Russell, Anthony W.; Derhy, Patrick H.; Kamp, Maarten C.

2015-01-01

Objective To determine trends in the incidence of foot-related hospitalisation and amputation amongst persons with diabetes in Queensland (Australia) between 2005 and 2010 that coincided with changes in state-wide ambulatory diabetic foot-related complication management. Methods All data from cases admitted for the principal reason of diabetes foot-related hospitalisation or amputation in Queensland from 2005–2010 were obtained from the Queensland Hospital Admitted Patient Data Collection dataset. Incidence rates for foot-related hospitalisation (admissions, bed days used) and amputation (total, minor, major) cases amongst persons with diabetes were calculated per 1,000 person-years with diabetes (diabetes population) and per 100,000 person-years (general population). Age-sex standardised incidence and age-sex adjusted Poisson regression models were also calculated for the general population. Results There were 4,443 amputations, 24,917 hospital admissions and 260,085 bed days used for diabetes foot-related complications in Queensland. Incidence per 1,000 person-years with diabetes decreased from 2005 to 2010: 43.0% for hospital admissions (36.6 to 20.9), 40.1% bed days (391 to 234), 40.0% total amputations (6.47 to 3.88), 45.0% major amputations (2.18 to 1.20), 37.5% minor amputations (4.29 to 2.68) (p Queensland over a recent six-year period. PMID:26098890

Safety concerns us all

CERN Multimedia

SC/GS/S

2004-01-01

In spite of periodic safety inspections, risks can never be entirely excluded. The Safety Commission invites you to inform your supervisor or Territorial Safety Officer (TSO) of any hazardous situations you may be aware of. Actions to be taken following the fall of two windowpanes A few weeks ago, a windowpane fell from the third floor of an office building, causing minor damage to a car parked outside. No one was hurt in the incident. The putty holding the window in place had gradually deteriorated over time, and strong winds undoubtedly triggered the incident. A few weeks later, a sudden draft caused a window on the fifth floor of the same building to shatter and fall to the ground below. No one was hurt and there was no material damage. The incident was caused by a fan set into the opening window: as the window slammed shut, the weight of the fan caused the glass to break. What can we do to improve safety? examine the windows of our offices and workshops and report any problems or faults, such as dam...

Software FMEA analysis for safety-related application software

International Nuclear Information System (INIS)

Park, Gee-Yong; Kim, Dong Hoon; Lee, Dong Young

2014-01-01

Highlights: • We develop a modified FMEA analysis suited for applying to software architecture. • A template for failure modes on a specific software language is established. • A detailed-level software FMEA analysis on nuclear safety software is presented. - Abstract: A method of a software safety analysis is described in this paper for safety-related application software. The target software system is a software code installed at an Automatic Test and Interface Processor (ATIP) in a digital reactor protection system (DRPS). For the ATIP software safety analysis, at first, an overall safety or hazard analysis is performed over the software architecture and modules, and then a detailed safety analysis based on the software FMEA (Failure Modes and Effect Analysis) method is applied to the ATIP program. For an efficient analysis, the software FMEA analysis is carried out based on the so-called failure-mode template extracted from the function blocks used in the function block diagram (FBD) for the ATIP software. The software safety analysis by the software FMEA analysis, being applied to the ATIP software code, which has been integrated and passed through a very rigorous system test procedure, is proven to be able to provide very valuable results (i.e., software defects) that could not be identified during various system tests

Ramp-related incidents involving wheeled mobility device users during transit bus boarding/alighting.

Science.gov (United States)

Frost, Karen L; Bertocci, Gina; Smalley, Craig

2015-05-01

To estimate the prevalence of wheeled mobility device (WhMD) ramp-related incidents while boarding/alighting a public transit bus and to determine whether the frequency of incidents is less when the ramp slope meets the proposed Americans with Disabilities Act (ADA) maximum allowable limit of ≤9.5°. Observational study. Community public transportation. WhMD users (N=414) accessing a public transit bus equipped with an instrumented ramp. Not applicable. Prevalence of boarding/alighting incidents involving WhMD users and associated ramp slopes; factors affecting incidents. A total of 4.6% (n=35) of WhMD users experienced an incident while boarding/alighting a transit bus. Significantly more incidents occurred during boarding (6.3%, n=26) than during alighting (2.2%, n=9) (Pboard/alight when the ramp slope exceeded the proposed ADA maximum allowable ramp slope was 5.1 (95% confidence interval, 2.9-9.0; P9.5° and ramps deployed to street level are associated with a higher frequency of incidents and provision of assistance. Transit agencies should increase awareness among bus operators of the effect kneeling and deployment location (street/sidewalk) have on the ramp slope. In addition, ramp components and the built environment may contribute to incidents. When prescribing WhMDs, skills training must include ascending/descending ramps at slopes encountered during boarding/alighting to ensure safe and independent access to public transit buses. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Reliability of containment and safety-related structures

International Nuclear Information System (INIS)

Nessim, M.A.

1995-09-01

A research program on Reliability of Containment and Safety-related Structures has been developed and is described in this document. This program is designed to support AECB's regulatory activities aimed at ensuring the safety of these structures. These activities include evaluating submissions by operators and requesting special assessments when necessary. The results of the proposed research will also be useful in revising and enhancing the CSA design standards for containment and safety-related structures. The process of developing the research program started with an information collection and review phase. The sources of information included C-FER's previous work in the area, various recent research publications, regulatory documents and relevant design standards, and a detailed discussion with AECB staff. The second step was to outline the process of reliability evaluation, and identify the required models and parameters. Comparison between the required and available information was used to identify gaps in the state-of-the-art, and the research program was designed to fill these gaps. The program is organized in four major topics, namely: development of an approach for reliability analysis; compilation and development of the required analysis tools; application to specific problems related to design, assessment, maintenance and testing of structures; and testing and validation. It is suggested that the program should be supported by an on-going process of communication and consultation between AECB staff and industry experts. This will lend credibility to the results and facilitate their future application. (author). 1 fig

Genetic Variants from Lipid-Related Pathways and Risk for Incident Myocardial Infarction

Science.gov (United States)

Song, Ci; Pedersen, Nancy L.; Reynolds, Chandra A.; Sabater-Lleal, Maria; Kanoni, Stavroula; Willenborg, Christina; Syvänen, Ann-Christine; Watkins, Hugh; Hamsten, Anders; Prince, Jonathan A.; Ingelsson, Erik

2013-01-01

Background Circulating lipids levels, as well as several familial lipid metabolism disorders, are strongly associated with initiation and progression of atherosclerosis and incidence of myocardial infarction (MI). Objectives We hypothesized that genetic variants associated with circulating lipid levels would also be associated with MI incidence, and have tested this in three independent samples. Setting and Subjects Using age- and sex-adjusted additive genetic models, we analyzed 554 single nucleotide polymorphisms (SNPs) in 41 candidate gene regions proposed to be involved in lipid-related pathways potentially predisposing to incidence of MI in 2,602 participants of the Swedish Twin Register (STR; 57% women). All associations with nominal P<0.01 were further investigated in the Uppsala Longitudinal Study of Adult Men (ULSAM; N = 1,142). Results In the present study, we report associations of lipid-related SNPs with incident MI in two community-based longitudinal studies with in silico replication in a meta-analysis of genome-wide association studies. Overall, there were 9 SNPs in STR with nominal P-value <0.01 that were successfully genotyped in ULSAM. rs4149313 located in ABCA1 was associated with MI incidence in both longitudinal study samples with nominal significance (hazard ratio, 1.36 and 1.40; P-value, 0.004 and 0.015 in STR and ULSAM, respectively). In silico replication supported the association of rs4149313 with coronary artery disease in an independent meta-analysis including 173,975 individuals of European descent from the CARDIoGRAMplusC4D consortium (odds ratio, 1.03; P-value, 0.048). Conclusions rs4149313 is one of the few amino acid changing variants in ABCA1 known to associate with reduced cholesterol efflux. Our results are suggestive of a weak association between this variant and the development of atherosclerosis and MI. PMID:23555974

Safety analyses for reprocessing and waste processing

International Nuclear Information System (INIS)

1983-03-01

Presentation of an incident analysis of process steps of the RP, simplified considerations concerning safety, and safety analyses of the storage and solidification facilities of the RP. A release tree method is developed and tested. An incident analysis of process steps, the evaluation of the SRL-study and safety analyses of the storage and solidification facilities of the RP are performed in particular. (DG) [de

Review of Public Safety in Viewpoint of Complex Networks

International Nuclear Information System (INIS)

Gai Chengcheng; Weng Wenguo; Yuan Hongyong

2010-01-01

In this paper, a brief review of public safety in viewpoint of complex networks is presented. Public safety incidents are divided into four categories: natural disasters, industry accidents, public health and social security, in which the complex network approaches and theories are need. We review how the complex network methods was developed and used in the studies of the three kinds of public safety incidents. The typical public safety incidents studied by the complex network methods in this paper are introduced, including the natural disaster chains, blackouts on electric power grids and epidemic spreading. Finally, we look ahead to the application prospects of the complex network theory on public safety.

Incidence of hypocalcemia in patients receiving denosumab for prevention of skeletal-related events in bone metastasis.

