WorldWideScience

Sample records for patient safety reporting

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

    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

  2. Knowledge Representation in Patient Safety Reporting: An Ontological Approach

    Liang Chen; Yang Gong

    2016-01-01

    Purpose: The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach: We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our desig...

  3. The complexity of patient safety reporting systems in UK dentistry.

    Renton, T; Master, S

    2016-10-21

    Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

  4. Knowledge Representation in Patient Safety Reporting: An Ontological Approach

    Liang Chen

    2016-10-01

    Full Text Available Purpose: The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach: We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our design, implementation, and evaluation of the ontology at its initial stage. Findings: We describe the design and initial outcomes of the ontology implementation. The evaluation results demonstrate the clinical validity of the ontology by a self-developed survey measurement. Research limitations: The proposed ontology was developed and evaluated using a small number of information sources. Presently, US data are used, but they are not essential for the ultimate structure of the ontology. Practical implications: The goal of improving patient safety can be aided through investigating patient safety reports and providing actionable knowledge to clinical practitioners. As such, constructing a domain specific ontology for patient safety reports serves as a cornerstone in information collection and text mining methods. Originality/value: The use of ontologies provides abstracted representation of semantic information and enables a wealth of applications in a reporting system. Therefore, constructing such a knowledge base is recognized as a high priority in health care.

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

    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.

  6. Patient-Reported Safety Information: A Renaissance of Pharmacovigilance?

    Härmark, Linda; Raine, June; Leufkens, Hubert; Edwards, I Ralph; Moretti, Ugo; Sarinic, Viola Macolic; Kant, Agnes

    2016-10-01

    The role of patients as key contributors in pharmacovigilance was acknowledged in the new EU pharmacovigilance legislation. This contains several efforts to increase the involvement of the general public, including making patient adverse drug reaction (ADR) reporting systems mandatory. Three years have passed since the legislation was introduced and the key question is: does pharmacovigilance yet make optimal use of patient-reported safety information? Independent research has shown beyond doubt that patients make an important contribution to pharmacovigilance signal detection. Patient reports provide first-hand information about the suspected ADR and the circumstances under which it occurred, including medication errors, quality failures, and 'near misses'. Patient-reported safety information leads to a better understanding of the patient's experiences of the ADR. Patients are better at explaining the nature, personal significance and consequences of ADRs than healthcare professionals' reports on similar associations and they give more detailed information regarding quality of life including psychological effects and effects on everyday tasks. Current methods used in pharmacovigilance need to optimise use of the information reported from patients. To make the most of information from patients, the systems we use for collecting, coding and recording patient-reported information and the methodologies applied for signal detection and assessment need to be further developed, such as a patient-specific form, development of a severity grading and evolution of the database structure and the signal detection methods applied. It is time for a renaissance of pharmacovigilance.

  7. Improving patient safety in radiotherapy through error reporting and analysis

    Findlay, Ú.; Best, H.; Ottrey, M.

    2016-01-01

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

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

    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.

  9. Can patients report patient safety incidents in a hospital setting? A systematic review.

    Ward, Jane K; Armitage, Gerry

    2012-08-01

    Patients are increasingly being thought of as central to patient safety. A small but growing body of work suggests that patients may have a role in reporting patient safety problems within a hospital setting. This review considers this disparate body of work, aiming to establish a collective view on hospital-based patient reporting. This review asks: (a) What can patients report? (b) In what settings can they report? (c) At what times have patients been asked to report? (d) How have patients been asked to report? 5 databases (MEDLINE, EMBASE, CINAHL, (Kings Fund) HMIC and PsycINFO) were searched for published literature on patient reporting of patient safety 'problems' (a number of search terms were utilised) within a hospital setting. In addition, reference lists of all included papers were checked for relevant literature. 13 papers were included within this review. All included papers were quality assessed using a framework for comparing both qualitative and quantitative designs, and reviewed in line with the study objectives. Patients are clearly in a position to report on patient safety, but included papers varied considerably in focus, design and analysis, with all papers lacking a theoretical underpinning. In all papers, reports were actively solicited from patients, with no evidence currently supporting spontaneous reporting. The impact of timing upon accuracy of information has yet to be established, and many vulnerable patients are not currently being included in patient reporting studies, potentially introducing bias and underestimating the scale of patient reporting. The future of patient reporting may well be as part of an 'error detection jigsaw' used alongside other methods as part of a quality improvement toolkit.

  10. Organising a manuscript reporting quality improvement or patient safety research.

    Holzmueller, Christine G; Pronovost, Peter J

    2013-09-01

    Peer-reviewed publication plays important roles in disseminating research findings, developing generalisable knowledge and garnering recognition for authors and institutions. Nonetheless, many bemoan the whole manuscript writing process, intimidated by the arbitrary and somewhat opaque conventions. This paper offers practical advice about organising and writing a manuscript reporting quality improvement or patient safety research for submission to a peer-reviewed journal. Each section of the paper discusses a specific manuscript component-from title, abstract and each section of the manuscript body, through to reference list and tables and figures-explaining key principles, offering content organisation tips and providing an example of how this section may read. The paper also offers a checklist of common mistakes to avoid in a manuscript.

  11. Patient Drug Safety Reporting: Diabetes Patients' Perceptions of Drug Safety and How to Improve Reporting of Adverse Events and Product Complaints.

    Patel, Puja; Spears, David; Eriksen, Betina Østergaard; Lollike, Karsten; Sacco, Michael

    2018-03-01

    Global health care manufacturer Novo Nordisk commissioned research regarding awareness of drug safety department activities and potential to increase patient feedback. Objectives were to examine patients' knowledge of pharmaceutical manufacturers' responsibilities and efforts regarding drug safety, their perceptions and experiences related to these efforts, and how these factors influence their thoughts and behaviors. Data were collected before and after respondents read a description of a drug safety department and its practices. We conducted quantitative survey research across 608 health care consumers receiving treatment for diabetes in the United States, Germany, United Kingdom, and Italy. This research validated initial, exploratory qualitative research (across 40 comparable consumers from the same countries) which served to guide design of the larger study. Before reading a drug safety department description, 55% of respondents were unaware these departments collect safety information on products and patients. After reading the description, 34% reported the department does more than they expected to ensure drug safety, and 56% reported "more confidence" in the industry as a whole. Further, 66% reported themselves more likely to report an adverse event or product complaint, and 60% reported that they were more likely to contact a drug safety department with questions. The most preferred communication methods were websites/online forums (39%), email (27%), and telephone (25%). Learning about drug safety departments elevates consumers' confidence in manufacturers' safety efforts and establishes potential for patients to engage in increased self-monitoring and reporting. Study results reveal potentially actionable insights for the industry across patient and physician programs and communications.

  12. The Impact of a Patient Safety Program on Medical Error Reporting

    2005-05-01

    307 The Impact of a Patient Safety Program on Medical Error Reporting Donald R. Woolever Abstract Background: In response to the occurrence of...a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety...communication, teamwork, and reporting. Objective: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This

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

    Yoo, Moon Sook; Kim, Kyoung Ja

    2017-09-01

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

  14. 2009 VHA Facility Quality and Safety Report - Patient Satisfaction

    Department of Veterans Affairs — The 2008 Hospital Report Card was mandated by the FY08 Appropriations Act, and focused on Congressionally-mandated metrics applicable to general patient populations....

  15. Patient-Reported Safety Information : A Renaissance of Pharmacovigilance?

    Härmark, Linda; Raine, June; Leufkens, Bert|info:eu-repo/dai/nl/075255049; Edwards, I Ralph; Moretti, Ugo; Sarinic, Viola Macolic; Kant, Agnes

    2016-01-01

    The role of patients as key contributors in pharmacovigilance was acknowledged in the new EU pharmacovigilance legislation. This contains several efforts to increase the involvement of the general public, including making patient adverse drug reaction (ADR) reporting systems mandatory. Three years

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

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

    2018-04-01

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

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

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

    2010-01-01

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

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

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

    2018-01-01

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

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

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

    2018-01-15

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

  20. Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events.

    Schneider, Eric C; Ridgely, M Susan; Quigley, Denise D; Hunter, Lauren E; Leuschner, Kristin J; Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C

    2017-06-01

    This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.

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

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

    2017-05-30

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

  2. Integrated care: an Information Model for Patient Safety and Vigilance Reporting Systems.

    Rodrigues, Jean-Marie; Schulz, Stefan; Souvignet, Julien

    2015-01-01

    Quality management information systems for safety as a whole or for specific vigilances share the same information types but are not interoperable. An international initiative tries to develop an integrated information model for patient safety and vigilance reporting to support a global approach of heath care quality.

  3. [The effectiveness of error reporting promoting strategy on nurse's attitude, patient safety culture, intention to report and reporting rate].

    Kim, Myoungsoo

    2010-04-01

    The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses. A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, X(2)-test, t-test, and ANCOVA with the SPSS 12.0 program. After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, porganizational culture and intention to report. The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.

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

    Sahlström, Merja; Partanen, Pirjo; Turunen, Hannele

    2018-04-16

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

  5. Patient safety event reporting in critical care: a study of three intensive care units.

    Harris, Carolyn B; Krauss, Melissa J; Coopersmith, Craig M; Avidan, Michael; Nast, Patricia A; Kollef, Marin H; Dunagan, W Claiborne; Fraser, Victoria J

    2007-04-01

    To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. Prospective, single-center, interventional study. A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. Adult patients admitted to these three study ICUs. Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal

  6. Using a quantitative risk register to promote learning from a patient safety reporting system.

    Mansfield, James G; Caplan, Robert A; Campos, John S; Dreis, David F; Furman, Cathie

    2015-02-01

    Patient safety reporting systems are now used in most health care delivery organizations. These systems, such as the one in use at Virginia Mason (Seattle) since 2002, can provide valuable reports of risk and harm from the front lines of patient care. In response to the challenge of how to quantify and prioritize safety opportunities, a risk register system was developed and implemented. Basic risk register concepts were refined to provide a systematic way to understand risks reported by staff. The risk register uses a comprehensive taxonomy of patient risk and algorithmically assigns each patient safety report to 1 of 27 risk categories in three major domains (Evaluation, Treatment, and Critical Interactions). For each category, a composite score was calculated on the basis of event rate, harm, and cost. The composite scores were used to identify the "top five" risk categories, and patient safety reports in these categories were analyzed in greater depth to find recurrent patterns of risk and associated opportunities for improvement. The top five categories of risk were easy to identify and had distinctive "profiles" of rate, harm, and cost. The ability to categorize and rank risks across multiple dimensions yielded insights not previously available. These results were shared with leadership and served as input for planning quality and safety initiatives. This approach provided actionable input for the strategic planning process, while at the same time strengthening the Virginia Mason culture of safety. The quantitative patient safety risk register serves as one solution to the challenge of extracting valuable safety lessons from large numbers of incident reports and could profitably be adopted by other organizations.

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

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

    2017-09-01

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

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

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

    2015-01-01

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

  9. Implementation and evaluation of a prototype consumer reporting system for patient safety events.

    Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C; Quigley, Denise D; Hunter, Lauren E; Ridgely, M Susan; Schneider, Eric C

    2017-08-01

    No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline. Mixed methods evaluation. The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015. Patients, family members and caregivers associated with two US healthcare systems. A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries. Key informant interviews, measurement of website traffic and analysis of completed reports. Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups. While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

  10. Return to driving after arthroscopic rotator cuff repair: patient-reported safety and maneuverability.

    Gholson, J Joseph; Lin, Albert; McGlaston, Timothy; DeAngelis, Joseph; Ramappa, Arun

    2015-01-01

    This survey investigated patients' return to driving after rotator cuff surgery, to determine whether pain, weakness, sling use, and narcotics correlate with self-assessed safety and maneuvering. Fifty-four patients (80.6% of those eligible) were surveyed 4 months after surgery. Return to driving ranged widely from same day to 4 months, with two not driving at 4 months; 12% reported narcotics use and 33% reported sling use. Drivers reporting weakness were more likely to feel unsafe (p = .02) and more likely to report difficulty maneuvering (p driving does not correspond to perceived safety; pain and weakness correspond with feeling unsafe and difficulty maneuvering. Although subjective, clinicians may find these self-assessments predictive when counseling patients on return to driving.

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

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

    2015-01-01

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

  12. 75 FR 16140 - Common Formats for Patient Safety Data Collection and Event Reporting

    2010-03-31

    ... FR 45457-45458. Definition of Common Formats The term ``Common Formats'' is used to describe clinical... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats for Patient Safety Data Collection and Event Reporting AGENCY: Agency for Healthcare Research and...

  13. Suspected adverse drug reactions in elderly patients reported to the Committee on Safety of Medicines.

    Castleden, C M; Pickles, H

    1988-01-01

    1. Spontaneous reports of suspected adverse drug reactions (ADRs) reported to the Committee on Safety of Medicines (CSM) have been studied in relation to patient age. 2. The proportion of reports received for the elderly increased between 1965 and 1983. 3. There was a correlation between the use of drugs and the number of ADR reports. Thus age-related prescription figures for two non-steroidal anti-inflammatory drugs (NSAI) and co-trimoxazole matched ADR reports for each drug in each age grou...

  14. 76 FR 67456 - Common Formats for Patient Safety Data Collection and Event Reporting

    2011-11-01

    ... information regarding the quality and safety of health care delivery. The Patient Safety Act (at 42 U.S.C... Formats in order to facilitate standardized data collection and improve the safety and quality of health... conjunction with an interagency Federal Patient Safety Work Group (PSWG), revises and refines the Common...

