A critical incident reporting system in anaesthesia.

Science.gov (United States)

Madzimbamuto, F D; Chiware, R

2001-01-01

To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Between May and October 2000, 62 completed critical incident forms were collected. The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome. Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The

SU-E-P-07: Retrospective Analysis of Incident Reports at a Radiology Department: Feedback From Incident Reporting System

Energy Technology Data Exchange (ETDEWEB)

Kakinohana, Y; Toita, T; Heianna, J; Murayama, S [School of medicine, University of the Ryukyus, Nishihara-cho, Okinawa (Japan)

2015-06-15

Purpose: To provide an overview of reported incidents that occurred in a radiology department and to describe the most common causal source of incidents. Methods: Incident reports from the radiology department at the University of the Ryukyus Hospital between 2008 and 2013 were collected and analyzed retrospectively. The incident report form contains the following items, causal factors of the incident and desirable corrective actions to prevent recurrence of similar incidents. These items allow the institution to investigate/analyze root causes of the incidents and suggest measures to be taken to prevent further, similar incidents. The ‘causal factors of the incident’ item comprises multiple selections from among 24 selections and includes some synonymous selections. In this study, this item was re-categorized into four causal source types: (i) carelessness, (ii) lack of skill or knowledge, (iii) deficiencies in communication, and (iv) external factors. Results: There were a total of 7490 incident reports over the study period and 276 (3.7%) were identified as originating from the radiology department. The most frequent causal source type was carelessness (62%). The other three types showed similar frequencies (10–14%). The staff members involved in incidents indicate three predominant desirable corrective actions to prevent or decrease the recurrence of similar incidents. These are ‘improvement in communication’ (24%), ‘staff training/education’ (19%), and ‘daily medical procedures’ (22%), and the most frequent was ‘improvement in communication’. Even though the most frequent causal factor was related to carelessness, the most desirable corrective action indicated by the staff members was related to communication. Conclusion: Our finding suggests that the most immediate causes are strongly related to carelessness. However, the most likely underlying causes of incidents would be related to deficiencies in effective communication. At our

NEA incident reporting system: Three years' experience

International Nuclear Information System (INIS)

Otsuka, Y.; Haeussermann, W.

1984-01-01

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

49 CFR 225.11 - Reporting of accidents/incidents.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Reporting of accidents/incidents. 225.11 Section... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.11 Reporting of accidents/incidents. Each railroad subject to this part shall submit to FRA...

EMS helicopter incidents reported to the NASA Aviation Safety Reporting System

Science.gov (United States)

Connell, Linda J.; Reynard, William D.

1993-01-01

The objectives of this evaluation were to: Identify the types of safety-related incidents reported to the Aviation Safety Reporting System (ASRS) in Emergency Medical Service (EMS) helicopter operations; Describe the operational conditions surrounding these incidents, such as weather, airspace, flight phase, time of day; and Assess the contribution to these incidents of selected human factors considerations, such as communication, distraction, time pressure, workload, and flight/duty impact.

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...

49 CFR 613.200 - Statewide transportation planning and programming.

Science.gov (United States)

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false Statewide transportation planning and programming. 613.200 Section 613.200 Transportation Other Regulations Relating to Transportation (Continued... Transportation Planning and Programming § 613.200 Statewide transportation planning and programming. The...

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.

Piloting a Statewide Home Visiting Quality Improvement Learning Collaborative.

Science.gov (United States)

Goyal, Neera K; Rome, Martha G; Massie, Julie A; Mangeot, Colleen; Ammerman, Robert T; Breckenridge, Jye; Lannon, Carole M

2017-02-01

Objective To pilot test a statewide quality improvement (QI) collaborative learning network of home visiting agencies. Methods Project timeline was June 2014-May 2015. Overall objectives of this 8-month initiative were to assess the use of collaborative QI to engage local home visiting agencies and to test the use of statewide home visiting data for QI. Outcome measures were mean time from referral to first home visit, percentage of families with at least three home visits per month, mean duration of participation, and exit rate among infants learning. A statewide data system was used to generate monthly run charts. Results Mean time from referral to first home visit was 16.7 days, and 9.4% of families received ≥3 visits per month. Mean participation was 11.7 months, and the exit rate among infants learning network, agencies tested and measured changes using statewide and internal data. Potential next steps are to develop and test new metrics with current pilot sites and a larger collaborative.

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.

Water Quality attainment Information from Clean Water Act Statewide Statistical Surveys

Data.gov (United States)

U.S. Environmental Protection Agency — Designated uses assessed by statewide statistical surveys and their state and national attainment categories. Statewide statistical surveys are water quality...

Water Quality Stressor Information from Clean Water Act Statewide Statistical Surveys

Data.gov (United States)

U.S. Environmental Protection Agency — Stressors assessed by statewide statistical surveys and their state and national attainment categories. Statewide statistical surveys are water quality assessments...

23 CFR 450.222 - Applicability of NEPA to statewide transportation plans and programs.

Science.gov (United States)

2010-04-01

... the Secretary concerning a long-range statewide transportation plan or STIP developed through the... 23 Highways 1 2010-04-01 2010-04-01 false Applicability of NEPA to statewide transportation plans... TRANSPORTATION PLANNING AND RESEARCH PLANNING ASSISTANCE AND STANDARDS Statewide Transportation Planning and...

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....

Statewide mesoscopic simulation for Wyoming.

Science.gov (United States)

2013-10-01

This study developed a mesoscopic simulator which is capable of representing both city-level and statewide roadway : networks. The key feature of such models are the integration of (i) a traffic flow model which is efficient enough to : scale to larg...

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.

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.

A correction factor for estimating statewide agricultural injuries from ambulance reports.

Science.gov (United States)

Scott, Erika E; Earle-Richardson, Giulia; Krupa, Nicole; Jenkins, Paul

2011-10-01

Agriculture ranks as one of the most hazardous industries in the nation. Agricultural injury surveillance is critical to identifying and reducing major injury hazards. Currently, there is no comprehensive system of identifying and characterizing fatal and serious non-fatal agricultural injuries. Researchers sought to calculate a multiplier for estimating the number of agricultural injury cases based on the number of times the farm box indicator was checked on the ambulance report. Farm injuries from 2007 that used ambulance transport were ascertained for 10 New York counties using two methods: (1) ambulance reports including hand-entered free text; and (2) community surveillance. The resulting multiplier that was developed from contrasting these two methods was then applied to the statewide Emergency Medical Services database to estimate the total number of agricultural injuries for New York state. There were 25,735 unique ambulance runs due to injuries in the 10 counties in 2007. Among these, the farm box was checked a total of 90 times. Of these 90, 63 (70%) were determined to be agricultural. Among injury runs where the farm box was not checked, an additional 59 cases were identified from the free text. Among these 122 cases (63 + 59), four were duplicates. Twenty-four additional unique cases were identified from the community surveillance for a total of 142. This yielded a multiplier of 142/90 = 1.578 for estimating all agricultural injuries from the farm box indicator. Sensitivity and specificity of the ambulance report method were 53.4% and 99.9%, respectively. This method provides a cost-effective way to estimate the total number of agricultural injuries for the state. However, it would not eliminate the more labor intensive methods that are required to identify of the actual individual case records. Incorporating an independent source of case ascertainment (community surveillance) increased the multiplier by 17%. Copyright © 2011 Elsevier Inc. All rights

Predictors of Suicidal Ideation in a Statewide Sample of Transgender Individuals

OpenAIRE

Rood, Brian A.; Puckett, Julia A.; Pantalone, David W.; Bradford, Judith B.

2015-01-01

Transgender individuals experience violence and discrimination, which, in addition to gender transitioning, are established correlates of psychological distress. In a statewide sample of 350 transgender adults, we investigated whether a history of violence and discrimination increased the odds of reporting lifetime suicidal ideation (SI) and whether differences in SI were predicted by gender transition status. Violence, discrimination, and transition status significantly predicted SI. Compare...

Analysis of Gastric Lavage Reported to a Statewide Poison Control System.

Science.gov (United States)

Donkor, Jimmy; Armenian, Patil; Hartman, Isaac N; Vohra, Rais

2016-10-01

As decontamination trends have evolved, gastric lavage (GL) has become a rare procedure. The current information regarding use, outcomes, and complications of GL could help refine indications for this invasive procedure. We sought to determine case type, location, and complications of GL cases reported to a statewide poison control system. This is a retrospective review of the California Poison Control System (CPCS) records from 2009 to 2012. Specific substances ingested, results and complications of GL, referring hospital ZIP codes, and outcomes were examined. Nine hundred twenty-three patients who underwent GL were included in the final analysis, ranging in age from 9 months to 88 years. There were 381 single and 540 multiple substance ingestions, with pill fragment return in 27%. Five hundred thirty-six GLs were performed with CPCS recommendation, while 387 were performed without. Complications were reported for 20 cases. There were 5 deaths, all after multiple ingestions. Among survivors, 37% were released from the emergency department, 13% were admitted to hospital wards, and 48% were admitted to intensive care units. The most commonly ingested substances were nontricyclic antidepressant psychotropics (n = 313), benzodiazepines (n = 233), acetaminophen (n = 191), nonsteroidal anti-inflammatory drugs (n = 107), diphenhydramine (n = 70), tricyclic antidepressants (n = 45), aspirin (n = 45), lithium (n = 36), and antifreeze (n = 10). The geographic distribution was clustered near regions of high population density, with a few exceptions. Toxic agents for which GL was performed reflected a broad spectrum of potential hazards, some of which are not life-threatening or have effective treatments. Continuing emergency physician and poison center staff education is required to assist in patient selection. Copyright © 2016 Elsevier Inc. All rights reserved.

Cost-effectiveness analysis of a statewide media campaign to promote adolescent physical activity.

Science.gov (United States)

Peterson, Michael; Chandlee, Margaret; Abraham, Avron

2008-10-01

A cost-effectiveness analysis of a statewide social marketing campaign was performed using a statewide surveillance survey distributed to 6th through 12th graders, media production and placement costs, and 2000 census data. Exposure to all three advertisements had the highest impact on both intent and behavior with 65.6% of the respondents considering becoming more active and 58.3% reporting becoming more active. Average cost of the entire campaign was $4.01 per person to see an ad, $7.35 per person to consider being more active, and $8.87 per person to actually become more active, with billboards yielding the most positive cost-effectiveness. Findings highlight market research as an essential part of social marketing campaigns and the importance of using multiple marketing modalities to enhance cost-effectiveness and impact.

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...

WisDOT statewide customer satisfaction survey.

Science.gov (United States)

2013-02-01

The purpose of this study was to develop and initiate a new customer satisfaction tool that would establish a set of baseline : departmental performance measures and be sustainable for future use. ETC Institute completed a statewide customer : survey...

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.)

Successful Statewide Walking Program Websites

Science.gov (United States)

Teran, Bianca Maria; Hongu, Nobuko

2012-01-01

Statewide Extension walking programs are making an effort to increase physical activity levels in America. An investigation of all 20 of these programs revealed that 14 use websites as marketing and educational tools, which could prove useful as the popularity of Internet communities continues to grow. Website usability information and an analysis…

Socioeconomic Disadvantage Is Associated with a Higher Incidence of Aneurysmal Subarachnoid Hemorrhage.

Science.gov (United States)

Nichols, Linda; Stirling, Christine; Otahal, Petr; Stankovich, Jim; Gall, Seana

2018-03-01

Aneurysmal subarachnoid hemorrhage (aSAH) incidence is not well studied. Varied definitions of "subarachnoid hemorrhage" have led to a lack of clarity regarding aSAH incidence. The impact of area-level socioeconomic disadvantage and geographical location on the incidence of aSAH also remains unclear. Using a population-based statewide study, we examined the incidence of aSAH in relation to socioeconomic disadvantage and geographical location. A retrospective cohort study of nontraumatic subarachnoid hemorrhages from 2010 to 2014 was undertaken. Researchers manually collected data from multiple overlapping sources including statewide administrative databases, individual digital medical records, and death registers. Age-standardized rates (ASRs) per 100,000 person years were calculated using the 2001 Australian population. Differences in incidence rate ratios were calculated by age, sex, area-level socioeconomic status, and geographical location using Poisson regression. The cohort of 237 cases (mean age, 61.0 years) with a female predominance of 166 (70.04%) included 159 confirmed aSAH, 52 community-based deaths, and 26 probable cases. The ASR for aSAH was 9.99 (95% confidence interval [CI], 8.69-11.29). A significant association between area-level socioeconomic disadvantage and incidence was observed, with the rate of aSAH in disadvantaged geographical areas being 1.40 times higher than that in advantaged areas (95% CI, 1.11-1.82; P = .012). This study uses a comprehensive search of multiple data sources to define a new baseline of aSAH within an Australian population. This study presents a higher incidence rate of aSAH with socioeconomic variations. As a key risk factor that may explain this paradox, addressing socioeconomic inequalities is important for effective prevention and management interventions. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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.

Predictors of Suicidal Ideation in a Statewide Sample of Transgender Individuals.

Science.gov (United States)

Rood, Brian A; Puckett, Julia A; Pantalone, David W; Bradford, Judith B

2015-09-01

Transgender individuals experience violence and discrimination, which, in addition to gender transitioning, are established correlates of psychological distress. In a statewide sample of 350 transgender adults, we investigated whether a history of violence and discrimination increased the odds of reporting lifetime suicidal ideation (SI) and whether differences in SI were predicted by gender transition status. Violence, discrimination, and transition status significantly predicted SI. Compared with individuals with no plans to transition, individuals with plans or who were living as their identified gender reported greater odds of lifetime SI. We discuss implications for SI disparities using Meyer's minority stress model.

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...

Pediatric Exposures to Topical Benzocaine Preparations Reported to a Statewide Poison Control System.

Science.gov (United States)

Vohra, Rais; Huntington, Serena; Koike, Jennifer; Le, Kevin; Geller, Richard J

2017-08-01

Topical benzocaine is a local anesthetic commonly used to relieve pain caused by teething, periodontal irritation, burns, wounds, and insect bites. Oral preparations may contain benzocaine concentrations ranging from 7.5% to 20%. Pediatric exposure to such large concentrations may result in methemoglobinemia and secondarily cause anemia, cyanosis, and hypoxia. This is a retrospective study of exposures reported to a statewide poison control system. The electronic health records were queried for pediatric exposures to topical benzocaine treated at a healthcare facility from 2004 to 2014. Cases of benzocaine exposure were reviewed for demographic and clinical information, and descriptive statistical analysis was performed. The query resulted in 157 cases; 58 were excluded due to co-ingestants, or miscoding of non-benzocaine exposures. Children four years of age and younger represented the majority of cases (93%) with a median age of 1 year. There were 88 cases of accidental/ exploratory exposure, while 6 cases resulted from therapeutic application or error, 4 cases from adverse reactions, and 1 case from an unknown cause. Asymptomatic children accounted for 75.5% of cases, but major clinical effects were observed in 5 patients. Those with serious effects were exposed to a range of benzocaine concentrations (7.5-20%), with 4 cases reporting methemoglobin levels between 20.2%-55%. Methylene blue was administered in 4 of the cases exhibiting major effects. The majority of exposures were accidental ingestions by young children. Most exposures resulted in minor to no effects. However, some patients required treatment with methylene blue and admission to a critical care unit. Therapeutic application by parents or caregivers may lead to adverse effects from these commonly available products.

Prevalence of Self-Reported Lifetime History of Traumatic Brain Injury and Associated Disability: A Statewide Population-Based Survey.

Science.gov (United States)

Whiteneck, Gale G; Cuthbert, Jeffrey P; Corrigan, John D; Bogner, Jennifer A

2016-01-01

To investigate the prevalence of all severities of traumatic brain injury (TBI), regardless of treatment setting, and their associated negative outcomes. A total of 2701 adult Coloradoans. A statewide, population-based, random digit-dialed telephone survey. The lifetime history of TBI was assessed by a modification of the Ohio State University TBI Identification Method; activity limitation and life satisfaction were also assessed. The distribution of self-reported lifetime injury was as follows: 19.8%, no injury; 37.7%, injury but no TBI; 36.4%, mild TBI; and 6.0%, moderate-severe TBI. Of those reporting a TBI, 23.1% were hospitalized, 38.5% were treated in an emergency department, 9.8% were treated in a physician's office, and 27.5% did not seek medical care. A clear gradient of activity limitations and low life satisfaction was seen, with the highest proportions of these negative outcomes occurring in people reporting more severe TBI and the lowest proportions in those not reporting a TBI. Approximately twice as many people reported activity limitations and low life satisfaction after nonhospitalized TBI compared with hospitalized TBI. This investigation highlights the seriousness of TBI as a public health problem and the importance of including all severities of TBI, no matter where, or if treated, in estimating the prevalence of disability co-occurring with TBI.

Effects of patient health literacy, patient engagement and a system-level health literacy attribute on patient-reported outcomes: a representative statewide survey.

Science.gov (United States)

Kaphingst, Kimberly A; Weaver, Nancy L; Wray, Ricardo J; Brown, Melissa L R; Buskirk, Trent; Kreuter, Matthew W

2014-10-07

The effects of health literacy are thought to be based on interactions between patients' skill levels and health care system demands. Little health literacy research has focused on attributes of health care organizations. We examined whether the attribute of individuals' experiences with front desk staff, patient engagement through bringing questions to a doctor visit, and health literacy skills were related to two patient-reported outcomes. We administered a telephone survey with two sampling frames (i.e., household landline, cell phone numbers) to a randomly selected statewide sample of 3358 English-speaking adult residents of Missouri. We examined two patient-reported outcomes - whether or not respondents reported knowing more about their health and made better choices about their health following their last doctor visit. Multivariable logistic regression models were used to examine the independent contributions of predictor variables (i.e., front desk staff, bringing questions to a doctor visit, health literacy skills). Controlling for self-reported health, having a personal doctor, time since last visit, number of chronic conditions, health insurance, and sociodemographic characteristics, respondents who had a good front desk experience were 2.65 times as likely (95% confidence interval [CI]: 2.13, 3.30) and those who brought questions were 1.73 times as likely (95% CI: 1.32, 2.27) to report knowing more about their health after seeing a doctor. In a second model, respondents who had a good front desk experience were 1.57 times as likely (95% CI: 1.26, 1.95) and those who brought questions were 1.66 times as likely (95% CI: 1.29, 2.14) to report making better choices about their health after seeing a doctor. Patients' health literacy skills were not associated with either outcome. Results from this representative statewide survey may indicate that one attribute of a health care organization (i.e., having a respectful workforce) and patient engagement through

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

Energy Technology Data Exchange (ETDEWEB)

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

2013-03-15

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

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

International Nuclear Information System (INIS)

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

2013-01-01

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

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.

Are Statewide Data Systems Meeting the Local Institution's Needs? AIR Forum Paper 1978.

Science.gov (United States)

Bryson, Charles H.

Statewide data collection systems emerged in the late sixties as the vehicle to achieving greater efficiency and accountability in higher education. The expectations of statewide systems were that they would meet the needs of various levels of management. The example presented in this paper is the Georgia management information system and its…

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.

Pediatric Exposures to Topical Benzocaine Preparations Reported to a Statewide Poison Control System

Directory of Open Access Journals (Sweden)

Rais Vohra

2017-07-01

Full Text Available Introduction: Topical benzocaine is a local anesthetic commonly used to relieve pain caused by teething, periodontal irritation, burns, wounds, and insect bites. Oral preparations may contain benzocaine concentrations ranging from 7.5% to 20%. Pediatric exposure to such large concentrations may result in methemoglobinemia and secondarily cause anemia, cyanosis, and hypoxia. Methods: This is a retrospective study of exposures reported to a statewide poison control system. The electronic health records were queried for pediatric exposures to topical benzocaine treated at a healthcare facility from 2004 to 2014. Cases of benzocaine exposure were reviewed for demographic and clinical information, and descriptive statistical analysis was performed. Results: The query resulted in 157 cases; 58 were excluded due to co-ingestants, or miscoding of non-benzocaine exposures. Children four years of age and younger represented the majority of cases (93% with a median age of 1 year. There were 88 cases of accidental/ exploratory exposure, while 6 cases resulted from therapeutic application or error, 4 cases from adverse reactions, and 1 case from an unknown cause. Asymptomatic children accounted for 75.5% of cases, but major clinical effects were observed in 5 patients. Those with serious effects were exposed to a range of benzocaine concentrations (7.5–20%, with 4 cases reporting methemoglobin levels between 20.2%–55%. Methylene blue was administered in 4 of the cases exhibiting major effects. Conclusion: The majority of exposures were accidental ingestions by young children. Most exposures resulted in minor to no effects. However, some patients required treatment with methylene blue and admission to a critical care unit. Therapeutic application by parents or caregivers may lead to adverse effects from these commonly available products.

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.

WisDOT statewide customer satisfaction survey : [project brief].

Science.gov (United States)

2013-03-01

The Wisconsin Department of Transportation (WisDOT) is a major public agency with numerous customers utilizing a variety of services and programs to support the entire statewide multimodal transportation system. The department also houses the Divisio...

Socioeconomic and travel demand forecasts for Virginia and potential policy responses : a report for VTrans2035 : Virginia's statewide multimodal transportation plan.

Science.gov (United States)

2009-01-01

VTrans2035, Virginia's statewide multimodal transportation plan, requires 25-year forecasts of socioeconomic and travel activity. Between 2010 and 2035, daily vehicle miles traveled (DVMT) will increase between 35% and 45%, accompanied by increases i...

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.

A guide for statewide impaired-driving task forces.

Science.gov (United States)

2009-09-01

The purpose of the guide is to assist State officials and other stakeholders who are interested in establishing an : Impaired-Driving Statewide Task Force or who are exploring ways to improve their current Task Force. The guide : addresses issues suc...

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

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.

Tobacco Smoke Pollution in Hospitality Venues Before and After Passage of Statewide Smoke-Free Legislation.

Science.gov (United States)

Buettner-Schmidt, Kelly; Boursaw, Blake; Lobo, Marie L; Travers, Mark J

2017-03-01

In 2012, North Dakota enacted a comprehensive statewide law prohibiting smoking in enclosed public places. Disparities in tobacco control exist in rural areas. This study's objective was to determine the extent to which the passage of a comprehensive, statewide, smoke-free law in a predominantly rural state influenced tobacco smoke pollution in rural and nonrural venues. A longitudinal cohort design study comparing the levels of tobacco smoke pollution before and after passage of the statewide smoke-free law was conducted in 64 restaurants and bars statewide in North Dakota. Particulate matter with a median aerodynamic diameter of <2.5 μm (a valid atmospheric marker of tobacco smoke pollution) was assessed. A significant 83% reduction in tobacco smoke pollution levels occurred after passage of the law. Significant reductions in tobacco smoke pollution levels occurred in each of the rural categories; however, no difference by rurality was noted in the analysis after passage of the law, in contrast to the study before passage. To our knowledge, this was the largest, single, rural postlaw study globally. A comprehensive statewide smoke-free law implemented in North Dakota dramatically decreased the level of tobacco smoke pollution in bars and restaurants. © 2016 The Authors. Public Health Nursing Published by Wiley Periodicals, Inc.

A case study: planning a statewide information resource for health professionals: an evidence-based approach

Science.gov (United States)

Chew, Katherine; Watson, Linda; Parker, Mary

2009-01-01

Question: What is the best approach for implementing a statewide electronic health library (eHL) to serve all health professionals in Minnesota? Setting: The research took place at the University of Minnesota Health Sciences Libraries. Methods: In January 2008, the authors began planning a statewide eHL for health professionals following the five-step process for evidence-based librarianship: formulating the question, finding the best evidence, appraising the evidence, assessing costs and benefits, and evaluating the effectiveness of resulting actions. Main Results: The authors identified best practices for developing a statewide eHL for health professionals relating to audience or population served, information resources, technology and access, funding model, and implementation and sustainability. They were compared to the mission of the eHL project to drive strategic directions by developing recommendations. Conclusion: EBL can guide the planning process for a statewide eHL, but findings must be tailored to the local environment to address information needs and ensure long-term sustainability. PMID:19851487

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.

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.

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

Human bromethalin exposures reported to a U.S. Statewide Poison Control System.