Science.gov (United States)

Yerram, Prakirthi; Kansagra, Shraddha; Abdelghany, Osama

2017-04-01

Background Denosumab therapy is commonly used for the prevention of skeletal-related events in patients with bone metastasis. However, a common side effect of denosumab is hypocalcemia. Objective The aim of the study is to determine the incidence of hypocalcemia in patients receiving denosumab for prevention of skeletal-related events in bone metastasis and evaluate risk factors for developing hypocalcemia. Methods This was a retrospective medication use evaluation reviewing the incidence of hypocalcemia in patients receiving outpatient denosumab for prevention of skeletal-related events at Yale-New Haven Hospital. Additionally, various risk factors were reviewed to determine their risk of developing hypocalcemia. Results As per Common Terminology Criteria for Adverse Events v4.03, of the 106 patients included in the study population, 37 (35%) patients had an incidence of hypocalcemia within 30 days of denosumab administration. Fourteen patients (13.2%) had an incidence of grade 1, 13 patients (12.3%) had an incidence of grade 2 hypocalcemia, and 7 patients (6.6%) had an incidence of grade 3 hypocalcemia. Grade 4 hypocalcemia occurred in three (2.8%) patients. Calcium supplementation did not decrease the risk of developing hypocalcemia. Patients who had one or more episodes of acute kidney insufficiency were at a higher risk of developing hypocalcemia (odds ratio = 7.5 (95% confidence interval = 1.8-36.3), p = 0.001). Conclusion This study found that the overall incidence of hypocalcemia and severe hypocalcemia was higher than reported in clinical trials. Additionally, calcium supplementation did not have an effect on incidence of hypocalcemia, while patients who experienced acute kidney insufficiency while on denosumab had a higher likelihood of developing hypocalcemia.

Driver perceptions of the safety implications of quiet electric vehicles.

Science.gov (United States)

Cocron, Peter; Krems, Josef F

2013-09-01

Previous research on the safety implications of quiet electric vehicles (EVs) has mostly focused on pedestrians' acoustic perception of EVs, and suggests that EVs are more difficult for pedestrians to hear and, therefore, compromise traffic safety. The two German field studies presented here examine the experiences of 70 drivers with low noise emissions of EVs and the drivers' long-term evaluation of the issue. Participants were surveyed via interviews and questionnaires before driving an EV for the first time, after 3 months of driving, and in the first study, again after 6 months. Based on participants' reports, a catalogue of safety-relevant incidents was composed in Study 1. The catalogue revealed that low noise-related critical incidents only rarely occur, and mostly take place in low-speed environments. The degree of hazard related to these incidents was rated as low to medium. In Study 1, driver concern for vulnerable road users as a result of low noise diminished with increasing driving experience, while perceived comfort due to this feature increased. These results were replicated in Study 2. In the second study, it was additionally examined, if drivers adjust their perceived risk of harming other road users over time. Results show that the affective assessment of risk also decreased with increased driving experience. Based on individual experience, drivers adjust their evaluation of noise-related hazards, suggesting that dangers associated with low noise emissions might be less significant than previously expected. Copyright © 2013 Elsevier Ltd. All rights reserved.

Incidence of legal blindness from age-related macular degeneration in denmark: year 2000 to 2010

DEFF Research Database (Denmark)

Bloch, Sara Brandi; Larsen, Michael; Munch, Inger Christine

2012-01-01

To report incidence rates of legal blindness from age-related macular degeneration (AMD) and other causes in Denmark from years 2000 to 2010 in the age group at risk of AMD aged 50 years and older.......To report incidence rates of legal blindness from age-related macular degeneration (AMD) and other causes in Denmark from years 2000 to 2010 in the age group at risk of AMD aged 50 years and older....

Advanced Test Reactor Safety Basis Upgrade Lessons Learned Relative to Design Basis Verification and Safety Basis Management

International Nuclear Information System (INIS)

G. L. Sharp; R. T. McCracken

2004-01-01

The Advanced Test Reactor (ATR) is a pressurized light-water reactor with a design thermal power of 250 MW. The principal function of the ATR is to provide a high neutron flux for testing reactor fuels and other materials. The reactor also provides other irradiation services such as radioisotope production. The ATR and its support facilities are located at the Test Reactor Area of the Idaho National Engineering and Environmental Laboratory (INEEL). An audit conducted by the Department of Energy's Office of Independent Oversight and Performance Assurance (DOE OA) raised concerns that design conditions at the ATR were not adequately analyzed in the safety analysis and that legacy design basis management practices had the potential to further impact safe operation of the facility.1 The concerns identified by the audit team, and issues raised during additional reviews performed by ATR safety analysts, were evaluated through the unreviewed safety question process resulting in shutdown of the ATR for more than three months while these concerns were resolved. Past management of the ATR safety basis, relative to facility design basis management and change control, led to concerns that discrepancies in the safety basis may have developed. Although not required by DOE orders or regulations, not performing design basis verification in conjunction with development of the 10 CFR 830 Subpart B upgraded safety basis allowed these potential weaknesses to be carried forward. Configuration management and a clear definition of the existing facility design basis have a direct relation to developing and maintaining a high quality safety basis which properly identifies and mitigates all hazards and postulated accident conditions. These relations and the impact of past safety basis management practices have been reviewed in order to identify lessons learned from the safety basis upgrade process and appropriate actions to resolve possible concerns with respect to the current ATR safety

Inroads into Equestrian Safety: Rider-Reported Factors Contributing to Horse-Related Accidents and Near Misses on Australian Roads

Science.gov (United States)

Thompson, Kirrilly; Matthews, Chelsea

2015-01-01

Simple Summary Riding horses on roads can be dangerous, but little is known about accidents and near misses. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52%) reported having experienced at least one accident or near miss in the 12 months prior to the survey, mostly attributed to speed. Whilst our findings confirmed factors identified overseas, we also identified issues around road rules, hand signals and road rage. This paper suggests strategies for improving the safety of horses, riders and other road users. Abstract Horse riding and horse-related interactions are inherently dangerous. When they occur on public roads, the risk profile of equestrian activities is complicated by interactions with other road users. Research has identified speed, proximity, visibility, conspicuity and mutual misunderstanding as factors contributing to accidents and near misses. However, little is known about their significance or incidence in Australia. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52%) reported having experienced at least one accident or near miss in the 12 months prior to the survey. Whilst our findings confirm the factors identified overseas, we also identified issues around rider misunderstanding of road rules and driver misunderstanding of rider hand signals. Of particular concern, we also found reports of potentially dangerous rider-directed road rage. We identify several areas for potential safety intervention including (1) identifying equestrians as vulnerable road users and horses as sentient decision-making vehicles; (2) harmonising laws regarding passing horses; (3) mandating personal protective equipment; (4) improving road signage; (5) comprehensive data collection; (6) developing mutual understanding amongst road-users; (7) safer road design and alternative riding spaces; and (8) increasing investment

Failure modes of safety-related components at fires on nuclear power plants

International Nuclear Information System (INIS)

Aaslund, A.

2000-03-01

Probabilistic assessment methods can be used to identify specific plant vulnerabilities. Application of such methods can also facilitate selection among system design alternatives available for safety enhancements. The quality of assessment results is however strongly dependent on realistic and accurate input data for modelling of system component behaviour and failure modes during conditions to be assessed. Use of conservative input data may not lead to results providing guidance on safety upgrades. Adequate input data for probabilistic assessments seems to be lacking for at least failure modes of some electrical components when exposed to a fire. This report presents an attempt to improve the situation with respect to such input data. In order to take advantage of information in existing documentation of fire incident occurrences some of the lessons learned from the fire at Browns Ferry Nuclear Power Plant on March 22, 1975 are discussed in this report. Also a summary of results from different fire tests of electrical cables presented in a fire risk analysis report is a part of the references. The failure modes used to describe fire-induced damage are 'open circuit' and 'hot short' which seems to be commonly accepted terms within the branch. Definitions of the terms are included in the report. Effects of the failure modes when occurring in some of the channels of the reactor protection system are discussed with respect to the existing design of the reactor protection system at Ringhals 2 nuclear power unit. Experiences from the Browns Ferry fire and results from fire tests of electrical cables indicate that the dominating failure mode for electrical cables is 'open circuit'. An 'open circuit' failure leads to circuit disjunction and loss of continuity. The circuit can no longer transmit its signal or power. When affecting channels of the reactor protection system an 'open circuit' failure can cause extensive inadvertent actions of safety related equipment

Climate and climate-related issues for the safety assessment SR-Can

International Nuclear Information System (INIS)

Naeslund, Jens-Ove

2006-11-01

The purpose of this report is to document current scientific knowledge of the climate-related conditions and processes relevant to the long-term safety of a KBS-3 repository to a level required for an adequate treatment in the safety assessment SR-Can. The report also includes a concise background description of the climate system. The report includes three main chapters: A description of the climate system (Chapter 2); Identification and discussion of climate-related issues (Chapter 3); and, A description of the evolution of climate-related conditions for the safety assessment (Chapter 4). Chapter 2 includes an overview of present knowledge of the Earth climate system and the climate conditions that can be expected to occur in Sweden on a 100,000 year time perspective. Based on this, climate-related issues relevant for the long-term safety of a KBS-3 repository are identified. These are documented in Chapter 3 'Climate-related issues' to a level required for an adequate treatment in the safety assessment. Finally, in Chapter 4, 'Evolution of climate-related conditions for the safety assessment' an evolution for a 120,000 year period is presented, including discussions of identified climate-related issues of importance for repository safety. The documentation is from a scientific point of view not exhaustive, since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of a safety assessment. As further described in the SR-Can Main Report and in the Features Events and Processes report, the content of the present report has been audited by comparison with FEP databases compiled in other assessment projects. This report follows as far as possible the template for documentation of processes regarded as internal to the repository system. However, the term processes is not used in this report, instead the term issue has been used. Each issue includes a set of processes together resulting in the behaviour of a

Climate and climate-related issues for the safety assessment SR-Can

Energy Technology Data Exchange (ETDEWEB)

Naeslund, Jens-Ove (comp.)

