National Fire Incident Reporting System (NFIRS)

Data.gov (United States)

Department of Homeland Security — The National Fire Incident Reporting System (NFIRS) is a reporting standard that fire departments use to uniformly report on the full range of their activities, from...

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.

Safety culture and learning from incidents: the role of incident reporting and causal analyses

International Nuclear Information System (INIS)

Wilpert, B.

1994-01-01

Nuclear industry more than any other industrial branch has developed and used predictive risk analysis as a method of feedforward control of safety and reliability. Systematic evaluation of operating experience, statistical documentation of component failures, systematic documentation and analysis of incidents are important complementary elements of feedback control: we are dealing here with adjustment and learning from experience, in particular from past incidents. Using preliminary findings from ongoing research at the Research Center Systems Safety at the Berlin University of Technology the contribution discusses preconditions for an effective use of lessons to be learnt from closely matched incident reporting and in depth analyses of causal chains leading to incidents. Such conditions are especially standardized documentation, reporting and analyzing methods of incidents; structured information flows and feedback loops; abstaining from culpability search; mutual trust of employees and management; willingness of all concerned to continually evaluate and optimize the established learning system. Thus, incident related reporting and causal analyses contribute to safety culture, which is seen to emerge from tightly coupled organizational measures and respective change in attitudes and behaviour. (author) 2 figs., 7 refs

How to Report a Pesticide Incident Involving Exposures to People

Science.gov (United States)

Pesticides incidents must be reported by pesticide registrants. Others, such as members of the public and environmental professionals, would like to report pesticide incidents. This website will facilitate such incident reporting.

OECD-FIRE PR02. Summary report to finalize project stage 1 (2002-2005)

International Nuclear Information System (INIS)

Kolar, L.

2005-12-01

The report is structured as follows: (1) Project background; (2) Project goals; (3) Project infrastructure; (4) Database scope; (5) Data collection history and current status; (6) Database structure; (7) Statistical observations; (8) Conclusions. The following data are presented in graphs: Fire extinguishing database; Building (site) of fire incidence and total number of incidences in the database; Component on which fire was initiated; Mechanism of combustion; Root cause of the fire; Fire detection types; Technical data of the fire detection system; Fire detector type; Fuel/flammable material/fire load; Fire extinguishing type; Technical data of the fire extinguishing system; Who extinguished the fire; Fire consequences. (P.A.)

49 CFR 225.15 - Accidents/incidents not to be reported.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Accidents/incidents not to be reported. 225.15... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.15 Accidents/incidents not to be reported. A railroad need not report: (a) Casualties which...

Factors influencing incident reporting in surgical care.

Science.gov (United States)

Kreckler, S; Catchpole, K; McCulloch, P; Handa, A

2009-04-01

To evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events. Anonymous web-based questionnaire survey. General Surgical Department in a UK teaching hospital. Of 203 eligible staff, 55 (76.4%) doctors and 82 (62.6%) nurses participated. Knowledge and use of local reporting system; propensity to report incidents which vary by outcome (harm, no harm, harm prevented); propensity to report surgical complications; practical and psychological barriers to reporting. Nurses were significantly more likely to know of the local reporting system and to have recently completed a report than doctors. The level of harm (F(1.8,246) = 254.2, pvs 53%, z = 4.633, psystems.

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

Reporting Helicopter Emergency Medical Services in Major Incidents

DEFF Research Database (Denmark)

Fattah, Sabina; Johnsen, Anne Siri; Sollid, Stephen J M

2016-01-01

OBJECTIVE: Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences...... variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. CONCLUSION: Based on opinions from European...

Hazmat Yearly Incident Summary Reports - Data Mining Tool

Data.gov (United States)

Department of Transportation — Series of Incident data and summary statistics reports produced which provide statistical information on incidents by type, year, geographical location, and others....

Real-time incident detection using social media data.

Science.gov (United States)

2016-05-09

The effectiveness of traditional incident detection is often limited by sparse sensor coverage, and reporting incidents to emergency response systems : is labor-intensive. This research project mines tweet texts to extract incident information on bot...

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.

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.

AIDS incidence and mortality in injecting drug users: the AjUDE-Brasil II Project

Directory of Open Access Journals (Sweden)

Cardoso Mauro Nogueira

2006-01-01

Full Text Available This paper presents AIDS incidence and mortality among injecting drug users (IDUs reached by the AjUDE-Brasil II Project. From a cross-sectional survey, 478 IDUs were interviewed in three Brazilian cities: Porto Alegre, São José do Rio Preto, and Itajaí. The cohort was followed up in the Brazilian surveillance database for AIDS and mortality during 2000 and 2001. AIDS incidence was 1.1 cases per 100 person-years, and the mortality rate was 2.8 deaths per 100 person-years. AIDS cases only occurred in IDUs who reported ever having shared injecting equipment. Female gender (RR = 5.30, homelessness (RR = 6.16, and report of previous sexual relations with same-sex partners (RR = 6.21 were associated with AIDS. Deaths occurred only among males. Homelessness (RR = 3.00, lack of income (RR = 2.65, HIV seropositive status (RR = 4.52, and no history of incarceration (RR = 3.71 were also associated with death. These findings support evidence that gender and socioeconomic conditions are both determinants of morbidity and mortality in Brazilian IDUs.

Incidents/accidents classification and reporting in Statoil.

Science.gov (United States)

Berentsen, Rune; Holmboe, Rolf H

2004-07-26

Based on requirements in the new petroleum regulations from Norwegian Petroleum Directorate (NPD) and the realisation of a need to improve and rationalise the routines for reporting and follow up of incidents, Statoil Exploration & Production Norway (Statoil E&P Norway) has formulated a new strategy and process for handling of incidents/accidents. The following past experiences serve as basis for the changes made to incident reporting in Statoil E&P Norway; too much resources were spent on a comprehensive handling and analysis of a vast amount of incidents with less importance for the safety level, taking the focus away from the more severe and important issues at hand, the assessment of "Risk Factor", i.e. the combination of recurrence frequency and consequence, was difficult to use. The high degree of subjectivity involved in the determination of the "Risk Factor" (in particular the estimation of the recurrence frequency) resulted in poor data quality and lack of consistency in the data material. The new system for categorisation and handling of undesirable incidents was established in January 2002. The intention was to get a higher degree of focus on serious incidents (injuries, damages, loss and near misses), with a thorough handling and follow-up. This is reflected throughout the handling of the serious incidents, all the way from immediate notification of the incident, through investigation and follow-up of corrective and preventive actions. Simultaneously, it was also an objective to rationalise/simplify the handling of less serious incidents. These incidents are, however, subjected to analyses twice a year in order to utilize the learning opportunity that they also provide. A year after the introduction of this new system for categorisation and follow-up of undesirable incidents, Statoil's experiences are predominantly good; the intention to get a higher degree of focus on serious incidents (injuries, damages, loss and near misses), has been met, the data

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...

Sci-Fri AM: Quality, Safety, and Professional Issues 06: An Evaluation of Incident Reporting and Learning using the Canadian National System for Incident Reporting – Radiation Treatment

Energy Technology Data Exchange (ETDEWEB)

Montgomery, Logan; Kildea, John [McGill University Health Centre (Canada)

2016-08-15

We report on the development and clinical deployment of an in-house incident reporting and learning system that implements the taxonomy of the Canadian National System for Incident Reporting – Radiation Treatment (NSIR-RT). In producing our new system, we aimed to: Analyze actual incidents, as well as potentially dangerous latent conditions. Produce recommendations on the NSIR-RT taxonomy. Incorporate features to divide reporting responsibility among clinical staff and expedite incident categorization within the NSIR-RT framework. Share anonymized incident data with the national database. Our multistep incident reporting workflow is focused around an initial report and a detailed follow-up investigation. An investigator, chosen at the time of reporting, is tasked with performing the investigation. The investigation feature is connected to our electronic medical records database to allow automatic field population and quick reference of patient and treatment information. Additional features include a robust visualization suite, as well as the ability to flag incidents for discussion at monthly Risk Management meetings and task ameliorating actions to staff. Our system was deployed into clinical use in January 2016. Over the first three months of use, 45 valid incidents were reported; 31 of which were reported as actual incidents as opposed to near-misses or reportable circumstances. However, we suspect there is ambiguity within our centre in determining the appropriate event type, which may be arising from the taxonomy itself. Preliminary trending analysis aided in revealing workflow issues pertaining to storage of treatment accessories and treatment planning delays. Extensive analysis will be undertaken as more data are accrued.

Sci-Fri AM: Quality, Safety, and Professional Issues 06: An Evaluation of Incident Reporting and Learning using the Canadian National System for Incident Reporting – Radiation Treatment

International Nuclear Information System (INIS)

Montgomery, Logan; Kildea, John

2016-01-01

We report on the development and clinical deployment of an in-house incident reporting and learning system that implements the taxonomy of the Canadian National System for Incident Reporting – Radiation Treatment (NSIR-RT). In producing our new system, we aimed to: Analyze actual incidents, as well as potentially dangerous latent conditions. Produce recommendations on the NSIR-RT taxonomy. Incorporate features to divide reporting responsibility among clinical staff and expedite incident categorization within the NSIR-RT framework. Share anonymized incident data with the national database. Our multistep incident reporting workflow is focused around an initial report and a detailed follow-up investigation. An investigator, chosen at the time of reporting, is tasked with performing the investigation. The investigation feature is connected to our electronic medical records database to allow automatic field population and quick reference of patient and treatment information. Additional features include a robust visualization suite, as well as the ability to flag incidents for discussion at monthly Risk Management meetings and task ameliorating actions to staff. Our system was deployed into clinical use in January 2016. Over the first three months of use, 45 valid incidents were reported; 31 of which were reported as actual incidents as opposed to near-misses or reportable circumstances. However, we suspect there is ambiguity within our centre in determining the appropriate event type, which may be arising from the taxonomy itself. Preliminary trending analysis aided in revealing workflow issues pertaining to storage of treatment accessories and treatment planning delays. Extensive analysis will be undertaken as more data are accrued.

Diabetes incidence and projections from prevalence surveys in Fiji.

Science.gov (United States)

Morrell, Stephen; Lin, Sophia; Tukana, Isimeli; Linhart, Christine; Taylor, Richard; Vatucawaqa, Penina; Magliano, Dianna J; Zimmet, Paul

2016-11-25

Type 2 diabetes mellitus (T2DM) incidence is traditionally derived from cohort studies that are not always feasible, representative, or available. The present study estimates T2DM incidence in Fijian adults from T2DM prevalence estimates assembled from surveys of 25-64 year old adults conducted over 30 years (n = 14,288). T2DM prevalence by five-year age group from five population-based risk factor surveys conducted over 1980-2011 were variously adjusted for urban-rural residency, ethnicity, and sex to previous censuses (1976, 1986, 1996, 2009) to improve representativeness. Prevalence estimates were then used to calculate T2DM incidence based on birth cohorts from the age-period (Lexis) matrix following the Styblo technique, first used to estimate annual risk of tuberculosis infection (incidence) from sequential Mantoux population surveys. Poisson regression of year, age, sex, and ethnicity strata (n = 160) was used to develop projections of T2DM prevalence and incidence to 2020 based on various scenarios of population weight measured by body mass index (BMI) change. T2DM prevalence and annual incidence increased in Fiji over 1980-2011. Prevalence was higher in Indians and men than i-Taukei and women. Incidence was higher in Indians and women. From regression analyses, absolute reductions of 2.6 to 5.1% in T2DM prevalence (13-26% lower), and 0.5-0.9 per 1000 person-years in incidence (8-14% lower), could be expected in 2020 in adults if mean population weight could be reduced by 1-4 kg, compared to the current period trend in weight gain. This is the first application of the Styblo technique to calculate T2DM incidence from population-based prevalence surveys over time. Reductions in population BMI are predicted to reduce T2DM incidence and prevalence in Fiji among adults aged 25-64 years.

30 CFR 250.187 - What are MMS' incident reporting requirements?

Science.gov (United States)

2010-07-01

... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What are MMS' incident reporting requirements... Reporting Requirements § 250.187 What are MMS' incident reporting requirements? (a) You must report all... other permit issued by MMS, and that are related to operations resulting from the exercise of your...

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country.

Science.gov (United States)

Abbasi, Shemila; Khan, Fauzia Anis; Khan, Sobia

2018-01-01

The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

Hazmat 10 Year Incident Summary Reports - Data Mining Tool

Data.gov (United States)

Department of Transportation — Series of Incident data and summary statistics reports produced which provide statistical information on incidents by type, year, geographical location, and others....

Which factors affect reported headache incidences after lumbar myelography?

International Nuclear Information System (INIS)

Sand, T.

1989-01-01

Nineteen publications were reviewed and subjected to a combined statistical analysis (meta-analysis) regarding the influence of study design factors upon reported headache and total symptom incidences after lumbar iohexol myelography. A significant association was found between reported side effects on one hand and needle diameter, follow-up time and the method of questioning respectively on the other. The combination of long follow-up time and specific questioning and the combination between larger diameter (20G) needles and long follow-up time, both seemed to be strong predictors for reporting high side effect incidences. Nine studies were similarly analyzed regarding the influence of early ambulation and contrast type upon reported headache incidences. Early ambulation significantly increased headache after iohexol or iopamidol lumbar myelography as opposed to metrizamide myelography. (orig.)

Improvement in the incident reporting and investigation procedures using process excellence (DMAI2C) methodology

International Nuclear Information System (INIS)

Miles, Elizabeth N.

2006-01-01

In 1996, Health and Safety introduced an incident investigation process called Learning to Look ( C) to Johnson and Johnson. This process provides a systematic way of analyzing work-related injuries and illness, uncovers root cause that leads to system defects, and points to viable solutions. The process analyzed involves three steps: investigation and reporting of the incident, determination of root cause, and development and implementation of a corrective action plan. The process requires the investigators to provide an initial communication for work-related serious injuries and illness as well as lost workday cases to Corporate Headquarters within 72h of the incident with a full investigative report to follow within 10 days. A full investigation requires a written report, a cause-result logic diagram (CRLD), a corrective action plan (CAP) and a report of incident costs (SafeCost) all due to be filed electronically. It is incumbent on the principal investigator and his or her investigative teams to assemble the various parts of the investigation and to follow up with the relevant parties to ensure corrective actions are implemented, and a full report submitted to Corporate executives. Initial review of the system revealed that the process was not working as designed. A number of reports were late, not signed by the business leaders, and in some instances, all cause were not identified. Process excellence was the process used to study the issue. The team used six sigma DMAI 2 C methodologies to identify and implement system improvements. The project examined the breakdown of the critical aspects of the reporting and investigation process that lead to system errors. This report will discuss the study findings, recommended improvements, and methods used to monitor the new improved process

The evaluation of a web-based incident reporting system.

Science.gov (United States)

Kuo, Ya-Hui; Lee, Ting-Ting; Mills, Mary Etta; Lin, Kuan-Chia

2012-07-01

A Web-based reporting system is essential to report incident events anonymously and confidentially. The purpose of this study was to evaluate a Web-based reporting system in Taiwan. User satisfaction and impact of system use were evaluated through a survey answered by 249 nurses. Incident events reported in paper and electronic systems were collected for comparison purposes. Study variables included system user satisfaction, willingness to report, number of reports, severity of the events, and efficiency of the reporting process. Results revealed that senior nurses were less willing to report events, nurses on internal medicine units had higher satisfaction than others, and lowest satisfaction was related to the time it took to file a report. In addition, the Web-based reporting system was used more often than the paper system. The percentages of events reported were significantly higher in the Web-based system in laboratory, environment/device, and incidents occurring in other units, whereas the proportions of reports involving bedsores and dislocation of endotracheal tubes were decreased. Finally, moderate injury event reporting decreased, whereas minor or minimal injury event reporting increased. The study recommends that the data entry process be simplified and the network system be improved to increase user satisfaction and reporting rates.

Photovoltaic Programme, Edition 2006. Summary report. Project list. Annual project reports 2005 (abstracts)

Energy Technology Data Exchange (ETDEWEB)

Nowak, S.

2006-07-01

This comprehensive, illustrated report for the Swiss Federal Office of Energy (SFOE) presents an overview of the work done as part of the 2005 research programme, along with the abstracts of the annual reports of the project leaders on research projects. It presents the programme's main points of focus, discusses the work done and the results obtained. Areas covered include cell technology (13 reports), solar modules and building integration (3 reports) , system technology (4 reports) as well as various further projects (5) that are connected with photovoltaics. Four further reports concern international co-operation. Further, several pilot and demonstration (P+D) projects are discussed. Lists of all research and development projects and pilot and demonstration projects are supplied. Work done at several institutions in Switzerland and at leading commercial companies is described.

EP&R Standards Project Report: Technical Review of National Incident Management Standards

Energy Technology Data Exchange (ETDEWEB)

Stenner, Robert D.

2007-04-24

The importance and necessity for a fully developed and implemented National Incident Management System (NIMS) has been demonstrated in recent years by the impact of national events such as Hurricane Katrina in 2005. Throughout the history of emergency response to major disasters, especially when multiple response organizations are involved, there have been systemic problems in the consistency and uniformity of response operations. Identifying national standards that support the development and implementation of NIMS is key to helping solve these systemic problems. The NIMS seeks to provide uniformity and consistency for incident management by using common terminology and protocols that will enable responders to coordinate their efforts to ensure an efficient response.

Critical Incident Reporting Systems: Perceived Competing Social ...

African Journals Online (AJOL)

The safe operation of complex socio-technical systems is dependent upon the reporting of safety critical incidents by operators within a system. Through the action of reporting, systems develop the capability as a learning organisation to improve human and organisational performance. The aim of the study is therefore to ...

Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database

DEFF Research Database (Denmark)

Andersen, Peter Oluf; Maaløe, Rikke; Andersen, Henning Boje

2010-01-01

Background Critical incident reports can identify areas for improvement in resuscitation practice. The Danish Patient Safety Database is a mandatory reporting system and receives critical incident reports submitted by hospital personnel. The aim of this study is to identify, analyse and categorize...... critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. Methods The search terms “cardiac arrest” and “resuscitation” were used to identify reports in the Danish Patient Safety Database. Identified critical incidents were then classified into categories. Results One...

Plutonium Reclamation Facility incident response project progress report

Energy Technology Data Exchange (ETDEWEB)

Austin, B.A.

1997-11-25

This report provides status of Hanford activities in response to process deficiencies highlighted during and in response to the May 14, 1997, explosion at the Plutonium Reclamation Facility. This report provides specific response to the August 4, 1997, memorandum from the Secretary which requested a progress report, in 120 days, on activities associated with reassessing the known and evaluating new vulnerabilities (chemical and radiological) at facilities that have been shut down, are in standby, are being deactivated or have otherwise changed their conventional mode of operation in the last several years. In addition, this report is intended to provide status on emergency response corrective activities as requested in the memorandum from the Secretary on August 28, 1997. Status is also included for actions requested in the second August 28, 1997, memorandum from the Secretary, regarding timely notification of emergencies.

Plutonium Reclamation Facility incident response project progress report

International Nuclear Information System (INIS)

Austin, B.A.

1997-01-01

This report provides status of Hanford activities in response to process deficiencies highlighted during and in response to the May 14, 1997, explosion at the Plutonium Reclamation Facility. This report provides specific response to the August 4, 1997, memorandum from the Secretary which requested a progress report, in 120 days, on activities associated with reassessing the known and evaluating new vulnerabilities (chemical and radiological) at facilities that have been shut down, are in standby, are being deactivated or have otherwise changed their conventional mode of operation in the last several years. In addition, this report is intended to provide status on emergency response corrective activities as requested in the memorandum from the Secretary on August 28, 1997. Status is also included for actions requested in the second August 28, 1997, memorandum from the Secretary, regarding timely notification of emergencies

Identifying Predictive Factors for Incident Reports in Patients Receiving Radiation Therapy

Energy Technology Data Exchange (ETDEWEB)

Elnahal, Shereef M., E-mail: selnaha1@jhmi.edu [Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Blackford, Amanda [Department of Oncology Biostatistics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Smith, Koren; Souranis, Annette N.; Briner, Valerie; McNutt, Todd R.; DeWeese, Theodore L.; Wright, Jean L.; Terezakis, Stephanie A. [Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (United States)

2016-04-01

Purpose: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. Methods and Materials: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause. A control group of patients without events was generated for comparison. Summary statistics, likelihood ratios, and mixed-effect logistic regression models were used for group comparisons. Results: The incident and control groups comprised 794 and 499 patients, respectively. Common root causes included documentation errors (26.5%), communication (22.5%), technical treatment planning (37.5%), and technical treatment delivery (13.5%). Incidents were more frequently reported in minors (age <18 years) than in adult patients (37.7% vs 0.4%, P<.001). Patients with head and neck (16% vs 8%, P<.001) and breast (20% vs 15%, P=.03) primaries more frequently had incidents, whereas brain (18% vs 24%, P=.008) primaries were less frequent. Larger tumors (17% vs 10% had T4 lesions, P=.02), and cases on protocol (9% vs 5%, P=.005) or with intensity modulated radiation therapy/image guided intensity modulated radiation therapy (52% vs 43%, P=.001) were more likely to have incidents. Conclusions: We found several treatment- and patient-specific variables associated with incidents. These factors should be considered by treatment teams at the time of peer review to identify patients at higher risk. Larger datasets are required to recommend changes in care process standards, to minimize safety risks.

Identifying Predictive Factors for Incident Reports in Patients Receiving Radiation Therapy

International Nuclear Information System (INIS)

Elnahal, Shereef M.; Blackford, Amanda; Smith, Koren; Souranis, Annette N.; Briner, Valerie; McNutt, Todd R.; DeWeese, Theodore L.; Wright, Jean L.; Terezakis, Stephanie A.

2016-01-01

Purpose: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. Methods and Materials: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause. A control group of patients without events was generated for comparison. Summary statistics, likelihood ratios, and mixed-effect logistic regression models were used for group comparisons. Results: The incident and control groups comprised 794 and 499 patients, respectively. Common root causes included documentation errors (26.5%), communication (22.5%), technical treatment planning (37.5%), and technical treatment delivery (13.5%). Incidents were more frequently reported in minors (age <18 years) than in adult patients (37.7% vs 0.4%, P<.001). Patients with head and neck (16% vs 8%, P<.001) and breast (20% vs 15%, P=.03) primaries more frequently had incidents, whereas brain (18% vs 24%, P=.008) primaries were less frequent. Larger tumors (17% vs 10% had T4 lesions, P=.02), and cases on protocol (9% vs 5%, P=.005) or with intensity modulated radiation therapy/image guided intensity modulated radiation therapy (52% vs 43%, P=.001) were more likely to have incidents. Conclusions: We found several treatment- and patient-specific variables associated with incidents. These factors should be considered by treatment teams at the time of peer review to identify patients at higher risk. Larger datasets are required to recommend changes in care process standards, to minimize safety risks.

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.

Science.gov (United States)

Westbrook, Johanna I; Li, Ling; Lehnbom, Elin C; Baysari, Melissa T; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O

2015-02-01

To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. Two major academic teaching hospitals in Sydney, Australia. Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. © The Author 2015. Published by Oxford University Press in association

Risk factors for radiotherapy incidents and impact of an online electronic reporting system

International Nuclear Information System (INIS)

Chang, David W.; Cheetham, Lynn; Marvelde, Luc te; Bressel, Mathias; Kron, Tomas; Gill, Suki; Tai, Keen Hun; Ball, David; Rose, William; Silva, Linas; Foroudi, Farshad

2014-01-01

Background and purpose: To ascertain the rate, type, significance, trends and the potential risk factors associated with radiotherapy incidents in a large academic department. Materials and methods: Data for all radiotherapy activities from July 2001 to January 2011 were reviewed from radiotherapy incident reporting forms. Patient and treatment data were obtained from the radiotherapy record and verification database (MOSAIQ) and the patient database (HOSPRO). Logistic regression analyses were performed to determine variables associated with radiotherapy incidents. Results: In that time, 65,376 courses of radiotherapy were delivered with a reported incident rate of 2.64 per 100 courses. The rate of incidents per course increased (1.96 per 100 courses to 3.52 per 100 courses, p < 0.001) whereas the proportion of reported incidents resulting in >5% deviation in dose (10.50 to 2.75%, p < 0.001) had decreased after the introduction of an online electronic reporting system. The following variables were associated with an increased rate of incidents: afternoon treatment time, paediatric patients, males, inpatients, palliative plans, head-and-neck, skin, sarcoma and haematological malignancies. In general, complex plans were associated with higher incidence rates. Conclusion: Radiotherapy incidents were infrequent and most did not result in significant dose deviation. A number of risk factors were identified and these could be used to highlight high-risk cases in the future. Introduction of an online electronic reporting system resulted in a significant increase in the number of incidents being reported

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

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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

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.

Human factors analysis of incident/accident report

International Nuclear Information System (INIS)

Kuroda, Isao

1992-01-01

Human factors analysis of accident/incident has different kinds of difficulties in not only technical, but also psychosocial background. This report introduces some experiments of 'Variation diagram method' which is able to extend to operational and managemental factors. (author)

Documentation of in-hospital falls on incident reports: qualitative investigation of an imperfect process.

Science.gov (United States)

Haines, Terry P; Cornwell, Petrea; Fleming, Jennifer; Varghese, Paul; Gray, Len

2008-12-11

Incident reporting is the prevailing approach to gathering data on accidental falls in hospitals for both research and quality assurance purposes, though is of questionable quality as staff time pressures, perception of blame and other factors are thought to contribute to under-reporting. This research aimed to identify contextual factors influencing recording of in-hospital falls on incident reports. A qualitative multi-centre investigation using an open written response questionnaire was undertaken. Participants were asked to describe any factors that made them feel more or less likely to record a fall on an incident report. 212 hospital staff from 30 wards in 7 hospitals in Queensland, Australia provided a response. A framework approach was employed to identify and understand inter-relationships between emergent categories. Three main categories were developed. The first, determinants of reporting, describes a hierarchical structure of primary (principle of reporting), secondary (patient injury), and tertiary determinants that influenced the likelihood that an in-hospital fall would be recorded on an incident report. The tertiary determinants frequently had an inconsistent effect. The second and third main categories described environmental/cultural facilitators and barriers respectively which form a background upon which the determinants of reporting exists. A distinctive framework with clear differences to recording of other types of adverse events on incident reports was apparent. Providing information to hospital staff regarding the purpose of incident reporting and the usefulness of incident reporting for preventing future falls may improve incident reporting practices.

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.

Documentation of in-hospital falls on incident reports: Qualitative investigation of an imperfect process

Directory of Open Access Journals (Sweden)

Fleming Jennifer

2008-12-01

Full Text Available Abstract Background Incident reporting is the prevailing approach to gathering data on accidental falls in hospitals for both research and quality assurance purposes, though is of questionable quality as staff time pressures, perception of blame and other factors are thought to contribute to under-reporting. Methods This research aimed to identify contextual factors influencing recording of in-hospital falls on incident reports. A qualitative multi-centre investigation using an open written response questionnaire was undertaken. Participants were asked to describe any factors that made them feel more or less likely to record a fall on an incident report. 212 hospital staff from 30 wards in 7 hospitals in Queensland, Australia provided a response. A framework approach was employed to identify and understand inter-relationships between emergent categories. Results Three main categories were developed. The first, determinants of reporting, describes a hierarchical structure of primary (principle of reporting, secondary (patient injury, and tertiary determinants that influenced the likelihood that an in-hospital fall would be recorded on an incident report. The tertiary determinants frequently had an inconsistent effect. The second and third main categories described environmental/cultural facilitators and barriers respectively which form a background upon which the determinants of reporting exists. Conclusion A distinctive framework with clear differences to recording of other types of adverse events on incident reports was apparent. Providing information to hospital staff regarding the purpose of incident reporting and the usefulness of incident reporting for preventing future falls may improve incident reporting practices.

The international Chernobyl project

International Nuclear Information System (INIS)

1991-01-01

This article summarizes the official report of the International Advisory Committee at the conference of the International Chernobyl Project held in Vienna, May 1991. More details will be found in the actual report, ''The International Chernobyl Project: An Overview'' (INI22:066284/5). Measurements and assessments carried out under the project provided general corroboration of the levels of surface cesium-137 contamination reported in the official maps. The project also concluded that the official procedures for estimating radiation doses to the population were scientifically sound, although they generally resulted in overestimates of two- to threefold. The project could find no marked increase in the incidence of leukemia or cancer, but reported absorbed thyroid doses in children might lead to a statistically detectable rise in the incidence of thyroid tumors. Significant non-radiation-related health disorders were found, and the accident had substantial psychological consequences in terms of anxiety and stress. The project concluded that the protective measures taken were too extreme, and that population relocation and foodstuff restrictions should have been less extensive

Community pharmacy incident reporting: a new tool for community pharmacies in Canada.

Science.gov (United States)

Ho, Certina; Hung, Patricia; Lee, Gary; Kadija, Medina

2010-01-01

Incident reporting offers insight into a variety of intricate processes in healthcare. However, it has been found that medication incidents are under reported in the community pharmacy setting. The Community Pharmacy Incident Reporting (CPhIR) program was created by the Institute for Safe Medication Practices Canada specifically for incident reporting in the community pharmacy setting in Canada. The initial development of key elements for CPhIR included several focus-group teleconferences with pharmacists from Ontario and Nova Scotia. Throughout the development and release of the CPhIR pilot, feedback from pharmacists and pharmacy technicians was constantly incorporated into the reporting program. After several rounds of iterative feedback, testing and consultation with community pharmacy practitioners, a final version of the CPhIR program, together with self-directed training materials, is now ready to launch. The CPhIR program provides users with a one-stop platform to report and record medication incidents, export data for customized analysis and view comparisons of individual and aggregate data. These unique functions allow for a detailed analysis of underlying contributing factors in medication incidents. A communication piece for pharmacies to share their experiences is in the process of development. To ensure the success of the CPhIR program, a patient safety culture must be established. By gaining a deeper understanding of possible causes of medication incidents, community pharmacies can implement system-based strategies for quality improvement and to prevent potential errors from occurring again in the future. This article highlights key features of the CPhIR program that will assist community pharmacies to improve their drug distribution system and, ultimately, enhance patient safety.

Final Project Report Project 10749-4.2.2.1 2007-2009

Energy Technology Data Exchange (ETDEWEB)

Zacher, Alan H.; Holladay, Johnathan E.; Frye, J. G.; Brown, Heather M.; Santosa, Daniel M.; Oberg, Aaron A.

2009-05-11

This is the final report for the DOE Project 10749-4.2.2.1 for the FY2007 - FY2009 period. This report is non-proprietary, and will be submitted to DOE as a final project report. The report covers activities under the DOE Project inside CRADA 269 (Project 53231) as well as project activites outside of that CRADA (Project 56662). This is the final report that is summarized from the non-proprietary quarterlies submitted to DOE over the past 2.5 years, which in turn are summaries from the proprietary technical reporting to UOP.

Unicycle Project Report

OpenAIRE

Thomson, S

2010-01-01

The Unicycle project implemented an institutional Open Educational Resource repository with a view to ensuring sustainability in approach by embedding OER as an Assessment, Learning and Teaching strategy. This is the final submitted report for the project.

Committee's report on ruthenium fall-out incident

International Nuclear Information System (INIS)

Borkowski, C.J.; Crawford, J.H.; Livingston, R.; Ritchie, R.H.; Rupp, A.F.; Taylor, E.H.

1983-07-01

Investigations of the fall-out incident of November 11 and 12, 1959, by responsible parties (Health Physics Division and Operations Division personnel) established beyond reasonable doubt that the incident had its origin in the expulsion of particles, heavily contaminated with ruthenium, which had been detached from the walls of the electric fan housing and ducts in the off-gas system associated with the brick stack. All available evidence indicates that the particles were loosened during maintenance work on the exhaust damper and the bearings of the electric fan and were carried up the stack in two bursts as particulate fall-out when this fan was put back into service. Radiographic and chemical analysis showed the activity to be almost entirely ruthenium (Ru 106 ) and its daughter rhodium (Rh 106 ) with very little, if any, strontium being present. This report summarizes the findings and sets forth the conclusions and recommendations of the Committee asked to investigate the incident

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

Survey of reportable incidents in nuclear power plants in Germany in the year 1992

International Nuclear Information System (INIS)

1993-01-01

In 1992, 223 reportable incidents in German nuclear power plant have been reported. There was no radioactivity release exceeding the maximum permissible limits, and there were no hazardous effects on the population or the environment. There was no incident belonging to category S of the official event scale, requiring urgent notification, while there were two incidents requiring immediate notification. All other incidents reported belonged to category N, the lowest on the scale, requiring normal notification. 216 incidents belonged to category 0 of the INES scale, and 7 to INES category 1 (disturbance). The tabulated survey of the report lists the various events and their position on the INES scale. The reportable events have been analysed thoroughly from various viewpoints, but no systematic pattern of weak points could be detected. (orig./HP) [de

The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008.

Science.gov (United States)

Rutherford, J S; Flin, R; Irwin, A

2015-07-01

The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance". A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative non-technical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.

Critical incidence reporting systems - an option in equine anaesthesia? Results from a panel meeting.

Science.gov (United States)

Hartnack, Sonja; Bettschart-Wolfensberger, Regula; Driessen, Bernd; Pang, Daniel; Wohlfender, Franziska

2013-11-01

To provide a brief introduction into Critical Incident Reporting Systems (CIRS) as used in human medicine, and to report the discussion from a recent panel meeting discussion with 23 equine anaesthetists in preparation for a new CEPEF-4 (Confidential Enquiry into Perioperative Equine Fatalities) study. Moderated group discussions, and review of literature. The first group discussion focused on the definition of 'preventable critical incidents' and/or 'near misses' in the context of equine anaesthesia. The second group discussion focused on categorizing critical incidents according to an established framework for analysing risk and safety in clinical medicine. While critical incidents do occur in equine anaesthesia, no critical incident reporting system including systematic collection and analysis of critical incidents is in place. Critical incident reporting systems could be used to improve safety in equine anaesthesia - in addition to other study types such as mortality studies. © 2013 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia.

Viruses associated with acute respiratory infections and influenza-like illness among outpatients from the Influenza Incidence Surveillance Project, 2010-2011.

Science.gov (United States)

Fowlkes, Ashley; Giorgi, Andrea; Erdman, Dean; Temte, Jon; Goodin, Kate; Di Lonardo, Steve; Sun, Yumei; Martin, Karen; Feist, Michelle; Linz, Rachel; Boulton, Rachelle; Bancroft, Elizabeth; McHugh, Lisa; Lojo, Jose; Filbert, Kimberly; Finelli, Lyn

2014-06-01

The Influenza Incidence Surveillance Project (IISP) monitored outpatient acute respiratory infection (ARI; defined as the presence of ≥ 2 respiratory symptoms not meeting ILI criteria) and influenza-like illness (ILI) to determine the incidence and contribution of associated viral etiologies. From August 2010 through July 2011, 57 outpatient healthcare providers in 12 US sites reported weekly the number of visits for ILI and ARI and collected respiratory specimens on a subset for viral testing. The incidence was estimated using the number of patients in the practice as the denominator, and the virus-specific incidence of clinic visits was extrapolated from the proportion of patients testing positive. The age-adjusted cumulative incidence of outpatient visits for ARI and ILI combined was 95/1000 persons, with a viral etiology identified in 58% of specimens. Most frequently detected were rhinoviruses/enteroviruses (RV/EV) (21%) and influenza viruses (21%); the resulting extrapolated incidence of outpatient visits was 20 and 19/1000 persons respectively. The incidence of influenza virus-associated clinic visits was highest among patients aged 2-17 years, whereas other viruses had varied patterns among age groups. The IISP provides a unique opportunity to estimate the outpatient respiratory illness burden by etiology. Influenza virus infection and RV/EV infection(s) represent a substantial burden of respiratory disease in the US outpatient setting, particularly among children.

[A project to reduce the incidence of intubation care errors among foreign health aides].