Science.gov (United States)

Huntington, Serena; Fenik, Yelena; Vohra, Rais; Geller, Richard J

2016-03-01

Bromethalin is an increasingly used alternative to long-acting anticoagulant and cholecalciferol rodenticides. There are few reports of human exposures, and no existing professional society guidelines on medical management of bromethalin ingestions. The aim of this retrospective data review is to characterize bromethalin exposures reported to the California Poison Control System (CPCS) between 1997 and 2014. This is an observational retrospective case review of our statewide poison control system's electronic medical records. Following Institutional Board Review and Research Committee approvals, poison center exposures related to bromethalin were extracted using substance code and free text search strategies. Case notes of bromethalin exposures were reviewed for demographic, clinical, laboratory, and outcome information; inclusion criteria for the study was single-substance, human exposure to bromethalin. There were 129 calls related to human bromethalin exposures (three cases met exclusion criteria). The age range of cases was 7 months-90 years old, with the majority of exposures (89 cases; 70.6%), occurring in children younger than 5 years of age (median age of 2 years). Most exposures occurred in the pediatric population as a result of exploratory oral exposure. One hundred and thirteen patients (89.7%) had no effects post exposure, while 10 patients (7.9%) had a minor outcome. Adverse effects were minor, self-limited, and mostly gastrointestinal upset. There were no moderate, major, or fatal effects in our study population. The approximate ingested dose, available in six cases, ranged from 0.067 mg/kg to 0.3 mg/kg (milligrams of bromethalin ingested per kilogram of body weight), and no dose-symptom threshold could be established from this series. Exposures were not confirmed through urine or serum laboratory testing. The prognosis for most accidental ingestions appears to be excellent. However, bromethalin exposures may result in a higher number of

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.

Characteristics and Effects of a Statewide STEM Program

Directory of Open Access Journals (Sweden)

Jeffrey D. Weld

2015-10-01

Full Text Available A comprehensive statewide STEM (science, technology, engineering, mathematics reform initiative enters its fifth year in the U.S. state of Iowa. A significant proportion of the state’s pre K-12 students and teachers participate in one or more of the twenty programs offered, ranging from classroom curricular innovations to teacher professional development, and from community STEM festivals to career exploration events. An external, inter-university evaluation consortium measures annual progress of the initiative through the Iowa STEM Monitoring Project. Results show citizens to be increasingly aware of and supporting of STEM education; students to be increasingly interested in STEM as well as outperforming nonparticipating peers on state math and science tests; and teachers more confident and knowledgeable in teaching STEM. Iowa’s STEM initiative has garnered national acclaim though challenges remain with regard to expanding the participation of learners of diversity, as well as ensuring the long-term sustainability of the programs and structures that define Iowa’s statewide STEM initiative.

Nebraska Statewide Wind Integration Study: April 2008 - January 2010

Energy Technology Data Exchange (ETDEWEB)

EnerNex Corporation, Knoxville, Tennessee; Ventyx, Atlanta, Georgia; Nebraska Power Association, Lincoln, Nebraska

2010-03-01

Wind generation resources in Nebraska will play an increasingly important role in the environmental and energy security solutions for the state and the nation. In this context, the Nebraska Power Association conducted a state-wide wind integration study.

Statewide screening for low-level radioactive waste shallow land burial sites

International Nuclear Information System (INIS)

Staub, W.P.; Cannon, J.B.; Stratton, L.E.

1984-01-01

A methodology was developed for statewide low-level waste site screening based on NRC site selection criteria. The methodology and criteria were tested in Tennessee to determine their effectiveness in narrowing the choice of sites for more intensive localized site screening. The statewide screening methodology entailed two steps. The first step was to select one or more physiographic provinces wherein sites meeting the criteria were most likely to be found. The second step was to select one or more suitable outcrop bands from within the most favorable physiographic provinces. These selections were based entirely on examination of existing literature and maps at scales no larger than 1:250,000. The statewide screening project identified only one suitable physiographic province (the Mississippi Embayment region) and one favorable outcrop band (the Coon Creek Formation) within a three county area of western Tennessee. Ground water monitoring and predictability proved to be the most difficult criterion to meet. This criterion alone eliminated other outcrop bands in the Mississippi Embayment as well as the Eastern Highland Rim and Western Highland Rim physiographic provinces. Other provinces failed to meet several screening criteria. 3 references, 3 figures, 1 table

Economic Disparities and Syphilis Incidence in Massachusetts, 2001-2013.

Science.gov (United States)

Smock, Laura; Caten, Evan; Hsu, Katherine; DeMaria, Alfred

We used area-level indicators of poverty to describe economic disparities in the incidence rate of infectious syphilis in Massachusetts to (1) determine whether methods developed in earlier AIDS analyses in Massachusetts could be applied to syphilis and (2) characterize syphilis trends during a time of increased rates of syphilis incidence. Using census tract data and population counts from the US Census Bureau and Massachusetts data on syphilis, we analyzed the incidence rate of syphilis infection from 2001 to 2013 by the poverty level of the census tract in which people with syphilis resided, stratified by age, sex, and race/ethnicity. The syphilis incidence rate increased in all census tract groups in Massachusetts from 2001 to 2013, and disparities in incidence rates by area poverty level persisted over time. The overall incidence rate of syphilis increased 6.9-fold from 2001 to 2013 in all census tract poverty-level groupings (from 1.5 to 10.3 per 100 000 population), but the rise in rate was especially high in the poorest census tracts (from 5.6 to 31.0 per 100 000 population) and among men (from 2.2 to 19.4 per 100 000 population). The highest syphilis incidence rate was among non-Hispanic black people. The largest changes in incidence rate occurred after 2010. One region had a disproportionate increase in incidence rates and a disproportionate impact on the statewide trend. Census tract poverty analyses can inform the targeting of interventions that make progress toward reducing disparities in rates of syphilis incidence possible.

Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators.

Science.gov (United States)

Ang, Darwin; McKenney, Mark; Norwood, Scott; Kurek, Stanley; Kimbrell, Brian; Liu, Huazhi; Ziglar, Michele; Hurst, James

2015-09-01

Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the state's registry are not publicly available. Promotion of optimal care throughout the state is not possible unless clinical benchmarks are available for comparison. Using publicly available administrative data from the State Department of Health and the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), we sought to create a statewide method for benchmarking trauma mortality and at the same time also identifying a pattern of unique complications that have an independent influence on mortality. Data for this study were obtained from State of Florida Agency for Health Care Administration. Adult trauma patients were identified as having International Classification of Disease ninth edition codes defined by the state. Multivariate logistic regression was used to create a predictive inpatient expected mortality model. The expected value of PSIs was created using the multivariate model and their beta coefficients provided by the AHRQ. Case-mix adjusted mortality results were reported as observed to expected (O/E) ratios to examine mortality, PSIs, failure to prevent complications, and failure to rescue from death. There were 50,596 trauma patients evaluated during the study period. The overall fit of the expected mortality model was very strong at a c-statistic of 0.93. Twelve of 25 trauma centers had O/E ratios benchmarking method that screens at risk trauma centers in the state for higher than expected mortality. Stratifying mortality based on failure to prevent PSIs may identify areas of needed improvement at a statewide level. Copyright © 2015 Elsevier Inc. All rights reserved.

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.

California Statewide Plug-In Electric Vehicle Infrastructure Assessment

Energy Technology Data Exchange (ETDEWEB)

Melaina, Marc; Helwig, Michael

2014-05-01

The California Statewide Plug-In Electric Vehicle Infrastructure Assessment conveys to interested parties the Energy Commission’s conclusions, recommendations, and intentions with respect to plug-in electric vehicle (PEV) infrastructure development. There are several relatively low-risk and high-priority electric vehicle supply equipment (EVSE) deployment options that will encourage PEV sales and

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\

Louisiana's statewide beach cleanup

Science.gov (United States)

Lindstedt, Dianne M.; Holmes, Joseph C.

1989-01-01

Litter along Lousiana's beaches has become a well-recognized problem. In September 1987, Louisiana's first statewide beach cleanup attracted about 3300 volunteers who filled 16,000 bags with trash collected along 15 beaches. An estimated 800,173 items were gathered. Forty percent of the items were made of plastic and 11% were of polystyrene. Of all the litter collected, 37% was beverage-related. Litter from the oil and gas, commercial fishing, and maritime shipping industries was found, as well as that left by recreational users. Although beach cleanups temporarily rid Louisiana beaches of litter, the real value of the effort is in public participation and education. Civic groups, school children, and individuals have benefited by increasing their awareness of the problems of trash disposal.

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

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

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

Statewide Transportation Improvement Program 2010-2013 : sorted by MPO and RPA.

Science.gov (United States)

2006-01-01

Iowas Statewide Transportation Improvement Program (STIP) has been : developed in conformance with the guidelines prescribed by 23 USC. The : STIP is generated to provide the Federal Highway Administration (FHWA) and : Federal Transit Administrati...

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.

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

Statewide Transportation Improvement program 2011-2014 : sorted by MPO and RPA.

Science.gov (United States)

2010-01-01

Iowas Statewide Transportation Improvement Program (STIP) has been : developed in conformance with the guidelines prescribed by 23 USC and 49 : USC. The STIP is generated to provide the Federal Highway Administration : (FHWA) and Federal Transit A...

Statewide Transportation Improvement Program 2012-2015 : sorted by MPO and RPA.

Science.gov (United States)

2011-01-01

Iowas Statewide Transportation Improvement Program (STIP) has been : developed in conformance with the guidelines prescribed by 23 USC and 49 : USC. The STIP is generated to provide the Federal Highway Administration : (FHWA) and Federal Transit A...

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.

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

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…

Creating a Statewide Educational Data System for Accountability and Improvement: A Comprehensive Information and Assessment System for Making Evidence-Based Change at School, District, and Policy Levels

Science.gov (United States)

Felner, Robert D.; Bolton, Natalie; Seitsinger, Anne M.; Brand, Stephen; Burns, Amy

2008-01-01

This article reports on one ongoing statewide effort to create a high-quality data reporting and utilization system (i.e., High-Performance Learning Community [HiPlaces] Assessment) to inform educational accountability and improvement efforts system. This effort has undergoing refinement for more than a decade. The article describes the features…

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...

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.

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

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/

Establishment of a Web-based System for Collection of Patient-reported Outcomes After Radical Prostatectomy in a Statewide Quality Improvement Collaborative.

Science.gov (United States)

Lucas, Steven M; Kim, Tae-Kyung; Ghani, Khurshid R; Miller, David C; Linsell, Susan; Starr, Jay; Peabody, James O; Hurley, Patrick; Montie, James; Cher, Michael L

2017-09-01

To report on the establishment of a unified, electronic patient-reported outcome (PRO) infrastructure and pilot results from the first 5 practices enrolled in the web-based collection system developed by the Michigan Urological Surgery Improvement Collaborative. Eligible patients were those undergoing radical prostatectomy of 5 academic and community practices. PRO was obtained using a validated 21-item web-based questionnaire, regarding urinary function, erection function, and sexual interest and satisfaction. Data were collected preoperatively, at 3 months, and 6 months postoperatively. Patients were provided a link via email to complete the surveys. Perioperative and PRO data were analyzed as reports for individual patients and summary performance reports for individual surgeons. Among 773 eligible patients, 688 (89%) were enrolled preoperatively. Survey completion rate was 88%, 84%, and 90% preoperatively, at 3 months, and 6 months. Electronic completion rates preoperatively, at 3 months, and 6 months were 70%, 70%, and 68%, respectively. Mean urinary function scores were 18.3, 14.3, and 16.6 (good function ≥ 17), whereas mean erection scores were 18.7, 7.3, and 9.1 (good erection score ≥ 22) before surgery, at 3 months, and 6 months. Variation was noted for erectile function among the practices. Collection of electronic PRO via this unified, web-based format was successful and provided results that reflect expected recovery and identify opportunities for improvement. This will be extended to more practices statewide to improve outcomes after radical prostatectomy. Copyright © 2017 Elsevier Inc. All rights reserved.

Results of the 1992 State-Wide Business and Industry Survey.

Science.gov (United States)

Jarrett, Carole, Comp.; And Others

As part of an effort to develop courses and programs that reflect California business and industry's current and future needs, two studies were performed by Solano Community College to examine statewide trends and issues related to office automation and marketing and management. In conducting the study of office automation, 5,000 surveys were…

From Theory to Practice: Considerations for Implementing a Statewide Voucher System.

Science.gov (United States)

Doyle, Denis P.

This monograph analyzes trends in American educational philosophy and history in its proposal to implement an all-public statewide school voucher system. Following an introduction, section 1, "Alternative Voucher Systems," discusses three concepts: universal unregulated vouchers, favored by Milton Friedman; regulated compensatory vouchers,…

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...

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.

Technical architecture of ONC-approved plans for statewide health information exchange.

Science.gov (United States)

Barrows, Randolph C; Ezzard, John

2011-01-01

ONC-approved state plans for HIE were reviewed for descriptions and depictions of statewide HIE technical architecture. Review was complicated by non-standard organizational elements and technical terminology across state plans. Findings were mapped to industry standard, referenced, and defined HIE architecture descriptions and characteristics. Results are preliminary due to the initial subset of ONC-approved plans available, the rapid pace of new ONC-plan approvals, and continuing advancements in standards and technology of HIE, etc. Review of 28 state plans shows virtually all include a direct messaging component, but for participating entities at state-specific levels of granularity (RHIO, enterprise, organization/provider). About ½ of reviewed plans describe a federated architecture, and ¼ of plans utilize a single-vendor "hybrid-federated" architecture. About 1/3 of states plan to leverage new federal and open exchange technologies (DIRECT, CONNECT, etc.). Only one plan describes a centralized architecture for statewide HIE, but others combine central and federated architectural approaches.

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)

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.

Costs and effects of a state-wide health promotion program in primary schools in Germany - the Baden-Württemberg Study: A cluster-randomized, controlled trial.

Directory of Open Access Journals (Sweden)

Dorothea Kesztyüs

Full Text Available To evaluate the cost-effectiveness of the state-wide implementation of the health promotion program "Join the Healthy Boat" in primary schools in Germany.Cluster-randomized intervention trial with wait-list control group. Anthropometric data of 1733 participating children (7.1 ± 0.6 years were taken by trained staff before and after a one year intervention period in the academic year 2010/11. Parents provided information about the health status, and the health behaviour of their children and themselves, parental anthropometrics, and socio-economic background variables. Incidence of abdominal obesity, defined as waist-to-height ratio (WHtR ≥ 0.5, was determined. Generalized linear models were applied to account for the clustering of data within schools, and to adjust for baseline-values. Losses to follow-up and missing data were analysed. From a societal perspective, the overall costs, costs per pupil, and incremental cost-effectiveness ratio (ICER to identify the costs per case of averted abdominal obesity were calculated.The final regression model for the incidence of abdominal obesity shows lower odds for the intervention group after an adjustment for grade, gender, baseline WHtR, and breakfast habits (odds ratio = 0.48, 95% CI [0.25; 0.94]. The intervention costs per child/year were €25.04. The costs per incidental case of averted abdominal obesity varied between €1515 and €1993, depending on the different dimensions of the target group.This study demonstrates the positive effects of state-wide, school-based health promotion on incidental abdominal obesity, at affordable costs and with proven cost-effectiveness. These results should support allocative decisions of policymakers. An early start to the prevention of abdominal obesity is of particular importance because of its close relationship to non-communicable diseases.German Clinical Trials Register (DRKS, Freiburg University, Germany, DRKS-ID: DRKS00000494.

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

23 CFR 450.216 - Development and content of the statewide transportation improvement program (STIP).

Science.gov (United States)

2010-04-01

... Programming § 450.216 Development and content of the statewide transportation improvement program (STIP). (a... Equity Bonus funds; (5) Emergency relief projects (except those involving substantial functional...

Making an Impact Statewide to Benefit 21st-Century School Leadership

Science.gov (United States)

Hewitt, Kimberly Kappler; Mullen, Carol A.; Davis, Ann W.; Lashley, Carl

2012-01-01

How can institutions of higher education, local education agencies, and departments of education partner to build capacity for 21st-Century school leadership? The model (IMPACT V) we describe utilizes a systems-wide partnership approach to cultivate shared leadership within influenced middle and high schools statewide to leverage technology as a…

Childhood tuberculosis in the State of Qatar: the effect of a limited expatriate screening programme on the incidence of tuberculosis.

Science.gov (United States)

Al-Marri, M R

2001-09-01

To determine incidence rates and the effectiveness of the expatriate screening programme on paediatric tuberculosis (TB) in the State of Qatar. A state-wide, population-based, retrospective analysis of all cases of tuberculosis among children 0-14 years of age reported to the TB Unit of the Division of Public Health during 1983-1996. One hundred and forty-four children with tuberculous disease were identified, with a steadily declining incidence rate (rate of notification) from 11/100000 children (0-14 years) population in 1983 to 7/100000 in 1996. This decrease in the childhood TB case notification rate correlated with foreign-born children, older children and the implementation of expatriate screening in 1986. Diagnosis in 56% of children was made abroad or within 3 months of arrival from vacation and 30% within one year of arrival. Comparison of the three age groups (nationality, sex, type of TB, radiological findings and screening. However older children were more likely to be symptomatic (P Qatar has a high rate of paediatric tuberculosis. The policy of BCG vaccination at birth should be continued, and screening children at school entry and on return from vacation would be useful for further case identification.

Staff turnover in statewide implementation of ACT: relationship with ACT fidelity and other team characteristics.

Science.gov (United States)

Rollins, Angela L; Salyers, Michelle P; Tsai, Jack; Lydick, Jennifer M

2010-09-01

Staff turnover on assertive community treatment (ACT) teams is a poorly understood phenomenon. This study examined annual turnover and fidelity data collected in a statewide implementation of ACT over a 5-year period. Mean annual staff turnover across all observations was 30.0%. Turnover was negatively correlated with overall fidelity at Year 1 and 3. The team approach fidelity item was negatively correlated with staff turnover at Year 3. For 13 teams with 3 years of follow-up data, turnover rates did not change over time. Most ACT staff turnover rates were comparable or better than other turnover rates reported in the mental health and substance abuse literature.

Costs and effects of a state-wide health promotion program in primary schools in Germany – the Baden-Württemberg Study: A cluster-randomized, controlled trial

Science.gov (United States)

Kesztyüs, Tibor; Kilian, Reinhold; Steinacker, Jürgen M

2017-01-01

Aim To evaluate the cost-effectiveness of the state-wide implementation of the health promotion program “Join the Healthy Boat” in primary schools in Germany. Methods Cluster-randomized intervention trial with wait-list control group. Anthropometric data of 1733 participating children (7.1 ± 0.6 years) were taken by trained staff before and after a one year intervention period in the academic year 2010/11. Parents provided information about the health status, and the health behaviour of their children and themselves, parental anthropometrics, and socio-economic background variables. Incidence of abdominal obesity, defined as waist-to-height ratio (WHtR) ≥ 0.5, was determined. Generalized linear models were applied to account for the clustering of data within schools, and to adjust for baseline-values. Losses to follow-up and missing data were analysed. From a societal perspective, the overall costs, costs per pupil, and incremental cost-effectiveness ratio (ICER) to identify the costs per case of averted abdominal obesity were calculated. Results The final regression model for the incidence of abdominal obesity shows lower odds for the intervention group after an adjustment for grade, gender, baseline WHtR, and breakfast habits (odds ratio = 0.48, 95% CI [0.25; 0.94]). The intervention costs per child/year were €25.04. The costs per incidental case of averted abdominal obesity varied between €1515 and €1993, depending on the different dimensions of the target group. Conclusion This study demonstrates the positive effects of state-wide, school-based health promotion on incidental abdominal obesity, at affordable costs and with proven cost-effectiveness. These results should support allocative decisions of policymakers. An early start to the prevention of abdominal obesity is of particular importance because of its close relationship to non-communicable diseases. Trial registration German Clinical Trials Register (DRKS), Freiburg University, Germany

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.

Criminal Justice Profile--Statewide, 1984. Supplement to "Crime and Delinquency in California."

Science.gov (United States)

California State Dept. of Justice, Sacramento. Bureau of Criminal Statistics and Special Services.

This California annual Criminal Justice Statewide Profile presents data which supplements the Bureau of Criminal Statistics' (BCS) annual Crime and Delinquency publication. This monograph summarizes and combines data pertaining to California's justice system. The profile consists of two sections. The first section consists of 12 tables displaying…

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.

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.

Development of a State-Wide 3-D Seismic Tomography Velocity Model for California

Science.gov (United States)

Thurber, C. H.; Lin, G.; Zhang, H.; Hauksson, E.; Shearer, P.; Waldhauser, F.; Hardebeck, J.; Brocher, T.

2007-12-01

We report on progress towards the development of a state-wide tomographic model of the P-wave velocity for the crust and uppermost mantle of California. The dataset combines first arrival times from earthquakes and quarry blasts recorded on regional network stations and travel times of first arrivals from explosions and airguns recorded on profile receivers and network stations. The principal active-source datasets are Geysers-San Pablo Bay, Imperial Valley, Livermore, W. Mojave, Gilroy-Coyote Lake, Shasta region, Great Valley, Morro Bay, Mono Craters-Long Valley, PACE, S. Sierras, LARSE 1 and 2, Loma Prieta, BASIX, San Francisco Peninsula and Parkfield. Our beta-version model is coarse (uniform 30 km horizontal and variable vertical gridding) but is able to image the principal features in previous separate regional models for northern and southern California, such as the high-velocity subducting Gorda Plate, upper to middle crustal velocity highs beneath the Sierra Nevada and much of the Coast Ranges, the deep low-velocity basins of the Great Valley, Ventura, and Los Angeles, and a high- velocity body in the lower crust underlying the Great Valley. The new state-wide model has improved areal coverage compared to the previous models, and extends to greater depth due to the data at large epicentral distances. We plan a series of steps to improve the model. We are enlarging and calibrating the active-source dataset as we obtain additional picks from investigators and perform quality control analyses on the existing and new picks. We will also be adding data from more quarry blasts, mainly in northern California, following an identification and calibration procedure similar to Lin et al. (2006). Composite event construction (Lin et al., in press) will be carried out for northern California for use in conventional tomography. A major contribution of the state-wide model is the identification of earthquakes yielding arrival times at both the Northern California Seismic

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

International Nuclear Information System (INIS)

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

1997-01-01

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

Building Statewide Infrastructure for the Academic Support of Students With Mild Traumatic Brain Injury.

Science.gov (United States)

Gioia, Gerard A; Glang, Ann E; Hooper, Stephen R; Brown, Brenda Eagan

To focus attention on building statewide capacity to support students with mild traumatic brain injury (mTBI)/concussion. Consensus-building process with a multidisciplinary group of clinicians, researchers, policy makers, and state Department of Education personnel. The white paper presents the group's consensus on the essential components of a statewide educational infrastructure to support the management of students with mTBI. The nature and recovery process of mTBI are briefly described specifically with respect to its effects on school learning and performance. State and local policy considerations are then emphasized to promote implementation of a consistent process. Five key components to building a statewide infrastructure for students with mTBI are described including (1) definition and training of the interdisciplinary school team, (2) professional development of the school and medical communities, (3) identification, assessment, and progress monitoring protocols, (4) a flexible set of intervention strategies to accommodate students' recovery needs, and (5) systematized protocols for active communication among medical, school, and family team members. The need for a research to guide effective program implementation is stressed. This guiding framework strives to assist the development of support structures for recovering students with mTBI to optimize academic outcomes. Until more evidence is available on academic accommodations and other school-based supports, educational systems should follow current best practice guidelines.

A Statewide Survey for Container-Breeding Mosquitoes in Mississippi.

Science.gov (United States)

Goddard, Jerome; Moraru, Gail M; Mcinnis, Sarah J; Portugal, J Santos; Yee, Donald A; Deerman, J Hunter; Varnado, Wendy C

2017-09-01

Container-breeding mosquitoes are important in public health due to outbreaks of Zika, chikungunya, and dengue viruses. This paper documents the distribution of container-breeding mosquito species in Mississippi, with special emphasis on the genus Aedes. Five sites in each of the 82 Mississippi counties were sampled monthly between May 1 and August 31, 2016, and 50,109 mosquitoes in 14 species were collected. The most prevalent and widely distributed species found was Ae. albopictus, being found in all 82 counties, especially during July. A recent invasive, Ae. japonicus, seems to be spreading rapidly in Mississippi since first being discovered in the state in 2011. The most abundant Culex species collected were Cx. quinquefasciatus (found statewide), Cx. salinarius (almost exclusively in the southern portion of the state), and Cx. restuans (mostly central and southern Mississippi). Another relatively recent invasive species, Cx. coronator, was found in 20 counties, predominantly in the southern one-third of the state during late summer. Co-occurrence data of mosquito species found in the artificial containers were also documented and analyzed. Lastly, even though we sampled extensively in 410 sites across Mississippi, no larval Ae. aegypti were found. These data represent the first modern statewide survey of container species in Mississippi, and as such, allows for better public health readiness for emerging diseases and design of more effective vector control programs.