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

    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.

  16. Patient safety

    Page 1 .... BMJ 2012;344:e832. Table 2. Unsafe medical care. Structural factors. Organisational determinants. Structural accountability (accreditation and regulation). Safety culture. Training, education and human resources. Stress and fatigue .... for routine take-off and landing, yet doctors feel that it is demeaning to do so?

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

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

    2017-02-01

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

  18. 77 FR 42736 - Common Formats for Patient Safety Data Collection and Event Reporting

    2012-07-20

    ... safety problems. The Patient Safety Act and Patient Safety Rule establish a framework by which doctors... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats... formats, specified by AHRQ, that allow health care providers to collect and submit standardized...

  19. Barriers to Implementing a Reporting and Learning Patient Safety System: Pediatric Chiropractic Perspective.

    Pohlman, Katherine A; Carroll, Linda; Hartling, Lisa; Tsuyuki, Ross T; Vohra, Sunita

    2016-04-01

    A reporting and learning system is a method of monitoring the occurrence of incidents that affect patient safety. This cross-sectional survey asked pediatric chiropractors about factors that may limit their participation in such a system. The list of potential barriers for participation was developed using a systematic approach. All members of the 2 pediatric councils associated with US national chiropractic organizations were invited to complete the survey (N = 400). The cross-sectional survey was created using an online survey tool (REDCap) and sent directly to member emails addressed by the respective executive committees. Of the 400 potential respondents, 81 responded (20.3%). The most common limitations to participating were identified as time pressure (96%) and patient concerns (81%). Reporting and learning systems have been utilized to increase safety awareness in many high-risk industries. To be successful, future patient safety studies with pediatric chiropractors need to ensure these barriers are understood and addressed. © The Author(s) 2015.

  20. IMPROVING PATIENT SAFETY:

    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...

  1. Suspected adverse drug reactions in elderly patients reported to the Committee on Safety of Medicines.

    Castleden, C M; Pickles, H

    1988-10-01

    1. Spontaneous reports of suspected adverse drug reactions (ADRs) reported to the Committee on Safety of Medicines (CSM) have been studied in relation to patient age. 2. The proportion of reports received for the elderly increased between 1965 and 1983. 3. There was a correlation between the use of drugs and the number of ADR reports. Thus age-related prescription figures for two non-steroidal anti-inflammatory drugs (NSAI) and co-trimoxazole matched ADR reports for each drug in each age group. 4. The reported ADR was more likely to be serious or fatal in the elderly. 5. The commonest ADRs reported for the elderly affected the gastrointestinal (GIT) and haemopoietic systems, where more reports were received than would be expected from prescription figures. 6. The drug suspected of causing a GIT reaction was a NSAI in 75% of the reports. 7. Ninety-one per cent of fatal reports of GIT bleeds and perforations associated with NSAI drugs were in patients over 60 years of age.

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

    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

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

    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

  4. Fusion safety status report

    1986-10-01

    This report includes information on a) tritium handling and safety; b) activation product generation and release; c) lithium safety; d) superconducting magnet safety; e) operational safety and shielding; f) environmental impact; g) recycling, decommissioning and waste management; and h) accident analysis. Recommendations for high priority research and development are presented, as well as the current status in each area

  5. Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.

    Lawton, Rebecca; O'Hara, Jane Kathryn; Sheard, Laura; Armitage, Gerry; Cocks, Kim; Buckley, Hannah; Corbacho, Belen; Reynolds, Caroline; Marsh, Claire; Moore, Sally; Watt, Ian; Wright, John

    2017-08-01

    To evaluate the efficacy of the Patient Reporting and Action for a Safe Environment intervention. A multicentre cluster randomised controlled trial. Clusters were 33 hospital wards within five hospitals in the UK. All patients able to give informed consent were eligible to take part. Wards were allocated to the intervention or control condition. The ward-level intervention comprised two tools: (1) a questionnaire that asked patients about factors contributing to safety (patient measure of safety (PMOS)) and (2) a proforma for patients to report both safety concerns and positive experiences (patient incident reporting tool). Feedback was considered in multidisciplinary action planning meetings. Primary outcomes were routinely collected ward-level harm-free care (HFC) scores and patient-level feedback on safety (PMOS). Intervention uptake and retention of wards was 100% and patient participation was high (86%). We found no significant effect of the intervention on any outcomes at 6 or 12 months. However, for new harms (ie, those for which the wards were directly accountable) intervention wards did show greater, though non-significant, improvement compared with control wards. Analyses also indicated that improvements were largest for wards that showed the greatest compliance with the intervention. Adherence to the intervention, particularly the implementation of action plans, was poor. Patient safety outcomes may represent too blunt a measure. Patients are willing to provide feedback about the safety of their care. However, we were unable to demonstrate any overall effect of this intervention on either measure of patient safety and therefore cannot recommend this intervention for wider uptake. Findings indicate promise for increasing HFC where wards implement ≥75% of the intervention components. ISRCTN07689702; pre-results. 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/.

  6. [Cardiac safety of electroconvulsive therapy in an elderly patient--a case report].

    Karakuła-Juchnowicz, Hanna; Próchnicki, Michał; Kiciński, Paweł; Olajossy, Marcin; Pelczarska-Jamroga, Agnieszka; Dzikowski, Michał; Jaroszyński, Andrzej

    2015-10-01

    Since electroconvulsive therapy (ECT) was introduced as treatment for psychiatric disorders in 1938, it has remained one of the most effective therapeutic methods. ECT is often used as a "treatment of last resort" when other methods fail, and a life-saving procedure in acute clinical states when a rapid therapeutic effect is needed. Mortality associated with ECT is lower, compared to the treatment with tricyclic antidepressants, and comparable to that observed in so-called minor surgery. In the literature, cases of effective and safe electroconvulsive therapy have been described in patients of advanced age, with a burden of many somatic disorders. However, cases of acute cardiac episodes have also been reported during ECT. The qualification of patients for ECT and the selection of a group of patients at the highest risk of cardiovascular complications remains a serious clinical problem. An assessment of the predictive value of parameters of standard electrocardiogram (ECG), which is a simple, cheap and easily available procedure, deserves special attention. This paper reports a case of a 74-year-old male patient treated with ECT for a severe depressive episode, in the context of cardiologic safety. Both every single ECT session and the full course were assessed to examine their impact on levels of troponin T, which is a basic marker of cardiac damage, and selected ECG parameters (QTc, QRS). In the presented case ECT demonstrated its high general and cardiac safety with no negative effect on cardiac troponin (TnT) levels, corrected QT interval (QTc) duration, or other measured ECG parameters despite initially increased troponin levels, the patient's advanced age, the burden of a severe somatic disease and its treatment (anticancer therapy). © 2015 MEDPRESS.

  7. National Patient Safety Foundation

    ... 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 ...

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

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

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

  9. 76 FR 12358 - Common Formats for Patient Safety Data Collection and Event Reporting

    2011-03-07

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats... information regarding the quality and safety of healthcare delivery. The Patient Safety Act (at 42 U.S.C. 299b...: Device or Supply, including Health Information Technology; Fall; Healthcare-Associated Infection...

  10. A cross-sectional study to identify organisational processes associated with nurse-reported quality and patient safety

    Tvedt, Christine; Sjetne, Ingeborg Strømseng; Helgeland, Jon; Bukholm, Geir

    2012-01-01

    Objectives The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing. Design This is an observational cross-sectional study using survey methods. Setting Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey. Participants All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses' practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture. Outcome measures Nurses' assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures. Results Quality system, nurse–physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses’ affiliations to medical department and hospital type. Conclusions Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care. PMID:23263021

  11. Injury & Safety Report - Legacy

    National Oceanic and Atmospheric Administration, Department of Commerce — The Injury & Safety Report is a mandatory post trip legal document observers fill out to report any injuries they have incurred, illnesses they have had, or...

  12. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.

    Pietrobon, Ricardo; Lima, Raquel; Shah, Anand; Jacobs, Danny O; Harker, Matthew; McCready, Mariana; Martins, Henrique; Richardson, William

    2007-05-01

    Studies have shown that 4% of hospitalized patients suffer from an adverse event caused by the medical treatment administered. Some institutions have created systems to encourage medical workers to report these adverse events. However, these systems often prove to be inadequate and/or ineffective for reviewing the data collected and improving the outcomes in patient safety. To describe the Web-application Duke Surgery Patient Safety, designed for the anonymous reporting of adverse and near-miss events as well as scheduled reporting to surgeons and hospital administration. SOFTWARE ARCHITECTURE: DSPS was developed primarily using Java language running on a Tomcat server and with MySQL database as its backend. Formal and field usability tests were used to aid in development of DSPS. Extensive experience with DSPS at our institution indicate that DSPS is easy to learn and use, has good speed, provides needed functionality, and is well received by both adverse-event reporters and administrators. This is the first description of an open-source application for reporting patient safety, which allows the distribution of the application to other institutions in addition for its ability to adapt to the needs of different departments. DSPS provides a mechanism for anonymous reporting of adverse events and helps to administer Patient Safety initiatives. The modifiable framework of DSPS allows adherence to evolving national data standards. The open-source design of DSPS permits surgical departments with existing reporting mechanisms to integrate them with DSPS. The DSPS application is distributed under the GNU General Public License.

  13. Ten years after the IOM report: Engaging residents in quality and patient safety by creating a House Staff Quality Council.

    Fleischut, Peter M; Evans, Adam S; Nugent, William C; Faggiani, Susan L; Lazar, Eliot J; Liebowitz, Richard S; Forese, Laura L; Kerr, Gregory E

    2011-01-01

    Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.

  14. Patient Safety Culture

    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...

  15. Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire.

    Ricci-Cabello, Ignacio; Saletti-Cuesta, Lorena; Slight, Sarah P; Valderas, Jose M

    2017-10-01

    There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients' perspectives. To explore patients' experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety. The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients' experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care. A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients' responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment. This study identified a number of patient-centred recommendations for improving patient safety in English general practices. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

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

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

    2017-06-12

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

  17. Developing patient safety in dentistry.

    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.

  18. Patient safety culture among nurses.

    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

  19. Annual Safety Report 1981

    1982-09-01

    A safety report from Section K (Nuclear Physics) of the Dutch National Institute for Nuclear and High Energy Physics is presented for 1981. The report begins with general matters concerning safety policy at NIKHEF, licences and expenditure. Works accidents (none of them radiological) are detailed and accident prevention considered. The measurement programme for neutron radiation in the vicinity of the accelerator is described and the results are discussed. The means and results of personnel dosimetry are also presented. The report is concluded with a list of publications concerning safety aspects at NIKHEF. (C.F.)

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

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

    2009-02-01

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

  1. Conscious sedation for patients undergoing enteroclysis: Comparing the safety and patient-reported effectiveness of two protocols

    Maglinte, Dean D.T.; Applegate, Kimberly E.; Rajesh, Arumugam; Jennings, S. Gregory; Ford, Jason M.; Savabi, Mojgan Sarah; Lappas, John C.

    2009-01-01

    Objective: To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis. Materials and methods: We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl). Results: All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n = 106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n = 25), and post-procedure vomiting without aspiration (n = 1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n = 45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n = 13), and post-procedure vomiting without aspiration (n = 1). 87% had only a vague recall of the procedure or of any discomfort. Conclusion: A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.

  2. Conscious sedation for patients undergoing enteroclysis: Comparing the safety and patient-reported effectiveness of two protocols

    Maglinte, Dean D.T. [Department of Radiology, Indiana University Medical Center, 550 N, University Boulevard, University Hospital Room 0279, Indianapolis, IN 46202-5253 (United States)], E-mail: dmaglint@iupui.edu; Applegate, Kimberly E.; Rajesh, Arumugam; Jennings, S. Gregory; Ford, Jason M. [Department of Radiology, Indiana University Medical Center, 550 N, University Boulevard, University Hospital Room 0279, Indianapolis, IN 46202-5253 (United States); Savabi, Mojgan Sarah [Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, 550 N, University Boulevard, Indianapolis, IN 46202-5253 (United States); Lappas, John C. [Department of Radiology, Indiana University Medical Center, 550 N, University Boulevard, University Hospital Room 0279, Indianapolis, IN 46202-5253 (United States)

    2009-06-15

    Objective: To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis. Materials and methods: We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl). Results: All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n = 106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n = 25), and post-procedure vomiting without aspiration (n = 1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n = 45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n = 13), and post-procedure vomiting without aspiration (n = 1). 87% had only a vague recall of the procedure or of any discomfort. Conclusion: A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.

  3. Patient safety: Safety culture and patient safety ethics

    Madsen, Marlene Dyrløv

    2006-01-01

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

  4. Patient safety: lessons learned

    Bagian, James P.

    2006-01-01

    The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report ''To Err Is Human: Building a Safer Health System.'' However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence ''shame and blame'') to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events. (orig.)

  5. 77 FR 22322 - Common Formats for Patient Safety Data Collection and Event Reporting

    2012-04-13

    ... safety reporting systems. This inventory provides an evidence base that informs construction of the Common Formats. The inventory includes many systems from the private sector, including prominent academic... HHS Web site: http://www.PSO.AHRQ.gov/index.html . FOR FURTHER INFORMATION CONTACT: Cathryn Niane...