Science.gov (United States)

Chen, Mei-Ju; Lu, Yu-Hua; Chen, Chiu-Chun; Li, Ai-Cheng

2014-08-01

Foreign health aides are the main providers of care for the elderly and the physically disabled in Taiwan. Correct care skills improve patient safety. In 2010, the incidence of mistakes among foreign health aides in our hospital unit was 58% for nasogastric tube care and 57% for tracheostomy tube care. A survey of foreign health aides and nurses in the unit identified the main causes of these mistakes as: communication difficulties, inaccurate instructions given to patients, and a lack of standard operating procedures given to the foreign health aides. This project was designed to reduce the rates of improper nasogastric tube care and improper tracheostomy tube care to 20%, respectively. This project implemented several appropriate measures. We produced patient instruction hand-outs in Bahasa Indonesia, established a dedicated file holder for Bahasa Indonesian tube care reference information, produced Bahasa Indonesian tube-care-related posters, produced a short film about tube care in Bahasa Indonesian, and established a standardized operating procedure for tube care in our unit. Between December 15th and 31st, 2011, we audited the performance of a total of 32 foreign health aides for proper execution of nasogastric tube care (21 aides) and of proper execution of tracheostomy tube care (11 aides). Patients with concurrent nasogastric and tracheostomy tubes were inspected separately for each care group. The incidence of improper care decreased from 58% to 18% nasogastric intubation and 57% to 18% for tracheostomy intubation. This project decreased significantly the incidence of improper tube care by the foreign health aides in our unit. Furthermore, the foreign health aides improved their tube nursing care skills. Therefore, this project improved the quality of patient care.

[A project to reduce the incidence of facial pressure ulcers caused by prolonged surgery with prone positioning].

Science.gov (United States)

Lee, Wen-Yi; Lin, Pao-Chen; Weng, Chia-Hsing; Lin, Yi-Lin; Tsai, Wen-Lin

2012-06-01

We observed in our institute a 13.6% incidence of prolonged surgery (>4 hours) induced facial pressure ulcers that required prone positioning. Causes identified included: (1) customized silicon face pillows used were not suited for every patient; (2) our institute lacked a standard operating procedure for prone positioning; (3) our institute lacked a postoperative evaluation and audit procedure for facial pressure ulcers. We designed a strategy to reduce post-prolonged surgery facial pressure ulcer incidence requiring prone positioning by 50% (i.e., from 13.6% to 6.8%). We implemented the following: (1) Created a new water pillow to relieve facial pressure; (2) Implemented continuing education pressure ulcer prevention and evaluation; (3) Established protocols on standard care for prone-position patients and proper facial pressure ulcer identification; (4) Established a face pressure ulcers accident reporting mechanism; and (5) Established an audit mechanism facial pressure ulcer cases. After implementing the resolution measures, 116 patients underwent prolonged surgery in a prone position (mean operating time: 298 mins). None suffered from facial pressure ulcers. The measures effectively reduced the incidence of facial pressure ulcers from 13.6% to 0.0%. The project used a water pillow to relieve facial pressure and educated staff to recognize and evaluate pressure ulcers. These measures were demonstrated effective in reducing the incidence of facial pressure ulcers caused by prolonged prone positioning.

Diet quality is associated with reduced incidence of cancer and self-reported chronic disease: Observations from Alberta's Tomorrow Project.

Science.gov (United States)

Solbak, Nathan M; Xu, Jian-Yi; Vena, Jennifer E; Csizmadi, Ilona; Whelan, Heather K; Robson, Paula J

2017-08-01

The objective of this study was to assess diet quality using the Healthy Eating Index-2005 Canada (HEI-2005-Canada) and its association with risk of cancer and chronic disease in a sample of Alberta's Tomorrow Project (ATP) participants. Food frequency questionnaires completed by 25,169 participants (38% men; mean age 50.3 (9.2)) enrolled between 2000 and 2008 were used to calculate HEI-2005-Canada scores. Data from a subset of participants (n=10,735) who reported no chronic disease at enrollment were used to investigate the association between HEI-2005-Canada score and development of self-reported chronic disease at follow-up (2008). Participants were divided into HEI-2005-Canada score quartiles. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for cancer and chronic disease incidence. In this cohort, mean HEI-2005-Canada scores for men and women were 50.9 and 55.5 (maximum range 0-100), respectively. In men, higher HEI-2005-Canada score (Q4 vs. Q1) was associated with lower cancer risk (HR (95% CI) 0.63 (0.49-0.83)) over the course of follow-up (mean (SD)=10.4 (2.3) years); the same was not observed in women. In contrast, higher overall HEI-2005-Canada score (Q4 vs. Q1) was associated with lower risk of self-reported chronic disease (0.85 (0.75-0.97)) in both men and women over follow-up (4.2 (2.3) years). In conclusion, in this cohort better diet quality was associated with a lower risk of cancer in men and lower risk of chronic disease in both sexes. Future studies with longer follow-up and repeated measures of diet may be helpful to elucidate sex-specific associations between dietary quality and disease outcomes. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Physicians' and Nurses' Perceptions of and Attitudes Toward Incident Reporting in Palestinian Hospitals.

Science.gov (United States)

Rashed, Anan; Hamdan, Motasem

2015-06-22

Underreporting of incidents that happen in health care services undermines the ability of the systems to improve patient safety. This study assessed the attitudes of physicians and nurses toward incident reporting and the factors influencing reporting in Palestinian hospitals. It also examined clinicians' views about the preferred features of incident reporting system. Cross-sectional self-administered survey of 475 participants, 152 physicians and 323 nurses, from 11 public hospitals in the West Bank; response rate, 81.3%. There was a low level of event reporting among participants in the past year (40.3%). Adjusted for sex and age, physicians were 2.1 times more likely to report incidents than nurses (95% confidence interval, 1.32-3.417; P = 0.002). Perceived main barriers for reporting were grouped under lack of proper structure for reporting, prevalence of blame, and punitive environment. The clinicians indicated fear of administrative sanctions, social and legal liability, and of their competence being questioned (P > 0.05). Getting help for patients, learning from mistakes, and ethical obligation were equally indicated motivators for reporting (P > 0.05). Meanwhile, clinicians prefer formal reporting (77.8%) of all type of errors (65.5%), disclosure of reporters (52.7%), using reports to improve patient safety (80.3%), and willingness to report to immediate supervisors (57.6%). Clinicians acknowledge the importance of reporting incidents; however, prevalence of punitive culture and inadequate reporting systems are key barriers. Improving feedback about reported errors, simplifying procedures, providing clear guidelines on what and who should report, and avoiding blame are essential to enhance reporting. Moreover, health care organizations should consider the opinions of the clinicians in developing reporting systems.

FutureGen Project Report

Energy Technology Data Exchange (ETDEWEB)

Cabe, Jim; Elliott, Mike

2010-09-30

This report summarizes the comprehensive siting, permitting, engineering, design, and costing activities completed by the FutureGen Industrial Alliance, the Department of Energy, and associated supporting subcontractors to develop a first of a kind near zero emissions integrated gasification combined cycle power plant and carbon capture and storage project (IGCC-CCS). With the goal to design, build, and reliably operate the first IGCC-CCS facility, FutureGen would have been the lowest emitting pulverized coal power plant in the world, while providing a timely and relevant basis for coal combustion power plants deploying carbon capture in the future. The content of this report summarizes key findings and results of applicable project evaluations; modeling, design, and engineering assessments; cost estimate reports; and schedule and risk mitigation from initiation of the FutureGen project through final flow sheet analyses including capital and operating reports completed under DOE award DE-FE0000587. This project report necessarily builds upon previously completed siting, design, and development work executed under DOE award DE-FC26- 06NT4207 which included the siting process; environmental permitting, compliance, and mitigation under the National Environmental Policy Act; and development of conceptual and design basis documentation for the FutureGen plant. For completeness, the report includes as attachments the siting and design basis documents, as well as the source documentation for the following: • Site evaluation and selection process and environmental characterization • Underground Injection Control (UIC) Permit Application including well design and subsurface modeling • FutureGen IGCC-CCS Design Basis Document • Process evaluations and technology selection via Illinois Clean Coal Review Board Technical Report • Process flow diagrams and heat/material balance for slurry-fed gasifier configuration • Process flow diagrams and heat/material balance

Incidence du cancer au Canada : tendances et projections (1983-2032)

OpenAIRE

Lin Xie; Robert Semenciw; Les Mery

2015-01-01

Dans cette monographie, nous présentons, pour 1983 à 2032, un historique et des projections du nombre de nouveaux cas et des taux d'incidence du cancer pour le Canada, à l'exception des cancers de la peau autres que le mélanome (c.-à -d. les carcinomes basocellulaire et spinocellulaire). Ces renseignements visent à faciliter la planification stratégique et l'affectation de ressources et d'infrastructures pour assurer la prestation future de soins de santé et de mesures de lutte contre le canc...

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.

WP1 – Final project report

NARCIS (Netherlands)

Drachsler, Hendrik; Scheffel, Maren; Orrego, Carola; Stieger, Lina; Hartkopf, Kathleen; Henn, Patrick; Hynes, Helen; Przibilla, Monika; Geiger, Uschi; Schroeder, Hanna; Sopka, Sasa

2015-01-01

This report contains the complete project reporting of the PATIENT project from October 2012 until end of March 2015. It provides a summary of all project activities and achievements that are based on the previous WP deliverables such as the project progress reports from WP1 (D1.01) and the quality

Pilot Critical Incident Reports as a Means to Identify Human Factors of Remotely Piloted Aircraft

Science.gov (United States)

Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

2016-01-01

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. Human factor issues included the impact of reduced sensory cues, traffic separation in the absence of an out-the-window view, control latencies, vigilance during monotonous and ultra-long endurance flights, control station design considerations, transfer of control between control stations, the management of lost link procedures, and decision-making during emergencies. Pilots participated willingly and enthusiastically in the study

The Incidence of Human Papillomavirus in Tanzanian Adolescent Girls Before Reported Sexual Debut.

Science.gov (United States)

Houlihan, Catherine F; Baisley, Kathy; Bravo, Ignacio G; Kapiga, Saidi; de Sanjosé, Silvia; Changalucha, John; Ross, David A; Hayes, Richard J; Watson-Jones, Deborah

2016-03-01

Acquisition of human papillomavirus (HPV) in women occurs predominantly through vaginal sex. However, HPV has been detected in girls reporting no previous sex. We aimed to determine incidence and risk factors for HPV acquisition in girls who report no previous sex in Tanzania, a country with high HPV prevalence and cervical cancer incidence. We followed 503 adolescent girls aged 15-16 years in Mwanza, Tanzania, with face-to-face interviews and self-administered vaginal swabs every 3 months for 18 months; 397 girls reported no sex before enrollment or during follow-up; of whom, 120 were randomly selected. Samples from enrollment, 6-, 12-, and 18-month visits were tested for 37 HPV genotypes. Incidence, clearance, point prevalence, and duration of any HPV and genotype-specific infections were calculated and associated factors were evaluated. Of 120 girls who reported no previous sex, 119 were included, contributing 438 samples. HPV was detected in 51 (11.6%) samples. The overall incidence of new HPV infections was 29.4/100 person-years (95% confidence interval: 15.9-54.2). The point prevalence of vaccine types HPV-6,-11,-16, and -18 was .9%, .9%, 2.0%, and 0%, respectively. Spending a night away from home and using the Internet were associated with incident HPV, and reporting having seen a pornographic movie was inversely associated with HPV incidence. Incident HPV infections were detected frequently in adolescent girls who reported no previous sex over 18 months. This is likely to reflect under-reporting of sex. A low-point prevalence of HPV genotypes in licensed vaccines was seen, indicating that vaccination of these girls might still be effective. Copyright © 2016 Society for Adolescent Health and Medicine. All rights reserved.

Viruses Associated With Acute Respiratory Infections and Influenza-like Illness Among Outpatients From the Influenza Incidence Surveillance Project, 2010–2011

Science.gov (United States)

Fowlkes, Ashley; Giorgi, Andrea; Erdman, Dean; Temte, Jon; Goodin, Kate; Di Lonardo, Steve; Sun, Yumei; Martin, Karen; Feist, Michelle; Linz, Rachel; Boulton, Rachelle; Bancroft, Elizabeth; McHugh, Lisa; Lojo, Jose; Filbert, Kimberly; Finelli, Lyn

2017-01-01

Background The Influenza Incidence Surveillance Project (IISP) monitored outpatient acute respiratory infection (ARI; defined as the presence of ≥2 respiratory symptoms not meeting ILI criteria) and influenza-like illness (ILI) to determine the incidence and contribution of associated viral etiologies. Methods From August 2010 through July 2011, 57 outpatient healthcare providers in 12 US sites reported weekly the number of visits for ILI and ARI and collected respiratory specimens on a subset for viral testing. The incidence was estimated using the number of patients in the practice as the denominator, and the virus-specific incidence of clinic visits was extrapolated from the proportion of patients testing positive. Results The age-adjusted cumulative incidence of outpatient visits for ARI and ILI combined was 95/1000 persons, with a viral etiology identified in 58% of specimens. Most frequently detected were rhinoviruses/enteroviruses (RV/EV) (21%) and influenza viruses (21%); the resulting extrapolated incidence of outpatient visits was 20 and 19/1000 persons respectively. The incidence of influenza virus-associated clinic visits was highest among patients aged 2–17 years, whereas other viruses had varied patterns among age groups. Conclusions The IISP provides a unique opportunity to estimate the outpatient respiratory illness burden by etiology. Influenza virus infection and RV/EV infection(s) represent a substantial burden of respiratory disease in the US outpatient setting, particularly among children. PMID:24338352

Simulation analysis of route diversion strategies for freeway incident management : final report.

Science.gov (United States)

1995-02-01

The purpose of this project was to investigate whether simulation models could : be used as decision aids for defining traffic diversion strategies for effective : incident management. A methodology was developed for using such a model to : determine...

Evaluation of the effectiveness of ATM messages used during incidents : final report.

Science.gov (United States)

2016-01-01

This project investigated the use of Intelligent Lane Control Signs based Active Traffic Management for : Incident Management on a heavily traveled urban freeway. The subject of the research was the ILCS : system on I-94 westbound in downtown Minneap...

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.

Public inquiry report. Les Ailes de Taillard wind farm project on the territory of municipalities of Burdignes, Saint-Sauveur-en-Rue. Conclusion. Les Ailes de Taillard: a territorial collaboration for a participative wind energy project

International Nuclear Information System (INIS)

Chevalier, Jean Paul

2015-03-01

The public inquiry report contains some generalities about the legal frameworks and the project (location, characteristics, environmental context, inquiry file content), a report of the inquiry organisation and procedure (decrees, modalities, meetings and visits, public information, noticed incidents, general atmosphere), remarks made by associations, concerned communities and the public, and then the statement of the inquiry commissioner on the various aspects of the project. A conclusive report notably outlines themes raised by remarks from different origins (negative remarks which mainly concerned environmental issues, and positive remarks). A last publication presents the project and highlights its participative dimension

Cancer incidence in south-east Nigeria: a report from Nnewi Cancer ...

African Journals Online (AJOL)

Background: This study is the first population based cancer incidence report from a cancer registry in south-east Nigeria. Objective: To evaluate the incidence of some invasive cancers in southeast Nigeria. Methodology: We collected all new cases of invasive cancers between 1st January and 31st December, 2013.

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.

Using incident reports to inform the prevention of medication administration errors.

Science.gov (United States)

Härkänen, Marja; Saano, Susanna; Vehviläinen-Julkunen, Katri

2017-11-01

To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health

A Profile of Criminal Incidents at School: Results from the 2003-05 National Crime Victimization Survey Crime Incident Report NCES 2010-318

Science.gov (United States)

Ruddy, Sally A.; Bauer, Lynn; Neiman, Samantha

2010-01-01

This report provides estimates of criminal incidents that occur at school. Incident-level data were obtained from the National Crime Victimization Survey (NCVS), the nation's primary source of information on criminal victimization and criminal incidents in the United States. The NCVS collects demographic information on respondents in the NCVS…

Spatial Distribution of Black Bear Incident Reports in Michigan.

Directory of Open Access Journals (Sweden)

Jamie E McFadden-Hiller

Full Text Available Interactions between humans and carnivores have existed for centuries due to competition for food and space. American black bears are increasing in abundance and populations are expanding geographically in many portions of its range, including areas that are also increasing in human density, often resulting in associated increases in human-bear conflict (hereafter, bear incidents. We used public reports of bear incidents in Michigan, USA, from 2003-2011 to assess the relative contributions of ecological and anthropogenic variables in explaining the spatial distribution of bear incidents and estimated the potential risk of bear incidents. We used weighted Normalized Difference Vegetation Index mean as an index of primary productivity, region (i.e., Upper Peninsula or Lower Peninsula, primary and secondary road densities, and percentage land cover type within 6.5-km2 circular buffers around bear incidents and random points. We developed 22 a priori models and used generalized linear models and Akaike's Information Criterion (AIC to rank models. The global model was the best compromise between model complexity and model fit (w = 0.99, with a ΔAIC 8.99 units from the second best performing model. We found that as deciduous forest cover increased, the probability of bear incident occurrence increased. Among the measured anthropogenic variables, cultivated crops and primary roads were the most important in our AIC-best model and were both positively related to the probability of bear incident occurrence. The spatial distribution of relative bear incident risk varied markedly throughout Michigan. Forest cover fragmented with agriculture and other anthropogenic activities presents an environment that likely facilitates bear incidents. Our map can help wildlife managers identify areas of bear incident occurrence, which in turn can be used to help develop strategies aimed at reducing incidents. Researchers and wildlife managers can use similar mapping

Spatial Distribution of Black Bear Incident Reports in Michigan.

Science.gov (United States)

McFadden-Hiller, Jamie E; Beyer, Dean E; Belant, Jerrold L

2016-01-01

Interactions between humans and carnivores have existed for centuries due to competition for food and space. American black bears are increasing in abundance and populations are expanding geographically in many portions of its range, including areas that are also increasing in human density, often resulting in associated increases in human-bear conflict (hereafter, bear incidents). We used public reports of bear incidents in Michigan, USA, from 2003-2011 to assess the relative contributions of ecological and anthropogenic variables in explaining the spatial distribution of bear incidents and estimated the potential risk of bear incidents. We used weighted Normalized Difference Vegetation Index mean as an index of primary productivity, region (i.e., Upper Peninsula or Lower Peninsula), primary and secondary road densities, and percentage land cover type within 6.5-km2 circular buffers around bear incidents and random points. We developed 22 a priori models and used generalized linear models and Akaike's Information Criterion (AIC) to rank models. The global model was the best compromise between model complexity and model fit (w = 0.99), with a ΔAIC 8.99 units from the second best performing model. We found that as deciduous forest cover increased, the probability of bear incident occurrence increased. Among the measured anthropogenic variables, cultivated crops and primary roads were the most important in our AIC-best model and were both positively related to the probability of bear incident occurrence. The spatial distribution of relative bear incident risk varied markedly throughout Michigan. Forest cover fragmented with agriculture and other anthropogenic activities presents an environment that likely facilitates bear incidents. Our map can help wildlife managers identify areas of bear incident occurrence, which in turn can be used to help develop strategies aimed at reducing incidents. Researchers and wildlife managers can use similar mapping techniques to

Incident and Trafficking Database: New Systems for Reporting and Accessing State Information

International Nuclear Information System (INIS)

Dimitrovski, D.; Kittley, S.

2015-01-01

The IAEA's Incident and Trafficking Database (ITDB) is the Agency's authoritative source for information on incidents in which nuclear and other radioactive material is out of national regulatory control. It was established in 1995 and, as of June 2014, 126 States participate in the ITDB programme. Currently, the database contains over 2500 confirmed incidents, out of which 21% involve nuclear material, 62% radioactive source and 17% radioactively contaminated material. In recent years, the system for States to report incidents to the ITDB has been evolving — moving from fax-based to secure email and most recently to secure on-line reporting. A Beta version of the on-line system was rolled out this June, offering a simple, yet secure, communication channel for member states to provide information. In addition the system serves as a central hub for information related to official communication of the IAEA with Member States so some communication that is traditionally shared by e-mail does not get lost when ITDB counterparts change. In addition the new reporting system incorporates optional features that allow multiple Member State users to collaboratively contribute toward an INF. States are also being given secure on-line access to a streamlined version of the ITDB. This improves States' capabilities to retrieve and analyze information for their own purposes. In addition, on-line access to ITDB statistical information on incidents is available to States through an ITDB Dashboard. The dashboard contains aggregate information on number and types of incidents, material involved, as well some other statistics related to the ITDB that is typically provided in the ITDB Quarterly reports. (author)

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

Safety Incident Management Team Report for NIMLT Case 50796

LENUS (Irish Health Repository)

2017-01-17

This is a report on the management of a patient safety incident involving BowelScreen and symptomatic colonoscopy services at Wexford General Hospital (WGH). The patient safety incident relates to the work of a Consultant Endoscopist (referred to as Clinician Y) employed by WGH who undertook screening colonoscopies on behalf of the BowelScreen Programme since the commencement of the screening programme in WGH in March 2013. Clinician Y also performed non-screening colonoscopies for the diagnosis of symptomatic patients as part of routine surgical service provision at WGH.\\r\

Incidence of diseases primarily affecting the skin by age group: population-based epidemiologic study in Olmsted County, Minnesota, and comparison with age-specific incidence rates worldwide.

Science.gov (United States)

Wessman, Laurel L; Andersen, Louise K; Davis, Mark D P

2018-01-29

Understanding the effects of age on the epidemiology of diseases primarily affecting the skin is important to the practice of dermatology, both for proper allocation of resources and for optimal patient-centered care. To fully appreciate the effect that age may have on the population-based calculations of incidence of diseases primarily affecting the skin in Olmsted County, Minnesota, and worldwide, we performed a review of all relevant Rochester Epidemiology Project-published data and compared them to similar reports in the worldwide English literature. Using the Rochester Epidemiology Project, population-based epidemiologic studies have been performed to estimate the incidence of specific skin diseases over the past 50 years. In older persons (>65 years), nonmelanoma skin cancer, lentigo maligna, herpes zoster, delusional infestation, venous stasis syndrome, venous ulcer, and burning mouth syndrome were more commonly diagnosed. In those younger than 65 years, atypical nevi, psoriatic arthritis, pityriasis rosea, herpes progenitalis, genital warts, alopecia areata, hidradenitis suppurativa, infantile hemangioma, Behçet's disease, and sarcoidosis (isolated cutaneous, with sarcoidosis-specific cutaneous lesions and with erythema nodosum) had a higher incidence. Many of the incidence rates by age group of diseases primarily affecting the skin derived from the Rochester Epidemiology Project were similar to those reported elsewhere. © 2018 The International Society of Dermatology.

EBT-P project status report

International Nuclear Information System (INIS)

1983-11-01

This Elmo Bumpy Torus Report describes the status of the EBT-P Project in September 1983 after phasedown of the Title II design effort. The report is intended to be a principle source of guidance in the event of a decision to resume work on the project

E-Community: Mobile application for reporting incidents of public services of a city

OpenAIRE

Jaime Suárez; Elvia Aispuro; Mónica Carreño; Andrés Sandoval; Italia Estrada; Jesús Hernández; Javier Aguilar; Yoshio Valles; Emma Ibarra

2013-01-01

This paper reports the mobile application call E-Community, an application of a social nature with the objective that the civilian population in the city of La Paz, Baja California Sur, Mexico, have an alternative to report incidents that deal with services public. Generally, citizens reported by telephone different types of incidents such as traffic accidents, water leaks, lighting shabby, fire, garbage collection, however sometimes the phone is not attended for various reasons so regularly ...

National critical incident reporting systems relevant to anaesthesia: a European survey.

Science.gov (United States)

Reed, S; Arnal, D; Frank, O; Gomez-Arnau, J I; Hansen, J; Lester, O; Mikkelsen, K L; Rhaiem, T; Rosenberg, P H; St Pierre, M; Schleppers, A; Staender, S; Smith, A F

2014-03-01

Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia. We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure. Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed. We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.

Analysis of human factors in incidents reported by Swiss nuclear power plants to the inspectorate

International Nuclear Information System (INIS)

Alder, H.P.; Hausmann, W.

1997-01-01

197 reported incidents in Swiss Nuclear Power Plants were analyzed by a team of the Swiss Federal Nuclear Safety Inspectorate (HSK) using the OECD/NEA Incident Reporting System. The following conclusions could be drawn from this exercise. While the observed cause reported by the plant was ''technical failure'' in about 90% of the incidents, the HSK-Team identified for more than 60% of the incidents ''human factors'' as the root cause. When analyzing this root cause further it was shown that only a smaller contribution came from the side of the operators and the more important shares were caused by plant maintenance, vendors/constructors and plant management with procedural and organizational deficiencies. These findings demonstrate that root cause analysis of incidents by the IRS-Code is a most useful tool to analyze incidents and to find weak points in plant performance. (author). 5 tabs

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

Statistical analysis of incidents reported in the Greek Petrochemical Industry for the period 1997-2003

International Nuclear Information System (INIS)

Konstandinidou, Myrto; Nivolianitou, Zoe; Markatos, Nikolaos; Kiranoudis, Chris

2006-01-01

This paper makes an analysis of all reported accidents and incidents in the Greek Petrochemical Industry for the period spanning from 1997 to 2003. The work performed is related to the analysis of important parameters of the incidents, their inclusion in a database adequately designed for the purposes of this analysis and an importance assessment of this reporting scheme. Indeed, various stakeholders have highlighted the importance of a reporting system for industrial accidents and incidents. The European Union has established for this purpose the Major Accident Reporting System (MARS) for the reporting of major accidents in the Member States. However, major accidents are not the only measure that can characterize the safety status of an establishment; neither are the former the only events from which important lessons can be learned. Near misses, industrial incidents without major consequences, as well as occupational accidents could equally supply with important findings the interested analyst, while statistical analysis of these incidents could give significant insight in the understanding and the prevention of similar incidents or major accidents in the future. This analysis could be more significant, if each industrial sector was separately analyzed, as the authors do for the petrochemical sector in the present article

Integrated Incident Management System (IIMS) web client application development, deployment and evaluation Staten Island (SI) demonstration project : final report.

Science.gov (United States)

2015-09-27

This evaluation report provides background on the development and findings. The aim of the UTRC project was to develop and : deploy Portable IIMS based on Smartphone web applications. Previously, traditional IIMS was deployed in the field vehicles : ...

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

DEFF Research Database (Denmark)

Maaløe, R; la Cour, M; Hansen, A

2006-01-01

The purpose of the present study was to measure the incidence and type of incidents that occurred in relation to anaesthesia and surgery during a 1-year period in six Danish hospitals. Furthermore, we wanted to identify risk factors for incidents, as well as risk factors for incidents being deeme...... critical....

SU-E-T-524: Web-Based Radiation Oncology Incident Reporting and Learning System (ROIRLS)

Energy Technology Data Exchange (ETDEWEB)

Kapoor, R; Palta, J; Hagan, M [Virginia Commonwealth University, Richmond, VA (United States); National Radiation Oncology Program (10P4H), Richmond, VA (United States); Grover, S; Malik, G [TSG Innovations Inc., Richmond, VA (United States)

2014-06-01

Purpose: Describe a Web-based Radiation Oncology Incident Reporting and Learning system that has the potential to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: The VA National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and near miss data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. Software used for this program is deployed on the VAs intranet as a Website. All data entry forms (adverse event or near miss reports, work product reports) utilize standard causal, RT process step taxonomies and data dictionaries defined in AAPM and ASTRO reports on error reporting (AAPM Work Group Report on Prevention of Errors and ASTROs safety is no accident report). All reported incidents are investigated by the radiation oncology domain experts. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The operational workflow is similar to that of the Aviation Safety Reporting System. This system is also synergistic with ROSIS and SAFRON. Results: The ROIRLS facilitates the collection of data that help in tracking adverse events and near misses and develop new interventions to prevent such incidents. The ROIRLS electronic infrastructure is fully integrated with each registered facility profile data thus minimizing key strokes and multiple entries by the event reporters. Conclusions: OIRLS is expected to improve the quality and safety of a broad spectrum of radiation therapy patients treated in the VA and fulfills our goal of Effecting Quality While Treating Safely The Radiation Oncology Incident Reporting and Learning System software used for this program has been developed, conceptualized and maintained by TSG Innovations

SU-E-T-524: Web-Based Radiation Oncology Incident Reporting and Learning System (ROIRLS)

International Nuclear Information System (INIS)

Kapoor, R; Palta, J; Hagan, M; Grover, S; Malik, G

2014-01-01

Purpose: Describe a Web-based Radiation Oncology Incident Reporting and Learning system that has the potential to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: The VA National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and near miss data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. Software used for this program is deployed on the VAs intranet as a Website. All data entry forms (adverse event or near miss reports, work product reports) utilize standard causal, RT process step taxonomies and data dictionaries defined in AAPM and ASTRO reports on error reporting (AAPM Work Group Report on Prevention of Errors and ASTROs safety is no accident report). All reported incidents are investigated by the radiation oncology domain experts. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The operational workflow is similar to that of the Aviation Safety Reporting System. This system is also synergistic with ROSIS and SAFRON. Results: The ROIRLS facilitates the collection of data that help in tracking adverse events and near misses and develop new interventions to prevent such incidents. The ROIRLS electronic infrastructure is fully integrated with each registered facility profile data thus minimizing key strokes and multiple entries by the event reporters. Conclusions: OIRLS is expected to improve the quality and safety of a broad spectrum of radiation therapy patients treated in the VA and fulfills our goal of Effecting Quality While Treating Safely The Radiation Oncology Incident Reporting and Learning System software used for this program has been developed, conceptualized and maintained by TSG Innovations

MORE: Management of requirements in NPP modernisation projects. Project report 2007

International Nuclear Information System (INIS)

Fredriksen, R.; Katta, V.; Raspotnig, C.; Valkonen, J.

2008-03-01

This report documents the work and related activities of the MORE project in the period January 1 - December 31 in 2007. The focus of this report is on improvements of the former project results, to identify and apply a couple of case studies from NPP projects, and activities in order to initiate and implement the industrial take-up and utilisation of the research results in real modernisation projects. The report also provides a brief description of the extended industrial network and disseminations of the results in Nordic and NKS related events such as seminars and workshops. (au)

MORE: Management of requirements in NPP modernisation projects. Project report 2007

Energy Technology Data Exchange (ETDEWEB)

Fredriksen, R.; Katta, V.; Raspotnig, C. [Institutt for energiteknikk (IFE) (Norway); Valkonen, J. [Technical Research Centre of Finland (VTT) (Finland)

2008-03-15

This report documents the work and related activities of the MORE project in the period January 1 - December 31 in 2007. The focus of this report is on improvements of the former project results, to identify and apply a couple of case studies from NPP projects, and activities in order to initiate and implement the industrial take-up and utilisation of the research results in real modernisation projects. The report also provides a brief description of the extended industrial network and disseminations of the results in Nordic and NKS related events such as seminars and workshops. (au)

SU-F-T-223: Radiotherapy Incident Reporting and Analysis System (RIRAS):Early Experience

International Nuclear Information System (INIS)

Kapoor, R; Palta, J; Hagan, M; Burkett, D; Leidholdt, E

2016-01-01

Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reporting facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly

SU-F-T-223: Radiotherapy Incident Reporting and Analysis System (RIRAS):Early Experience

Energy Technology Data Exchange (ETDEWEB)

Kapoor, R; Palta, J; Hagan, M [National Radiation Oncology Program (10P4H), Dept. of Veterans Affairs, Richmond, VA (United States); Burkett, D; Leidholdt, E [National Health Physics Program (10P4X), Dept. of Veterans Affairs, Little Rock, AR (United States)

2016-06-15

Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reporting facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly

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

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

Annual report on reactor safety research projects. Reporting period 2011. Progress report

International Nuclear Information System (INIS)

2011-01-01

Within its competence for energy research the Federal Ministry of Economics and Technology (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS)mbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRSF- Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the Internet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. It has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties. (orig.)

Annual report on reactor safety research projects. Reporting period 2014. Progress report

Energy Technology Data Exchange (ETDEWEB)

NONE

2014-07-01

Within its competence for energy research the Federal Ministry for Economic Affairs and Energy (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS) gGmbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRS-F-Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the lnternet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. lt has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties.

Annual report on reactor safety research projects. Reporting period 2013. Progress report

International Nuclear Information System (INIS)

2013-01-01

Within its competence for energy research the Federal Ministry of Economics and Technology (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS)mbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRSF- Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the Internet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. It has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties. (orig.)

Annual report on reactor safety research projects. Reporting period 2015. Progress report

International Nuclear Information System (INIS)

2015-01-01

Within its competence for energy research the Federal Ministry for Economic Affairs and Energy (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft tor Anlagen- und Reaktorsicherheit (GRS) gGmbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRS-F-Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are ·' prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the lnternet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. it has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties.

Perceptions of Police Legitimacy and Citizen Decisions to Report Hate Crime Incidents in Australia

Directory of Open Access Journals (Sweden)

Susann Wiedlitzka

2018-06-01

Full Text Available This article examines the importance of perceptions of police legitimacy in the decision to report hate crime incidents in Australia. It addresses an identified gap in the literature by analysing the 2011-2012 National Security and Preparedness Survey (NSPS results to not only explore differences between hate crime and non-hate crime reporting but also how individual characteristics and perceptions of legitimacy influence decisions about reporting crime to police. Using the NSPS survey data, we created three Generalised Linear Latent and Mixed Models (Gllamm, which explore the influence of individual characteristics and potential barriers on the decision to report crime/hate crime incidents to police. Our results suggest that hate crimes are less likely to be reported to police in comparison to non-hate crime incidents, and that more positive perceptions of police legitimacy and police cooperation are associated with the victim’s decision to report hate crime victimisation.

Pac-Rim LNG project : final project report specifications

International Nuclear Information System (INIS)

1996-01-01

PAC-RIM LNG Inc. has submitted a proposal to the British Columbia Environmental Assessment Office, to develop a liquefied natural gas project which would purchase pipeline quality natural gas from sources in northeast British Columbia and Alberta and transport it via a dedicated pipeline system to a LNG processing plant on tidewater on the Pacific coast. The project would include storage and processing facilities and a marine loading terminal. This document sets out the final project report specifications prepared by the Project Committee on the basis of input received from the public, First Nations and federal, provincial and local governments

Prototype road weather performance management tool : project report : draft report.

Science.gov (United States)

2016-09-30

This report is the Project Report for the Road Weather Performance Management (RW-PM) Tool developed for the project on Development and Demonstration of a Prototype Road Weather Performance Management Application that Uses Connected Vehicle Data (RW-...

Incidence du cancer au Canada : tendances et projections (1983-2032

Directory of Open Access Journals (Sweden)

Lin Xie

2015-01-01

Full Text Available Dans cette monographie, nous présentons, pour 1983 à 2032, un historique et des projections du nombre de nouveaux cas et des taux d'incidence du cancer pour le Canada, à l'exception des cancers de la peau autres que le mélanome (c.-à -d. les carcinomes basocellulaire et spinocellulaire. Ces renseignements visent à faciliter la planification stratégique et l'affectation de ressources et d'infrastructures pour assurer la prestation future de soins de santé et de mesures de lutte contre le cancer. Évolution projetée des taux d'incidence de cancer : De 2003-2007 à 2028-2032, les taux d'incidence normalisés selon l'âge (TINA pour l'ensemble des cancers devraient diminuer de 5 % pour les Canadiens, passant de 464,8 à 443,2 pour 100 000 habitants, et augmenter de 4 % pour les Canadiennes, passant de 358,3 à 371,0 pour 100 000 habitants. La diminution globale des taux de cancer chez les hommes sera le résultat de la baisse des taux de cancer du poumon chez les hommes de 65 ans et plus et des taux de cancer de la prostate chez les hommes de 75 ans et plus. L'augmentation globale des taux de cancer chez les femmes correspond à la hausse prévue des taux de cancer du poumon chez les femmes de 65 ans et plus. Elle représente également la hausse prévue des cas de cancer de l'utérus, de la thyroïde, du sein (chez les femmes de moins de 45 ans, du rein et du pancréas ainsi que des cas de leucémie et de mélanome. Parmi les changements les plus importants dans les TINA projetés sur un horizon de 25 ans, mentionnons une augmentation du nombre de cas de cancer de la thyroïde (55 % chez les hommes et 65 % chez les femmes et de cancer du foie chez les hommes (43 %, et une diminution du nombre de cas de cancer du larynx (47 % chez les hommes et 59 % chez les femmes, de cancer du poumon chez les hommes (34 % et de cancer de l'estomac (30 % chez les hommes et 24 % chez les femmes. Le taux d'incidence du cancer du poumon chez les femmes

Status Update on the NCRP Scientific Committee SC 5-1 Report: Decision Making for Late-Phase Recovery from Nuclear or Radiological Incidents - 13450

International Nuclear Information System (INIS)

Chen, S.Y.