2011-2013 Indiana Statewide Imagery and LiDAR Program: Lake Michigan Watershed Counties

Data.gov (United States)

National Oceanic and Atmospheric Administration, Department of Commerce — Indiana's Statewide LiDAR data is produced at 1.5-meter average post spacing for all 92 Indiana Counties covering more than 36,420 square miles. New LiDAR data was...

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

FINAL TECHNICAL REPORT FOR FORESTRY BIOFUEL STATEWIDE COLLABORATION CENTER (MICHIGAN)

Energy Technology Data Exchange (ETDEWEB)

LaCourt, Donna M.; Miller, Raymond O.; Shonnard, David R.

2012-04-24

A team composed of scientists from Michigan State University (MSU) and Michigan Technological University (MTU) assembled to better understand, document, and improve systems for using forest-based biomass feedstocks in the production of energy products within Michigan. Work was funded by a grant (DE-EE-0000280) from the U.S. Department of Energy (DOE) and was administered by the Michigan Economic Development Corporation (MEDC). The goal of the project was to improve the forest feedstock supply infrastructure to sustainably provide woody biomass for biofuel production in Michigan over the long-term. Work was divided into four broad areas with associated objectives: • TASK A: Develop a Forest-Based Biomass Assessment for Michigan – Define forest-based feedstock inventory, availability, and the potential of forest-based feedstock to support state and federal renewable energy goals while maintaining current uses. • TASK B: Improve Harvesting, Processing and Transportation Systems – Identify and develop cost, energy, and carbon efficient harvesting, processing and transportation systems. • TASK C: Improve Forest Feedstock Productivity and Sustainability – Identify and develop sustainable feedstock production systems through the establishment and monitoring of a statewide network of field trials in forests and energy plantations. • TASK D: Engage Stakeholders – Increase understanding of forest biomass production systems for biofuels by a broad range of stakeholders. The goal and objectives of this research and development project were fulfilled with key model deliverables including: 1) The Forest Biomass Inventory System (Sub-task A1) of feedstock inventory and availability and, 2) The Supply Chain Model (Sub-task B2). Both models are vital to Michigan’s forest biomass industry and support forecasting delivered cost, as well as carbon and energy balance. All of these elements are important to facilitate investor, operational and policy decisions. All

[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.

Statewide improvement approach to clinician burnout: Findings from the baseline year

Directory of Open Access Journals (Sweden)

Heather R. Britt

2017-12-01

We propose a socio-ecological framework for acting on burnout, using a data-driven quality improvement paradigm enabled by a statewide coalition, to ensure that continued efforts do not rest solely at the feet of individuals or systems. Despite high burnout levels, engagement and satisfaction with work are also high, suggesting there is still hope for stemming the tide of burnout.

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

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.

The smoking ban next door: do hospitality businesses in border areas have reduced sales after a statewide smoke-free policy?

Science.gov (United States)

Klein, Elizabeth G; Hood, Nancy E

2015-01-01

Despite numerous studies demonstrating no significant economic effects on hospitality businesses following a statewide smoke-free (SF) policy, regional concerns suggest that areas near states without SF policies may experience a loss of hospitality sales across the border. The present study evaluated the impact of Ohio's statewide SF policy on taxable restaurant and bar sales in border and non-border areas. Spline regression analysis was used to assess changes in monthly taxable sales at the county level in full-service restaurants and bars in Ohio. Data were analyzed from four years prior to policy implementation to three years post-policy. Change in the differences in the slope of taxable sales for border (n = 21) and non-border (n = 67) counties were evaluated for changes following the statewide SF policy enforcement, adjusted for unemployment rates, general trends in the hospitality sector, and seasonality. After adjusting for covariates, there was no statistically significant change in the difference in slope for taxable sales for either restaurants (β = 0.9, p = 0.09) or bars (β = 0.2, p = 0.07) following the SF policy for border areas compared to non-border areas of Ohio. Border regions in Ohio did not experience a significant change in bar and restaurant sales compared to non-border areas following a statewide SF policy. Results support that Ohio's statewide SF policy did not impact these two areas differently, and provide additional evidence for the continued use of SF policies to provide protection from exposure to secondhand smoke for both workers and the general public. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

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.

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 �

Pharmacy-based statewide naloxone distribution: A novel "top-down, bottom-up" approach.

Science.gov (United States)

Morton, Kate J; Harrand, Brianna; Floyd, Carly Cloud; Schaefer, Craig; Acosta, Julie; Logan, Bridget Claire; Clark, Karen

To highlight New Mexico's multifaceted approach to widespread pharmacy naloxone distribution and to share the interventions as a tool for improving pharmacy-based naloxone practices in other states. New Mexico had the second highest drug overdose death rate in 2014 of which 53% were related to prescription opioids. Opioid overdose death is preventable through the use of naloxone, a safe and effective medication that reverses the effects of prescription opioids and heroin. Pharmacists can play an important role in providing naloxone to individuals who use prescription opioids. Not applicable. Not applicable. A multifaceted approach was utilized in New Mexico from the top down with legislative passage of provisions for a statewide standing order and New Mexico Department of Health support for pharmacy-based naloxone delivery. A bottom up approach was also initiated with the development and implementation of a training program for pharmacists and pharmacy technicians. Naloxone Medicaid claims were used to illustrate statewide distribution and utilization of the pharmacist statewide standing order for naloxone. Percent of pharmacies dispensing naloxone in each county were calculated. Trained pharmacy staff completed a program evaluation form. Questions about quality of instruction and ability of trainer to meet stated objectives were rated on a Likert scale. There were 808 naloxone Medicaid claims from 100 outpatient pharmacies during the first half of 2016, a 9-fold increase over 2014. The "A Dose of R x eality" training program evaluation indicated that participants felt the training was free from bias and met all stated objectives (4 out of 4 on Likert scale). A multi-pronged approach coupling state and community collaboration was successful in overcoming barriers and challenges associated with pharmacy naloxone distribution and ensured its success as an effective avenue for naloxone acquisition in urban and rural communities. Copyright © 2017 American Pharmacists

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.

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

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...

Hawai'i Youth at Risk? Conceptual Challenges in Communicating a Statewide Mentoring Initiative.

Science.gov (United States)

Pollard, Vincent Kelly

This paper discusses several issues considered as part of a statewide mentoring initiative. It is divided into three sections. The first section summarizes the key issues associated with short-term mentoring and mentoring in a longer-term, socially transformative context. Data from Comprehensive School Alienation Program is discussed concerning…

Association of arsenic exposure with lung cancer incidence rates in the United States.

Directory of Open Access Journals (Sweden)

Joseph J Putila

Full Text Available Although strong exposure to arsenic has been shown to be carcinogenic, its contribution to lung cancer incidence in the United States is not well characterized. We sought to determine if the low-level exposures to arsenic seen in the U.S. are associated with lung cancer incidence after controlling for possible confounders, and to assess the interaction with smoking behavior.Measurements of arsenic stream sediment and soil concentration obtained from the USGS National Geochemical Survey were combined, respectively, with 2008 BRFSS estimates on smoking prevalence and 2000 U.S. Census county level income to determine the effects of these factors on lung cancer incidence, as estimated from respective state-wide cancer registries and the SEER database. Poisson regression was used to determine the association between each variable and age-adjusted county-level lung cancer incidence. ANOVA was used to assess interaction effects between covariates.Sediment levels of arsenic were significantly associated with an increase in incident cases of lung cancer (P<0.0001. These effects persisted after controlling for smoking and income (P<0.0001. Across the U.S., exposure to arsenic may contribute to up to 5,297 lung cancer cases per year. There was also a significant interaction between arsenic exposure levels and smoking prevalence (P<0.05.Arsenic was significantly associated with lung cancer incidence rates in the U.S. after controlling for smoking and income, indicating that low-level exposure to arsenic is responsible for excess cancer cases in many parts of the U.S. Elevated county smoking prevalence strengthened the association between arsenic exposure and lung cancer incidence rate, an effect previously unseen on a population level.

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

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...

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

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.

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.

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...

HPV vaccine hesitancy: findings from a statewide survey of health care providers.

Science.gov (United States)

McRee, Annie-Laurie; Gilkey, Melissa B; Dempsey, Amanda F

2014-01-01

Health care provider recommendations are critical for human papillomavirus (HPV) vaccine uptake. We sought to describe providers' HPV vaccine recommendation practices and explore their perceptions of parental hesitancy. A statewide sample (n = 575) of Minnesota health care providers (20% pediatricians, 47% family medicine physicians, and 33% nurse practitioners) completed our online survey in April 2013. Only 76% of health care providers reported routinely recommending HPV vaccine for girls ages 11 to 12 years, and far fewer (46%) did so for boys (p parents' concerns (74%), but many lacked time to probe reasons (47%) or believed that they could not change parents' minds (55%). Higher levels of self-efficacy and outcome expectations were associated with routine recommendations (p HPV vaccine. Improving providers' self-efficacy to address hesitancy may be important for improving vaccination rates. Copyright © 2014 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

Statewide Dissemination of a Rural, Non-Chain Restaurant Intervention: Adoption, Implementation and Maintenance

Science.gov (United States)

Nothwehr, F.; Haines, H.; Chrisman, M.; Schultz, U.

2014-01-01

The obesity epidemic calls for greater dissemination of nutrition-related programs, yet there remain few studies of the dissemination process. This study, guided by elements of the RE-AIM model, describes the statewide dissemination of a simple, point-of-purchase restaurant intervention. Conducted in rural counties of the Midwest, United States,…

Less Is More: Results of a Statewide Analysis of the Impact of Blood Transfusion on Coronary Artery Bypass Grafting Outcomes.

Science.gov (United States)

Crawford, Todd C; Magruder, J Trent; Fraser, Charles; Suarez-Pierre, Alejandro; Alejo, Diane; Bobbitt, Jennifer; Fonner, Clifford E; Canner, Joseph K; Horvath, Keith; Wehberg, Kurt; Taylor, Bradley; Kwon, Christopher; Whitman, Glenn J; Conte, John V; Salenger, Rawn

2018-01-01

Debate persists over the association between blood transfusions, especially those considered discretionary, and outcomes after cardiac operations. Using data from the Maryland Cardiac Surgery Quality Initiative, we sought to determine whether outcomes differed among coronary artery bypass grafting (CABG) patients receiving 1 U of red blood cells (RBCs) vs none. We used a statewide database to review patients who underwent isolated CABG from July 1, 2011, to June 30, 2016, across 10 Maryland cardiac surgery centers. We included patients who received 1 U or fewer of RBCs from the time of the operation through discharge. Propensity scoring, using 20 variables to control for treatment effect, was performed among patients who did and did not receive a transfusion. These two groups were matched 1:1 to assess for differences in our primary outcomes: operative death, prolonged postoperative length of stay (>14 days), and a composite postoperative respiratory complication of pneumonia or reintubation, or both. Of 10,877 patients who underwent CABG, 6,124 (56%) received no RBCs (group 1) during their operative hospitalization, and 981 (9.0%) received 1 U of RBCs (group 2), including 345 of 981 patients (35%) who received a transfusion intraoperatively. Propensity score matching generated 937 well-matched pairs. Compared with group 2, propensity-matched analysis revealed significantly greater 30-day survival in group 1 (99% vs 98%, p = 0.02) and reduced incidence of prolonged length of stay (3.7% vs 4.0%, p < 0.01). Our collaborative statewide analysis demonstrated that even 1 unit of blood was associated with significantly worse survival and longer length of stay after CABG. Multiinstitutional quality initiatives may seek to address discretionary transfusions and possess the potential to improve patient outcomes. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Preliminary concept for statewide intercity bus and rail transit system : priority corridor ranking and analysis.

Science.gov (United States)

2009-03-01

This product summarizes the preliminary concept and priority corridors for development of a potential : statewide intercity bus and rail network. The concept is based upon the results of Tasks 1 through 5 of Texas : Department of Transportation Proje...

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.

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

Taking Stock of Private-School Choice: Scholars Review the Research on Statewide Programs

Science.gov (United States)

Wolf, Patrick J.; Harris, Douglas N.; Berends, Mark; Waddington, R. Joseph; Austin, Megan

2018-01-01

In the past few years, four states have established programs that provide public financial support to students who choose to attend a private school. These programs--a tax-credit-funded scholarship initiative in Florida and voucher programs in Indiana, Louisiana, and Ohio--offer a glimpse of what expansive statewide choice might look like. What…

A task force model for statewide change in nursing education: building quality and safety.

Science.gov (United States)

Mundt, Mary H; Clark, Margherita Procaccini; Klemczak, Jeanette Wrona

2013-01-01

The purpose of this article was to describe a statewide planning process to transform nursing education in Michigan to improve quality and safety of patient care. A task force model was used to engage diverse partners in issue identification, consensus building, and recommendations. An example of a statewide intervention in nursing education and practice that was executed was the Michigan Quality and Safety in Nursing Education Institute, which was held using an integrated approach to academic-practice partners from all state regions. This paper describes the unique advantage of leadership by the Michigan Chief Nurse Executive, the existence of a nursing strategic plan, and a funding model. An overview of the Task Force on Nursing Education is presented with a focus on the model's 10 process steps and resulting seven recommendations. The Michigan Nurse Education Council was established to implement the recommendations that included quality and safety. Copyright © 2013 Elsevier Inc. All rights reserved.

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...

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.

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.

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.

A California statewide three-dimensional seismic velocity model from both absolute and differential times

Science.gov (United States)

Lin, G.; Thurber, C.H.; Zhang, H.; Hauksson, E.; Shearer, P.M.; Waldhauser, F.; Brocher, T.M.; Hardebeck, J.

2010-01-01

We obtain a seismic velocity model of the California crust and uppermost mantle using a regional-scale double-difference tomography algorithm. We begin by using absolute arrival-time picks to solve for a coarse three-dimensional (3D) P velocity (VP) model with a uniform 30 km horizontal node spacing, which we then use as the starting model for a finer-scale inversion using double-difference tomography applied to absolute and differential pick times. For computational reasons, we split the state into 5 subregions with a grid spacing of 10 to 20 km and assemble our final statewide VP model by stitching together these local models. We also solve for a statewide S-wave model using S picks from both the Southern California Seismic Network and USArray, assuming a starting model based on the VP results and a VP=VS ratio of 1.732. Our new model has improved areal coverage compared with previous models, extending 570 km in the SW-NE directionand 1320 km in the NW-SE direction. It also extends to greater depth due to the inclusion of substantial data at large epicentral distances. Our VP model generally agrees with previous separate regional models for northern and southern California, but we also observe some new features, such as high-velocity anomalies at shallow depths in the Klamath Mountains and Mount Shasta area, somewhat slow velocities in the northern Coast Ranges, and slow anomalies beneath the Sierra Nevada at midcrustal and greater depths. This model can be applied to a variety of regional-scale studies in California, such as developing a unified statewide earthquake location catalog and performing regional waveform modeling.

EMS Response to Mass Casualty Incidents: The Critical Importance of Automatic Statewide Mutual Aid and MCI Training

Science.gov (United States)

2008-09-01

incidents, dam failure, earthquakes, fires and wild fires, thunderstorms, tsunamis, volcanoes , winter storms, heat, landslides , nuclear power plant...President Bush reorganized the federal government and created the U.S. Department of Homeland Security, which produced the National Strategy for...to produce the best outcome and ensure personnel safety. This discipline prevented units from treating the first victim they came upon and ensured

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

Statewide prevalence of school children at risk of anaphylaxis and rate of adrenaline autoinjector activation in Victorian government schools, Australia.

Science.gov (United States)

Loke, Paxton; Koplin, Jennifer; Beck, Cara; Field, Michael; Dharmage, Shyamali C; Tang, Mimi L K; Allen, Katrina J

2016-08-01

The prevalence of school students at risk of anaphylaxis in Victoria is unknown and has not been previously studied. Similarly, rates of adrenaline autoinjector usage in the school environment have yet to be determined given increasing prescription rates. We sought to determine time trends in prevalence of school children at risk of anaphylaxis across all year levels and the annual usage rate of adrenaline autoinjectors in the school setting relative to the number of students at risk of anaphylaxis. Statewide surveys from more than 1,500 government schools including more than 550,000 students were used and prevalence rates (%) with 95% CIs were calculated. The overall prevalence of students at risk of anaphylaxis has increased 41% from 0.98% (95% CI, 0.95-1.01) in 2009 to 1.38% (95% CI, 1.35-1.41) in 2014. There was a significant drop in reporting of anaphylaxis risk with transition from the final year of primary school to the first year of secondary school, suggesting a change in parental reporting of anaphylaxis risk among secondary school students. The number of adrenaline autoinjectors activated per 1000 students at risk of anaphylaxis ranged from 6 to 8 per year, with consistently higher activation use in secondary school students than in primary school students. Statewide prevalence of anaphylaxis risk has increased in children attending Victorian government schools. However, adrenaline autoinjector activation has remained fairly stable despite known increase in the rates of prescription. Copyright © 2016 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

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...

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

Science.gov (United States)

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

2015-01-01

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

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)

Preventing child maltreatment: Examination of an established statewide home-visiting program.

Science.gov (United States)

Chaiyachati, Barbara H; Gaither, Julie R; Hughes, Marcia; Foley-Schain, Karen; Leventhal, John M

2018-05-01

Although home visiting has been used in many populations in prevention efforts, the impact of scaled-up home-visiting programs on abuse and neglect remains unclear. The objective of this study was to assess the impact of voluntary participation in an established statewide home-visiting program for socially high-risk families on child maltreatment as identified by Child Protective Services (CPS). Propensity score matching was used to compare socially high-risk families with a child born between January 1, 2008 and December 31, 2011 who participated in Connecticut's home-visiting program for first-time mothers and a comparison cohort of families who were eligible for the home-visiting program but did not participate. The main outcomes were child maltreatment investigations, substantiations, and out-of-home placements by CPS between January 1, 2008 and December 31, 2013. In the unmatched sample, families who participated in home-visiting had significantly higher median risk scores (P home visiting. First substantiations also occurred later in the child's life among home-visited families. There was a trend toward decreased out-of-home placement (HR 0.73, 95% CI 0.53-1.02, P = .06). These results from a scaled-up statewide program highlight the potential of home visiting as an important approach to preventing child abuse and neglect. Copyright © 2018 Elsevier Ltd. All rights reserved.

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

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

Employment status matters: a statewide survey of quality-of-life, prevention behaviors, and absenteeism and presenteeism.

Science.gov (United States)

Merchant, James A; Kelly, Kevin M; Burmeister, Leon F; Lozier, Matt J; Amendola, Alison; Lind, David P; KcKeen, Arlinda; Slater, Tom; Hall, Jennifer L; Rohlman, Diane S; Buikema, Brenda S

2014-07-01

To estimate quality-of-life (QoL), primary care, health insurance, prevention behaviors, absenteeism, and presenteeism in a statewide sample of the unemployed, self-employed, and organizationally employed. A statewide survey of 1602 Iowans included items from the Centers for Disease Control and Prevention QoL and Behavioral Risk Factor Surveillance System Survey prevention behavior questionnaires used to assess employee well-being; their indicator results are related to World Health Organization's Health and Work Performance Questionnaire-derived absenteeism and presenteeism scores. The unemployed exhibited poorer QoL and prevention behaviors; the self-employed exhibited many better QoL scores due largely to better prevention behaviors than those employed by organizations. Higher QoL measures and more prevention behaviors are associated with lower absenteeism and lower presenteeism. Employment status is related to measures of well-being, which are also associated with absenteeism and presenteeism.

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.

A Multilevel, Statewide Investigation of School District Anti-Bullying Policy Quality and Student Bullying Involvement.

Science.gov (United States)

Gower, Amy L; Cousin, Molly; Borowsky, Iris W

2017-03-01

Although nearly all states in the United States require school districts to adopt anti-bullying policies, little research examines the effect of these policies on student bullying and health. Using a statewide sample, we investigated associations between the quality of school district anti-bullying policies and student bullying involvement and adjustment. School district anti-bullying policies (N = 208) were coded for their quality based on established criteria. District-level data were combined with student reports of bullying involvement, emotional distress, and school connectedness from a state surveillance survey of 6th, 9th, and 12th grade students (N = 93,437). Results indicated that policy quality was positively related to bullying victimization. Furthermore, students reporting frequent perpetration/victimization who also attended districts with high-quality policies reported more emotional distress and less school connectedness compared with students attending districts with low quality policies. Although statistically significant, the magnitude of these associations was small. Having a high-quality school district anti-bullying policy is not sufficient to reduce bullying and protect bullying-involved young people. Future studies examining policy implementation will inform best practices in bullying prevention. © 2017, American School Health Association.

A School-Based Dental Program Evaluation: Comparison to the Massachusetts Statewide Survey.

Science.gov (United States)

Culler, Corinna S; Kotelchuck, Milton; Declercq, Eugene; Kuhlthau, Karen; Jones, Kari; Yoder, Karen M

2017-10-01

School-based dental programs target high-risk communities and reduce barriers to obtaining dental services by delivering care to students in their schools. We describe the evaluation of a school-based dental program operating in Chelsea, a city north of Boston, with a low-income and largely minority population, by comparing participants' oral health to a Massachusetts oral health assessment. Standardized dental screenings were conducted for students in kindergarten, third, and sixth grades. Outcomes were compared in bivariate analysis, stratified by grade and income levels. A greater percentage of Chelsea students had untreated decay and severe treatment need than students statewide. Yet, fewer Chelsea third graders had severe treatment need, and more had dental sealants. There was no significant difference in the percentage of Chelsea students having severe treatment need or dental sealants by income level. Students participating in our program do not have lower decay levels than students statewide. However, they do have lower levels of severe treatment need, likely due to treatment referrals. Our results confirm that school-based prevention programs can lead to increased prevalence of dental sealants among high-risk populations. Results provide support for the establishment of full-service school-based programs in similar communities. © 2017, American School Health Association.

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

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina.

Science.gov (United States)

Zolotor, Adam J; Runyan, Desmond K; Shanahan, Meghan; Durrance, Christine Piette; Nocera, Maryalice; Sullivan, Kelly; Klevens, Joanne; Murphy, Robert; Barr, Marilyn; Barr, Ronald G

2015-12-01

Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life. To assess the effectiveness of a statewide universal AHT prevention program. In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011). The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign. Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011. In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

Improving Accuracy and Relevance of Race/Ethnicity Data: Results of a Statewide Collaboration in Hawaii.

Science.gov (United States)

Pellegrin, Karen L; Miyamura, Jill B; Ma, Carolyn; Taniguchi, Ronald

2016-01-01

Current race/ethnicity categories established by the U.S. Office of Management and Budget are neither reliable nor valid for understanding health disparities or for tracking improvements in this area. In Hawaii, statewide hospitals have collaborated to collect race/ethnicity data using a standardized method consistent with recommended practices that overcome the problems with the federal categories. The purpose of this observational study was to determine the impact of this collaboration on key measures of race/ethnicity documentation. After this collaborative effort, the number of standardized categories available across hospitals increased from 6 to 34, and the percent of inpatients with documented race/ethnicity increased from 88 to 96%. This improved standardized methodology is now the foundation for tracking population health indicators statewide and focusing quality improvement efforts. The approach used in Hawaii can serve as a model for other states and regions. Ultimately, the ability to standardize data collection methodology across states and regions will be needed to track improvements nationally.

Contracting for Statewide Student Achievement Tests: A Review. Department of Public Instruction 98-4.

Science.gov (United States)

Wisconsin State Legislative Audit Bureau, Madison.

The Wisconsin legislature has required the Department of Public Instruction to adopt or approve standardized tests for statewide use to measure student attainment of knowledge and concepts in grades 4, 8, and 10. Although school districts generally gave high ratings to the contents of TerraNova (McGraw Hill), the testing instrument most recently…

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.

A Multilevel, Statewide Investigation of School District Anti-Bullying Policy Quality and Student Bullying Involvement

Science.gov (United States)

Gower, Amy L.; Cousin, Molly; Borowsky, Iris W.