2006-11-15

The purpose of this report is to document current scientific knowledge of the climate-related conditions and processes relevant to the long-term safety of a KBS-3 repository to a level required for an adequate treatment in the safety assessment SR-Can. The report also includes a concise background description of the climate system. The report includes three main chapters: A description of the climate system (Chapter 2); Identification and discussion of climate-related issues (Chapter 3); and, A description of the evolution of climate-related conditions for the safety assessment (Chapter 4). Chapter 2 includes an overview of present knowledge of the Earth climate system and the climate conditions that can be expected to occur in Sweden on a 100,000 year time perspective. Based on this, climate-related issues relevant for the long-term safety of a KBS-3 repository are identified. These are documented in Chapter 3 'Climate-related issues' to a level required for an adequate treatment in the safety assessment. Finally, in Chapter 4, 'Evolution of climate-related conditions for the safety assessment' an evolution for a 120,000 year period is presented, including discussions of identified climate-related issues of importance for repository safety. The documentation is from a scientific point of view not exhaustive, since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of a safety assessment. As further described in the SR-Can Main Report and in the Features Events and Processes report, the content of the present report has been audited by comparison with FEP databases compiled in other assessment projects. This report follows as far as possible the template for documentation of processes regarded as internal to the repository system. However, the term processes is not used in this report, instead the term issue has been used. Each issue includes a set of processes together resulting in the

Fundamentals of a graded approach to safety-related equipment setpoints

International Nuclear Information System (INIS)

Woodruff, B.A.; Cash, J.S. Jr.; Bockhorst, R.M.

1993-01-01

The concept of using a graded approach to reconstitute instrument setpoints associated with safety-related equipment was first presented to the industry by the U.S. Nuclear Regulatory Commission during the 1992 ISA/POWID Symposium in Kansas City, Missouri. The graded approach establishes that the manner in which a utility analyzes and documents setpoints is related to each setpoint's relative importance to safety. This allows a utility to develop separate requirements for setpoints of varying levels of safety significance. A graded approach to setpoints is a viable strategy that minimizes extraneous effort expended in resolving difficult issues that arise when formal setpoint methodology is applied blindly to all setpoints. Close examination of setpoint methodology reveals that the application of a graded approach is fundamentally dependent on the analytical basis of each individual setpoint

Study on some safety-related aspects of tyre use

NARCIS (Netherlands)

Jansen, S.T.H.; Schmeitz, A.J.C.; Maas, S.; Rodarius, C.; Akkermans, L.

2014-01-01

The tyre is a key component that affects road safety. The European commission has posted a tender aimed to study what measures on a European level can be taken in relation to the use of tyres to improve road safety. The results of this study, supported by a cost benefit analyses and carried out by

Road safety: serious injuries remain a major unsolved problem.

Science.gov (United States)

Beck, Ben; Cameron, Peter A; Fitzgerald, Mark C; Judson, Rodney T; Teague, Warwick; Lyons, Ronan A; Gabbe, Belinda J

2017-09-18

To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury. A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type. There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99-1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97-1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97-1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05-1.10; P road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups. As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.

Incidence of fall-related injuries in Iran: A population-based nationwide study.

Science.gov (United States)

Saadat, Soheil; Hafezi-Nejad, Nima; Ekhtiari, Yalda Soleiman; Rahimi-Movaghar, Afarin; Motevalian, Abbas; Amin-Esmaeili, Masoumeh; Sharifi, Vandad; Hajebi, Ahmad; Radgoodarzi, Reza; Hefazi, Mitra; Eslami, Vahid; Karimi, Hasti; Mohammad, Kazem; Rahimi-Movaghar, Vafa

2016-07-01

Fall-related injuries are considered to be a leading cause of morbidity and disability worldwide. The aim of this study was to investigate the incidence of fall-related injuries and its determinants in Iran. A cross-sectional household survey of a representative sample of 15-64 years old Iranians was carried out in 2011. A three-stage cluster sampling design was used. Total of 1525 clusters were randomly selected. Six households in each cluster were randomly selected, and one member of each household was interviewed. Data on the demographics and history of fall-related injury were obtained using the previously validated and reliability tested Short Form Injury Questionnaire 7 (SFIQ7). In all, 7886 subjects responded to the survey. The incidence rate of all fall-related injuries was 59 (95%CI: 45-72) per 1000 person-year. The incidence rate of First Aid Fall-Related Injuries (FAFRIs) and Medical Attended Fall-Related Injuries (MAFRIs) were 30±5 and 28±12, respectively. Homes were the most common place of falls (52.5%). For all and MAFRIs, the most common activity leading to fall injury was walking (37.8% and 47.6%, respectively) whereas for FAFRIs was playing (31.9%). For all and FAFRIs, the most common description was as follows: upper limb as the injured organ (52.0% and 61.2%, respectively) and superficial wound as the most prevalent type of injury (39.0% and 61.8%, respectively). However, for MAFRIs, lower limb injuries (52.9%) and fracture (43.6%) were more pronounced. Risk factors for MAFRI were as follows: paid work activity (OR: 3.11; 95%CI: 2.07-4.67), playing (OR: 14.64; 95%CI: 6.34-33.80), walking (OR: 57.09; 95%CI: 28.95-112.59), driving (OR: 2.86; 95%CI: 1.23-6.63), and recreation activities (OR: 44.11; 95%CI: 14.04-138.54). Higher age and education were the other risk factors for MAFRI, as well as residing in rural areas. This study revealed considerable incidence of fall injuries in Iranian population especially in rural regions who need access to

Detection of incidents and follow-up by the regulatory bodies; La detection des incidents et le suivi des enseignements par les autorites de surete

Energy Technology Data Exchange (ETDEWEB)

Gouffon, A

1990-12-01

Although France has established a large nuclear program based on PWR type reactors, experience gained up to this are are quite modest. Concept of PWR-900 reactors is based mostly on safety analyses and evaluations done a priori. At the time of their construction and start-up they have been considered as advanced safe systems. No data were available concerning any incidents during operation. The Three Mile Island accident in 1979 has changed the attitude concerning reactor safety. The result is the procedure adopted by Electricite de France for follow-up of incident situations during operation of a number of PWR-900 plants. Standardization of this type of NPPs demands extremely strict standards and control of safety systems. This safety analysis procedure consists of the following: analysis of incidents based on data collected by EDF during operation; every regular annual shutdown of a unit is the subject of detailed analysis; together with the detailed analysis, principal elements of operating experience for the series of PWR units are submitted for analysis to a permanent regulatory body.

Can we use IEC 61850 for safety related functions?

Directory of Open Access Journals (Sweden)

Luca Rocca

2016-08-01

Full Text Available Safety is an essential issue for processes that present high risk for human beings and environment. An acceptable level of risk is obtained both with actions on the process itself (risk reduction and with the use of special safety systems that switch the process into safe mode when a fault or an abnormal operation mode happens. These safety systems are today based on digital devices that communicate through digital networks. The IEC 61508 series specifies the safety requirements of all the devices that are involved in a safety function, including the communication network. Also electrical generation and distribution systems are processes that may have a significant level of risk, so the criteria stated by the IEC 61508 applies. Starting from this consideration, the paper analyzes the safety requirement for the communication network and compare them with the services of the communication protocol IEC 61850 that represents the most used protocol for automation of electrical plants. The goal of this job is to demonstrate that, from the technical point of view, IEC 61850 can be used for implementing safety-related functions, even if a formal safety certification is still missing.

Feedback of safety - related operational experience: Lessons learned

Energy Technology Data Exchange (ETDEWEB)

Elias, D [Commonwealth Edison Co. (United States)

1997-09-01

The presentation considers the following aspects of feedback of safety-related operational experience: lessons learned program, objectives, personnel characteristics; three types of documents for transmitting lessons learned issues.

Feedback of safety - related operational experience: Lessons learned

International Nuclear Information System (INIS)

Elias, D.

1997-01-01

The presentation considers the following aspects of feedback of safety-related operational experience: lessons learned program, objectives, personnel characteristics; three types of documents for transmitting lessons learned issues

Incidence and etiology of sports-related sudden cardiac death in Denmark--implications for preparticipation screening

DEFF Research Database (Denmark)

Holst, Anders Gaarsdal; Winkel, Bo Gregers; Theilade, Juliane

2010-01-01

BACKGROUND: Studies on incidences of sports-related sudden cardiac death (SrSCD) are few and data are needed for the discussion of preparticipation screening for cardiac disease. OBJECTIVE: We sought to chart the incidence and etiology of SrSCD in the young in Denmark (population 5.4 million...

