Evaluation of the patient safety Leadership Walkabout programme of a hospital in Singapore.

Science.gov (United States)

Lim, Raymond Boon Tar; Ng, Benjamin Boon Lui; Ng, Kok Mun

2014-02-01

The Patient Safety Leadership Walkabout (PSLWA) programme is a commonly employed tool in the West, in which senior leaders visit sites within the hospital that are involved in patient care to talk to healthcare staff about patient safety issues. As there is a lack of perspective regarding PSLWA in Asia, we carried out an evaluation of its effectiveness in improving the patient safety culture in Tan Tock Seng Hospital, Singapore. A mixed methods analysis approach was used to review and evaluate all documents, protocols, meeting minutes, post-walkabout surveys, action plans and verbal feedback pertaining to the walkabouts conducted from January 2005 to October 2012. A total of 321 patient safety issues were identified during the study period. Of these, 308 (96.0%) issues were resolved as of November 2012. Among the various categories of issues raised, issues related to work environment were the most common (45.2%). Of all the issues raised during the walkabouts, 72.9% were not identified through other conventional methods of error detection. With respect to the hospital's patient safety culture, 94.8% of the participants reported an increased awareness in patient safety and 90.2% expressed comfort in openly and honestly discussing patient safety issues. PSLWA serves as a good tool to uncover latent errors before actual harm reaches the patient. If properly implemented, it is an effective method for engaging leadership, identifying patient safety issues, and supporting a culture of patient safety in the hospital setting.

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

Science.gov (United States)

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

2016-11-01

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

Laboratory test requesting appropriateness and patient safety

CERN Document Server

Blasco, Álvaro; Carratalá, Arturo; Lopez-Garrígos, Maite; Rodriguez-Borja, Enrique

2016-01-01

Patient Safety emphasizes the reporting, analysis and prevention of medical errors that very often leads to adverse healthcare situations.1 in 10 patients are impacted by medical errors.The WHO calls the patient safety issue an endemic concern. A number of well-known experts of all areas in the medical field have collectedvery valuable information for a better patient treatment and higher safety culture in all medical disciplines.

Evaluation on safety issues of SMART

International Nuclear Information System (INIS)

Kim, W. S.; Seol, K. W.; Yoon, Y. K.; Lee, J. H.

2001-01-01

Safety issues on the SMART were evaluated in the light of the compliance with the Ministerial Ordinance of Technical Requirements applying to Nuclear Installations, which was recently revised. Evaluation concludes that regulatory requirements associated with following items have to be developed as the licensing criteria for the SMART: (1) proving the safety of design or materials different form existing reactors; (2) coping with beyond design basis accidents; (3) rulemaking on the safety of reactor safeguard vessel ; (4) ensuring integrity of steam generator tubes; and (5) classifying equipment based on their safety significance. Appropriate actions including implementation of new requirements under development should be taken for safety issues such as diversity of reactivity control and in-service inspection of steam generator tubes that are not complied with the current Technical Requirements. Safety level of the SMART design will be evaluated further by the more detailed assessment according to the Technical Requirements, and additional safety issues will be identified and resolved, if it necessary

Laboratory safety and the WHO World Alliance for Patient Safety.

Science.gov (United States)

McCay, Layla; Lemer, Claire; Wu, Albert W

2009-06-01

Laboratory medicine has been a pioneer in the field of patient safety; indeed, the College of American Pathology first called attention to the issue in 1946. Delivering reliable laboratory results has long been considered a priority, as the data produced in laboratory medicine have the potential to critically influence individual patients' diagnosis and management. Until recently, most attention on laboratory safety has focused on the analytic stage of laboratory medicine. Addressing this stage has led to significant and impressive improvements in the areas over which laboratories have direct control. However, recent data demonstrate that pre- and post-analytical phases are at least as vulnerable to errors; to further improve patient safety in laboratory medicine, attention must now be focused on the pre- and post-analytic phases, and the concept of patient safety as a multi-disciplinary, multi-stage and multi-system concept better understood. The World Alliance for Patient Safety (WAPS) supports improvement of patient safety globally and provides a potential framework for considering the total testing process.

Patient Safety and Healthcare Quality

Directory of Open Access Journals (Sweden)

Aikaterini Toska

2012-01-01

Full Text Available Introduction: Due to a variety of circumstances and world-wide research findings, patient safety andquality care during hospitalization have emerged as major issues. Patient safety deficits may burdenhealth systems as well as allocated resources. The international community has examined severalproposals covering general and systemic aspects in order to improve patient safety; several long-termprograms and strategies have also been implemented promoting the participation of health-relatedagents, and also government agencies and non-governmental organizations.Aim: Those factors that have negative correlations with patient safety and quality healthcare weredetermined; WHO and EU programs as well as the Greek health policy were also reviewed.Method: Local and international literature was reviewed, including EU and WHO official publications,by using the appropriate keywords.Conclusions: International cooperation on patient safety is necessary in order to improvehospitalization and healthcare quality standards. Such incentives depend heavily on establishing worldwideviable and effective health programs and planning. These improvements also require further stepson safe work procedures, environment safety, hazard management, infection control, safe use ofequipment and medication, and sufficient healthcare staff.

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

Directory of Open Access Journals (Sweden)

Elizabeth M. Borycki

2015-09-01

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

Patient safety and nutrition: is there a connection? | Nieuwoudt ...

African Journals Online (AJOL)

Nutrition care is not always recognised as a patient safety issue. This article explores the origins of the patient safety initiative and seeks to identify possible connections between nutrition care and patient safety. Examples of tools that can be used to improve the safety of nutrition care are provided. This is also a call to action ...

Safety issues and updates under MR environments

Energy Technology Data Exchange (ETDEWEB)

Kim, Soo Jung; Kim, Kyung Ah, E-mail: bellenina@daum.net

2017-04-15

Highlights: • Unexpected biological effects can occur within stronger magnetic fields. • MR safety for MR conditional items is not guaranteed beyond the tested conditions. • Updated knowledge about MR-related safety is important for a safe MR environment. - Abstract: Magnetic resonance (MR) imaging is a useful imaging tool with superior soft tissue contrast for diagnostic evaluation. The MR environments poses unique risks to patients and employees differently from ionizing radiation exposure originated from computed tomography and plain x-ray films. The technology associated with MR system has evolved continuously since its introduction in the late 1970s. MR systems have advanced with static magnetic fields, faster and stronger gradient magnetic fields and more powerful radiofrequency transmission coils. Higher field strengths of MR offers greater signal to noise capability and better spatial resolution, resulting in better visualization of anatomic detail, with a reduction in scan time. With the rapid evolution of technology associated with MR, we encounter new MR-related circumstances and unexpected dangerous conditions. A comprehensive update of our knowledge about MR safety is necessary to prevent MR-related accidents and to ensure safety for patients and staff associated with MR. This review presents an overview about MR-related safety issues and updates.

Status of safety issues at licensed power plants

International Nuclear Information System (INIS)

1991-05-01

As part of ongoing US Nuclear Regulatory Commission (NRC) efforts to ensure the quality and accountability of safety issue information, a program has been established whereby an annual NUREG report will be published on the status of licensee implementation and NRC verification of safety issues in major NRC requirement areas. This report, the second volume of a three-volume series, addresses the status of unresolved safety issues (USIs) at licensed plants. The data contained in these NUREG reports are a product of the NRC's Safety Issues Management System (SIMS) database, which is maintained by the Project Management Staff in the Office of Nuclear Reactor Regulation and by NRC regional personnel. The purpose of this report is to provide a comprehensive description of the status of implementation and verification of the 27 safety issues designated as USIs and to make this information available to other interested parties, including the public. A corollary purpose of this NUREG report is to serve as a follow-on to NUREG-0933, ''A Prioritization of Generic Safety Issues,'' which tracks safety issues up until requirements are approved for imposition at licensed plants. 3 figs., 4 tabs

Hydrogen Safety Issues Compared to Safety Issues with Methane and Propane

International Nuclear Information System (INIS)

Green, Michael A.

2005-01-01

The hydrogen economy is not possible if the safety standards currently applied to liquid hydrogen and hydrogen gas by many laboratories are applied to devices that use either liquid or gaseous hydrogen. Methane and propane are commonly used by ordinary people without the special training. This report asks, 'How is hydrogen different from flammable gasses that are commonly being used all over the world?' This report compares the properties of hydrogen, methane and propane and how these properties may relate to safety when they are used in both the liquid and gaseous state. Through such an analysis, sensible safety standards for the large-scale (or even small-scale) use of liquid and gaseous hydrogen systems can be developed. This paper is meant to promote discussion of issues related to hydrogen safety so that engineers designing equipment can factor sensible safety standards into their designs

Hydrogen Safety Issues Compared to Safety Issues with Methane andPropane

Energy Technology Data Exchange (ETDEWEB)

Green, Michael A.

2005-08-20

The hydrogen economy is not possible if the safety standards currently applied to liquid hydrogen and hydrogen gas by many laboratories are applied to devices that use either liquid or gaseous hydrogen. Methane and propane are commonly used by ordinary people without the special training. This report asks, 'How is hydrogen different from flammable gasses that are commonly being used all over the world?' This report compares the properties of hydrogen, methane and propane and how these properties may relate to safety when they are used in both the liquid and gaseous state. Through such an analysis, sensible safety standards for the large-scale (or even small-scale) use of liquid and gaseous hydrogen systems can be developed. This paper is meant to promote discussion of issues related to hydrogen safety so that engineers designing equipment can factor sensible safety standards into their designs.

Editorial safety science special issue road safety management.

NARCIS (Netherlands)

Wegman, F.C.M. & Hagezieker, M.P.

2014-01-01

The articles presented in this Special Issue on Road Safety Management represent an illustration of the growing interest in policy-related research in the area of road safety. The complex nature of this type of research combined with the observation that scientific journals pay limited attention to

Status of safety issues at licensed power plants

International Nuclear Information System (INIS)

1991-06-01

As part of ongoing US Nuclear Regulatory Commission (NRC) efforts to ensure the quality and accountability of safety issue information, a program has been established whereby an annual NUREG report will be published on the status of licensee implementation and NRC verification of safety issues in major NRC requirement areas. This report, the third volume of a three-volume series, addresses the status of generic safety issues (GSIs) at licensed plants. Volume 1 addressed the status of Three Mile Island Action Plan requirements and was published in March 1991. Volume 2 addressed the status of implementation and verification of unresolved safety issues and was published in May 1991. The annual NUREG report will combine these three areas in a single volume to be published in late 1991. The data contained in these NUREG reports are a product of the NRC's Safety Issues Management System (SIMS) database, which is maintained by the Project Management Staff in the Office of Nuclear Reactor Regulation and by NRC regional personnel. The purpose of this report is to provide a comprehensive description of the status of implementation and verification of the 34 GSIs and sub-issues that have been resolved by the NRC and involve implementation of an action or actions by licensees. This NUREG report also serves as a follow-on to NUREG-0933, ''A Prioritization of Generic Safety Issues,'' which tracks safety issues up until a request for action by licensees is issued by NRC. 3 figs., 6 tabs

Patient handover in orthopaedics, improving safety using Information Technology.

Science.gov (United States)

Pearkes, Tim

2015-01-01

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

Patient participation in patient safety still missing: Patient safety experts' views.

Science.gov (United States)

Sahlström, Merja; Partanen, Pirjo; Rathert, Cheryl; Turunen, Hannele

2016-10-01

The aim of this study was to elicit patient safety experts' views of patient participation in promoting patient safety. Data were collected between September and December in 2014 via an electronic semi-structured questionnaire and interviews with Finnish patient safety experts (n = 21), then analysed using inductive content analysis. Patient safety experts regarded patients as having a crucial role in promoting patient safety. They generally deemed the level of patient safety as 'acceptable' in their organizations, but reported that patient participation in their own safety varied, and did not always meet national standards. Management of patient safety incidents differed between organizations. Experts also suggested that patient safety training should be increased in both basic and continuing education programmes for healthcare professionals. Patient participation in patient safety is still lacking in clinical practice and systematic actions are needed to create a safety culture in which patients are seen as equal partners in the promotion of high-quality and safe care. © 2016 John Wiley & Sons Australia, Ltd.

High-heat tank safety issue resolution program plan

International Nuclear Information System (INIS)

Wang, O.S.

1993-12-01

The purpose of this program plan is to provide a guide for selecting corrective actions that will mitigate and/or remediate the high-heat waste tank safety issue for single-shell tank (SST) 241-C-106. This program plan also outlines the logic for selecting approaches and tasks to mitigate and resolve the high-heat safety issue. The identified safety issue for high-heat tank 241-C-106 involves the potential release of nuclear waste to the environment as the result of heat-induced structural damage to the tank's concrete, if forced cooling is interrupted for extended periods. Currently, forced ventilation with added water to promote thermal conductivity and evaporation cooling is used to cool the waste. At this time, the only viable solution identified to resolve this safety issue is the removal of heat generating waste in the tank. This solution is being aggressively pursued as the permanent solution to this safety issue and also to support the present waste retrieval plan. Tank 241-C-106 has been selected as the first SST for retrieval. The program plan has three parts. The first part establishes program objectives and defines safety issues, drivers, and resolution criteria and strategy. The second part evaluates the high-heat safety issue and its mitigation and remediation methods and alternatives according to resolution logic. The third part identifies major tasks and alternatives for mitigation and resolution of the safety issue. Selected tasks and best-estimate schedules are also summarized in the program plan

Assessment of Contributions to Patient Safety Knowledge by the Agency for Healthcare Research and Quality-Funded Patient Safety Projects

Science.gov (United States)

Sorbero, Melony E S; Ricci, Karen A; Lovejoy, Susan; Haviland, Amelia M; Smith, Linda; Bradley, Lily A; Hiatt, Liisa; Farley, Donna O

2009-01-01

Objective To characterize the activities of projects funded in Agency for Healthcare Research and Quality (AHRQ)' patient safety portfolio and assess their aggregate potential to contribute to knowledge development. Data Sources Information abstracted from proposals for projects funded in AHRQ' patient safety portfolio, information on safety practices from the AHRQ Evidence Report on Patient Safety Practices, and products produced by the projects. Study Design This represented one part of the process evaluation conducted as part of a longitudinal evaluation based on the Context–Input–Process–Product model. Principal Findings The 234 projects funded through AHRQ' patient safety portfolio examined a wide variety of patient safety issues and extended their work beyond the hospital setting to less studied parts of the health care system. Many of the projects implemented and tested practices for which the patient safety evidence report identified a need for additional evidence. The funded projects also generated a substantial body of new patient safety knowledge through a growing number of journal articles and other products. Conclusions The projects funded in AHRQ' patient safety portfolio have the potential to make substantial contributions to the knowledge base on patient safety. The full value of this new knowledge remains to be confirmed through the synthesis of results. PMID:21456108

Food control concept: Food safety/ingestion issues

International Nuclear Information System (INIS)

Armstrong, B.

1995-01-01

This talk outlines the issues in food safety/ingestion in the case of radiation accidents at nuclear power plants and how emergency preparedness plans can/should be tailored. The major topics are as follows: In Washington: food safety/ingestion issues exist at transition between response and regulatory worlds; agricultural concerns; customer concerns; Three Mile Island: detailed maps; development of response procedures; development of tools; legal issues

[Operating Room Nurses' Experiences of Securing for Patient Safety].

Science.gov (United States)

Park, Kwang Ok; Kim, Jong Kyung; Kim, Myoung Sook

2015-10-01

This study was done to evaluate the experience of securing patient safety in hospital operating rooms. Experiential data were collected from 15 operating room nurses through in-depth interviews. The main question was "Could you describe your experience with patient safety in the operating room?". Qualitative data from the field and transcribed notes were analyzed using Strauss and Corbin's grounded theory methodology. The core category of experience with patient safety in the operating room was 'trying to maintain principles of patient safety during high-risk surgical procedures'. The participants used two interactional strategies: 'attempt continuous improvement', 'immersion in operation with sharing issues of patient safety'. The results indicate that the important factors for ensuring the safety of patients in the operating room are manpower, education, and a system for patient safety. Successful and safe surgery requires communication, teamwork and recognition of the importance of patient safety by the surgical team.

The safety issues of medical robotics

Energy Technology Data Exchange (ETDEWEB)

Fei Baowei; Ng, W.S.; Chauhan, Sunita; Kwoh, Chee Keong

2001-08-01

In this paper, we put forward a systematic method to analyze, control and evaluate the safety issues of medical robotics. We created a safety model that consists of three axes to analyze safety factors. Software and hardware are the two material axes. The third axis is the policy that controls all phases of design, production, testing and application of the robot system. The policy was defined as hazard identification and safety insurance control (HISIC) that includes seven principles: definitions and requirements, hazard identification, safety insurance control, safety critical limits, monitoring and control, verification and validation, system log and documentation. HISIC was implemented in the development of a robot for urological applications that was known as URObot. The URObot is a universal robot with different modules adaptable for 3D ultrasound image-guided interstitial laser coagulation, radiation seed implantation, laser resection, and electrical resection of the prostate. Safety was always the key issue in the building of the robot. The HISIC strategies were adopted for safety enhancement in mechanical, electrical and software design. The initial test on URObot showed that HISIC had the potential ability to improve the safety of the system. Further safety experiments are being conducted in our laboratory.

The safety issues of medical robotics

International Nuclear Information System (INIS)

Fei Baowei; Ng, W.S.; Chauhan, Sunita; Kwoh, Chee Keong

2001-01-01

In this paper, we put forward a systematic method to analyze, control and evaluate the safety issues of medical robotics. We created a safety model that consists of three axes to analyze safety factors. Software and hardware are the two material axes. The third axis is the policy that controls all phases of design, production, testing and application of the robot system. The policy was defined as hazard identification and safety insurance control (HISIC) that includes seven principles: definitions and requirements, hazard identification, safety insurance control, safety critical limits, monitoring and control, verification and validation, system log and documentation. HISIC was implemented in the development of a robot for urological applications that was known as URObot. The URObot is a universal robot with different modules adaptable for 3D ultrasound image-guided interstitial laser coagulation, radiation seed implantation, laser resection, and electrical resection of the prostate. Safety was always the key issue in the building of the robot. The HISIC strategies were adopted for safety enhancement in mechanical, electrical and software design. The initial test on URObot showed that HISIC had the potential ability to improve the safety of the system. Further safety experiments are being conducted in our laboratory

Patient Safety in Spine Surgery: Regarding the Wrong-Site Surgery

OpenAIRE

Lee, Seung-Hwan; Kim, Ji-Sup; Jeong, Yoo-Chul; Kwak, Dae-Kyung; Chun, Ja-Hae; Lee, Hwan-Mo

2013-01-01

Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your sit...

Status of safety issues at licensed power plants

International Nuclear Information System (INIS)

1991-03-01

As part of ongoing US Nuclear Regulatory Commission (NRC) efforts to ensure the quality and accountability of safety issue information, a program has been established whereby an annual NUREG series report will be published on the status of licensee implementation and NRC verification of safety issues in major NRC requirement areas. The data contained in this report are a product of the NRC's Safety Issues Management System database, which is maintained by the Project Management Staff in the Office of Nuclear Reactor Regulation and by personnel in the NRC regions. This report has been prepared in order to provide a comprehensive description of the implementation and verification status of all the TMI Action Plan requirements at licensed reactors, and to make this information available to other interested parties, including the public. A corollary purpose of this report is for it to serve as a follow-on to NUREG-0933, ''A Prioritization of Safety Issues,'' which tracks safety issues up until requirements are approved for imposition at licensed facilities

Safety issues on advanced fuel

International Nuclear Information System (INIS)

Gross, H.; Krebs, W.D.

1998-01-01

In the recent years a general discussion has started whether unsolved safety issues are related to advanced fuel. Advanced fuel is in this context a summary of features like high burnup, improved clad materials, low leakage loading pattern with high peaking factors etc. The design basis accidents RIA and Loca are of special interest for this discussion. From the Siemens point of view RIA is not a safety issue. There are sufficient margins between the enthalpy rise calculated by modern 3D methods and the fuel failures which occurred in RIA simulation tests when the effect of pulse width is taken into account. The evaluation of possible uncertainties for the established Loca criteria (17% equivalent corrosion, 1200 C clad temperature) for high burnup makes sense. But fuel with high burnup has significantly lower peaking factors than fuel with lower burnup. This gives sufficient margin counterbalancing possible uncertainties. In contrast to the above incomplete control rod insertion at higher burnup is potentially a real safety issue. Although Siemens fuel was not affected by the reported incidents they addressed the problem and checked that they have sufficient design margin for their fuel. (orig.) [de

Implementing Protocols to Improve Patient Safety in the Medical Imaging Department.

Science.gov (United States)

Carrizales, Gwen; Clark, Kevin R

2015-01-01

Patient safety is a focal point in healthcare because of recent changes issued by CMS. Hospital reimbursement rates have fallen, and these reimbursement rates are governed by CMS mandates regarding patient safety procedures. Reimbursement changes are reflected in the National Patient Safety Goals (NPSGs) administered annually by The Joint Commission. Medical imaging departments have multiple areas of patient safety concerns including effective handoff communication, proper patient identification, and safe medication/contrast administration. This literature review examines those areas of patient safety within the medical imaging department and reveals the need for continued protocol and policy changes to keep patients safe.

Unresolved safety issues summary: aqua book

International Nuclear Information System (INIS)

1982-06-01

The unresolved safety issues summary is designed to provide the management of the Nuclear Regulatory Commission with a quarterly overview of the progress and plans for completion of generic tasks addressing unresolved safety issues reported to Congress pursuant to Section 210 of the Energy Reorganization Act of 1974 as amended. This summary utilizes data collected from the Office of Nuclear Reactor Regulation, Office of Nuclear Regulatory Research, and the National Laboratories and is prepared by the Office of Resource Management. The schedules in this book include a milestone at the end of each action plan which represents the initiation of the implementation process both with respect to incorporation of the technical resolution in the NRC official guidance or requirements and also the application of changes to individual operating plants. The progress and status for implementation of unresolved safety issues for which a technical resolution has been completed are reported specifically in a separate table provided in this summary

76 FR 67461 - Cosmetic Microbiological Safety Issues; Public Meeting

Science.gov (United States)

2011-11-01

...] Cosmetic Microbiological Safety Issues; Public Meeting AGENCY: Food and Drug Administration, HHS. ACTION... Administration (FDA) is announcing a public meeting entitled ``Cosmetic Microbiological Safety Issues.'' The... cosmetic microbiological safety and to suggest areas for the possible development of FDA guidance documents...

Categorization of reactor safety issues from a risk perspective

International Nuclear Information System (INIS)

1985-03-01

This report presents the results of an effort to identify and rank reactor safety and risk issues identified from past Probabilistic Risk Assessments (PRAs) and other safety analyses. Because of the varied scope of these analyses, the list of issues may be incomplete. Nevertheless, those studies comprised ordered analyses to whatever their respective depths; hence, they warranted scrutiny for whatever insights they could reveal with respect to issue importance. The top-ranked issues in terms of their contribution to the uncertainty in risk are described in some detail. All of these risk issues are compared to the generic safety issues for completeness and omissions

Unresolved safety issues: where do we go from here

International Nuclear Information System (INIS)

Aycock, M.B.

1980-01-01

Section 210 of the Energy reorganization Act of 1974, as amended requires the NRC to develop a program for resolving Unresolved Safety Issues related to nuclear power plants. Seventeen Unresolved Safety Issues were identified by the NRC in 1978 and by early 1979 the NRC Unresolved Safety Issues Program was quickly becoming a well defined and manageable effort. Although, the Three Mile Island accident caused the momentum developed in early 1979 to be lost, efforts on ongoing generic tasks were continued by a special NRC Task Force established in June 1979. The momentum that was lost must be regained, however, if the Congressional mandate in Section 210 is to be met. With increased industry involvement and the marriage of the Unresolved Safety Issues Program with the improved and broader safety program development, audit and evaluation activities of the new NRR Division of Safety Technology, this should be possible

Ethical and Safety Issues of Stem Cell-Based Therapy.

Science.gov (United States)

Volarevic, Vladislav; Markovic, Bojana Simovic; Gazdic, Marina; Volarevic, Ana; Jovicic, Nemanja; Arsenijevic, Nebojsa; Armstrong, Lyle; Djonov, Valentin; Lako, Majlinda; Stojkovic, Miodrag

2018-01-01

Results obtained from completed and on-going clinical studies indicate huge therapeutic potential of stem cell-based therapy in the treatment of degenerative, autoimmune and genetic disorders. However, clinical application of stem cells raises numerous ethical and safety concerns. In this review, we provide an overview of the most important ethical issues in stem cell therapy, as a contribution to the controversial debate about their clinical usage in regenerative and transplantation medicine. We describe ethical challenges regarding human embryonic stem cell (hESC) research, emphasizing that ethical dilemma involving the destruction of a human embryo is a major factor that may have limited the development of hESC-based clinical therapies. With previous derivation of induced pluripotent stem cells (iPSCs) this problem has been overcome, however current perspectives regarding clinical translation of iPSCs still remain. Unlimited differentiation potential of iPSCs which can be used in human reproductive cloning, as a risk for generation of genetically engineered human embryos and human-animal chimeras, is major ethical issue, while undesired differentiation and malignant transformation are major safety issues. Although clinical application of mesenchymal stem cells (MSCs) has shown beneficial effects in the therapy of autoimmune and chronic inflammatory diseases, the ability to promote tumor growth and metastasis and overestimated therapeutic potential of MSCs still provide concerns for the field of regenerative medicine. This review offers stem cell scientists, clinicians and patient's useful information and could be used as a starting point for more in-depth analysis of ethical and safety issues related to clinical application of stem cells.

Key issues for passive safety

International Nuclear Information System (INIS)

Hayns, M.R.

1996-01-01

The paper represents a summary of the introductory presentation made at this Advisory Group Meeting on the Technical Feasibility and Reliability of Passive Safety Systems. It was intended as an overview of our views on what are the key issues and what are the technical problems which might dominate any future developments of passive safety systems. It is, therefore, not a ''review paper'' as such and only record the highlights. (author)

Key issues for passive safety

Energy Technology Data Exchange (ETDEWEB)

Hayns, M R [AEA Technology, Harwell, Didcot (United Kingdom). European Institutions; Hicken, E F [Forschungszentrum Juelich GmbH (Germany)

1996-12-01

The paper represents a summary of the introductory presentation made at this Advisory Group Meeting on the Technical Feasibility and Reliability of Passive Safety Systems. It was intended as an overview of our views on what are the key issues and what are the technical problems which might dominate any future developments of passive safety systems. It is, therefore, not a ``review paper`` as such and only record the highlights. (author).

Unresolved safety issues summary: aqua book

International Nuclear Information System (INIS)

1983-06-01

The unresolved safety issues summary is designed to provide the management of the nuclear regulatory commission with a quarterly overview of the progress and plans for completion of generic tasks addressing unresolved safety issues reported to congress pursuant to section 210 of the Energy Reorganization Act of 1974 as amended. The schedules in this book include a milestone at the end of each action plan which represents the initiation of the implementation process both with respect to incorporation of the technical resolution in the NRC official guidance or requirements and also the application of changes to individual operating plants. The schedule for implementation will not normally be included in the task action plan(s) for the resolution of a USI since the nature and extent of the activities necessary to accomplish the implementation cannot normally be reasonably determined prior to the determination of a technical resolution. The progress and status for implementation of unresolved safety issues for which a technical resolution has been completed are reported specifically in a separate table provided in this summary

Effect of generic issues program on improving safety

International Nuclear Information System (INIS)

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

2010-01-01

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

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

OpenAIRE

Elizabeth M. Borycki

2015-01-01

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

Practicing industrial safety - issues involved

International Nuclear Information System (INIS)

Gunasekaran, P.

2016-01-01

Industrial safety is all about measures or techniques implemented to reduce the risk of injury, loss to persons, property or the environment in any industrial facility. The issue of industrial safety evolved concurrently with industrial development as a shift from compensation to prevention as well. Today, industrial safety is widely regarded as one of the most important factors that any business, large or small, must consider in its operations, as prevention of loss is also a part of profit. Factories Act of Central government and Rules made under it by the state deals with the provisions on industrial safety legislation. There are many other acts related to safety of personnel, property and environment. Occupational health and safety is also of primary concern. The aim is to regulate health and safety conditions for all employers. It includes safety standards and health standards. These acts encourage employers and employees to reduce workplace hazards and to implement new or improve existing safety and health standards; and develop innovative ways to achieve them. Maintain a reporting and record keeping system to monitor job-related injuries and illnesses; establish training programs to increase the number and competence of occupational safety and health personnel

Safety Issues with Hydrogen as a Vehicle Fuel

Energy Technology Data Exchange (ETDEWEB)

L. C. Cadwallader; J. S. Herring

1999-09-01

This report is an initial effort to identify and evaluate safety issues associated with the use of hydrogen as a vehicle fuel in automobiles. Several forms of hydrogen have been considered: gas, liquid, slush, and hydrides. The safety issues have been discussed, beginning with properties of hydrogen and the phenomenology of hydrogen combustion. Safety-related operating experiences with hydrogen vehicles have been summarized to identify concerns that must be addressed in future design activities and to support probabilistic risk assessment. Also, applicable codes, standards, and regulations pertaining to hydrogen usage and refueling have been identified and are briefly discussed. This report serves as a safety foundation for any future hydrogen safety work, such as a safety analysis or a probabilistic risk assessment.

Safety Issues with Hydrogen as a Vehicle Fuel

Energy Technology Data Exchange (ETDEWEB)

Cadwallader, Lee Charles; Herring, James Stephen

1999-10-01

This report is an initial effort to identify and evaluate safety issues associated with the use of hydrogen as a vehicle fuel in automobiles. Several forms of hydrogen have been considered: gas, liquid, slush, and hydrides. The safety issues have been discussed, beginning with properties of hydrogen and the phenomenology of hydrogen combustion. Safety-related operating experiences with hydrogen vehicles have been summarized to identify concerns that must be addressed in future design activities and to support probabilistic risk assessment. Also, applicable codes, standards, and regulations pertaining to hydrogen usage and refueling have been identified and are briefly discussed. This report serves as a safety foundation for any future hydrogen safety work, such as a safety analysis or a probabilistic risk assessment.

Road safety issues for bus transport management.

Science.gov (United States)

Cafiso, Salvatore; Di Graziano, Alessandro; Pappalardo, Giuseppina

2013-11-01

Because of the low percentage of crashes involving buses and the assumption that public transport improves road safety by reducing vehicular traffic, public interest in bus safety is not as great as that in the safety of other types of vehicles. It is possible that less attention is paid to the significance of crashes involving buses because the safety level of bus systems is considered to be adequate. The purpose of this study was to evaluate the knowledge and perceptions of bus managers with respect to safety issues and the potential effectiveness of various technologies in achieving higher safety standards. Bus managers were asked to give their opinions on safety issues related to drivers (training, skills, performance evaluation and behaviour), vehicles (maintenance and advanced devices) and roads (road and traffic safety issues) in response to a research survey. Kendall's algorithm was used to evaluate the level of concordance. The results showed that the majority of the proposed items were considered to have great potential for improving bus safety. The data indicated that in the experience of the participants, passenger unloading and pedestrians crossing near bus stops are the most dangerous actions with respect to vulnerable users. The final results of the investigation showed that start inhibition, automatic door opening, and the materials and internal architecture of buses were considered the items most strongly related to bus passenger safety. Brake assistance and vehicle monitoring systems were also considered to be very effective. With the exception of driver assistance systems for passenger and pedestrian safety, the perceptions of the importance of other driver assistance systems for vehicle monitoring and bus safety were not unanimous among the bus company managers who participated in this survey. The study results showed that the introduction of new technologies is perceived as an important factor in improving bus safety, but a better understanding

Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention.

Science.gov (United States)

Jha, V; Winterbottom, A; Symons, J; Thompson, Z; Quinton, N; Corrado, O J; Melville, C; Watt, I; Torgerson, D; Wright, J

2013-09-01

Training in patient safety is an important element of medical education. Most educational interventions on patient safety training adopt a 'health-professional lens' with limited consideration on the impact of safety lapses on the patient and their families and little or no involvement of patients in the design or delivery of the training. This paper describes a pilot study to test the feasibility and acceptability of implementing a patient-led educational intervention to facilitate safety training amongst newly qualified doctors. Patients and/or carers who had experienced harm during their care shared narratives of their stories with trainees; this was followed by a focused discussion on patient safety issues exploring the causes and consequences of safety incidents and lessons to be learned from these. The intervention, which will be further tested in an NIHR-funded randomised controlled trial (RCT), was successfully implemented into an existing training programme and found acceptance amongst the patients and trainees. The pilot study proved to be a useful step in refining the intervention for the RCT including identifying appropriate outcome measures and highlighting organisational issues.

International conference on topical issues in nuclear safety. Contributed papers

International Nuclear Information System (INIS)

2001-01-01

The objective of the Conference was to foster the exchange of information on topical issues in nuclear safety, with the aim of consolidating an international consensus on the present status of these issues, priorities for future work, and needs for strengthening international cooperation, including the IAEA recommendations for future activities. This book contains concise contributed papers submitted on issues falling within the thematic scope of the Conference: risk informed decision making, influence of external factors on safety, safety of fuel cycle facilities, safety of research reactors, and safety performance indicators

International conference on topical issues in nuclear safety. Contributed papers

Energy Technology Data Exchange (ETDEWEB)

NONE

2001-07-01

The objective of the Conference was to foster the exchange of information on topical issues in nuclear safety, with the aim of consolidating an international consensus on the present status of these issues, priorities for future work, and needs for strengthening international cooperation, including the IAEA recommendations for future activities. This book contains concise contributed papers submitted on issues falling within the thematic scope of the Conference: risk informed decision making, influence of external factors on safety, safety of fuel cycle facilities, safety of research reactors, and safety performance indicators.

Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Science.gov (United States)

Daker-White, Gavin; Hays, Rebecca; McSharry, Jennifer; Giles, Sally; Cheraghi-Sohi, Sudeh; Rhodes, Penny; Sanders, Caroline

2015-01-01

Objective Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model. Method Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies. Results Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system. Conclusion Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or

Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.

Science.gov (United States)

Balka, Ellen; Tolar, Marianne; Coates, Shannon; Whitehouse, Sandra

2013-12-01

Ineffective handovers in patient care, including those where information loss occurs between care providers, have been identified as a risk to patient safety. Computerization of health information is often offered as a solution to improve the quality of care handovers and decrease adverse events related to patient safety. The purpose of this paper is to broaden our understanding of clinical handover as a patient safety issue, and to identify socio-technical issues which may come to bear on the success of computer based handover tools. Three in depth ethnographic case studies were undertaken. Field notes were transcribed and analyzed with the aid of qualitative data analysis software. Within case analysis was performed on each case, and subsequently, cross case analyses were performed. We identified five types of socio-technical issues which must be addressed if electronic handover tools are to succeed. The inter-dependencies of these issues are addressed in relation to arenas in which health care work takes place. We suggest that the contextual nature of information, ethical and medico-legal issues arising in relation to information handover, and issues related to data standards and system interoperability must be addressed if computerized health information systems are to achieve improvements in patient safety related to handovers in care. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Safety and licensing issues for Indian PHWRs

International Nuclear Information System (INIS)

Srinivasan, G.R.; Das, M.

1997-01-01

India has achieved competency in design, construction, commissioning and operation of Pressurized Heavy Water Reactor based Nuclear Power Plants and has completed more than 120 reactor operating years with an extremely satisfactory safety record. In this paper, the safety management in NPCIL and operational safety aspects are discussed, licensing and regulatory approach is described and some of the main safety issues for Indian PHWRs are brought out. (author)

Role of a quality management system in improving patient safety - laboratory aspects.

Science.gov (United States)

Allen, Lynn C

2013-09-01

The aim of this study is to describe how implementation of a quality management system (QMS) based on ISO 15189 enhances patient safety. A literature review showed that several European hospitals implemented a QMS based on ISO 9001 and assessed the impact on patient safety. An Internet search showed that problems affecting patient safety have occurred in a number of laboratories across Canada. The requirements of a QMS based on ISO 15189 are outlined, and the impact of the implementation of each requirement on patient safety is summarized. The Quality Management Program - Laboratory Services in Ontario is briefly described, and the experience of Ontario laboratories with Ontario Laboratory Accreditation, based on ISO 15189, is outlined. Several hospitals that implemented ISO 9001 reported either a positive impact or no impact on patient safety. Patient safety problems in Canadian laboratories are described. Implementation of each requirement of the QMS can be seen to have a positive effect on patient safety. Average laboratory conformance on Ontario Laboratory Accreditation is very high, and laboratories must address and resolve any nonconformities. Other standards, practices, and quality requirements may also contribute to patient safety. Implementation of a QMS based on ISO 15189 provides a solid foundation for quality in the laboratory and enhances patient safety. It helps to prevent patient safety issues; when such issues do occur, effective processes are in place for investigation and resolution. Patient safety problems in Canadian laboratories might have been prevented had effective QMSs been in place. Ontario Laboratory Accreditation has had a positive impact on quality in Ontario laboratories. Copyright © 2013 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Characterization report for the ferrocyanide safety issue

International Nuclear Information System (INIS)

Pulsipher, B.A.; Burger, L.L.; Liebetrau, A.M.; Scheele, R.D.

1997-06-01

Recently PNNL was tasked by DOE to develop and demonstrate a risk-based strategic approach to characterizing Hanford's Nuclear Waste Tanks. This strategic approach was documented in a report entitled ''A Risk-Based Focused Decision-Management Approach for Justifying Characterization of Hanford Tank Waste''. In support of the general approach, a specific strategy for addressing each of the several safety issues associated with the tanks was developed. This report documents the approach for the Ferrocyanide Safety Issue. The purpose of this report is to describe a structured logic diagram (SLD) for determining the risk associated with the ferrocyanide tank safety issue and provide the supporting information for the SLD. The SLD addresses the resolution of risks resulting from the presence of ferrocyanide layers within the Hanford tanks. The informational requirements for determining risk from any reaction stemming from ferrocyanide are outlined in the SLD. This report will describe the potential paths to a successful resolution of the ferrocyanide safety issue. Complete development of the intervention pathway is outside the scope of this current activity. General descriptions of the approach, key components of the SLD, and conclusions are provided in the body of this report. The complete SLD, descriptions of each box shown in the SLD, a discussion on how to fill data needs, and a list of contributors is provided in the appendices

Strategy for resolution of the flammable gas safety issue

International Nuclear Information System (INIS)

Johnson, G.D.

1997-01-01

This document provides a strategy for resolution of the Flammable Gas Safety Issue. It defines the key elements required for the following: Closing the Flammable Gas Unreviewed Safety Question (USQ); Providing the administrative basis for resolving the safety issue; Defining the data needed to support these activities; and Providing the technical and administrative path for removing tanks from the Watch List

Strategy for resolution of the flammable gas safety issue

Energy Technology Data Exchange (ETDEWEB)

Johnson, G.D.

1997-05-23

This document provides a strategy for resolution of the Flammable Gas Safety Issue. It defines the key elements required for the following: Closing the Flammable Gas Unreviewed Safety Question (USQ); Providing the administrative basis for resolving the safety issue; Defining the data needed to support these activities; and Providing the technical and administrative path for removing tanks from the Watch List.

Patient safety initiatives in Central and Eastern Europe: A mixed methods approach by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Godycki-Cwirko, Maciek; Esmail, Aneez; Dovey, Susan; Wensing, Michel; Parker, Dianne; Kowalczyk, Anna; Błaszczyk, Honorata; Kosiek, Katarzyna

2015-01-01

ABSTRACT Background: Despite patient safety being recognized as an important healthcare issue in the European Union, there has been variable implementation of patient safety initiatives in Central and Eastern Europe (CEE). Objective: To assess the status of patient safety initiatives in countries in CEE; to describe a process of engagement in Poland, which can serve as a template for the implementation of patient safety initiatives in primary care. Methods: A mixed methods design was used. We conducted a review of literature focusing on publications from CEE, an inventory of patient safety initiatives in CEE countries, interviews with key informants, international survey, review of national reporting systems, and pilot demonstrator project in Poland with implementation of patient safety toolkits assessment. Results: There was no published patient safety research from Albania, Belarus, Greece, Latvia, Lithuania, Romania, or Russia. Nine papers were found from Bulgaria, Croatia, the Czech Republic, Poland, Serbia, and Slovenia. In most of the CEE countries, patient safety had been addressed at the policy level although the focus was mainly in hospital care. There was a dearth of activity in primary care. The use of patient improvement strategies was low. Conclusion: International cooperation as exemplified in the demonstrator project can help in the development and implementation of patient safety initiatives in primary care in changing the emphasis away from a blame culture to one where greater emphasis is placed on improvement and learning. PMID:26339839

Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF).

Science.gov (United States)

Parker, Dianne

2009-03-01

To provide sufficient information about the Manchester Patient Safety Framework (MaPSaF) to allow healthcare professionals to assess its potential usefulness. The assessment of safety culture is an important aspect of risk management, and one in which there is increasing interest among healthcare organizations. Manchester Patient Safety Framework offers a theory-based framework for assessing safety culture, designed specifically for use in the NHS. The framework covers multiple dimensions of safety culture, and five levels of safety culture development. This allows the generation of a profile of an organization's safety culture in terms of areas of relative strength and challenge, which can be used to identify focus issues for change and improvement. Manchester Patient Safety Framework provides a useful method for engaging healthcare professionals in assessing and improving the safety culture in their organization, as part of a programme of risk management.

Draft pilot report - Approaches to the resolution of safety issues

International Nuclear Information System (INIS)

2006-01-01

The purpose of this report is to present in a concise form how some safety matters associated with currently operating light water reactors have been addressed. The issues discussed in this report are common to member countries with currently operating LWRs (PWR, BWR, VVER) and, as such, have wide interest in the nuclear safety community. Accordingly, this report can serve as a reference for researchers, regulations and others (e.g., industry) interested in understanding the approach and status of issues. This report should also be useful for knowledge transfer by documenting what has been done or is planned regarding selected safety matters and as a source for identifying reference material containing additional detail. The issues addressed in this report should not be viewed as questioning the safety of operating reactors, which have reached very high operational safety record, but rather as areas where uncertainty in knowledge exists, where safety assessment has been based on conservative assumptions, and where regulatory decisions need, or will need to be confirmed. Thus, the development of sound technical bases through continuing research will improve the current knowledge and allow for more realistic safety assessment. The safety issues discussed in this initial version of the report are: - design basis accident spectrum; - severe accident issues; - reactor pressure vessel integrity; - hydrogen control; - containment integrity; - accident management; - station blackout; - high burnup fuel; - power up-rates; - ECCS strainer clogging; - boron dilution. For each issue, the scope of the issue is defined, its status discussed and planned work or research described, including schedule. This pilot version of the report is limited to input from nine countries (Belgium, Czech Republic, Finland, France, Germany, Japan, Korea, Sweden and the U.S.). An overview of this information for each issue by country is provided in the table. This document does not contain a

High-heat tank safety issue resolution program plan. Revision 2

International Nuclear Information System (INIS)

Wang, O.S.

1994-12-01

The purpose of this program plan is to provide a guide for selecting corrective actions that will mitigate and/or remediate the high-heat waste tank safety issue for single-shell tank 241-C-106. The heat source of approximately 110,000 Btu/hr is the radioactive decay of the stored waste material (primarily 90 Sr) inadvertently transferred into the tank in the later 1960s. Currently, forced ventilation, with added water to promote thermal conductivity and evaporation cooling, is used for heat removal. The method is very effective and economical. At this time, the only viable solution identified to permanently resolve this safety issue is the removal of heat-generating waste in the tank. This solution is being aggressively pursued as the only remediation method to this safety issue, and tank 241-C-106 has been selected as the first single-shell tank for retrieval. The current cooling method and other alternatives are addressed in this program as means to mitigate this safety issue before retrieval. This program plan has three parts. The first part establishes program objectives and defines safety issue, drivers, and resolution criteria and strategy. The second part evaluates the high-heat safety issue and its mitigation and remediation methods and other alternatives according to resolution logic. The third part identifies major tasks and alternatives for mitigation and resolution of the safety issue. A table of best-estimate schedules for the key tasks is also included in this program plan

Designing a Safety Reporting Smartphone Application to Improve Patient Safety After Total Hip Arthroplasty.

Science.gov (United States)

Krumsvik, Ole Andreas; Babic, Ankica

2017-01-01

This paper presents a safety reporting smartphone application which is expected to reduce the occurrence of postoperative adverse events after total hip arthroplasty (THA). A user-centered design approach was utilized to facilitate optimal user experience. Two main implemented functionalities capture patient pain levels and well-being, the two dimensions of patient status that are intuitive and commonly checked. For these and other functionalities, mobile technology could enable timely safety reporting and collection of patient data out of a hospital setting. The HCI expert, and healthcare professionals from the Haukeland University Hospital in Bergen have assessed the design with respect to the interaction flow, information content, and self-reporting functionalities. They have found it to be practical, intuitive, sufficient and simple for users. Patient self-reporting could help recognizing safety issues and adverse events.

Advanced nuclear reactor safety issues and research needs

International Nuclear Information System (INIS)

2002-01-01

On 18-20 February 2002, the OECD Nuclear Energy Agency (NEA) organised, with the co-sponsorship of the International Atomic Energy Agency (IAEA) and in collaboration with the European Commission (EC), a Workshop on Advanced Nuclear Reactor Safety Issues and Research Needs. Currently, advanced nuclear reactor projects range from the development of evolutionary and advanced light water reactor (LWR) designs to initial work to develop even further advanced designs which go beyond LWR technology (e.g. high-temperature gas-cooled reactors and liquid metal-cooled reactors). These advanced designs include a greater use of advanced technology and safety features than those employed in currently operating plants or approved designs. The objectives of the workshop were to: - facilitate early identification and resolution of safety issues by developing a consensus among participating countries on the identification of safety issues, the scope of research needed to address these issues and a potential approach to their resolution; - promote the preservation of knowledge and expertise on advanced reactor technology; - provide input to the Generation IV International Forum Technology Road-map. In addition, the workshop tried to link advancement of knowledge and understanding of advanced designs to the regulatory process, with emphasis on building public confidence. It also helped to document current views on advanced reactor safety and technology, thereby contributing to preserving knowledge and expertise before it is lost. (author)

Assessment of basic safety issues

International Nuclear Information System (INIS)

Queniart, D.

1996-01-01

Work on the French-German common safety approach for future nuclear power plants continued in 1994 to allow for more detailed discussion of some major issues, taking into account the options provided by the industry for the EPR (European Pressurized water Reactor) project, as described in the document entitled 'Conceptual Safety Features Review File'. Seven meetings of a GPR/RSK advisory experts subgroup, six GPR/RSK plenary sessions and six meetings of the safety authorities (DFD) dealt with the following topics: design of the systems and use of probabilistic approaches, application of a 'break preclusion' approach to the main primary pipings, protection against external hazards (aircraft crashes, explosions, earthquakes), provisions with respect to accidents involving core melt and to containment design, radiological consequences of reference accidents and accidents involving core melt at low pressure. The important aspects of the joint policy are recalled in the presentation. The whole set of GPR/RSK recommendations were agreed by the French and German safety authorities during the DFD meetings of 1994 and early 1995. The utilities decided to begin the basic design phase in February, 1995. Work is now continuing to develop the common French-German approach for future nuclear power plants, in the same way as before. In 1995, this mainly covers the design of the containment and of the systems, but also new issues such as the protection against secondary side overpressurization, radiological protection of workers and radioactive wastes. (J.S.). 3 figs., 1 tab

Light Water Reactor Generic Safety Issues Database (LWRGSIDB). User's manual

International Nuclear Information System (INIS)

1999-01-01

The IAEA Conference on 'The Safety of Nuclear Power: Strategy for the Future' in 1991 was a milestone in nuclear safety. The objective of this conference was to review nuclear power safety issues for which achieving international consensus would be desirable, to address concerns on nuclear safety and to formulate recommendations for future actions by national and international authorities to advance nuclear safety to the highest level. Two of the important items addressed by this conference were ensuring and enhancing safety of operating plants and treatment of nuclear power plants built to earlier safety standards. Some of the publications related to these two items that have been issued subsequent to this conference are: A Common Basis for Judging the Safety of Nuclear Power Plants Built to Earlier Standards, INSAG-8 (1995), the IAEA Safety Guide 50-SG-O12, Periodic Safety Review of Operational Nuclear Power Plants (1994) and IAEA Safety Reports Series No. 12, Evaluation of the Safety of Operating Nuclear Power Plants Built to Earlier Standards: A Common Basis for Judgement (1998). Some of the findings of the 1991 conference have not yet been fully addressed. An IAEA Symposium on Reviewing the Safety of Existing Nuclear Power Plants in 1996 showed that there is an urgent need for operating organizations and national authorities to review those operating nuclear power plants which do not reach the high safety levels of the vast majority of plants and to undertake improvements with assistance from the international community if required. Safety reviews of operating nuclear power plants take on added importance in the context of the Convention on Nuclear Safety and its implementation. In order to perform safety reviews and to reassess the safety of operating nuclear power plants in a uniform manner, it is imperative to have an internationally accepted reference. Existing guidance needs to be complemented by a list of safety issues which have been encountered and

Current safety issues of CANDU licensing

International Nuclear Information System (INIS)

Lee, Y.; Natalizio, A.

1994-01-01

As requested by Korea Institute of Nuclear Safety(KINS), the status of five generic licensing issues has been examined and their potential impact on a new plant that would be constructed in Canada has been evaluated. The results and conclusions of this evaluation are summarized as follows: steam explosion in calandria, hydrogen explosion in containment, use of PSA in reactor licensing, human factors, safety critical software

Does Employee Safety Matter for Patients Too? Employee Safety Climate and Patient Safety Culture in Health Care.

Science.gov (United States)

Mohr, David C; Eaton, Jennifer Lipkowitz; McPhaul, Kathleen M; Hodgson, Michael J

2015-04-22

We examined relationships between employee safety climate and patient safety culture. Because employee safety may be a precondition for the development of patient safety, we hypothesized that employee safety culture would be strongly and positively related to patient safety culture. An employee safety climate survey was administered in 2010 and assessed employees' views and experiences of safety for employees. The patient safety survey administered in 2011 assessed the safety culture for patients. We performed Pearson correlations and multiple regression analysis to examine the relationships between a composite measure of employee safety with subdimensions of patient safety culture. The regression models controlled for size, geographic characteristics, and teaching affiliation. Analyses were conducted at the group level using data from 132 medical centers. Higher employee safety climate composite scores were positively associated with all 9 patient safety culture measures examined. Standardized multivariate regression coefficients ranged from 0.44 to 0.64. Medical facilities where staff have more positive perceptions of health care workplace safety climate tended to have more positive assessments of patient safety culture. This suggests that patient safety culture and employee safety climate could be mutually reinforcing, such that investments and improvements in one domain positively impacts the other. Further research is needed to better understand the nexus between health care employee and patient safety to generalize and act upon findings.

Safety issue resolution strategy plan for inactive miscellaneous underground storage tanks

International Nuclear Information System (INIS)

Wang, O.S.; Powers, T.B.

1994-09-01

The purpose of this strategy plan is to identify, confirm, and resolve safely issues associated with inactive miscellaneous underground storage tanks (MUSTs) using a risk-based priority approach. Assumptions and processes to assess potential risks and operational concerns are documented in this report. Safety issue priorities are ranked based on a number of considerations including risk ranking and cost effectiveness. This plan specifies work scope and recommends schedules for activities related to resolving safety issues, such as collecting historical data, searching for authorization documents, performing Unreviewed Safety Question (USQ) screening and evaluation, identifying safety issues, imposing operational controls and monitoring, characterizing waste contents, mitigating and resolving safety issues, and fulfilling other remediation requirements consistent with the overall Tank Waste Remediation System strategy. Recommendations for characterization and remediation are also recommended according to the order of importance and practical programmatic consideration

Patient Safety Culture

DEFF Research Database (Denmark)

Kristensen, Solvejg

of health care professional’s behaviour, habits, norms, values, and basic assumptions related to patient care; it is the way things are done. The patient safety culture guides the motivation, commitment to and know-how of the safety management, and how all members of a work place interact. This thesis......Patient safety is highly prioritised in the Danish health care system, never the less, patients are still exposed to risk and harmed every day. Implementation of a patient safety culture has been suggested an effective mean to protect patients against adverse events. Working strategically...

76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Child Health Patient Safety...

Science.gov (United States)

2011-11-17

... Organizations: Voluntary Relinquishment From Child Health Patient Safety Organization, Inc. AGENCY: Agency for... notification of voluntary relinquishment from Child Health Patient Safety Organization, Inc. of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety...

76 FR 79192 - Patient Safety Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization

Science.gov (United States)

2011-12-21

... Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization AGENCY: Agency for Healthcare... voluntary relinquishment from the HSMS Patient Safety Organization of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109...

Patient Safety Movement: History and Future Directions.

Science.gov (United States)

Lark, Meghan E; Kirkpatrick, Kay; Chung, Kevin C

2018-02-01

Despite progress within the past 15 years, improving patient safety in health care remains an important public health issue. The history of safety policies, research, and development has revealed that this issue is more complex than initially perceived and is pertinent to all health care settings. Solutions, therefore, must be approached at the systems level and supplemented with a change in safety culture, especially in higher risk fields such as surgery. To do so, health care agents at all levels have started to prioritize the improvement of nontechnical skills such as teamwork, communication, and accountability, as reflected by the development of various checklists and safety campaigns. This progress may be sustained by adopting teamwork training programs that have proven successful in other high-risk industries, such as crew resource management in aviation. These techniques can be readily implemented among surgical teams; however, successful application depends heavily on the strong leadership and vigilance of individual surgeons. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

A prioritization of generic safety issues. Supplement 21, Revision insertion instructions

Energy Technology Data Exchange (ETDEWEB)

None, None

1996-12-31

The report presents the safety priority ranking for generic safety issues related to nuclear power plants. The purpose of these rankings is to assist in the timely and efficient allocation of NRC resources for the resolution of those safety issues that have a significant potential for reducing risk. The safety priority rankings are HIGH, MEDIUM, LOW, and DROP, and have been assigned on the basis of risk significance estimates, the ratio of risk to costs and other impacts estimated to result if resolution of the safety issues were implemented, and the consideration of uncertainties and other quantitative or qualitative factors. To the extent practical, estimates are quantitative.

A prioritization of generic safety issues. Supplement 21, Revision insertion instructions

International Nuclear Information System (INIS)

1996-01-01

The report presents the safety priority ranking for generic safety issues related to nuclear power plants. The purpose of these rankings is to assist in the timely and efficient allocation of NRC resources for the resolution of those safety issues that have a significant potential for reducing risk. The safety priority rankings are HIGH, MEDIUM, LOW, and DROP, and have been assigned on the basis of risk significance estimates, the ratio of risk to costs and other impacts estimated to result if resolution of the safety issues were implemented, and the consideration of uncertainties and other quantitative or qualitative factors. To the extent practical, estimates are quantitative.

Safety of research reactors. Topical issues paper no. 4

International Nuclear Information System (INIS)

Alcala-Ruiz, F.; Ferraz-Bastos, J.L.; Kim, S.C.; Voth, M.; Boeck, H.; Dimeglio, F.; Litai, D.

2001-01-01

Assessment of Research Reactors (INSARR) missions. The prime objective of these missions has been to conduct a comprehensive operational safety review of the research reactor facility and to verify compliance with the IAEA Safety Standards. The methods used during an INSARR mission have been collected and analysed. Some of the important issues identified are the following: general ageing of the facility; uncertain status of many research reactors (in extended shutdown); indefinite deferral of return to operation or decommissioning; inadequate regulatory supervision; insufficient systematic (periodic) reassessment of safety; lack of quality assurance (QA) programmes; lack of an international safety convention or arrangement; lack of financial support for safety measures (e.g. safety reassessment, safety upgrading, decommissioning) and utilization; lack of clear utilization programmes; inadequate emergency preparedness; inadequate safety documentation (e.g. safety analysis report, operating rules and procedures, emergency plan); inadequate funding of shutdown reactors; weak safety culture; loss of expertise and corporate memory; loss of information concerning radioactive materials contained in retired experimental devices stored in the facility indefinitely; obsolescence of equipment and lack of spare parts; inadequate training and qualifications of regulators and operators; safety implications of new fuel types. These issues have been addressed by the IAEA Secretariat and the chairman of the International Nuclear Safety Advisory Group (INSAG). INSAG has identified three major safety issues that are: the increasing age of research reactors, the number of research reactors that are not operating anymore but have not been decommissioned, and the number of research reactors in countries that do not have appropriate regulatory authorities. This issue paper discusses the concerns generated by an analysis of the results of INSARR missions and those expressed by INSAG. The

Guidelines for nuclear-power-plant safety-issue-prioritization information development

International Nuclear Information System (INIS)

Andrews, W.B.; Gallucci, R.H.V.; Heaberlin, S.W.; Bickford, W.E.; Konzek, G.J.; Strenge, D.L.; Smith, R.I.; Weakley, S.A.

1983-02-01

Pacific Northwest Laboratory has developed a methodology, with examples, to calculate - to an approximation serviceable for prioritization purposes - the risk, dose and cost impacts of implementing resolutions to reactor safety issues. This report is an applications guide to issue-specific calculations. A description of the approach, mathematical models, worksheets and step-by-step examples are provided. Analysis using this method is intended to provide comparable results for many issues at a cost of two staff-weeks per issue. Results will be used by the NRC to support decisions related to issue priorities in allocation of resources to complete safety issue resolutions

[Patient safety culture in Family practice residents of Galicia].

Science.gov (United States)

Portela Romero, Manuel; Bugarín González, Rosendo; Rodríguez Calvo, María Sol

To determine the views held by Family practice (FP) residents on the different dimensions of patient safety, in order to identify potential areas for improvement. A cross-sectional study. Seven FP of Galicia teaching units. 182 FP residents who completed the Medical Office Survey on Patient Safety Culture questionnaire. The Medical Office Survey on Patient Safety Culture questionnaire was chosen because it is translated, validated, and adapted to the Spanish model of Primary Care. The results were grouped into 12 composites assessed by the mentioned questionnaire. The study variables were the socio-demographic dimensions of the questionnaire, as well as occupational/professional variables: age, gender, year of residence, and teaching unit of FP of Galicia. The "Organisational learning" and "Teamwork" items were considered strong areas. However, the "Patient safety and quality issues", "Information exchange with other settings", and "Work pressure and pace" items were considered areas with significant potential for improvement. First-year residents obtained the best results and the fourth-year ones the worst. The results may indicate the need to include basic knowledge on patient safety in the teaching process of FP residents in order to increase and consolidate the fragile patient safety culture described in this study. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

The impact of nursing leadership on patient safety in a developing country.

Science.gov (United States)

Stewart, Lee; Usher, Kim

2010-11-01

This article is a report of a study to identify the ways nursing leaders and managers in a developing country have an impact on patient safety. The attempt to address the problem of patient safety in health care is a global issue. Literature addressing the significant impact that nursing leadership has on patient safety is extensive and focuses almost exclusively on the developed world. A critical ethnography was conducted with senior registered nursing leaders and managers throughout the Fiji Islands, specifically those in the Head Office of the Fiji Ministry of Health and the most senior nurse in a hospital or community health service. Semi-structured interviews were conducted with senior nursing leaders and managers in Fiji. Thematic analysis of the interviews was undertaken from a critical theory perspective, with reference to the macro socio-political system of the Fiji Ministry of Health. Four interrelated issues regarding the nursing leaders and managers' impact on patient safety emerged from the study. Empowerment of nursing leaders and managers, an increased focus on the patient, the necessity to explore conditions for front-line nurses and the direct relationship between improved nursing conditions and increased patient safety mirrored literature from developed countries. The findings have significant implications for developing countries and it is crucial that support for patient safety in developing countries become a focus for the international nursing community. Nursing leaders and managers' increased focus on their own place in the hierarchy of the health care system and on nursing conditions as these affect patient safety could decrease adverse patient outcomes. The findings could assist the global nursing community to better support developing countries in pursuing a patient safety agenda. © 2010 Blackwell Publishing Ltd.

A prioritization of generic safety issues. Supplement 19, Revision insertion instructions

International Nuclear Information System (INIS)

1995-11-01

The report presents the safety priority ranking for generic safety issues related to nuclear power plants. The purpose of these rankings is to assist in the timely and efficient allocation of NRC resources for the resolution of those safety issues that have a significant potential for reducing risk. The safety priority rankings are HIGH, MEDIUM, LOW, and DROP, and have been assigned on the basis of risk significance estimates, the ratio of risk to costs and other impacts estimated to result if resolution of the safety issues were implemented, and the consideration of uncertainties and other quantitative or qualitative factors. To the extent practical, estimates are quantitative. This document provides revisions and amendments to the report

A prioritization of generic safety issues. Supplement 19, Revision insertion instructions

Energy Technology Data Exchange (ETDEWEB)

None

1995-11-01

The report presents the safety priority ranking for generic safety issues related to nuclear power plants. The purpose of these rankings is to assist in the timely and efficient allocation of NRC resources for the resolution of those safety issues that have a significant potential for reducing risk. The safety priority rankings are HIGH, MEDIUM, LOW, and DROP, and have been assigned on the basis of risk significance estimates, the ratio of risk to costs and other impacts estimated to result if resolution of the safety issues were implemented, and the consideration of uncertainties and other quantitative or qualitative factors. To the extent practical, estimates are quantitative. This document provides revisions and amendments to the report.

Issues of Safety and Security: New Challenging to Malaysia Tourism Industry

OpenAIRE

Mohd Ayob Norizawati; Masron Tarmiji

2014-01-01

The safety and security issues nowadays become one of the forces causing changes in tourism industry in era of millennium. The main concern of this issues more focus on crime rates, terrorism, food safety, health issues and natural disaster. This topic gained the popularity in tourism research after 9/11 tragedy and since then the academicians and practitioners started seeking the best solution in ways to mitigate these negative impacts. For Malaysia, the image as safety and secure destinatio...

Assessment of Patient Safety Culture in Primary Health Care Settings in Kuwait

Directory of Open Access Journals (Sweden)

Maha Mohamed Ghobashi

2014-01-01

Full Text Available Background Patient safety is critical component of health care quality. We aimed to assess the awareness of primary healthcare staff members about patient safety culture and explore the areas of deficiency and opportunities for improvement concerning this issue.Methods: This descriptive cross sectional study surveyed 369 staff members in four primary healthcare centers in Kuwait using self-administered “Hospital Survey on Patient Safety Culture” adopted questionnaire. The total number of respondents was 276 participants (response rate = 74.79%.Results: Five safety dimensions with lowest positivity (less than 50% were identified and these are; the non – punitive response to errors, frequency of event reporting, staffing, communication openness, center handoffs and transitions with the following percentages of positivity 24%, 32%, 41%, 45% and 47% respectively. The dimensions of highest positivity were teamwork within the center’s units (82% and organizational learning (75%.Conclusion: Patient safety culture in primary healthcare settings in Kuwait is not as strong as improvements for the provision of safe health care. Well-designed patient safety initiatives are needed to be integrated with organizational policies, particularly the pressing need to address the bioethical component of medical errors and their disclosure, communication openness and emotional issues related to them and investing the bright areas of skillful organizational learning and strong team working attitudes.    

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

Science.gov (United States)

Pfeiffer, Yvonne; Schwappach, David

2016-01-01

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

Guidelines for nuclear-power-plant safety-issue prioritization information development

International Nuclear Information System (INIS)

Andrews, W.B.; Gallucci, R.H.V.; Konzek, G.J.

1983-05-01

This is the second in a series of reports to document the use of a methodology developed by the Pacific Northwest Laboratory to calculate, for prioritization purposes, the risk, dose and cost impacts of implementing resolutions to reactor safety issues. This report contains results of issue-specific analyses for 15 issues. Each issue was considered within the contraints of available information as of September 1982 and two staff-weeks of labor. The results will be referenced, as one consideration in setting priorities for reactor safety issues, in an NRC prioritization report to be published at a future date

Guidelines for nuclear power plant safety issue prioritization information development. Supplement 2

International Nuclear Information System (INIS)

Andrews, W.B.; Gallucci, R.H.V.; Konzek, G.J.; Heaberlin, S.W.; Fecht, B.A.; Allen, C.H.; Allen, R.D.; Bickford, W.E.; Carbaugh, E.H.; Lewis, J.R.

1983-12-01

This is the third in a series of reports to document the use of a methodology developed by the Pacific Northwest Laboratory to calculate, for prioritization purposes, the risk, dose and cost impacts of implementing resolutions to reactor safety issues (NUREG/CR-2800, Andrews et al. 1983). This report contains results of issue-specific analyses for 31 issues. Each issue was considered within the constraints of available information as of summer 1983, and two staff-weeks of labor. The results are referenced, as one consideration in setting priorities for reactor safety issues, in NUREG-0933, A Prioritization of Generic Safety Issues

Topical issues in nuclear, radiation and radioactive waste safety. Contributed papers

Energy Technology Data Exchange (ETDEWEB)

NONE

1998-08-01

The IAEA International Conference on Topical Issues in Nuclear, Radiation and Radioactive Waste Safety was held in Vienna, Austria, 30 August - 4 September 1998 with the objective to foster the exchange of information on topical issues in nuclear, radiation and radioactive waste safety, with the aim of consolidating an international consensus on: the present status of these issues; priorities for future work; and needs for strengthening international co-operation, including recommendations for the IAEA`s future activities. The document includes 43 papers presented at the Conference dealing with the following topical issues: Safety Management; Backfitting, Upgrading and Modernization of NPPs; Regulatory Strategies; Occupational Radiation Protection: Trends and Developments; Situations of Chronic Exposure to Residual Radioactive Materials: Decommissioning and Rehabilitation and Reclamation of Land; Radiation Safety in the Far Future: The Issue of Long Term Waste Disposal. A separate abstract and indexing were provided for each paper. Refs, figs, tabs

Topical issues in nuclear, radiation and radioactive waste safety. Contributed papers

International Nuclear Information System (INIS)

1998-08-01

The IAEA International Conference on Topical Issues in Nuclear, Radiation and Radioactive Waste Safety was held in Vienna, Austria, 30 August - 4 September 1998 with the objective to foster the exchange of information on topical issues in nuclear, radiation and radioactive waste safety, with the aim of consolidating an international consensus on: the present status of these issues; priorities for future work; and needs for strengthening international co-operation, including recommendations for the IAEA's future activities. The document includes 43 papers presented at the Conference dealing with the following topical issues: Safety Management; Backfitting, Upgrading and Modernization of NPPs; Regulatory Strategies; Occupational Radiation Protection: Trends and Developments; Situations of Chronic Exposure to Residual Radioactive Materials: Decommissioning and Rehabilitation and Reclamation of Land; Radiation Safety in the Far Future: The Issue of Long Term Waste Disposal. A separate abstract and indexing were provided for each paper

76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group

Science.gov (United States)

2011-09-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group AGENCY: Agency for Healthcare Research and... voluntary relinquishment from The Patient Safety Group of its status as a Patient Safety Organization (PSO...

An interagency space nuclear propulsion safety policy for SEI - Issues and discussion

Science.gov (United States)

Marshall, A. C.; Sawyer, J. C., Jr.