2017-01-01

Background: Although nearly all states in the United States require school districts to adopt anti-bullying policies, little research examines the effect of these policies on student bullying and health. Using a statewide sample, we investigated associations between the quality of school district anti-bullying policies and student bullying…

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

Implementing Statewide Severe Maternal Morbidity Review: The Illinois Experience.

Science.gov (United States)

Koch, Abigail R; Roesch, Pamela T; Garland, Caitlin E; Geller, Stacie E

2018-03-07

Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines. Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement. Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases). Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the

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

Statewide Policy Change in Pediatric Dental Care, and the Impact on Pediatric Dental and Physician Visits.

Science.gov (United States)

Zlotnick, Cheryl; Tam, Tammy; Ye, Yu

2017-10-01

Introduction In 2007, the California signed legislation mandating a dental visit for all children entering kindergarten or first grade; no such mandate was made for physician visits. This study examines the impact of this policy change on the risk factors associated with obtaining pediatric dental and physician health care visits. Methods Every 2 years, California Health Interview Survey conducts a statewide survey on a representative community sample. This cross-sectional study took advantage of these data to conduct a "natural experiment" assessing the impact of this policy change on both pediatric physician and dental care visits in the past year. Samples included surveys of adults and children (ages 5-11) on years 2005 (n = 5096), 2007 (n = 4324) and 2009 (n = 4100). Results Although few changes in risk factors were noted in pediatric physician visits, a gradual decrease in risk factors was found in pediatric dental visits from 2005 to 2009. Report of no dental visit was less likely for: younger children (OR -0.81, CI 0.75-0.88), insured children (OR 0.34, CI 0.22-0.53), and children who had a physician's visit last year (OR 0.37, CI 0.25-0.53) in 2005. By 2007, absence of insurance was the only risk factor related to having no dental visit (OR 0.34, CI 0.19-0.61). By 2009, no a priori measured risk factors were associated with not having a dental visit for children aged 5-11 years. Conclusions A statewide policy mandating pediatric dental visits appears to have reduced disparities. A policy for medical care may contribute to similar benefits.

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.

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.

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.

A Guide to Effective Statewide Laws/Policies: Preventing Discrimination against LGBT Students in K-12 Schools.

Science.gov (United States)

Lambda Legal Defense and Education Fund, New York, NY.

This document presents guidance for stopping discrimination, harassment, and violence against lesbian, gay, bisexual, and transgender (LGBT) students in schools. Section 1, "Lambda Legal Defense and Education Fund on the Legal Considerations for Creating and Changing Statewide Laws and Policies," discusses the various types of statewide…

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, ...

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.

Road Map to Statewide Implementation of the Pyramid Model. Roadmap to Effective Intervention Practices #6

Science.gov (United States)

Dunlap, Glen; Smith, Barbara J.; Fox, Lise; Blase, Karen

2014-01-01

This document is a guide--a "Road Map"--for implementing widespread use of the Pyramid Model for Promoting Social Emotional Competence in Infants and Young Children (http://www.challengingbehavior.org/do/pyramid_model. htm). It is a road map of systems change. The Road Map is written for statewide systems change, although it could be…

A statewide consortium's adoption of a unified nursing curriculum: evaluation of the first two years.

Science.gov (United States)

Tse, Alice M; Niederhauser, Victoria; Steffen, John J; Magnussen, Lois; Morrisette, Nova; Polokoff, Rachael; Chock, Johnelle

2014-01-01

This article provides an evaluation of the first two years of implementation of a statewide nursing consortium (SNC) curriculum on nursing faculty work life, teaching productivity, and quality of education. In response to the call for nursing education reform, the SNC incorporated new approaches to competency-based, student-centered learning and clinical education. Faculty and two cohorts of students were measured at three points over the first two years of the curriculum implementation. The expected positive impact of the SNC was documented at the start of the first year, but not sustained. Students reported having more confidence in their clinical skills at the start of the first year, yet demonstrated significantly less confidence in their ability after two years. Faculty indicated that the SNC allowed greater opportunity for collaboration, but that the experience did not alter their classroom performance or satisfaction beyond the first year.

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.)

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.

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

Effects of a Statewide Protocol for the Management of Peritoneal Dialysis-Related Peritonitis on Microbial Profiles and Antimicrobial Susceptibilities: A Retrospective Five-Year Review.

Science.gov (United States)

McGuire, Amanda L; Carson, Christine F; Inglis, Timothy J J; Chakera, Aron

2015-12-01

♦ Peritonitis is a major complication of peritoneal dialysis (PD) and is associated with significant morbidity and mortality. Early empirical antibiotic therapy is recommended, with the choice of agents guided by local resistance patterns. As routine use of specific antimicrobial agents can drive resistance, regular assessment of causative organisms and their susceptibility to empirical therapy is essential. ♦ We conducted a retrospective review of all PD peritonitis cases and positive PD fluid cultures obtained over a 5-year period in Western Australia following the introduction of a statewide protocol for the initial management of PD peritonitis with intraperitoneal vancomycin and gentamicin. ♦ The incidence of PD peritonitis decreased from 1 in 16 patient months (0.75/year at risk) to 1 in 29 patient months (0.41/year at risk) over the 5 years. There were 1,319 culture-positive samples and 1,069 unique isolates identified. Gram-positive bacteria accounted for 69.9% of positive cultures, with vancomycin resistance averaging 2% over the study period. Gram-negative bacteria accounted for 25.4% of positive cultures, with gentamicin resistance identified in an average of 8% of organisms. No increase in antimicrobial resistance to vancomycin or gentamicin occurred over the 5 years and there was no change in the proportion of gram-positive (69.9%), gram-negative (25.4%) or fungal (4.4%) organisms causing PD peritonitis. ♦ Over time, the peritonitis rates have dramatically improved although the profile of causative organisms remains similar. Empirical treatment of PD peritonitis with intraperitoneal vancomycin and gentamicin remains efficacious, with high levels of susceptibility and no evidence that the introduction of this statewide empirical PD peritonitis treatment protocol is driving resistance to these agents. Copyright © 2015 International Society for Peritoneal Dialysis.

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.

Design of a statewide radiation survey

International Nuclear Information System (INIS)

Nagda, N.L.; Koontz, M.D.; Rector, H.E.; Nifong, G.D.

1989-01-01

The Florida Institute of Phosphate Research (FIPR) recently sponsored a statewide survey to identify all significant land areas in Florida where the state's environmental radiation rule should be applied. Under this rule, newly constructed buildings must be tested for radiation levels unless approved construction techniques are used. Two parallel surveys - a land-based survey and a population-based survey - were designed and conducted to address the objective. Each survey included measurements in more than 3000 residences throughout the state. Other information sources that existed at the outset of the study, such as geologic profiles mapped by previous investigators and terrestrial uranium levels characterized through aerial gamma radiation surveys, were also examined. Initial data analysis efforts focused on determining the extent of evidence of radon potential for each of 67 counties in the state. Within 18 countries that were determined to have definite evidence of elevated radon potential, more detailed spatial analyses were conducted to identify areas of which the rule should apply. A total of 74 quadrangles delineated by the U.S. Geological Survey, representing about 7% of those constituting the state, were identified as having elevated radon potential and being subject to the rule

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.

Vermont travel model 2010-2011 (year 3) report.

Science.gov (United States)

2012-10-01

This report is being prepared under Task 1 of the Maintenance, Operation and Evaluation of the VTrans Statewide Transportation Model contract with the Vermont Agency of Transportation (VTrans) in the 2010-2011 year of the contract. The objectiv...

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...

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

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.

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.

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

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.

Analysis of Professional Fringe Benefits, 1978-79. OMNI Report.

Science.gov (United States)

Vater, James J.; Riddle, Richard A.

This report contains data collected from 275 Pennsylvania school districts for the 1978-79 school year. The data reflect policies and practices affecting fringe benefits for professional employees. The report is divided into three major sections. The first section presents comparative data for 30 variables on a statewide, size, and wealth basis.…

Analysis of Professional Fringe Benefits 1977-78. OMNI Report.

Science.gov (United States)

Caldwell, William E.; Vater, James J.

This report contains data collected from 275 Pennsylvania school districts for the 1977-78 school year. The data reflect policies and practices affecting fringe benefits for professional employees. The report is divided into three major sections. The first section presents comparative data for 30 variables on a statewide, size, and wealth basis.…

[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

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...

Child Safety: A State of the State Report. An Arkansas Kids Count Special Report.

Science.gov (United States)

Huddleston, Richard A.

This Kids Count report uses data from the Arkansas Department of Health to examine statewide trends in child safety. The findings suggested that in 1996, about one-third of child deaths in Arkansas were due to non-natural causes, with substantial racial and sex differences. Causes such as accidents, homicides, and suicides were more common for…

Avoiding a knowledge gap in a multiethnic statewide social marketing campaign: is cultural tailoring sufficient?

Science.gov (United States)

Buchthal, O Vanessa; Doff, Amy L; Hsu, Laura A; Silbanuz, Alice; Heinrich, Katie M; Maddock, Jay E

2011-03-01

In 2007, the State of Hawaii, Healthy Hawaii Initiative conducted a statewide social-marketing campaign promoting increased physical activity and nutrition. The campaign included substantial formative research to develop messages tailored for Hawaii's multiethnic Asian and Pacific Islander populations. The authors conducted a statewide random digital dialing telephone survey to assess the campaign's comparative reach among individuals with different ethnicities and different levels of education and income. This analysis suggests that the intervention was successful in reaching its target ethnic audiences. However, a knowledge gap related to the campaign appeared among individuals with incomes less than 130% of the poverty level and those with less than a high school education. These results varied significantly by message and the communication channel used. Recall of supermarket-based messages was significantly higher among individuals below 130% of the poverty level and those between 18 and 35 years of age, 2 groups that showed consistently lower recall of messages in other channels. Results suggest that cultural tailoring for ethnic audiences, although important, is insufficient for reaching low-income populations, and that broad-based social marketing campaigns should consider addressing socioeconomic status-related channel preferences in formative research and campaign design.

Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the Atmospheric Environment Safety Technology Project

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

This study analyzed aircraft incidents in the NASA Aviation Safety Reporting System (ASRS) that apply to two of the three technical challenges (TCs) in NASA's Aviation Safety Program's Atmospheric Environment Safety Technology Project. The aircraft incidents are related to airframe icing and atmospheric hazards TCs. The study reviewed incidents that listed their primary problem as weather or environment-nonweather between 1994 and 2011 for aircraft defined by Federal Aviation Regulations (FAR) Parts 121, 135, and 91. The study investigated the phases of flight, a variety of anomalies, flight conditions, and incidents by FAR part, along with other categories. The first part of the analysis focused on airframe-icing-related incidents and found 275 incidents out of 3526 weather-related incidents over the 18-yr period. The second portion of the study focused on atmospheric hazards and found 4647 incidents over the same time period. Atmospheric hazards-related incidents included a range of conditions from clear air turbulence and wake vortex, to controlled flight toward terrain, ground encounters, and incursions.

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

The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative.

Science.gov (United States)

Chang, Victor; Schwalb, Jason M; Nerenz, David R; Pietrantoni, Lisa; Jones, Sharon; Jankowski, Michelle; Oja-Tebbe, Nancy; Bartol, Stephen; Abdulhak, Muwaffak

2015-12-01

OBJECT Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved-and continue to improve-the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

Science.gov (United States)

Joubert, Kyla D; Mabry, Charles D; Kalkwarf, Kyle J; Betzold, Richard D; Spencer, Horace J; Spinks, Kara M; Porter, Austin; Karim, Saleema; Robertson, Ronald D; Sutherland, Michael J; Maxson, Robert T

2016-09-01

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Variations in statewide water quality of New Jersey streams, water years 1998-2009

Science.gov (United States)

Heckathorn, Heather A.; Deetz, Anna C.

2012-01-01

Statistical analyses were conducted for six water-quality constituents measured at 371 surface-water-quality stations during water years 1998-2009 to determine changes in concentrations over time. This study examined year-round concentrations of total dissolved solids, dissolved nitrite plus nitrate, dissolved phosphorus, total phosphorus, and total nitrogen; concentrations of dissolved chloride were measured only from January to March. All the water-quality data analyzed were collected by the New Jersey Department of Environmental Protection and the U.S. Geological Survey as part of the cooperative Ambient Surface-Water-Quality Monitoring Network. Stations were divided into groups according to the 1-year or 2-year period that the stations were part of the Ambient Surface-Water-Quality Monitoring Network. Data were obtained from the eight groups of Statewide Status stations for water years 1998, 1999, 2000, 2001-02, 2003-04, 2005-06, 2007-08, and 2009. The data from each group were compared to the data from each of the other groups and to baseline data obtained from Background stations unaffected by human activity that were sampled during the same time periods. The Kruskal-Wallis test was used to determine whether median concentrations of a selected water-quality constituent measured in a particular 1-year or 2-year group were different from those measured in other 1-year or 2-year groups. If the median concentrations were found to differ among years or groups of years, then Tukey's multiple comparison test on ranks was used to identify those years with different or equal concentrations of water-quality constituents. A significance level of 0.05 was selected to indicate significant changes in median concentrations of water-quality constituents. More variations in the median concentrations of water-quality constituents were observed at Statewide Status stations (randomly chosen stations scattered throughout the State of New Jersey) than at Background stations

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)

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.

Mindfulness-based stress reduction teachers, practice characteristics, cancer incidence, and health: a nationwide ecological description.

Science.gov (United States)

Robb, Sara Wagner; Benson, Kelsey; Middleton, Lauren; Meyers, Christine; Hébert, James R

2015-02-14

Studies have demonstrated the potential of the Mindfulness-Based Stress Reduction (MBSR) program to improve the condition of individuals with health outcomes such as hypertension, diabetes, and chronic pain; improve psychological well-being; reduce stress levels; and increase survival among cancer patients. To date, only one study has focused on the effect of long-term meditation on stress, showing a positive protective relationship. However, the relationship between meditation and cancer incidence remains unexplored. The objective of this study was to describe the state-level relationship between MBSR instructors and their practices and county-level health outcomes, including cancer incidence, in the United States. This ecologic study was performed using geospatial mapping and descriptive epidemiology of statewide MBSR characteristics and overall health, mental health state rankings, and age-adjusted cancer incidence rates. Weak to moderate state-level correlations between meditation characteristics and colorectal and cervical cancer incidence were detected, with states with more meditation (e.g., more MBSR teachers per population) correlated with a decreased cancer incidence. A negative correlation was detected between lung & bronchus cancer and years teaching MBSR only. Moderate positive correlations were detected between Hodgkin's Lymphoma and female breast cancer in relation to all meditation characteristics. Statistically significant correlations with moderate coefficients were detected for overall health ranks and all meditation characteristics, most strongly for total number of years teaching MBSR and total number of years of general meditation practice. Our analyses might suggest that a relationship exists between the total number of MBSR teachers per state and the total number of years of general meditation practice per state, and colorectal and cervical cancer incidence. Positive correlations were observed with overall health rankings. Despite this study

Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the System-Wide Safety and Assurance Technologies Project

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2015-01-01

The Aviation Safety Program (AvSP) System-Wide Safety and Assurance Technologies (SSAT) Project asked the AvSP Systems and Portfolio Analysis Team to identify SSAT-related trends. SSAT had four technical challenges: advance safety assurance to enable deployment of NextGen systems; automated discovery of precursors to aviation safety incidents; increasing safety of human-automation interaction by incorporating human performance, and prognostic algorithm design for safety assurance. This report reviews incident data from the NASA Aviation Safety Reporting System (ASRS) for system-component-failure- or-malfunction- (SCFM-) related and human-factor-related incidents for commercial or cargo air carriers (Part 121), commuter airlines (Part 135), and general aviation (Part 91). The data was analyzed by Federal Aviation Regulations (FAR) part, phase of flight, SCFM category, human factor category, and a variety of anomalies and results. There were 38 894 SCFM-related incidents and 83 478 human-factorrelated incidents analyzed between January 1993 and April 2011.

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

A pavement management research program for Oregon highways : interim report.

Science.gov (United States)

1985-03-01

This is the first in a series of reports documenting progress on a statewide pavement management research project. The overall project is conducting research into pavement life cycles of different rehabilitation treatment; the cost-effectiveness of e...

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.

Filling the Void: The Roles of a Local Applied Research Center and a Statewide Workforce Training Consortium

Science.gov (United States)

Perniciaro, Richard C.; Nespoli, Lawrence A.; Anbarasan, Sivaraman

2015-01-01

This chapter describes the development of an applied research center at Atlantic Cape Community College and a statewide workforce training consortium run by the community college sector in New Jersey. Their contributions to the economic development mission of the colleges as well as their impact on the perception of community colleges by…

State of Hawaii, Department of Health, Clean Water Branch State-wide Water Quality Sampling Dataset 1999-2006 (NODC Accession 0013723)

Data.gov (United States)

National Oceanic and Atmospheric Administration, Department of Commerce — The Monitoring Section of the State of Hawaii, Department of Health, Clean Water Branch collects water quality data at over 300 coastal locations state-wide using...

State of Hawaii, Department of Health, Clean Water Branch State-wide Water Quality Sampling Dataset 1973-1998 (NODC Accession 0013724)

Data.gov (United States)

National Oceanic and Atmospheric Administration, Department of Commerce — The Monitoring Section of the State of Hawaii, Department of Health, Clean Water Branch collects water quality data at over 300 coastal locations state-wide using...

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.

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.

Reporting of Sepsis Cases for Performance Measurement Versus for Reimbursement in New York State.

Science.gov (United States)

Prescott, Hallie C; Cope, Tara M; Gesten, Foster C; Ledneva, Tatiana A; Friedrich, Marcus E; Iwashyna, Theodore J; Osborn, Tiffany M; Seymour, Christopher W; Levy, Mitchell M

2018-05-01

Under "Rory's Regulations," New York State Article 28 acute care hospitals were mandated to implement sepsis protocols and report patient-level data. This study sought to determine how well cases reported under state mandate align with discharge records in a statewide administrative database. Observational cohort study. First 27 months of mandated sepsis reporting (April 1, 2014, to June 30, 2016). Hospitalizations with sepsis at New York State Article 28 acute care hospitals. Sepsis regulations with mandated reporting. We compared cases reported to the New York State Department of Health Sepsis Clinical Database with discharge records in the Statewide Planning and Research Cooperative System database. We classified discharges as 1) "coded sepsis discharges"-a diagnosis code for severe sepsis or septic shock and 2) "possible sepsis discharges," using Dombrovskiy and Angus criteria. Of 111,816 sepsis cases reported to the New York State Department of Health Sepsis Clinical Database, 105,722 (94.5%) were matched to discharge records in Statewide Planning and Research Cooperative System. The percentage of coded sepsis discharges reported increased from 67.5% in the first quarter to 81.3% in the final quarter of the study period (mean, 77.7%). Accounting for unmatched cases, as many as 82.7% of coded sepsis discharges were potentially reported, whereas at least 17.3% were unreported. Compared with unreported discharges, reported discharges had higher rates of acute organ dysfunction (e.g., cardiovascular dysfunction 63.0% vs 51.8%; p New York State Department of Health Sepsis Clinical Database. Incomplete reporting appears to be driven more by underrecognition than attempts to game the system, with minimal bias to risk-adjusted hospital performance measurement.

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.

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/.

Self-Reported Sleep Duration, Napping, and Incident Heart Failure: Prospective Associations in the British Regional Heart Study.

Science.gov (United States)

Wannamethee, S Goya; Papacosta, Olia; Lennon, Lucy; Whincup, Peter H

2016-09-01

To examine the associations between self-reported nighttime sleep duration and daytime sleep and incident heart failure (HF) in men with and without preexisting cardiovascular disease (CVD). Population-based prospective study. General practices in 24 British towns. Men aged 60-79 without prevalent HF followed for 9 years (N = 3,723). Information on incident HF cases was obtained from primary care records. Assessment of sleep was based on self-reported sleep duration at night and daytime napping. Self-reported short nighttime sleep duration and daytime sleep of longer than 1 hour were associated with preexisting CVD, breathlessness, depression, poor health, physical inactivity, and manual social class. In all men, self-reported daytime sleep of longer than 1 hour duration was associated with significantly greater risk of HF after adjustment for potential confounders (adjusted hazard ratio (aHR) = 1.69, 95% CI = 1.06-2.71) than in those who reported no daytime napping. Self-reported nighttime sleep duration was not associated with HF risk except in men with preexisting CVD (napping of longer than 1 hour is associated with greater risk of HF in older men. Self-reported short sleep (<6 hours) in men with CVD is associated with particularly high risk of developing HF. © 2016 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

Emergency Department Visits Prior to Suicide and Homicide: Linking Statewide Surveillance Systems.

Science.gov (United States)

Cerel, Julie; Singleton, Michael D; Brown, Margaret M; Brown, Sabrina V; Bush, Heather M; Brancado, Candice J

2016-01-01

Emergency departments (EDs) serve a wide range of patients who present at risk of impending suicide and homicide. Two statewide surveillance systems were probabilistically linked to understand who utilizes EDs and then dies violently within 6 weeks. Each identified case was matched with four randomly selected controls on sex, race, date of birth, resident zip code, and date of ED visit vs. date of death. Matched-pair odds ratios were estimated by conditional logistic regression to assess differences between cases and controls on reported diagnoses and expected payment sources. Of 1,599 suicides and 569 homicides in the 3-year study period, 10.7% of decedents who died by suicide (mean = 13.6 days) and 8.3% who died by homicide (mean = 16.3 days) were seen in a state ED within 6 weeks prior to death. ED attendees who died by suicide were more likely to have a diagnosis of injury/ poisoning diagnosis or mental disorder and more likely to have Medicare. Those who died by homicide were more likely to have a diagnosis of injury/poisoning and less likely to have commercial insurance. It is essential for research to further explore risk factors for imminent suicide and homicide in ED patients who present for psychiatric conditions and general injuries.

Hip fracture incidence is decreasing in the high incidence area of Oslo, Norway.

Science.gov (United States)

Støen, R O; Nordsletten, L; Meyer, H E; Frihagen, J F; Falch, J A; Lofthus, C M

2012-10-01

This study reports a significant decrease in age-adjusted incidence rates of hip fracture for women in Oslo, Norway, even compared with data from 1978/1979. Use of bisphosphonate may explain up to one third of the decline in the incidence. The aims of the present study were to report the current incidence of hip fractures in Oslo and to estimate the influence of bisphosphonates on the current incidence. Using the electronic diagnosis registers and lists from the operating theaters of the hospitals of Oslo, all patients with ICD-10 codes S72.0 and S72.1 (hip fracture) in 2007 were identified. Medical records of all identified patients were reviewed to verify the diagnosis. Age- and gender-specific annual incidence rates were calculated using the population of Oslo on January 1, 2007 as the population at risk. Data on the use of bisphosphonates were obtained from official registers. A total number of 1,005 hip fractures, 712 (71%) in women, were included. The age-adjusted fracture rates per 10,000 for the age group >50 years were 82.0 for women and 39.1 for men in 2007, compared with 110.8 and 41.4 in 1996/1997, 116.5 and 42.9 in 1988/1989, and 97.5 and 34.5 in 1978/1979, respectively. It was estimated that the use of bisphosphonates may explain up to 13% of the decline in incidence in women aged 60-69 years and up to 34% in women aged 70-79 years. The incidence of hip fractures in women in Oslo has decreased significantly during the last decade and is now at a lower level than in 1978/1979. This reduction was not evident in men. The incidence of hip fractures in Oslo is, however, still the highest in the world.

Leveraging a Statewide Clinical Data Warehouse to Expand Boundaries of the Learning Health System.

Science.gov (United States)

Turley, Christine B; Obeid, Jihad; Larsen, Rick; Fryar, Katrina M; Lenert, Leslie; Bjorn, Arik; Lyons, Genevieve; Moskowitz, Jay; Sanderson, Iain

2016-01-01

Learning Health Systems (LHS) require accessible, usable health data and a culture of collaboration-a challenge for any single system, let alone disparate organizations, with macro- and micro-systems. Recently, the National Science Foundation described this important setting as a cyber-social ecosystem. In 2004, in an effort to create a platform for transforming health in South Carolina, Health Sciences South Carolina (HSSC) was established as a research collaboration of the largest health systems, academic medical centers and research intensive universities in South Carolina. With work beginning in 2010, HSSC unveiled an integrated Clinical Data Warehouse (CDW) in 2013 as a crucial anchor to a statewide LHS. This CDW integrates data from independent health systems in near-real time, and harmonizes the data for aggregation and use in research. With records from over 2.7 million unique patients spanning 9 years, this multi-institutional statewide clinical research repository allows integrated individualized patient-level data to be used for multiple population health and biomedical research purposes. In the first 21 months of operation, more than 2,800 de-identified queries occurred through i2b2, with 116 users. HSSC has developed and implemented solutions to complex issues emphasizing anti-competitiveness and participatory governance, and serves as a recognized model to organizations working to improve healthcare quality by extending the traditional borders of learning health systems.