Statement of nuclear incidents at nuclear installations. Third quarter 2001

International Nuclear Information System (INIS)

2002-01-01

A statement of nuclear incidents at nuclear installations in Britain during the third quarter of 2001 is published today by the Health and Safety Executive (copy attached). It covers the period 1 July to 30 September 2001. The statement is published under arrangements that came into effect from the first quarter of 1993, derived from the Health and Safety Commission's powers under section 11 of the Health and Safety at Work, etc. Act 1974. Normally each incident mentioned in HSE's Quarterly Incident Statements will already have been made public by the licensee or site operator either through a press statement or by inclusion in the newsletter for the site concerned. The locations of the installations mentioned in the statement are as follows: Heysham 1 (British Energy Generation plc), Sellafield (British Nuclear Fuels plc), Chapelcross (British Nuclear Fuels plc)

Increasing Incidence of Severe Epstein-Barr Virus-Related Infectious Mononucleosis: Surveillance Study

Science.gov (United States)

Tattevin, Pierre; Le Tulzo, Yves; Minjolle, Sophie; Person, Arnaud; Chapplain, Jean Marc; Arvieux, Cedric; Thomas, Remi; Michelet, Christian

2006-01-01

Older patients are more susceptible to severe Epstein-Barr virus (EBV)-related infectious mononucleosis (IM). This condition may increase in industrialized countries where primary EBV infection occurs later in life. Between 1990 and 2004, 38 patients were admitted to our department with EBV-related IM. Two patients died. The annual incidence increased significantly (r = 0.623; P = 0.013). PMID:16672427

Staff report on the environmental qualification of safety-related electrical equipment

International Nuclear Information System (INIS)

1977-12-01

The current NRC safety review process for nuclear power plants includes criteria related to the qualification of certain electrical equipment. These criteria require that electrical equipment important to safety must be qualified to function in the environment that might result from various accident conditions. Although such criteria have been applied since the early days of commercial nuclear power, the details of these criteria have been changed over the years. The evolution of environmental qualification of safety-related electrical equipment is described in Appendix A

Statement of nuclear incidents at nuclear installations

International Nuclear Information System (INIS)

2001-07-01

A statement of nuclear incidents at nuclear installations in Britain during the first quarter of 2001 is published today by the Health and Safety Executive. It covers the period 1 January to 31 March 2001. The statement is published under arrangements that came into effect from the first quarter of 1993, derived from the Health and Safety Commission's powers under section 11 of the Health and Safety at Work, etc. Act 1974

"Heely"-related injuries in children.

Science.gov (United States)

Thing, J; Wade, D; Clark, H

2008-09-01

"Heelys", or shoes with an integral wheel embedded into the heel, are becoming increasingly popular among children in the UK. Despite the manufacturer's claims about their safety, increasing numbers of patients are attending the emergency department with "Heely"-related injuries. To assess the number and type of "Heely"-related injuries seen in the emergency department in a busy district general hospital and to assess the number of school days lost as a result of these injuries as a secondary measure of the impact on education and lifestyle. Medical staff working in the emergency department completed proformas for all children attending the department with "Heely"-related injuries between 26 December and 26 April 2007. Data collected included age, sex, mechanism of injury, diagnosis and number of days off school as a result of the injury. 35 patients with "Heely"-related injuries of mean age 9.6 years (range 6-15) were identified during the study period. The most common mechanism of injury was a fall onto an outstretched hand (20/35, 57%). Other mechanisms of injury identified were lateral upper limb injury (7/35), traumatic lower limb injury (2/35), rotational lower limb injury (2/35), head injury (2/35) and back injury (2/35). The most common diagnosis was fracture of the distal radius (10/35), two of which had an associated distal ulna fracture. Two tibial fractures and one nasal fracture were also seen. The average number of days off school was 4.5 days (range 0-20). None of the children included in this study were using safety equipment at the time of the injury. The number of "Heely"-related injuries seen in one department over a 4-month period suggests a much higher incidence of injuries than the 46/100,000 found by the manufacturers based on Consumer Product Safety Commission data in the USA. The discrepancy is almost certainly due to the reluctance of UK children to use safety equipment and to follow the manufacturer's safety advice. Larger scale studies

Do Cancer-Related Beliefs Influence the Severity, Incidence, and Persistence of Psychological Symptoms?

Science.gov (United States)

Desautels, Caroline; Trudel-Fitzgerald, Claudia; Ruel, Sophie; Ivers, Hans; Savard, Josée

Previous studies have suggested that negative beliefs about cancer may impair patients' psychological well-being, but only a few of these studies focused on specific psychological symptoms, and many were cross-sectional. The aim of this study was to investigate longitudinally the relationship of cancer-related cognitions with the severity, incidence, and persistence of anxiety, fear of cancer recurrence, depression, and insomnia symptoms during an 18-month period. Patients scheduled to undergo surgery for cancer (N = 962) completed a questionnaire assessing cancer-related cognitions at baseline (T1), the Hospital Anxiety and Depression Scale, the severity subscale of the Fear of Cancer Recurrence Inventory, and the Insomnia Severity Index at baseline (T1) and 2 (T2), 6 (T3), 10 (T4), 14 (T5), and 18 (T6) months later. Group × time factorial analyses using mixed models revealed that participants endorsing more negative cancer-related cognitions consistently reported more severe symptoms throughout the 18-month period. Logistic regression analyses suggested that endorsing more negative cancer-related cognitions at T1 significantly increased incidence and persistence rates of clinical levels of psychological symptoms. These findings suggest that the endorsement of negative cancer-related beliefs at the perioperative period influences the longitudinal evolution of anxiety, fear of cancer recurrence, depression, and insomnia symptoms in the following months. These results highlight the relevance of using cognitive restructuring early during the cancer care trajectory to potentially revise erroneous beliefs about cancer and prevent the incidence and persistence of psychological disturbances over time.

Detection of incidents and follow-up by the regulatory bodies

International Nuclear Information System (INIS)

Gouffon, A.

1990-12-01

Although France has established a large nuclear program based on PWR type reactors, experience gained up to this are are quite modest. Concept of PWR-900 reactors is based mostly on safety analyses and evaluations done a priori. At the time of their construction and start-up they have been considered as advanced safe systems. No data were available concerning any incidents during operation. The Three Mile Island accident in 1979 has changed the attitude concerning reactor safety. The result is the procedure adopted by Electricite de France for follow-up of incident situations during operation of a number of PWR-900 plants. Standardization of this type of NPPs demands extremely strict standards and control of safety systems. This safety analysis procedure consists of the following: analysis of incidents based on data collected by EDF during operation; every regular annual shutdown of a unit is the subject of detailed analysis; together with the detailed analysis, principal elements of operating experience for the series of PWR units are submitted for analysis to a permanent regulatory body

Lipids, lipid genes, and incident age-related macular degeneration: the three continent age-related macular degeneration consortium

NARCIS (Netherlands)

Klein, Ronald; Myers, Chelsea E.; Buitendijk, Gabriëlle H. S.; Rochtchina, Elena; Gao, Xiaoyi; de Jong, Paulus T. V. M.; Sivakumaran, Theru A.; Burlutsky, George; McKean-Cowdin, Roberta; Hofman, Albert; Iyengar, Sudha K.; Lee, Kristine E.; Stricker, Bruno H.; Vingerling, Johannes R.; Mitchell, Paul; Klein, Barbara E. K.; Klaver, Caroline C. W.; Wang, Jie Jin

2014-01-01

To describe associations of serum lipid levels and lipid pathway genes to the incidence of age-related macular degeneration (AMD). Meta-analysis. setting: Three population-based cohorts. population: A total of 6950 participants from the Beaver Dam Eye Study (BDES), Blue Mountains Eye Study (BMES),

Hazard detection in noise-related incidents - the role of driving experience with battery electric vehicles.

Science.gov (United States)

Cocron, Peter; Bachl, Veronika; Früh, Laura; Koch, Iris; Krems, Josef F

2014-12-01

The low noise emission of battery electric vehicles (BEVs) has led to discussions about how to address potential safety issues for other road users. Legislative actions have already been undertaken to implement artificial sounds. In previous research, BEV drivers reported that due to low noise emission they paid particular attention to pedestrians and bicyclists. For the current research, we developed a hazard detection task to test whether drivers with BEV experience respond faster to incidents, which arise due to the low noise emission, than inexperienced drivers. The first study (N=65) revealed that BEV experience only played a minor role in drivers' response to hazards resulting from low BEV noise. The tendency to respond, reaction times and hazard evaluations were similar among experienced and inexperienced BEV drivers; only small trends in the assumed direction were observed. Still, both groups clearly differentiated between critical and non-critical scenarios and responded accordingly. In the second study (N=58), we investigated additionally if sensitization to low noise emission of BEVs had an effect on hazard perception in incidents where the noise difference is crucial. Again, participants in all groups differentiated between critical and non-critical scenarios. Even though trends in response rates and latencies occurred, experience and sensitization to low noise seemed to only play a minor role in detecting hazards due to low BEV noise. An additional global evaluation of BEV noise further suggests that even after a short test drive, the lack of noise is perceived more as a comfort feature than a safety threat. Copyright © 2014 Elsevier Ltd. All rights reserved.

Consequences of a hypothetical incident for different sectors

CERN Document Server

Bertinelli, F; Garion, C; Jimenez, J M; Parma, V; Perin, A; Schmidt, R; Tavian, L; Tock, J P; van Weelderen, R

2011-01-01

During the 2009 long shutdown, the LHC machine has been partially consolidated by adding safety relief devices in order to better protect the cryostats against large helium release and consequently to mitigate the risks of collateral damages. After recalling the present relief valve implementation and other mitigations related to the collateral damages, this paper describes the damage process of a hypothetical incident, presents its consequences for the different sectors and for beam energies up to 5 TeV with emphasis on the induced downtime.

Laser exposure incidents: pilot ocular health and aviation safety issues.