  6. Safety Basis Report

    R.J. Garrett

    2002-01-01

    As part of the internal Integrated Safety Management Assessment verification process, it was determined that there was a lack of documentation that summarizes the safety basis of the current Yucca Mountain Project (YMP) site characterization activities. It was noted that a safety basis would make it possible to establish a technically justifiable graded approach to the implementation of the requirements identified in the Standards/Requirements Identification Document. The Standards/Requirements Identification Documents commit a facility to compliance with specific requirements and, together with the hazard baseline documentation, provide a technical basis for ensuring that the public and workers are protected. This Safety Basis Report has been developed to establish and document the safety basis of the current site characterization activities, establish and document the hazard baseline, and provide the technical basis for identifying structures, systems, and components (SSCs) that perform functions necessary to protect the public, the worker, and the environment from hazards unique to the YMP site characterization activities. This technical basis for identifying SSCs serves as a grading process for the implementation of programs such as Conduct of Operations (DOE Order 5480.19) and the Suspect/Counterfeit Items Program. In addition, this report provides a consolidated summary of the hazards analyses processes developed to support the design, construction, and operation of the YMP site characterization facilities and, therefore, provides a tool for evaluating the safety impacts of changes to the design and operation of the YMP site characterization activities

  7. Safety Basis Report

    R.J. Garrett

    2002-01-14

    As part of the internal Integrated Safety Management Assessment verification process, it was determined that there was a lack of documentation that summarizes the safety basis of the current Yucca Mountain Project (YMP) site characterization activities. It was noted that a safety basis would make it possible to establish a technically justifiable graded approach to the implementation of the requirements identified in the Standards/Requirements Identification Document. The Standards/Requirements Identification Documents commit a facility to compliance with specific requirements and, together with the hazard baseline documentation, provide a technical basis for ensuring that the public and workers are protected. This Safety Basis Report has been developed to establish and document the safety basis of the current site characterization activities, establish and document the hazard baseline, and provide the technical basis for identifying structures, systems, and components (SSCs) that perform functions necessary to protect the public, the worker, and the environment from hazards unique to the YMP site characterization activities. This technical basis for identifying SSCs serves as a grading process for the implementation of programs such as Conduct of Operations (DOE Order 5480.19) and the Suspect/Counterfeit Items Program. In addition, this report provides a consolidated summary of the hazards analyses processes developed to support the design, construction, and operation of the YMP site characterization facilities and, therefore, provides a tool for evaluating the safety impacts of changes to the design and operation of the YMP site characterization activities.

  8. The Relationships Among Perceived Patients' Safety Culture, Intention to Report Errors, and Leader Coaching Behavior of Nurses in Korea: A Pilot Study.

    Ko, YuKyung; Yu, Soyoung

    2017-09-01

    This study was undertaken to explore the correlations among nurses' perceptions of patient safety culture, their intention to report errors, and leader coaching behaviors. The participants (N = 289) were nurses from 5 Korean hospitals with approximately 300 to 500 beds each. Sociodemographic variables, patient safety culture, intention to report errors, and coaching behavior were measured using self-report instruments. Data were analyzed using descriptive statistics, Pearson correlation coefficient, the t test, and the Mann-Whitney U test. Nurses' perceptions of patient safety culture and their intention to report errors showed significant differences between groups of nurses who rated their leaders as high-performing or low-performing coaches. Perceived coaching behavior showed a significant, positive correlation with patient safety culture and intention to report errors, i.e., as nurses' perceptions of coaching behaviors increased, so did their ratings of patient safety culture and error reporting. There is a need in health care settings for coaching by nurse managers to provide quality nursing care and thus improve patient safety. Programs that are systematically developed and implemented to enhance the coaching behaviors of nurse managers are crucial to the improvement of patient safety and nursing care. Moreover, a systematic analysis of the causes of malpractice, as opposed to a focus on the punitive consequences of errors, could increase error reporting and therefore promote a culture in which a higher level of patient safety can thrive.

  9. 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).

    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

  10. Safety of aspirin desensitization in patients with reported aspirin allergy and cardiovascular disease.

    McMullan, Kathryn L; Wedner, H James

    2013-01-01

    Aspirin (ASA) is the drug of choice in patients with coronary artery disease for primary and secondary prevention. This poses a problem for those patients reporting hypersensitivity to this drug or class of drugs. Desensitization to ASA may be carried out safely and effectively in patients with reported ASA or nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity needing ASA for cardiac indications. Our 7-step protocol is one choice for a rapid desensitization protocol. A retrospective chart review was conducted evaluating ASA desensitization in patients with reported ASA or NSAID hypersensitivity and a cardiac indication for ASA. In 160 evaluations over 15 years, 89 desensitizations were performed in both the inpatient and outpatient setting with only 16 reactions (18%). Eleven of these 16 patients (68.7%) were able to take daily ASA. Twenty-six desensitization procedures were performed with our 7-step rapid desensitization protocol in 10 inpatients and 16 outpatients with 3 reactions (18.75% of reactions). Initial reaction to ASA involving angioedema and reacting to ASA within the past year increased the risk of having a reaction to desensitization. Desensitization may be safely performed in patients with reported ASA or NSAID hypersensitivity and a cardiac indication for ASA. Our 7-step rapid protocol may be used in both the inpatient and outpatient setting to desensitize these patients. Patients who had angioedema with ASA ingestion or a reaction to ASA within the past year are at higher risk for reaction during the desensitization protocol. The authors have no funding, financial relationships, or conflicts of interest to disclose. © 2012 Wiley Periodicals, Inc.

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

    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.

  12. Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining the role of ease of reporting, unit norms of openness, and participative leadership.

    Zaheer, Shahram; Ginsburg, Liane; Chuang, You-Ta; Grace, Sherry L

    2015-01-01

    Increased awareness regarding the importance of patient safety issues has led to the proliferation of theoretical conceptualizations, frameworks, and articles that apply safety experiences from high-reliability industries to medical settings. However, empirical research on patient safety and patient safety climate in medical settings still lags far behind the theoretical literature on these topics. The broader organizational literature suggests that ease of reporting, unit norms of openness, and participative leadership might be important variables for improving patient safety. The aim of this empirical study is to examine in detail how these three variables influence frontline staff perceptions of patient safety climate within health care organizations. A cross-sectional study design was used. Data were collected using a questionnaire composed of previously validated scales. The results of the study show that ease of reporting, unit norms of openness, and participative leadership are positively related to staff perceptions of patient safety climate. Health care management needs to involve frontline staff during the development and implementation stages of an error reporting system to ensure staff perceive error reporting to be easy and efficient. Senior and supervisory leaders at health care organizations must be provided with learning opportunities to improve their participative leadership skills so they can better integrate frontline staff ideas and concerns while making safety-related decisions. Finally, health care management must ensure that frontline staff are able to freely communicate safety concerns without fear of being punished or ridiculed by others.

  13. Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey.

    Doyle, Patricia; VanDenKerkhof, Elizabeth G; Edge, Dana S; Ginsburg, Liane; Goldstein, David H

    2015-02-01

    Quality and patient safety (PS) are critical components of medical education. This study reports on the self-reported PS competence of medical students and postgraduate trainees. The Health Professional Education in Patient Safety Survey was administered to medical students and postgraduate trainees in January 2012. PS dimension scores were compared across learning settings (classroom and clinical) and year in programme. Sixty-three percent (255/406) of medical students and 32% (141/436) of postgraduate trainees responded. In general, both groups were most confident in their learning of clinical safety skills (eg, hand hygiene) and least confident in learning about sociocultural aspects of safety (eg, understanding human factors). Medical students' confidence in most aspects of safety improved with years of training. For some of the more intangible dimensions (teamwork and culture), medical students in their final year had lower scores than students in earlier years. Thirty-eight percent of medical students felt they could approach someone engaging in unsafe practice, and the majority of medical students (85%) and postgraduate trainees (78%) agreed it was difficult to question authority. Our results suggest the need to improve the overall content, structure and integration of PS concepts in both classroom and clinical learning environments. Decreased confidence in sociocultural aspects of PS among medical students in the final year of training may indicate that culture in clinical settings negatively affects students' perceived PS competence. Alternatively, as medical students spend more time in the clinical setting, they may develop a clearer sense of what they do not know. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  14. Exposing exposure: enhancing patient safety through automated data mining of nuclear medicine reports for quality assurance and organ dose monitoring.

    Ikuta, Ichiro; Sodickson, Aaron; Wasser, Elliot J; Warden, Graham I; Gerbaudo, Victor H; Khorasani, Ramin

    2012-08-01

    To develop and validate an open-source informatics toolkit capable of creating a radiation exposure data repository from existing nuclear medicine report archives and to demonstrate potential applications of such data for quality assurance and longitudinal patient-specific radiation dose monitoring. This study was institutional review board approved and HIPAA compliant. Informed consent was waived. An open-source toolkit designed to automate the extraction of data on radiopharmaceuticals and administered activities from nuclear medicine reports was developed. After iterative code training, manual validation was performed on 2359 nuclear medicine reports randomly selected from September 17, 1985, to February 28, 2011. Recall (sensitivity) and precision (positive predictive value) were calculated with 95% binomial confidence intervals. From the resultant institutional data repository, examples of usage in quality assurance efforts and patient-specific longitudinal radiation dose monitoring obtained by calculating organ doses from the administered activity and radiopharmaceutical of each examination were provided. Validation statistics yielded a combined recall of 97.6% ± 0.7 (95% confidence interval) and precision of 98.7% ± 0.5. Histograms of administered activity for fluorine 18 fluorodeoxyglucose and iodine 131 sodium iodide were generated. An organ dose heatmap which displays a sample patient's dose accumulation from multiple nuclear medicine examinations was created. Large-scale repositories of radiation exposure data can be extracted from institutional nuclear medicine report archives with high recall and precision. Such repositories enable new approaches in radiation exposure patient safety initiatives and patient-specific radiation dose monitoring.

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

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

    2018-06-01

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

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

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

    2017-11-03

    Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (pprocess step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, pprocess at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  17. Pioglitazone utilization, efficacy & safety in Indian type 2 diabetic patients: A systematic review & comparison with European Medicines Agency Assessment Report.

    Pai, Sarayu A; Kshirsagar, Nilima A

    2016-11-01

    With pioglitazone ban and subsequent revoking in India along with varying regulatory decisions in other countries, it was decided to carry out a systematic review on its safety, efficacy and drug utilization in patients with type 2 diabetes mellitus (T2DM) in India and compare with the data from the European Medicines Agency Assessment Report (EMA-AR). Systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching Medline/PubMed, Google Scholar and Science Direct databases using 'pioglitazone AND India AND human' and 'pioglitazone AND India AND human AND patient' and compared with EMA-AR. Spontaneous reports in World Health Organization VigiBase from India were compared with VigiBase data from other countries. Sixty six publications, 26 (efficacy), 32 (drug utilization) and eight (safety), were retrieved. In India, pioglitazone was used at 15-30 mg/day mostly with metformin and sulphonylurea, being prescribed to 26.7 and 8.4 per cent patients in north and south, respectively. The efficacy in clinical trials (CTs) was similar to those in EMA-AR. Incidence of bladder cancer in pioglitazone exposed and non-exposed patients was not significantly different in an Indian retrospective cohort study. There were two cases and a series of eight cases of bladder cancer published but none reported in VigiBase. In India, probably due to lower dose, lower background incidence of bladder cancer and smaller sample size in epidemiological studies, association of bladder cancer with pioglitazone was not found to be significant. Reporting of CTs and adverse drug reactions to Clinical Trials Registry of India and Pharmacovigilance Programme of India, respectively, along with compliance studies with warning given in package insert and epidemiological studies with larger sample size are needed.

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

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

    2017-12-27

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

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

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

    2017-01-01

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

  20. Laboratory test requesting appropriateness and patient safety

    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.

  1. Managing acute pain in patients who report lactose intolerance: the safety of an old excipient re-examined.

    Mill, Deanna; Dawson, Jessica; Johnson, Jacinta Lee

    2018-05-01

    Lactose intolerance is exceedingly common, reportedly affecting up to 70% of the world's population, leading to both abdominal and systemic symptoms. Current treatment focuses predominantly on restricting dietary consumption of lactose. Given lactose is one of the most commonly used excipients in the pharmaceutical industry, consideration must be given to the lactose content and therefore safety of pharmaceutical preparations prescribed for patients with lactose intolerance. This article summarizes the current literature examining the likelihood of inducing adverse effects through the administration of lactose-containing pharmaceutical preparations in patients reporting lactose intolerance, describes how to assess this risk on an individual patient basis and reviews suitable analgesic options for this population. A case study is presented detailing a patient reporting lactose intolerance who insists on treatment with the lactose-free product codeine/ibuprofen (Nurofen Plus) rather than other codeine-free analgesics. It is important to assess the likelihood of lactose as an excipient inducing symptoms in this scenario, as reluctance to cease codeine could suggest codeine dependence, an issue that is becoming increasingly common in countries such as Australia and Canada. Given codeine dependence is associated with serious sequelae including hospitalization and death, the patient must either be reassured the lactose component in their prescribed analgesics will not induce symptoms or an alternative treatment strategy must be confirmed. General recommendations applying theory from the literature to the management of acute pain in lactose-intolerant patients are discussed and specific treatment options are outlined. Although large inter-individual variability is reported, most lactose-intolerant patients can tolerate the small quantities of lactose found in pharmaceutical preparations. Cumulative lactose exposure can be assessed in patients taking multiple medications

  2. China's Work Safety Report

    Liang Jiakun

    2005-01-01

    @@ General Situation of China's Work Safety in 2004 In 2004, the national work safety situation remained stable as a whole and gained momentum to improve. The totality of accidents held the line and began to drop. The safety conditions in industrial,mining, and commercial/trading enterprises improved. Progress was made in ensuring work safety in the relevant industries and fields. The safety situation in most provinces (autonomous regions, municipalities directly under the Central Government) kept stable.