Learning from radiation incidents: the new OTHEA website

International Nuclear Information System (INIS)

Shaw, P V; Ely, S Y; Croueail, P; Bataille, C

2010-01-01

OTHEA is the name of a new website (www.othea.net), created by the Health Protection Agency (UK) and the Centre d'etude sur l'evaluation de la protection dans le domaine nucleaire (CEPN, France), and supported by several other stakeholders including national societies and associations. The website is bi-lingual (French and English) and the purpose is to share the lessons learnt from radiological incidents that have occurred in the industrial, medical, research and teaching, and other non-nuclear sectors. OTHEA contains a collection of incident reports, categorised according to the sector and the type of application, and a search facility. The reports can be freely downloaded and printed, for example for use in radiation protection training activities. To encourage dissemination, the incident reports have been made anonymous, i.e. any information that could identify a particular individual, organisation or site has been removed. Each report contains a brief summary of the incident, the radiological consequences, and the lessons learnt. The aim is not to capture every single incident, but to provide a range of reports selected according to the value of the lessons learnt. For OTHEA to be a long-term success, it needs to be sustained with new reports. Therefore users are encouraged to submit incident reports that can be considered for inclusion in OTHEA. This note summarises the background to OTHEA, and provides a description of the operating features and content at its launch in summer 2010. (note)

Reported incidence and precipitating factors of work-related stress and mental ill-health in the United Kingdom (1996-2001).

Science.gov (United States)

Cherry, Nicola M; Chen, Yiqun; McDonald, J Corbett

2006-09-01

Work-related mental ill-health appears to be increasing. Population-based data on incidence are scarce but in the United Kingdom occupational physicians and psychiatrists report these conditions to voluntary surveillance schemes. To estimate the incidence of work-related stress and mental illness reported 1996-2001 by occupational physicians and 1999-2001 by psychiatrists. Estimated annual average incidence rates were calculated by sex, occupation and industry against appropriate populations at risk. An in-house coding scheme was used to classify and analyse data on precipitating events. An estimated annual average of 3,624 new cases were reported by psychiatrists, and 2,718 by occupational physicians; the rates were higher for men in reports based on the former and for women on the latter. Most diagnoses were of anxiety/depression or work-related stress, with post-traumatic stress accounting for approximately 10% of cases reported by psychiatrists. High rates of ill-health were seen among professional and associated workers and in those in personal and protective services. Factors (such as work overload) intrinsic to the job and issues with interpersonal relations were the most common causes overall. The steep increase in new cases of work-related mental ill-health reported by occupational physicians since 1996 may reflect a greater willingness by workers to seek help but may also signify an increasing dissonance between workers' expectations and the work environment. Greater expertise is needed to improve the workplace by adjustment of job demands, improvement of working relations, increasing workers' capacities and management of organizational change.

State-wide performance criteria for international safeguards

International Nuclear Information System (INIS)

Budlong-Sylvester, K.W.; Pilat, Joseph F.; Stanbro, W.D.

2001-01-01

Traditionally, the International Atomic Energy Agency (IAEA) has relied upon prescriptive criteria to guide safeguards implementation. The prospect of replacing prescriptive safeguards criteria with more flexible performance criteria would constitute a structural change in safeguards and raises several important questions. Performance criteria imply that while safeguards goals will be fixed, the means of attaining those goals will not be explicitly prescribed. What would the performance objectives be under such a system? How would they be formulated? How would performance be linked to higher level safeguards objectives? How would safeguards performance be measured State-wide? The implementation of safeguards under performance criteria would also signal a dramatic change in the manner the Agency does business. A higher degree of flexibility could, in principle, produce greater effectiveness and efficiency, but would come with a need for increased Agency responsibility in practice. To the extent that reliance on prescriptive criteria decreases, the burden of justifying actions and ensuring their transparency will rise. Would there need to be limits to safeguards implementation? What would be the basis for setting such limits? This paper addresses these and other issues and questions relating to both the formulation and the implementation of performance-based criteria.

The child sexual abuse epidemic in addis ababa: some reflections on reported incidents, psychosocial consequences and implications.

Science.gov (United States)

Jemal, Jibril

2012-03-01

Though child sexual abuse is a universal phenomenon, only reported cases of the incidence are common source of information to get insight on how to understand the problem. Besides, investigating complaints presented by victims themselves would be a stepping stone for designing prevention and rehabilitation programs. The objective of this study was to identify the nature of sexual incidence and experience victims face. The research was conducted by collecting reported child sexual abuse cases from Child Protection Units of Addis Ababa Police Commission and three selected non-governmental organizations working for the welfare of sexually abused children in Addis Ababa. 64 selected samples of victim children were included from the three organizations. They completed a semi-structured questionnaire and data were analyzed. Of the total reported crime cases committed against children (between July 2005 and December 2006), 23% of them were child sexual victimization. On average, 21 children were reported to be sexually abused each month where majority of the sexual abuse incidence were committed against female children in their own home by someone they closely know. The psychological trauma and physical complaints presented by victims include symptoms of anxiety and depression. It was found out that child sexual abuse cases presented to the legal office was not properly managed. Female children appear to be more prone to sexual abuse than their male counterparts. By virtue of their nature, many children are at risk of sexual victimization by people they truest. Based on the findings, several implications are made, which includes the importance of nation-wide study to formulate a comprehensive policy guideline for protection and criminalization of child sexual abuse in Ethiopia.

The Use of Categorized Time-Trend Reporting of Radiation Oncology Incidents: A Proactive Analytical Approach to Improving Quality and Safety Over Time

International Nuclear Information System (INIS)

Arnold, Anthony; Delaney, Geoff P.; Cassapi, Lynette; Barton, Michael

2010-01-01

Purpose: Radiotherapy is a common treatment for cancer patients. Although incidence of error is low, errors can be severe or affect significant numbers of patients. In addition, errors will often not manifest until long periods after treatment. This study describes the development of an incident reporting tool that allows categorical analysis and time trend reporting, covering first 3 years of use. Methods and Materials: A radiotherapy-specific incident analysis system was established. Staff members were encouraged to report actual errors and near-miss events detected at prescription, simulation, planning, or treatment phases of radiotherapy delivery. Trend reporting was reviewed monthly. Results: Reports were analyzed for the first 3 years of operation (May 2004-2007). A total of 688 reports was received during the study period. The actual error rate was 0.2% per treatment episode. During the study period, the actual error rates reduced significantly from 1% per year to 0.3% per year (p < 0.001), as did the total event report rates (p < 0.0001). There were 3.5 times as many near misses reported compared with actual errors. Conclusions: This system has allowed real-time analysis of events within a radiation oncology department to a reduced error rate through focus on learning and prevention from the near-miss reports. Plans are underway to develop this reporting tool for Australia and New Zealand.

Customer focused incident monitoring in anaesthesia.

Science.gov (United States)

Khan, F A; Khimani, S

2007-06-01

The database of incident forms relating to anaesthesia services in an institutional risk management programme were reviewed for 2003-2005, the aim being to identify any recurring patterns. Incidents were prospectively categorised as relating to attitude/behaviour, communication breakdown, delay in service, or were related to care, cost, environment, equipment, security, administrative process, quality of service or miscellaneous. The total number of anaesthesia-related incidents reported during the period was 287, which related to 0.44% of the total number of anaesthetics administered during the time period. In all, 170 incidents were reported by the department, 96 by internal customers and 21 by external customers. Only 30% of the complaints came from the operating room. Thirty-four per cent of all incidents related to communication, behaviour and delay in service. A requirement to teach communication skills and stress handling formally in anaesthesia training programmes, and at the time of induction of staff into the department, has been identified.

Radioactive material (RAM) accident/incident data analysis program

International Nuclear Information System (INIS)

Emerson, E.L.; McClure, J.D.

1985-03-01

This report describes the development of the Radioactive Material Transportation Accident/Incident Data Base (RAM-AIDB), which contains information on the occurrences of transportation accidents and incidents, for radioactive materials (RAM) that are involved in the process of transportation, loading and unloading operation, or temporary storage. These transportation operations are in support of the nuclear fuel cycle for electrical energy generation. This study analyzes in some detail basic accident/incident statistical data, RAM packaging accident response data, and the health effects associated with RAM transport accidents/incidents. This report presents a summary of US RAM transport accident/incident experience for the period 1971 through December 1981. In addition, a sample annual summary of accident/incident experience is presented for the calendar year 1981

Comparative Incidence of Conformational, Neurodegenerative Disorders.

Directory of Open Access Journals (Sweden)

Jesús de Pedro-Cuesta

Full Text Available The purpose of this study was to identify incidence and survival patterns in conformational neurodegenerative disorders (CNDDs.We identified 2563 reports on the incidence of eight conditions representing sporadic, acquired and genetic, protein-associated, i.e., conformational, NDD groups and age-related macular degeneration (AMD. We selected 245 papers for full-text examination and application of quality criteria. Additionally, data-collection was completed with detailed information from British, Swedish, and Spanish registries on Creutzfeldt-Jakob disease (CJD forms, amyotrophic lateral sclerosis (ALS, and sporadic rapidly progressing neurodegenerative dementia (sRPNDd. For each condition, age-specific incidence curves, age-adjusted figures, and reported or calculated median survival were plotted and examined.Based on 51 valid reported and seven new incidence data sets, nine out of eleven conditions shared specific features. Age-adjusted incidence per million person-years increased from ≤1.5 for sRPNDd, different CJD forms and Huntington's disease (HD, to 1589 and 2589 for AMD and Alzheimer's disease (AD respectively. Age-specific profiles varied from (a symmetrical, inverted V-shaped curves for low incidences to (b those increasing with age for late-life sporadic CNDDs and for sRPNDd, with (c a suggested, intermediate, non-symmetrical inverted V-shape for fronto-temporal dementia and Parkinson's disease. Frequently, peak age-specific incidences from 20-24 to ≥90 years increased with age at onset and survival. Distinct patterns were seen: for HD, with a low incidence, levelling off at middle age, and long median survival, 20 years; and for sRPNDd which displayed the lowest incidence, increasing with age, and a short median disease duration.These results call for a unified population view of NDDs, with an age-at-onset-related pattern for acquired and sporadic CNDDs. The pattern linking age at onset to incidence magnitude and survival might

Comparative Incidence of Conformational, Neurodegenerative Disorders

Science.gov (United States)

de Pedro-Cuesta, Jesús; Rábano, Alberto; Martínez-Martín, Pablo; Ruiz-Tovar, María; Alcalde-Cabero, Enrique; Almazán-Isla, Javier; Avellanal, Fuencisla; Calero, Miguel

2015-01-01

Background The purpose of this study was to identify incidence and survival patterns in conformational neurodegenerative disorders (CNDDs). Methods We identified 2563 reports on the incidence of eight conditions representing sporadic, acquired and genetic, protein-associated, i.e., conformational, NDD groups and age-related macular degeneration (AMD). We selected 245 papers for full-text examination and application of quality criteria. Additionally, data-collection was completed with detailed information from British, Swedish, and Spanish registries on Creutzfeldt-Jakob disease (CJD) forms, amyotrophic lateral sclerosis (ALS), and sporadic rapidly progressing neurodegenerative dementia (sRPNDd). For each condition, age-specific incidence curves, age-adjusted figures, and reported or calculated median survival were plotted and examined. Findings Based on 51 valid reported and seven new incidence data sets, nine out of eleven conditions shared specific features. Age-adjusted incidence per million person-years increased from ≤1.5 for sRPNDd, different CJD forms and Huntington's disease (HD), to 1589 and 2589 for AMD and Alzheimer's disease (AD) respectively. Age-specific profiles varied from (a) symmetrical, inverted V-shaped curves for low incidences to (b) those increasing with age for late-life sporadic CNDDs and for sRPNDd, with (c) a suggested, intermediate, non-symmetrical inverted V-shape for fronto-temporal dementia and Parkinson's disease. Frequently, peak age-specific incidences from 20–24 to ≥90 years increased with age at onset and survival. Distinct patterns were seen: for HD, with a low incidence, levelling off at middle age, and long median survival, 20 years; and for sRPNDd which displayed the lowest incidence, increasing with age, and a short median disease duration. Interpretation These results call for a unified population view of NDDs, with an age-at-onset-related pattern for acquired and sporadic CNDDs. The pattern linking age at onset to

76 FR 30855 - Accident/Incident Reporting Requirements

Science.gov (United States)

2011-05-27

... sidewalk/walkway D5--In airport; D6- In airplane; D7--In hotel room; E1--On parking lot; E2--In building... Control C--Auto Train Stop D--Automatic Block Signals System E--Broken Rail Monitoring F--Direct Traffic... of the accident/incident. This document updates and moves footnote number four to make it clear that...

Investigation of reactor incident reports with regard to human malfunctions as far as these had an effect on the incident history

International Nuclear Information System (INIS)

Hoffmann, E.

1984-01-01

The study has the aim to examine by means of a human failure analysis the operation of a nuclear power plant with regard to its weak points, in order to deduce by this starting-points for operational improvements. Contrary to most studies published on this subject and which are often based on free-hand hypotheses and plausibility studies here, the experience gained in the operation is systematically examined with regard to human malfunction and their deeper causes, i.e. on the experience which was founded on some 1,000 collected reports on incidents. (orig./GL) [de

The management of radiation treatment error through incident learning

International Nuclear Information System (INIS)

Clark, Brenda G.; Brown, Robert J.; Ploquin, Jodi L.; Kind, Anneke L.; Grimard, Laval

2010-01-01

Purpose: To assess efficacy of an incident learning system in the management of error in radiation treatment. Materials and methods: We report an incident learning system implementation customized for radiation therapy where any 'unwanted or unexpected change from normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment' is reported, investigated and learned from. This system thus captures near-miss (potential) and actual events. Incidents are categorized according to severity, type and origin. Results: Our analysis spans a period of 3 years with an average accrual of 11.6 incidents per week. We found a significant reduction in actual incidents of 28% and 47% in the second and third year when compared to the first year (p < 0.001), which we attribute to the many interventions prompted by the analysis of incidents reported. We also saw a similar significant reduction in incidents generated at the treatment unit correlating with the introduction of direct treatment parameter transfer and electronic imaging (p < 0.001). Conclusions: Implementation of an incident learning system has helped us to establish a just environment where all staff members report deviations from normal system behaviour and thus generate evidence to initiate safety improvements.

Transportation accidents/incidents involving radioactive materials (1971--1991)

International Nuclear Information System (INIS)

Cashwell, C.E.; McClure, J.D.

1992-01-01

The Radioactive Materials Incident Report (RMIR) database contains information on transportation-related accidents and incidents involving radioactive materials that have occurred in the United States. The RMIR was developed at Sandia National Laboratories (SNL) to support its research and development program efforts for the US Department of Energy (DOE). This paper will address the following topics: background information on the regulations and process for reporting a hazardous materials transportation incident, overview data of radioactive materials transportation accidents and incidents, and additional information and summary data on how packagings have performed in accident conditions

Transportation accidents/incidents involving radioactive materials (1971-1991)

International Nuclear Information System (INIS)

Cashwell, C.E.; McClure, J.D.

1993-01-01

In 1981, Sandia National Laboratories developed the Radioactive Materials Incident Report (RMIR) database to support its research and development activities for the U.S. Department of Energy (DOE). The RMIR database contains information on transportation accidents/incidents with radioactive materials that have occurred since 1971. The RMIR classifies a transportation accident/incident in one of six ways: as a transportation accident, a handling accident, a reported incident, missing or stolen, cask weeping, or other. This paper will define these terms and provide detailed examples of each. (J.P.N.)

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.

Science.gov (United States)

Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng

2017-11-03

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (pprocess step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, pprocess at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © 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.

Taxonometric Applications in Radiotherapy Incident Analysis

International Nuclear Information System (INIS)

Dunscombe, Peter B.; Ekaette, Edidiong U.; Lee, Robert C.; Cooke, David L.

2008-01-01

Recent publications in both the scientific and the popular press have highlighted the risks to which patients expose themselves when entering a healthcare system. Patient safety issues are forcing us to, not only acknowledge that incidents do occur, but also actively develop the means for assessing and managing the risks of such incidents. To do this, we ideally need to know the probability of an incident's occurrence, the consequences or severity for the patient should it occur, and the basic causes of the incident. A structured approach to the description of failure modes is helpful in terms of communication, avoidance of ambiguity, and, ultimately, decision making for resource allocation. In this report, several classification schemes or taxonomies for use in risk assessment and management are discussed. In particular, a recently developed approach that reflects the activity domains through which the patient passes and that can be used as a basis for quantifying incident severity is described. The estimation of incident severity, which is based on the concept of the equivalent uniform dose, is presented in some detail. We conclude with a brief discussion on the use of a defined basic-causes table and how adding such a table to the reports of incidents can facilitate the allocation of resources

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

NARCIS (Netherlands)

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

2009-01-01

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

Epidemiology of Traumatic Spinal Cord Injury Among Persons Older Than 21 Years: A Population-Based Study in South Carolina, 1998-2012.

Science.gov (United States)

Selassie, Anbesaw; Cao, Yue; Saunders, Lee L

2015-01-01

A gap exists in the current knowledge regarding the epidemiology of traumatic spinal cord injury (TSCI) in a statewide population. To describe population-based epidemiology and trend of TSCI in persons 22 years and older in South Carolina over a 15-year period from 1998 through 2012. Data on patients with TSCI were obtained from ongoing statewide TSCI surveillance and follow-up registry. Deaths were ascertained by linking surveillance files and the multiple cause-of-death dataset. Descriptive analyses were completed, and incidence and mortality rates were calculated based on the civilian adult population of the state. Over the 15 years, 3,365 persons with incident TSCI were discharged alive from acute care hospitalization, of whom 555 died during the period of observation. Age-standardized cumulative mortality rate was 14 per million, and the average incidence rate was estimated at 70.8 per million population per year. Age-standardized incidence rate of TSCI increased significantly from 66.9 in 1998 to 111.7 per million in 2012. Standardized incidence rates were significantly higher among non-Whites and males. Motor vehicle crashes and falls were the leading causes, accounting for nearly 70% of TSCI. Standardized incidence and mortality rates of TSCI in South Carolina are higher than reported rates for the US population. Motor vehicle crashes and falls are the leading causes of TSCI. There was a significant increase in the overall trend of the incidence rates over the 15 years. A well-coordinated preventive strategy is needed to reduce incidence and improve survival of persons with TSCI.

Accidental nuclear excursion Recuplex operation 234-5 facility. Final report: Date of incident: April 7, 1962

Energy Technology Data Exchange (ETDEWEB)

1962-08-01

On Saturday morning, April 7, 1962, at about 1059 Armed Forces time, an accidental nuclear excursion occurred in the plutonium waste recovery facility (Recuplex) of the 234-5 Building. This excursion did not result in any mechanical damage or spread of contamination. Three employees of the General Electric Company received overexposures to gamma and neutron radiation. None were fatally exposed; in each case the overexposure was recognized promptly, and following medical observation and testing the men were released to return to work. In compliance with AEC Manual Chapter 0703, an AEC-HAPO committee composed of two AEC employees and five General Electric employees was appointed by the Manger, HOO, with the concurrence of the General Manager, HAPO, to conduct an investigation of the incident. The committee`s purpose was to determine the cause, nature, and extent of the incident, and recommend action to be taken by others to minimize or preclude future incidents of this magnitude. A study of operating practices and operating conditions that appeared to exist prior to, during, and subsequent to the accident was made by the committee. The committee believes that this report provides sufficient information to answer questions which may arise as a result of the criticality incident except those relating to its cause.

Critical steps in learning from incidents: using learning potential in the process from reporting an incident to accident prevention.

Science.gov (United States)

Drupsteen, Linda; Groeneweg, Jop; Zwetsloot, Gerard 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. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.

Comparing electronic news media reports of potential bioterrorism-related incidents involving unknown white powder to reports received by the United States Centers for Disease Control and Prevention and the Federal Bureau of Investigation: U.S.A., 2009-2011.

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Fajardo, Geroncio C; Posid, Joseph; Papagiotas, Stephen; Lowe, Luis

2015-01-01

There have been periodic electronic news media reports of potential bioterrorism-related incidents involving unknown substances (often referred to as "white powder") since the 2001 intentional dissemination of Bacillus anthracis through the U.S. Postal System. This study reviewed the number of unknown "white powder" incidents reported online by the electronic news media and compared them with unknown "white powder" incidents reported to the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Federal Bureau of Investigation (FBI) during a 2-year period from June 1, 2009 and May 31, 2011. Results identified 297 electronic news media reports, 538 CDC reports, and 384 FBI reports of unknown "white powder." This study showed different unknown "white powder" incidents captured by each of the three sources. However, the authors could not determine the public health implications of this discordance. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

The incidence of acute urinary retention secondary to BPH is increasing among California men.

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Groves, H K; Chang, D; Palazzi, K; Cohen, S; Parsons, J K

2013-09-01

Current epidemiological patterns of adverse events of clinical BPH remain unclear. We investigated trends in acute urinary retention (AUR) associated with BPH in a large, population-based cohort. We utilized the California Office of Statewide Health Planning and Development Database to examine 3 724 016 emergency room (ER) visits in California among men aged  50 years from 2007 to 2010. Outcomes included AUR for which BPH was the primary diagnosis, AUR for which BPH was a secondary diagnosis and urethral catheterization for AUR. We generated adjusted odds ratios (ORadj) using multivariate logistic regression to determine longitudinal trends. A total of 17 023 men presented with a diagnosis of BPH-associated AUR, the unadjusted incidence of which increased from 4.00 per 1000 ER visits in 2007 to 5.23 per 1000 ER visits in 2010 (PBPH-associated AUR increased substantially in a large and ethnically diverse male population of the United States.

International Cyber Incident Repository System: Information Sharing on a Global Scale

Energy Technology Data Exchange (ETDEWEB)

Joyce, Amanda L.; Evans, PhD, Nathaniel; Tanzman, Edward A.; Israeli, Daniel

2017-02-02

According to the 2016 Internet Security Threat Report, the largest number of cyber attacks were recorded last year (2015), reaching a total of 430 million incidents throughout the world. As the number of cyber incidents increases, the need for information and intelligence sharing increases, as well. This fairly large increase in cyber incidents is driving the need for an international cyber incident data reporting system. The goal of the cyber incident reporting system is to make available shared and collected information about cyber events among participating international parties. In its 2014 report, Insurance Industry Working Session Readout Report-Insurance for CyberRelated Critical Infrastructure Loss: Key Issues, on the outcomes of a working session on cyber insurance, the U.S. Department of Homeland Security observed that “many participants cited the need for a secure method through which organizations could pool and share cyber incident information” and noted that one underwriter emphasized the importance of internationally harmonized data taxonomies. This cyber incident data reporting system could benefit all nations that take part in reporting incidents to provide a more common operating picture. In addition, this reporting system could allow for trending and anticipated attacks and could potentially benefit participating members by enabling them to get in front of potential attacks. The purpose of this paper is to identify options for consideration for such a system in fostering cooperative cyber defense.

Results from a Multi-Modal Program Evaluation of a Four Year Statewide Juvenile Sex Offender Treatment and Reentry Program

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Underwood, Lee A.; Dailey, Frances L. L.; Merino, Carrie; Crump, Yolanda

2015-01-01

The results of the Program Evaluation show the OJJ Statewide Sex Offender Treatment program is exceptionally productive in meeting over 90% of its established performance markers. These markers included successful screening and assessment of risk and psychosocial needs, completion of initial and master treatment plans, establishment of sex…

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...

The role of the NEA incident reporting system in trend and pattern studies

International Nuclear Information System (INIS)

Ishack, G.; Iwabuchi, H.