2013-01-01

In August 2008, the U.S. Department of Homeland Security (DHS) issued its final Protective Action Guide (PAG) for radiological dispersal device (RDD) and improvised nuclear device (IND) incidents. This document specifies protective actions for public health during the early and intermediate phases and cleanup guidance for the late phase of RDD or IND incidents, and it discusses approaches to implementing the necessary actions. However, while the PAG provides specific guidance for the early and intermediate phases, it prescribes no equivalent guidance for the late-phase cleanup actions. Instead, the PAG offers a general description of a complex process using a site-specific optimization approach. This approach does not predetermine cleanup levels but approaches the problem from the factors that would bear on the final agreed-on cleanup levels. Based on this approach, the decision-making process involves multifaceted considerations including public health, the environment, and the economy, as well as socio-political factors. In an effort to fully define the process and approach to be used in optimizing late-phase recovery and site restoration following an RDD or IND incident, DHS has tasked the NCRP with preparing a comprehensive report addressing all aspects of the optimization process. Preparation of the NCRP report is a three-year (2010-2013) project assigned to a scientific committee, the Scientific Committee (SC) 5-1; the report was initially titled, Approach to Optimizing Decision Making for Late- Phase Recovery from Nuclear or Radiological Terrorism Incidents. Members of SC 5-1 represent a broad range of expertise, including homeland security, health physics, risk and decision analysis, economics, environmental remediation and radioactive waste management, and communication. In the wake of the Fukushima nuclear accident of 2011, and guided by a recent process led by the White House through a Principal Level Exercise (PLE), the optimization approach has since

Status Update on the NCRP Scientific Committee SC 5-1 Report: Decision Making for Late-Phase Recovery from Nuclear or Radiological Incidents - 13450

Energy Technology Data Exchange (ETDEWEB)

Chen, S.Y. [Environmental Science Division, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439 (United States)

2013-07-01

In August 2008, the U.S. Department of Homeland Security (DHS) issued its final Protective Action Guide (PAG) for radiological dispersal device (RDD) and improvised nuclear device (IND) incidents. This document specifies protective actions for public health during the early and intermediate phases and cleanup guidance for the late phase of RDD or IND incidents, and it discusses approaches to implementing the necessary actions. However, while the PAG provides specific guidance for the early and intermediate phases, it prescribes no equivalent guidance for the late-phase cleanup actions. Instead, the PAG offers a general description of a complex process using a site-specific optimization approach. This approach does not predetermine cleanup levels but approaches the problem from the factors that would bear on the final agreed-on cleanup levels. Based on this approach, the decision-making process involves multifaceted considerations including public health, the environment, and the economy, as well as socio-political factors. In an effort to fully define the process and approach to be used in optimizing late-phase recovery and site restoration following an RDD or IND incident, DHS has tasked the NCRP with preparing a comprehensive report addressing all aspects of the optimization process. Preparation of the NCRP report is a three-year (2010-2013) project assigned to a scientific committee, the Scientific Committee (SC) 5-1; the report was initially titled, Approach to Optimizing Decision Making for Late- Phase Recovery from Nuclear or Radiological Terrorism Incidents. Members of SC 5-1 represent a broad range of expertise, including homeland security, health physics, risk and decision analysis, economics, environmental remediation and radioactive waste management, and communication. In the wake of the Fukushima nuclear accident of 2011, and guided by a recent process led by the White House through a Principal Level Exercise (PLE), the optimization approach has since

Analysis of human factor aspects in connection with available incident reports obligatorily reported by German nuclear power plants

International Nuclear Information System (INIS)

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

1993-01-01

Goal of the present study is the analysis of human factor aspects in connection with available incident reports obligatorily reported by German nuclear power plants. Based on psychological theories and empirical studies this study develops a classification scheme which permits the identification of foci of erroneous human actions. This classification scheme is applied to a selection of human factor relevant incidents by calculating frequencies of the occurrence of human error categories. The results allow insights into human factor related problem areas. (orig.) [de

NEA international co-operative projects

International Nuclear Information System (INIS)

1989-01-01

This text is consecrated at the international co-operative projects of the OECD Nuclear Energy Agency (NEA) in the field of reactor safety (Halden reactor project, Loft project, studies on the damaged Three Mile Island unit-2 reactor, inspection of reactor steel components, incident reporting system) and in the field of radioactive waste management (Stripa project, geochemical data bases, Alligator river project, seabed disposal of high-level radioactive waste, decommissioning of nuclear facilities)

Incidence et Caracteristiques des Signalements d'Enfants Maltraites: Comparaison Interculturelle (Incidence and Characteristics of Reported Child Abuse: Intercultural Comparisons).

Science.gov (United States)

Tourigny, Marc; Bouchard, Camil

1994-01-01

Analysis of 953 reports of child abuse in Montreal (Quebec) found the incidence slightly higher among Haitians than French-Canadians. Among Haitians, reporting tended to originate with police or school personnel, and cases consisted mainly of physical abuse. Results suggest that child-rearing practices of Haitian families are in conflict with…

75 FR 75911 - Adjustment of Monetary Threshold for Reporting Rail Equipment Accidents/Incidents for Calendar...

Science.gov (United States)

2010-12-07

..., Notice No. 3] RIN 2130-ZA04 Adjustment of Monetary Threshold for Reporting Rail Equipment Accidents... (DOT). ACTION: Final rule. SUMMARY: This rule increases the rail equipment accident/incident reporting threshold from $9,200 to $9,400 for certain railroad accidents/incidents involving property damage that...

Resource Roads demonstration project : final report

Energy Technology Data Exchange (ETDEWEB)

NONE

2009-07-15

British Columbia's vast network of resource roads are considered to be amongst the most dangerous, high-risk workplaces in the province. Resource roads, also known as industrial roads, forest service roads, or petroleum development roads, present several unique safety challenges as workplaces. They are built for the purpose of access, egress and transport of materials, resources, equipment and people. However, the lack the same diligence of enforcement and a consistent design, construction, maintenance and standard for use as public highways or municipal roads. There are also safety challenges related to public use of resource roads. This report presented a project, called ResourceRoads by WorkSafe BC that focused on the organization and implementation of a management structure that would provide a system of coordination and a process of compliance for the users of the defined road systems. The project was based on information gathered in two forest districts of Prince George and the South Peace Forest Districts. A committee consisting of the actual owner of the road and other users was formed. The report presented a history of British Columbia's resource road system, and discussed resource roads as industrial workplaces and worksites, as well as resource road fatality statistics. The demonstration project was outlined in terms of project leadership; scope; strategic objectives; project purpose; performance objectives; project communication; demonstration areas; and project stages. Project fundamentals and project findings were also presented along with recommendations and responses to the Auditor General report and the Forest Safety Ombudsman report. It was concluded that potential uses of new technologies for resource road vehicles should be reviewed. tabs., figs.

A self-report critical incident assessment tool for army night vision goggle helicopter operations.

Science.gov (United States)

Renshaw, Peter F; Wiggins, Mark W

2007-04-01

The present study sought to examine the utility of a self-report tool that was designed as a partial substitute for a face-to-face cognitive interview for critical incidents involving night vision goggles (NVGs). The use of NVGs remains problematic within the military environment, as these devices have been identified as a factor in a significant proportion of aircraft accidents and incidents. The self-report tool was structured to identify some of the cognitive features of human performance that were associated with critical incidents involving NVGs. The tool incorporated a number of different levels of analysis, ranging from specific behavioral responses to broader cognitive constructs. Reports were received from 30 active pilots within the Australian Army using the NVG Critical Incident Assessment Tool (NVGCIAT). The results revealed a correspondence between specific types of NVG-related errors and elements of the Human Factors Analysis and Classification System (HFACS). In addition, uncertainty emerged as a significant factor associated with the critical incidents that were recalled by operators. These results were broadly consistent with previous research and provide some support for the utility of subjective assessment tools as a means of extracting critical incident-related data when face-to-face cognitive interviews are not possible. In some circumstances, the NVGCIAT might be regarded as a substitute cognitive interview protocol with some level of diagnosticity.

UMTRA project list of reportable occurrences

Energy Technology Data Exchange (ETDEWEB)

1994-04-01

This UMTRA Project List of Reportable occurrences is provided to facilitate efficient categorization of reportable occurrences. These guidelines have been established in compliance with DOE minimum reporting requirements under DOE Order 5000.3B. Occurrences are arranged into nine groups relating to US Department of Energy (DOE) Uranium Mill Tailings Remedial Action (UMTRA) Project operations for active sites. These nine groupings are provided for reference to determined whether an occurrence meets reporting requirement criteria in accordance with the minimum reporting requirements. Event groups and significance categories that cannot or will not occur, and that do not apply to UMTRA Project operations, are omitted. Occurrence categorization shall be as follows: Group 1. Facility Condition; Group 2. Environmental; Group 3. Personnel Safety; Group 4. Personnel Radiation Protection; Group 5. Safeguards and Security; Group 6. Transportation; Group 7. Value Basis Reporting; Group 8. Facility Status; and Group 9. Cross-Category Items.

UMTRA project list of reportable occurrences

International Nuclear Information System (INIS)

1994-04-01

This UMTRA Project List of Reportable occurrences is provided to facilitate efficient categorization of reportable occurrences. These guidelines have been established in compliance with DOE minimum reporting requirements under DOE Order 5000.3B. Occurrences are arranged into nine groups relating to US Department of Energy (DOE) Uranium Mill Tailings Remedial Action (UMTRA) Project operations for active sites. These nine groupings are provided for reference to determined whether an occurrence meets reporting requirement criteria in accordance with the minimum reporting requirements. Event groups and significance categories that cannot or will not occur, and that do not apply to UMTRA Project operations, are omitted. Occurrence categorization shall be as follows: Group 1. Facility Condition; Group 2. Environmental; Group 3. Personnel Safety; Group 4. Personnel Radiation Protection; Group 5. Safeguards and Security; Group 6. Transportation; Group 7. Value Basis Reporting; Group 8. Facility Status; and Group 9. Cross-Category Items

Prototypical Consolidation Demonstration Project: Final report

International Nuclear Information System (INIS)

Gili, J.A.; Poston, V.K.

1993-11-01

This is the final report of the Prototypical Consolidation Demonstration Project, which was funded by the US Department of Energy's Office of Civilian Radioactive Waste Management. The project had two objectives: (a) to develop and demonstrate a prototype of production-scale equipment for the dry, horizontal consolidation and packaging of spent nuclear fuel rods from commercial boiling water reactor and pressurized water reactor fuel assemblies, and (b) to report the development and demonstration results to the US Department of Energy, Idaho Operations Office. This report summarizes the activities and conclusions of the project management contractor, EG ampersand G Idaho, Inc., and the fabrication and testing contractor, NUS Corporation (NUS). The report also presents EG ampersand G Idaho's assessments of the equipment and procedures developed by NUS

Educators' Reports on Incidence of Harassment and Advocacy toward LGBTQ Students

Science.gov (United States)

Dragowski, Eliza A.; McCabe, Paul C.; Rubinson, Florence

2016-01-01

This study is based on a national survey investigation of 968 educators, who reported the incidence of LGBTQ harassment in schools, and their advocacy efforts on behalf of this population. LGBTQ-related knowledge, attitudes, norms, and perceived ability to advocate were also assessed. Ninety percent of educators reported observing LGBTQ harassment…

Survey of reportable incidents in nuclear power plants of the Federal Republic of Germany in the year 1991

International Nuclear Information System (INIS)

1992-01-01

In 1991, there were 249 reportable nuclear power plant incidents in Germany (old and new federal Laender). The report comprehensively lists all these incidents. There was no release of radioactivity exceeding the maximum permissible limits, and there were no effects on man or the environment. There were no incidents of reporting category S (Urgent notification), and ten belonging to category E (immediate notification). The six incidents reported in the first half of 1991 from nuclear power plants in the new federal Laender all belonged to category AE 3, which is the lowest. (orig./DG) [de

Final project report

Energy Technology Data Exchange (ETDEWEB)

Nitin S. Baliga and Leroy Hood

2008-11-12

The proposed overarching goal for this project was the following: Data integration, simulation and visualization will facilitate metabolic and regulatory network prediction, exploration, and formulation of hypotheses. We stated three specific aims to achieve the overarching goal of this project: (1) Integration of multiple levels of information such as mRNA and protein levels, predicted protein-protein interactions/associations and gene function will enable construction of models describing environmental response and dynamic behavior. (2) Flexible tools for network inference will accelerate our understanding of biological systems. (3) Flexible exploration and queries of model hypotheses will provide focus and reveal novel dependencies. The underlying philosophy of these proposed aims is that an iterative cycle of experiments, experimental design, and verification will lead to a comprehensive and predictive model that will shed light on systems level mechanisms involved in responses elicited by living systems upon sensing a change in their environment. In the previous years report we demonstrated considerable progress in development of data standards, regulatory network inference and data visualization and exploration. We are pleased to report that several manuscripts describing these procedures have been published in top international peer reviewed journals including Genome Biology, PNAS, and Cell. The abstracts of these manuscripts are given and they summarize our accomplishments in this project.

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/

Fusion Simulation Project Workshop Report

Science.gov (United States)

Kritz, Arnold; Keyes, David

2009-03-01

The mission of the Fusion Simulation Project is to develop a predictive capability for the integrated modeling of magnetically confined plasmas. This FSP report adds to the previous activities that defined an approach to integrated modeling in magnetic fusion. These previous activities included a Fusion Energy Sciences Advisory Committee panel that was charged to study integrated simulation in 2002. The report of that panel [Journal of Fusion Energy 20, 135 (2001)] recommended the prompt initiation of a Fusion Simulation Project. In 2003, the Office of Fusion Energy Sciences formed a steering committee that developed a project vision, roadmap, and governance concepts [Journal of Fusion Energy 23, 1 (2004)]. The current FSP planning effort involved 46 physicists, applied mathematicians and computer scientists, from 21 institutions, formed into four panels and a coordinating committee. These panels were constituted to consider: Status of Physics Components, Required Computational and Applied Mathematics Tools, Integration and Management of Code Components, and Project Structure and Management. The ideas, reported here, are the products of these panels, working together over several months and culminating in a 3-day workshop in May 2007.

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

Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals. Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with "balanced" datasets (n_ Type  = 2860, n_ SeverityLevel  = 1160) from a state-wide incident reporting system. Testing was also undertaken with imbalanced "stratified" datasets (n_ Type  = 6000, n_ SeverityLevel =5950) from the state-wide system and an independent hospital reporting system. Classifier performance was evaluated using a confusion matrix, as well as F-score, precision and recall. The most effective combination was a OvsO ensemble of binary SVM RBF classifiers with binary count feature extraction. For incident type, classifiers performed well on balanced and stratified datasets (F-score: 78.3, 73.9%), but were worse on independent datasets (68.5%). Reports about falls, medications, pressure injury, aggression and blood products were identified with high recall and precision. "Documentation" was the hardest type to identify. For severity level, F-score for severity assessment code (SAC) 1 (extreme risk) was 87.3 and 64% for SAC4 (low risk) on balanced data. With stratified data, high recall was achieved for SAC1 (82.8-84%) but precision was poor (6.8-11.2%). High risk incidents (SAC2) were confused

In situ simulation: Taking reported critical incidents and adverse events back to the clinic

DEFF Research Database (Denmark)

Juul, Jonas; Paltved, Charlotte; Krogh, Kristian

2014-01-01

for content analysis4 and thematic analysis5. Medical experts and simulation faculty will design scenarios for in situ simulation training based on the analysis. Short-term observations using time logs will be performed along with interviews with key informants at the departments. Video data will be collected...... improve patient safety if coupled with training and organisational support2. Insight into the nature of reported critical incidents and adverse events can be used in writing in situ simulation scenarios and thus lead to interventions that enhance patient safety. The patient safety literature emphasises...... well-developed non-technical skills in preventing medical errors3. Furthermore, critical incidents and adverse events reporting systems comprise a knowledgebase to gain in-depth insights into patient safety issues. This study explores the use of critical incidents and adverse events reports to inform...

Effects of Helicobacter pylori infection and smoking on gastric cancer incidence in China: a population-level analysis of trends and projections

Science.gov (United States)

Goldie, Sue J.; Kuntz, Karen M.; Ezzati, Majid

2010-01-01

Objective Although gastric cancer incidence is declining in China, trends may differ from historical patterns in developed countries. Our aim was to (1) retrospectively estimate the effects of Helicobacter pylori (H. pylori) and smoking on past gastric cancer incidence and (2) project how interventions on these two risk factors can reduce future incidence. Methods We used a population-based model of intestinal-type gastric cancer to estimate gastric cancer incidence between 1985 and 2050. Disease and risk factor data in the model were from community-based epidemiological studies and national prevalence surveys. Results Between 1985 and 2005, age-standardized gastric cancer incidence among Chinese men declined from 30.8 to 27.2 per 100,000 (12%); trends in H. pylori and smoking prevalences accounted for >30% of overall decline. If past risk factor trends continue, gastric cancer incidence will decline an additional 30% by 2050. Yet, annual cases will increase from 116,000 to 201,000 due to population growth and aging. Assuming that H. pylori prevention/treatment and tobacco control are implemented in 2010, the decline in gastric cancer incidence is projected to increase to 33% with universal H. pylori treatment for 20-year-olds, 42% for a hypothetical childhood H. pylori vaccine, and 34% for aggressive tobacco control. Conclusions The decline in gastric cancer incidence has been slower than in developed countries and will be offset by population growth and aging. Public health interventions should be implemented to reduce the total number of cases. PMID:19642005

Survey to identify depth of penetration of critical incident reporting systems in Austrian healthcare facilities.

Science.gov (United States)

Sendlhofer, Gerald; Eder, Harald; Leitgeb, Karina; Gorges, Roland; Jakse, Heidelinde; Raiger, Marianne; Türk, Silvia; Petschnig, Walter; Pregartner, Gudrun; Kamolz, Lars-Peter; Brunner, Gernot

2018-01-01

Incident reporting systems or so-called critical incident reporting systems (CIRS) were first recommended for use in health care more than 15 years ago. The uses of these CIRS are highly variable among countries, ranging from being used to report critical incidents, falls, or sentinel events resulting in death. In Austria, CIRS have only been introduced to the health care sector relatively recently. The goal of this work, therefore, was to determine whether and specifically how CIRS are used in Austria. A working group from the Austrian Society for Quality and Safety in Healthcare (ASQS) developed a survey on the topic of CIRS to collect information on penetration of CIRS in general and on how CIRS reports are used to increase patient safety. Three hundred seventy-one health care professionals from 274 health care facilities were contacted via e-mail. Seventy-eight respondents (21.0%) completed the online survey, thereof 66 from hospitals and 12 from other facilities (outpatient clinics, nursing homes). In all, 64.1% of the respondents indicated that CIRS were used in the entire health care facility; 20.6% had not yet introduced CIRS and 15.4% used CIRS only in particular areas. Most often, critical incidents without any harm to patients were reported (76.9%); however, some health care facilities also use their CIRS to report patient falls (16.7%), needle stick injuries (17.9%), technical problems (51.3%), or critical incidents involving health care professionals. CIRS are not yet extensively or homogeneously used in Austria. Inconsistencies exist with respect to which events are reported as well as how they are followed up and reported to health care professionals. Further recommendations for general use are needed to support the dissemination in Austrian health care environments.

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.

Self-reported whole-grain intake and plasma alkylresorcinol concentrations in combination in relation to the incidence of colorectal cancer.

Science.gov (United States)

Knudsen, Markus Dines; Kyrø, Cecilie; Olsen, Anja; Dragsted, Lars O; Skeie, Guri; Lund, Eiliv; Aman, Per; Nilsson, Lena M; Bueno-de-Mesquita, H B; Tjønneland, Anne; Landberg, Rikard

2014-05-15

Self-reported food frequency questionnaires (FFQs) have occasionally been used to investigate the association between whole-grain intake and the incidence of colorectal cancer, but the results from those studies have been inconsistent. We investigated this association using intakes of whole grains and whole-grain products measured via FFQs and plasma alkylresorcinol concentrations, a biomarker of whole-grain wheat and rye intake, both separately and in combination (Howe's score with ranks). We conducted a nested case-control study in a cohort from a research project on Nordic health and whole-grain consumption (HELGA, 1992-1998). Incidence rate ratios and 95% confidence intervals were calculated using conditional logistic regression. Plasma alkylresorcinol concentrations alone and Howe's score with ranks were inversely associated with the incidence of distal colon cancer when the highest quartile was compared with the lowest (for alkylresorcinol concentrations, incidence rate ratio = 0.34, 95% confidence interval: 0.13, 0.92; for Howe's score with ranks, incidence rate ratio = 0.35, 95% confidence interval: 0.15, 0.86). No association was observed between whole-grain intake and any colorectal cancer (colon, proximal, distal or rectum cancer) when using an FFQ as the measure/exposure variable for whole-grain intake. The results suggest that assessing whole-grain intake using a combination of FFQs and biomarkers slightly increases the precision in estimating the risk of colon or rectal cancer by reducing the impact of misclassification, thereby increasing the statistical power of the study.

Final Project Report

DEFF Research Database (Denmark)

Duer, Karsten

1997-01-01

The report summarizes the work that has been carried out within the project "B1 AEROGELS" as a part of the IEA SH&CP Task 18 "Advanced Glazing and Associated Materials For SolarAnd Building Applications". By providing at the same time thermal insulation and transparency the silica aerogel is a very...

SU-E-T-511: Inter-Rater Variability in Classification of Incidents in a New Incident Reporting System

International Nuclear Information System (INIS)

Pappas, D; Reis, S; Ali, A; Kapur, A

2015-01-01

Purpose To determine how consistent the results of different raters are when reviewing the same cases within the Radiation Oncology Incident Learning System (ROILS). Methods Three second-year medical physics graduate students filled out incident reports in spreadsheets set up to mimic ROILS. All students studied the same 33 cases and independently entered their assessments, for a total of 99 reviewed cases. The narratives for these cases were obtained from a published International Commission on Radiological Protection (ICRP) report which included shorter narratives selected from the Radiation Oncology Safety Information System (ROSIS) database. Each category of questions was reviewed to see how consistent the results were by utilizing free-marginal multirater kappa analysis. The percentage of cases where all raters shared full agreement or full disagreement was recorded to show which questions were answered consistently by multiple raters for a given case. The consistency among the raters was analyzed between ICRP and ROSIS cases to see if either group led to more reliable results. Results The categories where all raters agreed 100 percent in their choices were the event type (93.94 percent of cases 0.946 kappa) and the likelihood of the event being harmful to the patient (42.42 percent of cases 0.409 kappa). The categories where all raters disagreed 100 percent in their choices were the dosimetric severity scale (39.39 percent of cases 0.139 kappa) and the potential future toxicity (48.48 percent of cases 0.205 kappa). ROSIS had more cases where all raters disagreed than ICRP (23.06 percent of cases compared to 15.58 percent, respectively). Conclusion Despite reviewing the same cases, the results among the three raters was widespread. ROSIS narratives were shorter than ICRP, which suggests that longer narratives lead to more consistent results. This study shows that the incident reporting system can be optimized to yield more consistent results

SU-E-T-511: Inter-Rater Variability in Classification of Incidents in a New Incident Reporting System

Energy Technology Data Exchange (ETDEWEB)

Pappas, D; Reis, S; Ali, A [Hofstra University, Hempstead, NY (United States); Kapur, A [Long Island Jewish Medical Center, New Hyde Park, NY (United States)

2015-06-15

Purpose To determine how consistent the results of different raters are when reviewing the same cases within the Radiation Oncology Incident Learning System (ROILS). Methods Three second-year medical physics graduate students filled out incident reports in spreadsheets set up to mimic ROILS. All students studied the same 33 cases and independently entered their assessments, for a total of 99 reviewed cases. The narratives for these cases were obtained from a published International Commission on Radiological Protection (ICRP) report which included shorter narratives selected from the Radiation Oncology Safety Information System (ROSIS) database. Each category of questions was reviewed to see how consistent the results were by utilizing free-marginal multirater kappa analysis. The percentage of cases where all raters shared full agreement or full disagreement was recorded to show which questions were answered consistently by multiple raters for a given case. The consistency among the raters was analyzed between ICRP and ROSIS cases to see if either group led to more reliable results. Results The categories where all raters agreed 100 percent in their choices were the event type (93.94 percent of cases 0.946 kappa) and the likelihood of the event being harmful to the patient (42.42 percent of cases 0.409 kappa). The categories where all raters disagreed 100 percent in their choices were the dosimetric severity scale (39.39 percent of cases 0.139 kappa) and the potential future toxicity (48.48 percent of cases 0.205 kappa). ROSIS had more cases where all raters disagreed than ICRP (23.06 percent of cases compared to 15.58 percent, respectively). Conclusion Despite reviewing the same cases, the results among the three raters was widespread. ROSIS narratives were shorter than ICRP, which suggests that longer narratives lead to more consistent results. This study shows that the incident reporting system can be optimized to yield more consistent results.

Self-Reported Minimalist Running Injury Incidence and Severity: A Pilot Study.

Science.gov (United States)

Ostermann, Katrina; Ridpath, Lance; Hanna, Jandy B

2016-08-01

Minimalist running entails using shoes with a flexible thin sole and is popular in the United States. Existing literature disagrees over whether minimalist running shoes (MRS) improve perceived severity of injuries associated with running in traditional running shoes (TRS). Additionally, the perceived injury patterns associated with MRS are relatively unknown. To examine whether injury incidence and severity (ie, degree of pain) by body region change after switching to MRS, and to determine if transition times affect injury incidences or severity with MRS. Runners who were either current or previous users of MRS were recruited to complete an Internet-based survey regarding self-reported injury before switching to MRS and whether self-reported pain from that injury decreased after switching. Questions regarding whether new injuries developed in respondents after switching to MRS were also included. Analyses were calculated using t tests, Wilcoxon signed rank tests, and Fischer exact tests. Forty-seven runners completed the survey, and 16 respondents reported injuries before switching to MRS. Among these respondents, pain resulting from injuries of the feet (P=.03) and knees (P=.01) decreased. Eighteen respondents (38.3%) indicated they sustained new injuries after switching to MRS, but the severity of these did not differ significantly from no injury. Neither time allowed for transition to MRS nor use or disuse of a stretching routine during this period was correlated with an increase in the incidence or severity of injuries. After switching to MRS, respondents perceived an improvement in foot and knee injuries. Additionally, respondents using MRS reported an injury rate of 38.3%, compared with the approximately 64% that the literature reports among TRS users. Future studies should be expanded to determine the full extent of the differences in injury patterns between MRS and TRS.

Using Pareto Analysis with Trend Analysis: Statistical Techniques to Investigate Incident Reports within a Housing System

Science.gov (United States)

Luna, Andrew L.

1998-01-01

The purpose of this study was to determine trends and difficulties concerning student incident reports within the residence halls as they relate to the incident reporting system from the Department of Housing and Residential Life at a Southeastern Doctoral I Granting Institution. This study used the frequency distributions of each classified…

77 FR 69925 - Assessment of Hazardous Materials Incident Data Collection, Analysis, Reporting, and Use

Science.gov (United States)

2012-11-21

...), 126 Stat. 835, July 6, 2012) requires the Department to conduct an assessment to improve the... adequacy of and suggestions for improvement to: 1. Information requested on the accident and incident... technology; and 5. The database used by PHMSA for recording and reporting such accidents and incidents...

Criteria for classification and reporting of fire incidences in nuclear power plants of India

International Nuclear Information System (INIS)

Kapoor, R.K.

1998-01-01

Is is important that all fires in and around fire effective neighbourhood of Nuclear Power Plant (NPP) should be promptly reported (Reportable fires) and investigated. However, the depth of investigation and the range of authorities to whom the individual fire incidence need to be reported depends upon the severity of fire. In case of conventional non-chemical industries, the severity of fire depends mainly on the extent of loss caused by fire on property and the burn injury to persons. In case of NPP, two additional losses viz, release of radioactivity to working/public environment and the risk to safety related systems of NPP due to fire assume greater importance. This paper describes the criteria used in NPPs of India for classification of reportable fire incidences into four categories, viz. Insignificant, small, medium and large fires. It also gives the level of investigation depending upon the severity of fire. The fire classification scheme is explained in this paper with the help of worked out examples and two incidences of fire in Indian NPPs. (author)

Changes in body mass index and incidence of diabetes: A longitudinal study of Alberta's Tomorrow Project Cohort.

Science.gov (United States)

Ye, Ming; Robson, Paula J; Eurich, Dean T; Vena, Jennifer E; Xu, Jian-Yi; Johnson, Jeffrey A

2018-01-01

Although obesity is a known risk factor for diabetes, the impact of body mass index (BMI) changes over time, especially BMI reduction, on diabetes development is less than clear. The objective of this study is to characterize the association between BMI changes over time and incidence of diabetes in a cohort of adults in Alberta. From 2000 to 2008, Alberta's Tomorrow Project (ATP) enrolled participants aged 35-69 to a population-based prospective cohort study. BMI was calculated from self-reported height and weight; change in BMI (∆BMI) was calculated as the difference between baseline and follow-up measurements. Diabetes cases were identified using the Canadian National Diabetes Surveillance System algorithm applied to linked administrative data (2000-2015). Multivariable Cox regression was used to examine the association between ∆BMI and incidence of diabetes. In a subset of the ATP cohort (n=19,164), 1168 incident cases of diabetes were identified during 198,853person-years of follow-up. Overall, BMI increase was associated with increased risk and BMI reduction was associated with reduced risk of diabetes. Particularly, compared to minimal BMI change (±5%), moderate (5%-10%) reduction in BMI was associated with 34% (95% CI: 12%-51%) reduction in risk of diabetes in participants with obesity; whereas 10% or greater increase in BMI was associated with an increased risk of diabetes of 64% or more in participants with overweight and obesity; in participants with normal and underweight, BMI changes was not apparently associated with risk of diabetes. Public health programs promoting weight loss, even at a moderate extent, would reduce risk of diabetes. Copyright © 2017 Elsevier Inc. All rights reserved.

Contributory factors in surgical incidents as delineated by a confidential reporting system.

Science.gov (United States)

Mushtaq, F; O'Driscoll, C; Smith, Fct; Wilkins, D; Kapur, N; Lawton, R

2018-05-01

Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) - with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures - those closest in time and space to the adverse event - pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.

SU-F-T-462: Lessons Learned From a Machine Incident Reporting System

International Nuclear Information System (INIS)

Sutlief, S; Hoisak, J

2016-01-01

Purpose: Linear accelerators must operate with minimal downtime. Machine incident logs are a crucial tool to meet this requirement. They providing a history of service and demonstrate whether a fix is working. This study investigates the information content of a large department linear accelerator incident log. Methods: Our department uses an electronic reporting system to provide immediate information to both key department staff and the field service department. This study examines reports for five linac logs during 2015. The report attributes for analysis include frequency, level of documentation, who solved the problem, and type of fix used. Results: Of the reports, 36% were documented as resolved. In another 25% the resolution allowed treatment to proceed although the reported problem recurred within days. In 5% only intermediate troubleshooting was documented. The remainder lacked documentation. In 60% of the reports, radiation therapists resolved the problem, often by clearing the appropriate faults or reinitializing a software or hardware service. 22% were resolved by physics and 10% by field service engineers. The remaining 8% were resolved by IT, Facilities, or resolved spontaneously. Typical fixes, in order of scope, included clearing the fault and moving on, closing and re-opening the patient session or software, cycling power to a sub-unit, recalibrating a device (e.g., optical surface imaging), and calling in Field Service (usually resolving the problem through maintenance or component replacement). Conclusion: The reports with undocumented resolution represent a missed opportunity for learning. Frequency of who resolves a problem scales with the proximity of the person’s role (therapist, physicist, or service engineer), which is inversely related to the permanence of the resolution. Review of lessons learned from machine incident logs can form the basis for guidance to radiation therapists and medical physicists to minimize equipment downtime and

SU-F-T-462: Lessons Learned From a Machine Incident Reporting System

Energy Technology Data Exchange (ETDEWEB)

Sutlief, S; Hoisak, J [University of California, San Diego, La Jolla, CA (United States)

2016-06-15

Purpose: Linear accelerators must operate with minimal downtime. Machine incident logs are a crucial tool to meet this requirement. They providing a history of service and demonstrate whether a fix is working. This study investigates the information content of a large department linear accelerator incident log. Methods: Our department uses an electronic reporting system to provide immediate information to both key department staff and the field service department. This study examines reports for five linac logs during 2015. The report attributes for analysis include frequency, level of documentation, who solved the problem, and type of fix used. Results: Of the reports, 36% were documented as resolved. In another 25% the resolution allowed treatment to proceed although the reported problem recurred within days. In 5% only intermediate troubleshooting was documented. The remainder lacked documentation. In 60% of the reports, radiation therapists resolved the problem, often by clearing the appropriate faults or reinitializing a software or hardware service. 22% were resolved by physics and 10% by field service engineers. The remaining 8% were resolved by IT, Facilities, or resolved spontaneously. Typical fixes, in order of scope, included clearing the fault and moving on, closing and re-opening the patient session or software, cycling power to a sub-unit, recalibrating a device (e.g., optical surface imaging), and calling in Field Service (usually resolving the problem through maintenance or component replacement). Conclusion: The reports with undocumented resolution represent a missed opportunity for learning. Frequency of who resolves a problem scales with the proximity of the person’s role (therapist, physicist, or service engineer), which is inversely related to the permanence of the resolution. Review of lessons learned from machine incident logs can form the basis for guidance to radiation therapists and medical physicists to minimize equipment downtime and

Savage Island Project borehole completion report

International Nuclear Information System (INIS)

Chamness, M.A.; Gilmore, T.J.; Teel, S.S.

1993-02-01

This report discusses three wells which were drilled in 1990 and 1991 in support of Pacific Northwest Laboratory's Ground-Water surveillance Project. These wells were intended to monitor the Rattlesnake Ridge interbed aquifer and the deeper portion of the unconfined aquifer to determine whether ground-water contamination emanating from the Hanford Site was migrating offsite through these aquifers. This report discusses well construction, lithologies encountered, and other data collected during drilling. At least three reports have been or are being prepared to discuss the results of this well monitoring project

The international Chernobyl project: Assessment of radiological consequences and evaluation of protective measures

International Nuclear Information System (INIS)

1991-08-01

This brochure gives a brief account of the findings of the International Chernobyl Project. Further details will be found in the report ''The International Chernobyl Project: An Overview'' (INI22:066284/5) and in the Technical Report (INI23:011339). Measurements and assessments carried out under the project provided general corroboration of the levels of surface cesium-137 contamination reported in the official maps. The project also concluded that the official procedures for estimating radiation doses to the population were scientifically sound, although they generally resulted in overestimates of two- to threefold. The project could find no marked increase in the incidence of leukemia or cancer, but reported absorbed thyroid doses in children might lead to a statistically detectable rise in the incidence of thyroid tumors. Significant non-radiation-related health disorders were found, and the accident had substantial psychological consequences in terms of anxiety and stress

Nuclear Safety Project. Annual report 1983

International Nuclear Information System (INIS)

1984-06-01

The annual report 1983 is a detailed description (in German language) of work within the Nuclear Safety Project performed in 1983 in the nuclear safety field by KfK institutes and departments and by external institutes on behalf of KfK. It includes for each individual research activity short summaries in English language on work performed, results obtained and plans for future work. This report was compiled by the project management. (orig.) [de

Nuclear safety project. Annual report 1985

International Nuclear Information System (INIS)

1986-07-01

The annual report 1985 is a detailed description (in German language) of work within the nuclear safety project performed in 1985 in the nuclear safety field by KfK institutes and departments and by external institutes on behalf of KfK. It includes for each individual research activity short summaries in English language on work performed, results obtained and plans for future work. This report was compiled by the project management. (orig./HP) [de

The Stripa project. Annual report 1990

International Nuclear Information System (INIS)

1991-07-01

The Stripa project is an international project being performed under the sponsorship of the OECD Nuclear Energy Agency (NEA). The project concerns research related to the disposal of highly radioactive waste in crystalline rock. The research and development division of the Swedish Nuclear Fuel and Waste Management Co. (SKB) has been entrusted with the management of the project, under the direction of representatives from each participating country. The aim of this report is to inform the OECD Nuclear Energy Agency and the participants in the project about the general progress of work during 1990

The Stripa project annual report 1991

International Nuclear Information System (INIS)

1992-05-01

The Stripa project is an international project being performed under the sponsorship of the OECD Nuclear Energy Agency (NEA). The project concerns research related to the disposal of highly radioactive waste in crystalline rock. The Research and Development Division of the Swedish Nuclear Fuel and Waste Management Company (SKB) has been entrusted with the management of the project, under the direction of representatives from each participating country. The aim of this report is to inform the OECD Nuclear Energy Agency and the participants in the project about the general progress of work during 1991

Status Report: Mathematics Curriculum-Development Projects Today

Science.gov (United States)

Arithmetic Teacher, 1972

1972-01-01

Brief reports on the Cambridge Conference on School Mathematics, Comprehensive School Mathematics Program, Computer-Assisted Instruction Projects at Stanford, Individually Prescribed Instruction Project, The Madison Project, Mathematics/Science Learning System, MINNEMAST, and School Mathematics Study Group. (MM)

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.