1991-01-01

An interagency Nuclear Safety Policy Working Group (NSPWG) was chartered to recommend nuclear safety policy, requirements, and guidelines for the Space Exploration Initiative nuclear propulsion program to facilitate the implementation of mission planning and conceptual design studies. The NSPWG developed a top level policy to provide the guiding principles for the development and implementation of the nuclear propulsion safety program and the development of Safety Functional Requirements. In addition, the NSPWG reviewed safety issues for nuclear propulsion and recommended top level safety requirements and guidelines to address these issues. Safety topics include reactor start-up, inadvertent criticality, radiological release and exposure, disposal, entry, safeguards, risk/reliability, operational safety, ground testing, and other considerations. In this paper the emphasis is placed on the safety policy and the issues and considerations that are addressed by the NSPWG recommendations.

Keeping nurse researchers safe: workplace health and safety issues.

Science.gov (United States)

Barr, Jennieffer; Welch, Anthony

2012-07-01

This article is a report of a qualitative study of workplace health and safety issues in nursing research. Researcher health and safety have become increasing concerns as there is an increased amount of research undertaken in the community and yet there is a lack of appropriate guidelines on how to keep researchers safe when undertaking fieldwork. This study employed a descriptive qualitative approach, using different sources of data to find any references to researcher health and safety issues. A simple descriptive approach to inquiry was used for this study. Three approaches to data collection were used: interviews with 15 researchers, audits of 18 ethics applications, and exploration of the literature between 1992 and 2010 for examples of researcher safety issues. Data analysis from the three approaches identified participant comments, narrative descriptions or statements focused on researcher health and safety. Nurse researchers' health and safety may be at risk when conducting research in the community. Particular concern involves conducting sensitive research where researchers are physically at risk of being harmed, or being exposed to the development of somatic symptoms. Nurse researchers may perceive the level of risk of harm as lower than the actual or potential harm present in research. Nurse researchers do not consistently implement risk assessment before and during research. Researcher health and safety should be carefully considered at all stages of the research process. Research focusing on sensitive data and vulnerable populations need to consider risk minimization through strategies such as appropriate researcher preparation, safety during data collection, and debriefing if required. © 2012 Blackwell Publishing Ltd.

An Organizational Learning Framework for Patient Safety.

Science.gov (United States)

Edwards, Marc T

Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

Characterization strategy report for the organic safety issues

International Nuclear Information System (INIS)

Goheen, S.C.; Campbell, J.A.; Fryxell, G.E.

1997-08-01

This report describes a logical approach to resolving potential safety issues resulting from the presence of organic components in hanford tank wastes. The approach uses a structured logic diagram (SLD) to provide a pathway for quantifying organic safety issue risk. The scope of the report is limited to selected organics (i.e., solvents and complexants) that were added to the tanks and their degradation products. The greatest concern is the potential exothermic reactions that can occur between these components and oxidants, such as sodium nitrate, that are present in the waste tanks. The organic safety issue is described in a conceptual model that depicts key modes of failure-event reaction processes in tank systems and phase domains (domains are regions of the tank that have similar contents) that are depicted with the SLD. Applying this approach to quantify risk requires knowing the composition and distribution of the organic and inorganic components to determine (1) how much energy the waste would release in the various domains, (2) the toxicity of the region associated with a disruptive event, and (3) the probability of an initiating reaction. Five different characterization options are described, each providing a different level of quality in calculating the risks involved with organic safety issues. Recommendations include processing existing data through the SLD to estimate risk, developing models needed to link more complex characterization information for the purpose of estimating risk, and examining correlations between the characterization approaches for optimizing information quality while minimizing cost in estimating risk

Safety issues of tooth whitening using peroxide-based materials.

Science.gov (United States)

Li, Y; Greenwall, L

2013-07-01

In-office tooth whitening using hydrogen peroxide (H₂O₂) has been practised in dentistry without significant safety concerns for more than a century. While few disputes exist regarding the efficacy of peroxide-based at-home whitening since its first introduction in 1989, its safety has been the cause of controversy and concern. This article reviews and discusses safety issues of tooth whitening using peroxide-based materials, including biological properties and toxicology of H₂O₂, use of chlorine dioxide, safety studies on tooth whitening, and clinical considerations of its use. Data accumulated during the last two decades demonstrate that, when used properly, peroxide-based tooth whitening is safe and effective. The most commonly seen side effects are tooth sensitivity and gingival irritation, which are usually mild to moderate and transient. So far there is no evidence of significant health risks associated with tooth whitening; however, potential adverse effects can occur with inappropriate application, abuse, or the use of inappropriate whitening products. With the knowledge on peroxide-based whitening materials and the recognition of potential adverse effects associated with the procedure, dental professionals are able to formulate an effective and safe tooth whitening regimen for individual patients to achieve maximal benefits while minimising potential risks.

Consideration of social scientific issues in a safety case. Final report

International Nuclear Information System (INIS)

Sailer, Michael; Kallenbach-Herbert, Beate; Brohmann, Bettina; Spieth-Achtnich, Angelika

2010-01-01

The research outcome presented here - a model for identifying and describing safety-relevant social scientific issues - provides a scientific basis for addressing these issues in a safety case. In order for them to be implemented in a repository process, it would be necessary to elaborate in greater detail the initial conceptual foundations that have been laid in this research project in line with the project's terms of reference. The requisite elaboration relates to binding rules for designing the repository process, particularly with regard to the stages in which the safety case is to be developed during planning, approval, construction and operation through to repository closure. Such detailed elaboration also needs to involve specifying the extent to which each social scientific issue and sub-issue is to be addressed in the different stages. Consideration would need to be given not only to the relevance of the issue for a given stage but also to the various options and methods for providing proof of safety. It would be possible to draw on experiences with handling safety management in nuclear power plants - a sphere in which over the last ten years efforts have been ongoing to develop methods for presentation by the operator and review by the authorities. Furthermore, it is likely that the social scientific issues relevant to a safety case cannot be defined once and for all in a single process, but that the need for continual revision and adaptation will arise due to both the increasing knowledge acquired during the course of the repository process and the experiences and expectations of stakeholders (similarly to experiences in the sphere of scientific-technological requirements). Appropriate conditions need to be defined for such a process. This process could be supported by implementing the option mentioned above whereby a regulatory definition of safety management for geological disposal is formulated which encompasses all safety-relevant social scientific

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

Directory of Open Access Journals (Sweden)

Predrag Dašić

2017-03-01

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

Safety issues for superconducting fusion magnets

International Nuclear Information System (INIS)

Hsieh, S.Y.; Reich, M.; Powell, J.R.

1978-01-01

Safety issues for future superconducting fusion magnet systems are examined. It is found that safety and failure experience with existing superconducting magnets is not very applicable to predictions as to the safety and reliability of fusion magnets. Such predictions will have to depend on analysis and judgement for many years to come, rather than on accumulated experience. A number of generic potential structural, thermal-hydraulic, and electrical safety problems are identified and analyzed. Prevention of quenches and non-uniform temperature distributions, if quenches should occur, is of great importance, since such events can trigger processes which lead to magnet damage or failure. Engineered safety features will be necessary for fusion magnets. Two of these, an energy dispersion system and external coil containment, appear capable of reducing the probability of coil disruption to very low levels. However, they do not prevent loss of function accidents which are of economic concern. Elaborate detector, temperature equalization, and energy removal systems will be required to minimize the chances of loss of function accidents

Verification and validation issues for digitally-based NPP safety systems

International Nuclear Information System (INIS)

Ets, A.R.

1993-01-01

The trend toward standardization, integration and reduced costs has led to increasing use of digital systems in reactor protection systems. While digital systems provide maintenance and performance advantages, their use also introduces new safety issues, in particular with regard to software. Current practice relies on verification and validation (V and V) to ensure the quality of safety software. However, effective V and V must be done in conjunction with a structured software development process and must consider the context of the safety system application. This paper present some of the issues and concerns that impact on the V and V process. These include documentation of systems requirements, common mode failures, hazards analysis and independence. These issues and concerns arose during evaluations of NPP safety systems for advanced reactor designs and digital I and C retrofits for existing nuclear plants in the United States. The pragmatic lessons from actual systems reviews can provide a basis for further refinement and development of guidelines for applying V and V to NPP safety systems. (author). 14 refs

Critical safety issues in the design of fusion machines

International Nuclear Information System (INIS)

Kramer, W.

1991-01-01

In the course of developing fusion machines both general safety considerations and safety assessments for the various components and systems of actual machines increase in number and become more and more coherent. This is particularly true for the NET/ITER projects where safety analysis plays an increasing role for the design of the machine. Since in a D/T tokamak the radiological hazards will be dominant basic radiological safety objectives are discussed. Critical safety issues as identified in particular by the NET/ITER community are reviewed. Subsequently, issues of major concern are considered both for normal operation and for conceivable accidents. The following accidents are considered to be crucial: Loss of cooling in plasma facing components, loss of vacuum, tritium system failure, and magnet system failure. To mitigate accident consequences a confinement concept based on passive features and multiple barriers including detritiation and filtering has to be applied. The reactor building as final barrier needs special attention to cope with both internal and external hazards. (orig.)

77 FR 11120 - Patient Safety Organizations: Voluntary Relinquishment From UAB Health System Patient Safety...

Science.gov (United States)

2012-02-24

... Organizations: Voluntary Relinquishment From UAB Health System Patient Safety Organization AGENCY: Agency for... notification of voluntary relinquishment from the UAB Health System Patient Safety Organization of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005...

Workplace engagement and workers' compensation claims as predictors for patient safety culture.

Science.gov (United States)

Thorp, Jonathon; Baqai, Waheed; Witters, Dan; Harter, Jim; Agrawal, Sangeeta; Kanitkar, Kirti; Pappas, James

2012-12-01

Demonstrate the relationship between employee engagement and workplace safety for predicting patient safety culture. Patient safety is an issue for the U.S. health-care system, and health care has some of the highest rates of nonfatal workplace injuries. Understanding the types of injuries sustained by health-care employees, the type of safety environment employees of health-care organizations work in, and how employee engagement affects patient safety is vital to improving the safety of both employees and patients. The Gallup Q survey and an approved, abbreviated, and validated subset of questions from the Hospital Survey on Patient Safety Culture were administered to staff at a large tertiary academic medical center in 2007 and 2009. After controlling for demographic variables, researchers conducted a longitudinal, hierarchical linear regression analysis to study the unique contributions of employee engagement, changes in employee engagement, and employee safety in predicting patient safety culture. Teams with higher baseline engagement, more positive change in engagement, fewer workers' compensation claims, and fewer part-time associates in previous years had stronger patient safety cultures in 2009. Baseline engagement and change in engagement were the strongest independent predictors of patient safety culture in 2009. Engagement and compensation claims were additive and complimentary predictors, independent of other variables in the analysis, including the demographic composition of the workgroups in the study. A synergistic effect exists between employee engagement and decreased levels of workers' compensation claims for improving patient safety culture. Organizations can improve engagement and implement safety policies, procedures, and devices for employees with an ultimate effect of improving patient safety culture.

Nuclear power systems: Their safety. Current issue review

International Nuclear Information System (INIS)

Myers, L.C.

1994-04-01

Human beings utilize energy in many forms and from a variety of sources. A number of countries have chosen nuclear-electric generation as a component of their energy system. At the end of 1992, there were 419 power reactors operating in 29 countries, accounting for more than 15% of the world's production of electricity. In 1992, 13 countries derived at least 25% of their electricity from nuclear units, with Lithuania leading at just over 78%, followed closely by France at 72%. In the same year, Canada produced about 16% of its electricity from nuclear units. Some 53 power reactors are under construction in 14 countries outside the former USSR. Within the ex-USSR countries, six new reactors are currently under construction. No human endeavour carries the guarantee of perfect safety and the question of whether of not nuclear-electric generation represents an 'acceptable' risk to society has long been vigorously debated. Until the events of late April 1986 in the then Soviet Union, nuclear safety had indeed been an issue for discussion, for some concern, but not for alarm. The accident at the Chernobyl reactor irrevocably changed all that. This disaster brought the matter of nuclear safety into the public mind in a dramatic fashion. Subsequent opening of the ex-Soviet nuclear power program to outside scrutiny has done little to calm people's concerns about the safety of nuclear power in that part of the world. This paper discusses the issue of safety in complex energy systems and provides brief accounts of some of the most serious reactor accidents that have occurred to date, as well as more recent, less dramatic events touching on the safety issue. (author). 7 refs

Patients' safety in the era of EMR/EHR automation

Directory of Open Access Journals (Sweden)

Bakheet Aldosari

2017-01-01

Full Text Available Accurate maintenance of the medical records of patients has become a worldwide problem with the rapid rise in the count of patients. Furthermore, providing them adequate health care keeping their safety in view is turning into a great challenge for physicians. As such, electronic health records (EHRs were developed to solve these issues by aiding physicians in imparting quality health care to patients as well as maintaining their safety. Nonetheless, rather than increasing their efficiency, EHRs have become a burden for the physicians as they ultimately increase their error rate and reduce output rate affecting patient safety. As health-IT is advancing progressively, new features are added to the existing EHRs with the aim to support physicians in providing better healthcare. Till date, some of the most advanced features include clinical support decision system (CDSS, computerized physician order entry (CPOE system, health information exchange (HIE, mobile documentation application, and a system of safety alerts on a dashboard. Proper training to the physicians on judiciously usage of these EHR functions is required to extract maximum benefit. Else, these can introduce a considerable number of medical errors, which can result in fatal outcomes for the patients.

Safety issues at the defense production reactors

International Nuclear Information System (INIS)

1987-01-01

The United States produces plutonium and tritium for use in nuclear weapons at the defense production reactors - the N Reactor in Washington and the Savannah River reactors in South Carolina. This report reaches general conclusions about the management of those reactors and highlights a number of safety and technical issues that should be resolved. The report provides an assessment of the safety management, safety review, and safety methodology employed by the Department of Energy and the private contractors who operate the reactors for the federal government. This report examines the safety objective established by the Department of Energy for the production reactors and the process the Department of its contractors use to implement the objective; focuses on a variety of uncertainties concerning the production reactors, particularly those related to potential vulnerabilities to severe accidents; and identifies ways in which the DOE approach to management of the safety of the production reactors can be improved

Harmed patients gaining voice: challenging dominant perspectives in the construction of medical harm and patient safety reforms.

Science.gov (United States)

Ocloo, Josephine Enyonam

2010-08-01

Patient safety is a central issue in healthcare. In the United Kingdom, where there is more accurate information on National Health Service (NHS) hospitals than on primary care or the private sector, the evidence on adverse incidents shows that avoidable medical harm is a major concern. This paper looks at the occurrence of medical harm and argues that in the construction of patient safety reforms, it is important to be aware of alternative narratives about issues of power and accountability from harmed patients and self-help groups, that challenge dominant perspectives on the issues. The paper draws upon evidence from two sources. First, the paper draws on experiences of self-help groups set up as a result of medical harm and part of a campaigning network, where evidence was gathered from 14 groups over more than 2 years. In addition, data were obtained from 21 individuals affected by harm that attended a residential workshop called the Break Through Programme; 18 questionnaires were completed from participants and a written narrative account of their experiences and observational data were gathered from a range of workshop sessions. Looking at the issues from harmed patients' perspectives, the research illustrates that a model of medical harm focussing predominantly upon the clinical markers and individual agency associated with a medical model operates to obscure a range of social processes. These social processes, connected to the power and dominance of the medical profession and the activities of a wider state, are seen to be a major part of the construction of harm that impacts upon patients, which is further compounded by its concealment. Understanding the experiences of harmed patients is therefore seen as an important way of generating knowledge about the medical and social processes involved in harm, that can lead to a broader framework for addressing patient safety. Copyright 2010 Elsevier Ltd. All rights reserved.

Can we improve patient safety?

Science.gov (United States)

Corbally, Martin Thomas

2014-01-01

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

76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Emergency Medicine Patient Safety...

Science.gov (United States)

2011-11-17

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Emergency Medicine Patient Safety Foundation AGENCY: Agency for... notification of voluntary relinquishment from Emergency Medicine Patient Safety Foundation of its status as a...

78 FR 40146 - Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety...

Science.gov (United States)

2013-07-03

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety Institute AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: The Patient Safety and...

76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission

Science.gov (United States)

2011-02-11

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: Oregon Patient Safety Commission: AHRQ...

Current safety issues related to research reactor operation

International Nuclear Information System (INIS)

Alcala-Ruiz, F.

2000-01-01

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

Health, safety and environmental issues in thin film manufacturing

NARCIS (Netherlands)

Alsema, E.A.; Baumann, A.E.; Hill, R.; Patterson, M.H.

1997-01-01

An investigation is made of Health, Safety and Environmental (HSE) aspects for the manufacturing, use and decommissioning of CdTe, CIS and a-Si modules. Issues regarding energy requirements, resource availability, emissions of toxic materials, occupational health and safety and module waste

Draft report on compilation of generic safety issues for light water reactor nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

NONE

1997-07-01

A generally accepted approach to characterizing the safety concerns in nuclear power plants is to express them as safety issues which need to be resolved. When such safety issues are applicable to a generation of plants of a particular design or to a family of plants of similar design, they are termed generic safety issues. Examples of generic safety issues are those related to reactor vessel embrittlement, control rod insertion reliability or strainer clogging. The safety issues compiled in this document are based on broad international experience. This compilation is one element in the framework of IAEA activities to assist Member States in reassessing the safety of operating nuclear power plants. Refs.

Draft report on compilation of generic safety issues for light water reactor nuclear power plants

International Nuclear Information System (INIS)

1997-07-01

A generally accepted approach to characterizing the safety concerns in nuclear power plants is to express them as safety issues which need to be resolved. When such safety issues are applicable to a generation of plants of a particular design or to a family of plants of similar design, they are termed generic safety issues. Examples of generic safety issues are those related to reactor vessel embrittlement, control rod insertion reliability or strainer clogging. The safety issues compiled in this document are based on broad international experience. This compilation is one element in the framework of IAEA activities to assist Member States in reassessing the safety of operating nuclear power plants. Refs

Relevant safety issues in designing the HTR-10 reactor

International Nuclear Information System (INIS)

Sun Yuliang; Xu Yuanghui

2001-01-01

The HTR-10 is a 10 MWth pebble bed high temperature gas cooled reactor being constructed as a research facility at the Institute of Nuclear Energy Technology. This paper discusses design issues of the HTR-10 which are related to safety. It addresses the safety criteria used in the development and assessment of the design, the safety important systems, and the safety classification of components. It also summarises the results of safety analysis, including the approach used for the radioactive source term, as well as the approach to containment design. (author)

Analysis of high burnup fuel safety issues

Energy Technology Data Exchange (ETDEWEB)

Lee, Chan Bock; Kim, D. H.; Bang, J. G.; Kim, Y. M.; Yang, Y. S.; Jung, Y. H.; Jeong, Y. H.; Nam, C.; Baik, J. H.; Song, K. W.; Kim, K. S

2000-12-01

Safety issues in steady state and transient behavior of high burnup LWR fuel above 50 - 60 MWD/kgU were analyzed. Effects of burnup extension upon fuel performance parameters was reviewed, and validity of both the fuel safety criteria and the performance analysis models which were based upon the lower burnup fuel test results was analyzed. It was found that further tests would be necessary in such areas as fuel failure and dispersion for RIA, and high temperature cladding corrosion and mechanical deformation for LOCA. Since domestic fuels have been irradiated in PWR up to burnup higher than 55 MWD/kgU-rod. avg., it can be said that Korea is in the same situation as the other countries in the high burnup fuel safety issues. Therefore, necessary research areas to be performed in Korea were derived. Considering that post-irradiation examination(PIE) for the domestic fuel of burnup higher than 30 MWD/kgU has not been done so far at all, it is primarily necessary to perform PIE for high burnup fuel, and then simulation tests for RIA and LOCA could be performed by using high burnup fuel specimens. For the areas which can not be performed in Korea, international cooperation will be helpful to obtain the test results. With those data base, safety of high burnup domestic fuels will be confirmed, current fuel safety criteria will be re-evaluated, and finally transient high burnup fuel behavior analysis technology will be developed through the fuel performance analysis code development.

Analysis of high burnup fuel safety issues

International Nuclear Information System (INIS)

Lee, Chan Bock; Kim, D. H.; Bang, J. G.; Kim, Y. M.; Yang, Y. S.; Jung, Y. H.; Jeong, Y. H.; Nam, C.; Baik, J. H.; Song, K. W.; Kim, K. S

2000-12-01

Safety issues in steady state and transient behavior of high burnup LWR fuel above 50 - 60 MWD/kgU were analyzed. Effects of burnup extension upon fuel performance parameters was reviewed, and validity of both the fuel safety criteria and the performance analysis models which were based upon the lower burnup fuel test results was analyzed. It was found that further tests would be necessary in such areas as fuel failure and dispersion for RIA, and high temperature cladding corrosion and mechanical deformation for LOCA. Since domestic fuels have been irradiated in PWR up to burnup higher than 55 MWD/kgU-rod. avg., it can be said that Korea is in the same situation as the other countries in the high burnup fuel safety issues. Therefore, necessary research areas to be performed in Korea were derived. Considering that post-irradiation examination(PIE) for the domestic fuel of burnup higher than 30 MWD/kgU has not been done so far at all, it is primarily necessary to perform PIE for high burnup fuel, and then simulation tests for RIA and LOCA could be performed by using high burnup fuel specimens. For the areas which can not be performed in Korea, international cooperation will be helpful to obtain the test results. With those data base, safety of high burnup domestic fuels will be confirmed, current fuel safety criteria will be re-evaluated, and finally transient high burnup fuel behavior analysis technology will be developed through the fuel performance analysis code development

Special Issue. 5th Meeting on Technology and Safety

International Nuclear Information System (INIS)

Kusakabe, Masashi; Kumagaya, Tadafusa; Minohara, Shinichi

2010-01-01

The documents in this Special Issue are the representative reports of achievements presented in the National Institute of Radiological Sciences (NIRS) 5th Meeting on Technology and Safety held on March 17, 2010. Personnel and investigators of NIRS and related companies gave their achievements by 19 oral and 31 poster presentations in fields of [IAR] irradiation (2 topics), accelerator/radiometry (9 topics), [EA] experimental animals (25 topics), [SM] safety management of facilities (5 topics), computer network system (4 topics), experimental instrument (1 topic), molecular imaging (2 topics) and others (2 topics). The Issue contains, as well as introductory and ending remarks, following 12 topics: [IAR] Working report of patient positioning system for radiotherapy with use of X-ray flat panel detector; Status of maintenance and management of facilities and equipments in Research center for Radiation Emergency Medicine; [EA] Past, present and future of mouse breeding in NIRS; Breeding of marmoset in NIRS/How can we have a bouncing marmoset baby?; Establishment of a genotyping method of transformed genes in transgenic mouse/genome walking method; Genetic monitoring system of mice by micro-satellite marker and its application in NIRS; Verification of sorting precision of FACSAria (Becton Dickinson and Co.), a highly sensitive, rapid sorting apparatus of cells/for precise sorting; Proposal of a task-solution workflow to determine the animal features for molecular imaging studies; [SM] Toward the introduction of Occupational Safety and Health Management System in NIRS; Use of unsealed radioisotopes less than the lower limit outside the legal control area; Arrangement of managing and supporting system for clinical studies; and Rearrangement of working system of personnel affairs. (T.T.)

Commercial truck parking and other safety issues.

Science.gov (United States)

2015-10-01

Commercial truck parking is a safety issue, since trucks are involved in approximately 10% of all fatal accidents on interstates and : parkways in Kentucky. Drivers experience schedule demands and long hours on the road, yet they cannot easily determ...

Status report on resolution of Waste Tank Safety Issues at the Hanford Site. Revision 1

International Nuclear Information System (INIS)

Dukelow, G.T.; Hanson, G.A.

1995-05-01

The purpose of this report is to provide and update the status of activities supporting the resolution of waste tank safety issues and system deficiencies at the Hanford Site. This report provides: (1) background information on safety issues and system deficiencies; (2) a description of the Tank Waste Remediation System and the process for managing safety issues and system deficiencies; (3) changes in safety issue description, prioritization, and schedules; and (4) a summary of the status, plans, order of magnitude, cost, and schedule for resolving safety issues and system deficiencies

Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Parker, Dianne; Wensing, Michel; Esmail, Aneez; Valderas, Jose M

2015-01-01

ABSTRACT Background: There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. Objective: To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance that should be assessed when investigating the relationship between safety culture and performance in primary care. Methods: Two consensus-based studies were carried out, in which subject matter experts and primary healthcare professionals from several EU states rated (a) the applicability to their healthcare system of several existing safety culture assessment tools and (b) the appropriateness and usefulness of a range of potential indicators of a positive patient safety culture to primary care settings. The safety culture tools were field-tested in four countries to ascertain any challenges and issues arising when used in primary care. Results: The two existing tools that received the most favourable ratings were the Manchester patient safety framework (MaPsAF primary care version) and the Agency for healthcare research and quality survey (medical office version). Several potential safety culture process indicators were identified. The one that emerged as offering the best combination of appropriateness and usefulness related to the collection of data on adverse patient events. Conclusion: Two tools, one quantitative and one qualitative, were identified as applicable and useful in assessing patient safety culture in primary care settings in Europe. Safety culture indicators in primary care should focus on the processes rather than the outcomes of care. PMID:26339832

76 FR 58812 - Patient Safety Organizations: Delisting for Cause of Patient Safety Organization One, Inc.

Science.gov (United States)

2011-09-22

... Organizations: Delisting for Cause of Patient Safety Organization One, Inc. AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: Patient Safety Organization One, Inc.: AHRQ has delisted Patient Safety Organization One, Inc. as a Patient Safety Organization (PSO...

Safety issues with bisphosphonate therapy for osteoporosis

DEFF Research Database (Denmark)

Suresh, Ernest; Pazianas, Michael; Abrahamsen, Bo

2014-01-01

Randomized controlled trials have demonstrated the efficacy of bisphosphonates (BP) in improving BMD and reducing fracture risk. Various safety issues that were not noted in clinical trials have, however, now emerged with post-marketing surveillance and increasing clinical experience. The risk...

Safety issues on advanced fuel

Energy Technology Data Exchange (ETDEWEB)

Gross, H.; Krebs, W.D. [Siemens AG, Bereich Energieerzeugug (KWU), Erlangen (Germany). Geschaeftsgebiet Nukleare Energieerzeugung

1998-05-01

In the recent years a general discussion has started whether unsolved safety issues are related to advanced fuel. Advanced fuel is in this context a summary of features like high burnup, improved clad materials, low leakage loading pattern with high peaking factors etc. The design basis accidents RIA and Loca are of special interest for this discussion. From the Siemens point of view RIA is not a safety issue. There are sufficient margins between the enthalpy rise calculated by modern 3D methods and the fuel failures which occurred in RIA simulation tests when the effect of pulse width is taken into account. The evaluation of possible uncertainties for the established Loca criteria (17% equivalent corrosion, 1200 C clad temperature) for high burnup makes sense. But fuel with high burnup has significantly lower peaking factors than fuel with lower burnup. This gives sufficient margin counterbalancing possible uncertainties. In contrast to the above incomplete control rod insertion at higher burnup is potentially a real safety issue. Although Siemens fuel was not affected by the reported incidents they addressed the problem and checked that they have sufficient design margin for their fuel. (orig.) [Deutsch] In den letzten Jahren hat eine allgemeine Diskussion begonnen, ob mit fortgeschrittenen Brennelementen (BE) ungeklaerte Sicherheitsprobleme verbunden sind. Dabei ist `Fortgeschrittene Brennelemente` ein Sammelbegriff fuer hohe Abbraende, verbesserte Huellrohrmaterialien, Low-leakage-Einsatzplanungen mit hohen Heissstellenfaktoren usw. Die Auslegungsstoerfaelle RIA und Loca sind in dieser Diskussion von besonderer Bedeutung. Aus der Sicht von Siemens ist der RIA kein Sicherheitsproblem. Zwischen den mit modernen 3D-Methoden berechneten Enthalpieerhoehungen und den in RIA-Experimenten aufgetretenen Brennstabdefekten bestehen ausreichende Abstaende, wenn der Einfluss der Pulsbreite beruecksichtigt wird. Die Untersuchung eventueller Unsicherheiten bei hohen

Safety culture and organizational issues during transition from operation to decommissioning of NPPs

International Nuclear Information System (INIS)

Slavcheva, K.; Mori, M.; D'Amico, N.; Sollima, C.

2005-01-01

The paper highlights the critical safety issues in a Nuclear Power Plant (NPP) to be managed during the transition period from operation to decommissioning. Pre-shutdown is an important period of a NPP lifetime due to the changes and issues to be faced by the NPP management, which include safety culture issues, organizational issues, plant safety issues and nuclear waste issues. Preservation of staff competence and moral, management and organizational capability, preservation of knowledge and corporate memory, preservation of safety culture, surveillance and permanent control to maintain adequate level of nuclear and radiation safety, development of appropriate solutions for the new incoming issues are the key challenges to be timely faced. The uncertainty regarding the future of the site, the future of the workers and the incoming re-organization originate numerous additional issues including stress for the personnel. It is necessary to take appropriate actions to reduce the uncertainty. The regulatory regime continues with the same rules as during operation. Responsibility for safety remains with the licensee and the regulatory supervision continues and oversees the safe operation and security of the NPP, the safe management and storage of spent nuclear fuel and radioactive waste. Anticipated attention from the Operator and the Regulator to key organizational and safety culture issues during the pre-shutdown phase has shown to be an effective preventive action. The Operator has to aim to preserve staff competence and motivation, preserve corporate memory, safety culture, reinforce monitoring and control on the health risk of workers and population, preserve the technical part of the organization from external disturb and distractions, ensure transparency and develop strategies to solve forthcoming issues. The Regulator has to aim to reorient its supervision, train its personnel and adapt its tools to the new situation, keep adequate presence onsite, keep dialogue

Measuring patient safety in a UK dental hospital: development of a dental clinical effectiveness dashboard.

Science.gov (United States)

Pemberton, M N; Ashley, M P; Shaw, A; Dickson, S; Saksena, A

2014-10-01

Patient safety is an important marker of quality for any healthcare organisation. In 2008, the British Government white paper entitled High quality care for all, resulting from a review led by Lord Darzi, identified patient safety as a key component of quality and discussed how it might be measured, analysed and acted upon. National and local clinically curated metrics were suggested, which could be displayed via a 'clinical dashboard'. This paper explains the development of a clinical effectiveness dashboard focused on patient safety in an English dental hospital and how it has helped us identify relevant patient safety issues in secondary dental care.

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

Science.gov (United States)

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

2011-01-01

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

Patient safety challenges in a case study hospital--of relevance for transfusion processes?

Science.gov (United States)

Aase, Karina; Høyland, Sindre; Olsen, Espen; Wiig, Siri; Nilsen, Stein Tore

2008-10-01

The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.

Patient safety culture among medical students in Singapore and Hong Kong.

Science.gov (United States)

Leung, Gilberto Ka Kit; Ang, Sophia Bee Leng; Lau, Tang Ching; Neo, Hong Jye; Patil, Nivritti Gajanan; Ti, Lian Kah

2013-09-01

Undergraduate education in medical schools plays an important role in promoting patient safety. Medical students from different backgrounds may have different perceptions and attitudes toward issues concerning safety. This study aimed to investigate whether patient safety cultures differed between students from two Asian countries, and if they did, to find out how they differed. This study also aimed to identify the educational needs of these students. A voluntary, cross-sectional and self-administered questionnaire survey was conducted on 259 students from two medical schools - one in Hong Kong and the other in Singapore. None of the students had received any formal teaching on patient safety. We used a validated survey instrument, the Attitudes to Patient Safety Questionnaire III (APSQ-III), which was designed specifically for students and covered nine key factors of patient safety culture. Of the 259 students, 81 (31.3%) were from Hong Kong and 178 (68.7%) were from Singapore. The overall response rate was 66.4%. Significant differences between the two groups of students were found for two key factors - 'patient safety training', with Hong Kong students being more likely to report having received more of such training (p = 0.007); and 'error reporting confidence', which Singapore students reported having less of (p working hours and professional incompetence were important causes of medical errors. The importance of patient involvement and team functioning were ranked relatively lower by the students. Students from different countries with no prior teaching on patient safety may differ in their baseline patient safety cultures and educational needs. Our findings serve as a reference for future longitudinal studies on the effects of different teaching and healthcare development programmes.

HRET patient safety leadership fellowship: the role of "community" in patient safety.

Science.gov (United States)

Leonhardt, Kathryn Kraft

2010-01-01

Community engagement is widely endorsed but poorly defined as a strategy to improve patient safety. With strong evidence that engaging patients can positively influence health outcomes, it is presumed that community engagement could improve patient safety. Leaning on the models from other disciplines such as public health, the adequate knowledge and application of the principles of community engagement are critical for this approach to be effective. This article provides a description of the theories supporting patient partnership and community engagement, reviews critical elements of successful community-based programs, and identifies the potential for empowering communities to improve patient safety.

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

Science.gov (United States)

Eichhorn, John H

2012-04-01

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

Ranking of safety issues for WWER-440 model 230 nuclear power plants

International Nuclear Information System (INIS)

1992-02-01

In response to requests from Member States operating Soviet designed WWER-440/230 nuclear power plants (NPPs) for assistance through the IAEA's nuclear safety services, a major international project was established to evaluate these first generation reactors as a complement to relevant ongoing national, bilateral and multilateral activities. The objective is to assist countries operating WWER-440/230 NPPs in performing comprehensive safety reviews aimed at identifying design and operational weaknesses. The scope of the project includes a review of the conceptual design of WWER-440/230 NPPs, safety review missions to each one of the operating reactors to review design and operational aspects and studies to resolve issues of generic safety concern. This report was prepared by a group of international experts and the IAEA staff and discussed by the Project Steering Committee, December 9-13, 1991 in Vienna. An overview of the safety issues identified is presented indicating their effect on the performance of the basic safety functions. Conceptual recommendations related to design issues are given as a technical basis for the safety modifications required

Patient safety culture among nurses.