1990-01-01

When the Incident Reporting System of the OECD Nuclear Energy Agency (NEA-IRS) was first instituted in 1980, Members recognized the fact that since the data thus collected only pertains to significant safety-related incidents, the system cannot be used for in-depth statistical analyses. Rather, the NEA-IRS is best suited, in addition to single event assessments, to studies that provide indications related to system, component or human performance; these indications could also initiate trend analyses on more complete data bases. Examples are the generic studies on the Loss of Containment Functions (completed last year) and the Loss of Residual Heat Removal (due for completion this year), and the studies related to the human factor. Another type of use of the IRS data was started last year by the NEA Principal Working Group 1 on Operating Experience and Human Factors (PWG 1) in response to the encouragement of the OECD/NEA Committee on the Safety of Nuclear Installations (CSNI), to make the best use of Operating Experience, notably of information disseminated through the NEA-IRS. These applications consisted of scanning the IRS data base for events that could be of interest to specialized domains such as radiation protection, fracture mechanics and fire protection. In the paragraphs which follow, some highlights of the results of these scans are presented (reference is made at the end of this paper to the reports detailing the results of these applications)

Fiscal Year 2006 Salary Report for the Illinois Public Community Colleges

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Illinois Community College Board, 2006

2006-01-01

Data about compensation received by employees in Illinois' 48 Illinois public community colleges are gathered by the Illinois Community College Board (ICCB). Data in the Fiscal Year 2006 Salary Report reflect the census date of October 1, 2005. Data are presented by peer groups with statewide totals. Most of the 25 tables in this report contain…

Estimating the incidence reporting rates of new influenza pandemics at an early stage using travel data from the source country.

Science.gov (United States)

Chong, K C; Fong, H F; Zee, C Y

2014-05-01

During the surveillance of influenza pandemics, underreported data are a public health challenge that complicates the understanding of pandemic threats and can undermine mitigation efforts. We propose a method to estimate incidence reporting rates at early stages of new influenza pandemics using 2009 pandemic H1N1 as an example. Routine surveillance data and statistics of travellers arriving from Mexico were used. Our method incorporates changes in reporting rates such as linearly increasing trends due to the enhanced surveillance. From our results, the reporting rate was estimated at 0·46% during early stages of the pandemic in Mexico. We estimated cumulative incidence in the Mexican population to be 0·7% compared to 0·003% reported by officials in Mexico at the end of April. This method could be useful in estimation of actual cases during new influenza pandemics for policy makers to better determine appropriate control measures.

Washington State Nursing Home Administrator Model Curriculum. Final Report.

Science.gov (United States)

Cowan, Florence Kelly

The course outlines presented in this final report comprise a proposed Fort Steilacoom Community College curriculum to be used as a statewide model two-year associate degree curriculum for nursing home administrators. The eight courses described are introduction to nursing, home administration, financial management of nursing homes, nursing home…

Programs across the United States that aid motorists in the reporting of impaired drivers to law enforcement

Science.gov (United States)

2007-03-01

The objective of this project was to identify States that use a statewide cellular drunk driving reporting program which provides free airtime and allows motorists with cell phones to dial a special number (such as *DUI) to report suspected drunk dri...

Changes in Obesity Awareness, Obesity Identification, and Self-Assessment of Health: Results from a Statewide Public Education Campaign

Science.gov (United States)

Tsai, Adam G.; Boyle, Tracy F.; Hill, James O.; Lindley, Corina; Weiss, Karl

2014-01-01

Background: Due to the high prevalence of obesity, individuals may be desensitized to weight as a personal health concern. Purpose: To evaluate changes in obesity awareness associated with a statewide public education campaign in Colorado. Methods: Cross-sectional random digit dial telephone surveys (n = 1,107 pre, n = 1101 post) were conducted…

Validation of a risk stratification tool for fall-related injury in a state-wide cohort.

Science.gov (United States)

McCoy, Thomas H; Castro, Victor M; Cagan, Andrew; Roberson, Ashlee M; Perlis, Roy H

2017-02-06

A major preventable contributor to healthcare costs among older individuals is fall-related injury. We sought to validate a tool to stratify such risk based on readily available clinical data, including projected medication adverse effects, using state-wide medical claims data. Sociodemographic and clinical features were drawn from health claims paid in the state of Massachusetts for individuals aged 35-65 with a hospital admission for a period spanning January-December 2012. Previously developed logistic regression models of hospital readmission for fall-related injury were refit in a testing set including a randomly selected 70% of individuals, and examined in a training set comprised of the remaining 30%. Medications at admission were summarised based on reported adverse effect frequencies in published medication labelling. The Massachusetts health system. A total of 68 764 hospitalised individuals aged 35-65 years. Hospital readmission for fall-related injury defined by claims code. A total of 2052 individuals (3.0%) were hospitalised for fall-related injury within 90 days of discharge, and 3391 (4.9%) within 180 days. After recalibrating the model in a training data set comprised of 48 136 individuals (70%), model discrimination in the remaining 30% test set yielded an area under the receiver operating characteristic curve (AUC) of 0.74 (95% CI 0.72 to 0.76). AUCs were similar across age decades (0.71 to 0.78) and sex (0.72 male, 0.76 female), and across most common diagnostic categories other than psychiatry. For individuals in the highest risk quartile, 11.4% experienced fall within 180 days versus 1.2% in the lowest risk quartile; 57.6% of falls occurred in the highest risk quartile. This analysis of state-wide claims data demonstrates the feasibility of predicting fall-related injury requiring hospitalisation using readily available sociodemographic and clinical details. This translatable approach to stratification allows for identification of

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

Science.gov (United States)

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

2018-05-01

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

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

Directory of Open Access Journals (Sweden)

Peter A Lazzarini

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

Staff turnover in statewide implementation of ACT: relationship with ACT fidelity and other team characteristics

OpenAIRE

Rollins, Angela L.; Salyers, Michelle P.; Tsai, Jack; Lydick, Jennifer M.

2010-01-01

Staff turnover on assertive community treatment (ACT) teams is a poorly understood phenomenon. This study examined annual turnover and fidelity data collected in a statewide implementation of ACT over a 5-year period. Mean annual staff turnover across all observations was 30.0%. Turnover was negatively correlated with overall fidelity at Year 1 and 3. The team approach fidelity item was negatively correlated with staff turnover at Year 3. For 13 teams with 3 years of follow-up data, turnover ...

Peer Crowd Identification and Adolescent Health Behaviors: Results From a Statewide Representative Study.

Science.gov (United States)

Jordan, Jeffrey W; Stalgaitis, Carolyn A; Charles, John; Madden, Patrick A; Radhakrishnan, Anjana G; Saggese, Daniel

2018-02-01

Peer crowds are macro-level subcultures that share similarities across geographic areas. Over the past decade, dozens of studies have explored the association between adolescent peer crowds and risk behaviors, and how they can inform public health efforts. However, despite the interest, researchers have not yet reported on crowd size and risk levels from a representative sample, making it difficult for practitioners to apply peer crowd science to interventions. The current study reports findings from the first statewide representative sample of adolescent peer crowd identification and health behaviors. Weighted data were analyzed from the 2015 Virginia Youth Survey of Health Behaviors ( n = 4,367). Peer crowds were measured via the I-Base Survey™, a photo-based peer crowd survey instrument. Frequencies and confidence intervals of select behaviors including tobacco use, substance use, nutrition, physical activity, and violence were examined to identify high- and low-risk crowds. Logistic regression was used to calculate adjusted odds ratios for each crowd and behavior. Risky behaviors clustered in two peer crowds. Hip Hop crowd identification was associated with substance use, violence, and some depression and suicidal behaviors. Alternative crowd identification was associated with increased risk for some substance use behaviors, depression and suicide, bullying, physical inactivity, and obesity. Mainstream and, to a lesser extent, Popular, identities were associated with decreased risk for most behaviors. Findings from the first representative study of peer crowds and adolescent behavior identify two high-risk groups, providing critical insights for practitioners seeking to maximize public health interventions by targeting high-risk crowds.

USFA NFIRS 2013 Fire Incident & Cause Data

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Department of Homeland Security — The 2013 Fire Causes & Incident data was provided by the U.S. Fire Administration’s (USFA) National Fire Data Center’s (NFDC’s) National Fire Incident Reporting...

40 CFR 68.81 - Incident investigation.

Science.gov (United States)

2010-07-01

... 40 Protection of Environment 15 2010-07-01 2010-07-01 false Incident investigation. 68.81 Section 68.81 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be...

Precursor incident program at EDF

International Nuclear Information System (INIS)

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

1998-01-01

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

The State of Washington's Children. [Seventh Annual Report].

Science.gov (United States)

Marvinney, Sandy, Ed.

This KIDS COUNT seventh annual report examines statewide trends in the well-being of Washington's children. The statistical portrait is based 24 key indicators of well-being: (1) teen birth rate; (2) teen pregnancy rate; (3) births to unmarried mothers; (4) divorces involving children; (5) family foster caseload; (6) average real wages; (7) per…

Safety-related incidents at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Lehtinen, P.

1986-03-01

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

Safety-related incidents at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Lehtinen, P.

1985-01-01

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

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

Incidence of hyperthyroidism in Sweden.

Science.gov (United States)

Abraham-Nordling, Mirna; Byström, Kristina; Törring, Ove; Lantz, Mikael; Berg, Gertrud; Calissendorff, Jan; Nyström, Helena Filipsson; Jansson, Svante; Jörneskog, Gun; Karlsson, F Anders; Nyström, Ernst; Ohrling, Hans; Orn, Thomas; Hallengren, Bengt; Wallin, Göran

2011-12-01

The incidence of hyperthyroidism has been reported in various countries to be 23-93/100,000 inhabitants per year. This extended study has evaluated the incidence for ~40% of the Swedish population of 9 million inhabitants. Sweden is considered to be iodine sufficient country. All patients including children, who were newly diagnosed with overt hyperthyroidism in the years 2003-2005, were prospectively registered in a multicenter study. The inclusion criteria are as follows: clinical symptoms and/or signs of hyperthyroidism with plasma TSH concentration below 0.2 mIE/l and increased plasma levels of free/total triiodothyronine and/or free/total thyroxine. Patients with relapse of hyperthyroidism or thyroiditis were not included. The diagnosis of Graves' disease (GD), toxic multinodular goiter (TMNG) and solitary toxic adenoma (STA), smoking, initial treatment, occurrence of thyroid-associated eye symptoms/signs, and demographic data were registered. A total of 2916 patients were diagnosed with de novo hyperthyroidism showing the total incidence of 27.6/100,000 inhabitants per year. The incidence of GD was 21.0/100,000 and toxic nodular goiter (TNG=STA+TMNG) occurred in 692 patients, corresponding to an annual incidence of 6.5/100,000. The incidence was higher in women compared with men (4.2:1). Seventy-five percent of the patients were diagnosed with GD, in whom thyroid-associated eye symptoms/signs occurred during diagnosis in every fifth patient. Geographical differences were observed. The incidence of hyperthyroidism in Sweden is in a lower range compared with international reports. Seventy-five percent of patients with hyperthyroidism had GD and 20% of them had thyroid-associated eye symptoms/signs during diagnosis. The observed geographical differences require further studies.

Decreasing incidence rates of bacteremia

DEFF Research Database (Denmark)

Nielsen, Stig Lønberg; Pedersen, C; Jensen, T G

2014-01-01

BACKGROUND: Numerous studies have shown that the incidence rate of bacteremia has been increasing over time. However, few studies have distinguished between community-acquired, healthcare-associated and nosocomial bacteremia. METHODS: We conducted a population-based study among adults with first......-time bacteremia in Funen County, Denmark, during 2000-2008 (N = 7786). We reported mean and annual incidence rates (per 100,000 person-years), overall and by place of acquisition. Trends were estimated using a Poisson regression model. RESULTS: The overall incidence rate was 215.7, including 99.0 for community......-acquired, 50.0 for healthcare-associated and 66.7 for nosocomial bacteremia. During 2000-2008, the overall incidence rate decreased by 23.3% from 254.1 to 198.8 (3.3% annually, p incidence rate of community-acquired bacteremia decreased by 25.6% from 119.0 to 93.8 (3.7% annually, p

Rodenticide incidents of exposure and adverse effects on non-raptor birds

Science.gov (United States)

Vyas, Nimish B.

2017-01-01

Interest in the adverse effects of rodenticides on birds has focused primarily on raptors. However, non-raptor birds are also poisoned (rodenticide exposure resulting in adverse effects including mortality) by rodenticides through consumption of the rodenticide bait and contaminated prey. A literature search for rodenticide incidents (evidence of exposure to a rodenticide, adverse effects, or exposure to placebo baits) involving non-raptor birds returned 641 records spanning the years 1931 to 2016. The incidents included 17 orders, 58 families, and 190 non-raptor bird species. Nineteen anticoagulant and non-anticoagulant rodenticide active ingredients were associated with the incidents. The number of incidents and species detected were compared by surveillance method. An incident was considered to have been reported through passive surveillance if it was voluntarily reported to the authorities whereas the report of an incident found through field work that was conducted with the objective of documenting adverse effects on birds was determined to be from active surveillance. More incidents were reported from passive surveillance than with active surveillance but a significantly greater number of species were detected in proportion to the number of incidents found through active surveillance than with passive surveillance (z = 7.61, p raptor bird poisonings from rodenticides may increase incident reportings and can strengthen the predictions of harm characterized by risk assessments.

A Meta-Analysis of the Incidence of Patient-Reported Dysphagia After Anterior Cervical Decompression and Fusion with the Zero-Profile Implant System.

Science.gov (United States)

Yang, Yi; Ma, Litai; Liu, Hao; Xu, MangMang

2016-04-01

Dysphagia is a well-known complication following anterior cervical surgery. It has been reported that the Zero-profile Implant System can decrease the incidence of dysphagia following surgery, however, dysphagia after anterior cervical decompression and fusion (ACDF) with the Zero-profile Implant System remains controversial. Previous studies only focus on small sample sizes. The objective of this study was to determine the incidence of dysphagia after ACDF with the Zero-profile Implant System. Studies were collected from PubMed, EMBASE, the Cochrane library and the China Knowledge Resource Integrated Database using the keywords "Zero-profile OR Zero-p) AND (dysphagia OR [swallowing dysfunction]". The software STATA (Version 13.0) was used for statistical analysis. Statistical heterogeneity across the various trials, a test of publication bias and sensitivity analysis was performed. 30 studies with a total of 1062 patients were included in this meta-analysis. The occurrence of post-operative transient dysphagia ranged from 0 to 76 % whilst the pooled incidence was 15.6 % (95 % CI, 12.6, 18.5 %). 23 studies reported no persistent dysphagia whilst seven studies reported persistent dysphagia ranging from 1 to 7 %). In summary, the present study observed a low incidence of both transient and persistent dysphagia after ACDF using the Zero-profile Implant System. Most of the dysphagia was mild and gradually decreased during the following months. Moderate or severe dysphagia was uncommon. Future randomized controlled multi-center studies and those focusing on the mechanisms of dysphagia and methods to reduce its incidence are required.

Contaminated Mexican steel incident

International Nuclear Information System (INIS)

1985-01-01

This report documents the circumstances contributing to the inadvertent melting of cobalt 60 (Co-60) contaminated scrap metal in two Mexican steel foundries and the subsequent distribution of contaminated steel products into the United States. The report addresses mainly those actions taken by US Federal and state agencies to protect the US population from radiation risks associated with the incident. Mexico had much more serious radiation exposure and contamination problems to manage. The United States Government maintained a standing offer to provide technical and medical assistance to the Mexican Government. The report covers the tracing of the source to its origin, response actions to recover radioactive steel in the United States, and return of the contaminated materials to Mexico. The incident resulted in significant radiation exposures within Mexico, but no known significant exposure within the United States. Response to the incident required the combined efforts of the Nuclear Regulatory Commission (NRC), Department of Energy, Department of Transportation, Department of State, and US Customs Service (Department of Treasury) personnel at the Federal level and representatives of all 50 State Radiation Control Programs and, in some instances, local and county government personnel. The response also required a diplomatic interface with the Mexican Government and cooperation of numerous commercial establishments and members of the general public. The report describes the factual information associated with the event and may serve as information for subsequent recommendations and actions by the NRC. 8 figures

Review of methodologies for analysis of safety incidents at NPPs. Final report of a co-ordinated research project 1998-2001

International Nuclear Information System (INIS)

2002-03-01

The safe operation of nuclear power plants around the world and the prevention of incidents in these installations remain key concerns for the nuclear community. In this connection, the feedback of operating experience plays a major role: every nuclear power plant or nuclear utility needs to have a system in place for collecting information on unusual events, whether these are incidents or merely deviations from normal operation. Reporting to the regulatory body of important events and lessons learned is normally carried out through the national reporting schemes based on regulatory reporting requirements. The most important lessons learned are further shared internationally, through, for example, the Joint IAEA/NEA Incident Reporting System (IRS) or the event information exchange of the World Association of Nuclear Operators (WANO). In order to properly assess the event, an adequate event investigation methodology has to be applied, which leads to the identification of correct root causes. Once these root causes have been ascertained, appropriate corrective actions can be established and corresponding lessons can be drawn. The overall goal of root cause analysis is the prevention of events or their recurrence and thus the overall improvement in plant safety. In 1998, the IAEA established a co-ordinated research project with the objective of exploring root cause methodologies and techniques currently in use in Member States, evaluating their strengths and limitations and developing criteria for appropriate event investigation methodologies. This report is the outcome of four years of co-ordinated research which involved 15 national and international research organizations

Self-Reported Periodontitis and Incident Type 2 Diabetes among Male Workers from a 5-Year Follow-Up to MY Health Up Study.

Directory of Open Access Journals (Sweden)

Atsushi Miyawaki

Full Text Available The purpose of this study was to examine whether periodontitis is associated with incident type 2 diabetes in a Japanese male worker cohort.The study participants were Japanese men, aged 36-55 years, without diabetes. Data were extracted from the MY Health Up study, consisting of self-administered questionnaire surveys at baseline and following annual health examinations for an insurance company in Japan. The oral health status of the participants was classified by two self-reported indicators: (1 gingival hemorrhage and (2 tooth loosening. Type 2 diabetes incidence was determined by self-reporting or blood test data. Modified Poisson regression approach was used to estimate the relative risks and the 95% confidence intervals of incident diabetes with periodontitis. Covariates included age, body mass index, family history of diabetes, hypertension, current smoking habits, alcohol use, dyslipidemia, and exercise habits.Of the 2895 candidates identified at baseline in 2004, 2469 men were eligible for follow-up analysis, 133 of whom were diagnosed with diabetes during the 5-year follow-up period. Tooth loosening was associated with incident diabetes [adjusted relative risk = 1.73, 95% confidence interval = 1.14-2.64] after adjusting for other confounding factors. Gingival hemorrhage displayed a similar trend but was not significantly associated with incident diabetes [adjusted relative risk = 1.32, 95% confidence interval = 0.95-1.85].Tooth loosening is an independent predictor of incident type 2 diabetes in Japanese men.

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

DEFF Research Database (Denmark)

Knudsen, Markus Dines; Kyrø, Cecilie; Olsen, Anja

2014-01-01

-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...... (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......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...

The role of patient simulation and incident reporting in the development and evaluation of medical devices and the training of their users

DEFF Research Database (Denmark)

Dieckmann, P; Rall, M; Østergaard, Doris

2009-01-01

incident report. Simulation can serve as a laboratory to analyse such cases and to create relevant and effective training scenarios based on such analyses. We will describe a methodological framework for analysing simulation scenarios in a way that allows discovering and discussing mismatches between...... conceptual models of the device design and mental models users hold about the device and its use. We further describe how incident reporting systems can be used as one source of data to conduct the necessary needs analyses - both for training and further needs for closer analysis of specific devices or some...

The incidence and aetiology of acute pancreatitis across Europe.

Science.gov (United States)

Roberts, Stephen E; Morrison-Rees, Sian; John, Ann; Williams, John G; Brown, Tim H; Samuel, David G

Acute pancreatitis is increasingly one of the most important acute gastrointestinal conditions throughout much of the world, although incidence and aetiology varies across countries and regions. This study investigated regional and national patterns in the incidence and aetiology of acute pancreatitis, demographic patterns in incidence and trends over time in incidence across Europe. A structured review of acute pancreatitis incidence and aetiology from studies of hospitalised patient case series, cohort studies or other population based studies from 1989 to 2015 and a review of trends in incidence from 1970 to 2015 across all 51 European states. The incidence of acute pancreatitis was reported from 17 countries across Europe and ranged from 4.6 to 100 per 100 000 population. Incidence was usually highest in eastern or northern Europe, although reported rates often varied according to case ascertainment criteria. Of 20 studies that reported on trends in incidence, all but three show percentage increases over time (overall median increase = 3.4% per annum; range = -0.4%-73%). The highest ratios of gallstone to alcohol aetiologies were identified in southern Europe (Greece, Turkey, Italy and Croatia) with lowest ratios mainly in eastern Europe (Latvia, Finland, Romania, Hungary, Russia and Lithuania). The incidence of acute pancreatitis varies across Europe. Gallstone is the dominant aetiology in southern Europe and alcohol in eastern Europe with intermediate ratios in northern and western Europe. Acute pancreatitis continues to increase throughout most of Europe. Copyright © 2017. Published by Elsevier B.V.

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

International Nuclear Information System (INIS)

1998-01-01

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

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

Science.gov (United States)

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

2014-01-01

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

Developing and maintaining state-wide adolescent pregnancy prevention coalitions: a preliminary investigation.

Science.gov (United States)

Nezlek, J B; Galano, J

1993-09-01

This paper presents the results of a study of state-wide adolescent pregnancy prevention coalitions. Key informants in five states throughout the southern United States were given semi-structured interviews regarding the adolescent pregnancy prevention coalitions in their states. From these interviews and other documents, conclusions were drawn regarding the nature and importance of the environments within which these coalitions operate, the universe of activities in which coalitions engage, and the stages of development of these coalitions. Katz and Kahn's model of social organizations served as the basis for understanding coalitions in terms of these three considerations. Future research should consider the utility of organizational models that can explain more fully the organization--committee hybrid structure that tends to characterize these coalitions.

A Statewide Partnership for Implementing Inquiry Science

Science.gov (United States)

Lytle, Charles

The North Carolina Infrastructure for Science Education (NC-ISE) is a statewide partnership for implementing standards-based inquiry science using exemplary curriculum materials in the public schools of North Carolina. North Carolina is the 11th most populous state in the USA with 8,000,000 residents, 117 school districts and a geographic area of 48,718 miles. NC-ISE partners include the state education agency, local school systems, three branches of the University of North Carolina, the state mathematics and science education network, businesses, and business groups. The partnership, based upon the Science for All Children model developed by the National Science Resources Centre, was initiated in 1997 for improvement in teaching and learning of science and mathematics. This research-based model has been successfully implemented in several American states during the past decade. Where effectively implemented, the model has led to significant improvements in student interest and student learning. It has also helped reduce the achievement gap between minority and non-minority students and among students from different economic levels. A key program element of the program is an annual Leadership Institute that helps teams of administrators and teachers develop a five-year strategic plan for their local systems. Currently 33 of the117 local school systems have joined the NC-ISE Program and are in various stages of implementation of inquiry science in grades K-8.

Invasive cancer incidence - Puerto Rico, 2007-2011.

Science.gov (United States)

O'Neil, Mary Elizabeth; Henley, S Jane; Singh, Simple D; Wilson, Reda J; Ortiz-Ortiz, Karen J; Ríos, Naydi Pérez; Torres Cintrón, Carlos R; Luna, Guillermo Tortolero; Zavala Zegarra, Diego E; Ryerson, A Blythe

2015-04-17

Cancer is a leading cause of morbidity and death in Puerto Rico. To set a baseline for identifying new trends and patterns of cancer incidence, Puerto Rico Central Cancer Registry staff and CDC analyzed data from Puerto Rico included in U.S. Cancer Statistics (USCS) for 2007-2011, the most recent data available. This is the first report of invasive cancer incidence rates for 2007-2011 among Puerto Rican residents by sex, age, cancer site, and municipality. Cancer incidence rates in Puerto Rico were compared with those in the U.S. population for 2011. A total of 68,312 invasive cancers were diagnosed and reported in Puerto Rico during 2007-2011. The average annual incidence rate was 330 cases per 100,000 persons. The cancer sites with the highest cancer incidence rates included prostate (152), female breast (84), and colon and rectum (43). Cancer incidence rates varied by municipality, particularly for prostate, lung and bronchus, and colon and rectum cancers. In 2011, cancer incidence rates in Puerto Rico were lower for all cancer sites and lung and bronchus, but higher for prostate and thyroid cancers, compared with rates within the U.S. Identifying these variations can aid evaluation of factors associated with high incidence, such as cancer screening practices, and development of targeted cancer prevention and control efforts. Public health professionals can monitor cancer incidence trends and use these findings to evaluate the impact of prevention efforts, such as legislation prohibiting tobacco use in the workplace and public places and the Puerto Rico Cessation Quitline in decreasing lung and other tobacco-related cancers.