Photovoltaic Programme, Edition 2006. Summary report. Project list. Annual project reports 2005; Programm Photovoltaik, Ausgabe 2006. Ueberblicksbericht. Liste der Projekte. Jahresberichte der Beauftragten 2005

Energy Technology Data Exchange (ETDEWEB)

Nowak, S.

2006-07-01

This comprehensive, illustrated report for the Swiss Federal Office of Energy (SFOE) presents an overview of the work done as part of the 2005 research programme, along with the annual reports of the project leaders on research projects. It presents the programme's main points of focus, discusses the work done and the results obtained. Areas covered include cell technology (13 reports), solar modules and building integration (3 reports) , system technology (4 reports) as well as various further projects (5) that are connected with photovoltaics. Four further reports concern international co-operation. Further, several pilot and demonstration (P+D) projects are discussed. Lists of all research and development projects and pilot and demonstration projects are supplied. Work done at several institutions in Switzerland and at leading commercial companies is described.

Photovoltaic Programme, Edition 2006. Summary report. Project list. Annual project reports 2005; Programm Photovoltaik, Ausgabe 2006. Ueberblicksbericht. Liste der Projekte. Jahresberichte der Beauftragten 2005

Energy Technology Data Exchange (ETDEWEB)

Nowak, S

2006-07-01

This comprehensive, illustrated report for the Swiss Federal Office of Energy (SFOE) presents an overview of the work done as part of the 2005 research programme, along with the annual reports of the project leaders on research projects. It presents the programme's main points of focus, discusses the work done and the results obtained. Areas covered include cell technology (13 reports), solar modules and building integration (3 reports) , system technology (4 reports) as well as various further projects (5) that are connected with photovoltaics. Four further reports concern international co-operation. Further, several pilot and demonstration (P+D) projects are discussed. Lists of all research and development projects and pilot and demonstration projects are supplied. Work done at several institutions in Switzerland and at leading commercial companies is described.

Medical students' perceptions of a novel institutional incident reporting system : A thematic analysis.

Science.gov (United States)

Gordon, Morris; Parakh, Dillan

2017-10-01

Errors in healthcare are a major patient safety issue, with incident reporting a key solution. The incident reporting system has been integrated within a new medical curriculum, encouraging medical students to take part in this key safety process. The aim of this study was to describe the system and assess how students perceived the reporting system with regards to its role in enhancing safety. Employing a thematic analysis, this study used interviews with medical students at the end of the first year. Thematic indices were developed according to the information emerging from the data. Through open, axial and then selective stages of coding, an understanding of how the system was perceived was established. Analysis of the interview specified five core themes: (1) Aims of the incident reporting system; (2) internalized cognition of the system; (3) the impact of the reporting system; (4) threshold for reporting; (5) feedback on the systems operation. Selective analysis revealed three overriding findings: lack of error awareness and error wisdom as underpinned by key theoretical constructs, student support of the principle of safety, and perceptions of a blame culture. Students did not interpret reporting as a manner to support institutional learning and safety, rather many perceived it as a tool for a blame culture. The impact reporting had on students was unexpected and may give insight into how other undergraduates and early graduates interpret such a system. Future studies should aim to produce interventions that can support a reporting culture.

Numerical analyses of an ex-core fuel incident: Results of the OECD-IAEA Paks Fuel Project

Energy Technology Data Exchange (ETDEWEB)

Hozer, Z., E-mail: hozer@aeki.kfki.h [Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, H-1525 Budapest, P.O. Box 49 (Hungary); Aszodi, A. [BME NTI Budapest (Hungary); Barnak, M. [IVS, Trnava (Slovakia); Boros, I. [BME NTI Budapest (Hungary); Fogel, M. [VUJE, Trnava (Slovakia); Guillard, V. [IRSN, Cadarache (France); Gyori, Cs. [ITU, EU, Karlsruhe (Germany); Hegyi, G. [Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, H-1525 Budapest, P.O. Box 49 (Hungary); Horvath, G.L. [VEIKI, Budapest (Hungary); Nagy, I. [Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, H-1525 Budapest, P.O. Box 49 (Hungary); Junninen, P. [VTT, Espoo (Finland); Kobzar, V. [KI, Moscow (Russian Federation); Legradi, G. [BME NTI Budapest (Hungary); Molnar, A. [Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, H-1525 Budapest, P.O. Box 49 (Hungary); Pietarinen, K. [VTT, Espoo (Finland); Perneczky, L. [Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, H-1525 Budapest, P.O. Box 49 (Hungary); Makihara, Y. [ATMEA, Paris (France); Matejovic, P. [IVS, Trnava (Slovakia); Perez-Fero, E.; Slonszki, E. [Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, H-1525 Budapest, P.O. Box 49 (Hungary)

2010-03-15

The OECD-IAEA Paks Fuel Project was developed to support the understanding of fuel behaviour in accident conditions on the basis of analyses of the Paks-2 incident. Numerical simulation of the most relevant aspects of the event and comparison of the calculation results with the available data from the incident was carried out between 2006 and 2007. A database was compiled to provide input for the code calculations. The activities covered the following three areas: (a) Thermal hydraulic calculations described the cooling conditions possibly established during the incident. (b) Simulation of fuel behaviour described the oxidation and degradation mechanisms of the fuel assemblies. (c) The release of fission products from the failed fuel rods was estimated and compared to available measured data. The applied used codes captured the most important events of the Paks-2 incident and the calculated results improved the understanding of the causes and mechanisms of fuel failure. The numerical analyses showed that the by-pass flow leading to insufficient cooling amounted to 75-90% of the inlet flow rate, the maximum temperature in the tank was between 1200 and 1400 deg. C, the degree of zirconium oxidation reached 4-12% and the mass of produced hydrogen was between 3 and 13 kg.

The Stripa project. Annual report 1988

International Nuclear Information System (INIS)

1989-05-01

The Stripa project is an international project being performed under the sponsorship of the OECD Nuclear Energy Agency (NEA). The project concerns research related to the disposal of highly radioactive waste in crystalline rock. The Research and Development Division of the Swedish Nuclear Fuel and Waste Management Company (SKB) hsa been enstrusted with the management of the project, under the direction of representatives from each participating country. The aim of this report is to inform the OECD Nuclear Energy Agency and the participants in the project about the general progress of work during 1988. (36 figs., 4 tabs.)

Prototype Rail Crossing Violation Warning Application Project Report.

Science.gov (United States)

2017-09-05

This report is the Project Report for the Rail Crossing Violation Warning (RCVW) safety application developed for the project on Rail Crossing Violation Warning Application and Infrastructure Connection, providing a means for equipped connected vehic...

[Preliminary results of an anonymous internet-based reporting system for critical incidents in ambulatory primary care].

Science.gov (United States)

Brun, A

2005-03-01

To learn from errors is not always easy, especially if they happened to others! This paper describes the organization and management of a critical incident reporting system for primary care physicians in Switzerland and reports about the difficulties and experiences during the first 18 months since the start of the program. It seems to be particularly difficult to enhance the attentiveness of physicians for apparently harmless daily critical incidents and to motivate them to report it even in an anonymous reporting system. As incentives for more intensive participation there are the hope for comments on reported cases by other participants and the expectation that reported errors will be avoided by the readers.

Photovoltaic Programme Edition 2007. Summary Report, Project List, Annual Project Reports 2006 (Abstracts)

Energy Technology Data Exchange (ETDEWEB)

NONE

2007-07-01

This 2007 edition summary report for the Swiss Federal Office of Energy (SFOE), reports on the work done within the framework of the Swiss Photovoltaics Program in 2006. The document contains 46 abstracts on work done in the photovoltaics area. The subjects reported on in the thin-film photovoltaics sector include advanced processing and characterisation of thin film silicon solar cells, high-rate deposition of micro-crystalline silicon, a new large-area VHF reactor for high-rate deposition of micro-crystalline silicon, the stability of zinc oxide in encapsulated thin film silicon solar cells, spectral photocurrent measurement, roll-to-roll technology for the production of thin film silicon modules, advanced thin film technologies, ultra thin silicon wafer cutting, bifacial thin industrial multi-crystalline silicon solar cells, flexible CIGS solar cells and mini-modules, large-area CIS-based thin-film solar modules and advanced thin-film technologies. In the area of dye-sensitised modules, the following projects are reported on: Dye-sensitised nano-crystalline solar cells, voltage enhancement of dye solar cells and molecular orientation as well as low band-gap and new hybrid device concepts for the improvement of flexible organic solar cells. Other projects reported on include a new PV wave making more efficient use of the solar spectrum, photovoltaic textiles, organic photovoltaic devices, photo-electrochemical and photovoltaic conversion and storage of solar energy, PV modules with antireflex glass, improved integration of PV into existing buildings, the seventh program at the LEEE-TISO, the 'PV enlargement' and 'Performance' programs, efficiency and annual electricity production of PV modules, photovoltaics system technology 2005-2006, an update on photovoltaics in view of the 'ecoinvent' v.2.0 tool and environmental information services for solar energy industries. The contributions to four Swiss IEA PVPS tasks and the Swiss

Photovoltaic Programme Edition 2007. Summary Report, Project List, Annual Project Reports 2006 (Abstracts)

Energy Technology Data Exchange (ETDEWEB)

NONE

2007-07-01

This 2007 edition summary report for the Swiss Federal Office of Energy (SFOE), reports on the work done within the framework of the Swiss Photovoltaics Program in 2006. The document contains 46 abstracts on work done in the photovoltaics area. The subjects reported on in the thin-film photovoltaics sector include advanced processing and characterisation of thin film silicon solar cells, high-rate deposition of micro-crystalline silicon, a new large-area VHF reactor for high-rate deposition of micro-crystalline silicon, the stability of zinc oxide in encapsulated thin film silicon solar cells, spectral photocurrent measurement, roll-to-roll technology for the production of thin film silicon modules, advanced thin film technologies, ultra thin silicon wafer cutting, bifacial thin industrial multi-crystalline silicon solar cells, flexible CIGS solar cells and mini-modules, large-area CIS-based thin-film solar modules and advanced thin-film technologies. In the area of dye-sensitised modules, the following projects are reported on: Dye-sensitised nano-crystalline solar cells, voltage enhancement of dye solar cells and molecular orientation as well as low band-gap and new hybrid device concepts for the improvement of flexible organic solar cells. Other projects reported on include a new PV wave making more efficient use of the solar spectrum, photovoltaic textiles, organic photovoltaic devices, photo-electrochemical and photovoltaic conversion and storage of solar energy, PV modules with antireflex glass, improved integration of PV into existing buildings, the seventh program at the LEEE-TISO, the 'PV enlargement' and 'Performance' programs, efficiency and annual electricity production of PV modules, photovoltaics system technology 2005-2006, an update on photovoltaics in view of the 'ecoinvent' v.2.0 tool and environmental information services for solar energy industries. The contributions to four Swiss IEA PVPS tasks and the Swiss interdepartmental platform for

Final Project Report for Award ER65581

Energy Technology Data Exchange (ETDEWEB)

Stoy, Paul C. [Montana State Univ., Bozeman, MT (United States)

2017-07-13

The attached final project report describes contributions of Montana State University (MSU) to the project "Bridging land-surface fluxes and aerosol concentrations to triggering convective rainfall" (PI: Fuentes).

Reactor vessel decommissioning project. Final report

International Nuclear Information System (INIS)

Schoonen, D.H.

1984-09-01

This report describes a reactor vessel decommissioning project; it documents and explains the project objectives, scope, performance results, and sodium removal process. The project was successfully completed in FY-1983, within budget and without significant problems or adverse impact on the environment. Waste generated by the operation included the reactor vessel, drained sodium, and liquid, solid, and gaseous wastes which were significantly less than project estimates. Personnel radiation exposures were minimized, such that the project total was one-half the predicted exposure level. Except for the sodium removed, the material remaining in the reactor vessel is essentially the same as when the vessel arrived for processing

Radioactive Materials Packaging (RAMPAC) Radioactive Materials Incident Report (RMIR). RAMTEMP users manual

International Nuclear Information System (INIS)

Tyron-Hopko, A.K.; Driscoll, K.L.

1985-10-01

The purpose of this document is to familiarize the potential user with RadioActive Materials PACkaging (RAMPAC), Radioactive Materials Incident Report (RMIR), and RAMTEMP databases. RAMTEMP is a minor image of RAMPAC. This reference document will enable the user to access and obtain reports from databases while in an interactive mode. This manual will be revised as necessary to reflect enhancements made to the system

National Writing Project. 2011-2012 Report

Science.gov (United States)

National Writing Project (NJ1), 2012

2012-01-01

This National Writing Project 2011-2012 Report describes how Writing Project teacher-leaders study and share effective practices that enhance student writing and learning, work collaboratively with other educators, design resources, and take on new roles in effecting positive change. It includes a financial summary for years ended September 30 for…

Incident reporting culture: scale development with validation and reliability and assessment of hospital nurses in Taiwan.

Science.gov (United States)

Chiang, Hui-Ying; Hsiao, Ya-Chu; Lin, Shu-Yuan; Lee, Huan-Fang

2011-08-01

To examine the psychometric validity and reliability of the incident reporting culture questionnaire (IRCQ; in Chinese) following an exploration of the reporting culture perceived by hospital nurses in Taiwan. Scale development with psychometric examination and a cross-sectional study. Ten teaching hospitals. A total of 1064 nurses participated with an average response rate of 83% between November 2008 and June 2009. The factorial construct, criterion-related validity, homogeneity and stability of the IRCQ were evaluated. The nurses' perceptions of the IRCQ were also explored. The four-factor structure of the 20-item IRCQ had satisfactory construct validity (explained variance: 49.37%), criterion-related validity (r = 0.42; P = 0.001), reliability (Cronbach's alpha: 0.83) and stability (3-week-interval correlation: r = 0.80; P = 0.001). These factors included 'application of learning from errors', 'readiness to provide feedback on incident reports', 'collegial atmospheres of unpleasantness and punishment' (CA) and 'incident management: confidential and system driven'. The nurses perceived a moderate overall reporting culture (mean positive response = 49.25%; range: 67.2-24.94%). They weakly agreed on the CA factor of five items (mean positive response = 24.94%; range: 33.0-17.2%). This study provides empirical evidence for the psychometric properties of the IRCQ and the reporting culture which nurses perceive in Taiwan. To Taiwanese nurses, the reporting culture within their work environments especially as it relates to coworker relations, inter-professional collaboration and non-punitive atmosphere is their major concern. Healthcare administrators should consider nurses' perceptions related to incident reporting when managing underreporting issues.

Automated metadata--final project report

International Nuclear Information System (INIS)

Schissel, David

2016-01-01

This report summarizes the work of the Automated Metadata, Provenance Cataloging, and Navigable Interfaces: Ensuring the Usefulness of Extreme-Scale Data Project (MPO Project) funded by the United States Department of Energy (DOE), Offices of Advanced Scientific Computing Research and Fusion Energy Sciences. Initially funded for three years starting in 2012, it was extended for 6 months with additional funding. The project was a collaboration between scientists at General Atomics, Lawrence Berkley National Laboratory (LBNL), and Massachusetts Institute of Technology (MIT). The group leveraged existing computer science technology where possible, and extended or created new capabilities where required. The MPO project was able to successfully create a suite of software tools that can be used by a scientific community to automatically document their scientific workflows. These tools were integrated into workflows for fusion energy and climate research illustrating the general applicability of the project's toolkit. Feedback was very positive on the project's toolkit and the value of such automatic workflow documentation to the scientific endeavor.

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.

Lessons for pediatric anesthesia from audit and incident reporting.

Science.gov (United States)

Bell, Graham

2011-07-01

This review will attempt to put the various systems that allow clinicians to assess errors, omissions, or avoidable incidents into context and where possible, look for areas that deserve more or less attention and resource specifically for those of us who practice pediatric anesthesia. Different approaches will be contrasted with respect to their outputs in terms of positive impact on the practice of anesthesia. These approaches include audits by governmental organizations, national representative bodies, specialist societies, commissioned boards of inquiry, medicolegal sources, and police force investigations. Implementation strategies are considered alongside the reports as the reports cannot be considered end points themselves. Specific areas where pediatric anesthetics has failed to address recurring risk through any currently available tools will be highlighted. © 2011 Blackwell Publishing Ltd.

Cancer incidence and thyroid disease among Estonian Chernobyl clean-up workers

Energy Technology Data Exchange (ETDEWEB)

Auvinen, A; Salomaa, S [eds.; Radiation and Nuclear Safety Authority, Helsinki (Finland); Rahu, M; Veidebaum, T; Tekkel, M [eds.; Inst. of Experimental and Clinical Medicine, Tallinn (Estonia); Hakulinen, T [ed.; Finnish Cancer Registry, Helsinki (Finland); Boice, Jr, J D [ed.; Int. Epidemiology Inst., MD (United States)

1998-09-01

The report describes the development and summarizes the results of the project Cancer incidence and thyroid disease among Estonian Chernobyl clean-up workers. One of the goals of the report is to give research protocols and questionnaires for researchers involved in other studies. Eight previously published articles are also included summarizing the results. The development of the collaboration work of the project is described in the introduction of the report. Epidemiological methods are described in an article complemented by the protocol and English version of the questionnaire administered to all cleanup workers, as well as the data collection form of the thyroid study. The results from biological biodosimetry using both glycophorin A and FISH methods have shown that the radiation doses received by the Chernobyl cleanup workers were relatively low. Thyroid nodularity was not associated with any radiation exposure characteristic in the thyroid screening study. Estonian Chernobyl cleanup workers were followed up for cancer incidence through the Estonian Cancer Registry. No cases of leukemia or thyroid cancer were observed by the end of 1993. It is too early to observe possible effect on other types of cancer. However, mortality from suicides was increased compared with general population. Further follow-up and the extension to other Baltic countries in the future will undoubtedly strengthen the study. There are also plans for future projects covering areas from psychosocial factors to radiation biology

SU-E-T-469: Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

International Nuclear Information System (INIS)

Kapoor, R; Palta, J; Hagan, M; Malik, G

2015-01-01

Purpose: This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process. Results: Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of �

SU-E-T-469: Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

Energy Technology Data Exchange (ETDEWEB)

Kapoor, R; Palta, J; Hagan, M [Veteran Health Administration, Richmond, Virginia (United States); Virginia Commonwealth University, Richmond, VA (United States); Malik, G [TSG Innovations Inc. (United States)

2015-06-15

Purpose: This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process. Results: Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of �

Pharmacovigilance in oncology: pattern of spontaneous notifications, incidence of adverse drug reactions and under-reporting

Directory of Open Access Journals (Sweden)

Marília Berlofa Visacri

2014-04-01

Full Text Available The high toxicity and narrow therapeutic window of antineoplastic agents makes pharmacovigilance studies essential in oncology. The objectives of the current study were to analyze the pattern of spontaneous notifications of adverse drug reactions (ADRs in oncology patients and to analyze the incidence of ADRs reported by outpatients on antineoplastic treatment in a tertiary care teaching hospital. To compose the pattern of ADR, the notification forms of reactions in oncology patients in 2010 were reviewed, and the reactions were classified based on the drug involved, mechanism, causality, and severity. To evaluate the incidence of reactions, a questionnaire at the time of chemotherapy was included, and the severity was classified based on the Common Terminology Criteria. The profiles of the 10 responses reported to the Pharmacovigilance Sector were type B, severe, possible, and they were primarily related to platinum compounds and taxanes. When the incidence of reactions was analyzed, it was observed that nausea, alopecia, fatigue, diarrhea, and taste disturbance were the most frequently reported reactions by oncology patients, and the grade 3 and 4 reactions were not reported. Based on this analysis, it is proposed that health professionals should be trained regarding notifications and clinical pharmacists should increasingly be brought on board to reduce under-reporting of ADRs.

Final report Hanford environmental compliance project 89-D-172

International Nuclear Information System (INIS)

Kelly, J.R.

1996-01-01

The Hanford Environmental Compliance (HEC) Project is unique in that it consisted of 14 subprojects which varied in project scope and were funded from more that one program. This report describes the HEC Project from inception to completion and the scope, schedule, and cost of the individual subprojects. Also provided are the individual subproject Cost closing statements and Project completion reports accompanied by construction photographs and illustrations

Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review.

Science.gov (United States)

Polisena, Julie; Gagliardi, Anna; Urbach, David; Clifford, Tammy; Fiander, Michelle

2015-03-29

Medical devices have improved the treatment of many medical conditions. Despite their benefit, the use of devices can lead to unintended incidents, potentially resulting in unnecessary harm, injury or complications to the patient, a complaint, loss or damage. Devices are used in hospitals on a routine basis. Research to date, however, has been primarily limited to describing incidents rates, so the optimal design of a hospital-based surveillance system remains unclear. Our research objectives were twofold: i) to explore factors that influence device-related incident recognition, reporting and resolution and ii) to investigate interventions or strategies to improve the recognition, reporting and resolution of medical device-related incidents. We searched the bibliographic databases: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and PsycINFO database. Grey literature (literature that is not commercially available) was searched for studies on factors that influence incident recognition, reporting and resolution published and interventions or strategies for their improvement from 2003 to 2014. Although we focused on medical devices, other health technologies were eligible for inclusion. Thirty studies were included in our systematic review, but most studies were concentrated on other health technologies. The study findings indicate that fear of punishment, uncertainty of what should be reported and how incident reports will be used and time constraints to incident reporting are common barriers to incident recognition and reporting. Relevant studies on the resolution of medical errors were not found. Strategies to improve error reporting include the use of an electronic error reporting system, increased training and feedback to frontline clinicians about the reported error. The available evidence on factors influencing medical device-related incident recognition, reporting and resolution by healthcare professionals can inform data collection and

Project Elderly. Interim and Final Reports.

Science.gov (United States)

Miami-Dade Community Coll., FL.

This report examines Project Elderly, a project developed to provide job possibilities for the older adult in the labor market in metropolitan Miami (FL). A survey questionnaire was developed to (1) assess the opportunities of the elderly for re-entry into volunteer and paid employment positions; (2) determine the extent of the senior population…

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)

Department of Veterans Affairs - Monthly Report to Congress of Data Incidents (April 2014)

Data.gov (United States)

Department of Veterans Affairs — This is a monthly report that the VA Office of Information Technology provides to congress about data incidents that took place during the month (April 2014). The...

Research program on regulatory safety - Overview report 2010

International Nuclear Information System (INIS)

Mailaender, R

2011-01-01

This report for the Swiss Federal Office of Energy (SFOE) summarises the program's main points of interest, work done in the year 2010 and the results obtained. The main highlights of the research program, which was co-ordinated by the Swiss Federal Nuclear Safety Inspectorate ENSI are reported on. Topics reported on include nuclear fuels and materials, the development of a data base on damage and internal incidents, external incidents and human factors. Also, system behaviour and hazardous accident events are reported on, as are radiation protection and waste disposal. Project highlights include the KORA II project, which examined corrosion crack development in austenitic structural materials, the OECD's Halden Reactor Project in the man-technology-organisational area, and work done in the Mont Terri rock research laboratory. Also, national and international co-operation is briefly looked at and work to be done in 2011 is reviewed. A list of current and completed projects completes the report

Project Final Report: HPC-Colony II

Energy Technology Data Exchange (ETDEWEB)

Jones, Terry R [ORNL; Kale, Laxmikant V [University of Illinois, Urbana-Champaign; Moreira, Jose [IBM T. J. Watson Research Center

2013-11-01

This report recounts the HPC Colony II Project which was a computer science effort funded by DOE's Advanced Scientific Computing Research office. The project included researchers from ORNL, IBM, and the University of Illinois at Urbana-Champaign. The topic of the effort was adaptive system software for extreme scale parallel machines. A description of findings is included.

OECD-IAEA Paks Fuel Project. Final Report

International Nuclear Information System (INIS)

2010-05-01

It is important for nuclear power plant designers, operators and regulators to effectively use lessons learned from events occurring at nuclear power plants since, in general, it is impossible to reproduce the event using experimental facilities. In particular, evaluation of the event using accident analysis codes is expected to contribute to improving understanding of phenomena during the events and to facilitate the validation of computer codes through simulation analyses. The information presented in this publication will be of use in future revisions of safety guides on accident analysis. During a fuel crud removal operation on the Paks-2 unit of the Paks nuclear power plant, Hungary on 10 April 2003, several fuel assemblies were severely damaged. The assemblies were being cleaned in a special tank under deep water in a service pit connected to the spent fuel storage pool. The first sign of fuel failures was the detection of some fission gases released from the cleaning tank. Later, visual inspection revealed that most of the 30 fuel assemblies suffered heavy oxidation and fragmentation. The first evaluation of the event showed that the severe fuel damage had been caused by inadequate cooling. The Paks-2 event was discussed in various committees of the OECD Nuclear Energy Agency (OECD/NEA) and of the International Atomic Energy Agency (IAEA). Recommendations were made to undertake actions to improve the understanding of the incident sequence and of the consequence this had on the fuel. It was considered that the Paks-2 event may constitute a useful case for a comparative exercise on safety codes, in particular for models devised to predict fuel damage and potential releases under abnormal cooling conditions and the analyses of the Paks-2 event may provide information which is relevant for in-reactor and spent fuel storage safety evaluations. The OECD-IAEA Paks Fuel Project was established in 2005 as a joint project between the IAEA and the OECD/NEA. The IAEA

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

Halifax Lateral Pipeline Project : comprehensive study report

International Nuclear Information System (INIS)

1998-12-01

The National Energy Board has requested the preparation of a comprehensive study report (CSR) for the proposed Halifax Lateral Pipeline Project in support of Maritimes and Northeast Pipeline Company's proposal to construct the lateral pipeline to transport natural gas produced in offshore Nova Scotia to the Tufts Cove electric generating station in the Halifax Regional Municipality. The project will also enhance the access of natural gas to potential markets located along the pipeline route. This CSR was prepared according to guidelines of the Canadian Environmental Assessment Agency. The report presents: (1) an overview of the project, (2) a summary of the regulatory requirements for assessment, (3) a description of the environmental assessment and regulatory process to date, (4) a summary of the predicted residual environmental and socio-economic effects associated with the project, and (5) a summary of the public consultation process. The environmental and socio-economic assessment focused on these eleven issues: groundwater resources, surface water resources, wetlands, soils, air quality, fish habitat, rare herpetiles, mammals, avifauna, rare plants and archaeological heritage resources. The report identified potential interactions between the project and valued socio-economic and environmental components. These were addressed in combination with recommended mitigative measures to reduce potential adverse effects. It was concluded that the overall environmental effects from the proposed project are likely to be minimal and can be effectively managed with good environmental management methods. 14 refs., 5 tabs., 5 figs., 2 appendices

40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

Science.gov (United States)

2010-07-01

... 40 Protection of Environment 32 2010-07-01 2010-07-01 false Published reports and material... Published reports and material contained in the public incident investigation dockets. (a) Demands for published investigation reports should be directed to the Office of Congressional and Public Affairs, U.S...

Final Technical Report. Project Boeing SGS

Energy Technology Data Exchange (ETDEWEB)

Bell, Thomas E. [The Boeing Company, Seattle, WA (United States)

2014-12-31

Boeing and its partner, PJM Interconnection, teamed to bring advanced “defense-grade” technologies for cyber security to the US regional power grid through demonstration in PJM’s energy management environment. Under this cooperative project with the Department of Energy, Boeing and PJM have developed and demonstrated a host of technologies specifically tailored to the needs of PJM and the electric sector as a whole. The team has demonstrated to the energy industry a combination of processes, techniques and technologies that have been successfully implemented in the commercial, defense, and intelligence communities to identify, mitigate and continuously monitor the cyber security of critical systems. Guided by the results of a Cyber Security Risk-Based Assessment completed in Phase I, the Boeing-PJM team has completed multiple iterations through the Phase II Development and Phase III Deployment phases. Multiple cyber security solutions have been completed across a variety of controls including: Application Security, Enhanced Malware Detection, Security Incident and Event Management (SIEM) Optimization, Continuous Vulnerability Monitoring, SCADA Monitoring/Intrusion Detection, Operational Resiliency, Cyber Range simulations and hands on cyber security personnel training. All of the developed and demonstrated solutions are suitable for replication across the electric sector and/or the energy sector as a whole. Benefits identified include; Improved malware and intrusion detection capability on critical SCADA networks including behavioral-based alerts resulting in improved zero-day threat protection; Improved Security Incident and Event Management system resulting in better threat visibility, thus increasing the likelihood of detecting a serious event; Improved malware detection and zero-day threat response capability; Improved ability to systematically evaluate and secure in house and vendor sourced software applications; Improved ability to continuously monitor

Assessment of Evidence Base from Medical Debriefs Data on Space Motion Sickness Incidence and Treatment

Science.gov (United States)

Younker, D.R.; Daniels, V.R.; Boyd, J.L.; Putcha, L.

2008-01-01

An objective of this data compilation and analysis project is to examine incidence and treatment efficacy of common patho-physiological disturbances during spaceflight. Analysis of medical debriefs data indicated that astronauts used medications to alleviate symptoms of four major ailments for which astronauts received treatment for sleep disturbances, space motion sickness (SMS), pain (headache, back pain) and sinus congestion. In the present data compilation and analysis project on SMS treatment during space missions, subject demographics (gender, age, first-time or repeat flyer), incidence and severity of SMS symptoms and subjective treatment efficacy from 317 crewmember debrief records were examined from STS-1 through STS-89. Preliminary analysis of data revealed that 50% of crew members reported SMS symptoms on at least one flight and 22% never experienced it. In addition, there were 387 medication dosing episodes reported, and promethazine was the most commonly used medication. Results of analysis of symptom check lists, medication use/efficacy and gender and flight record differences in incidence and treatment efficacy will be presented. Evidence gaps for treatment efficacy along with medication use trend analysis will be identified.

Work Project Report

CERN Document Server

Sallinen, Roosa-Maria

2015-01-01

I worked in High Power Converters section (HPC). My supervisors were Karsten Kahle and Charles-Mathieu Genton. Our team consisted of us and Francisco Rafael Blanquez Delgado who also helped me if I had any problems. The team’s main assignment is to design the new Static Var Compensator (SVC) for MEQ59 in Meyrin. The idea is to standardise all the SVCs needed at CERN in order to make the design, installation and maintenance easier and more cost effective. This report describes my project at CERN.

Continuum of eLearning: 2012 Project Summary Report

Science.gov (United States)

2012-10-01

multimedia, and Continuum of eLearning | Purpose and Vision 19 << UNCLASSIFIED>> (limited) situated learning. Future versions of the CoL self-paced...Continuum of eLearning : 2012 Project Summary Report Continuum of eLearning The Next Evolution of Joint Training on JKO October 2012 Joint...Technical Report November 2011 – August 2012 Continuum of eLearning : 2012 Project Summary Report N00140-06-D-0060 David T. Fautua, Sae Schatz, Andrea

Fast food consumption and gestational diabetes incidence in the SUN project.

Directory of Open Access Journals (Sweden)

Ligia J Dominguez

Full Text Available BACKGROUND: Gestational diabetes prevalence is increasing, mostly because obesity among women of reproductive age is continuously escalating. We aimed to investigate the incidence of gestational diabetes according to the consumption of fast food in a cohort of university graduates. METHODS: The prospective dynamic "Seguimiento Universidad de Navarra" (SUN cohort included data of 3,048 women initially free of diabetes or previous gestational diabetes who reported at least one pregnancy between December 1999 and March 2011. Fast food consumption was assessed through a validated 136-item semi-quantitative food frequency questionnaire. Fast food was defined as the consumption of hamburgers, sausages, and pizza. Three categories of fast food were established: low (0-3 servings/month, intermediate (>3 servings/month and ≤2 servings/week and high (>2 servings/week. Non-conditional logistic regression models were used to adjust for potential confounders. RESULTS: We identified 159 incident cases of gestational diabetes during follow-up. After adjusting for age, baseline body mass index, total energy intake, smoking, physical activity, family history of diabetes, cardiovascular disease/hypertension at baseline, parity, adherence to Mediterranean dietary pattern, alcohol intake, fiber intake, and sugar-sweetened soft drinks consumption, fast food consumption was significantly associated with a higher risk of incident gestational diabetes, with multivariate adjusted OR of 1.31 (95% conficence interval [CI]:0.81-2.13 and 1.86 (95% CI: 1.13-3.06 for the intermediate and high categories, respectively, versus the lowest category of baseline fast food consumption (p for linear trend: 0.007. CONCLUSION: Our results suggest that pre-pregnancy higher consumption of fast food is an independent risk factor for gestational diabetes.

77 FR 53779 - Reports by Air Carriers on Incidents Involving Animals During Air Transport

Science.gov (United States)

2012-09-04

... Involving Animals During Air Transport AGENCY: Office of the Secretary (OST), Department of Transportation... period of an NPRM on the reporting of incidents involving animals during air transport that was published... animal during air transport. The NPRM proposed to: (1) Expand the reporting requirement to U.S. carriers...

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.

Ceramics Technology Project database: September 1991 summary report

Energy Technology Data Exchange (ETDEWEB)

Keyes, B.L.P.

1992-06-01

The piston ring-cylinder liner area of the internal combustion engine must withstand very-high-temperature gradients, highly-corrosive environments, and constant friction. Improving the efficiency in the engine requires ring and cylinder liner materials that can survive this abusive environment and lubricants that resist decomposition at elevated temperatures. Wear and friction tests have been done on many material combinations in environments similar to actual use to find the right materials for the situation. This report covers tribology information produced from 1986 through July 1991 by Battelle columbus Laboratories, Caterpillar Inc., and Cummins Engine Company, Inc. for the Ceramic Technology Project (CTP). All data in this report were taken from the project`s semiannual and bimonthly progress reports and cover base materials, coatings, and lubricants. The data, including test rig descriptions and material characterizations, are stored in the CTP database and are available to all project participants on request. Objective of this report is to make available the test results from these studies, but not to draw conclusions from these data.

MORE: Management of Requirements in NPP Modernisation Projects, final report

International Nuclear Information System (INIS)

Fredriksen, R.; Katta, V.; Raspotnig, C.; Valkonen, J.

2008-09-01

This report documents the work and related activities of the MORE (Management of Requirements in NPP Modernisation Projects) (NKS-R project number NKS-R-2005-47) project. This report also provides a summary of the project activities and deliverables, and discusses possible application areas. The project has aimed at the industrial utilisation of the results from the TACO: (Traceability and Communication of Requirements in Digital I and C Systems Development) (NKS-R project number NKS-R-2002-16, completed June, 2005) project, and practical application of improved approaches and methods for requirements engineering and change management. Finally, the report provides a brief description of the extended industrial network and disseminations of the results in Nordic and NKS related events such as seminars and workshops. (au)

MORE: Management of Requirements in NPP Modernisation Projects, final report

Energy Technology Data Exchange (ETDEWEB)

Fredriksen, R.; Katta, V.; Raspotnig, C. (Inst. for energiteknikk (IFE) (Norway)); Valkonen, J. (Technical Research Centre of Finland (VTT) (Finland))

2008-09-15

This report documents the work and related activities of the MORE (Management of Requirements in NPP Modernisation Projects) (NKS-R project number NKS-R-2005-47) project. This report also provides a summary of the project activities and deliverables, and discusses possible application areas. The project has aimed at the industrial utilisation of the results from the TACO: (Traceability and Communication of Requirements in Digital I and C Systems Development) (NKS-R project number NKS-R-2002-16, completed June, 2005) project, and practical application of improved approaches and methods for requirements engineering and change management. Finally, the report provides a brief description of the extended industrial network and disseminations of the results in Nordic and NKS related events such as seminars and workshops. (author)

Smart Gun Technology project. Final report

Energy Technology Data Exchange (ETDEWEB)

Weiss, D.R.

1996-05-01

The goal of the Smart Gun Technology project is to eliminate the capability of an unauthorized user form firing a law officer`s firearm by implementing user-recognizing-and-authorizing (or {open_quotes}smart{close_quotes}) surety technologies. This project was funded by the National Institute of Justice. This report lists the findings and results of the project`s three primary objectives. First, to find and document the requirements for a smart firearm technology that law enforcement officers will value. Second, to investigate, evaluate, and prioritize technologies that meet the requirements for a law enforcement officer`s smart firearm. Third, to demonstrate and document the most promising technology`s usefulness in models of a smart firearm.

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.

Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists.