Science.gov (United States)

Ammouri, A A; Tailakh, A K; Muliira, J K; Geethakrishnan, R; Al Kindi, S N

2015-03-01

Patient safety is considered to be crucial to healthcare quality and is one of the major parameters monitored by all healthcare organizations around the world. Nurses play a vital role in maintaining and promoting patient safety due to the nature of their work. The purpose of this study was to investigate nurses' perceptions about patient safety culture and to identify the factors that need to be emphasized in order to develop and maintain the culture of safety among nurses in Oman. A descriptive and cross-sectional design was used. Patient safety culture was assessed by using the Hospital Survey on Patient Safety Culture among 414 registered nurses working in four major governmental hospitals in Oman. Descriptive statistics and general linear regression were employed to assess the association between patient safety culture and demographic variables. Nurses who perceived more supervisor or manager expectations, feedback and communications about errors, teamwork across hospital units, and hospital handoffs and transitions had more overall perception of patient safety. Nurses who perceived more teamwork within units and more feedback and communications about errors had more frequency of events reported. Furthermore, nurses who had more years of experience and were working in teaching hospitals had more perception of patient safety culture. Learning and continuous improvement, hospital management support, supervisor/manager expectations, feedback and communications about error, teamwork, hospital handoffs and transitions were found to be major patient safety culture predictors. Investing in practices and systems that focus on improving these aspects is likely to enhance the culture of patient safety in Omani hospitals and others like them. Strategies to nurture patient safety culture in Omani hospitals should focus upon building leadership capacity that support open communication, blame free, team work and continuous organizational learning. © 2014 International

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

International Nuclear Information System (INIS)

Naeslund, Jens-Ove

2006-11-01

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

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

Energy Technology Data Exchange (ETDEWEB)

Naeslund, Jens-Ove (comp.)

2006-11-15

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

The Norwegian Plan of Action for nuclear safety issues

International Nuclear Information System (INIS)

1997-07-01

The Plan of Action underlies Norwegian activities in the field of international co-operation to enhance nuclear safety and prevent radioactive contamination from activities in Eastern Europe and the former Soviet Union. Geographically the highest priority has been given to support for safety measures in north-west Russia. This information brochure outlines the main content of the Plan of Action for nuclear safety issues and lists a number of associated measures and projects

The Norwegian Plan of Action for nuclear safety issues

Energy Technology Data Exchange (ETDEWEB)

NONE

1997-07-01

The Plan of Action underlies Norwegian activities in the field of international co-operation to enhance nuclear safety and prevent radioactive contamination from activities in Eastern Europe and the former Soviet Union. Geographically the highest priority has been given to support for safety measures in north-west Russia. This information brochure outlines the main content of the Plan of Action for nuclear safety issues and lists a number of associated measures and projects.

Unresolved safety issues summary. Volume 3, Number 3. Aqua book

International Nuclear Information System (INIS)

1981-01-01

The 'Unresolved Safety Issues' summary is designed to provide the management of the Nuclear Regulatory Commission with a quarterly overview of the progress and plans for completion of generic tasks addressing Unresolved Safety Issues reported to Congress pursuant to section 210 of The Energy Reorganization Act of 1974 as amended. This summary utilizes data collected from the Office of Nuclear Reactor Regulation, Office of Nuclear Regulatory Research, and the National Laboratories and is prepared by the office of Management and Program Analysis. The definition of what constitutes completion of an unresolved safety issue (USI) has recently been expanded to include the implementation of the technical resolution. This is in acknowledgement of the fact that real safety benefits occur only after the implementation has taken place. The schedules in this book include a milestone at the end of each action plan which represents the initiation of the implementation process both with respect to incorporation of the technical resolution in the NRC official guidance or requirements and also the application of changes to individual operating plants. The schedule for implementation will not normally be included in the task action plan(s) for the resolution of a USI since the nature and extent of the activities necessary to accomplish the implementation cannot normally be reasonably determined prior to the determination of a technical resolution. The progress and status for implementation of unresolved safety issues for which a technical resolution has been completed are reported specifically in a separate table provided in this summary

Non-technical skills training to enhance patient safety.

Science.gov (United States)

Gordon, Morris

2013-06-01

  Patient safety is an increasingly recognised issue in health care. Systems-based and organisational methods of quality improvement, as well as education focusing on key clinical areas, are common, but there are few reports of educational interventions that focus on non-technical skills to address human factor sources of error. A flexible model for non-technical skills training for health care professionals has been designed based on the best available evidence, and with sound theoretical foundations.   Educational sessions to improve non-technical skills in health care have been described before. The descriptions lack the details to allow educators to replicate and innovate further.   A non-technical skills training course that can be delivered as either a half- or full-day intervention has been designed and delivered to a number of mixed groups of undergraduate medical students and doctors in postgraduate training. Participant satisfaction has been high and patient safety attitudes have improved post-intervention.   This non-technical skills educational intervention has been built on a sound evidence base, and is described so as to facilitate replication and dissemination. With the key themes laid out, clinical educators will be able to build interventions focused on numerous clinical issues that pay attention to human factor contributors to safety. © 2013 John Wiley & Sons Ltd.

Key practical issues in strengthening safety culture. INSAG-15. A report by the International Safety Advisory Group

International Nuclear Information System (INIS)

2002-01-01

This report describes the essential practical issues to be considered by organizations aiming to strengthen safety culture. It is intended for senior executives, managers and first line supervisors in operating organizations. Although safety culture cannot be directly regulated, it is important that members of regulatory bodies understand how their actions affect the development of attempts to strengthen safety culture and are sympathetic to the need to improve the less formal human related aspects of safety. The report is therefore of relevance to regulators, although not intended primarily for them. The International Nuclear Safety Advisory Group (INSAG) introduced the concept of safety culture in its INSAG-4 report in 1991. Since then, many papers have been written on safety culture, as it relates to organizations and individuals, its improvement and its underpinning prerequisites. Variations in national cultures mean that what constitutes a good approach to enhancing safety culture in one country may not be the best approach in another. However, INSAG seeks to provide pragmatic and practical advice of wide applicability in the principles and issues presented in this report. Nuclear and radiological safety are the prime concerns of this report, but the topics discussed are so general that successful application of the principles should lead to improvements in other important areas, such as industrial safety, environmental performance and, in some respects, wider business performance. This is because many of the attitudes and practices necessary to achieve good performance in nuclear safety, including visible commitment by management, openness, care and thoroughness in completing tasks, good communication and clarity in recognizing major issues and dealing with them as a priority, have wide applicability

78 FR 59036 - Patient Safety Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc.

Science.gov (United States)

2013-09-25

... Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc. AGENCY: Agency for... for the formation of Patient Safety Organizations (PSOs), which collect, aggregate, and analyze... Cogent Patient Safety Organization, Inc. of its status as a PSO, and has delisted the PSO accordingly...

76 FR 9350 - Patient Safety Organizations: Voluntary Delisting From Rocky Mountain Patient Safety Organization

Science.gov (United States)

2011-02-17

... Organizations: Voluntary Delisting From Rocky Mountain Patient Safety Organization AGENCY: Agency for Healthcare... Organization: AHRQ has accepted a notification of voluntary relinquishment from Rocky Mountain Patient Safety Organization, a component entity of Colorado Hospital Association, of its status as a Patient Safety...

Undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkship.

Science.gov (United States)

Lee, Hoo-Yeon; Hahm, Myung-Il; Lee, Sang Gyu

2018-04-04

The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. Cross-sectional study administered in face-to-face interviews using modified the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) from three colleges of medicine in Korea. We assessed medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. Confirmatory factor analysis and Spearman's correlation analyses was performed. In total, 194(91.9%) of the 211 third-year undergraduate students participated. 78% of medical students reported that the quality of care received by patients was impacted by teamwork during clinical rotations. Regarding error disclosure, positive scores ranged from 10% to 74%. Except for one question asking whether the disclosure of medical errors was an important component of patient safety (74%), the percentages of positive scores for all the other questions were below 20%. 41.2% of medical students have intention to disclose it when they saw a medical error committed by another team member. Many students had difficulty speaking up about medical errors. Error disclosure guidelines and educational efforts aimed at developing sophisticated communication skills are needed. This study may serve as a reference for other institutions planning patient safety education in their curricula. Assessing student perceptions of safety culture can provide clerkship directors and clinical service chiefs with information that enhances the educational environment and promotes patient safety.

Unresolved safety issues summary. Aqua Book. Volume 6, No. 3

International Nuclear Information System (INIS)

Butts, J.

1984-01-01

The unresolved safety issues summary is designed to provide the management of the Nuclear Regulatory Commission with a quarterly overview of the progress and plans for completion of generic tasks addressing unresolved safety issues reported to Congress pursuant to Section 210 of the Energy Reorganization Act of 1974 as amended. This summary utilizes data collected from the Office of Nuclear Reactor Regulation, Office of Nuclear Regulatory Research, and the national laboratories and is prepared by the Office of Nuclear Reactor Regulation

Advancing Measurement of Patient Safety Culture

Science.gov (United States)

Ginsburg, Liane; Gilin, Debra; Tregunno, Deborah; Norton, Peter G; Flemons, Ward; Fleming, Mark

2009-01-01

Objective To examine the psychometric and unit of analysis/strength of culture issues in patient safety culture (PSC) measurement. Data Source Two cross-sectional surveys of health care staff in 10 Canadian health care organizations totaling 11,586 respondents. Study Design A cross-validation study of a measure of PSC using survey data gathered using the Modified Stanford PSC survey (MSI-2005 and MSI-2006); a within-group agreement analysis of MSI-2006 data. Extraction Methods Exploratory factor analyses (EFA) of the MSI-05 survey data and confirmatory factor analysis (CFA) of the MSI-06 survey data; Rwg coefficients of homogeneity were calculated for 37 units and six organizations in the MSI-06 data set to examine within-group agreement. Principal Findings The CFA did not yield acceptable levels of fit. EFA and reliability analysis of MSI-06 data suggest two reliable dimensions of PSC: Organization leadership for safety (α=0.88) and Unit leadership for safety (α=0.81). Within-group agreement analysis shows stronger within-unit agreement than within-organization agreement on assessed PSC dimensions. Conclusions The field of PSC measurement has not been able to meet strict requirements for sound measurement using conventional approaches of CFA. Additional work is needed to identify and soundly measure key dimensions of PSC. The field would also benefit from further attention to strength of culture/unit of analysis issues. PMID:18823446

Guidelines for nuclear power plant safety issue prioritization information development. Supplement 5

International Nuclear Information System (INIS)

Daling, P.M.; Lavender, J.C.

1996-07-01

This is the sixth in a series of reports to document the development and use of a methodology developed by the Pacific Northwest Laboratory (PNL) to calculate, for prioritization purposes, the risk, dose, and cost impacts of implementing potential resolutions to reactor safety issues (see NUREG/CR-2800, Andrews, et al., 1983). This report contains the results of issue-specific analyses for 34 generic issues. Each issue was considered within the constraints of available information at the time the issues were examined and approximately 2 staff-weeks of labor. The results are referenced as one consideration in NUREG-0933, A Prioritization of Generic Safety Issues (Emrit, et al., 1983)

Guidelines for nuclear power plant safety issue prioritization information development. Supplement 5

Energy Technology Data Exchange (ETDEWEB)

Daling, P.M.; Lavender, J.C. [Pacific Northwest National Lab., Richland, WA (United States)

1996-07-01

This is the sixth in a series of reports to document the development and use of a methodology developed by the Pacific Northwest Laboratory (PNL) to calculate, for prioritization purposes, the risk, dose, and cost impacts of implementing potential resolutions to reactor safety issues (see NUREG/CR-2800, Andrews, et al., 1983). This report contains the results of issue-specific analyses for 34 generic issues. Each issue was considered within the constraints of available information at the time the issues were examined and approximately 2 staff-weeks of labor. The results are referenced as one consideration in NUREG-0933, A Prioritization of Generic Safety Issues (Emrit, et al., 1983).

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

Science.gov (United States)

Yassi, Annalee; Hancock, Tina

2005-01-01

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

Safety Culture and Issue in the Malaysian Manufacturing Sector

OpenAIRE

Ali Danish; Yusof Yusri; Adam Anbia

2017-01-01

. This paper highlights the Safety culture and issue in the Malaysian Manufacturing Sector and emphasis the high occupational accidents due to lack of safety culture and non-compliance of the requirements of Occupational Safety and Health Act 1994. The aim of this study is to review the occupational accidents occurrence in the Malaysia workplace since 2012-2016. Malaysia aimed to reduce the occupational accidents, the results show by DOSH increase that Occupational Noise Induced Hearing Loss ...

Medical error disclosure and patient safety: legal aspects

Directory of Open Access Journals (Sweden)

Olivier Guillod

2013-12-01

Full Text Available Reducing the number of preventable adverse events has become a public health issue. The paper discusses in which ways the law can contribute to that goal, especially by encouraging a culture of safety among healthcare professionals. It assesses the need or the usefulness to pass so-called disclosure laws and apology laws, to adopt mandatory but strictly confidential Critical Incidents Reporting Systems in hospitals, to change the fault-based system of medical liability or to amend the rules on criminal liability. The paper eventually calls for adding the law to the present agenda of patient safety.

Can we Improve Patient Safety?

Directory of Open Access Journals (Sweden)

Martin Thomas Corbally

2014-09-01

Full Text Available Despite greater awareness of patient safety issues especially in the operating room and the widespread implementation of surgical time out (WHO,errors, especially wrong site surgery, continue. Most such errors are due to lapses in communication where decision makers fail to consult or confirm operative findings but worryingly where parental concerns over the planned procedure are ignored or not followed through. The WHO surgical pause / Time Out aims to capture these errors and prevent them but the combination of human error and complex hospital environments can overwhelm even robust safety structures and simple common sense. Parents are the ultimate repository of information on their child's condition and planned surgery but are traditionally excluded from the process of Surgical pause and Time Out perhaps to avoid additional stress. In addition surgeons, like pilots, are subject to the phenomenon of plan continue fail with potentially disastrous outcomes.

Developing a research agenda for patient safety in primary care. Background, aims and output of the LINNEAUS collaboration on patient safety in primary care.

Science.gov (United States)

Esmail, Aneez; Valderas, Jose M; Verstappen, Wim; Godycki-Cwirko, Maciek; Wensing, Michel

2015-09-01

This paper is an introduction to a supplement to The European Journal of General Practice, bringing together a body of research focusing on the issue of patient safety in relation to primary care. The supplement represents the outputs of the LINNEAUS collaboration on patient safety in primary care, which was a four-year (2009-2013) coordination and support action funded under the Framework 7 programme by the European Union. Being a coordination and support action, its aim was not to undertake new research, but to build capacity through engaging primary care researchers and practitioners in identifying some of the key challenges in this area and developing consensus statements, which will be an essential part in developing a future research agenda. This introductory article describes the aims of the LINNEAUS collaboration, provides a brief summary of the reasons to focus on patient safety in primary care, the epidemiological and policy considerations, and an introduction to the papers included in the supplement.

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

Key issues of the common French-German safety approach for future PWRs

International Nuclear Information System (INIS)

Frisch, W.; Rohde, J.; Gros, G.; Queniart, D.

1996-01-01

The general common safety approach issued in May 1993 contains safety objectives, general principles and already some technical principles. Based on general safety approach, detailed recommendations have been developed in 1994 on key issues such as: system design and use of PSA; integrity of the primary circuit; external hazards; severe accidents and containment design; radiological consequences of reference accidents and low pressure core melt accidents. A selection of the detailed recommendations is presented in the full paper. (author)

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

Science.gov (United States)

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

2013-04-01

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

Priming patient safety: A middle-range theory of safety goal priming via safety culture communication.

Science.gov (United States)

Groves, Patricia S; Bunch, Jacinda L

2018-05-18

The aim of this paper is discussion of a new middle-range theory of patient safety goal priming via safety culture communication. Bedside nurses are key to safe care, but there is little theory about how organizations can influence nursing behavior through safety culture to improve patient safety outcomes. We theorize patient safety goal priming via safety culture communication may support organizations in this endeavor. According to this theory, hospital safety culture communication activates a previously held patient safety goal and increases the perceived value of actions nurses can take to achieve that goal. Nurses subsequently prioritize and are motivated to perform tasks and risk assessment related to achieving patient safety. These efforts continue until nurses mitigate or ameliorate identified risks and hazards during the patient care encounter. Critically, this process requires nurses to have a previously held safety goal associated with a repertoire of appropriate actions. This theory suggests undergraduate educators should foster an outcomes focus emphasizing the connections between nursing interventions and safety outcomes, hospitals should strategically structure patient safety primes into communicative activities, and organizations should support professional development including new skills and the latest evidence supporting nursing practice for patient safety. © 2018 John Wiley & Sons Ltd.

Environmental safety issues for semiconductors (research on scarce materials recycling)

International Nuclear Information System (INIS)

Izumi, Shigekazu

2004-01-01

In the 21st century, in the fabrication of various industrial parts, particularly, current and future electronics devices in the semiconductor industry, environmental safety issues should be carefully considered. We coined a new term, environmental safety issues for semiconductors, considering our semiconductor research and technology which include environmental and ecological factors. The main object of this analysis is to address the present situation of environmental safety problems in the semiconductor industry; some of which are: (1) the generation and use of hazardous toxic gases in the crystal growth procedure such as molecular beam epitaxy (MBE) and metalorganic chemical vapor deposition (MOCVD), (2) the generation of industrial toxic wastes in the semiconductor process and (3) scarce materials recycling from wastes in the MBE and MOCVD growth procedure

The perceptions of patient safety culture: A difference between physicians and nurses in Taiwan.

Science.gov (United States)

Huang, Chih-Hsuan; Wu, Hsin-Hung; Lee, Yii-Ching

2018-04-01

In order to pursue a better patient safety culture and provide a superior medical service for patients, this study aims to respectively investigate the perceptions of patient safety from the viewpoints of physicians and nurses in Taiwan. Little knowledge has clearly identified the difference of perceptions between physicians and nurses in patient safety culture. Understanding physicians and nurses' attitudes toward patient safety is a critical issue for healthcare organizations to improve medical quality. Confirmatory factor analysis (CFA) is used to verify the structure of data (e.g. reliability and validity), and Pearson's correlation analysis is conducted to demonstrate the relationships among seven patient safety culture dimensions. Research results illustrate that more teamwork is exhibited among team members, the more safety of a patient is committed. Perceptions of management and emotional exhaustion are important components that contribute to a better patient safety. More importantly, working conditions and stress recognition are found to be negatively related from the perceptions of nurses. Compared to physicians, nurses reported higher stress and challenges which result from multi-task working conditions in the hospital. This study focused on the contribution of a better patient safety culture from different viewpoints of physicians and nurses for healthcare organizations in Taiwan. A different attitudes toward patient safety is found between physicians and nurses. The results enable the hospital management to realize and design appropriate implications for hospital staffs to establish a better patient safety culture. Copyright © 2017. Published by Elsevier Inc.

Application of a methodology to determine priorities for nuclear power plant safety issues

International Nuclear Information System (INIS)

Daling, P.M.

1988-01-01

The Nuclear Regulatory Commission (NRC) Office of Nuclear Regulatory Research (RES) is sponsoring a research program to determine priorities of nuclear power plant safety issues. A methodology has been developed at the Pacific Northwest Laboratory (PNL) to provide technical assistance in the development of risk and cost estimates for implementing resolutions to the safety issues. The information development methods are intended to provide the NRC with a consistent level of information for use in ranking the issues. The NRC uses this information, along with judgmental factors, to rank the issues for further consideration by the NRC staff. The primary purpose of the priority rankings are to assist in the allocation of resources to issues that have high potential for reducing public risk as well as to remove issues from further consideration that have little safety significance

Analysis of safety issues in household meat consumption in Odeda ...

African Journals Online (AJOL)

The study analyzed the safety problems with household meat consumption in Odeda Local Government Area, Ogun state, Nigeria. The objectives were to describe the socioeconomic characteristics of the respondents; assess the level of awareness of safety issues in households' meat consumption; and evaluate the ...

Developing patient safety in dentistry.

Science.gov (United States)

Pemberton, M N

2014-10-01

Patient safety has always been important and is a source of public concern. Recent high profile scandals and subsequent reports, such as the Francis report into the failings at Mid Staffordshire, have raised those concerns even higher. Mortality and significant morbidity associated with the practice of medicine has led to many strategies to help improve patient safety, however, with its lack of associated mortality and lower associated morbidity, dentistry has been slower at systematically considering how patient safety can be improved. Recently, several organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry.

Patient safety climate and worker safety behaviours in acute hospitals in Scotland.

Science.gov (United States)

Agnew, Cakil; Flin, Rhona; Mearns, Kathryn

2013-06-01

To obtain a measure of hospital safety climate from a sample of National Health Service (NHS) acute hospitals in Scotland and to test whether these scores were associated with worker safety behaviors, and patient and worker injuries. Data were from 1,866 NHS clinical staff in six Scottish acute hospitals. A Scottish Hospital Safety Questionnaire measured hospital safety climate (Hospital Survey on Patient Safety Culture), worker safety behaviors, and worker and patient injuries. The associations between the hospital safety climate scores and the outcome measures (safety behaviors, worker and patient injury rates) were examined. Hospital safety climate scores were significantly correlated with clinical workers' safety behavior and patient and worker injury measures, although the effect sizes were smaller for the latter. Regression analyses revealed that perceptions of staffing levels and managerial commitment were significant predictors for all the safety outcome measures. Both patient-specific and more generic safety climate items were found to have significant impacts on safety outcome measures. This study demonstrated the influences of different aspects of hospital safety climate on both patient and worker safety outcomes. Moreover, it has been shown that in a hospital setting, a safety climate supporting safer patient care would also help to ensure worker safety. The Scottish Hospital Safety Questionnaire has proved to be a usable method of measuring both hospital safety climate as well as patient and worker safety outcomes. Copyright © 2013 National Safety Council and Elsevier Ltd. Published by Elsevier Ltd. All rights reserved.

Safety issues of nuclear production of hydrogen

International Nuclear Information System (INIS)

Piera, Mireia; Martinez-Val, Jose M.; Jose Montes, Ma

2006-01-01

Hydrogen is not an uncommon issue in Nuclear Safety analysis, particularly in relation to severe accidents. On the other hand, hydrogen is a household name in the chemical industry, particularly in oil refineries, and is also a well known chemical element currently produced by steam reforming of natural gas, and other methods (such as coal gasification). In the not-too-distant future, hydrogen will have to be produced (by chemical reduction of water) using renewable and nuclear energy sources. In particular, nuclear fission seems to offer the cheapest way to provide the primary energy in the medium-term. Safety principles are fundamental guidelines in the design, construction and operation both of hydrogen facilities and nuclear power plants. When these two technologies are integrated, a complete safety analysis must consider not only the safety practices of each industry, but any interaction that could be established between them. In particular, any accident involving a sudden energy release from one of the facilities can affect the other. Release of dangerous substances (chemicals, radiotoxic effluents) can also pose safety problems. Although nuclear-produced hydrogen facilities will need specific approaches and detailed analysis on their safety features, a preliminary approach is presented in this paper. No significant roadblocks are identified that could hamper the deployment of this new industry, but some of the hydrogen production methods will involve very demanding safety standards

76 FR 9351 - Patient Safety Organizations: Voluntary Delisting From West Virginia Center for Patient Safety

Science.gov (United States)

2011-02-17

... Patient Safety, a component entity of West Virginia Hospital Association, West Virginia Medical Institute (WVMI), and West Virginia State Medical. Association (WVSMA), of its status as a Patient Safety... Patient Safety, a component entity of West Virginia Hospital Association, West Virginia Medical Institute...

Safety issues at the defense production reactors

International Nuclear Information System (INIS)

1987-01-01

The United States produces plutonium and tritium for use in nuclear weapons at the defense production reactors endash the N Reactor in Washington and the Savannah River reactors in South Carolina. This report reaches general conclusions about the management of those reactors and highlights a number of safety and technical issues that should be resolved. The report provides an assessment of the safety management, safety review, and safety methodology employed by the Department of Energy and the private contractors who operate the reactors for the federal government. The report is necessarily based on a limited review of the defense production reactors. It does not address whether any of the reactors are ''safe,'' because such an analysis would involve a determination of acceptable risk endash a matter of obvious importance, but one that was beyond the purview of the committee. It also does not address whether the safety of the production reactors is comparable to that of commercial nuclear power stations, because even this narrower question extended beyond the charge to the committee and would have involved detailed analyses that the committee could not undertake

Contrast media. Safety issues and ESUR guidelines. 2. rev. ed.

Energy Technology Data Exchange (ETDEWEB)

Thomsen, Henrik S. [Copenhagen University Hospital, Herlev (Denmark). Dept. of Diagnostic Radiology; Copenhagen Univ., Herlev (Denmark). Dept. of Diagnostic Sciences; Webb, Judith A.W. (eds.) [St. Bartholomew' s Hospital London Univ. (United Kingdom). Dept. of Radiology

2009-07-01

In 1994 the European Society of Urogenital Radiology (ESUR) set up a committee to consider the safety of contrast media used for diagnostic imaging. Subsequently the committee questioned members, reviewed the literature, proposed guidelines and discussed these proposals with participants at the annual symposia of the society. The end result of this work was the successful first edition of this book, published in 2006. This second edition not only updates the previous edition, but also contains some completely new chapters, for example on gadolinium-based contrast agents, meta-analyses in contrast media research and various regulatory issues. Comprehensive consideration is given to the many different safety issues relating to iodinated, MR, ultrasound and barium contrast media. The text includes chapters on both acute and delayed non-renal adverse reactions and on renal adverse reactions. All those questions frequently raised in radiological practice are addressed, and the well-known ESUR guidelines on contrast media are included. This book, presented in a handy, easy to use format, provides an invaluable, unique and unparalleled source of information on the safety issues relating to contrast media. (orig.)

Contribution of safety issues to public perceptions of energy systems

International Nuclear Information System (INIS)

Otway, H.J.; Thomas, K.

1978-01-01

Public opposition is an important consideration for those responsible for energy planning; however, the formulation of socially viable policies requires an understanding of the reasons for this opposition. An attitude model was applied to identify the underlying determinants of public perceptions of five energy systems: nuclear, coal, oil, solar and hydro. Empirical results (heterogeneous sample of the general public, N = 224) are reported in which these energy systems were found to be perceived in terms of four basic dimensions: psychological aspects; economic benefits; socio-political implications; environmental and physical safety issues. For the total sample, safety issues made an appreciable contribution to attitudes toward all of the systems except nuclear energy, where it was not significant. A differential analysis of two sub-samples, those respondents PRO and CON nuclear energy, showed that benefits and safety issues were important determinants of PRO attitudes while CON attitudes were primarily due to psychological aspects and concerns about personal and political power. The role of technical information in the formation of public attitudes toward technological policies is discussed

Contrast media. Safety issues and ESUR guidelines. 2. rev. ed.

International Nuclear Information System (INIS)

Thomsen, Henrik S.; Copenhagen Univ., Herlev; Webb, Judith A.W.

2009-01-01

In 1994 the European Society of Urogenital Radiology (ESUR) set up a committee to consider the safety of contrast media used for diagnostic imaging. Subsequently the committee questioned members, reviewed the literature, proposed guidelines and discussed these proposals with participants at the annual symposia of the society. The end result of this work was the successful first edition of this book, published in 2006. This second edition not only updates the previous edition, but also contains some completely new chapters, for example on gadolinium-based contrast agents, meta-analyses in contrast media research and various regulatory issues. Comprehensive consideration is given to the many different safety issues relating to iodinated, MR, ultrasound and barium contrast media. The text includes chapters on both acute and delayed non-renal adverse reactions and on renal adverse reactions. All those questions frequently raised in radiological practice are addressed, and the well-known ESUR guidelines on contrast media are included. This book, presented in a handy, easy to use format, provides an invaluable, unique and unparalleled source of information on the safety issues relating to contrast media. (orig.)

Establishing research priorities for patient safety in emergency medicine: a multidisciplinary consensus panel.

Science.gov (United States)

Plint, Amy C; Stang, Antonia S; Calder, Lisa A

2015-01-01

Patient safety in the context of emergency medicine is a relatively new field of study. To date, no broad research agenda for patient safety in emergency medicine has been established. The objective of this study was to establish patient safety-related research priorities for emergency medicine. These priorities would provide a foundation for high-quality research, important direction to both researchers and health-care funders, and an essential step in improving health-care safety and patient outcomes in the high-risk emergency department (ED) setting. A four-phase consensus procedure with a multidisciplinary expert panel was organized to identify, assess, and agree on research priorities for patient safety in emergency medicine. The 19-member panel consisted of clinicians, administrators, and researchers from adult and pediatric emergency medicine, patient safety, pharmacy, and mental health; as well as representatives from patient safety organizations. In phase 1, we developed an initial list of potential research priorities by electronically surveying a purposeful and convenience sample of patient safety experts, ED clinicians, administrators, and researchers from across North America using contact lists from multiple organizations. We used simple content analysis to remove duplication and categorize the research priorities identified by survey respondents. Our expert panel reached consensus on a final list of research priorities through an in-person meeting (phase 3) and two rounds of a modified Delphi process (phases 2 and 4). After phases 1 and 2, 66 unique research priorities were identified for expert panel review. At the end of phase 4, consensus was reached for 15 research priorities. These priorities represent four themes: (1) methods to identify patient safety issues (five priorities), (2) understanding human and environmental factors related to patient safety (four priorities), (3) the patient perspective (one priority), and (4) interventions for

77 FR 25179 - Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute

Science.gov (United States)

2012-04-27

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... voluntary relinquishment from the Surgical Safety Institute of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the...

National Patient Safety Foundation

Science.gov (United States)

... News Member Testimonials Lifetime Members Stand Up for Patient Safety Welcome Stand Up Members Stand Up e-News ... PLS Webcast Archives Stand Up Templates and Logos Patient Safety Coalition Coalition Overview Coalition Member Roster Members-Only ...

Safety for all: bringing together patient and employee safety.

Science.gov (United States)

Stevenson, R Lynn; Moss, Lesley; Newlands, Tracey; Archer, Jana

2013-01-01

The safety of patients and of employees in healthcare have historically been separately managed and regulated. Despite efforts to reduce injury rates for employees and adverse events for patients, healthcare organizations continue to see less-than-optimal outcomes in both domains. This article challenges readers to consider how the traditional siloed approach to patient and employee safety can lead to duplication of effort, confusion, missed opportunities and unintended consequences. The authors propose that only through integrating patient and employee safety activities and challenging the paradigms that juxtapose the two will healthcare organizations experience sustained and improved safety practice and outcomes. Copyright © 2013 Longwoods Publishing.

Workshop on Regulatory Review and Safety Assessment Issues in Repository Licensing

International Nuclear Information System (INIS)

Wilmot, Roger D.

2011-02-01

The workshop described here was organised to address more general issues regarding regulatory review of SKB's safety assessment and overall review strategy. The objectives of the workshop were: - to learn from other programmes' experiences on planning and review of a license application for a nuclear waste repository, - to offer newly employed SSM staff an opportunity to learn more about selected safety assessment issues, and - to identify and document recommendations and ideas for SSM's further planning of the licensing review

The contribution of safety issues to public perceptions of energy systems

International Nuclear Information System (INIS)

Otway, H.J.; Thomas, Kerry

1978-01-01

Public opposition is an important consideration for those responsible for energy planning. An attitude model was applied to identify the underlying determinants of public perceptions of five energy systems: nuclear, coal, oil, solar and hydro. Empirical results are reported in which these energy systems were found to be perceived in terms of four basic dimensions: psychological aspects; economics benefits; socio-political implications; environmental and physical safety issues. For the total sample, safety issues made an appreciable contribution to attitudes toward all of the systems except nuclear energy, where it was not significant. A differential analysis of two sub-samples, those respondents PRO and CON nuclear energy, showed that benefits and safety issues were important determinants of PRO attitudes while CON attitudes were primarily due to psychological aspects and concerns about personal and political power. The role of technical information in the formation of public attitudes toward technological policies is discussed [fr

ISSUES OF FETUS DRUG SAFETY

Directory of Open Access Journals (Sweden)

A.V. Ostrovskaya

2010-01-01

Full Text Available The article is focused on the issue of fetus drug safety. Development of a child’s health depends both on hereditary information and environment factors. The reason for deviation from the process of normal prenatal development could be any xenobiotics, physical factors and some medications having a pathogenic effect during pregnancy on the embryo and fetus. Due to that, the physician’s preventive work based on the knowledge of embryogenesis processes and critical development periods. Key words: teratogenic action, medications, prenatal development, congenital malformation, newborns, children.(Pediatric Pharmacology. – 2010; 7(1:25-28

Evaluation of patient safety culture among Malaysian retail pharmacists: results of a self-reported survey

Science.gov (United States)

Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong

2016-01-01

Background Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. Objective To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. Methods A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. Results The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of “staff training and skills” were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. Conclusion The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety. PMID:27524887

Evaluation of patient safety culture among Malaysian retail pharmacists: results of a self-reported survey.

Science.gov (United States)

Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong

2016-01-01

Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of "staff training and skills" were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety.