  3. Acute care patients discuss the patient role in patient safety.

    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.

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

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

    2014-01-01

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

  5. 75 FR 65359 - Common Formats for Patient Safety Data Collection and Event Reporting

    2010-10-22

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats..., and analyze confidential information regarding the quality and safety of healthcare delivery. The... Information Technology (HIT) Device format and the remaining Common Formats Version 1.1 can be accessed...

  6. When should a multicampus hospital be considered a single entity for public reporting on patient safety issues?

    Naessens, James M; Culbertson, Richard A; Lefante, John J; Campbell, Claudia R

    2007-01-01

    Attempts to provide information to consumers about patient safety on specific hospitals have conflicted with organization self-perceptions and led to confusion among the general public. This article presents organizational theory framework and criteria to classify organizations as single versus multiple reporting entities. Operational definitions are presented. A case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System is used to demonstrate their utility. The study includes analysis of an employee survey on employee satisfaction and patient safety climate in 2004 among nurses and physicians at the 2 Mayo Clinic hospitals in Rochester, Minn. The criteria for a single organization are more strongly supported for the Mayo Clinic hospitals located in the same city than for hospitals in the same system but separated geographically. Although there is debate about the measurement of organizational culture, employee surveys provide some evidence of a commonality across hospitals in the same city. The case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System demonstrate the utility of the proposed criteria.

  7. Collection and Reporting Patient Safety Data Within the Military Health System

    2001-01-01

    .... As a result of the findings in the report, the President issued a memorandum on December 7, 1999, directing the Quality Interagency Coordination Task Force to evaluate the report recommendations...

  8. The aviation safety reporting system

    Reynard, W. D.

    1984-01-01

    The aviation safety reporting system, an accident reporting system, is presented. The system identifies deficiencies and discrepancies and the data it provides are used for long term identification of problems. Data for planning and policy making are provided. The system offers training in safety education to pilots. Data and information are drawn from the available data bases.

  9. RB research reactor Safety Report

    Sotic, O.; Pesic, M.; Vranic, S.

    1979-04-01

    This RB reactor safety report is a revised and improved version of the Safety report written in 1962. It contains descriptions of: reactor building, reactor hall, control room, laboratories, reactor components, reactor control system, heavy water loop, neutron source, safety system, dosimetry system, alarm system, neutron converter, experimental channels. Safety aspects of the reactor operation include analyses of accident causes, errors during operation, measures for preventing uncontrolled activity changes, analysis of the maximum possible accident in case of different core configurations with natural uranium, slightly and highly enriched fuel; influence of possible seismic events

  10. Patient Safety and Healthcare Quality

    Aikaterini Toska; Panagiotis Kyloudis; Maria Rekleiti; Maria Saridi

    2012-01-01

    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-relatedagent...

  11. Addressing Risk Assessment for Patient Safety in Hospitals through Information Extraction in Medical Reports

    Proux, Denys; Segond, Frédérique; Gerbier, Solweig; Metzger, Marie Hélène

    Hospital Acquired Infections (HAI) is a real burden for doctors and risk surveillance experts. The impact on patients' health and related healthcare cost is very significant and a major concern even for rich countries. Furthermore required data to evaluate the threat is generally not available to experts and that prevents from fast reaction. However, recent advances in Computational Intelligence Techniques such as Information Extraction, Risk Patterns Detection in documents and Decision Support Systems allow now to address this problem.

  12. Self-reported confidence in patient safety knowledge among Australian undergraduate nursing students: A multi-site cross-sectional survey study.

    Usher, Kim; Woods, Cindy; Parmenter, Glenda; Hutchinson, Marie; Mannix, Judy; Power, Tamara; Chaboyer, Wendy; Latimer, Sharon; Mills, Jane; Siegloff, Lesley; Jackson, Debra

    2017-06-01

    , Understanding that reporting adverse events and close calls can lead to change and can reduce recurrence of events, was rated significantly higher by third year students than first and second year students. In order are to achieve meaningful improvements in patient safety, and create harm free environments for patients, it is crucial that nursing students develop confidence communicating with others to improve patient safety, particularly in the areas of challenging poor practice, and recognising, responding to and disclosing adverse events, including errors and near misses. Copyright © 2017 Elsevier Ltd. All rights reserved.

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

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

    2016-02-01

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

  14. Incorrect order of draw could be mitigate the patient safety: a phlebotomy management case report

    Lima-Oliveira, Gabriel; Lippi, Giuseppe; Salvagno, Gian Luca; Montagnana, Martina; Picheth, Geraldo; Guidi, Gian Cesare

    2013-01-01

    Procedures involving phlebotomy are critical for obtaining diagnostic blood specimens and represent a well known and recognized problem, probably among the most important issues in laboratory medicine. The aim of this report is to show spurious hyperkalemia and hypocalcemia due to inadequate phlebotomy procedure. The diagnostic blood specimens were collected from a male outpatient 45 years old, with no clinical complaints. The tubes drawing order were as follows: i) clot activator and gel separator (serum vacuum tube), ii) K3EDTA, iii) a needleless blood gas dedicated-syringe with 80 I.U. lithium heparin, directly connected to the vacuum tube holder system. The laboratory testing results from serum vacuum tube and dedicated syringe were 4.8 and 8.5 mmol/L for potassium, 2.36 and 1.48 mmol/L for total calcium, respectively. Moreover 0.15 mmol/L of free calcium was observed in dedicated syringe. A new blood collection was performed without K3EDTA tube. Different results were found for potassium (4.7 and 4.5 mmol/L) and total calcium (2.37 and 2.38 mmol/L) from serum vacuum tube and dedicated syringe, respectively. Also free calcium showed different concentration (1.21 mmol/L) in this new sample when compared with the first blood specimen. Based on this case we do not encourage the laboratory managers training the phlebotomists to insert the dedicated syringes in needle-holder system at the end of all vacuum tubes. To avoid double vein puncture the dedicated syringe for free calcium determination should be inserted immediately after serum tubes before EDTA vacuum tubes. PMID:23894868

  15. Patient Safety Threat - Syringe Reuse

    ... Safety Stakeholder Meeting December 2009 The One & Only Campaign Patient Notification Toolkit Developing Documents for a Patient Notification Planning Media and Communication Strategies Writing for the Media Spokesperson Preparation Planning the ...

  16. RB research reactor safety report

    Sotic, O.; Pesic, M.; Vranic, S.

    1979-04-01

    This new version of the safety report is a revision of the safety report written in 1962 when the RB reactor started operation after reconstruction. The new safety report was needed because reactor systems and components have been improved and the administrative procedures were changed. the most important improvements and changes were concerned with the use of highly enriched fuel (80% enriched), construction of reactor converter outside the reactor vessel, improved control system by two measuring start-up channels, construction of system for heavy water leak detection, new inter phone connection between control room and other reactor rooms. This report includes description of reactor building with installations, rector vessel, reactor core, heavy water system, control system, safety system, dosimetry and alarm systems, experimental channels, neutron converter, reactor operation. Safety aspects contain analyses of accident reasons, method for preventing reactivity insertions, analyses of maximum hypothetical accidents for cores with natural uranium, 2% enriched and 80% enriched fuel elements. Influence of seismic events on the reactor safety and well as coupling between reactor and the converter are parts of this document

  17. Safety analysis reports - new strategies

    Booth, J.A.

    1994-01-01

    Within the past year there have been many external changes in the requirements of safety analysis reports. Now there is emphasis on open-quotes graded approachesclose quotes depending on the Hazard Classification of the project. The Energy Facility Contractors Group (EFCOG) has a Safety Analysis Working Group. The results of this group for the past year are discussed as well as the implications for EG ampersand G. New strategies include ideas for incorporating the graded approach, auditable safety documents, additional guidance for Hazard Classification per DOE-STD-1027-92. The emphasis in the paper is on those projects whose hazard classification is category three or less

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

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

    2017-12-21

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

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

    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...

  20. Systems Thinking and Patient Safety

    Schyve, Paul M

    2005-01-01

    Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that "first, do no harm" has been the ethical watchword throughout the history of medicine, nursing, and pharmacy...

  1. Culture matters: indigenizing patient safety in Bhutan.

    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

  2. Patient safety culture assessment in oman.

    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.

  3. Patient Safety Culture Assessment in Oman

    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

  4. Laboratory errors and patient safety.

    Miligy, Dawlat A

    2015-01-01

    Laboratory data are extensively used in medical practice; consequently, laboratory errors have a tremendous impact on patient safety. Therefore, programs designed to identify and reduce laboratory errors, as well as, setting specific strategies are required to minimize these errors and improve patient safety. The purpose of this paper is to identify part of the commonly encountered laboratory errors throughout our practice in laboratory work, their hazards on patient health care and some measures and recommendations to minimize or to eliminate these errors. Recording the encountered laboratory errors during May 2008 and their statistical evaluation (using simple percent distribution) have been done in the department of laboratory of one of the private hospitals in Egypt. Errors have been classified according to the laboratory phases and according to their implication on patient health. Data obtained out of 1,600 testing procedure revealed that the total number of encountered errors is 14 tests (0.87 percent of total testing procedures). Most of the encountered errors lay in the pre- and post-analytic phases of testing cycle (representing 35.7 and 50 percent, respectively, of total errors). While the number of test errors encountered in the analytic phase represented only 14.3 percent of total errors. About 85.7 percent of total errors were of non-significant implication on patients health being detected before test reports have been submitted to the patients. On the other hand, the number of test errors that have been already submitted to patients and reach the physician represented 14.3 percent of total errors. Only 7.1 percent of the errors could have an impact on patient diagnosis. The findings of this study were concomitant with those published from the USA and other countries. This proves that laboratory problems are universal and need general standardization and bench marking measures. Original being the first data published from Arabic countries that

  5. The safety and effectiveness profile of eldecalcitol in a prospective, post-marketing observational study in Japanese patients with osteoporosis: interim report.

    Saito, Hitoshi; Kakihata, Hiroyuki; Nishida, Yosuke; Yatomi, Sawako; Nihojima, Shigeru; Kobayashi, Yumiko; Tabata, Hidehiro; Nomura, Makoto

    2017-07-01

    This large-scale post-marketing surveillance study was conducted to assess the safety and effectiveness of eldecalcitol treatment in patients with osteoporosis in a Japanese clinical setting. A total of 3567 patients with osteoporosis were enrolled and received eldecalcitol 0.75 μg/day for 12 months. For this interim report, 3285 patients were eligible for analysis. Mean age was 74.9 ± 8.7 years; 86.8 % (2854/3285) were women. There were 142 reported adverse drug reactions (ADRs) in 129 patients (3.92 % of the total 3285 patients): the most common were hypercalcemia and increased blood calcium (0.88 %), renal impairment (0.27 %), abdominal discomfort (0.24 %), constipation (0.24 %), and pruritus (0.24 %). The incidence of ADRs was 5.10 % in men and 3.74 % in women. Although 10 serious ADRs were reported in 9 patients (0.27 %), no clinically significant safety issues were identified. Incidence of hypercalcemia or increased blood calcium was 8.47 % in patients with renal impairment and only 0.74 % in patients without renal impairment. At last observation, the incidence of new vertebral and nonvertebral fractures was 2.44 % and 1.70 %, respectively. There was a significant increase in bone mineral density at the lumbar spine and distal radius. The bone turnover markers BAP, serum NTX, urinary NTX, and TRACP-5b were suppressed by eldecalcitol treatment in both sexes. In conclusion, consistent with the findings of the phase III pivotal clinical trial, eldecalcitol was shown to have a favorable safety profile and effectiveness in Japanese patients with osteoporosis. However, periodic measurements of serum calcium were required to prevent occurrence of hypercalcemia during eldecalcitol treatment, especially in patients with renal impairment.

  6. NASA aviation safety reporting system

    1981-01-01

    Aviation safety reports that relate to loss of control in flight, problems that occur as a result of similar sounding alphanumerics, and pilot incapacitation are presented. Problems related to the go around maneuver in air carrier operations, and bulletins (and FAA responses to them) that pertain to air traffic control systems and procedures are included.

  7. Patient Safety and Healthcare Quality

    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.

  8. Healthcare professionals’ views of feedback on patient safety culture assessment.

    Zwijnenberg, N.C.; Hendriks, M.; Hoogervorst-Schilp, J.; Wagner, C.

    2016-01-01

    Background: By assessing patient safety culture, healthcare providers can identify areas for improvement in patient safety culture. To achieve this, these assessment outcomes have to be relevant and presented clearly. The aim of our study was to explore healthcare professionals’ views on the feedback of a patient safety culture assessment. Methods: Twenty four hospitals participated in a patient safety culture assessment in 2012. Hospital departments received feedback in a report and on a web...

  9. Annual report on occupational safety

    1985-09-01

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

  10. Patient safety in otolaryngology: a descriptive review.

    Danino, Julian; Muzaffar, Jameel; Metcalfe, Chris; Coulson, Chris

    2017-03-01

    Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within

  11. Improving Patient Safety: Improving Communication.

    Bittner-Fagan, Heather; Davis, Joshua; Savoy, Margot

    2017-12-01

    Communication among physicians, staff, and patients is a critical element in patient safety. Effective communication skills can be taught and improved through training and awareness. The practice of family medicine allows for long-term relationships with patients, which affords opportunities for ongoing, high-quality communication. There are many barriers to effective communication, including patient factors, clinician factors, and system factors, but tools and strategies exist to address these barriers, improve communication, and engage patients in their care. Use of universal precautions for health literacy, appropriate medical interpreters, and shared decision-making are evidence-based tools that improve communication and increase patient safety. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

  12. Assemblages of Patient Safety

    Balatsas Lekkas, Angelos

    2016-01-01

    This thesis identifies how design processes emerge during the use of devices in healthcare, by attending to assemblages where contingencies of risk and harm co-exist with the contribution of healthcare professionals to the safe care of patients. With support from the field of Science and Technology...... practices of interdisciplinary care....