Science.gov (United States)

Cook, T M; Counsell, D; Wildsmith, J A W

2009-02-01

Serious complications of central neuraxial block (CNB) are rare. Limited information on their incidence and impact impedes clinical decision-making and patient consent. The Royal College of Anaesthetists Third National Audit Project was designed to inform this situation. A 2 week national census estimated the number of CNB procedures performed annually in the UK National Health Service. All major complications of CNBs performed over 1 yr (vertebral canal abscess or haematoma, meningitis, nerve injury, spinal cord ischaemia, fatal cardiovascular collapse, and wrong route errors) were reported. Each case was reviewed by an expert panel to assess causation, severity, and outcome. 'Permanent' injury was defined as symptoms persisting for more than 6 months. Efforts were made to validate denominator (procedures performed) and numerator (complications) data through national databases. The census phase produced a denominator of 707,455 CNB. Eighty-four major complications were reported, of which 52 met the inclusion criteria at the time they were reported. Data were interpreted 'pessimistically' and 'optimistically'. 'Pessimistically' there were 30 permanent injuries and 'optimistically' 14. The incidence of permanent injury due to CNB (expressed per 100,000 cases) was 'pessimistically' 4.2 (95% confidence interval 2.9-6.1) and 'optimistically' 2.0 (1.1-3.3). 'Pessimistically' there were 13 deaths or paraplegias, 'optimistically' five. The incidence of paraplegia or death was 'pessimistically' 1.8 per 100,000 (1.0-3.1) and 'optimistically' 0.7 (0-1.6). Two-thirds of initially disabling injuries resolved fully. The data are reassuring and suggest that CNB has a low incidence of major complications, many of which resolve within 6 months.

Automated metadata--final project report

Energy Technology Data Exchange (ETDEWEB)

Schissel, David [General Atomics, San Diego, CA (United States)

2016-04-01

This report summarizes the work of the Automated Metadata, Provenance Cataloging, and Navigable Interfaces: Ensuring the Usefulness of Extreme-Scale Data Project (MPO Project) funded by the United States Department of Energy (DOE), Offices of Advanced Scientific Computing Research and Fusion Energy Sciences. Initially funded for three years starting in 2012, it was extended for 6 months with additional funding. The project was a collaboration between scientists at General Atomics, Lawrence Berkley National Laboratory (LBNL), and Massachusetts Institute of Technology (MIT). The group leveraged existing computer science technology where possible, and extended or created new capabilities where required. The MPO project was able to successfully create a suite of software tools that can be used by a scientific community to automatically document their scientific workflows. These tools were integrated into workflows for fusion energy and climate research illustrating the general applicability of the project’s toolkit. Feedback was very positive on the project’s toolkit and the value of such automatic workflow documentation to the scientific endeavor.

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.

[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.

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...

Ceramic Technology Project database: September 1993 summary report

Energy Technology Data Exchange (ETDEWEB)

Keyes, B.L.P.

1994-01-01

Data presented in this report represent an intense effort to improve processing methods, testing methods, and general mechanical properties of candidate ceramics for use in advanced heat engines. Materials discussed include GN-10, GS-44, GTE PY6, NT-154, NT-164, sintered-reaction-bonded silicon nitrides, silicon nitride combined with rare-earth oxides, NT-230, Hexoloy SX-G1, Dow Corning`s {beta}-Si{sub 3}N{sub 4}, and a few whisker-reinforced ceramic composites. Information in this report was taken from the project`s semiannual and bimonthly progress reports and from final reports summarizing the results of individual studies. Test results are presented in tabular form and in graphs. All data, including test rig descriptions and material characterizations, are stored in the CTP database and are available to all project participants on request. Objective of this report is to make available the test results from these studies but not to draw conclusions from those data.

The fracture zone project - final report

International Nuclear Information System (INIS)

Andersson, Peter

1993-09-01

This report summarizes the work and the experiences gained during the fracture zone project at the Finnsjoen study site. The project is probably the biggest effort, so far, to characterize a major fracture zone in crystalline bedrock. The project was running between 1984-1990 involving a large number of geological, geohydrological, geochemical, and geomechanical investigation. The methods used for identification and characterization are reviewed and discussed in terms of applicability and possible improvements for future investigations. The discussion is exemplified with results from the investigation within the project. Flow and transport properties of the zone determined from hydraulic tests and tracer tests are discussed. A large number of numerical modelling efforts performed within the fracture zone project, the INTRAVAL project, and the SKB91-study are summarized and reviewed. Finally, occurrence of similar zones and the relevance of major low angle fracture zones in connection to the siting of an underground repository is addressed

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.

Effective Transition (Project E.T.) Final Evaluation Report, 1992-93. OER Report.

Science.gov (United States)

Musante, Patricia

This report presents an evaluation of the Effective Transition (ET) project, an Elementary and Secondary Education Act Title VII-funded project in its second year of operation at Lafayette High School and Pershing Intermediate School in Brooklyn, New York. The project served a total of 300 students of limited English proficiency who were native…

NREL Energy Storage Projects: FY2013 Annual Report

Energy Technology Data Exchange (ETDEWEB)

Pesaran, A.; Ban, C.; Brooker, A.; Gonder, J.; Ireland, J.; Keyser, M.; Kim, G. H.; Long, D.; Neubauer, J.; Santhanagopalan, S.; Smith, K.; Tenent, R.; Wood, E.; Han, T.; Hartridge, S.; Shaffer, C. E.

2014-07-01

In FY13, DOE funded NREL to make technical contributions to various R&D activities. This report summarizes NREL's R&D projects in FY13 in support of the USABC; Battery Testing, Analysis, and Design; ABR; and BATT program elements. The FY13 projects under NREL's Energy Storage R&D program are discussed in depth in this report.

Project 2nd Periodic Report - Section 2

DEFF Research Database (Denmark)

Healy, Mark; Knowles, Emma; Johnstone, Cameron

The work described in this publication has received support from the European Community - Research Infrastructure Action under the FP7 “Capacities” Specific Programme through grant agreement number 262552, MaRINET. Project Periodic Report. 2nd Period: October 2012 – March 2014 inclusive.......The work described in this publication has received support from the European Community - Research Infrastructure Action under the FP7 “Capacities” Specific Programme through grant agreement number 262552, MaRINET. Project Periodic Report. 2nd Period: October 2012 – March 2014 inclusive....

Project schedule and cost estimate report

International Nuclear Information System (INIS)

1988-03-01

All cost tables represent obligation dollars, at both a constant FY 1987 level and an estimated escalation level, and are based on the FY 1989 DOE Congressional Budget submittal of December 1987. The cost tables display the total UMTRA Project estimated costs, which include both Federal and state funding. The Total Estimated Cost (TEC) for the UMTRA Project is approximately $992.5 million (in 1987 escalated dollars). Project schedules have been developed that provide for Project completion by September 1994, subject to Congressional approval extending DOE's authorization under Public Law 95-604. The report contains site-specific demographic data, conceptual design assumptions, preliminary cost estimates, and site schedules. A general project overview is also presented, which includes a discussion of the basis for the schedule and cost estimates, contingency assumptions, work breakdown structure, and potential project risks. The schedules and cost estimates will be revised as necessary to reflect appropriate decisions relating to relocation of certain tailings piles, or other special design considerations or circumstances (such as revised EPA groundwater standards), and changes in the Project mission. 27 figs', 97 tabs

Project Aprendizaje. Final Evaluation Report 1992-93.

Science.gov (United States)

Clark, Andrew

This report provides evaluative information regarding the effectiveness of Project Aprendizaje, a New York City program that served 269 Spanish-speaking students of limited English proficiency (LEP). The project promoted parent and community involvement by sponsoring cultural events, such as a large Latin American festival. Students developed…

Wheelchair incidents

NARCIS (Netherlands)

Drongelen AW van; Roszek B; Hilbers-Modderman ESM; Kallewaard M; Wassenaar C; LGM

2002-01-01

This RIVM study was performed to gain insight into wheelchair-related incidents with powered and manual wheelchairs reported to the USA FDA, the British MDA and the Dutch Center for Quality and Usability Research of Technical Aids (KBOH). The data in the databases do not indicate that incidents with

Prediction of Safety Incidents

Data.gov (United States)

National Aeronautics and Space Administration — Safety incidents, including injuries, property damage and mission failures, cost NASA and contractors thousands of dollars in direct and indirect costs. This project...

14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

Science.gov (United States)

2010-01-01

... involving animals during air transport. 234.13 Section 234.13 Aeronautics and Space OFFICE OF THE SECRETARY... REPORTS § 234.13 Reports by air carriers on incidents involving animals during air transport. (a) Any air... during air transport provided by the air carrier. (b) The report shall be made in the form and manner set...

Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study.

Science.gov (United States)

Seclen, Segundo Nicolas; Rosas, Moises Ernesto; Arias, Arturo Jaime; Medina, Cecilia Alexandra

2017-01-01

A recent report from a non-nationally representative, geographically diverse sample in four separate communities in Peru suggests an unusually high diabetes incidence. We aimed to estimate the national diabetes incidence rate using PERUDIAB, a probabilistic, national urban population-based longitudinal study. 662 subjects without diabetes, selected by multistage, cluster, random sampling of households, representing the 24 administrative and the 3 (coast, highlands and jungle) natural regions across the country, from both sexes, aged 25+ years at baseline, enrolled in 2010-2012, were followed for 3.8 years. New diabetes cases were defined as fasting blood glucose ≥126 mg/dL or on medical diabetes treatment. There were 49 cases of diabetes in 2408 person-years follow-up. The weighted cumulative incidence of diabetes was 7.2% while the weighted incidence rate was estimated at 19.5 (95% CI 13.9 to 28.3) new cases per 1000 person-years. Older age, obesity and technical or higher education were statistically associated with the incidence of diabetes. Our results confirm that the incidence of diabetes in Peru is among the highest reported globally. The fast economic growth in the last 20 years, high overweight and obesity rates may have triggered this phenomenon.

77 FR 36008 - Agency Information Collection Activities; Proposed Collection: Cargo Theft Incident Report...

Science.gov (United States)

2012-06-15

... Collection Activities; Proposed Collection: Cargo Theft Incident Report, Revision of a Currently Approved... collection: Revision of a currently approved collection. (2) The title of the form/collection: Cargo Theft... enforcement agencies. Brief Abstract: This collection is needed to collect information on cargo theft...

Epidemiology, Incidence and Mortality of Breast Cancer in Asia.

Science.gov (United States)

Ghoncheh, Mahshid; Momenimovahed, Zohre; Salehiniya, Hamid

2016-01-01

Breast cancer is the most common malignancy in women around the world. Information on the incidence and mortality of breast cancer is essential for planning health measures. This study aimed to investigate the incidence and mortality of breast cancer in the world using age-specific incidence and mortality rates for the year 2012 acquired from the global cancer project (GLOBOCAN 2012) as well as data about incidence and mortality of the cancer based on national reports. It was estimated that 1,671,149 new cases of breast cancer were identified and 521,907 cases of deaths due to breast cancer occurred in the world in 2012. According to GLOBOCAN, it is the most common cancer in women, accounting for 25.1% of all cancers. Breast cancer incidence in developed countries is higher, while relative mortality is greatest in less developed countries. Education of women is suggested in all countries for early detection and treatment. Plans for the control and prevention of this cancer must be a high priority for health policy makers; also, it is necessary to increase awareness of risk factors and early detection in less developed countries.

Sense of life worth living (ikigai) and incident functional disability in elderly Japanese: The Tsurugaya Project.

Science.gov (United States)

Mori, Kentaro; Kaiho, Yu; Tomata, Yasutake; Narita, Mamoru; Tanji, Fumiya; Sugiyama, Kemmyo; Sugawara, Yumi; Tsuji, Ichiro

2017-04-01

To test the hypothesis that elderly persons who feel ikigai (a sense of life worth living) have a lower risk of incident functional disability than those who do not. Recent studies have suggested that ikigai impacts on mortality. However, its impact upon disability is unknown. The aim of the present study was to investigate the association between ikigai and incident functional disability among elderly persons. We conducted a prospective cohort study of 830 Japanese elderly persons aged ≥70 years as a comprehensive geriatric assessment in 2003. Information on ikigai was collected by self-reported questionnaire. Data on functional disability were retrieved from the public Long-term Care Insurance database in which participants were followed up for 11 years. Hazard ratios (HRs) and 95% confidence intervals (CIs) for incidence of functional disability were calculated for three groups delineated according to the presence of ikigai (“no”, “uncertain” or “yes”) using the Cox proportional hazards regression model. The 11-year incidence of functional disability was 53.3% (442 cases). As compared with the “no” group, the multiple-adjusted HR (95% CI) of incident functional disability was 0.61 (0.36–1.02) for the “uncertain” group and 0.50 (0.30–0.84) for the “yes” group. A stronger degree of ikigai is significantly associated with a lower risk of incident functional disability. Copyright © 2017 Elsevier Inc. All rights reserved.

Project Radiation protection East. Status Report, July 1997

Energy Technology Data Exchange (ETDEWEB)

Snihs, J.O.; Sundewall, H.; Grapengiesser, S. [STEGRA Consultants (Sweden); Bennerstedt, T. [TeknoTelje (Sweden)

1997-12-01

Project Radiation Protection East is a Swedish program for radiation protection work in Central and Eastern Europe. The projects are assessed, planned and performed in close cooperation with partner organizations in the East. Since 1994 radiation protection cooperation concerning the former Soviet Navy training reactors in Paldiski, Estonia, is included in the project. This report presents a summary over some 140 projects, their status, allocated funds and their distribution over countries and project areas. 12 tabs.

Brief Report: Incidence of and Risk Factors for Autistic Disorder in Neonatal Intensive Care Unit Survivors.

Science.gov (United States)

Matsuishi, Toyojiro; Yamashita, Yushiro; Ohtani, Yasuyo; Ornitz, Edward; Kuriya, Norikazu; Murakami, Yoshihiko; Fukuda, Seiichi; Hashimoto, Takeo; Yamashita, Fumio

1999-01-01

Analysis of the incidence of autistic disorder (AD) among 5,271 children in a neonatal intensive care unit in Japan found that 18 children were later diagnosed with AD, an incidence more than twice as high as previously reported. Children with AD had a significantly higher history of the meconium aspiration syndrome than the controls. (Author/DB)

Identifying medication error chains from critical incident reports: a new analytic approach.

Science.gov (United States)

Huckels-Baumgart, Saskia; Manser, Tanja

2014-10-01

Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.

Physical and Sexual Violence and Incident Sexually Transmitted Infections

Science.gov (United States)

Anand, Mallika; Redding, Colleen A.; Peipert, Jeffrey F.

2009-01-01

Abstract Objective To investigate whether women aged 13–35 who were victims of interpersonal violence were more likely than nonvictims to experience incident sexually transmitted infections (STIs). Methods We examined 542 women aged 13–35 enrolled in Project PROTECT, a randomized clinical trial that compared two different methods of computer-based intervention to promote the use of dual methods of contraception. Participants completed a baseline questionnaire that included questions about their history of interpersonal violence and were followed for incident STIs over the 2-year study period. We compared the incidence of STIs in women with and without a history of interpersonal violence using bivariate analyses and multiple logistic regression. Results In the bivariate analyses, STI incidence was found to be significantly associated with African American race/ethnicity, a higher number of sexual partners in the past month, and a lower likelihood of avoidance of sexual partners who pressure to have sex without a condom. In both crude and adjusted regression analyses, time to STI incidence was faster among women who reported physical or sexual abuse in the year before study enrollment (HRRadj = 1.68, 95% CI 1.06, 2.65). Conclusions Women with a recent history of abuse are at significantly increased risk of STI incidence than are nonvictims. PMID:19245303

A reanalysis of a behavioral intervention to prevent incident HIV infections: Including indirect effects in modeling outcomes of Project EXPLORE

Science.gov (United States)

Eaton, Lisa A.; Kalichman, Seth C.; Kenny, David A.; Harel, Ofer

2013-01-01

Background Project EXPLORE -- a large-scale, behavioral intervention tested among men who have sex with men (MSM) at-risk for HIV infection --was generally deemed as ineffective in reducing HIV incidence. Using novel and more precise data analytic techniques we reanalyzed Project EXPLORE by including both direct and indirect paths of intervention effects. Methods Data from 4,296 HIV negative MSM who participated in Project EXPLORE, which included ten sessions of behavioral risk reduction counseling completed from 1999-2005, were included in the analysis. We reanalyzed the data to include parameters that estimate the overtime effects of the intervention on unprotected anal sex and the over-time effects of the intervention on HIV status mediated by unprotected anal sex simultaneously in a single model. Results We found the indirect effect of intervention on HIV infection through unprotected anal sex to be statistically significant up through 12 months post-intervention, OR=.83, 95% CI=.72-.95. Furthermore, the intervention significantly reduced unprotected anal sex up through 18 months post-intervention, OR=.79, 95% CI=.63-.99. Discussion Our results reveal effects not tested in the original model that offer new insight into the effectiveness of a behavioral intervention for reducing HIV incidence. Project EXPLORE demonstrated that when tested against an evidence-based, effective control condition can result in reductions in rates of HIV acquisition at one year follow-up. Findings highlight the critical role of addressing behavioral risk reduction counseling in HIV prevention. PMID:23245226

The Incidence of Needlestick Injuries During Perineorrhaphy and Attitudes Toward Occurrence Reports Among Medical Students

Directory of Open Access Journals (Sweden)

Nalinee Panichyawat

2016-07-01

Full Text Available Background: Medical students are at risk of needlestick injuries (NSIs while performing obstetrical procedures especially perineorrhaphy, because of their less experience. This study aims to determine the incidence and causes of NSIs during perineorrhaphy and medical students’ attitudes toward occurrence reports. Methods: A cross-sectional study was conducted. After completion of Obstetrics & Gynaecology rotation, the data from final year medical students were collected using a self-administered questionnaire. Results: Of 390 medical students, 290 (74.4% returned questionnaires with complete data. The annual NSIs incidence during perineorrhaphy was 26.9%. The most common site of injury was the index finger of the non- dominant hand (66.2%. Common causes of NSIs were time pressure (52.1% and lack of surgical skills (50.7%. Nearly half of students (41% did not report their occurrence, and 81.3% of injured students believed that NSIs were harmless. Conclusion: The incidence of NSIs during perineorrhaphy and the non-reporting occurrence were quite high among medical students. Structural clinical supervision by medical staffs, HBV vaccination for all medical students, and instruction on standard pre-exposure precaution should be applied. We advocate a strategy plan for increasing students’ awareness and having a simple occurrence reporting system for NSIs, with clear guidelines on post-exposure protocols in all medical schools and teaching hospitals.

CENELEC Project Report Smart House Roadmap (draft)

NARCIS (Netherlands)

Hartog, F.T.H. den; Suters, T.; Parsons, J.; Faller, J.

2010-01-01

This CENELEC project report has been drafted by a project team and steering group of representatives of interested parties and is to be endorsed on 2010-11-23. Neither the national members of CENELEC nor the CEN-CENELEC Management Centre can be held accountable for the technical content of this

Critical incidents and mortality reporting in pediatric anesthesia: the Australian experience.

Science.gov (United States)

Ragg, Philip

2011-07-01

Since 1960, the collection and analysis of mortality data for anesthesia in Australia has been of significant benefit to practising anesthetists. These figures include pediatric deaths which fortunately have been rare and often inevitable because of severe underlying disease and patient risk factors. The reporting of critical incidents and serious morbidity, on the other hand, has been far less impressive. Only one state in Australia, Victoria, currently has a committee that collects morbidity data and, as this reporting is voluntary, is likely to under-represent the true numbers of critical events. There is no specific pediatric morbidity database in Australia so much of this discussion will be regarding overall anesthesia critical event reporting which includes pediatrics as a subset. © 2011 Blackwell Publishing Ltd.

Massachusetts Crystalline Repository Project. Progress report, December 31, 1985

International Nuclear Information System (INIS)

1985-01-01

Project activities which have been undertaken include the following: review and comment on OCRD projects reports; review of pertinent DOE, NRC, EPA, and DOT quidelines and regulations; review of reports and maps released by the federal project group and contractors; attendance at DOE workshops and conferences; implementation of state-specific research activities; interaction with representatives of federal agencies and other participating states; and interface with media, state officials and legislators, and interested citizens

ROLL OUT THE TALENT : Final project report

OpenAIRE

Eerola, Tuomas; Tuominen, Pirjo; Hakkarainen, Riitta-Liisa; Laurikainen, Marja; Mero, Niina

2014-01-01

The ROLL OUT THE TALENT project was born out of the desire to recognise and support the strengths of vocational students and to develop new and innovative operating models. ROLL OUT THE TALENT promoted regional cooperation between institutes and companies. The project produced operating and study path models that take into consideration the individual strengths of vocational students and the principles of lifelong learning. This is the final report of the ROLL OUT THE TALENT project, and ...

The Oregon Applied Academics Project: Final Report

Science.gov (United States)

Pearson, Donna; Richardson, George B.; Sawyer, Jennifer M.

2013-01-01

This report contains the findings of the Oregon Applied Academics research and development project which spanned three academic years from 2010 through 2013. The overall purpose of the project was to develop and implement a technical math course that would meet graduation requirements and improve student performance. The State of Oregon has been…

Change in Reported Lyme Disease Incidence in the Northeast and Upper Midwest, 1991-2014

Data.gov (United States)

U.S. Environmental Protection Agency — This indicator shows how reported Lyme disease incidence has changed by state since 1991, based on the number of new cases per 100,000 people. The total change has...

Project characteristics monitoring report: BWIP (Basalt Waste Isolation Program) repository project

Energy Technology Data Exchange (ETDEWEB)

Friedli, E.A.; Herborn, D.I.; Taylor, C.D.; Tomlinson, K.M.

1988-03-01

This monitoring report has been prepared to show compliance with provisions of the Nuclear Waste Policy Act of 1982 (NWPA) and to provide local and state government agencies with information concerning the Basalt Waste Isolation Program (BWIP). This report contains data for the time period May 26, 1986 to February 1988. The data include employment figures, salaries, project purchases, taxes and fees paid, worker survey results, and project closedown personal interview summaries. This information has become particularly important since the decision in December 1987 to stop all BWIP activities except those for site reclamation. The Nuclear Waste Policy Amendments Act of 1987 requires nonreclamation work at the Hanford Site to stop as of March 22, 1988. 7 refs., 6 figs., 28 tabs.

Project characteristics monitoring report: BWIP [Basalt Waste Isolation Program] repository project

International Nuclear Information System (INIS)

Friedli, E.A.; Herborn, D.I.; Taylor, C.D.; Tomlinson, K.M.

1988-03-01

This monitoring report has been prepared to show compliance with provisions of the Nuclear Waste Policy Act of 1982 (NWPA) and to provide local and state government agencies with information concerning the Basalt Waste Isolation Program (BWIP). This report contains data for the time period May 26, 1986 to February 1988. The data include employment figures, salaries, project purchases, taxes and fees paid, worker survey results, and project closedown personal interview summaries. This information has become particularly important since the decision in December 1987 to stop all BWIP activities except those for site reclamation. The Nuclear Waste Policy Amendments Act of 1987 requires nonreclamation work at the Hanford Site to stop as of March 22, 1988. 7 refs., 6 figs., 28 tabs

The New Mexico Technology Deployment Pilot Project: A technology reinvestment project. Final report

Energy Technology Data Exchange (ETDEWEB)

NONE

1996-11-01

The New Mexico Technology Deployment Project (NMTDP) has been in operation for slightly more than two years. As one of the original TRP projects, NMTDP had the charter to develop and validate a new model for technology extraction which emphasized focused technology collaboration, early industry involvement, and a strong dual use commercialization and productization emphasis. Taken in total, the first two years of the NMTDP have been exceptionally successful, surpassing the goals of the project. This report describes the accomplishments and evolution of the NMTDP to date and discusses the future potential of the project. Despite the end of federal funding, and a subsequent reduction in level of effort, the project partners are committed to continuation of the project.

Sensationalization of reports of the Kashiwazaki-Kariwa nuclear power plant incident. A search for top stories in Japanese newspapers

International Nuclear Information System (INIS)

Nakajima, Tatsuo

2009-01-01

The purpose of this study is to clarify whether reports of nuclear accidents, particularly the damage done by the 2007 Niigata-ken Chuetsu-Oki earthquake to the Kashiwazaki-Kariwa nuclear power plant in Niigata, Japan, tend to be exaggerated by national media. News related to the Kashiwazaki incident was compared with that for nine other high-profile accidents in Japan, including the 1999 JCO critical accident and the 2005 JR-West Fukuchiyama Line derailment. Articles were extracted from four national newspapers in Japan, focusing on the 30 issues immediately following each accident. The numbers of articles and top stories related to the relevant accidents appearing on the front pages of the newspapers were counted. Based on these numbers, the Kashiwazaki incident was reported at a level similar to the JCO accident and Fukuchiyama line derailment in some newspapers, although these two accidents were more serious than the Kashiwazaki incident. This suggests that at least some newspapers in Japan sensationalized reports of the Kashiwazaki incident. (author)

Extreme project. Progress report 2006

International Nuclear Information System (INIS)

Eyrolle, F.; Masson, O.; Charmasson, S.

2007-01-01

The E.X.T.R.E.M.E. project introduced in 2005 to the S.E.S.U.R.E. / L.E.R.C.M. has for objectives to acquire data on the consequences of the extreme climatic meteorological episodes on the distribution of the artificial radioisotopes within the various compartments of the geosphere. This report presents the synthesis of the actions developed in 2006 in positioning and in co financing of the project by means of regional or national research programs (C.A.R.M.A., E.X.T.R.E.M.A., E.C.C.O.R.E.V.I.), of data acquisition, valuation and scientific collaboration. (N.C.)

Severn Barrage project. Detailed report - V. 5

Energy Technology Data Exchange (ETDEWEB)

1989-01-01

Prior to the present programme of work, the effects which a tidal power barrage would have on the region, during both construction and operation, had not been studied in detail. This volume of the Detailed Report therefore represents a significant extension of work into these aspects of the Severn Barrage Project. In the Regional Study, a number of benefits have been identified, some of which may represent net benefits nationally. The economic assessment of both regional and national benefits and costs is presented. The second part of this volume reports on the work done on the Legal Background for the Project. (author).

Patient safety incident reports related to traditional Japanese Kampo medicines: medication errors and adverse drug events in a university hospital for a ten-year period.

Science.gov (United States)

Shimada, Yutaka; Fujimoto, Makoto; Nogami, Tatsuya; Watari, Hidetoshi; Kitahara, Hideyuki; Misawa, Hiroki; Kimbara, Yoshiyuki

2017-12-21

Kampo medicine is traditional Japanese medicine, which originated in ancient traditional Chinese medicine, but was introduced and developed uniquely in Japan. Today, Kampo medicines are integrated into the Japanese national health care system. Incident reporting systems are currently being widely used to collect information about patient safety incidents that occur in hospitals. However, no investigations have been conducted regarding patient safety incident reports related to Kampo medicines. The aim of this study was to survey and analyse incident reports related to Kampo medicines in a Japanese university hospital to improve future patient safety. We selected incident reports related to Kampo medicines filed in Toyama University Hospital from May 2007 to April 2017, and investigated them in terms of medication errors and adverse drug events. Out of 21,324 total incident reports filed in the 10-year survey period, we discovered 108 Kampo medicine-related incident reports. However, five cases were redundantly reported; thus, the number of actual incidents was 103. Of those, 99 incidents were classified as medication errors (77 administration errors, 15 dispensing errors, and 7 prescribing errors), and four were adverse drug events, namely Kampo medicine-induced interstitial pneumonia. The Kampo medicine (crude drug) that was thought to induce interstitial pneumonia in all four cases was Scutellariae Radix, which is consistent with past reports. According to the incident severity classification system recommended by the National University Hospital Council of Japan, of the 99 medication errors, 10 incidents were classified as level 0 (an error occurred, but the patient was not affected) and 89 incidents were level 1 (an error occurred that affected the patient, but did not cause harm). Of the four adverse drug events, two incidents were classified as level 2 (patient was transiently harmed, but required no treatment), and two incidents were level 3b (patient was

Burden of type 2 diabetes in Mexico: past, current and future prevalence and incidence rates.

Science.gov (United States)

Meza, Rafael; Barrientos-Gutierrez, Tonatiuh; Rojas-Martinez, Rosalba; Reynoso-Noverón, Nancy; Palacio-Mejia, Lina Sofia; Lazcano-Ponce, Eduardo; Hernández-Ávila, Mauricio

2015-12-01

Mexico diabetes prevalence has increased dramatically in recent years. However, no national incidence estimates exist, hampering the assessment of diabetes trends and precluding the development of burden of disease analyses to inform public health policy decision-making. Here we provide evidence regarding current magnitude of diabetes in Mexico and its future trends. We used data from the Mexico National Health and Nutrition Survey, and age-period-cohort models to estimate prevalence and incidence of self-reported diagnosed diabetes by age, sex, calendar-year (1960-2012), and birth-cohort (1920-1980). We project future rates under three alternative incidence scenarios using demographic projections of the Mexican population from 2010-2050 and a Multi-cohort Diabetes Markov Model. Adult (ages 20+) diagnosed diabetes prevalence in Mexico increased from 7% to 8.9% from 2006 to 2012. Diabetes prevalence increases with age, peaking around ages 65-68 to then decrease. Age-specific incidence follows similar patterns, but peaks around ages 57-59. We estimate that diagnosed diabetes incidence increased exponentially during 1960-2012, roughly doubling every 10 years. Projected rates under three age-specific incidence scenarios suggest diabetes prevalence among adults (ages 20+) may reach 13.7-22.5% by 2050, affecting 15-25 million individuals, with a lifetime risk of 1 in 3 to 1 in 2. Diabetes prevalence in Mexico will continue to increase even if current incidence rates remain unchanged. Continued implementation of policies to reduce obesity rates, increase physical activity, and improve population diet, in tandem with diabetes surveillance and other risk control measures is paramount to substantially reduce the burden of diabetes in Mexico. Copyright © 2015 Elsevier Inc. All rights reserved.

Project Progress Assessment Report (PPAR) 2015

International Nuclear Information System (INIS)

Sall, Baba

2015-01-01

This evaluation reports reviews basic information, output achievement, equipment and human resources, comment and recommendations. It highlights outputs Fully achieved, those which are partially achieved or in progress and also non achieved outputs. Regarding comments and lessons learned, counterpart stated that the overall timeline of the project is respected, even if activities are delayed to adapt to technical, financial and human resources constraints. The results obtained are in line with expectations thanks to a rigorously respected scientific approach. The Collegial Coordination of the project (DSV-LNERV-CIRAD) and the TO are in phase on the conduct of the Project the collection of baseline data is a crucial phase in the implementation of tsetse control programs. It makes it possible to implement a good strategy. The scientific and technical rigor and the good atmosphere within the Project team are also to be retained.

Project Progress Assessment Report (PPAR) 2012

International Nuclear Information System (INIS)

Sall, Baba

2012-01-01

This evaluation reports reviews basic information, output achievement, equipment and human resources, comment and recommendations. It highlights outputs Fully achieved, those which are partially achieved or in progress and also non achieved outputs. Regarding comments and lessons learned, counterpart stated that the overall timeline of the project is respected, even if activities are delayed to adapt to technical, financial and human resources constraints. The results obtained are in line with expectations thanks to a rigorously respected scientific approach. The Collegial Coordination of the project (DSV-LNERV-CIRAD) and the TO are in phase on the conduct of the Project the collection of baseline data is a crucial phase in the implementation of tsetse control programs. It makes it possible to implement a good strategy. The scientific and technical rigor and the good atmosphere within the Project team are also to be retained.

Incidence and pattern of 12 years of reported transfusion adverse events in Zimbabwe: A retrospective analysis

NARCIS (Netherlands)

Mafirakureva, Nyashadzaishe; Khoza, Star; Mvere, David A.; Chitiyo, McLeod E.; Postma, Maarten J.; Van Hulst, Marinus

2014-01-01

Background. Haemovigilance hinges on a systematically structured reporting system, which unfortunately does not always exist in resource-limited settings. We determined the incidence and pattern of transfusion-related adverse events reported to the National Blood Service Zimbabwe. Materials and

Mountaineer Commercial Scale Carbon Capture and Storage Project Topical Report: Preliminary Public Design Report

Energy Technology Data Exchange (ETDEWEB)

Guy Cerimele

2011-09-30

This Preliminary Public Design Report consolidates for public use nonproprietary design information on the Mountaineer Commercial Scale Carbon Capture & Storage project. The report is based on the preliminary design information developed during the Phase I - Project Definition Phase, spanning the time period of February 1, 2010 through September 30, 2011. The report includes descriptions and/or discussions for: (1) DOE's Clean Coal Power Initiative, overall project & Phase I objectives, and the historical evolution of DOE and American Electric Power (AEP) sponsored projects leading to the current project; (2) Alstom's Chilled Ammonia Process (CAP) carbon capture retrofit technology and the carbon storage and monitoring system; (3) AEP's retrofit approach in terms of plant operational and integration philosophy; (4) The process island equipment and balance of plant systems for the CAP technology; (5) The carbon storage system, addressing injection wells, monitoring wells, system monitoring and controls logic philosophy; (6) Overall project estimate that includes the overnight cost estimate, cost escalation for future year expenditures, and major project risks that factored into the development of the risk based contingency; and (7) AEP's decision to suspend further work on the project at the end of Phase I, notwithstanding its assessment that the Alstom CAP technology is ready for commercial demonstration at the intended scale.

HET/JUPITER project assessment report

International Nuclear Information System (INIS)

Baxter, B.J.; Harrington, F.E.; Kaiser, G.G.; Wolf, J.

1979-05-01

This report is an assessment of the United States' Hot Engineering Test (HET) and the Federal Republic of Germany's Juelich Pilot Plant Thorium Element Reprocessing (JUPITER) Projects. The assessment was conducted with a view to developing mutually supportive roles in the achievement of hot engineering test objectives. Conclusions of the assessment are positive and identify several technical areas with potential for US/FRG cooperation. Recommendations presented in this report support a cost-effective US/FRG program to jointly develop high temperature gas-cooled reactor fuel recycle technology. (orig.) [de

Characteristics of bias-based harassment incidents reported by a national sample of U.S. adolescents.

Science.gov (United States)

Jones, Lisa M; Mitchell, Kimberly J; Turner, Heather A; Ybarra, Michele L

2018-06-01

Using a national sample of youth from the U.S., this paper examines incidents of bias-based harassment by peers that include language about victims' perceived sexual orientation, race/ethnicity, religion, weight or height, or intelligence. Telephone interviews were conducted with youth who were 10-20 years old (n = 791). One in six youth (17%) reported at least one experience with bias-based harassment in the past year. Bias language was a part of over half (52%) of all harassment incidents experienced by youth. Perpetrators of bias-based harassment were similar demographically to perpetrators of non-biased harassment. However, bias-based incidents were more likely to involve multiple perpetrators, longer timeframes and multiple harassment episodes. Even controlling for these related characteristics, the use of bias language in incidents of peer harassment resulted in significantly greater odds that youth felt sad as a result of the victimization, skipped school, avoided school activities, and lost friends, compared to non-biased harassment incidents. Copyright © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Budget Period 1 Summary Report: Hywind Maine Project

Energy Technology Data Exchange (ETDEWEB)

Keiser, Meagan [Statoil, Stavanger (Norway)

2014-02-28

In accordance with the Statement of Project Objectives (SOPO) agreed to between the Department of Energy (“DOE”) and Statoil for the Hywind Maine project, Statoil hereby submits a Budget Period 1 Summary Report which includes accomplishments for the project. The report includes summaries of the other submitted reports (see Section 1.2-2) and progress regarding innovations leading to potential reductions in the Cost of Energy (see Section 3). The Hywind Demo project, the world’s first full-scale 2.3 megawatts (MW) floating wind turbine, installed at a water depth of 200 meter (m), 10 kilometer (km) off the coast of Norway, has proven that the Hywind floating substructure is a suitable platform for conventional multi- MW turbines. A principal goal of the Hywind Maine Project was to leverage that experience, both to demonstrate the commercial feasibility of the technology and to further develop and optimize the technology all in order to bring the costs down in a larger scale development. With the Hywind Maine Project, Statoil planned to deploy four turbines of 3 MW in approximately 140 meters water depth. Although the project in Maine will not move forward, much value was gained through the BP1 work package. Advanced modeling related to the design basis, which will have applicability beyond the Maine project, was completed. In addition, initial supply chain analyses were conducted, which will help assist with development of updated cost of energy models. Geophysical and various environmental surveys were also conducted, the results of which Statoil has committed to share publicly, and which will help build a database of information that future developers may be able to access. Finally, Statoil gained a greater understanding of the US offshore wind industry and related markets, which will assist the company as it looks for full-scale, commercial opportunities.