Science.gov (United States)

Nakagawara, Van B; Wood, Kathryn J; Montgomery, Ron W

2008-09-01

A database of aviation reports involving laser illumination of flight crewmembers has been established and maintained at the Civil Aerospace Medical Institute. A review of recent laser illumination reports was initiated to investigate the significance of these events. Reports that involved laser exposures of civilian aircraft in the United States were analyzed for the 13-month period (January 1, 2004, through January 31, 2005). There were 90 reported instances of laser illumination during the study period. A total of 53 reports involved laser exposure of commercial aircraft. Lasers illuminated the cockpit in 41 (46%) of the incidents. Of those, 13 (32%) incidents resulted in a visual impairment or distraction to a pilot, including 1 incident that reportedly resulted in an ocular injury. Nearly 96% of these reports occurred in the last 3 months of the study period. There were no aviation accidents in which laser light illumination was found to be a contributing factor. Operational problems have resulted from laser illumination incidents in the national airspace system. Eye care practitioners, to provide effective consultations to their pilot patients, should be familiar with the problems that can occur with laser exposure.

Safety related experience in FFTF startup and operation

International Nuclear Information System (INIS)

Peterson, R.E.; Halverson, T.G.; Daughtry, J.W.

1982-06-01

The Fast Flux Test Facility (FFTF) is a 400 MW(t) sodium cooled fast reactor operating at the Hanford Engineering Development Laboratory, Richland, Washington, to conduct fuels and materials testing in support of the US LMFBR program. Startup and initial power ascension testing of the facility involved a comprehensive series of readiness reviews and acceptance tests, many of which relate to the inherent safety of the plant. Included are physics measurements, natural circulation, integrated containment leakage, shielding effectiveness, fuel failure detection, and plant protection system tests. Described are the measurements taken to confirm the design safety margins upon which the operating authorization of the plant was based. These measurements demonstrate that large margins of safety are available in the FFTF design

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

Full Text Available Introduction: Work-related accidents may cause damage to people, environment and lead to waste of time and money. Health, Safety and Environment Management System has been developed in order to reduce accidents. This study aimed to investigate the effect of implementation of this system on reduction of the accidents and its consequences and also on the safety performance indices in Kermanshah Petrochemical Company. Material and Method: In this study, records of accidents were collected by OSHA incident report form 301 over 4 years. Following, the mean annual accidents and its consequences and safety performance indices were calculated and reported. Then, using statistical analysis, the impacts of two years implementation of this system on the accidents and its consequences and safety performance indices were evaluated. Result: The results showed that the implementation of HSE system was significantly correlated with Frequency Severity Indicator, Accident Severity Rate, lost days, minor accidents and total incidents (P-value 0.05. 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.

Commercial grade item (CGI) dedication of generators for nuclear safety related applications

International Nuclear Information System (INIS)

Das, R.K.; Hajos, L.G.

1993-01-01

The number of nuclear safety related equipment suppliers and the availability of spare and replacement parts designed specifically for nuclear safety related application are shrinking rapidly. These have made it necessary for utilities to apply commercial grade spare and replacement parts in nuclear safety related applications after implementing proper acceptance and dedication process to verify that such items conform with the requirements of their use in nuclear safety related application. The general guidelines for the commercial grade item (CGI) acceptance and dedication are provided in US Nuclear Regulatory Commission (NRC) Generic Letters and Electric Power Research Institute (EPRI) Report NP-5652, Guideline for the Utilization of Commercial Grade Items in Nuclear Safety Related Applications. This paper presents an application of these generic guidelines for procurement, acceptance, and dedication of a commercial grade generator for use as a standby generator at Salem Generating Station Units 1 and 2. The paper identifies the critical characteristics of the generator which once verified, will provide reasonable assurance that the generator will perform its intended safety function. The paper also delineates the method of verification of the critical characteristics through tests and provide acceptance criteria for the test results. The methodology presented in this paper may be used as specific guidelines for reliable and cost effective procurement and dedication of commercial grade generators for use as standby generators at nuclear power plants

BP's driving safety strategy

Energy Technology Data Exchange (ETDEWEB)

Herman, B. [BP Canada Energy Company, Calgary, AB (Canada)

2006-07-01

This presentation focused on why it is important to drive safely. It addressed driver fatigue as well as BP's global driving standard. The Standard applies to all BP employees and contractors that drive any vehicle on BP business and consists of 10 mandatory elements focusing on safety of the driver, the safety of the journey, and the safety of the vehicle. The driving standards focus on several themes, including skill and competency of the driver, safety of the journey, and safety of the vehicle. Fatigue causes more than 20 per cent of motorway accidents and is the most frequent cause of accidental death of truck drivers. The presentation also discussed vehicle data recorders, driving immersion, and Driving Safety Program results. Journey management, driver training, vehicle inspections and policies, and statistics on vehicle incidents were also provided. The presentation revealed that a lack of pre-trip journey management, inadequate training or recall of training, and not following safe driving practices were major contributors to incident occurrences. It also revealed that traveling on gravel or ice and avoiding wildlife were factors in many vehicle incidents. 1 tab., 1 fig.

The spirit of safety: oriental safety culture

Energy Technology Data Exchange (ETDEWEB)

Kondo, J. [Science Council of Japan, Tokyo (Japan)

1996-09-01

Failure of a large system causes disasters. However, after an accident, the causes are frequently attributed to human error when the operators do not survive the accident. It might be difficult to prove that the real cause of the accident is human error. Process decision program chart (PDPC) would be a useful tool in indicating the causes of an accident since it can clearly show that if the operator made the correct choice, the safety of the system could be maintained. The case of the incident of the nuclear reactor at Mihama unit 2 is indicated by PDPC in which the sequence of events and the operations are indicated in this paper together with the safe operation. One can easily understand the cause of the incident and the way to avoid it. Also, PDPC for the Three Mile Island (TMI) accident is shown. Initially, in order to prevent an accident, mental training and safety culture is most important. The oriental safety culture based on Zentoism, a school of Buddhism is discussed. (orig.)

The spirit of safety: oriental safety culture

International Nuclear Information System (INIS)

Kondo, J.

1996-01-01

Failure of a large system causes disasters. However, after an accident, the causes are frequently attributed to human error when the operators do not survive the accident. It might be difficult to prove that the real cause of the accident is human error. Process decision program chart (PDPC) would be a useful tool in indicating the causes of an accident since it can clearly show that if the operator made the correct choice, the safety of the system could be maintained. The case of the incident of the nuclear reactor at Mihama unit 2 is indicated by PDPC in which the sequence of events and the operations are indicated in this paper together with the safe operation. One can easily understand the cause of the incident and the way to avoid it. Also, PDPC for the Three Mile Island (TMI) accident is shown. Initially, in order to prevent an accident, mental training and safety culture is most important. The oriental safety culture based on Zentoism, a school of Buddhism is discussed. (orig.)

Statement of nuclear incidents at nuclear installations: first quarter 1994

International Nuclear Information System (INIS)

1994-06-01

As a requirement of the 1974 Health and Safety at Work Act, the United Kingdom Health and Safety Inspectorate is required to publish reports of nuclear incidents at nuclear installations. This report covers the period 1st January to 31st March 1994. Two incidents are reported for Dungeness A Power Station, one at the Amersham International building on site at Harwell Laboratory, one at AEA Technology's Windscale Plant and one at British Nuclear Fuels Limited's Sellafield site. (UK)

Identification of Crew-Systems Interactions and Decision Related Trends

Science.gov (United States)

Jones, Sharon Monica; Evans, Joni K.; Reveley, Mary S.; Withrow, Colleen A.; Ancel, Ersin; Barr, Lawrence

2013-01-01

NASA Vehicle System Safety Technology (VSST) project management uses systems analysis to identify key issues and maintain a portfolio of research leading to potential solutions to its three identified technical challenges. Statistical data and published safety priority lists from academic, industry and other government agencies were reviewed and analyzed by NASA Aviation Safety Program (AvSP) systems analysis personnel to identify issues and future research needs related to one of VSST's technical challenges, Crew Decision Making (CDM). The data examined in the study were obtained from the National Transportation Safety Board (NTSB) Aviation Accident and Incident Data System, Federal Aviation Administration (FAA) Accident/Incident Data System and the NASA Aviation Safety Reporting System (ASRS). In addition, this report contains the results of a review of safety priority lists, information databases and other documented references pertaining to aviation crew systems issues and future research needs. The specific sources examined were: Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementation (SERFIs), Flight Deck Automation Issues (FDAI) and NTSB Most Wanted List and Open Recommendations. Various automation issues taxonomies and priority lists pertaining to human factors, automation and flight design were combined to create a list of automation issues related to CDM.

Risk-based evaluation tool for safety-related maintenance involving scaffolding

International Nuclear Information System (INIS)

Stevens, C.; Azizi, M.; Massman, M.

1988-01-01

The US Nuclear Regulatory Commission (NRC) has expressed a general concern that transient materials in and around safety systems at nuclear power plants represent a seismic safety hazard to the plant, in particular, the uncontrolled use of scaffolding during maintenance activities. Currently, most plants perform a seismic safety analysis for all uses of scaffolding near safety-related equipment to determine appropriate tie-down locations, scaffolding reinforcements, etc. This is both time-consuming and, for the most part, unnecessary. A workable engineering solution based on risk analysis techniques has been developed and is being used at the Palo Verde nuclear generating station (PVNGS)

Effect of STOP technique on safety climate in a construction company.