  13. Safety and Efficacy of Teneligliptin in Patients with Type 2 Diabetes Mellitus and Impaired Renal Function: Interim Report from Post-marketing Surveillance.

    Haneda, Masakazu; Kadowaki, Takashi; Ito, Hiroshi; Sasaki, Kazuyo; Hiraide, Sonoe; Ishii, Manabu; Matsukawa, Miyuki; Ueno, Makoto

    2018-06-01

    Teneligliptin is a novel oral dipeptidyl peptidase-4 inhibitor for the treatment of type 2 diabetes mellitus (T2DM). Safety and efficacy of teneligliptin have been demonstrated in clinical studies; however, data supporting its use in patients with moderate or severe renal impairment are limited. This interim analysis of a post-marketing surveillance of teneligliptin, exploRing the long-term efficacy and safety included cardiovascUlar events in patients with type 2 diaBetes treated bY teneligliptin in the real-world (RUBY), aims to verify the long-term safety and efficacy of teneligliptin in Japanese patients with T2DM and impaired renal function. For this analysis, we used the data from case report forms of the RUBY surveillance between May 2013 and June 2017. The patients were classified into G1-G5 stages of chronic kidney disease according to estimated glomerular filtration rate (eGFR) at initiation of teneligliptin treatment. Safety and efficacy were evaluated in these subgroups. Patients on dialysis were also assessed. Safety was assessed from adverse drug reactions (ADRs). Glycemic control was evaluated up to 2 years after teneligliptin initiation. A total of 11,677 patients were enrolled in the surveillance and 11,425 patient case-report forms were collected for the interim analysis. The incidence of ADRs in each subgroup was 2.98-6.98% of patients, with no differences in the ADR profile (including hypoglycemia and renal function ADRs) between subgroups. At 1 and 2 years after starting teneligliptin, the least-squares mean change in HbA1c adjusted to the baseline was - 0.68 to - 0.85% and - 0.71 to - 0.85% across the eGFR groups, respectively. Treatment with teneligliptin in patients on dialysis reduced or tended to reduce glycated albumin levels [- 2.29%, (p < 0.001) after 1 year; - 1.64%, (p = 0.064) after 2 years]. During long-term treatment, teneligliptin was generally well tolerated in patients with any stage of renal impairment from

  14. A region addresses patient safety.

    Feinstein, Karen Wolk; Grunden, Naida; Harrison, Edward I

    2002-06-01

    The Pittsburgh Regional Healthcare Initiative (PRHI) is a coalition of 35 hospitals, 4 major insurers, more than 30 major and small-business health care purchasers, dozens of corporate and civic leaders, organized labor, and partnerships with state and federal government all working together to deliver perfect patient care throughout Southwestern Pennsylvania. PRHI believes that in pursuing perfection, many of the challenges facing today's health care delivery system (eg, waste and error in the delivery of care, rising costs, frustration and shortage among clinicians and workers, financial distress, overcapacity, and lack of access to care) will be addressed. PRHI has identified patient safety (nosocomial infections and medication errors) and 5 clinical areas (obstetrics, orthopedic surgery, cardiac surgery, depression, and diabetes) as ideal starting points. In each of these areas of work, PRHI partners have assembled multifacility/multidisciplinary groups charged with defining perfection, establishing region-wide reporting systems, and devising and implementing recommended improvement strategies and interventions. Many design and conceptual elements of the PRHI strategy are adapted from the Toyota Production System and its Pittsburgh derivative, the Alcoa Business System. PRHI is in the proof-of-concept phase of development.

  15. Patient safety: break the silence.

    Johnson, Hope L; Kimsey, Diane

    2012-05-01

    A culture of patient safety requires commitment and full participation from all staff members. In 2008, results of a culture of patient safety survey conducted in the perioperative division of the Lehigh Valley Health Network in Pennsylvania revealed a lack of patient-centered focus, teamwork, and positive communication. As a result, perioperative leaders assembled a multidisciplinary team that designed a safety training program focusing on Crew Resource Management, TeamSTEPPS, and communication techniques. The team used video vignettes and an audience response system to engage learners and promote participation. Topics included using preprocedural briefings and postprocedural debriefings, conflict resolution, and assertiveness techniques. Postcourse evaluations showed that the majority of respondents believed they were better able to question the decisions or actions of someone with more authority. The facility has experienced a marked decrease in the number of incidents requiring a root cause analysis since the program was conducted. Copyright © 2012 AORN, Inc. Published by Elsevier Inc. All rights reserved.

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

    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

  17. Safety of belimumab in association with denosumab in a patient affected by Lupus Erythematosus: a case report

    Marco Scarati

    2017-04-01

    We present the clinical case of a female SLE patient treated simultaneously with belimumab (anti-BLyS for the underlying disease, and denosumab (anti-RANKL for concomitant severe osteoporosis. As these monoclonal antibodies have been recently introduced into the market, their combination has not been reported in literature yet. In this case, the combined administration proved a viable option for a SLE patient with osteoporosis and bisphosphonates contraindications.

  18. National nuclear safety report 2005. Convention on nuclear safety

    2006-01-01

    This National Nuclear Safety Report was presented at the 3rd. Review meeting. In general the information contained in the report are: Highlights / Themes; Follow-up from 2nd. Review meeting; Challenges, achievements and good practices; Planned measures to improve safety; Updates to National report to 3rd. Review meeting; Questions from peer review of National Report; and Conclusions

  19. Status of safety analysis reports

    Cserhati, A.

    1999-01-01

    The safety regulation connected to both of the Atomic Acts from 1980 and 1996 requires preparation of the Preliminary Safety Analysis Report (PSAR) as well as Final SAR (FSAR). In this respect the licensing procedure for the construction and commissioning of Paks NPP did not formally deviate from the standards applied in developed countries; this is particularly true if comparison is made with the standards applied for commissioning NPPs in the second half of the seventies. By the time the overall development of internationally accepted safety standards and some existing deficiencies of earlier SAR made necessary a general reassessment of the plant safety (AGNES project). The carried out PSR for Paks-1 and 2 also added a valuable contribution to the SAR content, however a formal update of SAR is not made yet. A Hungarian nuclear authority decree from 1997 obligates the licensee to prepare and submit a major upgrade of FSAR until the mid of 2000, after finishing the PSR for Paks-3 and 4. From this date a periodic update of FSAR is required every year. The operational license renewal affects only the PSR but not the FSAR updating. The new Nuclear Safety Code outlines the contents of PSAR and FSAR, based on US NRC Reg. Guide 1. 70. Rev. 3. Hungary by now can fulfill the upgrading of SAR without major external technical or financial help. The AGNES project covered the safety analysis chapters of SAR. It was financed mainly by the country. In the project there have been involved in limited cases as performers the VTT (Finland), Belgatom (Belgium), GRS (Germany), etc., the IVO (Finland) fulfilled tasks of an independent reviewer for safety analysis. The AGNES had certain interconnection with the similar IAEA RER safety reassessment project for WWER-440/213. The PSR for Paks-1 and 2 have been carried out by the Paks staff from the resources of the plant. During the evaluation of several parts of Paks-3 and 4 PSR documentation the authority intends to use certain

  20. Status of safety analysis reports

    Cserhati, A

    1999-06-01

    The safety regulation connected to both of the Atomic Acts from 1980 and 1996 requires preparation of the Preliminary Safety Analysis Report (PSAR) as well as Final SAR (FSAR). In this respect the licensing procedure for the construction and commissioning of Paks NPP did not formally deviate from the standards applied in developed countries; this is particularly true if comparison is made with the standards applied for commissioning NPPs in the second half of the seventies. By the time the overall development of internationally accepted safety standards and some existing deficiencies of earlier SAR made necessary a general reassessment of the plant safety (AGNES project). The carried out PSR for Paks-1 and 2 also added a valuable contribution to the SAR content, however a formal update of SAR is not made yet. A Hungarian nuclear authority decree from 1997 obligates the licensee to prepare and submit a major upgrade of FSAR until the mid of 2000, after finishing the PSR for Paks-3 and 4. From this date a periodic update of FSAR is required every year. The operational license renewal affects only the PSR but not the FSAR updating. The new Nuclear Safety Code outlines the contents of PSAR and FSAR, based on US NRC Reg. Guide 1. 70. Rev. 3. Hungary by now can fulfill the upgrading of SAR without major external technical or financial help. The AGNES project covered the safety analysis chapters of SAR. It was financed mainly by the country. In the project there have been involved in limited cases as performers the VTT (Finland), Belgatom (Belgium), GRS (Germany), etc., the IVO (Finland) fulfilled tasks of an independent reviewer for safety analysis. The AGNES had certain interconnection with the similar IAEA RER safety reassessment project for WWER-440/213. The PSR for Paks-1 and 2 have been carried out by the Paks staff from the resources of the plant. During the evaluation of several parts of Paks-3 and 4 PSR documentation the authority intends to use certain

  1. Patient Safety in Pediatrics: a Developing Discipline

    C. van der Starre (Cynthia)

    2011-01-01

    markdownabstract__Abstract__ The publication of the breakthrough report “To Err is Human” by the Institute of Medicine was the launch of patient safety initiatives all over the world. In the intensive care unit (ICU) of the Erasmus MC-Sophia Children’s Hospital this resulted in the institution

  2. Emotional influences in patient safety.

    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.

  3. AEA Technology safety report 1990

    1991-12-01

    AEA Technology is the trading name of the United Kingdom Atomic Energy Authority. Work in support of nuclear power at home and abroad continues to be an important part of our business but as nuclear power has matured AEA Technology has looked beyond its traditional role to other markets worldwide. We are a major commercial enterprise, with an annual turnover of Pound 450 million, selling a variety of technical services and products to customers worldwide. The scope of the business lies in the closely related fields of energy, environment and safety, targeted at both nuclear and non-nuclear markets. We also have a major role in providing innovative technology solutions to assist manufacturing industry. The 1990 report on safety within the Authority is presented here. (author).

  4. AEA Technology safety report 1990

    1991-12-01

    AEA Technology is the trading name of the United Kingdom Atomic Energy Authority. Work in support of nuclear power at home and abroad continues to be an important part of our business but as nuclear power has matured AEA Technology has looked beyond its traditional role to other markets worldwide. We are a major commercial enterprise, with an annual turnover of Pound 450 million, selling a variety of technical services and products to customers worldwide. The scope of the business lies in the closely related fields of energy, environment and safety, targeted at both nuclear and non-nuclear markets. We also have a major role in providing innovative technology solutions to assist manufacturing industry. The 1990 report on safety within the Authority is presented here. (author)

  5. 76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Child Health Patient Safety...

    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...

  6. 76 FR 79192 - Patient Safety Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization

    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...

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

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

    2016-06-01

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

  8. Challenging patient safety culture: survey results

    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

  9. Improving patient safety in radiation oncology

    Hendee, William R.; Herman, Michael G.

    2011-01-01

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

  10. Patient Safety, Present and Future

    Amalberti, R.

    2016-01-01

    Health care tends to oversimplify patient safety concepts. We tend to think about patient safety as a linear dimension that is only associated with the progressive reduction in the number of errors and accidents, with the simple notion that fewer are always better. We consider figures in isolation from the underlying context and prerequisites that drive safety models and the reality of the clinical fields. There is no one ultimate reference model of safety, but many models that can be adapted to fit the various clinical fields requirements and constraints. It is therefore not necessarily a bad result to observe a lower safety figure in a medical domain compared to the figures obtained in nonmedical ultra-safe models. The poor figures may represent the best local safety optimization while coping with the special health care requirements such as a high frequency of unplanned and nonstandard challenges. The paper distinguishes three classes of safety models that fit different field demands: the resilient and adaptive model, the high reliability (HRO) model, and the ultra-safe model. The lecture benchmarks the traits of each model while highlighting the specific dimensions for optimization. The conclusion is that firstly, that since the task requirements dictate the relevance and choice of the model and not the other way around, it is counterproductive to impose a model that is inadequate for the task requirements. Either you move the requirements and change the model, or you keep the constraints, and try to locally optimize the model to the clinical and organizational needs. (author)

  11. TIS General Safety Group Annual Report 2000

    Weingarten, W

    2001-01-01

    This report summarises the main activities of the General Safety (GS) Group of the Technical Inspection and Safety Division (TIS) during the year 2000, and the results obtained. The different topics in which the Group is active are covered: general safety inspections and ergonomy, electrical, chemistry and gas safety, chemical pollution containment and control, industrial hygiene, the safety of civil engineering works and outside contractors, fire prevention and the safety aspects of the LHC experiments.