Cyber Incidents Involving Control Systems

Energy Technology Data Exchange (ETDEWEB)

Robert J. Turk

2005-10-01

The Analysis Function of the US-CERT Control Systems Security Center (CSSC) at the Idaho National Laboratory (INL) has prepared this report to document cyber security incidents for use by the CSSC. The description and analysis of incidents reported herein support three CSSC tasks: establishing a business case; increasing security awareness and private and corporate participation related to enhanced cyber security of control systems; and providing informational material to support model development and prioritize activities for CSSC. The stated mission of CSSC is to reduce vulnerability of critical infrastructure to cyber attack on control systems. As stated in the Incident Management Tool Requirements (August 2005) ''Vulnerability reduction is promoted by risk analysis that tracks actual risk, emphasizes high risk, determines risk reduction as a function of countermeasures, tracks increase of risk due to external influence, and measures success of the vulnerability reduction program''. Process control and Supervisory Control and Data Acquisition (SCADA) systems, with their reliance on proprietary networks and hardware, have long been considered immune to the network attacks that have wreaked so much havoc on corporate information systems. New research indicates this confidence is misplaced--the move to open standards such as Ethernet, Transmission Control Protocol/Internet Protocol, and Web technologies is allowing hackers to take advantage of the control industry's unawareness. Much of the available information about cyber incidents represents a characterization as opposed to an analysis of events. The lack of good analyses reflects an overall weakness in reporting requirements as well as the fact that to date there have been very few serious cyber attacks on control systems. Most companies prefer not to share cyber attack incident data because of potential financial repercussions. Uniform reporting requirements will do much to make this

The Incidence and Prevalence of Systemic Lupus Erythematosus in San Francisco County, California: The California Lupus Surveillance Project.

Science.gov (United States)

Dall'Era, Maria; Cisternas, Miriam G; Snipes, Kurt; Herrinton, Lisa J; Gordon, Caroline; Helmick, Charles G

2017-10-01

Estimates of the incidence and prevalence of systemic lupus erythematosus (SLE) in the US have varied widely. The purpose of this study was to conduct the California Lupus Surveillance Project (CLSP) to determine credible estimates of SLE incidence and prevalence, with a special focus on Hispanics and Asians. The CLSP, which is funded by the Centers for Disease Control and Prevention, is a population-based registry of individuals with SLE residing in San Francisco County, CA, from January 1, 2007 through December 31, 2009. Data sources included hospitals, rheumatologists, nephrologists, commercial laboratories, and a state hospital discharge database. We abstracted medical records to ascertain SLE cases, which we defined as patients who met ≥4 of the 11 American College of Rheumatology classification criteria for SLE. We estimated crude and age-standardized incidence and prevalence, which were stratified by sex and race/ethnicity. The overall age-standardized annual incidence rate was 4.6 per 100,000 person-years. The average annual period prevalence was 84.8 per 100,000 persons. The age-standardized incidence rate in women and men was 8.6 and 0.7 per 100,000 person-years, respectively. This rate was highest among black women (30.5), followed by Hispanic women (8.9), Asian women (7.2), and white women (5.3). The age-standardized prevalence in women per 100,000 persons was 458.1 in blacks, 177.9 in Hispanics, 149.7 in Asians, and 109.8 in whites. Capture-recapture modeling estimated 33 additional incident cases and 147 additional prevalent cases. Comprehensive methods that include intensive case-finding provide more credible estimates of SLE in Hispanics and Asians, and confirm racial and ethnic disparities in SLE. The disease burden of SLE is highest in black women, followed by Hispanic women, Asian women, and white women. © 2017, American College of Rheumatology.

Tritium research laboratory cleanup and transition project final report

International Nuclear Information System (INIS)

Johnson, A.J.

1997-02-01

This Tritium Research Laboratory Cleanup and Transition Project Final Report provides a high-level summary of this project's multidimensional accomplishments. Throughout this report references are provided for in-depth information concerning the various topical areas. Project related records also offer solutions to many of the technical and or administrative challenges that such a cleanup effort requires. These documents and the experience obtained during this effort are valuable resources to the DOE, which has more than 1200 other process contaminated facilities awaiting cleanup and reapplication or demolition

Nuclear data project evaluation activity report. October 1998 - October 2000

Energy Technology Data Exchange (ETDEWEB)

Akovali, Y; Blackmon, J; Radford, D; Smith, M [Physics Division, Oak Ridge National Laboratory, Oak Ridge, TN (United States)

2001-02-01

This report summarizes the activities of the ORNL Nuclear Data Project since the IAEA Advisory Group meeting in December 1998. The group's future plans are also included. The ORNL Nuclear Data Project's responsibility includes the compilation/evaluation of astrophysics data, as well as the evaluation and compilation of nuclear structure data. The Nuclear Data Project, therefore, is composed of two groups. The Nuclear Data Project staff through September 2000 is listed below. Accomplishments for the period of October 1998 through September 2000 of the nuclear structure data group and the nuclear astrophysics group are submitted in this Nuclear Data Project report.

Nuclear data project evaluation activity report. October 1998 - October 2000

International Nuclear Information System (INIS)

Akovali, Y.; Blackmon, J.; Radford, D.; Smith, M.

2001-01-01

This report summarizes the activities of the ORNL Nuclear Data Project since the IAEA Advisory Group meeting in December 1998. The group's future plans are also included. The ORNL Nuclear Data Project's responsibility includes the compilation/evaluation of astrophysics data, as well as the evaluation and compilation of nuclear structure data. The Nuclear Data Project, therefore, is composed of two groups. The Nuclear Data Project staff through September 2000 is listed below. Accomplishments for the period of October 1998 through September 2000 of the nuclear structure data group and the nuclear astrophysics group are submitted in this Nuclear Data Project report

Incident Investigation in SMS and FRMS

NARCIS (Netherlands)

Stewart, S.; Koornneef, F.; Akselsson, R.; Kingston, J.; Stewart, D.

2009-01-01

Chapter 4: Incident Investigation in SMS and FRMS The European Commission HILAS project (Human Integration into the Lifecycle of Aviation Systems - a project supported by the European Commission’s 6th Framework between 2005-2009) was focused on using human factors knowledge and methodology to

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

Directory of Open Access Journals (Sweden)

van der Wal Gerrit

2011-02-01

Full Text Available Abstract Background Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review. Methods We conducted a retrospective study using a database from a record review study of 5375 patient records in 14 hospitals in the Netherlands. Trained nurses and physicians using a method based on the protocol of The Harvard Medical Practice Study previously reviewed the records. Four reporting systems were linked with the database of reviewed records: 1 informal and 2 formal complaints by patients/relatives, 3 medico-legal claims by patients/relatives and 4 incident reports by healthcare professionals. For each adverse event identified in patient records the equivalent was sought in these reporting systems by comparing dates and descriptions of the events. The study focussed on the number of adverse event matches, overlap of adverse events detected by different sources, preventability and severity of consequences of reported and non-reported events and sensitivity and specificity of reports. Results In the sample of 5375 patient records, 498 adverse events were identified. Only 18 of the 498 (3.6% adverse events identified by record review were found in one or more of the four reporting systems. There was some overlap: one adverse event had an equivalent in both a complaint and incident report and in three cases a patient/relative used two or three systems to complain about an adverse event. Healthcare professionals

In-depth analysis of the causal factors of incidents reported in the Greek petrochemical industry

Energy Technology Data Exchange (ETDEWEB)

Konstandinidou, Myrto [Institute of Nuclear Technology-Radiation Protection, National Center for Scientific Research ' Demokritos' , Aghia Paraskevi 15310 (Greece); Nivolianitou, Zoe, E-mail: zoe@ipta.demokritos.gr [Institute of Nuclear Technology-Radiation Protection, National Center for Scientific Research ' Demokritos' , Aghia Paraskevi 15310 (Greece); Kefalogianni, Eirini; Caroni, Chrys [School of Applied Mathematical and Physical Sciences, National Technical University of Athens, 9 Iroon Polytexneiou Str., Zografou Campus, 157 80 Athens (Greece)

2011-11-15

This paper presents a statistical analysis of all reported incidents in the Greek petrochemical industry from 1997 to 2003. A comprehensive database has been developed to include industrial accidents (fires, explosions and substance releases), occupational accidents, incidents without significant consequences and near misses. The study concentrates on identifying and analyzing the causal factors related to different consequences of incidents, in particular, injury, absence from work and material damage. Methods of analysis include logistic regression with one of these consequences as dependent variable. The causal factors that are considered cover four major categories related to organizational issues, equipment malfunctions, human errors (of commission or omission) and external causes. Further analyses aim to confirm the value of recording near misses by comparing their causal factors with those of more serious incidents. The statistical analysis highlights the connection between the human factor and the underlying causes of accidents or incidents. - Highlights: > The research work is original, based on field data collected directly from the petrochemical industry. > It deals with the in-depth statistical analysis of accident data on human-organizational causes. > It researches underlying causes of accidents and the parameters affecting them. > The causal factors that are considered cover four big taxonomies. > Near misses are worth recording for comparing their causal factors with more serious incidents.

Cumulative incidence of postoperative severe pain at Hospital Universitario San Jose, Popayan. Preliminar report

Directory of Open Access Journals (Sweden)

Ingrid Muñoz

2013-12-01

Full Text Available Introduction: Postoperative pain remains as a problem. National studies report incidences of 31% for moderate and 22% for severe pain. Inadequate analgesia is related to dissatisfaction and adverse outcomes. The aim of this study was to describe the incidence and characteristics of the postoperative pain in the post-anesthesia care unit (PACU at Hospital Universitario San José of Popayán (HUSJ in patients undergoing general anesthesia during the first postoperative hour. Methods: Cohort study. We recruited patients attending PACU and undergoing procedures using general anesthesia, between 18 and 70 years. Using a standardized collection form medical history, demographic data, medical history, anesthetic management, intraoperative analgesia and postoperative pain assessment by verbal and numerical pain scale (1-10 were recorded. Postoperative outcome data were also collected in the PACU. Results: The incidence of severe postoperative pain at 10 minutes was 12.3% 95%CI [7.1-18.2] (19 patients. Within 30 minutes of assessment 4.5% 95%CI [1.3-8.4] (7 patients and 1.9% 60 minutes 95%CI [0-4.5] (3 patients. 48.7% required rescue analgesic at PACU. Incidence of postoperative nausea and vomiting (PONV was significantly different in patients requiring rescue analgesic. Conclusion: The incidence of severe postoperative pain in the first postoperative hour at HUSJ is close to 12% and it decreases as time goes by. Patients requiring rescue analgesic have a higher incidence of postoperative complications such as PONV.

Nuclear power plant operating experiences from the IAEA/NEA Incident Reporting System 1999-2002

International Nuclear Information System (INIS)

2003-01-01

Incident reporting has become an increasingly important aspect of the operation and regulation of all public health and safety-related industries. Diverse industries such as aeronautics, chemicals, pharmaceuticals and explosives all depend on operating experience feedback to provide lessons learned about safety. The Incident Reporting System (IRS) is an essential element of the system for feeding back international operating experience for nuclear power plants. IRS reports contain information on events of Safety significance with important lessons learned. These experiences assist in reducing or eliminating recurrence of events at other plants. The IRS is jointly operated and managed by the Nuclear Energy Agency (NEA), a semi-autonomous body within the Organisation for Economic Co-operation and Development (OECD), and the International Atomic Energy Agency (IAEA). It is important that sufficient national resources be allocated to enable timely and high quality reporting of events important to safety, and to share these events in the IRS database. The first report, which covered the period July 1996 - June 1999, was widely acclaimed and encouraged both agencies to prepare this second report in order to highlight important lessons learned from around 300 events reported to the IRS for the period July 1999 - December 2002. Several areas were selected in this report to show the range of important topics available in the IRS. These include different types of failure in a variety of plant systems, as well as human performance considerations. This report is primarily aimed at senior officials in industry and government who have decision-making roles in the nuclear power industry

Ceramic Technology Project data base: September 1992 summary report

Energy Technology Data Exchange (ETDEWEB)

Keyes, B.L.P.

1993-06-01

Data presented in this report represent an intense effort to improve processing methods, testing methods, and general mechanical properties (rupture modulus, tensile, creep, stress-rupture, dynamic and cyclic fatigue, fracture toughness) of candidate ceramics for use in advanced heat engines. This work was performed by many facilities and represents only a small part of the data generated by the Ceramic Technology Project (CTP) since 1986. Materials discussed include GTE PY6, GN-10, NT-154, NT-164, SN-260, SN-251, SN-252, AY6, silicon nitride combined with rare-earth oxides, Y-TZP, ZTA, NC-433, NT-230, Hexoloy SA, MgO-PSZ-to-MgO-PSZ joints, MgO-PSZ-to-cast iron, and a few whisker/fiber-reinforced ceramics. Information in this report was taken from the project`s semiannual and bimonthly progress reports and from final reports summarizing the results of individual studies. Test results are presented in tabular form and in graphs. All data, including test rig descriptions and material characterizations, are stored in the CTP data base and are available to all project participants on request. The objective of this report is to make available the test results from these studies but not to draw conclusions from those data.

Application examples of the reports of the NEA Incident Reporting System of the OECD and evolution of the system

International Nuclear Information System (INIS)

Libmann, J.

1989-06-01

Some reports of the work group no. 1 of the Nuclear Installations Security Committee of NEA, are summarized. An example of the report coding system concerning human factors, is given. The aim of the study is to improve the report contents as well as the coding system. In this case, a fast data selection is possible, and allows an efficient analysis of a particular situation. Moreover, the corrective procedures of the nuclear installation conception or operation can be easily modified, by the national organisations. Due to the improvements in quality, the opinion of the member countries on the incident reporting systems efficiency was enhanced [fr

The international Chernobyl project. Technical report

International Nuclear Information System (INIS)

1991-01-01

This report contains the findings of the International Chernobyl Project. Separate chapters deal with the history of the accident and the Soviet emergency measures, environmental contamination, radiation exposure of the population, health impact, and protective measures. The conclusions and recommendations of the Project are presented, and an annex gives the available data on cesium 137 and strontium 90 contamination levels in populated areas of the BSSR, the RSFSR and the UkrSSR from June/July 1989: these data were used to draw up the area contamination maps. Ref, figs and tabs

DECOVALEX II PROJECT. Technical report - Task 1A and 1B

International Nuclear Information System (INIS)

Lanru Jing; Stephansson, Ove; Kautsky, F.

1998-08-01

DECOVALEX II project started in November 1995 as a continuation of the DECOVALEX I project, which was completed at the end of 1994. The project was initiated by recognizing the fact that a proper evaluation of the current capacities of numerical modelling of the coupled T-H-M processes in fractured media is needed not only for small scale, well controlled laboratory test cases such as those studied in DECOVALEX I, but also for less characterised, more complex and realistic in-situ experiments. This will contribute to validation and confidence building in the current mathematical models, numerical methods and computer codes. Four tasks were defined in the DECOVALEX II project: TASK 1 - numerical study of the RCF3 pumping test and shaft excavation at Sellafield by Nirex, UK; TASK 2 - numerical study of the in-situ T-H-M experiments at Kamaishi Mine by PNC, Japan; TASK 3 - review of current state-of-the-art of rock joint research and TASK 4 - report on the coupled T-H-M issues related to repository design and performance assessment. This report is one of the technical reports of the DECOVALEX II project, describing the work performed for TASK 1A and 1B - the predictions and model calibrations for the RCF 3 pumping test at Sellafield. Presented in this report are the descriptions of the project, tasks, approaches, methods and results of numerical modelling work carried out by the research teams. The report is a summary of the research reports written by the research teams and submitted to the project secretariat, and the discussions held during project workshops and task force group meetings. The opinions and conclusions in this report, however, reflect only ideas of the authors, not necessarily a collective representation of the funding organisations of the project

Estimation and Projection of Lung Cancer Incidence and Mortality in China

Directory of Open Access Journals (Sweden)

Xiaonong ZOU

2010-05-01

Full Text Available Background and objective The aim of this study is to analyze lung cancer epidemiological trend and estimate lung cancer burden in China. Methods Lung cancer age specific mortality and incidence rate ratios in different areas and sexes were obtained from national cancer registration database in 2004 and 2005. Cancer crude mortalities were retrieved from the database of the third national death survey, 2004-2005. Age specific incidence rates of lung cancer were calculated using mortality and M/I ratios. Annual percent change (APC was estimated by log regression model using Joint Point software by analyzing pooled lung cancer incidence data from 10 cancer registries from 1988 to 2005. Results The total estimated new cases and deaths of lung cancer in 2005 were 536 407 and 475 768 which were higher in male than in female. There was 1.63% increase of lung cancer incidence per year from 1988 to 2005, however, the trend showed a slowdown by 0.55% annually after adjusted by age. Conclusion Lung cancer is one of major health issues in China and the burden is getting serious. Ageing population is main cause for increasing incidence and mortality of lung cancer. Effective cancer prevention and control is imperative. Especially, tobacco control should be carried out in statewide.

Project W-049H disposal facility test report

International Nuclear Information System (INIS)

Buckles, D.I.

1995-01-01

The purpose of this Acceptance Test Report (ATR) for the Project W-049H, Treated Effluent Disposal Facility, is to verify that the equipment installed in the Disposal Facility has been installed in accordance with the design documents and function as required by the project criteria

A graphical study of tuberculosis incidence and trends in the WHO's European region (1980-2006).

Science.gov (United States)

Ríos, Martín; Monleón-Getino, Toni

2009-01-01

A graphical output was obtained using classical principal component analysis techniques in order to analyse tuberculosis trends in Europe over a 27-year period (1980-2006). Taxonomic methods were used to better define the interrelationship between the data in the 52 countries studied. Data were provided by the World Health Organization. Differences in the overall incidence and trends were identified during the 1980-2006 period. The highest rates of incidence were reported in Kazakhstan, Bosnia and Herzegovina, Romania and Kyrgyzstan. High and moderately high rates were reported in the former Soviet Union, the former Yugoslavia, some countries from the former Eastern Bloc, Turkey and Portugal. The lowest rates were reported in the eastern Mediterranean, Scandinavia and Iceland. Risk of infection was determined by social conditions, intravenous drug use, HIV infection and immigration from countries where tuberculosis is endemic. As regards development of tuberculosis in Europe, 1992 represents the change in the decreasing trend in the incidence observed from 1980, when the incidence presented a minimum general trend and started to increase. The linear model calculated to project the rate of increase from 2006 to 2015, reveals the tuberculosis rates observed during the 1980s.

Research and development project report for FY 1996

Energy Technology Data Exchange (ETDEWEB)

NONE

1997-09-01

This report summarizes results of research and development projects administered by NEDO for FY 1996. Overview of new energy projects and twelve chapters for individual projects are provided in the report. The new energy technology development projects administered by NEDO are classified into twelve categories, i.e., Development of technologies for solar energy utilization, Development of geothermal resources, Development of technologies for exploration and utilization of geothermal energy, Development of coal energy utilization technologies, Development of coal resources, Development of energy conversion and storage technologies, Development of hydrogen, alcohol and biomass technologies, Development of other oil-alternative energy technologies, Introduction and promotion of new energy sources, International energy-promotion activities, Promotion of development and introduction, and Activities of the NEDO Information Center. To ensure energy security and actively cope with environmental problems such as by taking carbon dioxide emission control measures, NEDO has stepped up its efforts to develop new energy- and energy saving-related technologies and introduce and diffuse them. 79 figs., 37 tabs.

Report: Improvements Needed in CSB’s Identity and Access Management and Incident Response Security Functions

Science.gov (United States)

Report #18-P-0030, October 30, 2017. Weaknesses in the Identity and Access Management and Incident Response metric domains leave the CSB vulnerable to attacks occurring and not being detected in a timely manner.

Brentwood Lessons Learned Project Report

Energy Technology Data Exchange (ETDEWEB)

Rivkin, Carl H. [National Renewable Energy Lab. (NREL), Golden, CO (United States); Caton, Melanie C. [National Renewable Energy Lab. (NREL), Golden, CO (United States); Ainscough, Christopher D. [National Renewable Energy Lab. (NREL), Golden, CO (United States); Marcinkoski, Jason [Dept. of Energy (DOE), Washington DC (United States)

2017-09-26

The purpose of this report is to document lessons learned in the installation of the hydrogen fueling station at the National Park Service Brentwood site in Washington, D.C., to help further the deployment of hydrogen infrastructure required to support hydrogen and other fuel cell technologies. Hydrogen fueling is the most difficult infrastructure component to build and permit. Hydrogen fueling can include augmenting hydrogen fueling capability to existing conventional fuel fueling stations as well as building brand new hydrogen fueling stations. This report was produced as part of the Brentwood Lessons Learned project. The project consisted of transplanting an existing modular hydrogen fueling station from Connecticut to the National Park Service Brentwood site. This relocation required design and construction at the Brentwood site to accommodate the existing station design as well as installation and validation of the updated station. One of the most important lessons learned was that simply moving an existing modular station to an operating site was not necessarily straight-forward - performing the relocation required significant effort and cost. The station has to function at the selected operating site and this functionality requires a power supply, building supports connecting to an existing alarm system, electrical grounding and lighting, providing nitrogen for purging, and providing deionized water if an electrolyzer is part of the station package. Most importantly, the station has to fit into the existing site both spatially and operationally and not disrupt existing operations at the site. All of this coordination and integration requires logistical planning and project management. The idea that a hydrogen fueling station can be simply dropped onto a site and made immediately operational is generally not realistic. Other important lessons learned include that delineating the boundaries of the multiple jurisdictions that have authority over a project for

Status report : Terra Nova project environmental assessment panel : recommendations

International Nuclear Information System (INIS)

2002-01-01

An application to the Canada-Newfoundland Offshore Petroleum Board (CNOPB) was submitted by Petro-Canada on August 5, 1996, notifying of its intent to develop the petroleum resources located at the Terra Nova field. The provincial and federal governments jointly appointed the Terra Nova Project Environmental Panel, and the board of the CNOPB referred to it the application documents for review. The environmental effects, considerations of human safety incorporated into the design and operation of the Project, the general approach to the development and exploitation of the petroleum resources, and the employment and industrial benefits expected to be derived from the Project were the issues under review by the Panel. On April 22, 1997, public hearings into the review began, and the final report was submitted to governments and the Board in August 1997. The report included 75 recommendations. The Project was approved in Decision 97.02 in December 1997, and the Board dealt with each of the recommendations. The respective positions of the Governments of Canada and Newfoundland and Labrador with regard to the recommendations that fell outside the jurisdiction of the Board were made public. A status report on every one of the 75 recommendations is provided in the present report. The recommendation is repeated, the verbatim response taken from Decision 97.02 included, followed by the status of the response. The production operations phase of the Project accounts for approximately 65 per cent of the recommendations. January 20, 2002 was the date the Project was begun

Uranium Mill Tailings Remedial Action Project. 1995 Environmental Report

Energy Technology Data Exchange (ETDEWEB)

NONE

1996-06-01

In accordance with U.S. Department of Energy (DOE) Order 23 1. 1, Environment, Safety and Health Reporting, the DOE prepares an annual report to document the activities of the Uranium Mill Tailings Remedial Action (UMTRA) Project environmental monitoring program. This monitoring must comply with appropriate laws, regulations, and standards, and it must identify apparent and meaningful trends in monitoring results. The results of all monitoring activities must be communicated to the public. The UMTRA Project has prepared annual environmental reports to the public since 1989.

Uranium Mill Tailings Remedial Action Project. 1995 Environmental Report

International Nuclear Information System (INIS)

1996-06-01

In accordance with U.S. Department of Energy (DOE) Order 23 1. 1, Environment, Safety and Health Reporting, the DOE prepares an annual report to document the activities of the Uranium Mill Tailings Remedial Action (UMTRA) Project environmental monitoring program. This monitoring must comply with appropriate laws, regulations, and standards, and it must identify apparent and meaningful trends in monitoring results. The results of all monitoring activities must be communicated to the public. The UMTRA Project has prepared annual environmental reports to the public since 1989

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.

Evaluation of nuclear facility decommissioning projects. Project summary report, Elk River Reactor

International Nuclear Information System (INIS)

Miller, R.L.; Adams, J.A.

1982-12-01

This report summarizes information concerning the decommissioning of the Elk River Reactor. Decommissioning data from available documents were input into a computerized data-handling system in a manner that permits specific information to be readily retrieved. The information is in a form that assists the Nuclear Regulatory Commission in its assessment of decommissioning alternatives and ALARA methods for future decommissionings projects. Samples of computer reports are included in the report. Decommissioning of other reactors, including NRC reference decommissioning studies, will be described in similar reports

Canadian Fusion Fuels Technology Project annual report 93/94

Energy Technology Data Exchange (ETDEWEB)

NONE

1994-12-31

The Canadian Fusion Fuels Technology Project exists to develop fusion technologies and apply them worldwide in today`s advanced fusion projects and to apply these technologies in fusion and tritium research facilities. CFFTP concentrates on developing capability in fusion fuel cycle systems, in tritium handling technologies and in remote handling. This is an annual report for CFFTP and as such also includes a financial report.

Canadian Fusion Fuels Technology Project annual report 93/94

International Nuclear Information System (INIS)

1994-01-01

The Canadian Fusion Fuels Technology Project exists to develop fusion technologies and apply them worldwide in today's advanced fusion projects and to apply these technologies in fusion and tritium research facilities. CFFTP concentrates on developing capability in fusion fuel cycle systems, in tritium handling technologies and in remote handling. This is an annual report for CFFTP and as such also includes a financial report

Manufacturing Methods and Technology Project Summary Reports

Science.gov (United States)

1984-12-01

Powder ME-16 Type Recoil Mechanism Testing Machine (Powder Gymnasticator ) Projects 677, 78 7814 - Synthetic Quenchants for ME-18 Heat Treating Weapon...were deemed most urgent. These two were the prime candidates for the GEPTTA. Figure I is an artist depiction of the General Purpose Transportability...REPORT (RCS DRCMT-302) MMT Project 677 7753 titled "Noise Suppressor for Powder Type Recoil Mecha- nism Testing Machine (Powder Gymnasticator )" was

Cancer incidence in Italian contaminated sites

Directory of Open Access Journals (Sweden)

Pietro Comba

2014-06-01

Full Text Available INTRODUCTION. The incidence of cancer among residents in sites contaminated by pollutants with a possible health impact is not adequately studied. In Italy, SENTIERI Project (Epidemiological study of residents in National Priority Contaminated Sites, NPCSs was implemented to study major health outcomes for residents in 44 NPCSs. METHODS. The Italian Association of Cancer Registries (AIRTUM records cancer incidence in 23 NPCSs. For each NPCSs, the incidence of all malignant cancers combined and 35 cancer sites (coded according to ICD-10, was analysed (1996-2005. The observed cases were compared to the expected based on age (5-year period,18 classes, gender, calendar period (1996-2000; 2001-2005, geographical area (North-Centre and Centre-South and cancer sites specific rates. Standardized Incidence Ratios (SIR with 90% Confidence Intervals were computed. RESULTS. In both genders an excess was observed for overall cancer incidence (9% in men and 7% in women as well as for specific cancer sites (colon and rectum, liver, gallbladder, pancreas, lung, skin melanoma, bladder and Non Hodgkin lymphoma. Deficits were observed for gastric cancer in both genders, chronic lymphoid leukemia (men, malignant thyroid neoplasms, corpus uteri and connective and soft-tissue tumours and sarcomas (women. DISCUSSION. This report is, to our knowledge, the first one on cancer risk of residents in NPCSs. The study, although not aiming to estimate the cancer burden attributable to the environment as compared to occupation or life-style, supports the credibility of an etiologic role of environmental exposures in contaminated sites. Ongoing analyses focus on the interpretation of risk factors for excesses of specific cancer types overall and in specific NPCSs in relation to the presence of carcinogenic pollutants.

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

In-depth analysis of the causal factors of incidents reported in the Greek petrochemical industry

International Nuclear Information System (INIS)

Konstandinidou, Myrto; Nivolianitou, Zoe; Kefalogianni, Eirini; Caroni, Chrys

2011-01-01

This paper presents a statistical analysis of all reported incidents in the Greek petrochemical industry from 1997 to 2003. A comprehensive database has been developed to include industrial accidents (fires, explosions and substance releases), occupational accidents, incidents without significant consequences and near misses. The study concentrates on identifying and analyzing the causal factors related to different consequences of incidents, in particular, injury, absence from work and material damage. Methods of analysis include logistic regression with one of these consequences as dependent variable. The causal factors that are considered cover four major categories related to organizational issues, equipment malfunctions, human errors (of commission or omission) and external causes. Further analyses aim to confirm the value of recording near misses by comparing their causal factors with those of more serious incidents. The statistical analysis highlights the connection between the human factor and the underlying causes of accidents or incidents. - Highlights: → The research work is original, based on field data collected directly from the petrochemical industry. → It deals with the in-depth statistical analysis of accident data on human-organizational causes. → It researches underlying causes of accidents and the parameters affecting them. → The causal factors that are considered cover four big taxonomies. → Near misses are worth recording for comparing their causal factors with more serious incidents.

Research Applications for Teaching (RAFT) Project. Final Report.

Science.gov (United States)

Thomson, James R., Jr.; Handley, Herbert M.

A report is given of the development and progress of the Research Applications for Teaching (RAFT) project, developed at Mississippi State University. Based upon research findings relative to effective teaching and effective schooling, five curriculum modules were prepared and implemented in instruction. In the second year of the project the…

West Valley Demonstration Project Annual Site Environmental Report Calendar Year 2004

Energy Technology Data Exchange (ETDEWEB)

West Valley Nuclear Services Company (WVNSCO) and URS Group, Inc.

2005-09-30

Annual Site Environmental Report for the West Valley Demonstration Project (WVDP) for Calendar Year 2004. The report summarizes the environmental protection program at the West Valley Demonstration Project for CY 2004.

West Valley Demonstration Project Annual Site Environmental Report Calendar Year 2004

International Nuclear Information System (INIS)

2005-01-01

Annual Site Environmental Report for the West Valley Demonstration Project (WVDP) for Calendar Year 2004. The report summarizes the environmental protection program at the West Valley Demonstration Project for CY 2004

Incidence and Management Costs of Freshwater Aquatic Nuisance Species at Projects Operated by the U.S. Army Corps of Engineers

Science.gov (United States)

2010-07-01

the occurrence of ANS impacts (Yes or No) from freshwater algae, large aquatic plants, fish, zebra mussels, Asiatic clams, water fleas, crayfish...2005. Freshwater aquatic nuisance species impacts and management costs and benefits at federal water resources projects. ERDC/TN ANSRP-06-3...ER D C/ EL T R- 10 -1 3 Aquatic Nuisance Species Research Program Incidence and Management Costs of Freshwater Aquatic Nuisance Species

Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study

OpenAIRE

Seclen, Segundo Nicolas; Rosas, Moises Ernesto; Arias, Arturo Jaime; Medina, Cecilia Alexandra

2017-01-01

Objective A recent report from a non-nationally representative, geographically diverse sample in four separate communities in Peru suggests an unusually high diabetes incidence. We aimed to estimate the national diabetes incidence rate using PERUDIAB, a probabilistic, national urban population-based longitudinal study. Research design and methods 662 subjects without diabetes, selected by multistage, cluster, random sampling of households, representing the 24 administrative and the 3 (coast, ...

SDC Supplier Obligation project : household energy from 2011 : final report

OpenAIRE

Sustainable Development Commission

2008-01-01

This report is based on 'SDC Supplier Obligation engagement project : process plan'. Evaluation of the engagement process used in this report can be found in 'SDC Supplier Obligation project : an evaluation of the Sustainable Development Commission's stakeholder and public engagement process'. This report presents the findings of the Sustainable Development Commission’s stakeholder and public engagement process and informs the development of Department for Environment, Food and Rural Af...

Incidence and Mortality and Epidemiology of Breast Cancer in the World.

Science.gov (United States)

Ghoncheh, Mahshid; Pournamdar, Zahra; Salehiniya, Hamid

2016-01-01

Breast cancer is the most common malignancy in women around the world. Information on the incidence and mortality of breast cancer is essential for planning health measures. This study aimed to investigate the incidence and mortality of breast cancer in the world using age-specific incidence and mortality rates for the year 2012 acquired from the global cancer project (GLOBOCAN 2012) as well as data about incidence and mortality of the cancer based on national reports. It was estimated that 1,671,149 new cases of breast cancer were identified and 521,907 cases of deaths due to breast cancer occurred in the world in 2012. According to GLOBOCAN, it is the most common cancer in women, accounting for 25.1% of all cancers. Breast cancer incidence in developed countries is higher, while relative mortality is greatest in less developed countries. Education of women is suggested in all countries for early detection and treatment. Plans for the control and prevention of this cancer must be a high priority for health policy makers; also, it is necessary to increase awareness of risk factors and early detection in less developed countries.

Health-hazard evaluation report HETA 86-456-1877, South Texas Nuclear Project, Wadsworth, Texas

International Nuclear Information System (INIS)

Sinks, T.H.; Hartle, R.W.

1988-03-01

An evaluation was made of an outbreak of dermatitis among workers at the South Texas Nuclear Project construction site, Wadsworth, Texas. The dermatitis occurred ten times more frequently among carpenters than other laborers, with the incidence in 1986 being 250% greater than it was in 1985. Some workers demonstrated pruritic, macular/papular lesions. Carpenters working on the inside of the power-project buildings had a higher incidence of skin disease than those employed on the outside of the buildings. Samples of plywood and lumber treated with fire-retardant indicated that they contained 3 and 5% phosphate, respectively. Arsenic was not detected but formaldehyde was detected at 59 parts per million. General environmental air samples were taken with no evidence found of airborne phosphate, melamine, dicyandiamide, or formaldehyde. Concentrations of total particulates ranged from 0.1 to 0.6mg/m 3 . The authors conclude that the workers were probably suffering from a contact dermatitis. The authors recommend specific precautions

Perioperative anaesthetic adverse events in Thailand (PAAd THAI) study: Incident report of perioperative convulsion.

Science.gov (United States)

Eiamcharoenwit, Jatuporn; Akavipat, Phuping; Ariyanuchitkul, Thidarat; Wirachpisit, Nichawan; Pulnitiporn, Aksorn; Pongraweewan, Orawan

2018-01-01

The aim of this study was to identify the characteristics of perioperative convulsion and to suggest possible correcting strategies. The multi-centre study was conducted prospectively in 22 hospitals across Thailand in 2015. The occurrences of perioperative adverse events were collected. The data was collated by site manager and forwarded to the data management unit. All perioperative convulsion incidences were enrolled and analysed. The consensus was documented for the relevant factors and the corrective strategies. Descriptive statistics were used. From 2,000 incident reports, perioperative convulsions were found in 16 patients. Six episodes (37.5%) were related to anaesthesia, 31.3% to patients, 18.8% to surgery, and 12.5% to systemic processes. The contributing factor was an inexperienced anaesthesia performer (25%), while the corrective strategy was improvements to supervision (43.8%). Incidents of perioperative convulsion were found to be higher than during the last decade. The initiation and maintenance of safe anaesthesia should be continued.

Final report for the 'Melt-Vessel Interactions' Project. European Union R and TD Program 4th Framework. MVI project final research report

International Nuclear Information System (INIS)

Sehgal, B.R.; Dinh, T.N.; Nourgaliev, R.R.; Bui, V.A.; Green, J.; Kolb, G.; Karbojian, A.; Theerthan, S.A.; Gubaidulline, A.; Bonnet, J.M.; Rouge, S.; Narcoux, M.; Liegeois, A.; Turland, B.D.; Dobson, G.P.; Siccama, A.; Ikonen, K.; Parozzi, F.; Kolev, N.; Caira, M.

1999-04-01

The Melt Vessel Interaction (MVI) project is concerned with the consequences of the interactions that a core melt, generated during a postulated severe accident in a light water reactor, may have with the pressure vessel. In particular, the issues concerned with the failure of the vessel bottom head are the focus of the research. The specific objectives of the project are to obtain data and develop validated models, which could be applied to prototypic plants, and accident conditions, for resolution of issues related to the melt vessel interactions. The project work has been performed by nine partners having varied responsibility. The work included a large number of experiments, with simulant materials, whose observations and results are employed, respectively, to understand the physical mechanisms and to develop validated models. Applications to the prototypic geometry and conditions have also been performed. This report is volume 1 of the Final Report for the Project, in which a summary of the progress achieved in the experimental program is provided. We have, however, included some aspects of the modeling activities. Volume 2 of the Final report describes the progress achieved in the modeling program. The progress achieved in the experimental and modeling parts of the Project has led to the resolution of some of the issues of melt vessel interaction. Considerable progress was also achieved towards resolution of the remaining issues

Radioactive contamination incidents involving protective clothing

Energy Technology Data Exchange (ETDEWEB)

Reichelt, R.; Clay, M.; Eichorst, J.