Science.gov (United States)

Darvishi, Ebrahim; Maleki, Afshin; Dehestaniathar, Saeed; Ebrahemzadih, Mehrzad

2015-01-01

Safety programs are a core part of safety management in workplaces that can reduce incidents and injuries. The aim of this study was to investigate the influence of Safety Training Observation Program (STOP) technique as a behavior modification program on safety climate in a construction company. This cross-sectional study was carried out on workers of the Petrochemical Construction Company, western Iran. In order to improve safety climate, an unsafe behavior modification program entitled STOP was launched among workers of project during 12 months from April 2013 and April 2014. The STOP technique effectiveness in creating a positive safety climate was evaluated using the Safety Climate Assessment Toolkit. 76.78% of total behaviors were unsafe. 54.76% of total unsafe acts/ at-risk behaviors were related to the fall hazard. The most cause of unsafe behaviors was associated with habit and unavailability of safety equipment. After 12 month of continuous implementation the STOP technique, 55.8% of unsafe behaviors reduced among workers. The average score of safety climate evaluated using of the Toolkit, before and after the implementation of the STOP technique was 5.77 and 7.24, respectively. The STOP technique can be considered as effective approach for eliminating at-risk behavior, reinforcing safe work practices, and creating a positive safety climate in order to reduction incidents/injuries.

Incident detection and isolation in drilling using analytical redundancy relations

DEFF Research Database (Denmark)

Willersrud, Anders; Blanke, Mogens; Imsland, Lars

2015-01-01

must be avoided. This paper employs model-based diagnosis using analytical redundancy relations to obtain residuals which are affected differently by the different incidents. Residuals are found to be non-Gaussian - they follow a multivariate t-distribution - hence, a dedicated generalized likelihood...... measurements available. In the latter case, isolation capability is shown to be reduced to group-wise isolation, but the method would still detect all serious events with the prescribed false alarm probability...

Cancer incidence in relatives of British Fanconi Anaemia patients

Directory of Open Access Journals (Sweden)

Hodgson Shirley V

2008-09-01

Full Text Available Abstract Background Fanconi anemia (FA is an autosomal recessive DNA repair disorder with affected individuals having a high risk of developing acute myeloid leukaemia and certain solid tumours. Thirteen complementation groups have been identified and the genes for all of these are known (FANCA, B, C, D1/BRCA2, D2, E, F, G, I, J/BRIP1, L, M and N/PALB2. Previous studies of cancer incidence in relatives of Fanconi anemia cases have produced conflicting results. A study of British FA families was therefore carried out to investigate this question, since increases in cancer risk in FA heterozygotes would have implications for counselling FA family members, and possibly also for the implementation of preventative screening measures in FA heterozygotes. Methods Thirty-six families took part and data was collected on 575 individuals (276 males, 299 females, representing 18,136 person years. In this cohort, 25 males and 30 females were reported with cancer under the age of 85 years, and 36 cancers (65% could be confirmed from death certificates, cancer registries or clinical records. Results A total of 55 cancers were reported in the FA families compared to an estimated incidence of 56.95 in a comparable general population cohort, and the relative risk of cancer was 0.97 (95% C.I. = 0.71–1.23, p = 0.62 for FA family members. Analysis of relative risk for individual cancer types in each carrier probability group did not reveal any significant differences with the possible exception of prostate cancer (RR = 3.089 (95% C.I. = 1.09 – 8.78; Χ2 = 4.767, p = 0.029. Conclusion This study has not shown a significant difference in overall cancer risk in FA families.

Safety issues related to the intermediate heat storage for the EU DEMO

Energy Technology Data Exchange (ETDEWEB)

Carpignano, Andrea [NEMO group, Dipartimento Energia, Politecnico di Torino, C.so Duca degli Abruzzi 24, 10129 Torino (Italy); Pinna, Tonio [ENEA, 00044 Frascati (Italy); Savoldi, Laura; Sobrero, Giulia; Uggenti, Anna Chiara [NEMO group, Dipartimento Energia, Politecnico di Torino, C.so Duca degli Abruzzi 24, 10129 Torino (Italy); Zanino, Roberto, E-mail: roberto.zanino@polito.it [NEMO group, Dipartimento Energia, Politecnico di Torino, C.so Duca degli Abruzzi 24, 10129 Torino (Italy)

2016-11-01

Highlights: • IHS affects only the PHTS and the BoP (Balance of Plant). • PIEs list does not change but IHS influences PIEs evolution. • Additional issues to be addressed in PIEs study due to the implementation of HIS. • No safety/operational major obstacles were found for IHS concept. - Abstract: The functional deviations able to compromise system safety in the EU DEMO Primary Heat Transfer System (PHTS) with intermediate heat storage (IHS) based on molten salts are identified and compared to the deviations identified with PHTS without IHS. The resulting safety issues for the Balance of Plant (BoP) have been taken into account. Functional Failure Mode and Effects Analysis (FFMEA) is used to highlight the Postulated Initiating Events (PIE) of incident/accident sequences and to provide some safety insights during the preliminary design. The architecture of the system with IHS does not introduce new PIE with respect to the case without IHS, but it modifies some of them. In particular the two Postulated Initiating Events that are affected by the presence of IHS are the LOCA in the tubes of the HX between primary and intermediate circuit and the loss of heat sink for the first wall or the breeding zone. In fact the IHS introduces some advantages concerning the stability of the secondary circuit, but some weaknesses are associated to the physical-chemical nature of molten salts, especially oxidizing power, corrosive nature and risk of solidification. These issues can be managed in the design by the introduction of new safety functions.

Preventive Effects of Safety Helmets on Traumatic Brain Injury after Work-Related Falls

Directory of Open Access Journals (Sweden)

Sang Chul Kim

2016-10-01

Full Text Available Introduction: Work-related traumatic brain injury (TBI caused by falls is a catastrophic event that leads to disabilities and high socio-medical costs. This study aimed to measure the magnitude of the preventive effect of safety helmets on clinical outcomes and to compare the effect across different heights of fall. Methods: We collected a nationwide, prospective database of work-related injury patients who visited the 10 emergency departments between July 2010 and October 2012. All of the adult patients who experienced work-related fall injuries were eligible, excluding cases with unknown safety helmet use and height of fall. Primary and secondary endpoints were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs of safety helmet use and height of fall for study outcomes, and adjusted for any potential confounders. Results: A total of 1298 patients who suffered from work-related fall injuries were enrolled. The industrial or construction area was the most common place of fall injury occurrence, and 45.0% were wearing safety helmets at the time of fall injuries. The safety helmet group was less likely to have intracranial injury comparing with the no safety helmet group (the adjusted odds ratios (ORs (95% confidence interval (CI: 0.42 (0.24–0.73, however, there was no statistical difference of in-hospital mortality between two groups (the adjusted ORs (95% CI: 0.83 (0.34–2.03. In the interaction analysis, preventive effects of safety helmet on intracranial injury were significant within 4 m height of fall. Conclusions: A safety helmet is associated with prevention of intracranial injury resulting from work-related fall and the effect is preserved within 4 m height of fall. Therefore, wearing a safety helmet can be an intervention for protecting fall-related intracranial injury in the workplace.

On Safety Management. A Frame of Reference for Studies of Safety Management with Examples From Non-Nuclear Contexts of Relevance for Nuclear Safety

Energy Technology Data Exchange (ETDEWEB)

Svensson, Ola; Salo, Ilkka; Allwin, Pernilla (Risk Analysis, Social and Decision Research Unit, Dept. of Psychology, Stockholm Univ., Stockholm (Sweden))

2004-11-15

operations, and safety management for each organization respectively. The analyses are described and summarized in detail in each chapter. To summarize some general themes from the analyzes the following are important to mention: -A distinct division of responsibilities for safety work between organizational units. -A clear communication about the organization's safety policy and how each member of the organization is a part of the policy. -Channels for information and information feedback are clearly represented in the system structure. -Availability to incident reporting systems and the responsibility of each member of the organization to report incidents. -The importance to differentiate between established structures for information management and established structures for information content. -To make clear the range and meaning of power and authority. -Identification of the organizations' competence and integrity in relation to safety management.

Nuclear safety

International Nuclear Information System (INIS)

Tarride, Bruno

2015-10-01

The author proposes an overview of methods and concepts used in the nuclear industry, at the design level as well as at the exploitation level, to ensure an acceptable safety level, notably in the case of nuclear reactors. He first addresses the general objectives of nuclear safety and the notion of acceptable risk: definition and organisation of nuclear safety (relationships between safety authorities and operators), notion of acceptable risk, deterministic safety approach and main safety principles (safety functions and confinement barriers, concept of defence in depth). Then, the author addresses the safety approach at the design level: studies of operational situations, studies of internal and external aggressions, safety report, design principles for important-for-safety systems (failure criterion, redundancy, failure prevention, safety classification). The next part addresses safety during exploitation and general exploitation rules: definition of the operation domain and of its limits, periodic controls and tests, management in case of incidents, accidents or aggressions

Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data.

Science.gov (United States)

Ferroli, Paolo; Caldiroli, Dario; Acerbi, Francesco; Scholtze, Maurizio; Piro, Alfonso; Schiariti, Marco; Orena, Eleonora F; Castiglione, Melina; Broggi, Morgan; Perin, Alessandro; DiMeco, Francesco

2012-11-01

Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within

Configuration control during maintenance of safety related equipment

International Nuclear Information System (INIS)

Irish, C.S.

2001-01-01

Possibly the most important aspect of performing maintenance of safety related equipment is maintaining the component's original design basis. Assuring that the repaired item will perform the same safety function within the original performance and equipment qualification parameters is commonly referred to as configuration control. Maintaining configuration control of a technologically current well documented item is easy. Unfortunately, this does not describe most safety related items requiring maintenance within the global nuclear industry. Items such as motors, transformers, metal clad switchgear (low and medium voltage circuit breakers), refrigeration compressors, and electronic components (i.e. circuit boards, power supplies, regulators, etc.) which routinely require repair have been in service for twenty plus years. As a result, finding replacement parts and or material to repair the items to the original condition is becoming more and more difficult. An added difficulty is the lack of original technical documentation available on the item which is being repaired. The lack of technical documentation makes it difficult to identify replacement material and parts when the original part or material is not available. The lack of documentation also makes it difficult to test the repaired item to make sure that the original configuration has been maintained after the repair. The presentation will discuss the details of repairing various items including motors, metal clad switchgear, refrigeration compressors and power supplies and the controls which are necessary to maintain the configuration of the original item. The discussion will include the Quality Assurance and engineering necessary to identify and evaluate replacement material and parts necessary to perform repairs on safety related equipment when the original material or part is not available. Examples of repairs which required different parts or materials than the original to be used in the repair will be

Configuration control during maintenance of safety related equipment

International Nuclear Information System (INIS)

Irish, C.S.