  12. Effectiveness and safety of oxycodone/naloxone in the management of chronic pain in patients with systemic sclerosis with recurrent digital ulcers: two case reports

    Ughi N

    2016-03-01

    Full Text Available Nicola Ughi, Chiara Crotti, Francesca Ingegnoli Division of Rheumatology, Department of Clinical Sciences and Community Health, Gaetano Pini Institute, The University of Milan, Milan, Italy Abstract: Digital ulcers (DUs are a severe and frequent clinical feature of patients with systemic sclerosis (SSc. The presence of DUs may cause severe pain and often lead to impairment of patient’s functional activities and health-related quality of life. Moreover, poor patient cooperation during the wound care procedure due to pain may be associated with a negative outcome of DU healing. Therefore, pain management has a key role in patients with SSc. These two case reports describe the effectiveness and safety of oxycodone/naloxone in patients with SSc complicated by painful chronic DUs. Such a therapy has provided pain relief and consequently an increased compliance during redressing wounds. Keywords: oxycodone, naloxone, systemic sclerosis, pain, digital ulcer, scleroderma, analgaesia, wound healing, opioids, calcinosis, UCLA-SCTC GIT 2.0

  13. Patient Safety and Organizational Learning

    Zinck Pedersen, Kirstine

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

  14.  Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors

    Panesar SS

    2013-03-01

    Full Text Available  Sukhmeet S Panesar,1 Andrew Carson-Stevens,2 Sarah A Salvilla,1 Bhavesh Patel,3 Saqeb B Mirza,4 Bhupinder Mann51Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK; 2Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK; 3National Patient Safety Agency, London, UK; 4Department of Trauma and Orthopaedic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, Hampshire, UK; 5Buckinghamshire Healthcare NHS Trust, Stoke Mandeville Hospital, Aylesbury, UKBackground: With scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS in England and Wales is an underused resource which collects intelligence from reports about health care error.Methods: Using methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs and 95% confidence intervals (CIs.Results: The largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%. Of those, 14,482/48,095 (30.1% resulted in iatrogenic harm to the patient and 71/48,095 (0.15% resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38; self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18; and infection control (OR 1.91, 95% CI 1.69, 2.17. We analyze these data to quantify the extent and type of iatrogenic

  15. When bad things happen: adverse event reporting and disclosure as patient safety and risk management tools in the neonatal intensive care unit.

    Donn, Steven M; McDonnell, William M

    2012-01-01

    The Institute of Medicine has recommended a change in culture from "name and blame" to patient safety. This will require system redesign to identify and address errors, establish performance standards, and set safety expectations. This approach, however, is at odds with the present medical malpractice (tort) system. The current system is outcomes-based, meaning that health care providers and institutions are often sued despite providing appropriate care. Nevertheless, the focus should remain to provide the safest patient care. Effective peer review may be hindered by the present tort system. Reporting of medical errors is a key piece of peer review and education, and both anonymous reporting and confidential reporting of errors have potential disadvantages. Diagnostic and treatment errors continue to be the leading sources of allegations of malpractice in pediatrics, and the neonatal intensive care unit is uniquely vulnerable. Most errors result from systems failures rather than human error. Risk management can be an effective process to identify, evaluate, and address problems that may injure patients, lead to malpractice claims, and result in financial losses. Risk management identifies risk or potential risk, calculates the probability of an adverse event arising from a risk, estimates the impact of the adverse event, and attempts to control the risk. Implementation of a successful risk management program requires a positive attitude, sufficient knowledge base, and a commitment to improvement. Transparency in the disclosure of medical errors and a strategy of prospective risk management in dealing with medical errors may result in a substantial reduction in medical malpractice lawsuits, lower litigation costs, and a more safety-conscious environment. Thieme Medical Publishers, Inc.

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

    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.

  17. NIKHEF-K safety report 1982

    1983-12-01

    In this safety report, general information is offered about the safety policy at the NIKHEF-K institute Amsterdam. Costs, prevention, training courses and inspection related to (radiation) safety are briefly discussed. Small accidents are reported. Some measurements have been carried out, but no measurable increase of radiation doses have been found. (Auth.)

  18. Safety for all: bringing together patient and employee safety.

    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.

  19. Can we improve patient safety?

    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.

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

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

    2016-01-01

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

  1. Implementing Patient Safety Initiatives in Rural Hospitals

    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…

  2. Patient safety culture in primary care

    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

  3. Annual report on occupational safety 1985

    1986-09-01

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

  4. Comprehensive School Safety Initiative Report

    National Institute of Justice, 2014

    2014-01-01

    The National Institute of Justice (NIJ) developed the Comprehensive School Safety Initiative in consultation with federal partners and Congress. It is a research-focused initiative designed to increase the safety of schools nationwide through the development of knowledge regarding the most effective and sustainable school safety interventions and…

  5. Can we Improve Patient Safety?

    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.

  6. Systems engineered health and safety criteria for safety analysis reports

    Beitel, G.A.; Morcos, N.

    1993-01-01

    The world of safety analysis is filled with ambiguous words: codes and standards, consequences and risks, hazard and accident, and health and safety. These words have been subject to disparate interpretations by safety analysis report (SAR) writers, readers, and users. open-quotes Principal health and safety criteriaclose quotes has been one of the most frequently misused phrases; rarely is it used consistently or effectively. This paper offers an easily understood definition for open-quotes principal health and safety criteriaclose quotes and uses systems engineering to convert an otherwise mysterious topic into the primary means of producing an integrated SAR. This paper is based on SARs being written for environmental restoration and waste management activities for the U.S. Department of Energy (DOE). Requirements for these SARs are prescribed in DOE Order 5480-23, open-quotes Nuclear Safety Analysis Reports.close quotes

  7. Threats to patient safety in primary care reported by older people with multimorbidity: baseline findings from a longitudinal qualitative study and implications for intervention.

    Hays, Rebecca; Daker-White, Gavin; Esmail, Aneez; Barlow, Wendy; Minor, Brian; Brown, Benjamin; Blakeman, Thomas; Sanders, Caroline; Bower, Peter

    2017-11-21

    In primary care, older patients with multimorbidity (two or more long-term conditions) are especially likely to experience patient safety incidents. Risks to safety in this setting arise as a result of patient, staff and system factors; particularly where these interact or fail to do so. Recent research and policy highlight the important contribution patients can make to improving safety. Older patients with multimorbidity may have the most to gain from increasing their involvement but before interventions can be developed to support them to improve their patient safety, more needs to be known about how this is threatened and how patients respond to perceived threats. We sought to identify and describe threats to patient safety in primary care among older people with multimorbidity, to provide a better understanding of how these are experienced and to inform the development of interventions to reduce risks to patient safety. Twenty-six older people, aged 65 or over, with multimorbidity were recruited to a longitudinal qualitative study. At baseline, data on their health and healthcare were collected through semi-structured interviews. Data were analysed thematically, using a framework developed from a previous synthesis of qualitative studies of patient safety in primary care. Threats to patient safety were organised into six themes, across three domains of health and care. These encompassed all aspects of the patient journey, from access to everyday management. Across the journey, many issues arose due to poor communication, and uncoordinated care created extra burdens for patients and healthcare staff. Patients' sense of safety and trust in their care providers were especially threatened when they felt their needs were ignored, or when they perceived responses from staff as inappropriate or insensitive. For older patients with multimorbidity, patient safety is intrinsically linked to the challenges people face when managing health conditions, navigating the

  8. Assessment of safety and efficacy of lamotrigine over the course of 1-year observation in Japanese patients with bipolar disorder: post-marketing surveillance study report

    Terao, Takeshi; Ishida, Atsuko; Kimura, Toshifumi; Yoshida, Mitsuhiro; Hara, Terufumi

    2017-01-01

    Background A post-marketing surveillance (PMS) study was conducted with a 1-year observation period to assess the safety and efficacy of lamotrigine in routine clinical practice in patients with bipolar disorder (BD). Patients and methods Central enrollment method was used to recruit patients diagnosed with BD who were being treated for the first time with lamotrigine to prevent the recurrence/relapse of BD mood episodes. Adverse drug reactions (ADRs) and recurrence/relapse were assessed. Improvement of mania and depression was also assessed using the Hamilton’s Rating Scale for Depression (HAM-D) and the Young Mania Rating Scale (YMRS) at treatment initiation, 4–6 months post treatment initiation, and 10–12 months post treatment initiation. Results A total of 237/989 patients (24.0%) reported ADRs, most commonly rash (9.1%), and the incidence of serious ADRs was 3.3% (33/989 patients). Skin disorders occurred in 130 patients (13.1%), mostly within 8 weeks post treatment. A total of 237/703 patients (33.7%) experienced recurrence/relapse of mood episodes. The 25th percentile of the time to recurrence/relapse of mood episodes was 105 days. Remission of depression symptoms (HAM-D ≤7) occurred in 147/697 patients (21.1%) at treatment initiation, rising to 361 patients (67.4%) at 10–12 months post treatment. Remission of manic symptoms (YMRS ≤13) occurred in 615/676 patients (91.0%) at treatment initiation, rising to 500 patients (97.3%) at 10–12 months post treatment. Conclusion The results of this PMS study suggest that lamotrigine is a well-tolerated and effective drug for preventing recurrence/relapse of BD in clinical practice. PMID:28652744

  9. 76 FR 58812 - Patient Safety Organizations: Delisting for Cause of Patient Safety Organization One, Inc.

    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...

  10. 77 FR 11120 - Patient Safety Organizations: Voluntary Relinquishment From UAB Health System Patient Safety...

    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...

  11. 76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group

    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...

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

    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

  13. Managing patient safety through NPSGs and employee performance.

    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.

  14. Annual report on occupational safety 1987

    1988-01-01

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

  15. Safety analysis reports. Current status (third key report)

    1999-01-01

    A review of Ukrainian regulations and laws concerned with Nuclear power and radiation safety is presented with an overview of the requirements for the Safety Analysis Report Contents. Status of Safety Analysis Reports (SAR) is listed for each particular Ukrainian NPP including SAR development schedules. Organisational scheme of SAR development works includes: general technical co-ordination on Safety Analysis Report development; list of leading organisations and utilization of technical support within international projects

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

    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.

  17. Chemical Safety Vulnerability Working Group Report

    1994-09-01

    This report marks the culmination of a 4-month review conducted to identify chemical safety vulnerabilities existing at DOE facilities. This review is an integral part of DOE's efforts to raise its commitment to chemical safety to the same level as that for nuclear safety.

  18. Knowledge, beliefs and attitudes report on patient care and safety in undergraduate students: validating the modified APSQ-III questionnaire

    Ezequiel García Elorrio

    2016-12-01

    Full Text Available Resumen INTRODUCCIÓN La seguridad del paciente tiene por objetivo lograr una atención en salud libre de daño. La Organización Mundial de la Salud indica que este objetivo se logra a través de la comunicación, el análisis y la prevención de eventos adversos en los pacientes. La cultura organizacional ha sido identificada como uno de los principales factores para el éxito de las intervenciones para mejorar la seguridad del paciente. Un componente esencial de la cultura en seguridad es la actitud de los profesionales de la salud hacia el error médico. Las actitudes pueden mejorarse a través de una educación apropiada en las carreras biomédicas, pero la inclusión en los programas de Argentina es escasa. El cuestionario Actitudes para la Seguridad del Paciente mide conocimientos, creencias y actitudes sobre seguridad del paciente en estudiantes de medicina de una institución en Argentina y puede resultar una herramienta útil para ser utilizada en nuestro país. OBJETIVO Validar el cuestionario modificado de Actitudes para la Seguridad del Paciente III (APSQ III, por su sigla en inglés Attitudes to Patient Safety Questionnaire III, para la medición de conocimientos, creencias y actitudes de los estudiantes de medicina del Instituto Universitario Centro de Educación Médica e Investigaciones Clínicas. Describir el nivel de conocimientos, creencias y actitudes en seguridad del paciente de los estudiantes de medicina del referido instituto en los años 2012, 2015 y 2016. MÉTODOS Diseño: estudio descriptivo. Alcance: exploratorio. Ambiente: Instituto Universitario Centro de Educación Médica e Investigaciones Clínicas en Buenos Aires, Argentina. Población: estudiantes de medicina de cuarto y quinto año. Muestreo: se estimó un tamaño de la muestra de 100 participantes para poder obtener estimaciones significativas de acuerdo al α de Cronbach >0,6. RESULTADOS La fiabilidad (consistencia interna del instrumento, mediante α de

  19. National Nuclear Safety Report 2001. Convention on Nuclear Safety

    2001-01-01

    The First National Nuclear Safety Report was presented at the first review meeting of the Nuclear Safety Convention. At that time it was concluded that Argentina met the obligations of the Convention. This second National Nuclear Safety Report is an updated report which includes all safety aspects of the Argentinian nuclear power plants and the measures taken to enhance the safety of the plants. The present report also takes into account the observations and discussions maintained during the first review meeting. The conclusion made in the first review meeting about the compliance by Argentina of the obligations of the Convention are included as Annex 1. In general, the information contained in this Report has been updated since March 31, 1998 to March 31, 2001. Those aspects that remain unchanged were not addressed in this second report with the objective of avoiding repetitions and in order to carry out a detailed analysis considering article by article. As a result of the above mentioned detailed analysis of all the Articles, it can be stated that the country fulfils all the obligations imposed by the Nuclear Safety Convention

  20. National nuclear safety report 2004. Convention on nuclear safety

    2004-01-01

    The second National Nuclear Safety Report was presented at the second review meeting of the Nuclear Safety Convention. At that time it was concluded that Argentina met the obligations of the Convention. This third National Nuclear Safety Report is an updated report which includes all safety aspects of the Argentinian nuclear power plants and the measures taken to enhance the safety of the plants. The present report also takes into account the observations and discussions maintained during the second review meeting. The conclusion made in the first review meeting about the compliance by Argentina of the obligations of the Convention are included as Annex I and those belonging to the second review meeting are included as Annex II. In general, the information contained in this Report has been updated since March 31, 2001 to April 30, 2004. Those aspects that remain unchanged were not addressed in this third report. As a result of the detailed analysis of all the Articles, it can be stated that the country fulfils all the obligations imposed by the Nuclear Safety Convention. The questions and answers originated at the Second Review Meeting are included as Annex III

  1. Model for safety reports including descriptive examples

    1995-12-01

    Several safety reports will be produced in the process of planning and constructing the system for disposal of high-level radioactive waste in Sweden. The present report gives a model, with detailed examples, of how these reports should be organized and what steps they should include. In the near future safety reports will deal with the encapsulation plant and the repository. Later reports will treat operation of the handling systems and the repository

  2. Patient safety in external beam radiotherapy, results of the ACCIRAD project: Current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe.