Detailed semantic analyses of human error incidents occurring at nuclear power plant in USA (interim report). Characteristics of human error incidents occurring in the period from 1992 to 1996

International Nuclear Information System (INIS)

Hirotsu, Yuko; Tsuge, Tadashi; Sano, Toshiaki; Takano, Kenichi; Gouda, Hidenori

2001-01-01

CRIEPI has been conducting detailed analyses of all human error incidents at domestic nuclear power plants (NPPs) collected from Japanese Licensee Event Reports (LERs) using J-HPES (Japanese version of HPES) as an analysis method. Results obtained by the analyses have been stored in J-HPES database. Since 1999, human error incidents have been selected from U.S. LERs, and they are analyzed using J-HPES. In this report, the results, which classified error action, cause, and preventive measure, are summarized for U.S. human error cases occurring in the period from 1992 to 1996. It was suggested as a result of classification that the categories of error action were almost the same as those of Japanese human error cases. Therefore, problems in the process of error action and checkpoints for preventing errors will be extracted by analyzing both U.S. and domestic human error cases. It was also suggested that the interrelations between error actions, causes, and organizational factors could be identified. While taking these suggestions into consideration, we will continue to analyze U.S. human error cases. (author)

Stuck in Neutral: Stalled Progress in Statewide Comprehensive Smoke-Free Laws and Cigarette Excise Taxes, United States, 2000–2014

Science.gov (United States)

King, Brian A.; Babb, Stephen D.

2016-01-01

Introduction Increasing tobacco excise taxes and implementing comprehensive smoke-free laws are two of the most effective population-level strategies to reduce tobacco use, prevent tobacco use initiation, and protect nonsmokers from secondhand smoke. We examined state laws related to smoke-free buildings and to cigarette excise taxes from 2000 through 2014 to see how implementation of these laws from 2000 through 2009 differs from implementation in more recent years (2010–2014). Methods We used legislative data from LexisNexis, an online legal research database, to examine changes in statewide smoke-free laws and cigarette excise taxes in effect from January 1, 2000, through December 31, 2014. A comprehensive smoke-free law was defined as a statewide law prohibiting smoking in all indoor areas of private work sites, restaurants, and bars. Results From 2000 through 2009, 21 states and the District of Columbia implemented comprehensive smoke-free laws prohibiting smoking in work sites, restaurants, and bars. In 2010, 4 states implemented comprehensive smoke-free laws. The last state to implement a comprehensive smoke-free law was North Dakota in 2012, bringing the total number to 26 states and the District of Columbia. From 2000 through 2009, 46 states and the District of Columbia implemented laws increasing their cigarette excise tax, which increased the national average state excise tax rate by $0.92. However, from 2010 through 2014, only 14 states and the District of Columbia increased their excise tax, which increased the national average state excise tax rate by $0.20. Conclusion The recent stall in progress in enacting and implementing statewide comprehensive smoke-free laws and increasing cigarette excise taxes may undermine tobacco prevention and control efforts in the United States, undercutting efforts to reduce tobacco use, exposure to secondhand smoke, health disparities, and tobacco-related illness and death. PMID:27309417

Radiological incidents in industrial gamma radiography in the Philippines, 1979-1993

International Nuclear Information System (INIS)

Borras, A.M.

1994-01-01

Among the many practices of radiation sources, the practice of industrial gamma radiography in the country has the most number of reported radiological incidents. During the past fourteen (14) years, from 1979-1993, twenty (20) incidents that have occurred were reported to the Institute. This paper presents the nature and extent of the 20 reported incidents as well as the results of the analysis of why these incidents happened. The results of the analysis showed that the causes of these incidents are mainly human error and equipment failure. Hence, the factors that can minimize or prevent the chance of occurrence and/or recurrence of incidents and in minimizing the hazard in case of radiological incidents are: a) proper training and re-training of personnel; b) proper and regular inspection and maintenance of equipment; c) adequate radiation survey; and d) proper storage and inventory of the radiography sealed sources. (author). 3 refs.; 5 figs.; 1 tab

Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.

Science.gov (United States)

Wylie, Matthew C; Baier, Rosa R; Gardner, Rebekah L

2014-10-01

Although electronic health record use improves healthcare delivery, adoption into clinical practice is incomplete. We sought to identify the extent of adoption in Rhode Island and the characteristics of physicians and electronic health records associated with positive experience. We performed a cross-sectional study of data collected by the Rhode Island Department of Health for the Health Information Technology Survey 2009 to 2013. Survey questions included provider and practice demographics, health record information, and Likert-type scaled questions regarding how electronic health record use affected clinical practice. The survey response rate ranged from 50% to 65%, with 62% in 2013. Increasing numbers of physicians in Rhode Island use an electronic health record. In 2013, 81% of physicians used one, and adoption varied by clinical subspecialty. Most providers think that electronic health record use improves billing and quality improvement but has not improved job satisfaction. Physicians with longer and more sophisticated electronic health record use report positive effects of introduction on all aspects of practice examined (P electronic health record introduction (P electronic health record vendors most frequently used in Rhode Island, 5 were associated with improved job satisfaction. We report the largest statewide study of electronic health record adoption to date. We found increasing physician use in Rhode Island, and the extent of adoption varies by subspecialty. Although older physicians are less likely to be positive about electronic health record adoption, longer and more sophisticated use are associated with more positive opinions, suggesting acceptance will grow over time. Copyright © 2014 Elsevier Inc. All rights reserved.

Performance measures to characterize directional corridor travel time delay based on probe vehicle data : final report.

Science.gov (United States)

2015-10-01

Anonymous probe vehicle data are currently being collected on roadways throughout the United States. These data are being incorporated into local and statewide mobility reports to measure the performance of freeways and arterial systems. Predefined s...

Police Incident Blotter (Archive)

Data.gov (United States)

Allegheny County / City of Pittsburgh / Western PA Regional Data Center — The Police Blotter Archive contains crime incident data after it has been validated and processed to meet Uniform Crime Reporting (UCR) standards, published on a...

Classification of medication incidents associated with information technology.

Science.gov (United States)

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

2014-02-01

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

A five-year history of hazardous materials incidents in Chester County, PA

International Nuclear Information System (INIS)

Shorten, C.V.; McNamara, J.

1993-01-01

The Emergency Planning and Community Right-to-Know Act (EPCRA) of 1986 established Local Emergency Planning Committees (LEPCs) to oversee emergency response planning at the community level. In Pennsylvania, each county was assigned its own LEPC, and Chester County held its first LEPC meeting on October 15, 1987. From the data of that meeting through September 1992, 300 hazardous materials incidents have been reported. The majority of these incidents were met with fire department response, but several warranted response by hazardous materials teams. This report presents an analysis of the database of reported hazardous materials incidents in Chester County, including chemical identification, amount released, type of response, location, and trends. Over 235 of the reported spills were either gasoline, diesel fuel, home heating oil, or kerosene, often in five to 50 gallon amounts from transportation accidents. A number of extremely hazardous substance (EHS) incidents were reported, however, including sulfuric acid, chlorine, ammonia, phosphorus, formaldehyde, bromine, methyl mercaptan, and hydrofluoric acid. The most commonly released EHS's were ammonia and chlorine. The number of hazardous materials incidents reported in Chester County increased from only 14 in 1988 to 95 in 1991, with 67 in 1992 through September. This dramatic increase is attributable to both increased reporting and an increased number of incidents. This database clearly indicates both the success of EPCRA reporting system and the magnitude of hazardous materials incidents in this part of Pennsylvania

Dissociative Tendencies and Traffic Incidents

Directory of Open Access Journals (Sweden)

Valle, Virginia

2012-01-01

Full Text Available This paper analyses the relationship between dissociative experiences and road traffic incidents (crashes and traffic tickets in drivers (n=295 from Mar del Plata (Argentina city. A self-report questionnaire was applied to assess traffic crash involvement and sociodemographic variables. Dissociative tendencies were assessed by a modified version of the DES scale. To examine differences in DES scores tests of the difference of means were applied. Drivers who reported to be previously involved in traffic incidents obtained higher puntuations in the dissociative experiences scale than drivers who did not report such events. This result is observed for the total scale and for the three sub-scales (absorption, amnesia and depersonalization. However, differences appeared mainly for minor damage collisions. Further studies are needed to evaluate the role of dissociative tendencies as a risk factor in road traffic safety.

The State of Washington's Children, Fall 2001. [Ninth Annual Report].

Science.gov (United States)

Washington Univ., Seattle. School of Public Health and Community Medicine.

This Kids Count report is the ninth to examine annually statewide trends in the well-being of Washington's children. The statistical portrait is based on indicators of child well-being in five areas: (1) family and community, including teen birth rate, teen pregnancy rate, divorces involving children, and births to unmarried mothers; (2) economic…

[Rules and regulations applying to incidents in radiotherapy].

Science.gov (United States)

Lohr, F; Baus, W; Vorwerk, H; Schlömp, B; André, L; Georg, D; Hodapp, N

2012-07-01

Radiotherapy is an essential and reliable element of the treatment armamentarium in oncology. Numerous rules, regulations, and protocols minimize the associated risks. It can, however, never be excluded that errors in the treatment delivery chain result in inadequate tumor doses or unnecessary damage to organs at risk. A legal framework governs the management of such incidents. The most important European and North American regulations are reported. Various directives issued by the European Union are differently implemented nationally. This applies particularly to the characterization of incidents that must be reported to authorities. Reporting thresholds, audit systems, and the extent of the integration of voluntary reporting systems vary. Radiotherapy incidents are dealt with differently on an international level. Changes are to be expected based on the European Basic Safety Standards Directive that is currently being prepared and will have to be implemented nationally in due course.

Rules and regulations applying to incidents in radiotheraphy

International Nuclear Information System (INIS)

Lohr, F.; Andre, L.; Georg, D.; Hodapp, N.

2012-01-01

Aims and purpose: Radiotherapy is an essential and reliable element of the treatment armamentarium in oncology. Numerous rules, regulations, and protocols minimize the associated risks. It can, however, never be excluded that errors in the treatment delivery chain result in inadequate tumor doses or unnecessary damage to organs at risk. A legal framework governs the management of such incidents. The most important European and North American regulations are reported. Results: Various directives issued by the European Union are differently implemented nationally. This applies particularly to the characterization of incidents that must be reported to authorities. Reporting thresholds, audit systems, and the extent of the integration of voluntary reporting systems vary. Conclusion: Radiotherapy incidents are dealt with differently on an international level. Changes are to be expected based on the European Basic Safety Standards Directive that is currently being prepared and will have to be implemented nationally in due course. (orig.)

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

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

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

Developing a statewide public health initiative to reduce infant mortality in Oklahoma.

Science.gov (United States)

Dooley, Suzanna; Patrick, Paul; Lincoln, Alicia; Cline, Janette

2014-01-01

The Preparing for a Lifetime, It's Everyone's Responsibility initiative was developed to improve the health and well- being of Oklahoma's mothers and infants. The development phase included systematic data collection, extensive data analysis, and multi-disciplinary partnership development. In total, seven issues (preconception/interconception health, tobacco use, postpartum depression, breastfeeding, infant safe sleep, preterm birth, and infant injury prevention) were identified as crucial to addressing infant mortality in Oklahoma. Workgroups were created to focus on each issue. Data and media communications workgroups were added to further partner commitment and support for policy and programmatic changes across multiple agencies and programs. Leadership support, partnership, evaluation, and celebrating small successes were important factors that lead to large scale adoption and support for the state-wide initiative to reduce infant mortality.

Appendix : airborne incidents : an econometric analysis of severity

Science.gov (United States)

2014-12-19

This is the Appendix for Airborne Incidents: An Econometric Analysis of Severity Report. : Airborne loss of separation incidents occur when an aircraft breaches the defined separation limit (vertical and/or horizontal) with another aircraft or terrai...

Quality Assessment of Colonoscopy Reporting: Results from a Statewide Cancer Screening Program

Directory of Open Access Journals (Sweden)

Jun Li

2010-01-01

Full Text Available This paper aimed to assess quality of colonoscopy reports and determine if physicians in practice were already documenting recommended quality indicators, prior to the publication of a standardized Colonoscopy Reporting and Data System (CO-RADS in 2007. We examined 110 colonoscopy reports from 2005-2006 through Maryland Colorectal Cancer Screening Program. We evaluated 25 key data elements recommended by CO-RADS, including procedure indications, risk/comorbidity assessments, procedure technical descriptions, colonoscopy findings, specimen retrieval/pathology. Among 110 reports, 73% documented the bowel preparation quality and 82% documented specific cecal landmarks. For the 177 individual polyps identified, information on size and morphology was documented for 87% and 53%, respectively. Colonoscopy reporting varied considerately in the pre-CO-RADS period. The absence of key data elements may impact the ability to make recommendations for recall intervals. This paper provides baseline data to assess if CO-RADS has an impact on reporting and how best to improve the quality of reporting.

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

Science.gov (United States)

2010-07-01

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

Successful long-term maintenance following Nutrition Care Process Terminology implementation across a state-wide health-care system.

Science.gov (United States)

Vivanti, Angela; O'Sullivan, Therese A; Porter, Jane; Hogg, Marion

2017-09-01

Three years following a state-wide Nutrition Care Process Terminology (NCPT) implementation project, the present study aimed to (i) assess changes in NCPT knowledge and attitudes, (ii) identify implementation barriers and enablers and (iii) seek managers' opinions post-implementation. Pre-implementation and three years post-implementation, all Queensland Government hospitals state-wide were invited to repeat a validated NCPT survey. Additionally, a separate survey sought dietetic managers' opinions regarding NCPT's use and acceptance, usefulness for patient care, role in service planning and continued use. A total of 238 dietitians completed the survey in 2011 and 82 dietitians in 2014. Use of diagnostic statement in the previous six months improved (P  0.05). Key elements in sustaining NCPT implementation over three years included ongoing management support, workshops/tutorials, discussion and mentor and peer support. The most valued resources were pocket guides, ongoing workshops/tutorials and mentor support. Dietetic managers held many positive NCPT views, however, opinions differed around the usefulness of service planning, safer practice, improving patient care and facilitating communication. Some managers would not support NCPT unless it was recommended for practice. Immediate improvements following the NCPT implementation project were sustained over three years. Moving forward, a professional focus on continuing to incorporate NCPT into standard practice will provide structure for process and outcomes assessment. © 2017 State of Queensland. Nutrition and Dietetics © 2017 Dietitians Association of Australia.

Under Pressure: Financial Effect of the Hospital-Acquired Conditions Initiative-A Statewide Analysis of Pressure Ulcer Development and Payment.

Science.gov (United States)

Meddings, Jennifer; Reichert, Heidi; Rogers, Mary A M; Hofer, Timothy P; McMahon, Laurence F; Grazier, Kyle L

2015-07-01

To assess the financial effect of the 2008 Hospital-Acquired Conditions Initiative (HACI) pressure ulcer payment changes on Medicare, other payers, and hospitals. Retrospective before-and-after study of all-payer statewide administrative data for more than 2.4 million annual adult discharges in 2007 and 2009 using the Healthcare Cost and Utilization Project State Inpatient Datasets for California. How often and by how much the 2008 payment changes for pressure ulcers affected hospital payment was assessed. Nonfederal acute care California hospitals (N = 311). Adults discharged from acute-care hospitals. Pressure ulcer rates and hospital payment changes. Hospital-acquired pressure ulcer rates were low in 2007 (0.28%) and 2009 (0.27%); present-on-admission pressure ulcer rates increased from 2.3% in 2007 to 3.0% in 2009. According to clinical stage of pressure ulcer (available in 2009), hospital-acquired Stage III and IV ulcers occurred in 603 discharges (0.02%); 60,244 discharges (2.42%) contained other pressure ulcer diagnoses. Payment removal for Stage III and IV hospital-acquired ulcers reduced payment in 75 (0.003%) discharges, for a statewide payment decrease of $310,444 (0.001%) for all payers and $199,238 (0.001%) for Medicare. For all other pressure ulcers, the Hospital-Acquired Conditions Initiative reduced hospital payment in 20,246 (0.81%) cases (including 18,953 cases with present-on-admission ulcers), reducing statewide payment by $62,538,586 (0.21%) for all payers and $47,237,984 (0.32%) for Medicare. The total financial effect of the 2008 payment changes for pressure ulcers was negligible. Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure ulcers other than Stages III and IV. The removal of payment for hospital-acquired Stage III and IV ulcers by implementation of the HACI policy was 1/200th that of the removal of payment for other types of pressure ulcers that occurred in implementation of the

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

Science.gov (United States)

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

2015-01-01

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

An error taxonomy system for analysis of haemodialysis incidents.

Science.gov (United States)

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

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

Illinois statewide gas utility plan, 1993-2002. Volume 1. Executive summary

International Nuclear Information System (INIS)

1992-12-01

The second Illinois Statewide Natural Gas Utility Plan is a continuation of the Least-Cost Planning effort introduced by the Public Utilities Act of 1986. The purpose of the Plan, like its predecessor, is to provide a framework and a set of policies which will allow and encourage local distribution companies to develop least-cost plans consistent with the goals of the Act: to provide efficient, environmentally sound, reliable, and equitable public utility service at the least possible cost. The Plan assesses natural gas demand and supply under five scenarios for the period 1993-2002. Key issues related to the development of least-cost natural gas plans are identified, and policies for addressing the issues are developed. The rationale and potential for natural gas demand side management (DSM) programs and policies are explored, and recommendations made with respect to utility DSM capability-building and DSM cost-recovery

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

Science.gov (United States)

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

2008-09-01

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

Critical incident monitoring in anaesthesia.

Science.gov (United States)

Choy, Y C

2006-12-01

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

Radiological Cs-137 accidents/incidents in Estonia

International Nuclear Information System (INIS)

Sinisso, Mark

1997-01-01

Two radiological accidents/incidents in Estonia are reported. The first -21 October 1994, three brothers entered the Tammiku repository and stole a radioactive Cs-137 source and received dangerous doses of radiation. The other incident (early 1995) involved an abandoned source - a discarded metal cylinder containing Cs-137. Chronologies and factual data are considered for both events. Concise descriptions of the incidents, a medical overview of the fate of injured people and lessons learned are presented

Radiological Cs-137 accidents/incidents in Estonia

Energy Technology Data Exchange (ETDEWEB)

Sinisso, Mark [Ministry of Foreign Affairs, Tallin (Estonia)

1997-12-31

Two radiological accidents/incidents in Estonia are reported. The first -21 October 1994, three brothers entered the Tammiku repository and stole a radioactive Cs-137 source and received dangerous doses of radiation. The other incident (early 1995) involved an abandoned source - a discarded metal cylinder containing Cs-137. Chronologies and factual data are considered for both events. Concise descriptions of the incidents, a medical overview of the fate of injured people and lessons learned are presented

Incidence of self-reported brain injury and the relationship with substance abuse: findings from a longitudinal community survey

Directory of Open Access Journals (Sweden)

Butterworth Peter

2010-03-01

Full Text Available Abstract Background Traumatic or serious brain injury (BI has persistent and well documented adverse outcomes, yet 'mild' or 'moderate' BI, which often does not result in hospital treatment, accounts for half the total days of disability attributed to BI. There are currently few data available from community samples on the incidence and correlates of these injuries. Therefore, the study aimed to assess the 1 incidence of self-reported mild (not requiring hospital admission and moderate (admitted to hospital brain injury (BI, 2 causes of injury 3 physical health scores and 4 relationship between BI and problematic alcohol or marijuana use. Methods An Australian community sequential-cohort study (cohorts aged 20-24, 40-44 and 60-64 years at wave one used a survey methodology to assess BI and substance use at baseline and four years later. Results Of the 7485 wave one participants, 89.7% were re-interviewed at wave two. There were 56 mild (230.8/100000 person-years and 44 moderate BI (180.5/100000 person-years reported between waves one and two. Males and those in the 20-24 year cohort had increased risk of BI. Sports injury was the most frequent cause of BI (40/100 with traffic accidents being a greater proportion of moderate (27% than mild (7% BI. Neither alcohol nor marijuana problems at wave one were predictors of BI. BI was not a predictor of developing substance use problems by wave two. Conclusions BI were prevalent in this community sample, though the incidence declined with age. Factors associated with BI in community samples differ from those reported in clinical samples (e.g. typically traumatic brain injury with traffic accidents the predominate cause. Further, detailed evaluation of the health consequences of these injuries is warranted.

The State of Washington's Children, Summer 2002. [Tenth Annual Report].

Science.gov (United States)

Connell, Frederick A.; Brandon, Richard; Hill, Sheri L.; Carter, S. Louise; Garrison, Michelle M.; DeWys, Shelley; Mandell, Dorothy J.

This Kids Count report is the tenth to examine annually statewide trends in the well-being of Washington's children and focuses on child poverty and the needs of the working poor. The statistical portrait is based on indicators of child well-being in five areas: (1) family and community, including teen birth rate, teen pregnancy rate, births to…

Association of ambient particulate matter with heart failure incidence and all-cause readmissions in Tasmania: an observational study.

Science.gov (United States)

Huynh, Quan L; Blizzard, Christopher Leigh; Marwick, Thomas H; Negishi, Kazuaki

2018-05-10

We sought to investigate the relationship between air quality and heart failure (HF) incidence and rehospitalisation to elucidate whether there is a threshold in this relationship and whether this relationship differs for HF incidence and rehospitalisation. This retrospective observational study was performed in an Australian state-wide setting, where air pollution is mainly associated with wood-burning for winter heating. Data included all 1246 patients with a first-ever HF hospitalisation and their 3011 subsequent all-cause readmissions during 2009-2012. Daily particulate matter <2.5 µm (PM 2.5 ), temperature, relative humidity and influenza infection were recorded. Poisson regression was used, with adjustment for time trend, public and school holiday and day of week. Tasmania has excellent air quality (median PM 2.5 =2.9 µg/m 3 (IQR: 1.8-6.0)). Greater HF incidences and readmissions occurred in winter than in other seasons (p<0.001). PM 2.5 was detrimentally associated with HF incidence (risk ratio (RR)=1.29 (1.15-1.42)) and weakly so with readmission (RR=1.07 (1.02-1.17)), with 1 day time lag. In multivariable analyses, PM 2.5 significantly predicted HF incidence (RR=1.12 (1.01-1.24)) but not readmission (RR=0.96 (0.89-1.04)). HF incidence was similarly low when PM <4 µg/m 3 and only started to rise when PM 2.5 ≥4 µg/m 3 . Stratified analyses showed that PM 2.5 was associated with readmissions among patients not taking beta-blockers but not among those taking beta-blockers (p interaction =0.011). PM 2.5 predicted HF incidence, independent of other environmental factors. A possible threshold of PM 2.5 =4 µg/m 3 is far below the daily Australian national standard of 25 µg/m 3 . Our data suggest that beta-blockers might play a role in preventing adverse association between air pollution and patients with HF. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial

Survey of incidents in West German nuclear power plants in the last quarter of the year 1988

International Nuclear Information System (INIS)

1989-01-01

There were 79 incidents reported. Six incidents belong to reporting category E (immediate notification), the remaining 73 incidents belong to reporting category N (normal notification). The survey covers all incidents reported to GRS until the 15th of February 1989 and also includes incidents that happened before the last quarter of 1988 but were recorded later. There was no release of radioactivity involved in the incidents, and there are no effects on man or the environment reported. (orig./HP) [de

The CSB Incident Screening Database: description, summary statistics and uses.