2003-01-01

Possibly the most important aspect of performing maintenance of safety related equipment is maintaining the component's original design basis. Assuring that the repaired item will perform the same safety function within the original performance and equipment qualification parameters is commonly referred to as configuration control. Maintaining configuration control of a technologically current well documented item is easy. Unfortunately, this does not describe most safety related items requiring maintenance within the global nuclear industry. Items such as motors, transformers, metal clad switchgear (low and medium voltage circuit breakers), refrigeration compressors, and electronic components (i.e. circuit boards, power supplies, regulators, etc.) which routinely require repair have been in service for twenty plus years. As a result, finding replacement parts and or material to repair the items to the original condition is becoming more and more difficult. An added difficulty is the lack of original technical documentation available on the item which is being repaired. The lack of technical documentation makes it difficult to identify replacement material and parts when the original part or material is not available. The lack of documentation also makes it difficult to test the repaired item to make sure that the original configuration has been maintained after the repair. The presentation will discuss the details of repairing various items including motors, metal clad switchgear, refrigeration compressors and power supplies and the controls which are necessary to maintain the configuration of the original item. The discussion will include the Quality Assurance and engineering necessary to identify and evaluate replacement material and parts necessary to perform repairs on safety related equipment when the original material or part is not available. Examples of repairs which required different parts or materials than the original to be used in the repair will be

Safety in design and operation of low energy particle accelerators

International Nuclear Information System (INIS)

Badawy, I.

1991-01-01

This paper studies the safety in design and operation of low energy accelerators which produce beams of accelerated charged particles and radiations. As radiation sources, the accelerators are widely used in scientific research, industry, food and medical applications. The risks to human and environment are considered. The safety in accelerators is discussed-particularly-the shielding against ionizing radiations, overexposure to RF radiation fire hazards and power failures. Also the paper studies the emergency response at incidents. Emergency procedures are recommended for each type of emergency. Reporting to the competent Authority is also recommended to be prepared for each incident. The basic principles of regulatory control, licensing and inspections for accelerator facilities are discussed. The relation with the competent authority is pointed out. 4 fig

Some Subjects and Relations According to the Act about Safety at Work

OpenAIRE

Marino Đ. Učur

2015-01-01

Complex relations in the field of safety at work could not be present without the subjects which have a specific status and specific rights, obligations and responsibilities regulated by the Occupational Health and Safety Act. This paper deals with: employer’s designated employee for the implementation of occupational health and safety activities, employees’ elected representative for health and safety protection at work, occupational medicine specialist, occupational health and safety sp...

Commercial-grade motors in safety-related applications: Final report

International Nuclear Information System (INIS)

Holzman, P.M.

1988-04-01

The objective of this project was to discuss the process necessary to utilize commercial grade equipment in safety related applications and to provide utilities with guidance for accepting commercial grade motors for safety-related applications. The generic commercial-grade concepts presented in this report can be successfully applied to motors. Commercial grade item utilization has the greatest applicability to motors in ''mild'' environments, because these motors are essentially similar to commercial grade motors in materials, construction methods, and capabilities. The acceptance process is less applicable to motors that are subject to ''harsh'' environments during postulated accidents, because of the unique design features and testing required to qualify these motors

An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital.

Science.gov (United States)

Hemsley, Bronwyn; Georgiou, Andrew; Hill, Sophie; Rollo, Megan; Steel, Joanne; Balandin, Susan

2016-04-01

To review the research literature on the experiences of patients with communication disabilities in hospital according to the Generic Model of patient safety. In 2014 and 2015, we searched four scientific databases for studies with an aim or result relevant to safety of hospital patients with communication disabilities. The review included 27 studies. A range of adverse event types were outlined in qualitative research. Little detail was provided about contributing or protective factors for safety incidents in hospital for these patients or the impact of the incidents on the patient or organisations involved. Further research addressing the safety of patients with communication disabilities is needed. Sufficient detail is required to identify the nature, timing, and detection of incidents; factors that contribute to or prevent adverse events; and detail the impact of the adverse events. In order to provide safe and effective care to people with communication disabilities in hospital, a priority for health and disability services must be the design and evaluation of ecologically appropriate and evidence-based interventions to improve patient care, communication, and reduce the risk of costly and harmful patient safety incidents. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Development of FPGA-based safety-related I and C systems

Energy Technology Data Exchange (ETDEWEB)

Goto, Y.; Oda, N.; Miyazaki, T.; Hayashi, T.; Sato, T.; Igawa, S. [08, Shinsugita-cho, Isogo-ku, Yokohama 235-8523 (Japan); 1, Toshiba-cho, Fuchu, Tokyo 183-8511 (Japan)

2006-07-01

Toshiba has developed Non-rewritable (NRW) Field Programmable Gate Array (FPGA)-based safety-related Instrumentation and Control (I and C) system [1]. Considering application to safety-related systems, nonvolatile and non-rewritable FPGA which is impossible to be changed after once manufactured has been adopted in Toshiba FPGA-based system. FPGA is a device which consists only of defined digital circuit: hardware, which performs defined processing. FPGA-based system solves issues existing both in the conventional systems operated by analog circuits (analog-based system) and the systems operated by central processing unit (CPU-based system). The advantages of applying FPGA are to keep the long-life supply of products, improving testability (verification), and to reduce the drift which may occur in analog-based system. The system which Toshiba developed this time is Power Range Monitor (PRM). Toshiba is planning to expand application of FPGA-based technology by adopting this development method to the other safety-related systems from now on. (authors)

Safety Outreach and Incident Response Stakeholder Strategy

Energy Technology Data Exchange (ETDEWEB)

Rosewater, David Martin [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Conover, David [Pacific Northwest National Lab. (PNNL), Richland, WA (United States)

2016-06-01

The objective of this document is to set out a strategy to reach all stakeholders that can impact the timely deployment of safe stationary energy storage systems in the built environment with information on ESS technology and safety that is relevant to their role in deployment of the technology.

Aviation and healthcare: a comparative review with implications for patient safety.

Science.gov (United States)

Kapur, Narinder; Parand, Anam; Soukup, Tayana; Reader, Tom; Sevdalis, Nick

2016-01-01

Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

Incidence and factors related to delirium in an intensive care unit.

Science.gov (United States)

Mori, Satomi; Takeda, Juliana Rumy Tsuchihashi; Carrara, Fernanda Souza Angotti; Cohrs, Cibelli Rizzo; Zanei, Suely Sueko Viski; Whitaker, Iveth Yamaguchi

2016-01-01

To identify the incidence of delirium, compare the demographic and clinical characteristics of patients with and without delirium, and verify factors related to delirium in critical care patients. Prospective cohort with a sample made up of patients hospitalized in the Intensive Care Unit (ICU) of a university hospital. Demographic, clinical variables and evaluation with the Confusion Assessment Method for Intensive Care Unit to identify delirium were processed to the univariate analysis and logistic regression to identify factors related to the occurrence of delirium. Of the total 149 patients in the sample, 69 (46.3%) presented delirium during ICU stay, whose mean age, severity of illness and length of ICU stay were statistically higher. The factors related to delirium were: age, midazolam, morphine and propofol. Results showed high incidence of ICU delirium associated with older age, use of sedatives and analgesics, emphasizing the need for relevant nursing care to prevent and identify early, patients presenting these characteristics. Identificar a incidência de delirium, comparar as características demográficas e clínicas dos pacientes com e sem delirium e verificar os fatores relacionados ao delirium em pacientes internados em Unidade de Terapia Intensiva (UTI). Coorte prospectiva, cuja amostra foi constituída de pacientes internados em UTI de um hospital universitário. Variáveis demográficas, clínicas e da avaliação com o Confusion Assessment Method for Intensive Care Unit para identificação de delirium foram processadas para análise univariada, e regressão logística para identificar fatores relacionados à ocorrência do delirium. Do total de 149 pacientes da amostra, 69 (46,3%) apresentaram delirium durante a internação na UTI, observando-se que a média da idade, o índice de gravidade e o tempo de permanência nas UTI foram estatisticamente maiores. Os fatores relacionados ao delirium foram: idade, midazolam, morfina e propofol. Os

Patient Safety and Organizational Learning

DEFF Research Database (Denmark)

Zinck Pedersen, Kirstine

pragmatism, situated learning theory and science and technology studies, the paper contrasts the notion of ‘systemic’ learning expressed by the safety policy program with notions of learning as a socio-materially situated practice. Based on fieldwork conducted in 2010 in a Danish university hospital, I...... propose that learning, and more specifically learning from critical incidents, should be understood as a practical and experience-based activity as well as an equally individual and social achievement, which is always formed in relation to the specificities of the concrete situation. Parting from......The key trope of patient safety policy is learning. With the motto of going from ‘a culture of blame to a learning culture’, the safety program introduces a ‘systemic perspective’ to facilitate openness and willingness to talk about failures, hereby making failures into a system property. Within...