1996-10-01

The study focuses on incidents at Department of Energy (DOE) facilities involving the migration of radioactive contaminants through protective clothing. The authors analyzed 68 occurrence reports for the following factors: (1) type of work; (2) working conditions; (3) type of anti-contamination (anti-C) material; (4) area of body or clothing contaminated; and (5) nature of spread of contamination. A majority of reports identified strenuous work activities such as maintenance, construction, or decontamination and decommissioning (D&D) projects. The reports also indicated adverse working conditions that included hot and humid or cramped work environments. The type of anti-C clothing most often identified was cotton or water-resistant, disposable clothing. Most of the reports also indicated contaminants migrating through perspiration-soaked areas, typically in the knees and forearms. On the basis of their survey, the authors recommend the use of improved engineering controls and resilient, breathable, waterproof protective clothing for work in hot, humid, or damp areas where the possibility of prolonged contact with contamination cannot be easily avoided or controlled.

Radioactive contamination incidents involving protective clothing

International Nuclear Information System (INIS)

Reichelt, R.; Clay, M.; Eichorst, J.

1996-10-01

The study focuses on incidents at Department of Energy (DOE) facilities involving the migration of radioactive contaminants through protective clothing. The authors analyzed 68 occurrence reports for the following factors: (1) type of work; (2) working conditions; (3) type of anti-contamination (anti-C) material; (4) area of body or clothing contaminated; and (5) nature of spread of contamination. A majority of reports identified strenuous work activities such as maintenance, construction, or decontamination and decommissioning (D ampersand D) projects. The reports also indicated adverse working conditions that included hot and humid or cramped work environments. The type of anti-C clothing most often identified was cotton or water-resistant, disposable clothing. Most of the reports also indicated contaminants migrating through perspiration-soaked areas, typically in the knees and forearms. On the basis of their survey, the authors recommend the use of improved engineering controls and resilient, breathable, waterproof protective clothing for work in hot, humid, or damp areas where the possibility of prolonged contact with contamination cannot be easily avoided or controlled

Radioactive contamination incidents involving protective clothing

International Nuclear Information System (INIS)

Reichelt, R.A.; Clay, M.E.; Eichorst, A.J.

1998-01-01

The study focuses on incidents at Department of Energy facilities involving the migration of radioactive contaminants through protective clothing. The authors analyzed 68 occurrence reports for the following factors: (1) type of work, (2) working conditions, (3) type of anti-contamination material; (4) area of body or clothing contaminated; and (5) nature of spread of contamination. A majority of reports identified strenuous work activities such as maintenance, construction, or decontamination and decommissioning projects. The reports also indicated adverse working conditions that included hot and humid or cramped work environments. The type of anti-contamination clothing most often identified was cotton or water-resistant disposable clothing. Most of the reports also indicated contaminants migrating through perspiration-soaked areas, typically in the knees and forearms. On the basis of their survey, the authors recommend the use of improved engineering controls and resilient, breathable, waterproof protective clothing for work in hot, humid, or damp areas where the possibility of prolonged contact with contamination cannot be easily avoided or controlled. 1 ref., 6 figs., 1 tab

How often are patients harmed when they visit the computed tomography suite? A multi-year experience, in incident reporting, in a large academic medical center

International Nuclear Information System (INIS)

Mansouri, Mohammad; Aran, Shima; Shaqdan, Khalid W.; Abujudeh, Hani H.

2016-01-01

Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. (orig.)

Leven estuary project. Fisheries Department final report

OpenAIRE

Bayliss, B.D.

1997-01-01

This is the report on the Leven estuary project: Fisheries Department final report produced by the Environment Agency North West in 1997. This report contains information about Leven estuary, river Leven catchment, river Crake catchment and the Ulverston Discharges. The Leven estuary is characterised by being very shallow, and shares the extremely variable tides and currents that characterize the whole of Morecambe Bay. There was little detailed knowledge of the impact on the Leven estuary, a...

Final Report for NMBSA Project, Monika Kaden, 2016

Energy Technology Data Exchange (ETDEWEB)

Ward, William Carl [Los Alamos National Lab. (LANL), Los Alamos, NM (United States)

2016-12-13

The following pages define the objectives and results for Project 022, requested by Monika Kaden, a sculptor who maintains studios in Santa Fe. This effort was first approved in February 2016, and was completed during several different time segments spread over the year, depending on Monika’s availability. The project deliverables that are of primary use to the customer are digital data files that are to be delivered electronically. This report is a summary overview of how the project was conducted.

Light Water Reactor Sustainability Constellation Pilot Project FY11 Summary Report

International Nuclear Information System (INIS)

Johansen, R.

2011-01-01

Summary report for Fiscal Year 2011 activities associated with the Constellation Pilot Project. The project is a joint effor between Constellation Nuclear Energy Group (CENG), EPRI, and the DOE Light Water Reactor Sustainability Program. The project utilizes two CENG reactor stations: R.E. Ginna and Nine Point Unit 1. Included in the report are activities associate with reactor internals and concrete containments.

The Diffuse Involvement of Bilateral Breasts in the Incidence of Burkitt's Lymphoma: A Case Report

International Nuclear Information System (INIS)

Lee, Myung Su; Lee, Sa Rah; Yang, Woo Ick; Kim, Eun Kyung; Jung, Hae Kyoung

2009-01-01

The incidence of Burkitt's lymphoma involving both breasts is rare. We report such a case that was diagnosed by a core biopsy of a hypoechoic lesion visualized from the ultrasonographic results of a patient that was clinically suspected of mastitis

A Bayesian approach for estimating under-reported dengue incidence with a focus on non-linear associations between climate and dengue in Dhaka, Bangladesh.

Science.gov (United States)

Sharmin, Sifat; Glass, Kathryn; Viennet, Elvina; Harley, David

2018-04-01

Determining the relation between climate and dengue incidence is challenging due to under-reporting of disease and consequent biased incidence estimates. Non-linear associations between climate and incidence compound this. Here, we introduce a modelling framework to estimate dengue incidence from passive surveillance data while incorporating non-linear climate effects. We estimated the true number of cases per month using a Bayesian generalised linear model, developed in stages to adjust for under-reporting. A semi-parametric thin-plate spline approach was used to quantify non-linear climate effects. The approach was applied to data collected from the national dengue surveillance system of Bangladesh. The model estimated that only 2.8% (95% credible interval 2.7-2.8) of all cases in the capital Dhaka were reported through passive case reporting. The optimal mean monthly temperature for dengue transmission is 29℃ and average monthly rainfall above 15 mm decreases transmission. Our approach provides an estimate of true incidence and an understanding of the effects of temperature and rainfall on dengue transmission in Dhaka, Bangladesh.

LYNX community advocacy & service engagement (CASE) project final report.

Science.gov (United States)

2009-05-14

This report is a final assessment of the Community Advocacy & Service Engagement (CASE) project, a LYNX-FTA research project designed : to study transit education and public engagement methods in Central Florida. In the Orlando area, as in other part...

FINAL PROJECT REPORT - EVALUATION AND TESTING OF HTGR REACTOR BUILDING RESPONSE TO DEPRESSURIZATION ACCIDENTS

Energy Technology Data Exchange (ETDEWEB)

ALLIANCE LIMITED, NGNP INDUSTRY

2017-07-25

This report provides a description of the project, summarizes each phase of the project, and ends with project conclusions. In addition, the report contains a descriptive index of the technical reports generated during the course of the project.

Operating Experience from Events Reported to the IAEA Incident Reporting System for Research Reactors

International Nuclear Information System (INIS)

2015-03-01

Operating experience feedback is an effective mechanism in providing lessons learned from events and the associated corrective actions to prevent them, helping to improve safety at nuclear installations. The Incident Reporting System for Research Reactors (IRSRR), which is operated by the IAEA, is an important tool for international exchange of operating experience feedback for research reactors. The IRSRR reports contain information on events of safety significance with their root causes and lessons learned which help in reducing the occurrence of similar events at research reactors. To improve the effectiveness of the system, it is essential that national organizations demonstrate an appropriate interest for the timely reporting of events important to safety and share the information in the IRSRR database. At their biennial technical meetings, the IRSRR national coordinators recommended collecting the operating experience from the events reported to the IRSRR and disseminating it in an IAEA publication. This publication highlights the root causes, safety significance, lessons learned, corrective actions and the causal factors for the events reported to the IRSRR up to September 2014. The publication also contains relevant summary information on research reactor events from sources other than the IRSRR, operating experience feedback from the International Reporting System for Operating Experience considered relevant to research reactors, and a description of the elements of an operating experience programme as established by the IAEA safety standards. This publication will be of use to research reactor operating organizations, regulators and designers, and any other organizations or individuals involved in the safety of research reactors

Salt repository project closeout status report

International Nuclear Information System (INIS)

1988-06-01

This report provides an overview of the scope and status of the US Department of Energy (DOE's) Salt Repository Project (SRP) at the time when the project was terminated by the Nuclear Waste Policy Amendments Act of 1987. The report reviews the 10-year program of siting a geologic repository for high-level nuclear waste in rock salt formations. Its purpose is to aid persons interested in the information developed during the course of this effort. Each area is briefly described and the major items of information are noted. This report, the three salt Environmental Assessments, and the Site Characterization Plan are the suggested starting points for any search of the literature and information developed by the program participants. Prior to termination, DOE was preparing to characterize three candidate sites for the first mined geologic repository for the permanent disposal of high-level nuclear waste. The sites were in Nevada, a site in volcanic tuff; Texas, a site in bedded salt (halite); and Washington, a site in basalt. These sites, identified by the screening process described in Chapter 3, were selected from the nine potentially acceptable sites shown on Figure I-1. These sites were identified in accordance with provisions of the Nuclear Waste Policy Act of 1982. 196 refs., 21 figs., 11 tabs

Psychological Trauma in the Workplace: Variation of Incident Severity among Industry Settings and between Recurring vs Isolated Incidents.

Science.gov (United States)

DeFraia, G S

2015-07-01

Psychologically traumatic workplace events (known as critical incidents) occur within various work environments, with workgroups in certain industries vulnerable to multiple incidents. With the increasing prevalence of incidents in the USA, incident response is a growing practice area within occupational medicine, industrial psychology, occupational social work and other occupational health professions. To analyze a measure of incident severity based on level of disruption to the workplace and explore whether incident severity varied among different industry settings or between workgroups experiencing multiple vs single traumatic incidents. Administrative data mining was employed to examine practice data from a workplace trauma response unit in the USA. Bivariate analyses were conducted to test whether scores from an instrument measuring incident severity level varied among industry settings or between workgroups impacted by multiple vs isolated events. Incident severity level differed among various industry settings. Banks, retail stores and fast food restaurants accounted for the most severe incidents, while industrial and manufacturing sites reported less severe incidents. Workgroups experiencing multiple incidents reported more severe incidents than workgroups experiencing a single incident. Occupational health practitioners should be alert to industry differences in several areas: pre-incident resiliency training, the content of business recovery plans, assessing worker characteristics, strategies to assist continuous operations and assisting workgroups impacted by multiple or severe incidents.

Childhood Cancer Incidence in India Betweem 2012 and 2014: Report of a Population-based Cancer Registry.

Science.gov (United States)

Das, Suman; Paul, Dilip Kumar; Anshu, Kumar; Bhakta, Subhajit

2017-12-15

To provide an overview of childhood cancer incidence in India between 2012-2014. Secondary data analysis on age-adjusted rates of cancer incidence for children (0-14 years) were collected from the report of the National Cancer Registry Programme in the year 2016. Age-adjusted rates of childhood cancer incidence ranged from 18.5 per million in the state of Nagaland to 235.3 per million in Delhi for boys. The rates were 11.4 per million in East Khasi Hill district and 152.3 per million in Delhi for girls. Leukemia was the most predominant cancer for both boys and girls. Lymphoma was the second most common cancer in boys, and brain tumors in girls. Childhood cancer incidence is increasing in India compared to population-based cancer registry survey of 2009-2011. Cancers are mostly affecting 0-4 years age group, and there is a rising trend of Non-Hodgkin's lymphoma.

MIT LMFBR blanket research project. Final summary report

International Nuclear Information System (INIS)

Driscoll, M.J.

1983-08-01

This is a final summary report on an experimental and analytical program for the investigation of LMFBR blanket characteristics carried out at MIT in the period 1969 to 1983. During this span of time, work was carried out on a wide range of subtasks, ranging from neutronic and photonic measurements in mockups of blankets using the Blanket Test Facility at the MIT Research Reactor, to analytic/numerical investigations of blanket design and economics. The main function of this report is to serve as a resource document which will permit ready reference to the more detailed topical reports and theses issued over the years on the various aspects of project activities. In addition, one aspect of work completed during the final year of the project, on doubly-heterogeneous blanket configurations, is documented for the record

Piloting violence and incident reporting measures on one acute mental health inpatient unit.

Science.gov (United States)

Woods, Phil; Ashley, Carolyn; Kayto, Denise; Heusdens, Carol

2008-05-01

During May, 2006, on one acute mental health inpatient unit, nursing staff evaluated each patient three times a day (i.e., once each nursing shift) using the Broset Violence Checklist (BVC). Associated data were collected using the Staff Observation and Aggression Scale-Revised (SOAS-R) if an adverse incident occurred. At the end of the data collection period, the nursing staff were asked to complete a short questionnaire anonymously to evaluate how useful they had found the instruments. N = 93 patients were admitted to the unit during the month of study. Seven incidents were reported using the SOAS-R. A slight trend was noted for higher BVC score in aggressive patients. A potential high occurrence of underreporting on incidents was observed. There was limited feedback data from nursing staff at the end of the study, but the responses received were encouraging for continued use of the instruments in practice. The pilot study fulfilled its purpose in two ways. First, it allowed staff on the unit to experience using structured instruments to support their practice. Second, it allowed an opportunity to raise awareness of potential underreporting and tolerance of aggression on the unit.

Creating European guidelines for Chiropractic Incident Reporting and Learning Systems (CIRLS: relevance and structure

Directory of Open Access Journals (Sweden)

Wangler Martin

2011-04-01

Full Text Available Abstract Background In 2009, the heads of the Executive Council of the European Chiropractors' Union (ECU and the European Academy of Chiropractic (EAC involved in the European Committee for Standardization (CEN process for the chiropractic profession, set out to establish European guidelines for the reporting of adverse reactions to chiropractic treatment. There were a number of reasons for this: first, to improve the overall quality of patient care by aiming to reduce the application of potentially harmful interventions and to facilitate the treatment of patients within the context of achieving maximum benefit with a minimum risk of harm; second, to inform the training objectives for the Graduate Education and Continuing Professional Development programmes of all 19 ECU member nations, regarding knowledge and skills to be acquired for maximising patient safety; and third, to develop a guideline on patient safety incident reporting as it is likely to be part of future CEN standards for ECU member nations. Objective To introduce patient safety incident reporting within the context of chiropractic practice in Europe and to help individual countries and their national professional associations to develop or improve reporting and learning systems. Discussion Providing health care of any kind, including the provision of chiropractic treatment, can be a complex and, at times, a risky activity. Safety in healthcare cannot be guaranteed, it can only be improved. One of the most important aspects of any learning and reporting system lies in the appropriate use of the data and information it gathers. Reporting should not just be seen as a vehicle for obtaining information on patient safety issues, but also be utilised as a tool to facilitate learning, advance quality improvement and to ultimately minimise the rate of the occurrence of errors linked to patient care. Conclusions Before a reporting and learning system can be established it has to be clear

12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

Science.gov (United States)

2010-01-01

... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Reports of change in control of bank management... change in control of bank management incident to a merger. (a) A State member bank has inquired whether Pub. L. 88-593 (78 Stat. 940) requires reports of change in control of bank management in situations...

Accident and safety analyses for the HTR-modul. Partial project 1: Computer codes for system behaviour calculation. Final report. Pt. 2

International Nuclear Information System (INIS)

Lohnert, G.; Becker, D.; Dilcher, L.; Doerner, G.; Feltes, W.; Gysler, G.; Haque, H.; Kindt, T.; Kohtz, N.; Lange, L.; Ragoss, H.

1993-08-01

The project encompasses the following project tasks and problems: (1) Studies relating to complete failure of the main heat transfer system; (2) Pebble flow; (3) Development of computer codes for detailed calculation of hypothetical accidents; (a) the THERMIX/RZKRIT temperature buildup code (covering a.o. a variation to include exothermal heat sources); (b) the REACT/THERMIX corrosion code (variation taking into account extremely severe air ingress into the primary loop); (c) the GRECO corrosion code (variation for treating extremely severe water ingress into the primary loop); (d) the KIND transients code (for treating extremely fast transients during reactivity incidents. (4) Limiting devices for safety-relevant quantities. (5) Analyses relating to hypothetical accidents. (a) hypothetical air ingress; (b) effects on the fuel particles induced by fast transients. The problems of the various tasks are defined in detail and the main results obtained are explained. The contributions reporting the various project tasks and activities have been prepared for separate retrieval from the database. (orig./HP) [de

Accident and safety analyses for the HTR-modul. Partial project 1: Computer codes for system behaviour calculation. Final report. Pt. 1

International Nuclear Information System (INIS)

Lohnert, G.; Becker, D.; Dilcher, L.; Doerner, G.; Feltes, W.; Gysler, G.; Haque, H.; Kindt, T.; Kohtz, N.; Lange, L.; Ragoss, H.

1993-08-01

The project encompasses the following project tasks and problems: (1) Studies relating to complete failure of the main heat transfer system; (2) Pebble flow; (3) Development of computer codes for detailed calculation of hypothetical accidents; (a) the THERMIX/RZKRIT temperature buildup code (covering a.o. a variation to include exothermal heat sources); (b) the REACT/THERMIX corrosion code (variation taking into account extremely severe air ingress into the primary loop); (c) the GRECO corrosion code (variation for treating extremely severe water ingress into the primary loop); (d) the KIND transients code (for treating extremely fast transients during reactivity incidents. (4) Limiting devices for safety-relevant quantities. (5) Analyses relating to hypothetical accidents. (a) hypothetical air ingress; (b) effects on the fuel particles induced by fast transients. The problems of the various tasks are defined in detail and the main results obtained are explained. The contributions reporting the various project tasks and activities have been prepared for separate retrieval from the database. (orig./HP) [de

Risk factors and short-term projections for serotype-1 poliomyelitis incidence in Pakistan: A spatiotemporal analysis.

Directory of Open Access Journals (Sweden)

Natalie A Molodecky

2017-06-01

Full Text Available Pakistan currently provides a substantial challenge to global polio eradication, having contributed to 73% of reported poliomyelitis in 2015 and 54% in 2016. A better understanding of the risk factors and movement patterns that contribute to poliovirus transmission across Pakistan would support evidence-based planning for mass vaccination campaigns.We fit mixed-effects logistic regression models to routine surveillance data recording the presence of poliomyelitis associated with wild-type 1 poliovirus in districts of Pakistan over 6-month intervals between 2010 to 2016. To accurately capture the force of infection (FOI between districts, we compared 6 models of population movement (adjacency, gravity, radiation, radiation based on population density, radiation based on travel times, and mobile-phone based. We used the best-fitting model (based on the Akaike Information Criterion [AIC] to produce 6-month forecasts of poliomyelitis incidence. The odds of observing poliomyelitis decreased with improved routine or supplementary (campaign immunisation coverage (multivariable odds ratio [OR] = 0.75, 95% confidence interval [CI] 0.67-0.84; and OR = 0.75, 95% CI 0.66-0.85, respectively, for each 10% increase in coverage and increased with a higher rate of reporting non-polio acute flaccid paralysis (AFP (OR = 1.13, 95% CI 1.02-1.26 for a 1-unit increase in non-polio AFP per 100,000 persons aged <15 years. Estimated movement of poliovirus-infected individuals was associated with the incidence of poliomyelitis, with the radiation model of movement providing the best fit to the data. Six-month forecasts of poliomyelitis incidence by district for 2013-2016 showed good predictive ability (area under the curve range: 0.76-0.98. However, although the best-fitting movement model (radiation was a significant determinant of poliomyelitis incidence, it did not improve the predictive ability of the multivariable model. Overall, in Pakistan the risk of polio cases

National Writing Project 2009 Annual Report

Science.gov (United States)

National Writing Project (NJ1), 2009

2009-01-01

Writing as a tool for thinking, learning, and communicating is crucial to academic and career success as well as to active citizenship in a democracy. This annual report of the National Writing Project features teachers of math, chemistry, art, history, and business who develop their students as writers. These educators employ writing to engage…

Geothermal policy project. Quarterly report, June 1-August 31, 1980

Energy Technology Data Exchange (ETDEWEB)

Connor, T.D.

1980-11-01

Efforts continued to initiate geothermal and water source heat pump study activities in newly selected project states and to carry forward policy development in existing project states. Follow-up contacts were made with several project states, and state meetings and workshops were held in nine project states. Two state-specific documents were prepared during this reporting period, for Nevada and Wyoming.

Pesticide exposure and self-reported incident depression among wives in the Agricultural Health Study.

Science.gov (United States)

Beard, John D; Hoppin, Jane A; Richards, Marie; Alavanja, Michael C R; Blair, Aaron; Sandler, Dale P; Kamel, Freya

2013-10-01

Depression in women is a public health problem. Studies have reported positive associations between pesticides and depression, but few studies were prospective or presented results for women separately. We evaluated associations between pesticide exposure and incident depression among farmers' wives in the Agricultural Health Study, a prospective cohort study in Iowa and North Carolina. We used data on 16,893 wives who did not report physician-diagnosed depression at enrollment (1993-1997) and who completed a follow-up telephone interview (2005-2010). Among these wives, 1054 reported physician diagnoses of depression at follow-up. We collected information on potential confounders and on ever use of any pesticide, 11 functional and chemical classes of pesticides, and 50 specific pesticides by wives and their husbands via self-administered questionnaires at enrollment. We used inverse probability weighting to adjust for potential confounders and to account for possible selection bias induced by the death or loss of 10,639 wives during follow-up. We used log-binomial regression models to estimate risk ratios and 95% confidence intervals. After weighting for age at enrollment, state of residence, education level, diabetes diagnosis, and drop out, wives' incident depression was positively associated with diagnosed pesticide poisoning, but was not associated with ever using any pesticide. Use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives' depression. Among wives who never used pesticides, husbands' ever use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives' incident depression. Our study adds further evidence that high level pesticide exposure, such as pesticide poisoning, is associated with increased risk of depression and sets a lower bound on the level of exposure related to depression, thereby providing reassurance that the moderate levels

Fast Breeder Project status report, 1974

International Nuclear Information System (INIS)

Hueper, R.

A compilation of the papers read at the Status Report of the Fast Breeder Project at the Karlsruhe Nuclear Research Center on March 26, 1974 is presented. The first papers present a general survey of the present state of research and development work performed by the German, Belgian, and Netherlands research centers on the SNR 300 Prototype Fast Breeder Reactor (Kalkar Nuclear Power Station), on the SNR follow-on program, alternative fuels and coolants and basic problems, on work performed by industry with respect to the licensing procedure and construction of the SNR 300, and on commissioning and the planned conversion of KNK, the Compact Sodium Cooled Nuclear Reactor. The detailed papers deal with results elaborated at the institutes of GfK Karlsruhe, SCK/CEN Mol, RCN Petten, and TNO Apeldoorn. Most of these efforts have been concentrated upon fuel pin and materials development and on the physics and safety of fast reactors. The status report concludes with a reference to the future program under the Project. (U.S.)

49 CFR 225.19 - Primary groups of accidents/incidents.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Primary groups of accidents/incidents. 225.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.19 Primary groups of accidents/incidents. (a) For reporting purposes reportable railroad...

Association Between Old Firm Football Matches and Reported Domestic (Violence Incidents in Strathclyde, Scotland

Directory of Open Access Journals (Sweden)

Damien J. Williams

2013-09-01

Full Text Available Media reports have suggested that the number of reports of domestic violence may increase when Scotland’s two largest, Glasgow-based football (soccer clubs, Rangers and Celtic (traditionally referred to as the “Old Firm” play one another. This study considers the number of domestic (violence incidents reported to Strathclyde Police between 2008 and 2011 in the 24 hours following these matches, and compares it with the number reported during two appropriate comparator periods. There is a statistically significant increase in the number of reports following Old Firm matches compared with the comparator periods. This preliminary analysis confirms previous speculation concerning the association between Old Firm matches and reports of domestic violence, and highlights the need to better understand the factors leading to such violence to inform preventive interventions.

The comparative incidence of reported concussions presenting for follow-up management in South African Rugby Union.

Science.gov (United States)

Shuttleworth-Edwards, Ann B; Noakes, Timothy D; Radloff, Sarah E; Whitefield, Victoria J; Clark, Susan B; Roberts, Craig O; Essack, Fathima B; Zoccola, Diana; Boulind, Melissa J; Case, Stephanie E; Smith, Ian P; Mitchell, Julia L G

2008-09-01

The objective of this study was to compare the seasonal concussion incidence for school, university, club and provincial level Rugby Union players in South Africa. The study presents a retrospective statistical analysis of the number of reported concussions documented annually for groups of Rugby Union players as a proportion of those who received preseason neurocognitive assessment. Between 2002 and 2006, concussion management programs using computerized neuropsychological assessment were implemented for clinical and research purposes by psychologists in selected South African institutions involved in Rugby Union from school through to the professional level. The incidence figures were based on 175 concussive episodes reported for 165 athletes who were referred for neurocognitive assessment from a population of 1366 athletes who received preseason baseline testing. Concussion management routines varied according to the protocols adopted by the different psychologists and rugby organizations. It was expected that the incidence of concussion would vary significantly due to level of play and different management protocols. There was wide disparity in the manner in which concussion follow-up was managed by the various organizations. Within broadly comparable cohorts, tighter control was associated with a relatively higher concussion incidence for athletes per rugby playing season, with average institutional figures ranging from 4% to 14% at school level and 3% to 23% at adult level. This analysis suggests that concussion goes unrecognized and therefore incorrectly managed in a number of instances. Recommendations for optimal identification of concussed athletes for follow-up management are presented.

S.E.N.S.I.B. project. Progress report 2006

International Nuclear Information System (INIS)

2007-01-01

This report presents the state of progress of all the studies which establish at present the S.E.N.S.I.B. project. For year 2006, the progress of the project is globally in compliance with the general schedule of realization of the S.E.N.S.I.B. project and with the perspectives announced in 2005. Factors of sensitivity were identified in diverse circles ( thematic studies) and methods and specific tools of the project are developed. 14 publications (reviews and congress) and 9 I.R.S.N. reports were produced. An international work group was launched to the I.R.S.N. initiative. The web site of S.E.N.S.I.B. on the I.R.S.N. scientific site was built. The S.E.N.S.I.B. project receives a financial participation of the Ademe. (N.C.)

Introspecting into Deviance: Two Project Reports on Labeling Theory.

Science.gov (United States)

Posner, Judith

1979-01-01

Reports on two projects appropriate for undergraduate courses in the sociology of deviance, specifically courses emphasizing the labeling or symbolic interactionist perspective. The first project involves the use of confessional novels, and the second draws on the experiences of students regarding their own stigmas. (Author)

Yakima/Klickitat Fisheries Project Genetic Studies; Yakima/Klickitat Fisheries Project Monitoring and Evaluation, 2005-2006 Annual Report.

Energy Technology Data Exchange (ETDEWEB)

Busack, Craig A.; Fritts, Anthony L.; Kassler, Todd (Washington Department of Fish and Wildlife, Olympia, WA)

2006-05-01

This report covers one of many topics under the Yakima/Klickitat Fisheries Project's Monitoring and Evaluation Program (YKFPME). The YKFPME is funded under two BPA contracts, one for the Yakama Nation and the other for the Washington Department of Fish and Wildlife (Contract number 22370, Project Number 1995-063-25). A comprehensive summary report for all of the monitoring and evaluation topics will be submitted after all of the topical reports are completed. This approach to reporting enhances the ability of people to get the information they want, enhances timely reporting of results, and provides a condensed synthesis of the whole YKFPME. The current report was completed by the Washington Department of Fish and Wildlife.

Ceramic Technology Project. Semiannual progress report for April 1993 through September 1993

Energy Technology Data Exchange (ETDEWEB)

1994-04-01

The Ceramic Technology Project was originally developed by the Department of Energy`s Office of Transportation Systems (OTS) in Conservation and Renewable Energy. This project, part of the OTS`s Materials Development Program, was developed to meet the ceramic technology requirements of the OTS`s automotive technology programs. During the course of the Ceramic Technology Project, remarkable progress has been made in the development of reliable structural ceramics. However, further work is needed to reduce the cost of ceramics to facilitate their commercial introduction, especially in the highly cost-sensitive automotive market. The work described in this report is organized according to the following WBS project elements: Project Management and Coordination; Materials and Processing; Materials Design Methodology; Data Base and Life Prediction; and Technology Transfer. This report includes contributions from all currently active project participants. Separate abstracts were prepared for the 47 projects reported here.

Reported incidences and factors associated with percutaneous ...

African Journals Online (AJOL)

Microsoft Office User

precautions, training and reduction of long working hours are necessary in order to reduce infections from .... -4-. Incidences of percutaneous injuries and mucocutaneous blood exposure ... than 40 hours per week (14.9 %) (p= 0.001).

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

NARCIS (Netherlands)

Drupsteen, L.; Groeneweg, J.; Zwetsloot, G.I.J.M.

2013-01-01

Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process.

Waste Tank Vapor Characterization Project: Annual status report for FY 1995

International Nuclear Information System (INIS)

Ligotke, M.W.; Fruchter, J.S.; Huckaby, J.L.; Birn, M.B.; McVeety, B.D.; Evans, J.C. Jr.; Pool, K.H.; Silvers, K.L.; Goheen, S.C.

1995-11-01

This report compiles information collected during the Fiscal Year 1995 pertaining to the waste tank vapor characterization project. Information covers the following topics: project management; organic sampling and analysis; inorganic sampling and analysis; waste tank vapor data reports; and the waste tanks vapor database

Psychological Trauma in the Workplace: Variation of Incident Severity among Industry Settings and between Recurring vs Isolated Incidents

Directory of Open Access Journals (Sweden)

GS DeFraia

2015-07-01

Full Text Available Background: Psychologically traumatic workplace events (known as critical incidents occur within various work environments, with workgroups in certain industries vulnerable to multiple incidents. With the increasing prevalence of incidents in the USA, incident response is a growing practice area within occupational medicine, industrial psychology, occupational social work and other occupational health professions. Objective: To analyze a measure of incident severity based on level of disruption to the workplace and explore whether incident severity varied among different industry settings or between workgroups experiencing multiple vs single traumatic incidents. Methods: Administrative data mining was employed to examine practice data from a workplace trauma response unit in the USA. Bivariate analyses were conducted to test whether scores from an instrument measuring incident severity level varied among industry settings or between workgroups impacted by multiple vs isolated events. Results: Incident severity level differed among various industry settings. Banks, retail stores and fast food restaurants accounted for the most severe incidents, while industrial and manufacturing sites reported less severe incidents. Workgroups experiencing multiple incidents reported more severe incidents than workgroups experiencing a single incident. Conclusion: Occupational health practitioners should be alert to industry differences in several areas: pre-incident resiliency training, the content of business recovery plans, assessing worker characteristics, strategies to assist continuous operations and assisting workgroups impacted by multiple or severe incidents.

The United States Department of Energy (DOE) Computerized Accident/Incident Reporting System (CAIRS)

International Nuclear Information System (INIS)

Briscoe, G.J.

1993-01-01

The Department of Energy's (DOE) Computerized Accident/Incident Reporting System (CAIRS) is a comprehensive data base containing more than 50,000 investigation reports of injury/illness, property damage and vehicle accident cases representing safety data from 1975 to the present for more than 150 DOE contractor organizations. A special feature is that the text of each accident report is translated using a controlled dictionary and rigid sentence structure called Factor Relationship and Sequence of Events (FRASE) that enhances the ability to retrieve specific types of information and to perform detailed analyses. DOE summary and individual contractor reports are prepared quarterly and annually. In addition, ''Safety Performance Profile'' reports for individual organizations are prepared to provide advance information to appraisal teams, and special topical reports are prepared for areas of concern such as an increase in the number of security injuries or environmental releases. The data base is open to all DOE and Contractor registered users with no access restrictions other than that required by the Privacy Act

Subject Access Project. Third Quarterly Report.

Science.gov (United States)

Atherton, Pauline

This third quarterly report for the period January to March 1977 describes the production schedule, records, and estimated costs and times in creating the Subject Access Project data base. Plans for on-line use of the data base and search strategy design are outlined. A table of specifications for preparing the data base for on-line searching is…

Final report investigation project agricultural products and environment

International Nuclear Information System (INIS)

Loria, L.G.; Jimenez Dam, R.; Mora Rodriguez, P.

1998-01-01

The document presents the after-action report on six investigation projects: Thermoluminescence, Spectrometry gamma of low level, Agricultural products, Radon in the subsoil, Nuclear instrumentation, and X-ray fluorescence, executed between 1995-1997 by the Laboratory of Physical Nuclear Applied of the University of Costa Rica, in the which objectives are shown, applied methodology as well as the achievements and results each project. (Author) [es

Admiralty Inlet Pilot Tidal Project Final Technical Report

Energy Technology Data Exchange (ETDEWEB)

Collar, Craig [Public Utility District No. 1 of Snohomish County, Everett, WA (United States)

2015-09-14

This document represents the final report for the Admiralty Inlet Pilot Tidal Project, located in Puget Sound, Washington, United States. The Project purpose was to license, permit, and install a grid-connected deep-water tidal turbine array (two turbines) to be used as a platform to gather operational and environmental data on tidal energy generation. The data could then be used to better inform the viability of commercial tidal energy generation from technical, economic, social, and environmental standpoints. This data would serve as a critical step towards the responsible advancement of commercial scale tidal energy in the United States and around the world. In late 2014, Project activities were discontinued due to escalating costs, and the DOE award was terminated in early 2015. Permitting, licensing, and engineering design activities were completed under this award. Final design, deployment, operation, and monitoring were not completed. This report discusses the results and accomplishments achieved under the subject award.

Marine radioecology. Final reports from sub-projects within the Nordic nuclear safety research project EKO-1

International Nuclear Information System (INIS)

Palsson, S.E.

2001-04-01

This report contains a collection of eight papers describing research done in the NKS/EKO-1 project. It also contains a preface giving a summary of the results. The EKO-1 project as a whole has been described in the report NKS(97)FR4. The aim of the project was to make a joint Nordic study on radionuclides in sediments and water and the interaction between these two phaseS. Relatively less emphasis had been put on this factor compared to others in previous Nordic studies on marine radioecology. For some of the participating countries this work was the first of its kind undertaken. The project involved field, laboratory and model studies. The work and results helped to highlight the important role of sediments when assessing the consequences of real or possible releases of radionuclides to the marine environment (au)

MORE - Management of requirements in NPP modernisation projects. Project report 2006

Energy Technology Data Exchange (ETDEWEB)

Thunem, A.P.J.; Thunem, H.P.J. [IFE (Norway); Valkonen, J. [VTT (Finland)

2007-02-15

The purpose of the report is to document the work and related activities in the period January 1 December 31 in 2006, including dissemination activities. The work in this period has been concentrated on further research for adopting an approach for dependable requirements engineering and its supporting tool. The majority of the efforts in 2006, however, was spent on making the researchers, developers, utilities and licensees more aware of the importance of the area of requirements engineering, and in that respect organising an international seminar on dependable requirements engineering. This seminar was defined as a deliverable in the Activity Plan for 2006 and became also the most important deliverable for 2006. Therefore, this report naturally features a detailed summary of the seminar, which proved to be a true success and at the same time a door opener for more initiatives within the topic, proposed by several participants. More efforts within dissemination of the background and objectives of the project MORE within the nuclear community and towards NPPs that do carry out modernisation projects continued to be one important focus. (au)

MORE - Management of requirements in NPP modernisation projects. Project report 2006

International Nuclear Information System (INIS)

Thunem, A.P.J.; Thunem, H.P.J.; Valkonen, J.

2007-02-01

The purpose of the report is to document the work and related activities in the period January 1 December 31 in 2006, including dissemination activities. The work in this period has been concentrated on further research for adopting an approach for dependable requirements engineering and its supporting tool. The majority of the efforts in 2006, however, was spent on making the researchers, developers, utilities and licensees more aware of the importance of the area of requirements engineering, and in that respect organising an international seminar on dependable requirements engineering. This seminar was defined as a deliverable in the Activity Plan for 2006 and became also the most important deliverable for 2006. Therefore, this report naturally features a detailed summary of the seminar, which proved to be a true success and at the same time a door opener for more initiatives within the topic, proposed by several participants. More efforts within dissemination of the background and objectives of the project MORE within the nuclear community and towards NPPs that do carry out modernisation projects continued to be one important focus. (au)

Enhancing Police Responses to Domestic Violence Incidents: Reports From Client Advocates in New South Wales.