En Route Patient Safety: A Mixed-Methods Study

Science.gov (United States)

2014-03-01

Army, Navy, volunteers, and civilians who meet the planes lack proper safety training First-names-only rule • MCD often refuses to give report...record; EMED = emergency medical; GPMRC = Global Patient Movement Requirements Center; MCD = medical crew director; MDG = Medical Group; OI...crews voiced concerns that “the biggest issue as far as taking report from the MCD is it’s always second hand.” However, several nurses who filled

IMPROVING PATIENT SAFETY:

DEFF Research Database (Denmark)

Bagger, Bettan; Taylor Kelly, Hélène; Hørdam, Britta

Improving patient safety is both a national and international priority as millions of patients Worldwide suffer injury or death every year due to unsafe care. University College Zealand employs innovative pedagogical approaches in educational design. Regional challenges related to geographic......, social and cultural factors have resulted in a greater emphasis upon digital technology. Attempts to improve patient safety by optimizing students’ competencies in relation to the reporting of clinical errors, has resulted in the development of an interdisciplinary e-learning concept. The program makes...

Challenging patient safety culture: survey results

NARCIS (Netherlands)

Hellings, Johan; Schrooten, Ward; Klazinga, Niek; Vleugels, Arthur

2007-01-01

PURPOSE: The purpose of this paper is to measure patient safety culture in five Belgian general hospitals. Safety culture plays an important role in the approach towards greater patient safety in hospitals. DESIGN/METHODOLOGY/APPROACH: The Patient Safety Culture Hospital questionnaire was

Researchers' Roles in Patient Safety Improvement.

Science.gov (United States)

Pietikäinen, Elina; Reiman, Teemu; Heikkilä, Jouko; Macchi, Luigi

2016-03-01

In this article, we explore how researchers can contribute to patient safety improvement. We aim to expand the instrumental role researchers have often occupied in relation to patient safety improvement. We reflect on our own improvement model and experiences as patient safety researchers in an ongoing Finnish multi-actor innovation project through self-reflective narration. Our own patient safety improvement model can be described as systemic. Based on the purpose of the innovation project, our improvement model, and the improvement models of the other actors in the project, we have carried out a wide range of activities. Our activities can be summarized in 8 overlapping patient safety improvement roles: modeler, influencer, supplier, producer, ideator, reflector, facilitator, and negotiator. When working side by side with "practice," researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds-as well as other actors involved in patient safety improvement-in structuring their work and collaborating productively.

The perception of the patient safety climate by professionals of the emergency department.

Science.gov (United States)

Rigobello, Mayara Carvalho Godinho; Carvalho, Rhanna Emanuela Fontenele Lima de; Guerreiro, Juliana Magalhães; Motta, Ana Paula Gobbo; Atila, Elizabeth; Gimenes, Fernanda Raphael Escobar

2017-07-01

The aim of this study was to assess the patient safety climate from the perspective of healthcare professionals working in the emergency department of a hospital in Brazil. Emergency departments are complex and dynamic environments. They are prone to adverse events that compromise the quality of care provided and reveal the importance of patient safety culture and climate. This was a quantitative, descriptive, cross-sectional study. The Safety Attitudes Questionnaire (SAQ) - Short Form 2006 was used for data collection, validated and adapted into Portuguese. The study sample consisted of 125 participants. Most of the participants were female (57.6%) and had worked in emergency department for more than 10years (56.8%). Sixty-two participants (49.6%) were nursing professionals. The participants demonstrated satisfaction with their jobs and dissatisfaction with the actions of management with regard to safety issues. Participants' perceptions about the patient safety climate were found to be negative. Knowledge of professionals' perceptions of patient safety climate in the context of emergency care helps with assessments of the safety culture, contributes to improvement of health care, reduces adverse events, and can focus efforts to improve the quality of care provided to patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Non-technical issues in safety assessments for nuclear disposal facilities

International Nuclear Information System (INIS)

Kallenbach-Herbert, Beate; Brohmann, Bettina

2010-09-01

The paper highlights that a comprehensive approach to safety affords the consideration of technology, organisation, personnel and social environment. In several safety relevant contexts of nuclear waste disposal these fields are closely interrelated. The approach for the consideration of socio-scientific aspects which is sketched in this paper supports the systematic treatment of safety relevant non-technical issues in the safety case or in safety assessments for a disposal project. Furthermore it may foster the dialogue among specialists from the technical, the natural- and the socio-scientific field on questions of disposal safety. In this way it may contribute to a better understanding among the affected scientific disciplines in nuclear waste disposal.

Issue on NPP-I and C important to safety-Data Communication

International Nuclear Information System (INIS)

Koo, I. S.; Hong, S. B.; Cho, J. W.; Choi, Y. S.; Lee, J. C.

2010-01-01

1. Issue on CDV and FDIS of IEC61500 - Nuclear Power Plants - Instrumentation and control important to safety -Data communication - Activities on IEC TC45, SC45A/WGA3. 2. As issue the requirements for safety data communication which is essential part of digital I and C systems, the fundamental technology for IT based nuclear I and C is established. 3. Approval and circulation of IED61500 CDV and FDIS - Issue of the international standard, IEC 61500. 4. Issue one IEC61500, three interim documents, three presentations and five technical support to industry, and participation in IEC TC45 and SC45A plenary meeting and intermediate meeting on SC45A/WGA3. 5. Based on IEC61500, an new project on wireless technologyes application to NPP will be proceeded

Focusing on patient safety in the Neonatal Intensive Care Unit environment

Directory of Open Access Journals (Sweden)

Ilias Chatziioannidis

2017-02-01

Full Text Available Patient safety in the Neonatal Intensive Care Unit (NICU environment is an under-researched area, but recently seems to get high priority on the healthcare quality agenda worldwide. NICU, as a highly sensitive and technological driven environment, signals the importance for awareness in causation of mistakes and accidents. Adverse events and near misses that comprise the majority of human errors, cause morbidity often with devastating results, even death. Likewise in other organizations, errors causes are multiple and complex. Other high reliability organizations, such as air force and nuclear industry, offer examples of how standardized/homogenized work and removal of systems weaknesses can minimize errors. It is widely accepted that medical errors can be explained based on personal and/or system approach. The impact/effect of medical errors can be reduced when thorough/causative identification approach is followed by detailed analysis of consequences and prevention measures. NICU’s medical and nursing staff should be familiar with patient safety language, implement best practices, and support safety culture, maximizing efforts for reducing errors. Furthermore, top management commitment and support in developing patient safety culture is essential in order to assure the achievement of the desirable organizational safety outcomes. The aim of the paper is to review patient safety issues in the NICU environment, focusing on development and implementation of strategies, enhancing high quality standards for health care.

Anesthesia Quality and Patient Safety in China: A Survey.

Science.gov (United States)

Zhu, Bin; Gao, Huan; Zhou, Xiangyong; Huang, Jeffrey

There has been no nationwide investigation into anesthesia quality and patient safety in China. The authors surveyed Chinese anesthesiologists about anesthesia quality by sending a survey to all anesthesiologist members of the New Youth Anesthesia Forum via WeChat. The respondents could choose to use a mobile device or desktop to complete the survey. The overall response rate was 43%. Intraoperative monitoring: 77.9% of respondents reported that electrocardiogram monitoring was routinely applied for all patients; only 55% of the respondents reported that they routinely used end-tidal carbon dioxide monitoring for their patients under general anesthesia. 10.3% of respondents admitted that they had at least one wrong medicine administration in the past 3 months; 12.4% reported that they had at least one case of cardiac arrest in the past year. This is the first anesthesia quality survey in China. The findings revealed potential anesthesia safety issues in China.

Why is patient safety so hard? A selective review of ethnographic studies.

Science.gov (United States)

Dixon-Woods, Mary

2010-01-01

Ethnographic studies are valuable in studying patient safety. This is a narrative review of four reports of ethnographic studies of patient safety in UK hospitals conducted as part of the Patient Safety Research Programme. Three of these studies were undertaken in operating theatres and one in an A&E Department. The studies found that hospitals were rarely geared towards ensuring perfect performances. The coordination and mobilization of the large number of inter-dependent processes and resources needed to support the achievement of tasks was rarely optimal. This produced significant strain that staff learned to tolerate by developing various compensatory strategies. Teamwork and inter-professional communication did not always function sufficiently well to ensure that basic procedural information was shared or that the required sequence of events was planned. Staff did not always do the right things, for a wide range of different reasons, including contestations about what counted as the right thing. Structures of authority and accountability were not always clear or well-functioning. Patient safety incidents were usually not reported, though there were many different reasons for this. It can be concluded that securing patient safety is hard. There are multiple interacting influences on safety, and solutions need to be based on a sound understanding of the nature of the problems and which approaches are likely to be best suited to resolving them. Some solutions that appear attractive and straightforward are likely to founder. Addressing safety problems requires acknowledgement that patient safety is not simply a technical issue, but a site of organizational and professional politics.

Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC).

Science.gov (United States)

Chen, I-Chi; Li, Hung-Hui

2010-06-07

Patient safety is a critical component to the quality of health care. As health care organizations endeavour to improve their quality of care, there is a growing recognition of the importance of establishing a culture of patient safety. In this research, the authors use the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire to assess the culture of patient safety in Taiwan and attempt to provide an explanation for some of the phenomena that are unique in Taiwan. The authors used HSOPSC to measure the 12 dimensions of the patient safety culture from 42 hospitals in Taiwan. The survey received 788 respondents including physicians, nurses, and non-clinical staff. This study used SPSS 15.0 for Windows and Amos 7 software tools to perform the statistical analysis on the survey data, including descriptive statistics and confirmatory factor analysis of the structural equation model. The overall average positive response rate for the 12 patient safety culture dimensions of the HSOPSC survey was 64%, slightly higher than the average positive response rate for the AHRQ data (61%). The results showed that hospital staff in Taiwan feel positively toward patient safety culture in their organization. The dimension that received the highest positive response rate was "Teamwork within units", similar to the results reported in the US. The dimension with the lowest percentage of positive responses was "Staffing". Statistical analysis showed discrepancies between Taiwan and the US in three dimensions, including "Feedback and communication about error", "Communication openness", and "Frequency of event reporting". The HSOPSC measurement provides evidence for assessing patient safety culture in Taiwan. The results show that in general, hospital staffs in Taiwan feel positively toward patient safety culture within their organization. The existence of discrepancies between the US data and the Taiwanese data suggest that cultural uniqueness should be taken into

PATIENT SAFETY IN SURGERY: THE QUALITY OF IMPLEMENTATION OF PATIENT SAFETY CHECKLISTS IN A REGIONAL HOSPITAL

Directory of Open Access Journals (Sweden)

V. Karyadinata

2012-09-01

Full Text Available Introduction. Patient safety and the avoidance of inhospital adverse events is a key focus of clinical practice and medical audit. A large of proportion of medical errors affect surgical patients in the peri-operative setting. Safety checklists have been adopted by the medical profession from the aviation industry as a cheap and reliable method of avoiding errors which arise from complex or stressful situations. Current evidence suggests that the use of periooperative checklists has led to a decrease in surgical morbidity and hospital costs. Aim. To assess the quality of implementation of a modified patient safety checklist in a UK district general hospital. Methods. An observational tool was designed to assess in real time the peri-operative performance of the surgical safety checklist in patients undergoing general surgical, urological or orthopaedic procedures. Initiation of the checklist, duration of performance and staff participation were audited in real time. Results. 338 cases were monitored. Nurses were most active in initiating the safety checklist. The checklist was performed successfully in less than a minute in most cases. 11-24% of staff (according to professional group present in the operating room did not participate in the checklist. Critical safety checks (patient identity and procedure name were performed in all cases across all specialties. Variations were noted in checking other categories, such as deep vein thrombosis (DVT prophylaxis or patient warming. Conclusions. There is still a potential for improving the practice and culture of surgical patient safety activities. Staff training and designation of patient safety leadership roles is needed in increasing compliance and implementation of patient safety mechanism, such as peri-operative checklists. There is significant data to advocate the need to implement patient safety surgical checklists internationally

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review.

Science.gov (United States)

Feldman, Sue S; Buchalter, Scott; Hayes, Leslie W

2018-06-04

The area of healthcare quality and patient safety is starting to use health information technology to prevent reportable events, identify them before they become issues, and act on events that are thought to be unavoidable. As healthcare organizations begin to explore the use of health information technology in this realm, it is often unclear where fiscal and human efforts should be focused. The purpose of this study was to provide a foundation for understanding where to focus health information technology fiscal and human resources as well as expectations for the use of health information technology in healthcare quality and patient safety. A literature review was conducted to identify peer-reviewed publications reporting on the actual use of health information technology in healthcare quality and patient safety. Inductive thematic analysis with open coding was used to categorize a total of 41 studies. Three pre-set categories were used: prevention, identification, and action. Three additional categories were formed through coding: challenges, outcomes, and location. This study identifies five main categories across seven study settings. A majority of the studies used health IT for identification and prevention of healthcare quality and patient safety issues. In this realm, alerts, clinical decision support, and customized health IT solutions were most often implemented. Implementation, interface design, and culture were most often noted as challenges. This study provides valuable information as organizations determine where they stand to get the most "bang for their buck" relative to health IT for quality and patient safety. Knowing what implementations are being effectivity used by other organizations helps with fiscal and human resource planning as well as managing expectations relative to cost, scope, and outcomes. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture

Key practical issues in strengthening safety culture. INSAG-15. A report by the International Safety Advisory Group [Russian Edition

International Nuclear Information System (INIS)

2015-01-01

This report describes the essential practical issues to be considered by organizations aiming to strengthen safety culture. It is intended for senior executives, managers and first line supervisors in operating organizations. Although safety culture cannot be directly regulated, it is important that members of regulatory bodies understand how their actions affect the development of attempts to strengthen safety culture and are sympathetic to the need to improve the less formal human related aspects of safety. The report is therefore of relevance to regulators, although not intended primarily for them. The International Nuclear Safety Advisory Group (INSAG) introduced the concept of safety culture in its INSAG-4 report in 1991. Since then, many papers have been written on safety culture, as it relates to organizations and individuals, its improvement and its underpinning prerequisites. Variations in national cultures mean that what constitutes a good approach to enhancing safety culture in one country may not be the best approach in another. However, INSAG seeks to provide pragmatic and practical advice of wide applicability in the principles and issues presented in this report. Nuclear and radiological safety are the prime concerns of this report, but the topics discussed are so general that successful application of the principles should lead to improvements in other important areas, such as industrial safety, environmental performance and, in some respects, wider business performance. This is because many of the attitudes and practices necessary to achieve good performance in nuclear safety, including visible commitment by management, openness, care and thoroughness in completing tasks, good communication and clarity in recognizing major issues and dealing with them as a priority, have wide applicability

Patient participation in patient safety and nursing input - a systematic review.

Science.gov (United States)

Vaismoradi, Mojtaba; Jordan, Sue; Kangasniemi, Mari

2015-03-01

This systematic review aims to synthesise the existing research on how patients participate in patient safety initiatives. Ambiguities remain about how patients participate in routine measures designed to promote patient safety. Systematic review using integrative methods. Electronic databases were searched using keywords describing patient involvement, nursing input and patient safety initiatives to retrieve empirical research published between 2007 and 2013. Findings were synthesized using the theoretical domains of Vincent's framework for analysing risk and safety in clinical practice: "patient", "healthcare provider", "task", "work environment", "organisation & management". We identified 17 empirical research papers: four qualitative, one mixed-method and 12 quantitative designs. All 17 papers indicated that patients can participate in safety initiatives. Improving patient participation in patient safety necessitates considering the patient as a person, the nurse as healthcare provider, the task of participation and the clinical environment. Patients' knowledge, health conditions, beliefs and experiences influence their decisions to engage in patient safety initiatives. An important component of the management of long-term conditions is to ensure that patients have sufficient knowledge to participate. Healthcare providers may need further professional development in patient education and patient care management to promote patient involvement in patient safety, and ensure that patients understand that they are 'allowed' to inform nurses of adverse events or errors. A healthcare system characterised by patient-centredness and mutual acknowledgement will support patient participation in safety practices. Further research is required to improve international knowledge of patient participation in patient safety in different disciplines, contexts and cultures. Patients have a significant role to play in enhancing their own safety while receiving hospital care. This

Workshop on Regulatory Review and Safety Assessment Issues in Repository Licensing

Energy Technology Data Exchange (ETDEWEB)

Wilmot, Roger D. (Galson Sciences Limited (United Kingdom))

2011-02-15

The workshop described here was organised to address more general issues regarding regulatory review of SKB's safety assessment and overall review strategy. The objectives of the workshop were: - to learn from other programmes' experiences on planning and review of a license application for a nuclear waste repository, - to offer newly employed SSM staff an opportunity to learn more about selected safety assessment issues, and - to identify and document recommendations and ideas for SSM's further planning of the licensing review

Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.

Science.gov (United States)

Smith, Scott Alan; Yount, Naomi; Sorra, Joann

2017-02-16

A number of private and public companies calculate and publish proprietary hospital patient safety scores based on publicly available quality measures initially reported by the U.S. federal government. This study examines whether patient safety culture perceptions of U.S. hospital staff in a large national survey are related to publicly reported patient safety ratings of hospitals. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (Hospital SOPS) assesses provider and staff perceptions of hospital patient safety culture. Consumer Reports (CR), a U.S. based non-profit organization, calculates and shares with its subscribers a Hospital Safety Score calculated annually from patient experience survey data and outcomes data gathered from federal databases. Linking data collected during similar time periods, we analyzed relationships between staff perceptions of patient safety culture composites and the CR Hospital Safety Score and its five components using multiple multivariate linear regressions. We analyzed data from 164 hospitals, with patient safety culture survey responses from 140,316 providers and staff, with an average of 856 completed surveys per hospital and an average response rate per hospital of 56%. Higher overall Hospital SOPS composite average scores were significantly associated with higher overall CR Hospital Safety Scores (β = 0.24, p Consumer Reports Hospital Safety Score, which is a composite of patient experience and outcomes data from federal databases. As hospital managers allocate resources to improve patient safety culture within their organizations, their efforts may also indirectly improve consumer-focused, publicly reported hospital rating scores like the Consumer Reports Hospital Safety Score.

Generic safety issues for nuclear power plants with light water reactors and measures taken for their resolution

International Nuclear Information System (INIS)

1998-09-01

The IAEA Conference on 'The Safety of Nuclear Power: Strategy for the Future' in 1991 was a milestone in nuclear safety. Two of the important items addressed by this conference were ensuring and enhancing safety of operating plants and treatment of nuclear power plants built to earlier safety standards. A number of publications related to these two items issued subsequent to this conference were: A Common Basis for Judging the Safety of Nuclear Power Plants Built to Earlier Standards, INSAG-9 (1995), the IAEA Safety Guide 50-SG-O12, periodic Safety Review of Operational Nuclear Power Plants (1994) and an IAEA publication on the Safety Evaluation of Operating Nuclear Power Plants Built to Earlier Standards - A Common Basis for Judgement (1997). Some of the findings of the 1991 Conference have not yet been fully addressed. An IAEA Symposium on reviewing the Safety of Existing Nuclear Power Plants in 1996 showed that there is an urgent need for operating organizations and national authorities to review operating nuclear power plants which do not meet the high safety levels of the vast majority of plants and to undertake improvements with assistance from the international community if required. Safety reviews of operating nuclear power plants take on added importance in the context of the Convention on Nuclear safety and its implementation. The purpose of this TECDOC compilation based on broad international experience, is to assist the Member States in the reassessment of operating plants by providing a list of generic safety issues identified in nuclear power plants together with measures taken to resolve these issues. These safety issues are generic in nature with regard to light water reactors and the measures for their resolution are for use as a reference for the safety reassessment of operating plants. The TECDOC covers issues thought to be significant to Member States based on consensus process. It provides an introduction to the use of generic safety issues for

Acute care patients discuss the patient role in patient safety.

Science.gov (United States)

Rathert, Cheryl; Huddleston, Nicole; Pak, Youngju

2011-01-01

Patient safety has been a highly researched topic in health care since the year 2000. One strategy for improving patient safety has been to encourage patients to take an active role in their safety during their health care experiences. However, little research has shed light on how patients view their roles. This study attempted to address this deficit by inductively exploring the results of a qualitative study in which patients reported their ideas about what they believe their roles should be. Patients with an overnight stay in the previous 90 days at one of three hospitals were surveyed using a mailing methodology. Of 1,040 respondents, 491 provided an open-ended response regarding what they believe the patient role should be. Qualitative analysis found several prominent themes. The largest proportion of responses (23%) suggested that patients should follow instructions given by care providers. Other prominent themes were that patients should ask questions and become informed about their conditions and treatments, and many implied that they should expect competent care. Our results suggest that patients believe they should be able to trust that they are being provided competent care, as opposed to assuming a leadership role in their safety. Our results suggest that engaging patients in safety efforts may be complex, requiring a variety of strategies. Managers must provide environments conducive to staff and patient interactions to support patients in this effort. Different types of patients may require different engagement strategies.

U.S. Food System Working Conditions as an Issue of Food Safety.

Science.gov (United States)

Clayton, Megan L; Smith, Katherine C; Pollack, Keshia M; Neff, Roni A; Rutkow, Lainie

2017-02-01

Food workers' health and hygiene are common pathways to foodborne disease outbreaks. Improving food system jobs is important to food safety because working conditions impact workers' health, hygiene, and safe food handling. Stakeholders from key industries have advanced working conditions as an issue of public safety in the United States. Yet, for the food industry, stakeholder engagement with this topic is seemingly limited. To understand this lack of action, we interviewed key informants from organizations recognized for their agenda-setting role on food-worker issues. Findings suggest that participants recognize the work standards/food safety connection, yet perceived barriers limit adoption of a food safety frame, including more pressing priorities (e.g., occupational safety); poor fit with organizational strategies and mission; and questionable utility, including potential negative consequences. Using these findings, we consider how public health advocates may connect food working conditions to food and public safety and elevate it to the public policy agenda.

14 CFR 414.35 - Public notification of the criteria by which a safety approval was issued.

Science.gov (United States)

2010-01-01

... issued. For each grant of a safety approval, the FAA will publish in the Federal Register a notice of the... which a safety approval was issued. 414.35 Section 414.35 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION LICENSING SAFETY APPROVALS Safety...

Nuclear reactors safety issues

International Nuclear Information System (INIS)

Barre, Francois; Seiler, Nathalie

2008-01-01

Full text of publication follows: Since the seventies, economic incentives have led the utilities to drive a permanent evolution of the light water reactor (LWR). The evolution deals with the reactor designs as well as the way to operate them in a more flexible manner. It is for instance related to the fuel technologies and management. On the one hand, the technologies are in continuous evolution, such as the fuel pellets (MOX, Gd fuel, or Cr doped fuels..) as well as advanced cladding materials (M5 TM , MDA or ZIRLO). On the other hand, the fuel management is also subject to continuous evolution in particular in terms of increasing the level of burn-up, the reactor (core) power, the enrichment, as well as the duration of reactor cycles. For instance, in a few years in France, the burn-up has raised beyond the value of 39 GWj/t, initially authorized up to 52 GWj/t for the UO 2 fuel. In the near future, utilities foreseen to reach fuel burn-up of 60 GWj/t for MOX fuel and 70 GWj/t for UO 2 fuel. Furthermore, the future reactor of fourth generation will use new fuels of advanced conception. Furthermore with the objective of improving the safety margins, methods and calculation tools used by the utilities in the elaboration of their safety demonstrations submitted to the Safety Authority, are in movement. The margin evaluation methodologies often consist of a calculation chain of best-estimate multi-field simulations (e.g. various codes being coupled to simulate in a realistic way the evolution of the thermohydraulic, neutronic and mechanic state of the reactor). The statistical methods are more and more sophisticated and the computer codes are integrating ever-complex physical models (e.g. three-dimensional at fine scale). Following this evolution, the Institute of Radioprotection and Nuclear Safety (IRSN), whose one of the roles is to examine the safety records and to rend a technical expertise, considers the necessity of reevaluating the safety issues for advanced

Safety culture issues and perspectives

International Nuclear Information System (INIS)

Dahlgren Persson, K.

1999-01-01

indicators, the symptoms and significance of shortcomings and degradation in the safety management processes and safety culture and hence failed to take effective corrective actions at an early stage. Key performance issues such as critical oversight, self assessment processes and effective corrective action programmes were not fully appreciated by senior management even after performance deficiencies were identified by the regulator and other external agencies. The seeming inability of the regulator to influence this senior management level, especially at the early stages of safety performance degradation was a major contributing factor in the continuation of the performance decline to the point that regulatory intervention became a necessity. Recovery processes commonly used a new utility senior management team to kick-start the change process and corresponding regulatory resource increases focused on monitoring the recovery. A comprehensive recovery plan and an interactive relationship with the regulator were deemed essential for a successful recovery. A review of the developing safety culture was a factor considered necessary to ensure sustainability. Public involvement in the regulatory monitoring process helped restore their confidence in the regulator, utility and plant management. The group recommended IAEA continue work to develop guidance for senior corporate management and regulators in this area (author) (ml)

Patients' and healthcare workers' perceptions of a patient safety advisory.

Science.gov (United States)

Schwappach, David L B; Frank, Olga; Koppenberg, Joachim; Müller, Beat; Wasserfallen, Jean-Blaise

2011-12-01

To assess patients' and healthcare workers' (hcw) attitudes and experiences with a patient safety advisory, to investigate predictors for patients' safety-related behaviors and determinants for staff support for the advisory. Cross-sectional surveys of patients (n= 1053) and hcw (n= 275). Three Swiss hospitals. Patients who received the safety advisory and hcw caring for these patients. Patient safety advisory disseminated to patients at the study hospitals. Attitudes towards and experiences with the advisory. Hcw support for the intervention and patients' intentions to apply the recommendations were modelled using regression analyses. Patients (95%) and hcw (78%) agreed that hospitals should educate patients how to prevent errors. Hcw and patients' evaluations of the safety advisory were positive and followed a similar pattern. Patients' intentions to engage in safety were significantly predicted by behavioral control, subjective norms, attitudes, safety behaviors during hospitalization and experiences with taking action. Hcw support for the campaign was predicted by rating of the advisory (Odds ratio (OR) 3.4, confidence interval (CI) 1.8-6.1, Ppatients (OR 1.9, CI 1.1-3.3, P= 0.034) and experience of unpleasant situations (OR 0.6, CI 0.4-1.0, P= 0.035). The safety advisory was well accepted by patients and hcw. To be successful, the advisory should be accompanied by measures that target norms and barriers in patients, and support staff in dealing with difficult situations.

Legislation for the countermeasures on special issues of nuclear safety regulations

International Nuclear Information System (INIS)

Cho, Byung Sun; Lee, Mo Sung; Chung, Gum Chun; Kim, Heon Jin; Oh, Ho Chul

2004-02-01

Since the present nuclear safety regulation has some legal problems that refer to special issues and contents of regulatory provisions, this report has preformed research on the legal basic theory of nuclear safety regulation to solve the problems. In addition, this report analyzed the problems of each provisions and suggested the revision drafts on the basis of analyzing problems and the undergoing theory of nuclear safety regulation

Legislation for the countermeasures on special issues of nuclear safety regulations

Energy Technology Data Exchange (ETDEWEB)

Cho, Byung Sun; Lee, Mo Sung; Chung, Gum Chun; Kim, Heon Jin; Oh, Ho Chul [Chongju Univ., Cheongju (Korea, Republic of)

2004-02-15

Since the present nuclear safety regulation has some legal problems that refer to special issues and contents of regulatory provisions, this report has preformed research on the legal basic theory of nuclear safety regulation to solve the problems. In addition, this report analyzed the problems of each provisions and suggested the revision drafts on the basis of analyzing problems and the undergoing theory of nuclear safety regulation.

Technical Issues and Proposes on the Legislation of Probabilistic Safety Assessment in Periodic Safety Review

International Nuclear Information System (INIS)

Hwang, Seok-Won; Jeon, Ho-Jun; Na, Jang-Hwan

2015-01-01

Korean Nuclear Power Plants have performed a comprehensive safety assessment reflecting design and procedure changes and using the latest technology every 10 years. In Korea, safety factors of PSR are revised to 14 by revision of IAEA Safety Guidelines in 2003. In the revised safety guidelines, safety analysis field was subdivided into deterministic safety analysis, PSA (Probabilistic safety analysis), and hazard analysis. The purpose to examine PSA as a safety factor on PSR is to make sure that PSA results and assumptions reflect the latest state of NPPs, validate the level of computer codes and analytical models, and evaluate the adequacy of PSA instructions. In addition, its purpose is to derive the plant design change, operating experience of other plants and safety enhancement items as well. In Korea, PSA is introduced as a new factor. Thus, the overall guideline development and long-term implementation strategy are needed. Today in Korea, full-power PSA model revision and low-power and shutdown (LPSD) PSA model development is being performed as a part of the post Fukushima action items for operating plants. The scope of the full-power PSA is internal/external level 1, 2 PSA. But in case of fire PSA, the scope is level 1 PSA using new method, NUREG/CR-6850. In case of LPSD PSA, level 1 PSA for all operating plants, and level 2 PSA for 2 demonstration plants are under development. The result of the LPSD PSA will be used as major input data for plant specific SAMG (Severe Accident Management Guideline). The scope of PSA currently being developed in Korea cannot fulfill 'All Mode, All Scope' requirements recommended in the IAEA Safety Guidelines. Besides the legislation of PSA, step-by-step development strategy for non-performed scopes such as level 3 PSA and new fire PSA is one of the urgent issues in Korea. This paper suggests technical issues and development strategies for each PSA technical elements.

Dust Combustion Safety Issues for Fusion Applications

Energy Technology Data Exchange (ETDEWEB)

L. C. Cadwallader

2003-05-01

This report summarizes the results of a safety research task to identify the safety issues and phenomenology of metallic dust fires and explosions that are postulated for fusion experiments. There are a variety of metal dusts that are created by plasma erosion and disruptions within the plasma chamber, as well as normal industrial dusts generated in the more conventional equipment in the balance of plant. For fusion, in-vessel dusts are generally mixtures of several elements; that is, the constituent elements in alloys and the variety of elements used for in-vessel materials. For example, in-vessel dust could be composed of beryllium from a first wall coating, tungsten from a divertor plate, copper from a plasma heating antenna or diagnostic, and perhaps some iron and chromium from the steel vessel wall or titanium and vanadium from the vessel wall. Each of these elements has its own unique combustion characteristics, and mixtures of elements must be evaluated for the mixture’s combustion properties. Issues of particle size, dust temperature, and presence of other combustible materials (i.e., deuterium and tritium) also affect combustion in air. Combustion in other gases has also been investigated to determine if there are safety concerns with “inert” atmospheres, such as nitrogen. Several coolants have also been reviewed to determine if coolant breach into the plasma chamber would enhance the combustion threat; for example, in-vessel steam from a water coolant breach will react with metal dust. The results of this review are presented here.

Application of the risk-based strategy to the Hanford tank waste organic-nitrate safety issue

International Nuclear Information System (INIS)

Hunter, V.L.; Colson, S.D.; Ferryman, T.; Gephart, R.E.; Heasler, P.; Scheele, R.D.

1997-12-01

This report describes the results from application of the Risk-Based Decision Management Approach for Justifying Characterization of Hanford Tank Waste to the organic-nitrate safety issue in Hanford single-shell tanks (SSTs). Existing chemical and physical models were used, taking advantage of the most current (mid-1997) sampling and analysis data. The purpose of this study is to make specific recommendations for planning characterization to help ensure the safety of each SST as it relates to the organic-nitrate safety issue. An additional objective is to demonstrate the viability of the Risk-Based Strategy for addressing Hanford tank waste safety issues

Application of the risk-based strategy to the Hanford tank waste organic-nitrate safety issue

Energy Technology Data Exchange (ETDEWEB)

Hunter, V.L.; Colson, S.D.; Ferryman, T.; Gephart, R.E.; Heasler, P.; Scheele, R.D.

1997-12-01

This report describes the results from application of the Risk-Based Decision Management Approach for Justifying Characterization of Hanford Tank Waste to the organic-nitrate safety issue in Hanford single-shell tanks (SSTs). Existing chemical and physical models were used, taking advantage of the most current (mid-1997) sampling and analysis data. The purpose of this study is to make specific recommendations for planning characterization to help ensure the safety of each SST as it relates to the organic-nitrate safety issue. An additional objective is to demonstrate the viability of the Risk-Based Strategy for addressing Hanford tank waste safety issues.

Evaluation of patient safety culture among Malaysian retail pharmacists: results of a self-reported survey

Directory of Open Access Journals (Sweden)

Sivanandy P

2016-07-01

Full Text Available Palanisamy Sivanandy,1 Mari Kannan Maharajan,1 Kingston Rajiah,1 Tan Tyng Wei,2 Tan Wee Loon,2 Lim Chong Yee2 1Department of Pharmacy Practice, School of Pharmacy, 2School of Pharmacy, International Medical University, Wilayah Persekutuan Kuala Lumpur, Malaysia Background: Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use.Objective: To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia.Methods: A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted.Results: The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of “staff training and skills” were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup.Conclusion: The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety. Keywords

Ecological Issues Related to Children's Health and Safety

Science.gov (United States)

Aldridge, Jerry; Kohler, Maxie

2009-01-01

Issues concerning the health and safety of children and youth occur at multiple levels. Bronfenbrenner (1995) proposed an ecological systems approach in which multiple systems interact to enhance or diminish children's development. The same systems are at work in health promotion. The authors present and review articles that reflect the multiple…

Safety in paediatric imaging

International Nuclear Information System (INIS)

Carter, D.; Filice, I.; Murray, D.; Thomas, K.