    Malicki, Julian; Bly, Ritva; Bulot, Mireille; Godet, Jean-Luc; Jahnen, Andreas; Krengli, Marco; Maingon, Philippe; Prieto Martin, Carlos; Przybylska, Kamila; Skrobała, Agnieszka; Valero, Marc; Jarvinen, Hannu

    2017-04-01

    To describe the current status of implementation of European directives for risk management in radiotherapy and to assess variability in risk management in the following areas: 1) in-country regulatory framework; 2) proactive risk assessment; (3) reactive analysis of events; and (4) reporting and learning systems. The original data were collected as part of the ACCIRAD project through two online surveys. Risk assessment criteria are closely associated with quality assurance programs. Only 9/32 responding countries (28%) with national regulations reported clear "requirements" for proactive risk assessment and/or reactive risk analysis, with wide variability in assessment methods. Reporting of adverse error events is mandatory in most (70%) but not all surveyed countries. Most European countries have taken steps to implement European directives designed to reduce the probability and magnitude of accidents in radiotherapy. Variability between countries is substantial in terms of legal frameworks, tools used to conduct proactive risk assessment and reactive analysis of events, and in the reporting and learning systems utilized. These findings underscore the need for greater harmonisation in common terminology, classification and reporting practices across Europe to improve patient safety and to enable more reliable inter-country comparisons. Copyright © 2017 Elsevier B.V. All rights reserved.

  3. Aviation Safety Reporting System: Process and Procedures

    Connell, Linda J.

    1997-01-01

    The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.

  4. National nuclear safety report 1998. Convention on nuclear safety

    1998-01-01

    The Argentine Republic subscribed the Convention on Nuclear Safety, approved by a Diplomatic Conference in Vienna, Austria, in June 17th, 1994. According to the provisions in Section 5th of the Convention, each Contracting Party shall submit for its examination a National Nuclear Safety Report about the measures adopted to comply with the corresponding obligations. This Report describes the actions that the Argentine Republic is carrying on since the beginning of its nuclear activities, showing that it complies with the obligations derived from the Convention, in accordance with the provisions of its Article 4. The analysis of the compliance with such obligations is based on the legislation in force, the applicable regulatory standards and procedures, the issued licenses, and other regulatory decisions. The corresponding information is described in the analysis of each of the Convention Articles constituting this Report. The present National Report has been performed in order to comply with Article 5 of the Convention on Nuclear Safety, and has been prepared as much as possible following the Guidelines Regarding National Reports under the Convention on Nuclear Safety, approved in the Preparatory Meeting of the Contracting Parties, held in Vienna in April 1997. This means that the Report has been ordered according to the Articles of the Convention on Nuclear Safety and the contents indicated in the guidelines. The information contained in the articles, which are part of the Report shows the compliance of the Argentine Republic, as a contracting party of such Convention, with the obligations assumed

  5. Preliminary Integrated Safety Analysis Status Report

    Gwyn, D.

    2001-01-01

    This report provides the status of the potential Monitored Geologic Repository (MGR) Integrated Safety Analysis (EA) by identifying the initial work scope scheduled for completion during the ISA development period, the schedules associated with the tasks identified, safety analysis issues encountered, and a summary of accomplishments during the reporting period. This status covers the period from October 1, 2000 through March 30, 2001

  6. Patient safety in undergraduate radiography curricula: A European perspective

    England, A.; Azevedo, K.B.; Bezzina, P.; Henner, A.; McNulty, J.P.

    2016-01-01

    Purpose: To establish an understanding of patient safety within radiography education across Europe by surveying higher education institutions registered as affiliate members of the European Federation of Radiographer Societies (EFRS). Method: An online survey was developed to ascertain data on: programme type, patient safety definitions, relevant safety topics, specific areas taught, teaching and assessment methods, levels of teaching and curriculum drivers. Responses were identifiable in terms of educational institution and country. All 54 affiliated educational institutions were invited to participate. Descriptive and thematic analyses are reported. Results: A response rate of 61.1% (n = 33) was achieved from educational institutions representing 19 countries. Patient safety topics appear to be extremely well covered across curricula, however, topics including radiation protection and optimisation were not reported as being taught at an ‘advanced level’ by five and twelve respondents, respectively. Respondents identified the clinical department as the location of most patient safety-related teaching. Conclusions: Patient safety topics are deeply embedded within radiography curricula across Europe. Variations exist in terms of individual safety topics including, teaching and assessment methods, and the depth in which subjects are taught. Results from this study provide a baseline for assessing developments in curricula and can also serve as a benchmark for comparisons. - Highlights: • First European report on patient safety (PS). • PS deeply embedded within training curricula. • Terms and definitions largely consistent. • Some variety in the delivery and assessment methods. • Report provides baseline and opportunities for comparisons.

  7. Annual safety research report, JFY 2010

    2011-09-01

    In the safety infrastructure research working group report, 'the effective conducting of nuclear safety infrastructure research', published by METI in March 2010, the roles of regulatory agencies and JNES and their cooperation, and the research road map for nuclear safety regulation researches were summarized. As for the regulatory issues the governments or JNES considered necessary, JNES had compiled' safety research plan' in respective research areas necessary for solving the regulatory issues (safety research needs) and was conducting safety research to obtain the results, etc. Safety research areas, subjects and research projects were as follows: design review of nuclear power plant (4 subjects and each subject having several research projects totaled 19), control management of nuclear power plant (3 subjects and each subject having several research projects totaled 11), nuclear fuel cycle (2 subjects and each subject having several research projects totaled 5), nuclear fuel cycle backend (2 subjects and each subject having several research projects totaled 6), nuclear emergency preparedness and response (3 subjects and each subject having several research projects totaled 5) and bases of nuclear safety technology (3 subjects and each subject having several research projects totaled 7). In JFY 2010, JNES worked on the 53 research projects of 17 subjects in 6 areas as safety researches. This annual safety research report summarized respective achievements and stage of regulatory tools necessary for solving regulatory issues according to the safety research plan, JFY 2010 Edition as well as the situation of the reflection for the safety regulations. (T. Tanaka)

  8. Organizational safety culture and medical error reporting by Israeli nurses.

    Kagan, Ilya; Barnoy, Sivia

    2013-09-01

    To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.

  9. Hot Cell Facility (HCF) Safety Analysis Report

    MITCHELL,GERRY W.; LONGLEY,SUSAN W.; PHILBIN,JEFFREY S.; MAHN,JEFFREY A.; BERRY,DONALD T.; SCHWERS,NORMAN F.; VANDERBEEK,THOMAS E.; NAEGELI,ROBERT E.

    2000-11-01

    This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood of these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR.

  10. Hot Cell Facility (HCF) Safety Analysis Report

    MITCHELL, GERRY W.; LONGLEY, SUSAN W.; PHILBIN, JEFFREY S.; MAHN, JEFFREY A.; BERRY, DONALD T.; SCHWERS, NORMAN F.; VANDERBEEK, THOMAS E.; NAEGELI, ROBERT E.

    2000-01-01

    This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood of these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR

  11. NASA Aviation Safety Reporting System (ASRS)

    Connell, Linda J.

    2017-01-01

    The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

  12. Environment and safety research status report: 1993

    1993-03-01

    The 1993 status report discusses ongoing and planned research activities in the GRI Environment and Safety Program. The objectives and goals, accomplishments, and strategy along with the basis for each project area are presented for the supply, end use, and gas operations subprograms. Within the context of these subprograms, contract status summaries under their conceptual titles are given for the following project areas: Gas Supply Environmental and Safety Research, Air Quality Research, End Use Equipment Safety Research, Gas Operations Safety Research, Liquefied Natural Gas, Safety Research, and Gas Operations Environmental Research

  13. Nurses' perceptions of patient safety culture in Jordanian hospitals.

    Khater, W A; Akhu-Zaheya, L M; Al-Mahasneh, S I; Khater, R

    2015-03-01

    Patients' safety culture is a key aspect in determining healthcare organizations' ability to address and reduce risks of patients. Nurses play a major role in patients' safety because they are accountable for direct and continuous patient care. There is little known information about patients' safety culture in Jordanian hospitals, particularly from the perspective of healthcare providers. The study aimed to assess patient safety culture in Jordanian hospitals from nurses' perspective. A cross-sectional, descriptive design was utilized. A total number of 658 nurses participated in the current study. Data were collected using an Arabic version of the hospital survey of patients' safety culture. Teamwork within unit dimensions had a high positive response, and was perceived by nurses to be the only strong suit in Jordanian hospitals. Areas that required improvement, as perceived by nurses, are as follows: communication openness, staffing, handoff and transition, non-punitive responses to errors, and teamwork across units. Regression analysis revealed factors, from nurses' perspectives, that influenced patients' safety culture in Jordanian hospital. Factors included age, total years of experience, working in university hospitals, utilizing evidence-based practice and working in hospitals that consider patient safety to be a priority. Participants in this study were limited to nurses. Therefore, there is a need to assess patient safety culture from other healthcare providers' perspectives. Moreover, the use of a self-reported questionnaire introduced the social desirability biases. The current study provides insight into how nurses perceive patient safety culture. Results of this study have revealed that there is a need to replace the traditional culture of shame/blame with a non-punitive culture. Study results implied that improving patient safety culture requires a fundamental transformation of nurses' work environment. New policies to improve collaboration between

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

    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.

  15. Educating future leaders in patient safety

    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

  16. Researchers' Roles in Patient Safety Improvement.

    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.

  17. Laboratory safety and the WHO World Alliance for Patient Safety.

    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.

  18. Patient safety culture in Norwegian nursing homes.

    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

  19. MedWatch, the FDA Safety Information and Adverse Event Reporting Program

    ... Reporting Program MedWatch: The FDA Safety Information and Adverse Event Reporting Program Share Tweet Linkedin Pin it ... approved information that can help patients avoid serious adverse events. Potential Signals of Serious Risks/New Safety ...

  20. Delay in diagnosis of cancer as a patient safety issue - a root cause analysis based on a representative case report

    Mansour Paul

    2011-07-01

    Full Text Available Abstract Background It is well known in the literature that imaging has almost no value for diagnosis of superficial bladder cancer. However, wide gap exists between knowledge on diagnosis of bladder cancer and actual clinical practice. Case presentation Delay in diagnosis of bladder cancer in a male person with tetraplegia occurred because of reliance on negative flexible cystoscopy and single biopsy, negative ultrasound examination of urinary bladder, and computerised tomography of pelvis. Difficulties in scheduling cystoscopy also contributed to a delay of nearly ten months between the onset of haematuria and establishing a histological diagnosis of vesical malignancy in this patient. The time interval between transurethral resection and cystectomy was 42 days. This delay was mainly due to scheduling of surgery. Conclusion We learn from this case that doctors should be aware of the limitations of negative flexible cystoscopy and single biopsy, cytology of urine, ultrasound examination of urinary bladder, and computed tomography of pelvis for diagnosis of bladder cancer in spinal cord injury patients. Random bladder biopsies must be considered under general anaesthesia when there is high suspicion of bladder cancer. Spinal cord injury patients with lesions above T-6 may develop autonomic dysreflexia; therefore, one should be extremely well prepared to prevent or manage autonomic dysreflexia when performing cystoscopy and bladder biopsy. Spinal cord injury patients, who pass blood in urine, should be accorded top priority in scheduling of investigations and surgical procedures.

  1. Implementation of patient safety strategies in European hospitals.

    Suñol, R; Vallejo, P; Groene, O; Escaramis, G; Thompson, A; Kutryba, B; Garel, P

    2009-02-01

    This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU). To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital. Data were collected on patient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the chi(2) test and Fisher exact test. Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies--for example, using bracelets for adult patient identification and correct labelling of medication.

  2. 2011 NASA Range Safety Annual Report

    Dumont, Alan G.

    2012-01-01

    Welcome to the 2011 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides a NASA Range Safety overview for current and potential range users. As is typical with odd year editions, this is an abbreviated Range Safety Annual Report providing updates and links to full articles from the previous year's report. It also provides more complete articles covering new subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed and updated in the 2011 NASA Range Safety Annual Report include a program overview and 2011 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again the web-based format was used to present the annual report. We continually receive positive feedback on the web-based edition and hope you enjoy this year's product as well. As is the case each year, contributors to this report are too numerous to mention, but we thank individuals from the NASA Centers, the Department of Defense, and civilian organizations for their contributions. In conclusion, it has been a busy and productive year. I'd like to extend a personal Thank You to everyone who contributed to make this year a successful one, and I look forward to working with all of you in the upcoming year.

  3. High-intensity interval training and hyperoxia during chemotherapy: A case report about the feasibility, safety and physical functioning in a colorectal cancer patient.