Science.gov (United States)

Gomez, Manuel R; Casper, Susan; Smith, E Allen

2008-11-15

This paper briefly describes the Chemical Incident Screening Database currently used by the CSB to identify and evaluate chemical incidents for possible investigations, and summarizes descriptive statistics from this database that can potentially help to estimate the number, character, and consequences of chemical incidents in the US. The report compares some of the information in the CSB database to roughly similar information available from databases operated by EPA and the Agency for Toxic Substances and Disease Registry (ATSDR), and explores the possible implications of these comparisons with regard to the dimension of the chemical incident problem. Finally, the report explores in a preliminary way whether a system modeled after the existing CSB screening database could be developed to serve as a national surveillance tool for chemical incidents.

Introduction of a prehospital critical incident monitoring system--pilot project results.

Science.gov (United States)

Stella, Julian; Davis, Anna; Jennings, Paul; Bartley, Bruce

2008-01-01

Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited. Implementation of an incident monitoring process in a prehospital setting. This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations. Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for

Development of a model web-based system to support a statewide quality consortium in radiation oncology.

Science.gov (United States)

Moran, Jean M; Feng, Mary; Benedetti, Lisa A; Marsh, Robin; Griffith, Kent A; Matuszak, Martha M; Hess, Michael; McMullen, Matthew; Fisher, Jennifer H; Nurushev, Teamour; Grubb, Margaret; Gardner, Stephen; Nielsen, Daniel; Jagsi, Reshma; Hayman, James A; Pierce, Lori J

A database in which patient data are compiled allows analytic opportunities for continuous improvements in treatment quality and comparative effectiveness research. We describe the development of a novel, web-based system that supports the collection of complex radiation treatment planning information from centers that use diverse techniques, software, and hardware for radiation oncology care in a statewide quality collaborative, the Michigan Radiation Oncology Quality Consortium (MROQC). The MROQC database seeks to enable assessment of physician- and patient-reported outcomes and quality improvement as a function of treatment planning and delivery techniques for breast and lung cancer patients. We created tools to collect anonymized data based on all plans. The MROQC system representing 24 institutions has been successfully deployed in the state of Michigan. Since 2012, dose-volume histogram and Digital Imaging and Communications in Medicine-radiation therapy plan data and information on simulation, planning, and delivery techniques have been collected. Audits indicated >90% accurate data submission and spurred refinements to data collection methodology. This model web-based system captures detailed, high-quality radiation therapy dosimetry data along with patient- and physician-reported outcomes and clinical data for a radiation therapy collaborative quality initiative. The collaborative nature of the project has been integral to its success. Our methodology can be applied to setting up analogous consortiums and databases. Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Agency procedures for the NRC incident response plan. Final report

International Nuclear Information System (INIS)

1983-02-01

The NRC Incident Response Plan, NUREG-0728/MC 0502 describes the functions of the NRC during an incident and the kinds of actions that comprise an NRC response. The NRC response plan will be activated in accordance with threshold criteria described in the plan for incidents occurring at nuclear reactors and fuel facilities involving materials licensees; during transportation of licensed material, and for threats against facilities or licensed material. In contrast to the general overview provided by the Plan, the purpose of these agency procedures is to delineate the manner in which each planned response function is performed; the criteria for making those response decisions which can be preplanned; and the information and other resources needed during a response. An inexperienced but qualified person should be able to perform functions assigned by the Plan and make necessary decisions, given the specified information, by becoming familiar with these procedures. This rule of thumb has been used to determine the amount of detail in which the agency procedures are described. These procedures form a foundation for the training of response personnel both in their normal working environment and during planned emergency exercises. These procedures also form a ready reference or reminder checklist for technical team members and managers during a response

Incident Reporting in Mashhad Hospitals

Directory of Open Access Journals (Sweden)

Davoodi R

2013-10-01

Full Text Available Objectives: In this study, our aim was to evaluate and classify the voluntary error reports in the hospitals of Mashhad University of Medical Sciences. Patients have the right to receive health care in accordance to the best standards. Health care carries a risk of harm for patient safety, and with respect to today’s stressful systems with a large number of patients, it would be inevitable. The meaning of risk management is to predict adverse events and reduce their occurrence.Materials and Methods: A voluntary medical error reporting form was designed and approved by the clinical governance team of Mashhad Medical University. They were then distributed inside hospitals in the way in which everyone (health providers and patients could access them easily. The forms were collected and classified monthly in all wards. Classification was performed on the base of type, outcome and reporter. Data gathering took place from spring to autumn 2012. The data was analyzed by the SPSS software. Results: 2500 errors were extracted from 1000 voluntary error reporting forms of the 12 hospitals of Mashhad Medical University. The most frequent error type was treatment errors (36% related to drug administration, standard procedures and surgical events. Conclusions: Error reporting as a basic activity has an important role in discovering pitfalls of the health care system. To promote the reporting culture, its non punitive base must become clear for all professors and staff members, because this kind of reporting could lead to fewer medical errors and higher staff awareness about probable errors.

Communicating the Improvements Developed from Critical Incident Reports is an Essential Part of CIRS.

Science.gov (United States)

Hubertus, J; Piehlmeier, W; Heinrich, M

2016-09-01

The Critical Incident Reporting System (CIRS) is a tool for employees to report anonymously of near misses. Its efficiency and improvement of safety is proved by many studies. Our department introduced CIRS in 2009 and it is used frequently. As the number of reports decreased over time we asked for factors responsible for the reduced use. All employees had access to CIRS and have been trained in several courses of instruction. Accomplished results and consequences were published in biannual newsletters. In 2014 we initiated an anonymous employee attitude survey to ask for their experience and satisfaction with CIRS. 88 near misses were reported since 2009. 44 (50%) reports were classified as RS1, 34 (38.6%) as RS2, and 10 (11.4%) as RS3. No RS4 reports were notified. Most reports concerned problems with administration of medication (n=26; 29.5%) and problems with technical devices (n=18; 20.5%). 75 (83%) of our employees participated in the survey. 64 (86.5%) discerned that CIRS is anonymous. 31 (41.9%) reported already a near miss. Of note, two-third didn't realize an improvement following their report. On the other hand, only half of the pollees stated to read the newsletter. Even if efficiency and advantages of CIRS are proved and undeniable, sufficient and perpetual feedback of results and improvements developed by the CIRS team and regular trainings of the employees are mandatory for the success of CIRS. © Georg Thieme Verlag KG Stuttgart · New York.

Using the critical incident survey to assess hospital service quality.

Science.gov (United States)

Longo, B; Connor, G; Barnhart, T

1993-01-01

This survey was designed to determine "standards of excellence" in hospital services as defined by (a) former patients, (b) physicians, (c) hospital employees, and (d) corporate insurance subscribers. One hundred forty-seven (147) patients, 188 employees, and 20 corporate subscribers were interviewed by telephone, and 52 physicians were interviewed in their offices. The interview consisted of a single question: "Can you think of a time when, as a patient/employee/employer/physician, you had a particularly satisfying or dissatisfying experience with a local hospital?" Reported incidents were reviewed, and 239 "critical incidents" were identified. These incidents were classified into 12 descriptive categories relating to the underlying factors in the incident reports. Six focus groups were later held with participants segregated by the population pool they represented. These groups were asked to develop definitions of "excellence" in hospital service quality and standards for service which would "exceed expectations." The focus groups created 122 standards of excellence, which were classified into 43 categories. Overall, the largest percentages of corporate, physician, and employee critical incidents were classified as "Administrative Policy" issues. Patients most often reported "Nurturing" incidents as critical to their perceptions of hospital service quality.

Investigation and evaluation of cracking incidents in piping in pressurized water reactors. Technical report

International Nuclear Information System (INIS)

1980-09-01

This report summarizes an investigation of known cracking incidents in pressurized water reactor plants. Several instances of cracking in feedwater piping in 1979, together with reported cases of stress corrosion cracking at Three Mile Island Unit 1, led to the establishment of the third Pipe Crack Study Group. Major differences between the scope of the third PCSG and the previous two are: (1) the emphasis given to systems safety implications of cracking, and (2) the consideration given all cracking mechanisms known to affect PWR piping, including the failure of small lines in secondary safety systems. The present PCSG reviewed existing information on cracking of PWR pipe systems, either contained in written records of collected from meetings in the United States, and made recommendations in response to the PCSG charter questions and to othe major items that may be considered to either reduce the potential for cracking or to improve licensing bases

A global model of malaria climate sensitivity: comparing malaria response to historic climate data based on simulation and officially reported malaria incidence

Directory of Open Access Journals (Sweden)

Edlund Stefan

2012-09-01

Full Text Available Abstract Background The role of the Anopheles vector in malaria transmission and the effect of climate on Anopheles populations are well established. Models of the impact of climate change on the global malaria burden now have access to high-resolution climate data, but malaria surveillance data tends to be less precise, making model calibration problematic. Measurement of malaria response to fluctuations in climate variables offers a way to address these difficulties. Given the demonstrated sensitivity of malaria transmission to vector capacity, this work tests response functions to fluctuations in land surface temperature and precipitation. Methods This study of regional sensitivity of malaria incidence to year-to-year climate variations used an extended Macdonald Ross compartmental disease model (to compute malaria incidence built on top of a global Anopheles vector capacity model (based on 10 years of satellite climate data. The predicted incidence was compared with estimates from the World Health Organization and the Malaria Atlas. The models and denominator data used are freely available through the Eclipse Foundation’s Spatiotemporal Epidemiological Modeller (STEM. Results Although the absolute scale factor relating reported malaria to absolute incidence is uncertain, there is a positive correlation between predicted and reported year-to-year variation in malaria burden with an averaged root mean square (RMS error of 25% comparing normalized incidence across 86 countries. Based on this, the proposed measure of sensitivity of malaria to variations in climate variables indicates locations where malaria is most likely to increase or decrease in response to specific climate factors. Bootstrapping measures the increased uncertainty in predicting malaria sensitivity when reporting is restricted to national level and an annual basis. Results indicate a potential 20x improvement in accuracy if data were available at the level ISO 3166–2

Perceived job insecurity as a risk factor for incident coronary heart disease

DEFF Research Database (Denmark)

Virtanen, Marianna; Nyberg, Solja T; Batty, George David

2013-01-01

To determine the association between self reported job insecurity and incident coronary heart disease.......To determine the association between self reported job insecurity and incident coronary heart disease....

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

Science.gov (United States)

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

2016-05-01

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

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

Science.gov (United States)

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

2016-01-01

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

Radiological incident preparedness for community hospitals: a demonstration project.

Science.gov (United States)

Jafari, Mary Ellen

2010-08-01

In November 2007, the Wisconsin Division of Public Health Hospital Disaster Preparedness Program State Expert Panel on Radiation Emergencies issued a report titled The Management of Patients in a Radiological Incident. Gundersen Lutheran Health System was selected to conduct a demonstration project to implement the recommendations in that report. A comprehensive radiological incident response plan was developed and implemented in the hospital's Trauma and Emergency Center, including the purchase and installation of radiation detection and identification equipment, staff education and training, a tabletop exercise, and three mock incident test exercises. The project demonstrated that the State Expert Panel report provides a flexible template that can be implemented at community hospitals using existing staff for an approximate cost of $25,000.

Regionalism and Statewide Coordination of Postsecondary Education. Report No. 26.

Science.gov (United States)

Martorana, S. V.; McGuire, W. Gary

Initial findings are reported of a continuing study of a new American postsecondary educational planning and coordination concept and its implementation: regionalism and regionalization. Regionalism is defined as that view of a geographic subsection of a state or of several adjoining states that considers all or a number of the postsecondary…

Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine.

Science.gov (United States)

Martín Delgado, M C; Merino de Cos, P; Sirgo Rodríguez, G; Álvarez Rodríguez, J; Gutiérrez Cía, I; Obón Azuara, B; Alonso Ovies, Á

2015-01-01

To explore contributing factors (CF) associated to related critical patients safety incidents. SYREC study pos hoc analysis. A total of 79 Intensive Care Departments were involved. The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Tuberculosis incidence in prisons: a systematic review.

Science.gov (United States)

Baussano, Iacopo; Williams, Brian G; Nunn, Paul; Beggiato, Marta; Fedeli, Ugo; Scano, Fabio

2010-12-21

Transmission of tuberculosis (TB) in prisons has been reported worldwide to be much higher than that reported for the corresponding general population. A systematic review has been performed to assess the risk of incident latent tuberculosis infection (LTBI) and TB disease in prisons, as compared to the incidence in the corresponding local general population, and to estimate the fraction of TB in the general population attributable (PAF%) to transmission within prisons. Primary peer-reviewed studies have been searched to assess the incidence of LTBI and/or TB within prisons published until June 2010; both inmates and prison staff were considered. Studies, which were independently screened by two reviewers, were eligible for inclusion if they reported the incidence of LTBI and TB disease in prisons. Available data were collected from 23 studies out of 582 potentially relevant unique citations. Five studies from the US and one from Brazil were available to assess the incidence of LTBI in prisons, while 19 studies were available to assess the incidence of TB. The median estimated annual incidence rate ratio (IRR) for LTBI and TB were 26.4 (interquartile range [IQR]: 13.0-61.8) and 23.0 (IQR: 11.7-36.1), respectively. The median estimated fraction (PAF%) of tuberculosis in the general population attributable to the exposure in prisons for TB was 8.5% (IQR: 1.9%-17.9%) and 6.3% (IQR: 2.7%-17.2%) in high- and middle/low-income countries, respectively. The very high IRR and the substantial population attributable fraction show that much better TB control in prisons could potentially protect prisoners and staff from within-prison spread of TB and would significantly reduce the national burden of TB. Future studies should measure the impact of the conditions in prisons on TB transmission and assess the population attributable risk of prison-to-community spread. Please see later in the article for the Editors' Summary.

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.

Using Logistic Regression for Validating or Invalidating Initial Statewide Cut-Off Scores on Basic Skills Placement Tests at the Community College Level

Science.gov (United States)

Secolsky, Charles; Krishnan, Sathasivam; Judd, Thomas P.

2013-01-01

The community colleges in the state of New Jersey went through a process of establishing statewide cut-off scores for English and mathematics placement tests. The colleges wanted to communicate to secondary schools a consistent preparation that would be necessary for enrolling in Freshman Composition and College Algebra at the community college…

The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies.

Science.gov (United States)

Ferris, Mollie; Quan, Samuel; Kaplan, Belle S; Molodecky, Natalie; Ball, Chad G; Chernoff, Greg W; Bhala, Nij; Ghosh, Subrata; Dixon, Elijah; Ng, Siew; Kaplan, Gilaad G

2017-08-01

We compared the incidence of appendicitis or appendectomy across the world and evaluated temporal trends. Population-based studies reported the incidence of appendicitis. We searched MEDLINE and EMBASE databases for population-based studies reporting the incidence of appendicitis or appendectomy. Time trends were explored using Poisson regression and reported as annual percent change (APC) with 95% confidence intervals (CI). APC were stratified by time periods and pooled using random effects models. Incidence since 2000 was pooled for regions in the Western world. The search retrieved 10,247 citations with 120 studies reporting on the incidence of appendicitis or appendectomy. During the 21st century the pooled incidence of appendicitis or appendectomy (in per 100,000 person-years) was 100 (95% CI: 91, 110) in Northern America, and the estimated number of cases in 2015 was 378,614. The pooled incidence ranged from 105 in Eastern Europe to 151 in Western Europe. In Western countries, the incidence of appendectomy steadily decreased since 1990 (APC after 1989=-1.54; 95% CI: -2.22, -0.86), whereas the incidence of appendicitis stabilized (APC=-0.36; 95% CI: -0.97, 0.26) for both perforated (APC=0.95; 95% CI: -0.25, 2.17) and nonperforated appendicitis (APC=0.44; 95% CI: -0.84, 1.73). In the 21st century, the incidence of appendicitis or appendectomy is high in newly industrialized countries in Asia (South Korea pooled: 206), the Middle East (Turkey pooled: 160), and Southern America (Chile: 202). Appendicitis is a global disease. The incidence of appendicitis is stable in most Western countries. Data from newly industrialized countries is sparse, but suggests that appendicitis is rising rapidly.

Cancer incidence and mortality in Serbia 1999-2009

NARCIS (Netherlands)

Mihajlovic, Jovan; Pechlivanoglou, Petros; Miladinov-Mikov, Marica; Zivković, Snežana; Postma, Maarten J

2013-01-01

BACKGROUND: Despite the increase in cancer incidence in the last years in Serbia, no nation-wide, population-based cancer epidemiology data have been reported. In this study cancer incidence and mortality rates for Serbia are presented using nation-wide data from two population-based cancer

The Soft Underbelly of System Change: The Role of Leadership and Organizational Climate in Turnover during Statewide Behavioral Health Reform

OpenAIRE

Aarons, Gregory A.; Sommerfeld, David H.; Willging, Cathleen E.

2011-01-01

This study examined leadership, organizational climate, staff turnover intentions, and voluntary turnover during a large-scale statewide behavioral health system reform. The initial data collection occurred nine months after initiation of the reform with a follow-up round of data collected 18 months later. A self-administered structured assessment was completed by 190 participants (administrators, support staff, providers) employed by 14 agencies. Key variables included leadership, organizati...

National arrangements for incidents involving radioactivity (NAIR) 1982/83

International Nuclear Information System (INIS)

Roberts, G.C.

1984-01-01

A summary is presented of the data on incidents notified under the National Arrangements for Incidents involving Radioactivity (NAIR), extending the data previously reported to include information for 1982/83. The categories of incidents discussed include transport, damaged sources or containers, undamaged sources, empty containers found and hoaxes or false alarms. It is concluded that the Arrangements continue to demonstrate their value in minimizing the alarm potentially inherent in even minor incidents involving radioactive materials. (U.K.)

Colorectal cancer incidence in path_MLH1 carriers subjected to different follow-up protocols : A Prospective Lynch Syndrome Database report

NARCIS (Netherlands)

Seppala, Toni; Pylvanainen, Kirsi; Evans, Dafydd Gareth; Jarvinen, Heikki; Renkonen-Sinisalo, Laura; Bernstein, Inge; Holinski-Feder, Elke; Sala, Paola; Lindblom, Annika; Macrae, Finlay; Blanco, Ignacio; Sijmons, Rolf; Jeffries, Jacqueline; Vasen, Hans; Burn, John; Nakken, Sigve; Hovig, Eivind; Rodland, Einar Andreas; Tharmaratnam, Kukatharmini; Cappel, Wouter H. de Vos tot Nederveen; Hill, James; Wijnen, Juul; Jenkins, Mark; Genuardi, Maurizio; Green, Kate; Lalloo, Fiona; Sunde, Lone; Mints, Miriam; Bertario, Lucio; Pineda, Marta; Navarro, Matilde; Morak, Monika; Frayling, Ian M.; Plazzer, John-Paul; Sampson, Julian R.; Capella, Gabriel; Moslein, Gabriela; Mecklin, Jukka-Pekka; Moller, Pal

2017-01-01

BACKGROUND: We have previously reported a high incidence of colorectal cancer (CRC) in carriers of pathogenicMLH1variants(path_MLH1) despite follow-up with colonoscopy including polypectomy. METHODS: The cohort included Finnish carriers enrolled in 3-yearly colonoscopy (n = 505; 4625 observation

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

NARCIS (Netherlands)

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

2015-01-01

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

Incidence and costs of achalasia in The Netherlands

NARCIS (Netherlands)

van Hoeij, F. B.; Ponds, F. A.; Smout, A. J.; Bredenoord, A. J.

2018-01-01

Recent reports show increasing incidence of achalasia in some populations. The aim of this study was to estimate incidence, prevalence, and healthcare costs of achalasia in a large cohort in The Netherlands. Data were obtained from the largest Dutch healthcare insurance company (±4.4 million

Effect of Emergency Argon on FCF Operational Incidents

International Nuclear Information System (INIS)

Solbrig, Charles

2011-01-01

The following report presents analyses of operational incidents which are considered in the safety analysis of the FCF argon cell and the effect that the operability of the emergency argon system has on the course of these incidents. The purpose of this study is to determine if the emergency argon system makes a significant difference in ameliorating the course of these incidents. Six incidents were considered. The following three incidents were analyzed. These are: 1. Cooling failing on 2. Vacuum Pump Failing on 3. Argon Supplies Failing on. In the remaining three incidents, the emergency argon supply would have no effect on the course of these transients since it would not come on during these incidents. The transients are 1. Loss of Cooling 2. Loss of power (Differs from above by startup delay till the Diesel Generators come on.) 3. Cell rupture due to an earthquake or other cause. The analyses of the first three incidents are reported on in the next three sections. This report is issued realizing the control parameters used may not be optimum, and additional modeling must be done to model the inertia of refrigeration system, but the major conclusion concerning the need for the emergency argon system is still valid. The timing of some events may change with a more accurate model but the differences between the transients with and without emergency argon will remain the same. Some of the parameters assumed in the analyses are Makeup argon supply, 18 cfm, initiates when pressure is = -6 iwg., shuts off when pressure is = -3.1 iwg. 170,000 ft3 supply. Min 1/7th always available, can be cross connected to HFEF argon supply dewar. Emergency argon supply, 900 cfm, initiates when pressure is = -8 iwg. shuts off when pressure is =-4 iwg. reservoir 220 ft3, refilled when tank farm pressure reduces to 1050 psi which is about 110 ft3.

Cancer incidence in atomic bomb survivors. Part IV: Comparison of cancer incidence and mortality

International Nuclear Information System (INIS)

Ron, E.; Preston, D.L.; Mabuchi, Kiyohiko; Thompson, D.E.; Soda, Midori

1994-01-01

This report compares cancer incidence and mortality among atomic bomb survivors in the Radiation Effects Research Foundation Life Span Study (LSS) cohort. Because the incidence data are derived from the Hiroshima and Nagasaki tumor registries, case ascertainment is limited to the time (1958-1987) and geographic restrictions (Hiroshima and Nagasaki) of the registries, whereas mortality data are available from 1950-1987 anywhere in Japan. With these conditions, there were 9,014 first primary incident cancer cases identified among LSS cohort members compared with 7,308 deaths for which cancer was listed as the underlying cause of death on death certificates. When deaths were limited to those occurring between 1958-1987 in Hiroshima or Nagasaki, there were 3,155 more incident cancer cases overall, and 1,262 more cancers of the digestive system. For cancers of the oral cavity and pharynx, skin, breast, female and male genital organs, urinary system and thyroid, the incidence series was at least twice as large as the comparable mortality series. Although the incidence and mortality data are dissimilar in many ways, the overall conclusions regarding which solid cancers provide evidence of a significant dose response generally confirm the mortality findings. When either incidence or mortality data are evaluated, significant excess risks are observed for all solid cancers, stomach, colon, liver (when it is defined as primary liver cancer or liver cancer not otherwise specified on the death certificate), lung, breast, ovary and urinary bladder. No significant radiation effect is seen for cancers of the pharynx, rectum, gallbladder, pancreas, nose, larynx, uterus, prostate or kidney in either series. There is evidence of a significant excess of nonmelanoma skin cancer in the incidence data, but not in the mortality series. 19 refs., 2 figs., 10 tabs

Handling of incidents, near-misses

International Nuclear Information System (INIS)

Renborg, Bo; Jonsson, Klas; Broqvist, Kristoffer; Keski-Seppaelae, Sven

2006-12-01

This work has primarily been done as a study of available literature about reporting systems. The following items have also been considered: the participants' experience of safety work in general and reporting systems in particular, as well as correspondence with researchers and organisations that have experience from reporting systems in safety-critical applications. A number of definitions of the English term 'near-miss' have been found in the documentation about safety-critical systems. An important conclusion is that creating a precise definition in itself is not critical. The main objective is to persuade the individuals to report perceived risks as well as actual events or conditions. In this report, we have chosen to use the following definition of what should be reported: A condition or an incident with potential for more serious consequences. The reporting systems that have been evaluated have all data in the same system; they do not divide data into separate systems for incidents or 'near-misses'. The term incident in the literature is not used consistently, especially if both Swedish and English texts are considered. In a large portion of the documentation where the reporting system is mentioned, the focus lies more on analysis than on the problem with the willingness to report. Even when the focus is on reporting it is often dealing with the design of the actual report in order to enable the subsequent treatment of data. In some cases this has led to unnecessary complicated report forms. The cornerstone of a high willingness to report is the creation of a 'no-blame' culture. Based on experience it can be concluded that the question whether a report could lead to personal reprisals is crucial. Even a system that explicitly gives the reporter immunity is still brittle. The bare suspicion (that immunity may vanish) in the mind of the one reporting reduces the willingness to report dramatically. Meaning that the purpose of the analysis of reports must be to