2006-01-01

Those of us working in a dedicated paediatric environment are aware of the important safety issues with regard to paediatrics. Our goal when working with paediatric patients, the goal is to obtain the best quality images while keeping patients safe and their distress to a minimum. This article will discuss some of the issues regarding paediatric safety in a diagnostic imaging department, including radiation doses and the risk to paediatric patients, reducing medication errors, safe sedation practice and environmental safety. Also discussed are some conditions requiring special consideration to maintain patient safety such as epiglottitis and suspected child abuse. Promotion of a patient/family-centered care system will create an environment of trust where parents or guardians will know that their children are being well cared for in a safe, effective environment. (author)

Patient safety in primary care: a survey of general practitioners in the Netherlands

Directory of Open Access Journals (Sweden)

Wensing Michel

2010-01-01

Full Text Available Abstract Background Primary care encompasses many different clinical domains and patient groups, which means that patient safety in primary care may be equally broad. Previous research on safety in primary care has focused on medication safety and incident reporting. In this study, the views of general practitioners (GPs on patient safety were examined. Methods A web-based survey of a sample of GPs was undertaken. The items were derived from aspects of patient safety issues identified in a prior interview study. The questionnaire used 10 clinical cases and 15 potential risk factors to explore GPs' views on patient safety. Results A total of 68 GPs responded (51.5% response rate. None of the clinical cases was uniformly judged as particularly safe or unsafe by the GPs. Cases judged to be unsafe by a majority of the GPs concerned either the maintenance of medical records or prescription and monitoring of medication. Cases which only a few GPs judged as unsafe concerned hygiene, the diagnostic process, prevention and communication. The risk factors most frequently judged to constitute a threat to patient safety were a poor doctor-patient relationship, insufficient continuing education on the part of the GP and a patient age over 75 years. Language barriers and polypharmacy also scored high. Deviation from evidence-based guidelines and patient privacy in the reception/waiting room were not perceived as risk factors by most of the GPs. Conclusion The views of GPs on safety and risk in primary care did not completely match those presented in published papers and policy documents. The GPs in the present study judged a broader range of factors than in previously published research on patient safety in primary care, including a poor doctor-patient relationship, to pose a potential threat to patient safety. Other risk factors such as infection prevention, deviation from guidelines and incident reporting were judged to be less relevant than by policy

Patient safety in primary care: a survey of general practitioners in The Netherlands.

Science.gov (United States)

Gaal, Sander; Verstappen, Wim; Wensing, Michel

2010-01-21

Primary care encompasses many different clinical domains and patient groups, which means that patient safety in primary care may be equally broad. Previous research on safety in primary care has focused on medication safety and incident reporting. In this study, the views of general practitioners (GPs) on patient safety were examined. A web-based survey of a sample of GPs was undertaken. The items were derived from aspects of patient safety issues identified in a prior interview study. The questionnaire used 10 clinical cases and 15 potential risk factors to explore GPs' views on patient safety. A total of 68 GPs responded (51.5% response rate). None of the clinical cases was uniformly judged as particularly safe or unsafe by the GPs. Cases judged to be unsafe by a majority of the GPs concerned either the maintenance of medical records or prescription and monitoring of medication. Cases which only a few GPs judged as unsafe concerned hygiene, the diagnostic process, prevention and communication. The risk factors most frequently judged to constitute a threat to patient safety were a poor doctor-patient relationship, insufficient continuing education on the part of the GP and a patient age over 75 years. Language barriers and polypharmacy also scored high. Deviation from evidence-based guidelines and patient privacy in the reception/waiting room were not perceived as risk factors by most of the GPs. The views of GPs on safety and risk in primary care did not completely match those presented in published papers and policy documents. The GPs in the present study judged a broader range of factors than in previously published research on patient safety in primary care, including a poor doctor-patient relationship, to pose a potential threat to patient safety. Other risk factors such as infection prevention, deviation from guidelines and incident reporting were judged to be less relevant than by policy makers.

A multilevel model of patient safety culture: cross-level relationship between organizational culture and patient safety behavior in Taiwan's hospitals.

Science.gov (United States)

Chen, I-Chi; Ng, Hui-Fuang; Li, Hung-Hui

2012-01-01

As health-care organizations endeavor to improve their quality of care, there is a growing recognition of the importance of establishing a culture of patient safety. The main objective of this study was to investigate the cross-level influences of organizational culture on patient safety behavior in Taiwan's hospitals. The authors measured organizational culture (bureaucratic, supportive and innovative culture), patient safety culture and behavior from 788 hospital workers among 42 hospitals in Taiwan. Multilevel analysis was applied to explore the relationship between organizational culture (group level) and patient safety behavior (individual level). Patient safety culture had positive impact on patient safety behavior in Taiwan's hospitals. The results also indicated that bureaucratic, innovative and supportive organizational cultures all had direct influence on patient safety behavior. However, only supportive culture demonstrated significant moderation effect on the relationship between patient safety culture and patient safety behavior. Furthermore, organizational culture strength was shown correlated negatively with patient safety culture variability. Overall, organizational culture plays an important role in patient safety activities. Safety behaviors of hospital staff are partly influenced by the prevailing cultural norms in their organizations and work groups. For management implications, constructed patient priority from management commitment to leadership is necessary. For academic implications, research on patient safety should consider leadership, group dynamics and organizational learning. These factors are important for understanding the barriers and the possibilities embedded in patient safety. Copyright © 2011 John Wiley & Sons, Ltd.

Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study.

Science.gov (United States)

Mascherek, Anna C; Schwappach, David L B

2016-08-05

Identifying patient safety priorities in mental healthcare is an emerging issue. A variety of aspects of patient safety in medical care apply for patient safety in mental care as well. However, specific aspects may be different as a consequence of special characteristics of patients, setting and treatment. The aim of the present study was to combine knowledge from the field and research and bundle existing initiatives and projects to define patient safety priorities in mental healthcare in Switzerland. The present study draws on national expert panels, namely, round-table discussion and modified Delphi consensus method. As preparation for the modified Delphi questionnaire, two round-table discussions and one semistructured questionnaire were conducted. Preparative work was conducted between May 2015 and October 2015. The modified Delphi was conducted to gauge experts' opinion on priorities in patient safety in mental healthcare in Switzerland. In two independent rating rounds, experts made private ratings. The modified Delphi was conducted in winter 2015. Nine topics were defined along the treatment pathway: diagnostic errors, non-drug treatment errors, medication errors, errors related to coercive measures, errors related to aggression management against self and others, errors in treatment of suicidal patients, communication errors, errors at interfaces of care and structural errors. Patient safety is considered as an important topic of quality in mental healthcare among experts, but it has been seriously neglected up until now. Activities in research and in practice are needed. Structural errors and diagnostics were given highest priority. From the topics identified, some are overlapping with important aspects of patient safety in medical care; however, some core aspects are unique. 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/

Educating future leaders in patient safety

Science.gov (United States)

Leotsakos, Agnès; Ardolino, Antonella; Cheung, Ronny; Zheng, Hao; Barraclough, Bruce; Walton, Merrilyn

2014-01-01

Education of health care professionals has given little attention to patient safety, resulting in limited understanding of the nature of risk in health care and the importance of strengthening systems. The World Health Organization developed the Patient Safety Curriculum Guide: Multiprofessional Edition to accelerate the incorporation of patient safety teaching into higher educational curricula. The World Health Organization Curriculum Guide uses a health system-focused, team-dependent approach, which impacts all health care professionals and students learning in an integrated way about how to operate within a culture of safety. The guide is pertinent in the context of global educational reforms and growing recognition of the need to introduce patient safety into health care professionals’ curricula. The guide helps to advance patient safety education worldwide in five ways. First, it addresses the variety of opportunities and contexts in which health care educators teach, and provides practical recommendations to learning. Second, it recommends shared learning by students of different professions, thus enhancing student capacity to work together effectively in multidisciplinary teams. Third, it provides guidance on a range of teaching methods and pedagogical activities to ensure that students understand that patient safety is a practical science teaching them to act in evidence-based ways to reduce patient risk. Fourth, it encourages supportive teaching and learning, emphasizing the need to establishing teaching environments in which students feel comfortable to learn and practice patient safety. Finally, it helps educators incorporate patient safety topics across all areas of clinical practice. PMID:25285012

Patient safety culture in primary care

NARCIS (Netherlands)

Verbakel, N.J.

2015-01-01

Background A constructive patient safety culture is a main prerequisite for patient safety and improvement initiatives. Until now, patient safety culture (PSC) research was mainly focused on hospital care, however, it is of equal importance in primary care. Measuring PSC informs practices on their

Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions.

Science.gov (United States)

Bishop, Andrea C; Macdonald, Marilyn

2017-06-01

The risk associated with receiving health care has called for an increased focus on the role of patients in helping to improve safety. Recent research has highlighted that patient involvement in patient safety practices may be influenced by patient perceptions of patient safety practices and the perceptions of their health care providers. The objective of this research was to describe patient involvement in patient safety practices by exploring patient and nursing staff perceptions of safety. Qualitative focus groups were conducted with a convenience sample of nursing staff and patients who had previously completed a patient safety survey in 2 tertiary hospital sites in Eastern Canada. Six focus groups (June 2011 to January 2012) were conducted and analyzed using inductive thematic analysis. Four themes were identified: (1) wanting control, (2) feeling connected, (3) encountering roadblocks, and (4) sharing responsibility for safety. Both patient and nursing staff participants highlighted the importance of building a personal connection as a precursor to ensuring that patients are involved in their care and safety. However, perceptions of provider stress and nursing staff workload often reduced the ability of the nursing staff and patient participants to connect with one another and promote involvement. Current strategies aimed at increasing patient awareness of patient safety may not be enough. The findings suggest that providing the context for interaction to occur between nursing staff and patients as well as targeted interventions aimed at increasing patient control may be needed to ensure patient involvement in patient safety.

Issues of Safety and Security: New Challenging to Malaysia Tourism Industry

Directory of Open Access Journals (Sweden)

Mohd Ayob Norizawati

2014-01-01

Full Text Available The safety and security issues nowadays become one of the forces causing changes in tourism industry in era of millennium. The main concern of this issues more focus on crime rates, terrorism, food safety, health issues and natural disaster. This topic gained the popularity in tourism research after 9/11 tragedy and since then the academicians and practitioners started seeking the best solution in ways to mitigate these negative impacts. For Malaysia, the image as safety and secure destination was tarnished a few years lately and new unfortunates incident in this year bring more damage to Malaysia image. Healthy issues, terrorism, Lahad Datu intrusion, repeated kidnapping and shooting in Sabah, twin airlines incident, riot and illegal demonstration and false reporting by international media brings new challenging to Malaysia. Although some incident may be had short-term impact to Malaysia tourism industry, but it’s still gave the big impact to Malaysia branding process. Many travellers and Malaysian itself still believe that Malaysia is a one of safer destination and country to visit and stayed in, but more outstanding efforts was require to make sure Malaysia tourism industry was capable to recover from this negative impact as soon as possible.

Patient safety in the care of mentally ill people in Switzerland: Action plan 2016

Science.gov (United States)

Richard, Aline; Mascherek, Anna C; Schwappach, David L B

2017-01-01

Background: Patient safety in mental healthcare has not attracted great attention yet, although the burden and the prevalence of mental diseases are high. The risk of errors with potential for harm of patients, such as aggression against self and others or non-drug treatment errors is particularly high in this vulnerable group. Aim: To develop priority topics and strategies for action to foster patient safety in mental healthcare. Method: The Swiss patient safety foundation together with experts conducted round table discussions and a Delphi questionnaire to define topics along the treatment pathway, and to prioritise these topics. Finally, fields of action were developed. Results: An action plan was developed including the definition and prioritization of 9 topics where errors may occur. A global rating task revealed errors concerning diagnostics and structural errors as most important. This led to the development of 4 fields of action (awareness raising, research, implementation, and education and training) including practice-oriented potential starting points to enhance patient safety. Conclusions: The action plan highlights issues of high concern for patient safety in mental healthcare. It serves as a starting point for the development of strategies for action as well as of concrete activities.

A Secure ECC-based RFID Mutual Authentication Protocol to Enhance Patient Medication Safety.

Science.gov (United States)

Jin, Chunhua; Xu, Chunxiang; Zhang, Xiaojun; Li, Fagen

2016-01-01

Patient medication safety is an important issue in patient medication systems. In order to prevent medication errors, integrating Radio Frequency Identification (RFID) technology into automated patient medication systems is required in hospitals. Based on RFID technology, such systems can provide medical evidence for patients' prescriptions and medicine doses, etc. Due to the mutual authentication between the medication server and the tag, RFID authentication scheme is the best choice for automated patient medication systems. In this paper, we present a RFID mutual authentication scheme based on elliptic curve cryptography (ECC) to enhance patient medication safety. Our scheme can achieve security requirements and overcome various attacks existing in other schemes. In addition, our scheme has better performance in terms of computational cost and communication overhead. Therefore, the proposed scheme is well suitable for patient medication systems.

The Helsinki Declaration on Patient Safety in Anesthesiology: a way forward with the European Board and the European Society of Anesthesiology.

Science.gov (United States)

Petrini, F; Solca, M; De Robertis, E; Peduto, V A; Pasetto, A; Conti, G; Antonelli, M; Pelosi, P

2010-11-01

Anesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, emergency medicine and pain therapy, is acknowledged as the leading medical specialty in addressing issues of patient safety, but there is still a long way to go. Several factors pose hazards in Anesthesiology, like increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, as well as new drugs and devices. To better design educational and research strategies to improve patient safety, the European Board of Anesthesiology (EBA) and the European Society of Anesthesiology (ESA) have produced a blueprint for patient safety in Anesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anesthesiology, was endorsed together with the World Health Organization (WHO), the World Federation of Societies of Anesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. It was signed by several Presidents of National Anesthesiology Societies as well as other stakeholders. The Helsinki Declaration on Patient Safety in Anesthesiology represents a shared European view of what is necessary to improve patient safety, recommending practical steps that all anesthesiologists can include in their own clinical practice. The Italian Society of Anaesthesia, Analgesia, Reanimation and Intensive Care (SIAARTI) is looking forward to continuing work on "patient safety" issues in Europe, and to cooperating with the ESA in the best interest of European patients.

Resolution of the Hanford site ferrocyanide safety issue

International Nuclear Information System (INIS)

Cash, R.J.; Lilga, M.A.; Babad, H.

1997-01-01

The Ferrocyanide Safety Issue at the Hanford Site was officially resolved in December 1996. This paper summarizes the key activities that led to final resolution of this safety hazard, a process that began in 1990 after it and other safety concerns were identified for the underground high-level waste storage tanks at the Hanford Site. At the time little was known about ferrocyanide-nitrate/nitrite reactions and their potential to cause offsite releases of radioactivity. The ferrocyanide hazard was a perceived problem, but it took six years of intense studies and analyses of tank samples to prove that the problem no longer exists. The issue revolved around the fact that ferrocyanide and nitrate mixtures can be made to explode violently if concentrated, dry, and heated to temperatures of at least 250 degrees C. The studies conducted over the last six years have shown that the combined effects of temperature, radiation, and pH during 40 or more years of storage have destroyed almost all of the ferrocyanide originally added to tanks. This was shown in laboratory experiments using simulant wastes and confirmed by actual samples taken from the ferrocyanide tanks. The tank waste sludges are now too dilute to support a sustained exothermic reaction, even if dried out and heated to high temperatures. 2 tabs., 18 refs

Involving patients in patient safety programmes: A scoping review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care.

Science.gov (United States)

Trier, Hans; Valderas, Jose M; Wensing, Michel; Martin, Helle Max; Egebart, Jonas

2015-09-01

Patient involvement has only recently received attention as a potentially useful approach to patient safety in primary care. To summarize work conducted on a scoping review of interventions focussing on patient involvement for patient safety; to develop consensus-based recommendations in this area. Scoping review of the literature 2006-2011 about methods and effects of involving patients in patient safety in primary care identified evidence for previous experiences of patient involvement in patient safety. This information was fed back to an expert panel for the development of recommendations for healthcare professionals and policy makers. The scoping review identified only weak evidence in support of the effectiveness of patient involvement. Identified barriers included a number of patient factors but also the healthcare workers' attitudes, abilities and lack of training. The expert panel recommended the integration of patient safety in the educational curricula for healthcare professionals, and expected a commitment from professionals to act as first movers by inviting and encouraging the patients to take an active role. The panel proposed a checklist to be used by primary care clinicians at the point of care for promoting patient involvement. There is only weak evidence on the effectiveness of patient involvement in patient safety. The recommendations of the panel can inform future policy and practice on patient involvement in safety in primary care.

Role of effective nurse-patient relationships in enhancing patient safety.

Science.gov (United States)

Conroy, Tiffany; Feo, Rebecca; Boucaut, Rose; Alderman, Jan; Kitson, Alison

2017-08-02

Ensuring and maintaining patient safety is an essential aspect of care provision. Safety is a multidimensional concept, which incorporates interrelated elements such as physical and psychosocial safety. An effective nurse-patient relationship should ensure that these elements are considered when planning and providing care. This article discusses the importance of an effective nurse-patient relationship, as well as healthcare environments and working practices that promote safety, thus ensuring optimal patient care.

NS [Nuclear Safety] update. Current safety and security activities and developments taking place in the Department of Nuclear Safety and Security, Issue no. 11, June 2009

International Nuclear Information System (INIS)

2009-06-01

The current issue presents information about the following topics: Nuclear Safety Review for the Year 2008; Feedback from IRS Topical Studies and Events Applied to Safety Standards; Education and Training Programmes at the IAEA Department of Nuclear Safety and Security; Peer Review of Operational Safety Performance (PROSPER)

Containment-emergency-sump performance. Technical findings related to Unresolved Safety Issue A-43

International Nuclear Information System (INIS)

1983-04-01

This report summarizes key technical findings related to the Unresolved Safety Issue A-43, Containment Emergency Sump Performance, and provides recommendations for resolution of attendant safety issues. The key safety questions relate to: (a) effects of insulation debris on sump performance; (b) sump hydraulic performance as determined by design features, submergence, and plant induced effects, and (c) recirculation pump performance wherein air and/or particulate ingestion can occur. The technical findings presented in this report provide information relevant to the design and performance evaluation of the containment emergency sump

Collegiate Aviation Research and Education Solutions to Critical Safety Issues

Science.gov (United States)

Bowen, Brent (Editor)

2002-01-01

This Conference Proceedings is a collection of 6 abstracts and 3 papers presented April 19-20, 2001 in Denver, CO. The conference focus was "Best Practices and Benchmarking in Collegiate and Industry Programs". Topics covered include: satellite-based aviation navigation; weather safety training; human-behavior and aircraft maintenance issues; disaster preparedness; the collegiate aviation emergency response checklist; aviation safety research; and regulatory status of maintenance resource management.

Emerging issues in occupational safety and health.

Science.gov (United States)

Schulte, Paul A

2006-01-01

In developed countries, changes in the nature of work and the workforce may necessitate recalibrating the vision of occupational safety and health (OSH) researchers, practitioners, and policymakers to increase the focus on the most important issues. New methods of organizing the workplace, extensive labor contracting, expansion of service and knowledge sectors, increase in small business, aging and immigrant workers, and the continued existence of traditional hazards in high-risk sectors such as construction, mining, agriculture, health care, and transportation support the need to address: 1) broader consideration of the role and impact of work, 2) relationship between work and psychological dysfunction, 3) increased surveillance basis for research and intervention, 4) overcoming barriers to the conduct and use of epidemiologic research, 5) information and knowledge transfer and application, 6) economic issues in prevention, and 7) the global interconnectedness of OSH. These issues are offered to spur thinking as new national research agendas for OSH are considered for developed countries.

Collegiate Aviation Research and Education Solutions to Critical Safety Issues. UNO Aviation Monograph Series. UNOAI Report.

Science.gov (United States)

Bowen, Brent, Ed.

This document contains four papers concerning collegiate aviation research and education solutions to critical safety issues. "Panel Proposal Titled Collegiate Aviation Research and Education Solutions to Critical Safety Issues for the Tim Forte Collegiate Aviation Safety Symposium" (Brent Bowen) presents proposals for panels on the…

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

DEFF Research Database (Denmark)

Kristensen, Solvejg; Mainz, Jan; Bartels, Paul

2009-01-01

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

Patients for patient safety in China: a cross sectional study.

Science.gov (United States)

Zhang, Qiongwen; Li, Yulin; Li, Jing; Mao, Xuanyue; Zhang, Lijuan; Ying, Qinghua; Wei, Xin; Shang, Lili; Zhang, Mingming

2012-02-01

To investigate the baseline status of patients' awareness, knowledge, and attitudes to patient safety in China, and to determine the factors that influence patients' involvement in patient safety. We conducted a cross sectional survey using questionnaires adapted from recent studies on patient safety from outside China. The items included medical errors, infection, medication safety, and other aspects of patient safety. The questionnaire included 17 items and 5 domains. The survey was conducted between Jan. 2009 and Dec. 2010 involving 1000 patients from ten grade-A hospitals in seven provinces or cities in China. Most patients from the surgery departments completed the questionnaires voluntarily and anonymously. Five reviewers independently input the data into Microsoft Excel 2003, and the data were double-checked. Data were analyzed using SPSS 15.0 software for differences in the perceptions and attitudes of patients toward patient safety among different genders, ages, and regions. We distributed 1000 questionnaires and collected 959 completed questionnaires (response rate: 96%). Among the respondents, 58% of patients did not know what medical error is. Sixty-five percent of patients wanted disclosure of all medical errors. After errors occurred, 58% of patients wanted explanations of all possible harms that had resulted. Among 187 patients who had experienced medical errors, 83% of patients had sought appropriate legal action. About 52% of patients understood hospital infection, but 28% patients did not know that infections could occur in hospital. Seventy-eight percent of patients thought that medical staff should wash their hands before examining patients. More than half of the patients (68%) were willing to remind the staff of hygiene if they saw unsanitary conditions in a health clinic. Only 14% of patients knew the side effects of medications that they took. The majority of patients surveyed expressed willingness to contribute to patient safety, but their

Decommissioning: Regulatory activities and identification of key organizational and human factors safety issues

International Nuclear Information System (INIS)

Durbin, N.E.; Melber, B.D.; Lekberg, A.

2001-12-01

In the late 1990's the Swedish government decided to shut down Unit 1 of the Barsebaeck nuclear power plant. This report documents some of the efforts made by the Swedish Nuclear Power Inspectorate (SKI) to address human factors and organizational issues in nuclear safety during decommissioning of a nuclear facility. This report gives a brief review of the background to the decommissioning of Barsebaeck 1 and points out key safety issues that can arise during decommissioning. The main regulatory activities that were undertaken were requirements that the plant provide special safety reports on decommissioning focusing on first, the operation of both units until closure of Unit 1 and second, the operation of Unit 2 when Unit 1 was closed. In addition, SKI identified areas that might be affected by decommissioning and called these areas out for special attention. With regard to these areas of special attention, SKI required that the plant provide monthly reports on changing and emerging issues as well as self-assessments of the areas to be addressed in the special safety reports. Ten key safety issues were identified and evaluated with regard to different stages of decommissioning and with regard to the actions taken by Barsebaeck. Some key conclusions from SKI's experience in regulating a decommissioning nuclear power plant conclude the report

Safety in GPR prospecting: a rarely-considered issue

Science.gov (United States)

Persico, Raffaele; Pajewski, Lara; Trela, Christiane; Carrick Utsi, Erica

2016-04-01

Safety issues (of people first of all, but also of the equipment and environment) are rarely considered in Ground-Penetrating Radar (GPR) prospecting and, more in general, in near-surface geophysical prospecting. As is right and fully understandable, the scientific community devotes greatest attention first of all to the theoretical and practical aspects of GPR technique, affecting the quality of attainable results, secondly to the efforts and costs needed to achieve them [1-2]. However, the (luckily) growing GPR market and range of applications make it worth giving serious consideration to safety issues, too. The existing manuals dealing with safety in geophysics are mainly concerned with applications requiring "deep" geophysical prospecting, for example the search for oilfields and other hydrocarbon resources [3]. Near-surface geophysics involves less dangers than deep geophysics, of course. Nevertheless, several accidents have already happened during GPR experimental campaigns. We have personally had critical experiences and collected reliable testimonies concerning occurred problems as mountain sicks, fractures of legs, stomach problems, allergic reactions, encounters with potentially-dangerous animals, and more. We have also noticed that much more attention is usually paid to safety issues during indoor experimental activities (in laboratory), rather than during outdoor fieldworks. For example, the Italian National research Council is conventioned with safety experts who hold periodical seminaries about safety aspects. Having taken part to some of them, to our experience we have never heard a "lecture" devoted to outdoor prospecting. Nowadays, any aspects associated to the use of the technologies should be considered. The increasing sensibility and sense of responsibility towards environmental matters impose GPR end-users to be careful not to damage the environment and also the cultural heritage. Near-surface prospecting should not compromise the flora and

Current status of environmental, health, and safety issues of nickel metal-hydride batteries for electric vehicles

Energy Technology Data Exchange (ETDEWEB)

Corbus, D; Hammel, C J; Mark, J

1993-08-01

This report identifies important environment, health, and safety issues associated with nickel metal-hydride (Ni-MH) batteries and assesses the need for further testing and analysis. Among the issues discussed are cell and battery safety, workplace health and safety, shipping requirements, and in-vehicle safety. The manufacture and recycling of Ni-MH batteries are also examined. This report also overviews the ``FH&S`` issues associated with other nickel-based electric vehicle batteries; it examines venting characteristics, toxicity of battery materials, and the status of spent batteries as a hazardous waste.

Current status of environmental, health, and safety issues of nickel metal-hydride batteries for electric vehicles

International Nuclear Information System (INIS)

Corbus, D.; Hammel, C.J.; Mark, J.

1993-08-01

This report identifies important environment, health, and safety issues associated with nickel metal-hydride (Ni-MH) batteries and assesses the need for further testing and analysis. Among the issues discussed are cell and battery safety, workplace health and safety, shipping requirements, and in-vehicle safety. The manufacture and recycling of Ni-MH batteries are also examined. This report also overviews the ''FH ampersand S'' issues associated with other nickel-based electric vehicle batteries; it examines venting characteristics, toxicity of battery materials, and the status of spent batteries as a hazardous waste

A new method for the assessment of patient safety competencies during a medical school clerkship using an objective structured clinical examination

Directory of Open Access Journals (Sweden)

Renata Mahfuz Daud-Gallotti

2011-01-01

Full Text Available INTRODUCTION: Patient safety is seldom assessed using objective evaluations during undergraduate medical education. OBJECTIVE: To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure. METHODS: In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated. RESULTS: A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59 ± 1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54 offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains. CONCLUSIONS: An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical

Safety issues and their ranking for WWER-1000 model 320 nuclear power plants. A publication of the extrabudgetary programme on the safety of WWER and RBMK nuclear power plants

International Nuclear Information System (INIS)

1996-03-01

The objective of this report is to present a consolidated list of safety deficiencies, called safety issues, ranked according to their safety significance and the corrective measures to improve overall safety. It is intended for use as a reference to facilitate the development of plant specific safety improvement programmes and to serve as a basis for reviewing their implementation. To the extent that information was made available to the IAEA, the country/plant specific status with respect to each safety issue is described. Section 2 provides an overview of the impact of the relevant issues on the main safety functions in different operational conditions and other aspects important to overall plant safety. A summary of the safety issues and their respective ranking is given in Tables 1 and 2 at the end of Section 2. Section 3 deals with individual safety issues identified in the design which are presented according to the structure below. Section 4 presents the safety issues related to operational safety according to a similar structure but without the ranking. 73 refs, 3 tabs

Safety issues and their ranking for WWER-1000 model 320 nuclear power plants. A publication of the extrabudgetary programme on the safety of WWER and RBMK nuclear power plants

International Nuclear Information System (INIS)

1997-04-01

The objective of this report is to present a consolidated list of safety deficiencies, called safety issues, ranked according to their safety significance and the corrective measures to improve overall safety. It is intended for use as a reference to facilitate the development of plant specific safety improvement programmes and to serve as a basis for reviewing their implementation. To the extent that information was made available to the IAEA, the country/plant specific status with respect to each safety issue is described. Section 2 provides an overview of the impact of the relevant issues on the main safety functions in different operational conditions and other aspects important to overall plant safety. A summary of the safety issues and their respective ranking is given in Tables 1 and 2 at the end of Section 2. Section 3 deals with individual safety issues identified in the design which are presented according to the structure below. Section 4 presents the safety issues related to operational safety according to a similar structure but without the ranking

Occupational safety and health issues associated with green building

NARCIS (Netherlands)

Terwoert, J.; Ustailieva, E.

2013-01-01

This e-fact provides information on the work-related risk factors and the occupational safety and health (OSH) issues associated the planning and construction of green buildings, their maintenance, renovation (retrofitting), demolition, on-site waste collection. Some of these OSH risks are new

Medical and Dental Patient Issues

Science.gov (United States)

... A RadiationAnswers.org Ask the Experts Medical and Dental Patient Issues What's My Risk? The risks of ... developed by our topic editors for this category: Dental-Patient Issues Medical CT Reference Books and Articles ...

Ferrocyanide Safety Program: Data requirements for the ferrocyanide safety issue developed through the data quality objectives (DQO) process

International Nuclear Information System (INIS)

Buck, J.W.; Anderson, C.M.; Pulsipher, B.A.; Toth, J.J.; Turner, P.J.; Cash, R.J.; Dukelow, G.T.; Meacham, J.E.

1993-12-01

This document records the data quality objectives (DQO) process applied to the Ferrocyanide Waste Tank Safety Issue at the Hanford Site by the Pacific Northwest Laboratory and Westinghouse Hanford Company. Specifically, the major recommendations and findings from this Ferrocyanide DQO process are presented so that decision makers can determine the type, quantity, and quality of data required for addressing tank safety issues. The decision logic diagrams and error tolerance equations also are provided. Finally, the document includes the DQO sample-size formulas for determining specific tank sampling requirements

The future of nuclear power after Sizewell B. 3 v.: v. 1 Economic issues; v. 2 Environmental and safety issues; v. 3 Public perception issues

International Nuclear Information System (INIS)

1987-01-01

The three days of conference proceedings are published in three separate volumes. The first includes 7 papers relating to economic issues - those presented at the Sizewell-B public inquiry and the changes in the economic situation since the inquiry ended. The electricity demand, how this demand is to be met by nuclear and other fuel sources and how energy conservation might be an economic alternative to simply building more generating capacity are all issues discussed. The possible privatisation of the industry is also touched on. Volume two has 8 papers concerned with environmental and safety issues. These include the influence of the Sizewell-B decision on nuclear licensing and reactor safety, the technical and safety aspects of pressurized water reactors (PWR), the roles of British Nuclear Fuels and the United Kingdom Atomic Energy Authority, and radiation protection and effluent discharge control. The six papers in volume 3 look at public perception issues - not only towards nuclear power but towards the public inquiry process. The local authority view, the Friends of the Earth case against the PWR, and technical expertise in the decision process are also topics covered. All the papers are indexed separately. (UK)

[Nursing students' point of view on biosecurity and patient safety].

Science.gov (United States)

Cararro, Telma Elisa; Gelbcke, Francine Lima; Sebold, Luciara Fabiane; Kempfer, Silvana Silveira; Zapelini, Maria Christina; Waterkemper, Roberta

2012-09-01

This study is aimed at identifying the knowledge of nursing students about the subject area of patient safety and its relationship with the teaching of biosecurity. Exploratory qualitative study conducted at the Universidade Federal de Santa Catarina (Federal University of Santa Catarina), with 17 students in the third phase of the Undergraduate Nursing Program. Three categories emerged after an exhaustive reading of the responses caring for self and others; biosecurity and care for the environment; biosecurity: health education and continuing education in health services. The following issues were identified, students' concern about risk prevention, care and self care as prerogatives for patient's safety; and education as a proposal for the minimization of risks. The study of biosecurity is considered important in undergraduate studies, minimizing losses and mistakes in the undergraduate students' conduct.

Mobility and safety issues in drivers with dementia.

Science.gov (United States)

Carr, David B; O'Neill, Desmond

2015-10-01

Although automobiles remain the mobility method of choice for older adults, late-life cognitive impairment and progressive dementia will eventually impair the ability to meet transport needs of many. There is, however, no commonly utilized method of assessing dementia severity in relation to driving, no consensus on the specific types of assessments that should be applied to older drivers with cognitive impairment, and no gold standard for determining driving fitness or approaching loss of mobility and subsequent counseling. Yet, clinicians are often called upon by patients, their families, health professionals, and driver licensing authorities to assess their patients' fitness-to-drive and to make recommendations about driving privileges. We summarize the literature on dementia and driving, discuss evidenced-based assessments of fitness-to-drive, and outline the important ethical and legal concerns. We address the role of physician assessment, referral to neuropsychology, functional screens, dementia severity tools, driving evaluation clinics, and driver licensing authority referrals that may assist clinicians with an evaluation. Finally, we discuss mobility counseling (e.g. exploration of transportation alternatives) since health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance our patients' social connectedness and quality of life, while meeting their psychological and medical needs and maintaining personal and public safety.