Science.gov (United States)

Goodman-Delahunty, Jane; Crehan, Anna Corbo

2016-07-01

In an online survey about experiences with the police complaint system, 239 client advocates described a recent incident in which a client with grounds to lodge a complaint declined to do so. Almost one third of those incidents involved domestic violence. Thematic analysis of case descriptions revealed that many police did not take domestic violence reports seriously. A typology of problematic police conduct was developed. Many officers failed to observe current procedures and appeared to lack knowledge of relevant laws. Citizens feared retaliatory victimization by police and/or perceived that complaining was futile. Implications of these findings are reviewed in light of procedural justice theory. © The Author(s) 2015.

Reporting Crime Victimizations to the Police and the Incidence of Future Victimizations: A Longitudinal Study.

Science.gov (United States)

Ranapurwala, Shabbar I; Berg, Mark T; Casteel, Carri

2016-01-01

Law enforcement depends on cooperation from the public and crime victims to protect citizens and maintain public safety; however, many crimes are not reported to police because of fear of repercussions or because the crime is considered trivial. It is unclear how police reporting affects the incidence of future victimization. To evaluate the association between reporting victimization to police and incident future victimization. We conducted a retrospective cohort study using National Crime Victimization Survey 2008-2012 data. Participants were 12+ years old household members who may or may not be victimized, were followed biannually for 3 years, and who completed at least one follow-up survey after their first reported victimization between 2008 and 2012. Crude and adjusted generalized linear mixed regression for survey data with Poisson link were used to compare rates of future victimization. Out of 18,657 eligible participants, 41% participants reported to their initial victimization to police and had a future victimization rate of 42.8/100 person-years (PY) (95% CI: 40.7, 44.8). The future victimization rate of those who did not report to the police (59%) was 55.0/100 PY (95% CI: 53.0, 57.0). The adjusted rate ratio comparing police reporting to not reporting was 0.78 (95%CI: 0.72, 0.84) for all future victimizations, 0.80 (95% CI: 0.72, 0.90) for interpersonal violence, 0.73 (95% CI: 0.68, 0.78) for thefts, and 0.95 (95% CI: 0.84, 1.07) for burglaries. Reporting victimization to police is associated with fewer future victimization, underscoring the importance of police reporting in crime prevention. This association may be attributed to police action and victim services provisions resulting from reporting.

[Report of Cancer Incidence and Mortality in China, 2014].

Science.gov (United States)

Chen, W Q; Li, H; Sun, K X; Zheng, R S; Zhang, S W; Zeng, H M; Zou, X N; Gu, X Y; He, J

2018-01-23

Objective: The registration data of local cancer registries in 2014 were collected by National Central Cancer Registry (NCCR)in 2017 to estimate the cancer incidence and mortality in China. Methods: The data submitted from 449 registries were checked and evaluated, and the data of 339 registries out of them were qualified and selected for the final analysis. Cancer incidence and mortality were stratified by area, gender, age group and cancer type, and combined with the population data of 2014 to estimate cancer incidence and mortality in China. The age composition of standard population of Chinese census in 2000 and Segi's population were used for age-standardized incidence and mortality in China and worldwide, respectively. Results: Total covered population of 339 cancer registries (129 in urban and 210 in rural) in 2014 were 288 243 347 (144 061 915 in urban and 144 181 432 in rural areas). The mortality verified cases (MV%) were 68.01%. Among them, 2.19% cases were identified through death certifications only (DCO%), and the mortality to incidence ratio was 0.61. There were about 3, 804, 000 new cases diagnosed as malignant cancer and 2, 296, 000 cases dead in 2014 in the whole country. The incidence rate was 278.07/100, 000 (males 301.67/100, 000, females 253.29/100, 000) in China, age-standardized incidence rates by Chinese standard population (ASIRC) and by world standard population were 190.63/100, 000 and 186.53/100, 000, respectively, and the cumulative incidence rate (0-74 age years old) was 21.58%. The cancer incidence and ASIRC in urban areas were 302.13/100, 000 and 196.58/100, 000, respectively, whereas in rural areas, those were 248.94/100, 000 and 182.64/100, 000, respectively. The cancer mortality in China was 167.89/100, 000 (207.24/100, 000 in males and 126.54/100, 000 in females), age-standardized mortality rates by Chinese standard population (ASMRC) and by world standard population were 106.98/100, 000 and 106.09/100, 000, respectively. And

Evaluation of Career Education Projects, 1976-1977. Report #7829.

Science.gov (United States)

Chern, Hermine J.; And Others

Evaluations of thirty career education projects in the school district of Philadelphia, Pennsylvania are contained in this report. Fifteen of the projects concern classroom or shop instruction, six concern development and/or field testing of curriculum materials, and the remainder involve staff development, installation of shop equipment, job…

Patient safety with reference to the occurrence of adverse events in admitted patients on the basis of incident reporting in a tertiary care hospital in North India

OpenAIRE

Moonis Mirza; Farooq A. Jan; Rauf Ahmad Wani; Fayaz Ahmad Sofi

2016-01-01

Background: A good quality report should lend itself for detailed analysis of the chain of events that lead to the incident. This knowledge can then be used to consider what interventions, and at what level in the chain, can prevent the incident from occurring again. Aim was to study the occurrence of adverse events on the basis of incident reporting. Methods: Critical analysis of incident reporting of adverse events taking place in admitted patients for one year by using WHO Structured q...

Final Report of the Final Meeting of Project Coordinators

International Nuclear Information System (INIS)

Cordero Calderon, Carlos F.

1996-06-01

The Costa Rican Electricity Institute has always been worried of the verification of the good state of the works and thus to guarantee their operation. For that reason, it has established different sorts of auscultation of the Arenal's Dam. Some investigations have been done to find new methods to improve and to eliminate risks in different works or projects. The Arenal's Dam is one of the greatest engineering works in Costa Rica, it has the Arenal, Corobici and Sandillal Hydroelectric Plants. Furthermore, the irrigation system in the Tempisque River Valley, in the Guanacaste province. One special characteristic of the Site of the Dam, is the near location of the Arenal Volcano, in full activity and located at 6 Km. from the dam. This report has two goals, one is the traditional permanent measurements report for the project, and the other, is to present it as a final work of the Project Arcal XVIII, to the International Atomic Energy Agency. This report analyses the geo-hydraulic, structural and topographic auscultation, as well as the activities accomplished during the ARCAL XVIII /8/018, Application of Tracer Techniques for Leakage in Dams and Damming Project, based on information gathered through the geo-chemical auscultation, until June 1996. (author).30 ills., 80 charts, 35 tabs

Aquatic Species Project report, FY 1989--1990

Energy Technology Data Exchange (ETDEWEB)

Brown, L.M.; Sprague, S.

1992-01-01

This report summarizes the progress and research accomplishments of the Aquatic Species Project. The four articles included are summaries of individual research projects and are entered into the EDB as such. The goal of the Aquatic Species Project is to develop the technology base for large-scale production of oil-rich microalgae. The project is also developing methods to convert the microalgal lipids into liquid fuels needed for industry and transportation. Researchers in the Aquatics Species Project focus on the use of microalgae as a feedstock for producing renewable, high-energy liquid fuels such as diesel. It is important for the United States to develop alternative renewable oil sources because 42% of the current energy market in the United States is for liquid fuels, and 38% of these fuels are imported. In 1979, the US Department of Energy (DOE) and the National Renewable Energy Laboratory (NREL) initiated the Aquatic Species Project as part of the overall effort in biofuels. The project began to focus exclusively on fuels from microalgae in 1982. Estimates show that the technology being developed by the project can provide as much as 7% of the total current energy demand. The program`s basic premise is that microalgae, which have been called the most productive biochemical factories in the world, can produce up to 30 times more oil per unit of growth area than land plants. Selected papers were processed separately for inclusion in the Energy Science and Technology Database.

Tampa electric company - IGCC project. Quarterly report, January 1, 1996--March 31, 1996

Energy Technology Data Exchange (ETDEWEB)

NONE

1998-02-01

This quarterly report consists of materials presented at a recent review of the project. The project is an IGCC project being conducted by Tampa Electric Company. The report describes the status of the facility construction, components, operations staff training, and discusses aspects of the project which may impact the final scheduled completion.

Change in Reported Lyme Disease Incidence in the Northeast and Upper Midwest, 1991-2014

Science.gov (United States)

This indicator shows how reported Lyme disease incidence has changed by state since 1991, based on the number of new cases per 100,000 people. The total change has been estimated from the average annual rate of change in each state. This map is limited to the 14 states where Lyme disease is most common, where annual rates are consistently above 10 cases per 100,000. Connecticut, New York, and Rhode Island had too much year-to-year variation in reporting practices to allow trend calculation. For more information: www.epa.gov/climatechange/science/indicators

Observed Hearing Loss and Incident Dementia in a Multiethnic Cohort.

Science.gov (United States)

Golub, Justin S; Luchsinger, José A; Manly, Jennifer J; Stern, Yaakov; Mayeux, Richard; Schupf, Nicole

2017-08-01

To determine whether observed hearing loss (OHL) is associated with incident dementia in a multiethnic population. Prospective epidemiological cohort study. Community in northern Manhattan. Participants in the Washington Heights-Inwood Columbia Aging Project, a longitudinal study on aging and dementia in an ethnically diverse community (n = 1,881). OHL was defined when the examiner observed it or according to self-reported hearing aid use. A consensus panel diagnosed dementia using standard research criteria. A Cox proportional hazards model was used to examine the relationship between OHL at baseline and risk of incident dementia (mean 7.3 ± 4.4 years of longitudinal followup, range 0.9-20 years). OHL was associated with 1.69 (95% confidence interval (CI) = 1.3-2.3, P < .010) times the risk of incident dementia, adjusting for demographic characteristics, cardiovascular risk factors, apolipoprotein E4 genotype, and stroke. When stratified according to race, the association between OHL and incident dementia was high in all groups but was statistically significant only in blacks (hazard ratio = 2.62, 95% CI = 1.5-4.5, P < .010). OHL was associated with greater risk of incident dementia in a multiethnic cohort. More study is needed to determine whether HL contributes to dementia and whether treating HL can reduce the risk of dementia. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Low-Cost Solar Array Project. Progress report 12, January-April 1979 and proceedings of the 12th Project Integration Meeting

Energy Technology Data Exchange (ETDEWEB)

1979-01-01

This report describes progress made by the Low-Cost Solar Array Project during the period January through April 1979. It includes reports on project analysis and integration; technology development in silicon material, large-area sheet silicon, and encapsulation; production process and equipment development; engineering and operations, and a discussion of the steps taken to integrate these efforts. It includes a report on, and copies of viewgraphs presented at the Project Integration Meeting held April 4-5, 1979.

South Dakota Geothermal Commercialization Project. Final report, July 1979-October 1985

Energy Technology Data Exchange (ETDEWEB)

Wegman, S.

1985-01-01

This report describes the activities of the South Dakota Energy Office in providing technical assistance, planning, and commercialization projects for geothermal energy. Projects included geothermal prospect identification, area development plans, and active demonstration/commercialization projects. (ACR)

Estimated incidence of pertussis in people aged <50 years in the United States

Science.gov (United States)

Chen, Chi-Chang; Balderston McGuiness, Catherine; Krishnarajah, Girishanthy; Blanchette, Christopher M.; Wang, Yuanyuan; Sun, Kainan; Buck, Philip O.

2016-01-01

ABSTRACT The introduction of pertussis vaccination in the United States (US) in the 1940s has greatly reduced its burden. However, the incidence of pertussis is difficult to quantify, as many cases are not laboratory-confirmed or reported, particularly in adults. This study estimated pertussis incidence in a commercially insured US population aged pertussis or cough illness using International Classification of Diseases (ICD-9) codes, a commercial outpatient laboratory database for patients with a pertussis laboratory test, and the Centers for Disease Control influenza surveillance database. US national pertussis incidence was projected using 3 methods: (1) diagnosed pertussis, defined as a claim for pertussis (ICD-9 033.0, 033.9, 484.3) during 2008–2013; (2) based on proxy pertussis predictive logistic regression models; (3) using the fraction of cough illness (ICD-9 033.0, 033.9, 484.3, 786.2, 466.0, 466.1, 487.1) attributed to laboratory-confirmed pertussis, estimated by time series linear regression models. Method 1 gave a projected annual incidence of diagnosed pertussis of 9/100,000, which was highest in those aged pertussis of 649/100,000, approximately 58–93 times higher than method 1 depending on the year. These estimations, which are consistent with considerable underreporting of pertussis in people aged pertussis burden. PMID:27246119

Regional Versus General Anesthesia and the Incidence of Unplanned Health Care Resource Utilization for Postoperative Pain After Wrist Fracture Surgery: Results From a Retrospective Quality Improvement Project.

Science.gov (United States)

Sunderland, Sarah; Yarnold, Cynthia H; Head, Stephen J; Osborn, Jill A; Purssell, Andrew; Peel, John K; Schwarz, Stephan K W

2016-01-01

The establishment at our center of a dedicated regional anesthesia service in 2008-2009 has resulted in a marked increase in single-shot brachial plexus blocks (sBPBs) for ambulatory wrist fracture surgery. Despite the documented benefits of regional over general anesthesia (GA), there has been a perceived increase among sBPB patients in postoperative return rates for pain at our institution. We conducted a retrospective quality improvement project to examine this. After exemption from human ethics board review, we sought to identify and contact all wrist fracture surgery patients treated at our center between 2003 and 2012. Our primary outcome was the incidence of unplanned physician visits (office/clinic or emergency department) for pain in the first 48 hours after surgery. Other main outcomes included the incidence of seeking any form of medical attention for pain and self-reporting of severe pain in the first 48 hours. Of 1008 identified patients, 419 could be contacted; 195 qualified for analysis. The incidence of unplanned physician visits in the first 48 hours was 12% (13 of 118) among sBPB patients versus 4% (3 of 77) in GA patients (odds ratio [OR], 3.1; 95% confidence interval [95% CI], 0.8-11.1; P = 0.11). More sBPB versus GA patients sought any form of medical attention for pain (20% vs 5%; OR, 4.7; 95% CI, 1.4-10.9; P = 0.003). Similarly, more sBPB patients reported severe postoperative pain (41% vs 10%; OR, 5.9; 95% CI, 2.6-13.4; P resource utilization caused by pain after hospital discharge than those undergoing GA. These findings warrant confirmation in a prospective trial and emphasize the need for a defined postdischarge analgesic pathway as well as the potential merits of perineural home catheters.

Changing incidence of diverticular disease of the colon in Korea : a serial radiologic study (report III)

Energy Technology Data Exchange (ETDEWEB)

Kwoen, Young Teck; Han, Sung Il; Chung, Soo Kyo; Bahk, Yong Whee [Catholic University Medical College, Seoul (Korea, Republic of)

1988-10-15

Diverticular disease of the colon (DDC), the most common affliction in developed countries, increases in incidence. It is an acquired disease where overactivity of smooth muscle of the colon causes mucosa and sub mucosa to herniate through the muscle layer of the bowel. Starting from 1964, we have periodically carried out radiologic survey to acertain the tendency of DDC to gradually increase in the Koreans. Initially Kim reported the incidence to be 0.2% in 1964 but the incidence in 1979 increased to 2.5% as reported by Chung et al. As the third survey on the series of the study on DDC, we have recently reviewed 1,859 consecutive new cases of double contrast barium enemas performed at the department of radiology, Kangnam St. Mary's Hospital, Catholic University Medical College during the 5 year's period from Feb. 1983 to May 1987. The results were as follows. 1. The present study revealed an incidence 6.0% of DDC, 7.2% in male and 5.0% in female. 2. The distribution of diverticular was 37.0% in cecum, 39.0% in ascending colon, 13.6% in transverse colon, 6.2% in descending colon, 3.7% in sigmoid colon. 3. The mean number of diverticular was 5. 4. The average age of patients with DDC was 50.5 years. From the present study, it has emerged that the diverticular disease of the colon in the Koreans is definitely on gradual increase with a significant change in the site of predominant involvement from the right to the left colon.

Changing incidence of diverticular disease of the colon in Korea : a serial radiologic study (report III)

International Nuclear Information System (INIS)

Kwoen, Young Teck; Han, Sung Il; Chung, Soo Kyo; Bahk, Yong Whee

1988-01-01

Diverticular disease of the colon (DDC), the most common affliction in developed countries, increases in incidence. It is an acquired disease where overactivity of smooth muscle of the colon causes mucosa and sub mucosa to herniate through the muscle layer of the bowel. Starting from 1964, we have periodically carried out radiologic survey to acertain the tendency of DDC to gradually increase in the Koreans. Initially Kim reported the incidence to be 0.2% in 1964 but the incidence in 1979 increased to 2.5% as reported by Chung et al. As the third survey on the series of the study on DDC, we have recently reviewed 1,859 consecutive new cases of double contrast barium enemas performed at the department of radiology, Kangnam St. Mary's Hospital, Catholic University Medical College during the 5 year's period from Feb. 1983 to May 1987. The results were as follows. 1. The present study revealed an incidence 6.0% of DDC, 7.2% in male and 5.0% in female. 2. The distribution of diverticular was 37.0% in cecum, 39.0% in ascending colon, 13.6% in transverse colon, 6.2% in descending colon, 3.7% in sigmoid colon. 3. The mean number of diverticular was 5. 4. The average age of patients with DDC was 50.5 years. From the present study, it has emerged that the diverticular disease of the colon in the Koreans is definitely on gradual increase with a significant change in the site of predominant involvement from the right to the left colon.

Nuclear power plant operating experiences from the IAEA / Nea incident reporting system 2002-2005

International Nuclear Information System (INIS)

2006-01-01

The Incident Reporting System (IRS) is an essential element of the international operating experience feedback system for nuclear power plants. The IRS is jointly operated and managed by the Nuclear Energy Agency (NEA), a semi-autonomous body within the Organisation for Economic Co-operation and Development (OECD), and the International Atomic Energy Agency (IAEA), a specialized agency within the United Nations System. (author)

The Stripa project annual report 1984

International Nuclear Information System (INIS)

1985-07-01

This is an autonomous OECD/NEA project relating to the final disposal of highly radioactive waste. Research is being performed in a granite formation 350 m below the ground surface. The first phase consists of three parts, namely hydrogeological and hydrogeochemical investigations in boreholes, tracer migration tests and large-scale tests of the behaviour of backfill material. The second phase includes the following investigations: detection and characterization of fracture zones, sealing of boreholes and shafts, hydrogoelogical characterization of the Stripa site and isotopic characterization of its groundwaters. The estimated cost of both phases is 111 MSEK and they are scheduled for completion in 1986. A summary of the progress of the project phase I and phase II is given in this report. (G.B.)

U.S. LCI Database Project--Final Phase I Report

Energy Technology Data Exchange (ETDEWEB)

2003-08-01

This Phase I final report reviews the process and provides a plan for the execution of subsequent phases of the database project, including recommended data development priorities and a preliminary cost estimate. The ultimate goal of the project is to develop publicly available LCI Data modules for commonly used materials, products, and processes.

FINAL REPORT FOR THE DIII-D RADIATIVE DIVERTOR PROJECT

International Nuclear Information System (INIS)

O'NEIL, RC; STAMBAUGH, RD

2002-01-01

OAK A271 FINAL REPORT FOR THE DIII-D RADIATIVE DIVERTOR PROJECT. The Radiative Divertor Project originated in 1993 when the DIII-D Five Year Plan for the period 1994--1998 was prepared. The Project Information Sheet described the objective of the project as ''to demonstrate dispersal of divertor power by a factor of then with sufficient diagnostics and modeling to extend the results to ITER and TPX''. Key divertor components identified were: (1) Carbon-carbon and graphite armor tiles; (2) The divertor structure providing a gas baffle and cooling; and (3) The divertor cryopumps to pump fuel and impurities

Nuclear fusion project. Semi-annual report of the Association KfK/EURATOM

International Nuclear Information System (INIS)

Kast, G.

1987-05-01

This semi-annual report gives 36 short descriptions of the work done in the framework of the Nuclear Fusion Project and outlines studies for NET/INTOR and for ECRH power sources at 150 GHz. Tables of fusion technology contracts, of NET contracts, of KfK departments contributing to the Fusion Project, and of the Fusion Project management staff complete this report. (GG)

Final report for the 'Melt-Vessel Interactions' Project. European Union R and TD Program 4th Framework. MVI project final research report

Energy Technology Data Exchange (ETDEWEB)

Sehgal, B.R.; Dinh, T.N.; Nourgaliev, R.R.; Bui, V.A.; Green, J.; Kolb, G.; Karbojian, A.; Theerthan, S.A.; Gubaidulline, A. [Royal Inst. of Tech., Stockholm (Sweden). Div. of Nuclear Power Safety; Helle, M.; Kymaelaeinen, O.; Tuomisto, H. [IVO Power Engineering Ltd., Vantaa (Finland); Bonnet, J.M.; Rouge, S.; Narcoux, M.; Liegeois, A. [CEA - Grenoble (France); Turland, B.D.; Dobson, G.P. [AEA Technology plc, Dorchester (United Kingdom); Siccama, A. [ECN Nuclear Research, Petten (Netherlands); Ikonen, K. [VTT Energy, Helsinki (Finland); Parozzi, F. [ENEL - SRI/PAM/GRA, Segrate, MI (Italy); Kolev, N. [Siemens AG, Erlangen (Germany); Caira, M. [Univ. of Roma (Italy)

1999-04-01

The Melt Vessel Interaction (MVI) project is concerned with the consequences of the interactions that a core melt, generated during a postulated severe accident in a light water reactor, may have with the pressure vessel. In particular, the issues concerned with the failure of the vessel bottom head are the focus of the research. The specific objectives of the project are to obtain data and develop validated models, which could be applied to prototypic plants, and accident conditions, for resolution of issues related to the melt vessel interactions. The project work has been performed by nine partners having varied responsibility. The work included a large number of experiments, with simulant materials, whose observations and results are employed, respectively, to understand the physical mechanisms and to develop validated models. Applications to the prototypic geometry and conditions have also been performed. This report is volume 1 of the Final Report for the Project, in which a summary of the progress achieved in the experimental program is provided. We have, however, included some aspects of the modeling activities. Volume 2 of the Final report describes the progress achieved in the modeling program. The progress achieved in the experimental and modeling parts of the Project has led to the resolution of some of the issues of melt vessel interaction. Considerable progress was also achieved towards resolution of the remaining issues.

42 CFR 137.353 - What is contained in a construction project financial report?

Science.gov (United States)

2010-10-01

... financial report? 137.353 Section 137.353 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND... § 137.353 What is contained in a construction project financial report? Construction project financial reports contain information regarding the amount of funds expended during the reporting period, and...

Summary Report for Capsule Dry Storage Project

Energy Technology Data Exchange (ETDEWEB)

JOSEPHSON, W S

2003-09-04

There are 1.936 cesium (Cs) and strontium (Sr) capsules stored in pools at the Waste Encapsulation and Storage Facility (WESF). These capsules will be moved to dry storage on the Hanford Site as an interim measure to reduce risk. The Cs/Sr Capsule Dry Storage Project (CDSP) is conducted under the assumption the capsules will eventually be moved to the repository at Yucca Mountain, and the design criteria include requirements that will facilitate acceptance at the repository. The storage system must also permit retrieval of capsules in the event vitrification of the capsule contents is pursued. A cut away drawing of a typical cesium chloride (CsCI) capsule and the capsule property and geometry information are provided in Figure 1.1. Strontium fluoride (SrF{sub 2}) capsules are similar in design to CsCl capsules. Further details of capsule design, current state, and reference information are given later in this report and its references. Capsule production and life history is covered in WMP-16938, Capsule Characterization Report for Capsule Dry Storage Project, and is briefly summarized in Section 5.2 of this report.

Nuclear safety research project. Annual report 1995

International Nuclear Information System (INIS)

Hueper, R.

1996-08-01

The reactor safety R and D work of the Karlsruhe Research Centre (FZK) has been part of the Nuclear Safety Research Project (PSF) since 1990. The present annual report 1995 summarizes the R and D results. The research tasks are coordinated in agreement with internal and external working groups. The contributions to this report correspond to the status of early 1996. An abstract in English precedes each of them, whenever the respective article is written in German. (orig.) [de

Security incidents on the Internet, 1989--1995

Energy Technology Data Exchange (ETDEWEB)

Howard, J.D.

1995-12-31

This paper presents an analysis of trends in Internet security based on an investigation of 4,299 Internet security-related incidents reported to the CERT{reg_sign} Coordination Center (CERT{reg_sign}/CC) from 1989 through 1995. Prior to this research, knowledge of actual Internet security incidents was limited and primarily anecdotal. This research: (1) developed a taxonomy to classify Internet attacks and incidents, (2) organized, classified, and analyzed CERT{reg_sign}/CC incident records, (3) summarized the relative frequency of the use of tools and vulnerabilities, success in achieving access, and results of attacks, (4) estimated total Internet incident activity, (5) developed recommendations for Internet users and suppliers, and (6) developed recommendations for future research. With the exception of denial-of-service attacks, security incidents were found to be increasing at a rate less than Internet growth. Estimates showed that most, if not all, severe incidents were reported to the CERT{reg_sign}/CC, and that more than one out of three above average incidents (in terms of duration and number of sites) were reported. Estimates also indicated that a typical Internet site was involved in, at most, around one incident (of any kind) per year, and a typical Internet host in, at most, around one incident in 45 years. The probability of unauthorized privileged access was around an order of magnitude less likely. As a result, simple and reasonable security precautions should be sufficient for most Internet users.

Site environmental report for the Yucca Mountain Project. Calendar Year 2005

Energy Technology Data Exchange (ETDEWEB)

None, None

2006-10-01

This site environmental report describes the environmental program conducted during 2005 by the U.S. Department of Energy, Office of Repository Development. The report describes the environmental laws and regulations that were applicable to the Yucca Mountain Project in 2005, the actions taken to comply with those laws and regulations, and the Project’s environmental program. The report also summarizes the data collected to monitor potential impacts of the Project on the environment.

Review of incidents to be reported under the Radiation Protection Ordinance for the years 1987 and 1988

International Nuclear Information System (INIS)

1989-01-01

The total of 80 incidents were caused by human failure, intentional disruption, theft, fire, violation of rules, transport losses, accidents, equipment deficiencies. 15 ionization smoke detectors were reported lost or stolen. (HP) [de

Portland Public Schools Project Chrysalis: Year 2 Evaluation Report.

Science.gov (United States)

Mitchell, Stephanie J.; Gabriel, Roy M.; Hahn, Karen J.; Laws, Katherine E.

In 1994, the Chrysalis Project in Portland Public Schools received funding to prevent or delay the onset of substance abuse among a special target population: high-risk, female adolescents with a history of childhood abuse. Findings from the evaluation of the project's second year of providing assistance to these students are reported here. During…

Report of the Task Force on the Incident of 19th September 2008 at the LHC

CERN Document Server

Bajko, M; Catalan-Lasheras, N; Claudet, S; Cruikshank, P; Dahlerup-Petersen, K; Denz, R; Fessia, P; Garion, C; Jimenez, JM; Kirby, G; Lebrun, Ph; Le Naour, S; Mess, K-H; Modena, M; Montabonnet, V; Nunes, R; Parma, V; Perin, A; de Rijk, G; Rijllart, A; Rossi, L; Schmidt, R; Siemko, A; Strubin, P; Tavian, L; Thiesen, H; Tock, J; Todesco, E; Veness, R; Verweij, A; Walckiers, L; Van Weelderen, R; Wolf, R; Fehér, S; Flora, R; Koratzinos, M; Limon, P; Strait, J

2009-01-01

This report summarizes the findings and recommendations of the AT department Task Force established to investigate the 19th September 2008 incident which occurred in sector 3-4 of the LHC. It includes a number of annexes where specific analyses are detailed.

Nuclear Safety Project - annual report 1980

International Nuclear Information System (INIS)

1981-08-01

The Annual Report 1980 is a detailed description (in German language) of work within the Nuclear Safety Project performed in 1980 in the nuclear safety field by KfK institutes and departments and by external institutes on behalf of KfK. It includes for each individual research activity short summaries in English language on work completed, essential results, plans for the near future. (orig./RW) [de

NCSS Peace Studies Project: An Interim Report.

Science.gov (United States)

Ferber, Michael

This preliminary report of a National Council for the Social Studies (NCSS) project briefly assesses teaching materials related to peace and nuclear warfare. Covering elementary, secondary, and higher education, the materials discussed present a variety of activities, decision-making approaches, and analytical assessments of policies of many…

Iowa Hill Pumped Storage Project Investigations - Final Technical Report

Energy Technology Data Exchange (ETDEWEB)

Hanson, David [Sacramento Municipal Unitlity District, Sacramento, CA (United States)

2016-07-01

This Final Technical Report is a summary of the activities and outcome of the Department of Energy (DOE) Assistance Agreement DE-EE0005414 with the Sacramento Municipal Utility District (SMUD). The Assistance Agreement was created in 2012 to support investigations into the Iowa Hill Pumped-storage Project (Project), a new development that would add an additional 400 MW of capacity to SMUD’s existing 688MW Upper American River Hydroelectric Project (UARP) in the Sierra Nevada mountains east of Sacramento, California.

Incidence of bruxism in TMD population.

Science.gov (United States)

Chandwani, Briesh; Ceneviz, Caroline; Mehta, Noshir; Scrivani, Steven

2011-01-01

The objective of the study presented here was to examine the incidence of bruxism in patients suffering from temporomandibular disorders. Two cohorts of patients suffering from temporomandibular disorders were evaluated. One group, composed of 163 patients, was asked specifically about the occurrence of bruxism, while the other group, composed of 200 patients, was not specifically asked about bruxism (self-reporting). The incidence of bruxism was only 20.5% for the group that only self-reported bruxism, while the incidence was 65% when asked specifically about bruxism. It is critical to ask specifically about bruxism. Patients are more likely to report bruxism when asked specifically about it. It is important to incorporate this as part of a TMD evaluation.

International Chernobyl project [AEA report

International Nuclear Information System (INIS)

Anon.

1991-01-01

The IAEA have co-ordinated the first international assessment of the radiological consequences of the Chernobyl accident in the affected areas outside the 30km prohibited zone around the reactor. These areas have a total population of about 1 million people, living in approximately 2700 settlements. The main aim of the project was to answer the question 'Is it safe for the population to go on living in the affected areas?'. The project did not investigate radiological health effects among more than 100 000 people evacuated from the 30 km prohibited zone. Nor did it study effects among the emergency personnel temporarily brought into the region for accident management and recovery work (the so-called 'liquidators'). Project teams reviewed official data on environmental contamination from 500 settlements, data collection practices and reporting and also official information on radiation doses received by people living in seven settlements. Other project teams reviewed official data at key medical centres and institutes. Then they examined people both from surveyed contaminated settlement and from surveyed control settlements. The team concluded that there were significant non-radiation related health disorders in populations of both contaminated and control settlements. None of the disorders could be attributed directly to radiation exposure. In particular, no evidence was found for a significant increase in foetal abnormalities; infant and prenatal mortality rates had fallen since the accident. Children were found to be generally healthy with no abnormalities in either thyroid stimulating or thyroid hormones. The accident had created substantial negative psychological consequences, manifesting themselves in terms of anxiety and stress due to continuing high levels of uncertainty. (author)

Management of water hyacinth. A CSC/UNEP project. Progress report

International Nuclear Information System (INIS)

1981-05-01

The water hyacinth project was initially proposed at the Regional Workshop on Rural Technology held at Dacca in January 1978. In November 1978, national coordinators met at New Delhi and outlined the project in detail as reported in CSC(79)RT-4. The meeting was attended by delegates from Bangladesh, Egypt, Guyana, India, Malaysia, Papua New Guinea, Sri Lanka, Commonwealth Science Council and the United Nations Environment Programme. Following this a proposal was submitted to UNEP seeking funding support to meet the external cost component of the project. This support was subsequently granted. The project aims to achieve an integrated approach towards managing water hyacinth. The underlying intention was that management would cover both eradication of the plant as well as making productive use of it when possible. Productive uses envisaged include biogas synthesis, production of papers and boards and as a source of proteins. Another interesting possibility is the use of the plant to control industrial as well as domestic water pollution . All these were detailed in a three and a half year time plan. The project had its first review meeting in June 1979 in Papua New Guinea. The major intention of this meeting was to examine status reports from each country in an attempt to quantify the problem caused by water hyacinth and assess the work plan in relation to this. The report of this meeting has been published as CSC(79)RT-5. At this meeting Papua New Guinea decided to withdraw from this project as water hyacinth was not regarded as a severe problem. The use of dugong as a control agent was not recommended by Papua New Guinea. In April 1980 an interim review meeting attended by the Regional Coordinator and representatives of UNEP and CSC was held in London where, based on the progress made in the participating countries, activities and time schedules were refined and sharpened (CSC (80)RT-16). It look some time to resolve the external funding question . It was

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center.

Directory of Open Access Journals (Sweden)

Jih-Shuin Jerng

Full Text Available There have been concerns about the workplace interpersonal conflict (WIC among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs.We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship and the three properties (disagreement, interference, and negative emotion, and analyzed relevant data.Of the 147 incidents with WIC, the most common related processes were patient transfer (20%, laboratory tests (17%, surgery (16% and medical imaging (16%. All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9% also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57% were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%, and the majority (67% of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064. The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1% than not on it (17.0%. The distributions of worker job types were similar between those with and without negative emotion (p = 0.125.The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center.

Science.gov (United States)

Jerng, Jih-Shuin; Huang, Szu-Fen; Liang, Huey-Wen; Chen, Li-Chin; Lin, Chia-Kuei; Huang, Hsiao-Fang; Hsieh, Ming-Yuan; Sun, Jui-Sheng

2017-01-01

There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs. We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data. Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125). The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.

Project Portal User-Centered Design and Engineering Report

Science.gov (United States)

2016-06-01

TECHNICAL REPORT 3013 June 2016 Project Portal User-Centered Design and Engineering Report Deborah Gill-Hesselgrave Veronica Higgins Sarah...Design and Engineering Branch Under authority of Chris Raney, Head Command and Control Technology and Experiments Division iii EXECUTIVE...navy.mil  Christian Szatkowski christian.szatkowski@navy.mil  Roni Higgins roni.higgins@navy.mil  Jake Viraldo jacob.viraldo@navy.mil B

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.

Masking in reports of "most serious" events: bias in estimators of sports injury incidence in Canadian children

Directory of Open Access Journals (Sweden)

A. Gupta

2016-08-01

Full Text Available Introduction: Surveys that collect information on injuries often focus on the single "most serious" event to help limit recall error and reduce survey length. However, this can mask less serious injuries and result in biased incidence estimates for specific injury subcategories. Methods: Data from the 2002 Health Behaviour in School-aged Children (HBSC survey and from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP were used to compare estimates of sports injury incidence in Canadian children. Results: HBSC data indicate that 6.7% of children report sustaining a sports injury that required an emergency department (ED visit. However, details were only collected on a child's "most serious" injury, so children who had multiple injuries requiring an ED visit may have had sports injuries that went unreported. The rate of 6.7% can be seen to be an underestimate by as much as 4.3%. Corresponding CHIRPP surveillance data indicate an incidence of 9.9%. Potential masking bias is also highlighted in our analysis of injuries attended by other health care providers. Conclusion: The "one most serious injury" line of questioning induces potentially substantial masking bias in the estimation of sports injury incidence, which limits researchers' ability to quantify the burden of sports injury. Longer survey recall periods naturally lead to greater masking. The design of future surveys should take these issues into account. In order to accurately inform policy decisions and the direction of future research, researchers must be aware of these limitations.

Federal Workplace Literacy Project. Internal Evaluation Report.

Science.gov (United States)

Matuszak, David J.

This report describes the following components of the Nestle Workplace Literacy Project: six job task analyses, curricula for six workplace basic skills training programs, delivery of courses using these curricula, and evaluation of the process. These six job categories were targeted for training: forklift loader/checker, BB's processing systems…

Exploratory Shaft, Phase 1, Project B-314: Title 1 design report system design description

International Nuclear Information System (INIS)

Hanlen, D.F.

1983-01-01

The report describes the project and the project systems, the principal design bases, and principal hazards and project interfaces. This report also contains the Title 1 Estimate Summary. 5 figs., 8 tabs

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/.

Mirage project. Second summary progress report (Work period January to December 1984)

International Nuclear Information System (INIS)

Come, B.

1985-01-01

This report summarizes the second year of work (1984) in the CEC project MIRAGE on migration of radionuclides in the geosphere. It complements CEC reports EUR 9304 (Description of the project) and EUR 9543 (Works carried out in 1983) on the same topic

How effective project management will add value to your uranium project

International Nuclear Information System (INIS)