Smoking and Home Fire Safety

Science.gov (United States)

... Materials Working with the Media Fire Protection Technology Smoking fire safety outreach materials As a member of ... Not reported 7% In transport 1% 195 incidents Smoking fire safety messages to share It is important ...

Trend evaluation of incident and failure data from japanese nuclear power plants

International Nuclear Information System (INIS)

Kondo, S.; Hada, M.; Mikami, Y.

1990-01-01

Major incident and failure at nuclear power plants in Japan have to be reported to the regulatory agency i.e. Ministry of International Trade and Industry (MITI). Nuclear Power Safety Information Research Center (NUSIRC) has established a system for the collection, classification and analysis of this report under the contract to MITI. In this paper, the authors give several results of trend analyses of the incidents related to electric and instrumentation and control (I and C) systems reported, especially, the trend of the contribution of troubles in I and C system to the operation states, analysis of dominant contributors to the failure of I and C systems. Also, the relations of failure frequency of these systems with the plant age and effect of periodic inspections of it are discussed in some detail

Analysis of a radiological incident and lessons to be learned: a case of industrial radiographic incident in great Britain

International Nuclear Information System (INIS)

Croft, J.; Lefaure, Ch.

2000-01-01

This note describes a case study to provide feedback analysis and lessons to be learned from a radiological incident. This one occurred in the UK. It has been published in the European ALARA Newsletter no. 2 (January 1997) and has been selected from the IRID database (Ionising Radiation Incident Database) managed by the Health and Safety Executive, National Radiological Protection Board and Environmental Agency. (authors)

Radiation incidents in dentistry

International Nuclear Information System (INIS)

Lovelock, D.J.

1996-01-01

Most dental practitioners act as their own radiographer and radiologist, unlike their medical colleagues. Virtually all dental surgeons have a dental X-ray machine for intraoral radiography available to them and 40% of dental practices have equipment for dental panoramic tomography. Because of the low energy of X-ray equipment used in dentistry, radiation incidents tend to be less serious than those associated with other aspects of patient care. Details of 47 known incidents are given. The advent of the 1985 and 1988 Ionising Radiation Regulations has made dental surgeons more aware of the hazards of radiation. These regulations, and general health and safety legislation, have led to a few dental surgeons facing legal action. Because of the publicity associated with these court cases, it is expected that there will be a decrease in radiation incidents arising from the practice of dentistry. (author)

Integrating incident investigation into the management system

International Nuclear Information System (INIS)

Peterson, E.E.

1992-01-01

In the last 10 yr, the size and frequency of incidents affecting the communities and environment surrounding chemical processing facilities has increased. The chemical process industry, which has always concerned itself with the safety of its facilities, has responded by committing to stricter standards of operation and management. A critical element of these management practices is the use of a structured incident investigation program. Many facilities have implemented and disciplined themselves to perform good investigation of incidents. However, most of these facilities maintain incident investigation as part of their safety management programs. This allows the process to be disconnected from the management system that deals with the day-to-day business of the facility. The first step of integration is understanding the objectives and functions of the management system into which the integration is to occur. To begin, a common definition of management is needed. Management, for the purposes of this discussion, is defined as the system of activities used to control, coordinate, and improve the flow of work within a facility or organization. This definition refers to several concepts that need further development in order to understand how incident investigation can be integrated into a management system, including (a) flow of work, (b) control, and (c) improvement. Application can be made to the nuclear industry

The lessons of the incident at Three Mile Island

International Nuclear Information System (INIS)

Wilson, R.

1979-01-01

Although the radiation level in the incident did not exceed the danger level of 100 millirem it should be asked why the important safety valve was closed, why the security building was not isolated and why the safety cooling system had been withdrawn. (J.S.)

The NLstart2run study: Incidence and risk factors of running-related injuries in novice runners

NARCIS (Netherlands)

Kluitenberg, B.; van Middelkoop, M.; Smits, D.W.; Verhagen, E.A.L.M.; Hartgens, F.; Diercks, R.; van der Worp, H.

2015-01-01

Running is a popular form of physical activity, despite of the high incidence of running-related injuries (RRIs). Because of methodological issues, the etiology of RRIs remains unclear. Therefore, the purposes of the study were to assess the incidence of RRIs and to identify risk factors for RRIs in

The NLstart2run study : Incidence and risk factors of running-related injuries in novice runners

NARCIS (Netherlands)

Kluitenberg, B; van Middelkoop, M; Smits, D W; Verhagen, E; Hartgens, F; Diercks, R; van der Worp, H

2015-01-01

Running is a popular form of physical activity, despite of the high incidence of running-related injuries (RRIs). Because of methodological issues, the etiology of RRIs remains unclear. Therefore, the purposes of the study were to assess the incidence of RRIs and to identify risk factors for RRIs in

Pediatric melanoma: incidence, treatment, and prognosis

Directory of Open Access Journals (Sweden)

Saiyed FK

2017-04-01

Full Text Available Faiez K Saiyed,1 Emma C Hamilton,1 Mary T Austin,1,2 1Department of Pediatric Surgery, McGovern Medical School, 2Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA Abstract: The purpose of this review is to outline recent advancements in diagnosis, treatment, and prevention of pediatric melanoma. Despite the recent decline in incidence, it continues to be the deadliest form of skin cancer in children and adolescents. Pediatric melanoma presents differently from adult melanoma; thus, the traditional asymmetry, border irregularity, color variegation, diameter >6 mm, and evolution (ABCDE criteria have been modified to include features unique to pediatric melanoma (amelanotic, bleeding/bump, color uniformity, de novo/any diameter, evolution of mole. Surgical and medical management of pediatric melanoma continues to derive guidelines from adult melanoma treatment. However, more drug trials are being conducted to determine the specific impact of drug combinations on pediatric patients. Alongside medical and surgical treatment, prevention is a central component of battling the incidence, as ultraviolet (UV-related mutations play a central role in the vast majority of pediatric melanoma cases. Aggressive prevention measures targeting sun safety and tanning bed usage have shown positive sun-safety behavior trends, as well as the potential to decrease melanomas that manifest later in life. As research into the field of pediatric melanoma continues to expand, a prevention paradigm needs to continue on a community-wide level. Keywords: melanoma, pediatric, adolescent, childhood

The PEC reactor. Safety analysis: Detailed reports

Energy Technology Data Exchange (ETDEWEB)

1988-01-01

In the safety-analysis of the PEC Brasimone reactor (Italy), attention was focused on the role of plant-incident analysis during the design stage and the conclusions reached. The analysis regarded the following: thermohydraulic incidents at full power; incidents with the reactor shut down; reactivity incidents; core local faults; analysis of fuel-handling incidents; engineered safeguards and passive safety features; coolant leakage and sodium fires; research and development studies on the seismic behaviour of the PEC fast reactor; generalized sodium fire; severe accidents, accident sequences with shudown; reference accident. Both the theoretical and experimental analyses demonstrated the adequacy of the design of the PEC fast reactor, aimed at minimizing the consequences of a hypothetical disruptive core accident with mechanical energy release. It was shown that the containment barriers were sized correctly and that the residual heat from a disassembled core would be removed. The re-evaluation of the source term emphasized the conservative nature of the hypotheses assumed in the preliminary safety analysis for calculating the risk to the public.

Incident reporting to BfArM - regulatory framework, results and challenges.

Science.gov (United States)

Seidel, Robin; Stößlein, Ekkehard; Lauer, Wolfgang

2016-04-01

Medical devices are manifold and one of the most innovative fields of technology. As technologies advance, former limits cease to exist and complex devices become reality. Medical devices represent a very dynamic field with high economic relevance. The manufacturer of a medical device is obliged to minimize product-related risks as well as to demonstrate compliance with the so-called "essential requirements" regarding safety and performance before placing the device on the market. Any critical incident in relation to the application of a medical device has to be reported to the competent authority for risk assessment, which in Germany is either the Federal Institute for Drugs and Medical Devices (BfArM) or the Paul Ehrlich Institute (PEI) depending on the type of device. In this article, the German regulatory framework for medical devices and the resulting tasks for BfArM are described as well as the topics of its recently installed research and development group on prospective risk identification and application safety for medical devices. Results of failure mode and root cause analyses of incident data are presented as well as further data on cases with the result "root-cause analysis not possible". Finally an outlook is given on future challenges regarding risk assessment for medical devices.

Performance Monitoring for Nuclear Safety Related Instrumentation at PUSPATI TRIGA Reactor (RTP)

International Nuclear Information System (INIS)

Zareen Khan Abdul Jalil Khan; Ridzuan Abdul Mutalib; Mohd Sabri Minhat

2015-01-01

The Reactor TRIGA PUSPATI (RTP) at Malaysia Nuclear Agency is a TRIGA Mark II type reactor and pool type cooled by natural circulation of light water. This paper describe on performance monitoring for nuclear safety related instrumentation in TRIGA PUSPATI Reactor (RTP) of based on various parameter of reactor safety instrument channel such as log power, linear power, Fuel temperature, coolant temperature will take into consideration. Methodology of performance on estimation and monitoring is to evaluate and analysis of reactor parameters which is important of reactor safety and control. And also to estimate power measurement, differential of log and linear power and fuel temperature during reactor start-up, operation and shutdown .This study also focus on neutron power fluctuation from fission chamber during reactor start-up and operation. This work will present result of performance monitoring from RTP which indicated the safety parameter identification and initiate safety action on crossing the threshold set point trip. Conclude that performance of nuclear safety related instrumentation will improved the reactor control and safety parameter during reactor start-up, operation and shutdown. (author)