Safety issues and their ranking for 'small series' WWER-1000 nuclear power plants. A publication of the extrabudgetary programme on the safety of WWER and RBMK nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

NONE

2000-09-01

This report presents the safety issues in 'small series' WWER-1000 nuclear power plants (NPPs). Safety issues are deviations from current recognized safety practices in design and operation judged to be safety significant by their impact on the plants' defence in depth. This report is intended to serve as reference for the development of plant specific safety improvement programmes and for the evaluation of measures proposed and/or implemented. The identification of safety issues is based on safety studies conducted by the operators of 'small series' WWER-1000 units and by organizations dealing with these reactors, on findings of IAEA safety missions to 'small series' WWER-1000 plants in South Ukraine, at Novovoronezh and Kalinin, and on information obtained from specialists from various countries during an IAEA consultants meeting, 8-12 September 1997 in Vienna, within the framework of the Extra budgetary Programme on the Safety of WWER and RBMK NPPs. Safety issues are first presented according to their impact on the main safety functions and are then described individually. The safety issues are characterized by issue title and specified by issue clarification. Safety issues connected with plant design are followed by the ranking of the issue and ranking justification. Altogether 85 safety issues have been identified, 12 of which are in Category III (defence in depth is insufficient, immediate corrective action is necessary), 38 in Category 11 (defence in depth is degraded, action is needed to resolve the issue) and 22 in Category I (departure from international practices, to be addressed as part of actions to resolve higher priority issues). In the case of operational safety issues (13 safety issues) no ranking is provided as the available material was considered insufficient. For each safety issue, comments and recommendations are made by the IAEA; the status of corresponding measures to improve safety implemented or planned at each site are presented in the

Safety issues and their ranking for 'small series' WWER-1000 nuclear power plants. A publication of the extrabudgetary programme on the safety of WWER and RBMK nuclear power plants

International Nuclear Information System (INIS)

2000-09-01

This report presents the safety issues in 'small series' WWER-1000 nuclear power plants (NPPs). Safety issues are deviations from current recognized safety practices in design and operation judged to be safety significant by their impact on the plants' defence in depth. This report is intended to serve as reference for the development of plant specific safety improvement programmes and for the evaluation of measures proposed and/or implemented. The identification of safety issues is based on safety studies conducted by the operators of 'small series' WWER-1000 units and by organizations dealing with these reactors, on findings of IAEA safety missions to 'small series' WWER-1000 plants in South Ukraine, at Novovoronezh and Kalinin, and on information obtained from specialists from various countries during an IAEA consultants meeting, 8-12 September 1997 in Vienna, within the framework of the Extra budgetary Programme on the Safety of WWER and RBMK NPPs. Safety issues are first presented according to their impact on the main safety functions and are then described individually. The safety issues are characterized by issue title and specified by issue clarification. Safety issues connected with plant design are followed by the ranking of the issue and ranking justification. Altogether 85 safety issues have been identified, 12 of which are in Category III (defence in depth is insufficient, immediate corrective action is necessary), 38 in Category 11 (defence in depth is degraded, action is needed to resolve the issue) and 22 in Category I (departure from international practices, to be addressed as part of actions to resolve higher priority issues). In the case of operational safety issues (13 safety issues) no ranking is provided as the available material was considered insufficient. For each safety issue, comments and recommendations are made by the IAEA; the status of corresponding measures to improve safety implemented or planned at each site are presented in the

Radiological protection, safety and security issues in the industrial and medical applications of radiation sources

International Nuclear Information System (INIS)

Vaz, Pedro

2015-01-01

The use of radiation sources, namely radioactive sealed or unsealed sources and particle accelerators and beams is ubiquitous in the industrial and medical applications of ionizing radiation. Besides radiological protection of the workers, members of the public and patients in routine situations, the use of radiation sources involves several aspects associated to the mitigation of radiological or nuclear accidents and associated emergency situations. On the other hand, during the last decade security issues became burning issues due to the potential malevolent uses of radioactive sources for the perpetration of terrorist acts using RDD (Radiological Dispersal Devices), RED (Radiation Exposure Devices) or IND (Improvised Nuclear Devices). A stringent set of international legally and non-legally binding instruments, regulations, conventions and treaties regulate nowadays the use of radioactive sources. In this paper, a review of the radiological protection issues associated to the use of radiation sources in the industrial and medical applications of ionizing radiation is performed. The associated radiation safety issues and the prevention and mitigation of incidents and accidents are discussed. A comprehensive discussion of the security issues associated to the global use of radiation sources for the aforementioned applications and the inherent radiation detection requirements will be presented. Scientific, technical, legal, ethical, socio-economic issues are put forward and discussed. - Highlights: • The hazards associated to the use of radioactive sources must be taken into account. • Security issues are of paramount importance in the use of radioactive sources. • Radiation sources can be used to perpetrate terrorist acts (RDDs, INDs, REDs). • DSRS and orphan sources trigger radiological protection, safety and security concerns. • Regulatory control, from cradle to grave, of radioactive sources is mandatory.

The root cause of patient safety concerns in an Internet pharmacy.

Science.gov (United States)

Montoya, Isaac D

2008-07-01

The Internet has become a revolutionary technology that affords worldwide opportunities never seen before. One such opportunity is the purchase of drugs over the Internet and the business of Internet pharmacies which has become prolific. Associated with this proliferation is the concern for patient safety. Numerous studies have shown that drugs purchased over the Internet come from pharmacies in a country other than the one where the patient resides and these pharmacies are not licensed, sometimes provide drugs without a prescription and that are not of the same composition as they should be, and do not provide adequate directions to the patient. In addition, the packaging of the drugs may be compromised resulting in altered medication. This paper examines the root cause of patient safety issues in Internet pharmacies. A review of the literature including the marketing literature was conducted. Healthcare marketing concepts guide business owners to identify patients' wants and distinguish them from their needs. Marketing principles detail aggressive marketing strategies within an organization's mission and in an ethical manner. Some Internet pharmacies misinterpret proven marketing principles and become overly aggressive in the market place focusing only on sales and profit rather than focusing on patient safety and long-term success of the Internet pharmacy.

ISSUES AND RECENT TRENDS IN VEHICLE SAFETY COMMUNICATION SYSTEMS

Directory of Open Access Journals (Sweden)

Sadayuki TSUGAWA

2005-01-01

Full Text Available This paper surveys the research on the applications of inter-vehicle communications, the issues of the deployment and technology, and the current status of inter-vehicle communications projects in Europe, the United States and Japan. The inter-vehicle communications, defined here as communications between on-board ITS computers, improve road traffic safety and efficiency by expanding the horizon of the drivers and on-board sensors. One of the earliest studies on inter-vehicle communications began in Japan in the early 1980s. The inter-vehicle communications play an essential role in automated platooning and cooperative driving systems developed since the 1990's by enabling vehicles to obtain data that would be difficult or impossible to measure with on-board sensors. During these years, interest in applications for inter-vehicle communications increased in the EU, the US and Japan, resulting in many national vehicle safety communications projects such as CarTALK2000 in the EU and VSCC in the US. The technological issues include protocol and communications media. Experiments employ various kinds of protocols and typically use infrared, microwave or millimeter wave media. The situation is ready for standardization. The deployment strategy is another issue. To be feasible, deployment should begin with multiple rather than single services that would work even at a low penetration rate of the communication equipment. In addition, non-technological, legal and institutional issues remained unsolved. Although inter-vehicle communications involve many issues, such applications should be promoted because they will lead to safer and more efficient automobile traffic.

NS [Nuclear Safety] update. Current safety and security activities and developments taking place in the Department of Nuclear Safety and Security, Issue no. 12, September 2009

International Nuclear Information System (INIS)

2009-09-01

The current issue presents information about the following topics: Nuclear Security Report 2009; G8 Nuclear Safety and Security Group (NSSG); Uranium Production Site Appraisal Team (UPSAT); New Entrant Nuclear Power Programmes Safety Guide on the Establishment of the Safety Infrastructure (DS424)

Patient safety risk assessment and risk management: A review on Indian hospitals

Directory of Open Access Journals (Sweden)

Gaurav Sharma

2011-01-01

Full Text Available This paper is intended to discuss a critical need expressed by present healthcare system of India, and how to provide a better health facility and diluting the medication errors caused by inappropriate management of the hospitals. Adverse events related to medication occur due to pathetic infrastructures, corporal punishment by the patient if unsatisfied, doctors on strike and working only for riches, trivial financial aid, and lack of basic amenities in the government-run hospitals of India. Government should reduce the barriers of awareness, accountability, ability, and action into accelerators of patient safety in the government organizations. Physicians, nurses, and pharmacists are truly the critical ingredient to rapid safety practice adoption. Various approaches like Technological Iatrogenesis, Computerized Provider Order Entry, and Electronic Health Record should be used. Although patient safety is recognized as a serious issue in health system, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.

Specific issues, exact locations: case study of a community mapping project to improve safety in a disadvantaged community.

Science.gov (United States)

Qummouh, Rana; Rose, Vanessa; Hall, Pat

2012-12-01

Safety is a health issue and a significant concern in disadvantaged communities. This paper describes an example of community-initiated action to address perceptions of fear and safety in a suburb in south-west Sydney which led to the development of a local, community-driven research project. As a first step in developing community capacity to take action on issues of safety, a joint resident-agency group implemented a community safety mapping project to identify the extent of safety issues in the community and their exact geographical location. Two aerial maps of the suburb, measuring one metre by two metres, were placed on display at different locations for four months. Residents used coloured stickers to identify specific issues and exact locations where crime and safety were a concern. Residents identified 294 specific safety issues in the suburb, 41.9% (n=123) associated with public infrastructure, such as poor lighting and pathways, and 31.9% (n=94) associated with drug-related issues such as drug activity and discarded syringes. Good health promotion practice reflects community need. In a very practical sense, this project responded to community calls for action by mapping resident knowledge on specific safety issues and exact locations and presenting these maps to local decision makers for further action.

Patient safety culture in Norwegian nursing homes.

Science.gov (United States)

Bondevik, Gunnar Tschudi; Hofoss, Dag; Husebø, Bettina Sandgathe; Deilkås, Ellen Catharina Tveter

2017-06-20

Patient safety culture concerns leader and staff interaction, attitudes, routines, awareness and practices that impinge on the risk of patient-adverse events. Due to their complex multiple diseases, nursing home patients are at particularly high risk of adverse events. Studies have found an association between patient safety culture and the risk of adverse events. This study aimed to investigate safety attitudes among healthcare providers in Norwegian nursing homes, using the Safety Attitudes Questionnaire - Ambulatory Version (SAQ-AV). We studied whether variations in safety attitudes were related to professional background, age, work experience and mother tongue. In February 2016, 463 healthcare providers working in five nursing homes in Tønsberg, Norway, were invited to answer the SAQ-AV, translated and adapted to the Norwegian nursing home setting. Previous validation of the Norwegian SAQ-AV for nursing homes identified five patient safety factors: teamwork climate, safety climate, job satisfaction, working conditions and stress recognition. SPSS v.22 was used for statistical analysis, which included estimations of mean values, standard deviations and multiple linear regressions. P-values safety factors teamwork climate, safety climate, job satisfaction and working conditions. Not being a Norwegian native speaker was associated with a significantly higher mean score for job satisfaction and a significantly lower mean score for stress recognition. Neither professional background nor work experience were significantly associated with mean scores for any patient safety factor. Patient safety factor scores in nursing homes were poorer than previously found in Norwegian general practices, but similar to findings in out-of-hours primary care clinics. Patient safety culture assessment may help nursing home leaders to initiate targeted quality improvement interventions. Further research should investigate associations between patient safety culture and the occurrence

Safety issues and their ranking for WWER-440 model 213 nuclear power plants. A publication of the extrabudgetary programme on the safety of WWER and RBMK nuclear power plants

International Nuclear Information System (INIS)

1996-04-01

The objective of this report is to present a consolidated list of generic safety concerns, called safety issues, ranked according to their safety significance and the corrective measures to improve safety. It is intended for use as a reference to facilitate the development of plant specific safety improvement programmes and to serve as a basis for reviewing their implementation. Section 2 provides and overview of the impact of all relevant issues on the main safety functions and other aspects important to overall plant safety. Section 3 presents safety issues identified in design according to the structure described below. Section 4 presents the safety issues in the area of operation, according to the same structure except that no ranking is given. At the end of Section 2, Tables 1 and 2 present a summary of all safety issues in a tabular form. 138 refs, tabs

Hydrogen peroxide safety issues

International Nuclear Information System (INIS)

Conner, W.V.

1993-01-01

A literature survey was conducted to review the safety issues involved in handling hydrogen peroxide solutions. Most of the information found in the literature is not directly applicable to conditions at the Rocky Flats Plant, but one report describes experimental work conducted previously at Rocky Flats to determine decomposition reaction-rate constants for hydrogen peroxide solutions. Data from this report were used to calculate decomposition half-life times for hydrogen peroxide in solutions containing several decomposition catalysts. The information developed from this survey indicates that hydrogen peroxide will undergo both homogeneous and heterogeneous decomposition. The rate of decomposition is affected by temperature and the presence of catalytic agents. Decomposition of hydrogen peroxide is catalyzed by alkalies, strong acids, platinum group and transition metals, and dissolved salts of transition metals. Depending upon conditions, the consequence of a hydrogen peroxide decomposition can range from slow evolution of oxygen gas to a vapor, phase detonation of hydrogen peroxide vapors

IAEA activities on communication of nuclear safety issues

International Nuclear Information System (INIS)

Wieland, P.

2001-01-01

The regulatory authorities in several countries have taken the initiative to overcome the renowned difficulties of communicating nuclear safety issues. They communicate with segments of the public specially in case of nuclear/radiological accidents, waste disposal, transport of radioactive material or food irradiation. This reflects the full recognition of the importance of the topic. However it is also recognized that there is hitherto a need of international assistance in order to develop a regulatory communication strategy that could be harmonized and at the same time customized to the different needs. Communications on nuclear, radiation, transport and radioactive waste safety are needed to: disseminate information on safety to the public in both routine and emergency situations ; be attentive to public concerns, and address them; maintain social trust and confidence by keeping society informed on the established safety standards and how they are enforced; facilitate the decision-making process on nuclear matters by promptly presenting factual information in a clear manner; integrate and maintain an information network at both the national and international levels; improve co-operation with other countries and international organizations; encourage the dissemination of factual information on nuclear issues in schools. A major factor in addressing all of these questions is understanding the audience(s). A two way communication process is needed to establish what particular audiences want to know and in what form they prefer to receive information. This will differ depending on the audience and circumstances. For example, the information on a routine day-to-day basis will be different from what might be needed at the time of an accident. Communication with the news media is a matter of particular importance, as they are both an audience in themselves and a channel for communicating with wider audiences. (author)

Planning exercise for the resolution of high level waste tank safety issues

International Nuclear Information System (INIS)

Bunting, J.; Saveland, J.

1992-01-01

Several conditions have been found to exist within high level radioactive waste storage tanks at the Hanford site which could lead to uncontrolled exothermic reactions and/or to the release of tank contents into the environment. These conditions have led to the establishment of four priority 1 safety issues for the Hanford tanks. Resolution of these safety issues will require the coordinated efforts of professionals in chemical, nuclear, operations, safety, and other technical areas. A coordinated and integrated approach is necessary in order to achieve resolution in the shortest possible time, while ensuring that the steps taken do not complicate the later jobs of vitrification and ultimate disposal. This paper describes the purpose, process, and results of an effort to develop a suggested approach. (author)

Undergraduate baccalaureate nursing students' self-reported confidence in learning about patient safety in the classroom and clinical settings: an annual cross-sectional study (2010-2013).

Science.gov (United States)

Lukewich, Julia; Edge, Dana S; Tranmer, Joan; Raymond, June; Miron, Jennifer; Ginsburg, Liane; VanDenKerkhof, Elizabeth

2015-05-01

Given the increasing incidence of adverse events and medication errors in healthcare settings, a greater emphasis is being placed on the integration of patient safety competencies into health professional education. Nurses play an important role in preventing and minimizing harm in the healthcare setting. Although patient safety concepts are generally incorporated within many undergraduate nursing programs, the level of students' confidence in learning about patient safety remains unclear. Self-reported patient safety competence has been operationalized as confidence in learning about various dimensions of patient safety. The present study explores nursing students' self-reported confidence in learning about patient safety during their undergraduate baccalaureate nursing program. Cross-sectional study with a nested cohort component conducted annually from 2010 to 2013. Participants were recruited from one Canadian university with a four-year baccalaureate of nursing science program. All students enrolled in the program were eligible to participate. The Health Professional Education in Patient Safety Survey was administered annually. The Health Professional Education in Patient Safety Survey captures how the six dimensions of the Canadian Patient Safety Institute Safety Competencies Framework and broader patient safety issues are addressed in health professional education, as well as respondents' self-reported comfort in speaking up about patient safety issues. In general, nursing students were relatively confident in what they were learning about the clinical dimensions of patient safety, but they were less confident about the sociocultural aspects of patient safety. Confidence in what they were learning in the clinical setting about working in teams, managing adverse events and responding to adverse events declined in upper years. The majority of students did not feel comfortable speaking up about patient safety issues. The nested cohort analysis confirmed these

Simulation research to enhance patient safety and outcomes: recommendations of the Simnovate Patient Safety Domain Group

OpenAIRE

Pucher, PH; Tamblyn, R; Boorman, D; Dixon-Woods, Mary Margaret; Donaldson, L; Draycott, T; Forster, A; Nadkarni, V; Power, C; Sevdalis, N; Aggarwal, R

2017-01-01

The use of simulation-based training has established itself in healthcare but its implementation has been varied and mostly limited to technical and non-technical skills training. This article discusses the possibilities of the use of simulation as part of an overarching approach to improving patient safety, and represents the views of the Simnovate Patient Safety Domain Group, an international multidisciplinary expert group dedicated to the improvement of patient safety. The application and ...

Resolution of Generic Safety Issue 29: Bolting degradation or failure in nuclear power plants

International Nuclear Information System (INIS)

Johnson, R.E.

1990-06-01

This report describes the US Nuclear Regulatory Commission's (NRC's) Generic Safety Issue 29, ''Bolting Degradation or Failure in Nuclear Power Plants,'' including the bases for establishing the issue and its historical highlights. The report also describes the activities of the Atomic Industrial Forum (AIF) relevant to this issue, including its cooperation with the Materials Properties Council (MPC) to organize a task group to help resolve the issue. The Electric Power Research Institute, supported by the AIF/MPC task group, prepared and issued a two-volume document that provides, in part, the technical basis for resolving Generic Safety Issue 29. This report presents the NRC's review and evaluation of the two-volume document and NRC's conclusion that this document, in conjunction with other information from both industry and NRC, provides the bases for resolving this issue

[Analysis of patient complaints in Primary Care: An opportunity to improve clinical safety].

Science.gov (United States)

Añel-Rodríguez, R M; Cambero-Serrano, M I; Irurzun-Zuazabal, E

2015-01-01

To determine the prevalence and type of the clinical safety problems contained in the complaints made by patients and users in Primary Care. An observational, descriptive, cross-sectional study was conducted by analysing both the complaint forms and the responses given to them in the period of one year. At least 4.6% of all claims analysed in this study contained clinical safety problems. The family physician is the professional who received the majority of the complaints (53.6%), and the main reason was the problems related to diagnosis (43%), mainly the delay in diagnosis. Other variables analysed were the severity of adverse events experienced by patients (in 68% of cases the patient suffered some harm), the subsequent impact on patient care, which was affected in 39% of cases (7% of cases even requiring hospital admission), and the level of preventability of adverse events (96% avoidable) described in the claims. Finally the type of response issued to each complaint was analysed, being purely bureaucratic in 64% of all cases. Complaints are a valuable source of information about the deficiencies identified by patients and healthcare users. There is considerable scope for improvement in the analysis and management of claims in general, and those containing clinical safety issues in particular. To date, in our area, there is a lack of appropriate procedures for processing these claims. Likewise, we believe that other pathways or channels should be opened to enable communication by patients and healthcare users. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.

Antipsychotic interventions in prodromal psychosis: safety issues.

Science.gov (United States)

Liu, Chen-Chung; Demjaha, Arsime

2013-03-01

In recent years, psychopharmacological intervention in prodromal psychosis, also known as the ultra-high risk (UHR) mental state for psychosis, has attracted much attention. Whilst it has been shown that antipsychotic use in UHR individuals may be effective in potentially delaying or even averting progression to frank psychosis, their use in subjects that do not necessarily convert to psychosis has raised considerable ethical concerns because of their adverse effects. Recent treatment guidelines for patients at UHR for psychosis recommend the use of antipsychotics only in exceptional conditions and with great precautions. To date only a few studies have investigated the use of antipsychotic medications in UHR patients and the potential benefits and risks related to their use in prodromal psychosis remain unclear. We review here all published studies that included UHR patients treated with antipsychotics, regardless of study design. These studies were all of second-generation antipsychotics, given that first-generation antipsychotics cannot be recommended because of their adverse drug reactions. We specifically examine the available descriptions of adverse reactions of the individual antipsychotic medication in each study and discuss the potential effects of various demographic and clinical factors that may impact on safety issues of pharmacological interventions in UHR patients. Clinical trials to date investigating potential benefits of antipsychotic treatments in preventing transition to psychosis were of relatively short duration and have involved a small number of patients. Whilst it appears that pharmacological intervention at this stage may be effective in both reducing the psychopathology and decreasing transition rates, and is potentially safe, in the absence of sufficient evidence-based knowledge to guide treatment, definitive clinical recommendations and guidelines cannot be derived. Certain adverse events take time to develop, such as metabolic syndrome

Study on operational safety issues in the Japanese disposal concept

International Nuclear Information System (INIS)

Suzuki, Satoru; Kitagawa, Yoshito; Hyodo, Hideaki; Kubota, Shigeru; Iijima, Masayoshi; Tamura, Akio; Ishiguro, Katsuhiko; Fujihara, Hiroshi

2014-01-01

In Japan, vitrified high-level radioactive waste (HLW) and certain types of low-level radioactive waste that results from the reprocessing of spent fuel and classified as TRU waste will be disposed of in deep geological formations. NUMO aims to ensure the safety of local residents and workers during the operational phase and after repository closure and will therefore establish a safety case for the geological disposal programme at the end of each stage of the stepwise siting process. Although the Japanese programme is still in the stage before initiation of the siting process, updating the generic (non-site-specific) safety case is required for building confidence among stakeholders. This study focuses on operational safety issues for the Japanese HLW disposal concept. (authors)

A framework for elaborating a geological disposal safety case: Main issues to be addressed

International Nuclear Information System (INIS)

Besnus, F.; Gay, D.

2002-01-01

International guidance on safety standards for the geological disposal of radioactive waste is being elaborated by IAEA. A comparison of experiences acquired in developing deep repository projects shows that many important issues related to the progressive building of confidence in the safety demonstration of such facilities are commonly addressed by the various organisations involved in radioactive waste management. However, there is still some discrepancies in defining the steps that form the staged elaboration of a safety case. This paper intends to propose a framework for defining the safety case in describing the main issues to be addressed and highlighting questions of consistency between former steps. (author)

[A safety culture in hospitals].

NARCIS (Netherlands)

J.F. Lange (Johan); C.M. Dekker-van Doorn (Connie); M.H.T.M. Haerkens (Mark H. T. M.); J. Klein (Jan)

2011-01-01

textabstractPatient safety is currently a central issue in health care. Many principles of patient safety, such as a safety management system, have been copied from high-risk industries. However, without a fundamental understanding of the differences between health care and industry, most incentives

NS [Nuclear Safety] update. Current safety and security activities and developments taking place in the Department of Nuclear Safety and Security, Issue no. 6, March 2008

International Nuclear Information System (INIS)

2008-03-01

The current issue presents information about the following activities: 1) International Conference on Illicit Nuclear Trafficking which took place in November 2007 in Edinburgh. The principal aim of the conference was to examine the threat and context of illicit nuclear trafficking of radioactive material, specifically, what is being done to combat such trafficking and where more needs to be done. The conference was also to consider how the obligations and commitments of the legally binding and non-binding international instruments could be and are being implemented by various States. 2) INSAG Message on Nuclear Safety Infrastructure in which the INSAG Chairman Richard Meserve addressed nuclear safety in the current context and various issues that warrant special attention. 3) approved for publication the Safety Requirements publication on Safety of Nuclear Fuel Cycle Facilities. 4) The Asian Nuclear Safety Network (ANSN)

From the Harvard Medical Practice Study to the Luxembourg Declaration. Changes in the approach to patient safety. Closing remarks

Directory of Open Access Journals (Sweden)

Gianfranco Damiani

2005-12-01

Full Text Available Since the Harvard Medical Practice Study was published in 1991 the growing mass of international literature has demonstrated that medical adverse events can cause iatrogenic illnesses, prolonged hospitalisations and increased costs. In 1999-2001, reports made by the Institute of Medicine (IOM in the USA, the Department of Health (DoH in the UK and the Australian Patient Safety Foundation (APSF stressed the necessity for creating a safer environment and a reporting culture throughout healthcare systems. They also emphasized the need for researchers to investigate means of turning policies into practice. Since their publication a lot of effort has gone into collecting data on adverse events and near misses. As a result, in 2001, the AHRQ published a Health Technology Assessment report on best practices for patient safety. While in Australia national meetings have been dedicated to address important issues across the whole spectrum of healthcare. In the UK the Audit Commission has published a report that is also focused on medication safety: “A spoonful of sugar”. In 2004 the World Health Organisation promoted a Patient Safety Alliance; while in April 2005the Standing Committee of European Doctors organised a Conference in Luxembourg called “Patient safety - Making it happen!”. The issue of patient safety is therefore seen as a priority by EU institutional bodies and by many European health stakeholders.

Patient safety culture assessment in oman.

Science.gov (United States)

Al-Mandhari, Ahmed; Al-Zakwani, Ibrahim; Al-Kindi, Moosa; Tawilah, Jihane; Dorvlo, Atsu S S; Al-Adawi, Samir

2014-07-01

To illustrate the patient safety culture in Oman as gleaned via 12 indices of patient safety culture derived from the Hospital Survey on Patient Safety Culture (HSPSC) and to compare the average positive response rates in patient safety culture between Oman and the USA, Taiwan, and Lebanon. This was a cross-sectional research study employed to gauge the performance of HSPSC safety indices among health workers representing five secondary and tertiary care hospitals in the northern region of Oman. The participants (n=398) represented different professional designations of hospital staff. Analyses were performed using univariate statistics. The overall average positive response rate for the 12 patient safety culture dimensions of the HSPSC survey in Oman was 58%. The indices from HSPSC that were endorsed the highest included 'organizational learning and continuous improvement' while conversely, 'non-punitive response to errors' was ranked the least. There were no significant differences in average positive response rates between Oman and the United States (58% vs. 61%; p=0.666), Taiwan (58% vs. 64%; p=0.386), and Lebanon (58% vs. 61%; p=0.666). This study provides the first empirical study on patient safety culture in Oman which is similar to those rates reported elsewhere. It highlights the specific strengths and weaknesses which may stem from the specific milieu prevailing in Oman.

Patient Safety Culture Assessment in Oman

Science.gov (United States)

Al-Mandhari, Ahmed; Al-Zakwani, Ibrahim; Al-Kindi, Moosa; Tawilah, Jihane; Dorvlo, Atsu S.S.; Al-Adawi, Samir

2014-01-01

Objective To illustrate the patient safety culture in Oman as gleaned via 12 indices of patient safety culture derived from the Hospital Survey on Patient Safety Culture (HSPSC) and to compare the average positive response rates in patient safety culture between Oman and the USA, Taiwan, and Lebanon. Methods This was a cross-sectional research study employed to gauge the performance of HSPSC safety indices among health workers representing five secondary and tertiary care hospitals in the northern region of Oman. The participants (n=398) represented different professional designations of hospital staff. Analyses were performed using univariate statistics. Results The overall average positive response rate for the 12 patient safety culture dimensions of the HSPSC survey in Oman was 58%. The indices from HSPSC that were endorsed the highest included ‘organizational learning and continuous improvement’ while conversely, ‘non-punitive response to errors’ was ranked the least. There were no significant differences in average positive response rates between Oman and the United States (58% vs. 61%; p=0.666), Taiwan (58% vs. 64%; p=0.386), and Lebanon (58% vs. 61%; p=0.666). Conclusion This study provides the first empirical study on patient safety culture in Oman which is similar to those rates reported elsewhere. It highlights the specific strengths and weaknesses which may stem from the specific milieu prevailing in Oman. PMID:25170407

Global patient safety and antiretroviral drug-drug interactions in the resource-limited setting.

Science.gov (United States)

Seden, Kay; Khoo, Saye H; Back, David; Byakika-Kibwika, Pauline; Lamorde, Mohammed; Ryan, Mairin; Merry, Concepta

2013-01-01

Scale-up of HIV treatment services may have contributed to an increase in functional health facilities available in resource-limited settings and an increase in patient use of facilities and retention in care. As more patients are reached with medicines, monitoring patient safety is increasingly important. Limited data from resource-limited settings suggest that medication error and antiretroviral drug-drug interactions may pose a significant risk to patient safety. Commonly cited causes of medication error in the developed world include the speed and complexity of the medication use cycle combined with inadequate systems and processes. In resource-limited settings, specific factors may contribute, such as inadequate human resources and high disease burden. Management of drug-drug interactions may be complicated by limited access to alternative medicines or laboratory monitoring. Improving patient safety by addressing the issue of antiretroviral drug-drug interactions has the potential not just to improve healthcare for individuals, but also to strengthen health systems and improve vital communication among healthcare providers and with regulatory agencies.

NS [Nuclear Safety] update. Current safety and security activities and developments taking place in the Department of Nuclear Safety and Security, Issue no. 10, March 2009

International Nuclear Information System (INIS)

2009-03-01

The current issue contains information about the following meetings: Application of the Code of Conduct on the Safety of Research Reactors (the 'Code'). Environmental Modelling for Radiation Safety (EMRAS II); Convention on the Safety of Spent Fuel Management and on the Safety of Radioactive Waste Management (the Joint Convention). The document also gives an overview on International Nuclear Security Advisory Service (INSServ)

Communication elements supporting patient safety in psychiatric inpatient care.

Science.gov (United States)

Kanerva, A; Kivinen, T; Lammintakanen, J

2015-06-01

culture is connected with the cultural issues of communication; and being active in information collecting is related to a nurse's personal working style, which affects communication. It is important to pay attention to all the three areas and use this knowledge in developing patient safety practices and strategies where communication aspect and culture are noted and developed. In mental health nursing, it is important to develop processes concerning communication in multidisciplinary teams and across unit boundaries. © 2015 John Wiley & Sons Ltd.

Building patient safety in intensive care nursing : Patient safety culture, team performance and simulation-based training

OpenAIRE

Ballangrud, Randi

2013-01-01

Aim: The overall aim of the thesis was to investigate patient safety culture, team performance and the use of simulation-based team training for building patient safety in intensive care nursing. Methods: Quantitative and qualitative methods were used. In Study I, 220 RNs from ten ICUs responded to a patient safety culture questionnaire analysed with statistics. Studies II-IV were based on an evaluation of a simulation-based team training programme. Studies II-III included 53 RNs from seven I...

The relationship between organizational leadership for safety and learning from patient safety events.

Science.gov (United States)

Ginsburg, Liane R; Chuang, You-Ta; Berta, Whitney Blair; Norton, Peter G; Ng, Peggy; Tregunno, Deborah; Richardson, Julia

2010-06-01

To examine the relationship between organizational leadership for patient safety and five types of learning from patient safety events (PSEs). Forty-nine general acute care hospitals in Ontario, Canada. A nonexperimental design using cross-sectional surveys of hospital patient safety officers (PSOs) and patient care managers (PCMs). PSOs provided data on organization-level learning from (a) minor events, (b) moderate events, (c) major near misses, (d) major event analysis, and (e) major event dissemination/communication. PCMs provided data on organizational leadership (formal and informal) for patient safety. Hospitals were the unit of analysis. Seemingly unrelated regression was used to examine the influence of formal and informal leadership for safety on the five types of learning from PSEs. The interaction between leadership and hospital size was also examined. Formal organizational leadership for patient safety is an important predictor of learning from minor, moderate, and major near-miss events, and major event dissemination. This relationship is significantly stronger for small hospitals (learning from safety events. Formal leadership support for safety is of particular importance in small organizations where the economic burden of safety programs is disproportionately large and formal leadership is closer to the front lines.

Contrast media. Safety issues and ESUR guidelines

Energy Technology Data Exchange (ETDEWEB)

Thomsen, H.S. (ed.) [Copenhagen Univ. Hospital, Herlev (Denmark). Dept. of Diagnostic Radiology 54E2

2006-07-01

In 1994 the European Society of Urogenital Radiology (ESUR) set up a committee to consider the safety of the contrast media used in radiology departments. Since then, the committee has questioned members, reviewed the literature, proposed guidelines, and discussed these proposals with participants at the annual symposia on urogenital radiology. This book represents the end result of this hard work. It contains all of the agreed guidelines, updated when necessary, and thereby comprehensively covers the many different safety issues relating to the diverse contrast media: barium contrast media, iodinated contrast media, MR contrast media (both gadolinium-based extracellular and organ-specific) and ultrasound contrast media. The prevention and treatment of both acute and delayed non-renal adverse reactions as well as the renal adverse reactions are covered in detail. The inclusion of all the ESUR guidelines within one book will offer an invaluable, unique and unparalleled resource. (orig.)

Contrast media. Safety issues and ESUR guidelines

International Nuclear Information System (INIS)

Thomsen, H.S.

2006-01-01

In 1994 the European Society of Urogenital Radiology (ESUR) set up a committee to consider the safety of the contrast media used in radiology departments. Since then, the committee has questioned members, reviewed the literature, proposed guidelines, and discussed these proposals with participants at the annual symposia on urogenital radiology. This book represents the end result of this hard work. It contains all of the agreed guidelines, updated when necessary, and thereby comprehensively covers the many different safety issues relating to the diverse contrast media: barium contrast media, iodinated contrast media, MR contrast media (both gadolinium-based extracellular and organ-specific) and ultrasound contrast media. The prevention and treatment of both acute and delayed non-renal adverse reactions as well as the renal adverse reactions are covered in detail. The inclusion of all the ESUR guidelines within one book will offer an invaluable, unique and unparalleled resource. (orig.)

Addressing the fundamental issues in reliability evaluation of passive safety of AP1000 for a comparison with active safety of PWR

International Nuclear Information System (INIS)

Hashim Muhammad; Yoshikawa, Hidekazu; Yang Ming

2013-01-01

Passive safety systems adopted in advanced Pressurized Water Reactor (PWR), such as AP1000 and EPR, should attain higher reliability than the existing active safety systems of the conventional PWR. The objective of this study is to discuss the fundamental issues relating to the reliability evaluation of AP1000 passive safety systems for a comparison with the active safety systems of conventional PWR, based on several aspects. First, comparisons between conventional PWR and AP1000 are made from the both aspects of safety design and cost reduction. The main differences between these PWR plants exist in the configurations of safety systems: AP1000 employs the passive safety system while reducing the number of active systems. Second, the safety of AP1000 is discussed from the aspect of severe accident prevention in the event of large break loss of coolant accidents (LOCA). Third, detailed fundamental issues on reliability evaluation of AP1000 passive safety systems are discussed qualitatively by using single loop models of safety systems of both PWRs plants. Lastly, methodology to conduct quantitative estimation of dynamic reliability for AP1000 passive safety systems in LOCA condition is discussed, in order to evaluate the reliability of AP1000 in future by a success-path-based reliability analysis method (i.e., GO-FLOW). (author)

Safety issues relating to the design of fusion power facilities

International Nuclear Information System (INIS)

Stasko, R.R.; Wong, K.Y.; Russell, S.B.

1986-06-01

In order to make fusion power a viable future source of energy, it will be necessary to ensure that the cost of power for fusion electric generation is competitive with advanced fission concepts. In addition, fusion power will have to live up to its original promise of being a more radiologically benign technology than fission, and be able to demonstrate excellent operational safety performance. These two requirements are interrelated, since the selection of an appropriate safety philosophy early in the design phase could greatly reduce or eliminate the capital costs of elaborate safety related and protective sytems. This paper will briefly overview a few of the key safety issues presently recognized as critical to the ultimate achievement of licensable, environmentally safe and socially acceptable fusion power facilities. 12 refs

Package leaflets of the most consumed medicines in Portugal: safety and regulatory compliance issues. A descriptive study

Directory of Open Access Journals (Sweden)

Carla Pires

Full Text Available CONTEXT AND OBJECTIVES: Package leaflets are necessary for safe use of medicines. The aims of the present study were: 1 to assess the compliance between the content of the package leaflets and the specifications of the pharmaceutical regulations; and 2 to identify potential safety issues for patients. DESIGN AND SETTING: Qualitative descriptive study, involving all the package leaflets of branded medicines from the three most consumed therapeutic groups in Portugal, analyzed in the Department of Pharmacoepidemiology, School of Pharmacy, University of Lisbon. METHODS: A checklist validated through an expert consensus process was used to gather the data. The content of each package leaflet in the sample was classified as compliant or non-compliant with compulsory regulatory issues (i.e. stated dosage and descriptions of adverse reactions and optional regulatory issues (i.e. adverse reaction frequency, symptoms and procedures in cases of overdose. RESULTS: A total of 651 package leaflets were identified. Overall, the package leaflets were found to be compliant with the compulsory regulatory issues. However, the optional regulatory issues were only addressed in around half of the sample of package leaflets, which made it possible to identify some situations of potentially compromised drug safety. CONCLUSION: Ideally, the methodologies for package leaflet approval should be reviewed and optimized as a way of ensuring the inclusion of the minimum essential information for safe use of medicines.

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

Science.gov (United States)

Heget, Jeffrey R; Bagian, James P; Lee, Caryl Z; Gosbee, John W

2002-12-01

In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

Japan's regulatory and safety issues regarding nuclear materials transport

International Nuclear Information System (INIS)

Saito, T.; Yamanaka, T.

2004-01-01

This paper focuses on the regulatory and safety issues on nuclear materials transport which the Government of Japan (GOJ) faces and needs to well handle. Background information about the status of nuclear power plants (NPP) and nuclear fuel cycle (NFC) facilities in Japan will promote a better understanding of what this paper addresses

Campus Safety and Student Privacy Issues in Higher Education

Science.gov (United States)

Burnett, Kristen Slater

2010-01-01

The purpose of this study is to delve into, and further understand, the perceptions of higher education administrators when they experience having to simultaneously balance the issues of campus safety and student privacy. The research surveyed approximately 900 (with 147 returns) administrators who self-identified as having a role in incidents of…

Involving patients in patient safety programmes: A scoping review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

NARCIS (Netherlands)

Trier, H.; Valderas, J.M.; Wensing, M.; Martin, H.M.; Egebart, J.

2015-01-01

BACKGROUND: Patient involvement has only recently received attention as a potentially useful approach to patient safety in primary care. OBJECTIVE: To summarize work conducted on a scoping review of interventions focussing on patient involvement for patient safety; to develop consensus-based

Assessment of policy issues in nuclear safety regulation according to circumstantial changes

Energy Technology Data Exchange (ETDEWEB)

Chang, Soon Heung; Lee, Byong Ho; Baek, Won Pil; Lee, Kwang Gu; Huh, Gyun Young; Hahn, Young Tae [Korea Advanced Institute of Science and Technology, Taejon (Korea, Republic of)

2000-03-15

The objective of the work is to assess various issues in nuclear safety regulation in consideration of circumstantial changes. Emphasis is given to the safety of operating NPPs. It is concluded that the Periodic Safety Review (PSR) should be implemented in Korea as soon as possible, in harmonization with the regulation for life extension of NPPs. The IAEA guidelines, including 10 year intervals and 11 safety factors, should be used as the basic guidelines. The approach to improve regulatory effectiveness is also reviewed and a transition to 'knowledge-based regulation' is suggested.

Assessment of policy issues in nuclear safety regulation according to circumstantial changes

Energy Technology Data Exchange (ETDEWEB)

Chang, Soon Heung; Chang, Soon Heung; Lee, Byong Ho; Baek, Won Pil; Roh, Chang Hyun; Lee, Kwang Gu; Kim, Hong Chae; Lee, Yong Ho [Korea Advanced Institute of Science and Technology, Taejon (Korea, Republic of)

1999-03-15

The objective of the work is to assess various issues in nuclear safety regulation in consideration of circumstantial changes. Emphasis is given to the safety of operating NPPs. It is concluded that the Periodic Safety Review (PSR) should be implemented in Korea as soon as possible, in harmonization with the regulation for life extension of NPPs. The IAEA guidelines, including 10 year intervals and 11 safety factors, should be used as the basic guidelines. Efforts are also required to cope with other circumstantial changes such as the establishment of International Nuclear Regulators Association (INRA)

Implementing Patient Safety Initiatives in Rural Hospitals

Science.gov (United States)

Klingner, Jill; Moscovice, Ira; Tupper, Judith; Coburn, Andrew; Wakefield, Mary

2009-01-01

Implementation of patient safety initiatives can be costly in time and energy. Because of small volumes and limited resources, rural hospitals often are not included in nationally driven patient safety initiatives. This article describes the Tennessee Rural Hospital Patient Safety Demonstration project, whose goal was to strengthen capacity for…

An analysis of electronic health record-related patient safety concerns

Science.gov (United States)

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

2014-01-01

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

Positioning Continuing Education: Boundaries and Intersections between the Domains Continuing Education, Knowledge Translation, Patient Safety and Quality Improvement

Science.gov (United States)

Kitto, Simon; Bell, Mary; Peller, Jennifer; Sargeant, Joan; Etchells, Edward; Reeves, Scott; Silver, Ivan

2013-01-01

Public and professional concern about health care quality, safety and efficiency is growing. Continuing education, knowledge translation, patient safety and quality improvement have made concerted efforts to address these issues. However, a coordinated and integrated effort across these domains is lacking. This article explores and discusses the…

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

Energy Technology Data Exchange (ETDEWEB)

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

2016-11-01

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

Eminent radiological safety issues confronting the State of Hawaii

International Nuclear Information System (INIS)

Hashimoto, H.H.

1984-01-01

The State of Hawaii currently has over one hundred radioactive material use licenses. Nuclear Regulatory Commission licenses are primarily held by hospitals, industrial radiographers, and academic institutions. Complementing this, the State Department of Health regulates x-ray machines, radium, and has an emergency response role for accidents involving radioactive materials. The existing radiation protection program was created by piecemeal legislation. As a result, regulatory surveillance and actual control vary widely among the agencies. The State Legislature, in 1980, decided that action must be taken to set a clear state policy towards the use and disposal of nuclear materials. It was therefore recommended that the State of Hawaii Radiation Safety Advisory Committee be convened to assist the state in the evaluation of the issues. This report contains issue papers on radiation related topics addressed by the Radiation Safety Advisory Committe. Topics discussed include transportation, environmental monitoring, emergency response, and waste disposal. A survey of various radioactive sources identified medical applications as a category requiring stricter control. Selected chapters of the Hawaii Revised Statutes are also examined

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

Directory of Open Access Journals (Sweden)

Afrisya Iriviranty

2016-07-01

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

Food safety measurement issues. Way forward

International Nuclear Information System (INIS)

Venkatesh Iyengar

2013-01-01

Ensuring food safety (FS) is a persistent concern frequently faced by many countries. Safeguarding the quality of food that is fit for human consumption is the primary responsibility of the governmental regulatory agencies. For most part, agro-industries and food processors assume voluntary leadership for producing safe food. However, in the event of FS breach, the regulatory responsibility kicks into identify and rectify the situation. Notwithstanding whether it is the regulator or the industry that institutes the remedial action (e.g. improved hygiene and refined agricultural and manufacturing practices), the role of laboratory measurements is central in safeguarding the integrity of a functioning FS system. There are many analytical tools available to implement this task, such as validated analytical methods, natural matrix reference materials, field tested monitoring systems (proactive assessment) and effective surveillance systems (constant vigilance to prevent repeat safety violations). Way forward: existing FS tools are insufficient and should be strengthened with innovative approaches. Examples are: assembling swift intervention logistics to face FS breaches; rapid response systems including communication; robust metrology based measurement systems located at strategic locations in the country; and inter-disciplinary human resource to match the need for capacity development. These issues are discussed. (author)

Identification of unresolved safety issues relating to nuclear power plants. Report to Congress

International Nuclear Information System (INIS)

1979-01-01

The report describes the review undertaken over the last year that resulted in identifying 17 issues as Unresolved Safety Issues. In addition, the report provides specific discussions of why certain issues were not included. The report also provides a brief background discussion describing Section 210 of the Energy Reorganization Act and the NRC program for the resolution of generic issues described in NUREG-0410

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

Science.gov (United States)

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

2014-10-01

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

Managing patient safety through NPSGs and employee performance.

Science.gov (United States)

Adair, Liberty

2010-01-01

Patient safety can only exist in a culture of patient safety, which implies it is a value perceived by all. Culture predicts safety outcomes and leadership predicts the culture. Leaders are obligated to continually mitigate hazard and take action consciously. Healthcare workers should focus on preventing and reporting mistakes with the National Patient Safety Goals (NPSGs) in mind. These include: accuracy of patient identification, effectiveness of communication among caregivers, improving safety of medications, reducing infections, reducing risk of falls, and encouraging patients to be involved in care. Poor performers and reckless behavior need to be mitigated. If employees recognize their roles in the process, feel empowered,and have appropriate tools, resources,and data to implement solutions, errors can be avoided and patient safety becomes paramount.

Fixing broken bones and broken homes: domestic violence as a patient safety issue.

Science.gov (United States)

Cohn, Felicia; Rudman, William J

2004-11-01

Domestic violence (DV) is a significant problem in terms of both patient harm and cost. To better address this problem, the diagnosis and treatment of DV are considered within the emerging model of patient safety and medical error reduction. The case of a female patient who presents in the clinical setting following an incident of DV shows how medical errors can be analyzed as they are in medical cases not involving DV, such as when a person with abdominal pain is sent away from the emergency department with instructions to take an acid reducer and later suffers a burst appendix. A number of factors inhibit the correct diagnosis and treatment of DV victims seeking additional treatment. Physicians often fail to screen for DV, misidentify symptoms, or deny the possibility of underlying DV, and patients often hide the symptoms and refuse to admit the problem. However, human factor errors related to knowledge, cultural norms, and individual biases; organizational factors, including lack of training and reimbursement; and technology factors related to information accessibility appear to play significant roles. Failure to diagnose or adequately address DV can be interpreted as medical errors. Addressing DV requires a systemic response, which might begin with integrating education and training about DV into the clinical setting, ensuring the use of existing screening tools, and providing adequate and appropriate reimbursement levels.

Materials-related issues in the safety and licensing of nuclear fusion facilities

Science.gov (United States)

Taylor, N.; Merrill, B.; Cadwallader, L.; Di Pace, L.; El-Guebaly, L.; Humrickhouse, P.; Panayotov, D.; Pinna, T.; Porfiri, M.-T.; Reyes, S.; Shimada, M.; Willms, S.

2017-09-01

Fusion power holds the promise of electricity production with a high degree of safety and low environmental impact. Favourable characteristics of fusion as an energy source provide the potential for this very good safety and environmental performance. But to fully realize the potential, attention must be paid in the design of a demonstration fusion power plant (DEMO) or a commercial power plant to minimize the radiological hazards. These hazards arise principally from the inventory of tritium and from materials that become activated by neutrons from the plasma. The confinement of these radioactive substances, and prevention of radiation exposure, are the primary goals of the safety approach for fusion, in order to minimize the potential for harm to personnel, the public, and the environment. The safety functions that are implemented in the design to achieve these goals are dependent on the performance of a range of materials. Degradation of the properties of materials can lead to challenges to key safety functions such as confinement. In this paper the principal types of material that have some role in safety are recalled. These either represent a potential source of hazard or contribute to the amelioration of hazards; in each case the related issues are reviewed. The resolution of these issues lead, in some instances, to requirements on materials specifications or to limits on their performance.

The use of information technology to enhance patient safety and nursing efficiency.

Science.gov (United States)

Lee, Tso-Ying; Sun, Gi-Tseng; Kou, Li-Tseng; Yeh, Mei-Ling

2017-10-23

Issues in patient safety and nursing efficiency have long been of concern. Advancing the role of nursing informatics is seen as the best way to address this. The aim of this study was to determine if the use, outcomes and satisfaction with a nursing information system (NIS) improved patient safety and the quality of nursing care in a hospital in Taiwan. This study adopts a quasi-experimental design. Nurses and patients were surveyed by questionnaire and data retrieval before and after the implementation of NIS in terms of blood drawing, nursing process, drug administration, bar code scanning, shift handover, and information and communication integration. Physiologic values were easier to read and interpret; it took less time to complete electronic records (3.7 vs. 9.1 min); the number of errors in drug administration was reduced (0.08% vs. 0.39%); bar codes reduced the number of errors in blood drawing (0 vs. 10) and transportation of specimens (0 vs. 0.42%); satisfaction with electronic shift handover increased significantly; there was a reduction in nursing turnover (14.9% vs. 16%); patient satisfaction increased significantly (3.46 vs. 3.34). Introduction of NIS improved patient safety and nursing efficiency and increased nurse and patient satisfaction. Medical organizations must continually improve the nursing information system if they are to provide patients with high quality service in a competitive environment.

Safety performance indicators. Topical issues paper no. 5

International Nuclear Information System (INIS)

Dahlgren, K.; Lederman, L.; Szikszai, T.; Palomo, J.

2001-01-01

performance, they are just one of a larger set of tools including probabilistic safety assessment (PSA), regulatory inspection, quality assurance, external reviews and self-assessment needed to assess operational safety performance. The integration of information compiled from such evaluation tools yields the best results. Two areas of increasingly common interest are 'risk based' indicators, and 'safety culture' indicators. The key to managing the nuclear business today is to establish a high quality safety management system as well as developing a strong safety culture within the entire organization. 'The safety management system comprises those arrangements made by the organization for the management of safety in order to promote a strong safety culture and achieve good safety performance'. This definition, presented in INSAG-13, illustrates the close connection between 'safety management systems' and 'safety culture' and that they are in fact inseparable. To manage safety effectively you need a systematic approach and at the same time be aware of the effects of the approach on individual and collective human behaviour. This issue covers the following: development of safety performance indicators, indicator selection and use, recommended indicators, indicators collected from nuclear power plant initiatives, management of safety and safety culture, need and feasibility of an international system, plant management needs, regulatory use of safety performance indicators, public communication, and recommendations for priorities in future work

Patient-Centered Robot-Aided Passive Neurorehabilitation Exercise Based on Safety-Motion Decision-Making Mechanism

Directory of Open Access Journals (Sweden)

Lizheng Pan

2017-01-01

Full Text Available Safety is one of the crucial issues for robot-aided neurorehabilitation exercise. When it comes to the passive rehabilitation training for stroke patients, the existing control strategies are usually just based on position control to carry out the training, and the patient is out of the controller. However, to some extent, the patient should be taken as a “cooperator” of the training activity, and the movement speed and range of the training movement should be dynamically regulated according to the internal or external state of the subject, just as what the therapist does in clinical therapy. This research presents a novel motion control strategy for patient-centered robot-aided passive neurorehabilitation exercise from the point of the safety. The safety-motion decision-making mechanism is developed to online observe and assess the physical state of training impaired-limb and motion performances and regulate the training parameters (motion speed and training rage, ensuring the safety of the supplied rehabilitation exercise. Meanwhile, position-based impedance control is employed to realize the trajectory tracking motion with interactive compliance. Functional experiments and clinical experiments are investigated with a healthy adult and four recruited stroke patients, respectively. The two types of experimental results demonstrate that the suggested control strategy not only serves with safety-motion training but also presents rehabilitation efficacy.

78 FR 17212 - Patient Safety Organizations: Voluntary Relinquishment From Universal Safety Solution PSO

Science.gov (United States)

2013-03-20

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26, provides for the...

The Danish patient safety experience: the Act on Patient Safety in the Danish Health care system

DEFF Research Database (Denmark)

Lundgaard, Mette; Rabøl, Louise; Jensen, Elisabeth Agnete Brøgger

2005-01-01

This paper describes the process that lead to the passing of the Act for Patient Safety in the Danisk health care sytem, the contents of the act and how the act is used in the Danish health care system. The act obligates frontline health care personnel to report adverse events, hospital owners...... to act on the reports and the National Board of Health to commuicate the learning nationally. The act protects health care providers from sanctions as a result of reporting. In January 2004, the Act on Patient Safety in the Danish health care system was put into force. In the first twelve months 5740...... adverse events were reported. the reports were analyzed locally (hospital and region), anonymized ad then sent to the National Board af Health. The Act on Patient Safety has driven the work with patient safety forward but there is room for improvement. Continuous and improved feedback from all parts...

Health Sector Reform in the Kurdistan Region - Iraq: Financing Reform, Primary Care, and Patient Safety.

Science.gov (United States)

Anthony, C Ross; Moore, Melinda; Hilborne, Lee H; Mulcahy, Andrew W

2014-12-30

In 2010, the Kurdistan Regional Government asked the RAND Corporation to help guide reform of the health care system in the Kurdistan Region of Iraq. The overarching goal of reform was to help establish a health system that would provide high-quality services efficiently to everyone to prevent, treat, and manage physical and mental illnesses and injuries. This article summarizes the second phase of RAND's work, when researchers analyzed three distinct but intertwined health policy issue areas: development of financing policy, implementation of early primary care recommendations, and evaluation of quality and patient safety. For health financing, the researchers reviewed the relevant literature, explored the issue in discussions with key stakeholders, developed and assessed various policy options, and developed plans or approaches to overcome barriers and achieve stated policy objectives. In the area of primary care, they developed and helped to implement a new management information system. In the area of quality and patient safety, they reviewed relevant literature, discussed issues and options with health leaders, and recommended an approach toward incremental implementation.

Patients' evaluations of patient safety in English general practices: a cross-sectional study.

Science.gov (United States)

Ricci-Cabello, Ignacio; Marsden, Kate S; Avery, Anthony J; Bell, Brian G; Kadam, Umesh T; Reeves, David; Slight, Sarah P; Perryman, Katherine; Barnett, Jane; Litchfield, Ian; Thomas, Sally; Campbell, Stephen M; Doos, Lucy; Esmail, Aneez; Valderas, Jose M

2017-07-01

Description of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients. To examine patient-reported experiences and outcomes of patient safety in primary care. Cross-sectional study in 45 general practices across five regions in the north, centre, and south of England. A version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included 'practice activation' (what a practice does to create a safe environment); 'patient activation' (how proactive are patients in ensuring safe healthcare delivery); 'experiences of safety events' (safety errors); 'outcomes of safety' (harm); and 'overall perception of safety' (how safe patients rate their practice). Questionnaires were returned by 1244 patients (18.4%). Scores were high for 'practice activation' (mean [standard error] = 80.4 out of 100 [2.0]) and low for 'patient activation' (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]). Priority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation. © British Journal of General Practice 2017.

Review of EU-APR Design for Selected Safety Issues of WERNA RHWG 2013

Energy Technology Data Exchange (ETDEWEB)

Kim, Yong Soo; Kim, Ji Hwan [KHNP CRI, Daejeon (Korea, Republic of)

2016-10-15

Western European Nuclear Regulators' Association (WENRA) was established in 1999 to develop a harmonized approach to nuclear safety and radiation protection and their regulation. In 2013, the Reactor Harmonization Working Group (RHWG) of WENRA sets out the common positions on the seven selected key safety issues. This paper is to introduce the regulatory positions of WENRA RHWG 2013 and to review the compliance of the EU-APR with them. In this paper, we reviewed the compliance of the EUAPR regarding seven safety issues for new NPPs presented by WERNA RHWG in 2013. The EU-APR design fully complies with all WERNA RHWG safety issues since the following measures have been incorporated in it: - Successive five levels of DiD maintaining independence between different levels of DiD - Diverse design against multiple failure events such as ATWS, SBO, Loss of Ultimate Heat Sink, and Loss of Spent Fuel Pool Cooling - SAs dedicated mitigation systems to ensure the containment integrity during the SAs. - Practically eliminates accident sequences with a large or early release of radiological materials by diverse designs for multiple failure events, SAs dedicated mitigation system, and double containment design - Standard site parameters not lead to core melt accidents due to natural or man-made external hazards.

Implementation of Safety and Security Issues in the Transport of Radioactive Material in Argentina

International Nuclear Information System (INIS)

López Vietri, J.; Elechosa, C.; Gerez Miranda, C.; Menossi, S.; Rodríguez Roldán, M.S.; Fernández, A.

2016-01-01

This paper is intended to describe implementation of safety and security issues in the transport of radioactive material by the Nuclear Regulatory Authority (in Spanish Autoridad Regulatoria Nuclear, ARN), which is the Competent Authority of Argentina in Safety, Security and Safeguards of radioactive and nuclear material. There are depicted main regulatory activities dealing with the mentioned issues, and relevant milestones of national regulatory standards and guidance applied, that are based on requirements and guides from IAEA. Interfaces between Safety and Security sections are most of the times complementary but sometimes conflictive, therefore the resolution of such conflicts and goals achieved during their implementation are also commented; as well as future joint planned activities between both sections of ARN as a way to provide safety and security without compromising one or the other. (author)

RBMK safety issues

International Nuclear Information System (INIS)

Weber, J.P.; Reichenbach, D.; Tscherkashow, J.M.

1995-01-01

On the basis of information and documents from the RBMK operation countries, the Western consortium mainly examined the two most modern plants, Ignalin-2 and Smolensk-3. The identification of numerous shortcomings, some of which had already been recongized by the participating Eastern organizations, resulted in some 300 specific recommendations to reactor designers, operators and licensing authorities. These recommendations are to be acted upon at once; only a small number did not meet with the approval of the Eastern partners. The safety review provided the Western consotrium with a profound insight into the design and safety of third-generation RBMK reactors; the Eastern partners were able to accumulate experience in working with Western safety philosophy. (orig.) [de

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M.; Wensing, Michel; Esmail, Aneez

2015-01-01

ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement. PMID:26339841

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care.

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M; Wensing, Michel; Esmail, Aneez

2015-09-01

Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. To outline a research agenda for patient safety improvement in primary care in Europe and beyond. The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

Applying importance-performance analysis to patient safety culture.

Science.gov (United States)

Lee, Yii-Ching; Wu, Hsin-Hung; Hsieh, Wan-Lin; Weng, Shao-Jen; Hsieh, Liang-Po; Huang, Chih-Hsuan

2015-01-01

The Sexton et al.'s (2006) safety attitudes questionnaire (SAQ) has been widely used to assess staff's attitudes towards patient safety in healthcare organizations. However, to date there have been few studies that discuss the perceptions of patient safety both from hospital staff and upper management. The purpose of this paper is to improve and to develop better strategies regarding patient safety in healthcare organizations. The Chinese version of SAQ based on the Taiwan Joint Commission on Hospital Accreditation is used to evaluate the perceptions of hospital staff. The current study then lies in applying importance-performance analysis technique to identify the major strengths and weaknesses of the safety culture. The results show that teamwork climate, safety climate, job satisfaction, stress recognition and working conditions are major strengths and should be maintained in order to provide a better patient safety culture. On the contrary, perceptions of management and hospital handoffs and transitions are important weaknesses and should be improved immediately. Research limitations/implications - The research is restricted in generalizability. The assessment of hospital staff in patient safety culture is physicians and registered nurses. It would be interesting to further evaluate other staff's (e.g. technicians, pharmacists and others) opinions regarding patient safety culture in the hospital. Few studies have clearly evaluated the perceptions of healthcare organization management regarding patient safety culture. Healthcare managers enable to take more effective actions to improve the level of patient safety by investigating key characteristics (either strengths or weaknesses) that healthcare organizations should focus on.

Emotional influences in patient safety.

Science.gov (United States)

Croskerry, Pat; Abbass, Allan; Wu, Albert W

2010-12-01

The way that health care providers feel, both within themselves and toward their patients, may influence their clinical performance and impact patient safety, yet this aspect of provider behavior has received relatively little attention. How providers feel, their emotional or affective state, may exert a significant, unintended influence on their patients, and may compromise safety. We examined a broad literature across multiple disciplines to review the interrelationships between emotion, decision making, and behavior, and to assess their potential impact on patient safety. There is abundant evidence that the emotional state of the health care provider may be influenced by factors including characteristics of the patient, ambient conditions in the health care setting, diurnal, circadian, infradian, and seasonal variables, as well as endogenous disorders of the individual provider. These influences may lead to affective biases in decision making, resulting in errors and adverse events. Clinical reasoning and judgment may be particularly susceptible to emotional influence, especially those processes that rely on intuitive judgments. There are many ways that the emotional state of the health care provider can influence patient care. To reduce emotional errors, the level of awareness of these factors should be raised. Emotional skills training should be incorporated into the education of health care professionals. Specifically, clinical teaching should promote more openness and discussion about the provider's feelings toward patients. Strategies should be developed to help providers identify and de-bias themselves against emotional influences that may impact care, particularly in the emotionally evocative patient. Psychiatric conditions within the provider, which may compromise patient safety, need to be promptly detected, diagnosed, and managed.

Generic safety issues for nuclear power plants with pressurized heavy water reactors and measures for their resolution

International Nuclear Information System (INIS)

2007-06-01

The IAEA Conference on The Safety of Nuclear Power: Strategy for the Future in 1991 was a milestone in nuclear safety. The objective of this conference was to review nuclear power safety issues for which achieving international consensus would be desirable, to address concerns on nuclear safety and to formulate recommendations for future actions by national and international authorities to advance nuclear safety to the highest level. Two of the important items addressed by this conference were ensuring and enhancing safety of operating plants and treatment of nuclear power plants built to earlier safety standards. Publications related to these two items, that have been issued subsequent to this conference, include: A Common Basis for Judging the Safety of Nuclear Power Plants Built to Earlier Standards, INSAG-8 (1995), the IAEA Safety Guide 50-SG-O12, Periodic Safety Review of Operational Nuclear Power Plants (1994) and an IAEA publication on the Safety Evaluation of Operating Nuclear Power Plants Built to Earlier Standards - A Common Basis for Judgement (1997). Some of the findings of the 1991 conference have not yet been fully addressed. An IAEA Symposium on Reviewing the Safety of Existing Nuclear Power Plants in 1996 showed that there is an urgent need for operating organizations and national authorities to review operating nuclear power plants which do not meet the high safety levels of the vast majority of plants and to undertake improvements, with assistance from the international community if required. Safety reviews of operating nuclear power plants take on added importance in the context of the Convention on Nuclear Safety and its implementation. To perform safety reviews and to reassess the safety of operating nuclear power plants in a uniform manner, it is imperative to have an internationally accepted reference. Existing guidance needs to be complemented by a list of safety issues which have been encountered and resolved in other plants and which can

A review of patient safety measures based on routinely collected hospital data.

Science.gov (United States)

Tsang, Carmen; Palmer, William; Bottle, Alex; Majeed, Azeem; Aylin, Paul

2012-01-01

The literature on patient safety measures derived from routinely collected hospital data was reviewed to inform indicator development. MEDLINE and Embase databases and Web sites were searched. Of 1738 citations, 124 studies describing the application, evaluation, or validation of hospital-based medical error or complication of care measures were reviewed. Studies were frequently conducted in the United States (n = 88) between 2005 and 2009 (n = 77) using Agency for Healthcare Research and Quality patient safety indicators (PSIs; n = 79). The most frequently cited indicators included "postoperative hemorrhage or hematoma" and "accidental puncture and laceration." Indicator refinement is supported by international coding algorithm translations but is hampered by data issues, including coding inconsistencies. The validity of PSIs and similar adverse event screens beyond internal measurement and the effects of organizational factors on patient harm remain uncertain. Development of PSIs in ambulatory care settings, including general practice and psychiatric care, needs consideration.

Medical students' situational motivation to participate in simulation based team training is predicted by attitudes to patient safety.

Science.gov (United States)

Escher, Cecilia; Creutzfeldt, Johan; Meurling, Lisbet; Hedman, Leif; Kjellin, Ann; Felländer-Tsai, Li

2017-02-10

Patient safety education, as well as the safety climate at clinical rotations, has an impact on students' attitudes. We explored medical students' self-reported motivation to participate in simulation-based teamwork training (SBTT), with the hypothesis that high scores in patient safety attitudes would promote motivation to SBTT and that intrinsic motivation would increase after training. In a prospective cohort study we explored Swedish medical students' attitudes to patient safety, their motivation to participate in SBTT and how motivation was affected by the training. The setting was an integrated SBTT course during the surgical semester that focused on non-technical skills and safe treatment of surgical emergencies. Data was collected using the Situational Motivation Scale (SIMS) and the Attitudes to Patient Safety Questionnaire (APSQ). We found a positive correlation between students' individual patient safety attitudes and self-reported motivation (identified regulation) to participate in SBTT. We also found that intrinsic motivation increased after training. Female students in our study scored higher than males regarding some of the APSQ sub-scores and the entire group scored higher or on par with comparable international samples. In order to enable safe practice and professionalism in healthcare, students' engagement in patient safety education is important. Our finding that students' patient safety attitudes show a positive correlation to motivation and that intrinsic motivation increases after training underpins patient safety climate and integrated teaching of patient safety issues at medical schools in order to help students develop the knowledge, skills and attitudes required for safe practice.

Culture matters: indigenizing patient safety in Bhutan.

Science.gov (United States)

Pelzang, Rinchen; Johnstone, Megan-Jane; Hutchinson, Alison M

2017-09-01

Studies show that if quality of healthcare in a country is to be achieved, due consideration must be given to the importance of the core cultural values as a critical factor in improving patient safety outcomes. The influence of Bhutan's traditional (core) cultural values on the attitudes and behaviours of healthcare professionals regarding patient care are not known. This study aimed to explore the possible influence of Bhutan's traditional cultural values on staff attitudes towards patient safety and quality care. Undertaken as a qualitative exploratory descriptive inquiry, a purposeful sample of 94 healthcare professionals and managers were recruited from three levels of hospitals, a training institute and the Ministry of Health. Interviews were transcribed verbatim and analysed using thematic analysis strategies. The findings of the study suggest that Bhutanese traditional cultural values have both productive and counterproductive influences on staff attitudes towards healthcare delivery and the processes that need to be in place to ensure patient safety. Productive influences encompassed: karmic incentives to avoid preventable harm and promote safe patient care; and the prospective adoption of the 'four harmonious friends' as a culturally meaningful frame for improving understanding of the role and importance of teamwork in enhancing patient safety. Counterproductive influences included: the adoption of hierarchical and authoritative styles of management; unilateral decision-making; the legitimization of karmic beliefs; differential treatment of patients; and preferences for traditional healing practices and rituals. Although problematic in some areas, Bhutan's traditional cultural values could be used positively to inform and frame an effective model for improving patient safety in Bhutan's hospitals. Such a model must entail the institution of an 'indigenized' patient safety program, with patient safety research and reporting systems framed around local

76 FR 7855 - Patient Safety Organizations: Voluntary Delisting From Community Medical Foundation for Patient...

Science.gov (United States)

2011-02-11

... Organizations: Voluntary Delisting From Community Medical Foundation for Patient Safety AGENCY: Agency for... Medical Foundation for Patient Safety, of its status as a Patient Safety Organization (PSO). The Patient... notification from Community Medical Foundation for Patient Safety, PSO number P0029, to voluntarily relinquish...

Modeling issues associated with production reactor safety assessment

International Nuclear Information System (INIS)

Stack, D.W.; Thomas, W.R.

1990-01-01

This paper describes several Probabilistic Safety Assessment (PSA) modeling issues that are related to the unique design and operation of the production reactors. The identification of initiating events and determination of a set of success criteria for the production reactors is of concern because of their unique design. The modeling of accident recovery must take into account the unique operation of these reactors. Finally, a more thorough search and evaluation of common-cause events is required to account for combinations of unique design features and operation that might otherwise not be included in the PSA. It is expected that most of these modeling issues also would be encountered when modeling some of the other more unique reactor and nonreactor facilities that are part of the DOE nuclear materials production complex. 9 refs., 2 figs

Research on patient safety: falls and medications.

Science.gov (United States)