    Freitag, Nils; Weber, Pia Deborah; Sanders, Tanja Christiane; Schulz, Holger; Bloch, Wilhelm; Schumann, Moritz

    2018-06-01

    We conducted a case study to examine the feasibility and safety of high-intensity interval training (HIIT) with increased inspired oxygen content in a colon cancer patient undergoing chemotherapy. A secondary purpose was to investigate the effects of such training regimen on physical functioning. A female patient (51 years; 49.1 kg; 1.65 m; tumor stage: pT3, pN2a (5/29), pM1a (HEP), L0, V0, R0) performed 8 sessions of HIIT (5 × 3 minutes at 90% of Wmax, separated by 2 minutes at 45% Wmax) with an increased inspired oxygen fraction of 30%. Patient safety, training adherence, cardiorespiratory fitness (peak oxygen uptake and maximal power output during an incremental cycle ergometer test), autonomous nervous function (i.e., heart rate variability during an orthostatic test) as well as questionnaire-assessed quality of life (EORTC QLQ-C30) were evaluated before and after the intervention.No adverse events were reported throughout the training intervention and a 3 months follow-up. While the patient attended all sessions, adherence to total training time was only 51% (102 of 200 minutes; mean training time per session 12:44 min:sec). VO2peak and Wmax increased by 13% (from 23.0 to 26.1 mL min kg) and 21% (from 83 to 100 W), respectively. Heart rate variability represented by the root mean squares of successive differences both in supine and upright positions were increased after the training by 143 and 100%, respectively. The EORTC QLQ-C30 score for physical functioning (7.5%) as well as the global health score (10.7%) improved, while social function decreased (17%). Our results show that a already short period of HIIT with concomitant hyperoxia was safe and feasible for a patient undergoing chemotherapy for colon cancer. Furthermore, the low overall training adherence of only 51% and an overall low training time per session (∼13 minutes) was sufficient to induce clinically meaningful improvements in physical functioning. However, this case also

  4. Template for safety reports with descriptive example

    1995-12-01

    This report provides a template for future safety reports on long-term safety in support of important decisions and permit applications in connection with the construction of a deep repository system. The template aims at providing a uniform structure for describing long-term safety, after the repository has been closed and sealed. The availability of such a structure will simplify both preparation and review of the safety reports, and make it possible to follow how safety assessments are influenced by the progressively more detailed body of data that emerges. A separate section containing 'descriptive examples' has been appended to the template. This section illustrates what the different chapters of the template should contain. 279 refs

  5. Template for safety reports with descriptive example

    NONE

    1995-12-01

    This report provides a template for future safety reports on long-term safety in support of important decisions and permit applications in connection with the construction of a deep repository system. The template aims at providing a uniform structure for describing long-term safety, after the repository has been closed and sealed. The availability of such a structure will simplify both preparation and review of the safety reports, and make it possible to follow how safety assessments are influenced by the progressively more detailed body of data that emerges. A separate section containing `descriptive examples` has been appended to the template. This section illustrates what the different chapters of the template should contain. 279 refs.

  6. Pioglitazone utilization, efficacy & safety in Indian type 2 diabetic patients: A systematic review & comparison with European Medicines Agency Assessment Report

    Sarayu A Pai

    2016-01-01

    Interpretation & conclusions: In India, probably due to lower dose, lower background incidence of bladder cancer and smaller sample size in epidemiological studies, association of bladder cancer with pioglitazone was not found to be significant. Reporting of CTs and adverse drug reactions to Clinical Trials Registry of India and Pharmacovigilance Programme of India, respectively, along with compliance studies with warning given in package insert and epidemiological studies with larger sample size are needed.

  7. Annual report on occupational safety 1989

    1990-01-01

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

  8. Nuclear Safety Research Department annual report 2000

    Majborn, B.; Nielsen, Sven Poul; Damkjær, A.

    2001-01-01

    The report presents a summary of the work of the Nuclear Safety Research Department in 2000. The department's research and development activities were organized in two research programmes: "Radiation Protection and Reactor Safety" and "Radioecology andTracer Studies". In addtion the department...

  9. Nuclear Safety Research Department annual report 2001

    Majborn, B.; Damkjær, A.; Nielsen, Sven Poul

    2002-01-01

    The report presents a summary of the work of the Nuclear Safety Research Department in 2001. The department's research and development activities were organized in two research programmes: "Radiation Protection and Reactor Safety" and "Radioecology andTracer Studies". In addition the department...

  10. Report of the tunnel safety working group

    Gannon, J.

    1991-04-01

    On 18 February 1991 the Project Manager formed a working group to address the safety guidelines and requirements for the underground facilities during the period of accelerator construction, installation, and commissioning. The following report summarizes the research and discussions conducted by the group and the recommended guidelines for safety during this phase of the project

  11. Assessing the relationship between patient safety culture and EHR strategy.

    Ford, Eric W; Silvera, Geoffrey A; Kazley, Abby S; Diana, Mark L; Huerta, Timothy R

    2016-07-11

    Purpose - The purpose of this paper is to explore the relationship between hospitals' electronic health record (EHR) adoption characteristics and their patient safety cultures. The "Meaningful Use" (MU) program is designed to increase hospitals' adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated. Design/methodology/approach - Providers' perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality's surveys on patient safety culture (level 1) and the American Hospital Association's survey and healthcare information technology supplement (level 2). Findings - The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers' perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research. Originality/value - Relating EHR MU and providers' care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.

  12. Health and safety annual report 1992

    1993-01-01

    BNFL operates 6 sites in the United Kingdom concerned with the nuclear fuel cycle. The annual report on occupational health and safety gives information on all aspects of health and safety within BNFL with special reference to radiation doses received by the workforce and radiation protection measures taken by the company. BNFL's safety policy is set out. Radiation doses to all workers have remained low. Other industrial accidents are also listed and its safety measures for transport, radioactive effluents and in the event of an incident, are mentioned briefly. (UK)

  13. National report of Brazil. Nuclear Safety Convention

    1998-09-01

    This document represents the national report prepared as a fulfillment of the brazilian obligations related to the Convention on Nuclear Safety. In chapter 2 some details are given about the existing nuclear installations. Chapter 3 provides details about the legislation and regulations, including the regulatory framework and the regulatory body. Chapter 4 covers general safety considerations as described in articles 10 to 16 of the Convention. Chapter 5 addresses to the safety of the installations during siting, design, construction and operation. Chapter 6 describes planned activities to further enhance nuclear safety. Chapter 7 presents the final remarks related to the degree of compliance with the Convention obligations

  14. 76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Emergency Medicine Patient Safety...

    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...

  15. 78 FR 40146 - Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety...

    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...

  16. 78 FR 59036 - Patient Safety Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc.

    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...

  17. 76 FR 9350 - Patient Safety Organizations: Voluntary Delisting From Rocky Mountain Patient Safety Organization

    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...

  18. 76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission

    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...

  19. 76 FR 9351 - Patient Safety Organizations: Voluntary Delisting From West Virginia Center for Patient Safety

    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...

  20. Identifying organizational cultures that promote patient safety.

    Singer, Sara J; Falwell, Alyson; Gaba, David M; Meterko, Mark; Rosen, Amy; Hartmann, Christine W; Baker, Laurence

    2009-01-01

    Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate. This study explored how aspects of general organizational culture relate to hospital patient safety climate. In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures. Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate. Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and

  1. Nuclear safety research project. Annual report 1995

    Hueper, R.

    1996-08-01

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

  2. Nuclear Safety Project. Annual report 1983

    1984-06-01

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

  3. Nuclear safety project. Annual report 1985

    1986-07-01

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

  4. Annual report on occupational safety 1983

    1984-08-01

    The 1983 Annual Report on occupational safety at BNFL is presented. Data for whole-body radiation doses and skin and extremity doses are given for BNFL employees together with 1982 data for comparison. Similarly, accidental deaths and major injuries are recorded. Finally information on the frequency of both nuclear and non-nuclear incidents reported to the Health and Safety Executive is given. (U.K.)

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

    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.

  6. Safety and health annual report 1996

    1997-01-01

    The 1996 report on the Health and Safety performance of the nuclear fuel cycle company BNFL at its sites in the United Kingdom demonstrates a continuing improvement. The site locations and developments are briefly described and international developments in subsidiary organisations noted. Other sections of the report cover health and safety policy, radiological and industrial safety, emergency planning, incidents, occupational health services, compensation scheme developments, transport, putting radiation in perspective, and safety and health research. Data are provided on: radioactive discharges; industrial safety of BNFL and contractors' employees; radiation dose summaries for BNFL and contractors' employees. There is evidence of the expected plateauing out of doses to BNFL employees at a level less than or similar to background radiation. (UK)

  7. National Safety Council Final Report

    Norris, Karen; Shannon, Tom

    2005-01-01

    In December 1995, the National Safety Council (NSC) entered into Cooperative Agreement No.DE-FC02-96EW 12729 with the US Department of Energy (DOE) to work together over the next few years on safety and health initiatives surrounding the management of radioactive materials. As a result, three publications, including print and non-print deliverables, were developed and distributed: (1) Series of Backgrounders, Web Services for WIPP; (2) A Guide to Foreign Research Reactor Spent Fuel; and (3) A Guide to the US Department of Energy's Low-Level Radioactive Waste. DOE and its predecessor agencies have maintained a record of safe transportation of radioactive materials for more than 50 years. Thousands of shipments involving three million packages of radioactive materials are shipped each year in the United States. Historically, DOE shipments constitute less than one percent of the total radioactive material shipments; however, they comprise a significant portion (approaching 75 percent) of the curies, or amounts of radioactivity shipped annually. DOE operations and field offices are responsible for detailed planning and for ensuring full regulatory compliance for their shipments. Packaging is designed to protect workers and limit the risk to the public during transportation. DOE headquarters and program offices provide policy direction and oversight for packaging and transportation activities for their respective offices. The publications NSC produced under the agreement also included primary points of contact for external audiences, including the press, the public, and stakeholders who would not have access to DOE regulations, manuals, and practices

  8. The impact of health information technology on patient safety.

    Alotaibi, Yasser K; Federico, Frank

    2017-12-01

    Since the original Institute of Medicine (IOM) report was published there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety.  This article is intended to review the current available scientific evidence on the impact of different health information technologies on improving patient safety outcomes. We conclude that health information technology improves patient's safety by reducing medication errors, reducing adverse drug reactions, and improving compliance to practice guidelines. There should be no doubt that health information technology is an important tool for improving healthcare quality and safety. Healthcare organizations need to be selective in which technology to invest in, as literature shows that some technologies have limited evidence in improving patient safety outcomes.

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

    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.

  10. Safety analysis report 231-Z Building

    Powers, C.S.

    1989-03-01

    This report provides an intensive review of the nuclear safety of the operation of the 231-Z Building. For background information complete descriptions of the floor plan, building services, alarm systems, and glove box systems are included in this report. In addition, references are included to The Plutonium Laboratory Radiation Work Procedures, Safety Guides, 231-Z Operating Procedures Manual and Nuclear Materials accountability Procedures. Engineered and administrative features contribute to the overall safety of personnel, the building, and environs. The consequences of credible incidents were considered and are discussed.

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

    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

  12. KIT safety management. Annual report 2012

    Frank, Gerhard

    2013-01-01

    The KIT Safety Management Service Unit (KSM) guarantees radiological and conventional technical safety and security of Karlsruhe Institute of Technology and controls the implementation and observation of legal environmental protection requirements. KSM is responsible for - licensing procedures, - industrial safety organization, - control of environmental protection measures, - planning and implementation of emergency preparedness and response, - operation of radiological laboratories and measurement stations, - extensive radiation protection support and the - the execution of security tasks in and for all organizational units of KIT. Moreover, KSM is in charge of wastewater and environmental monitoring for all facilities and nuclear installations all over the KIT campus. KSM is headed by the Safety Commissioner of KIT, who is appointed by the Presidential Committee. Within his scope of procedure for KIT, the Safety Commissioner controls the implementation of and compliance with safety-relevant requirements. The KIT Safety Management is certified according to DIN EN ISO 9001, its industrial safety management is certified by the VBG as ''AMS-Arbeitsschutz mit System'' and, hence, fulfills the requirements of NLF / ISO-OSH 2001. KSM laboratories are accredited according to DIN EN ISO/IEC 17025. To the extent possible, KSM is committed to maintaining competence in radiation protection and to supporting research and teaching activities. The present reports lists the individual tasks of the KIT Safety Management and informs about the results achieved in 2012. Status figures in principle reflect the status at the end of the year 2012. The processes described cover the areas of competence of KSM.

  13. Plutonium Finishing Plant safety evaluation report

    1995-01-01

    The Plutonium Finishing Plant (PFP) previously known as the Plutonium Process and Storage Facility, or Z-Plant, was built and put into operation in 1949. Since 1949 PFP has been used for various processing missions, including plutonium purification, oxide production, metal production, parts fabrication, plutonium recovery, and the recovery of americium (Am-241). The PFP has also been used for receipt and large scale storage of plutonium scrap and product materials. The PFP Final Safety Analysis Report (FSAR) was prepared by WHC to document the hazards associated with the facility, present safety analyses of potential accident scenarios, and demonstrate the adequacy of safety class structures, systems, and components (SSCs) and operational safety requirements (OSRs) necessary to eliminate, control, or mitigate the identified hazards. Documented in this Safety Evaluation Report (SER) is DOE's independent review and evaluation of the PFP FSAR and the basis for approval of the PFP FSAR. The evaluation is presented in a format that parallels the format of the PFP FSAR. As an aid to the reactor, a list of acronyms has been included at the beginning of this report. The DOE review concluded that the risks associated with conducting plutonium handling, processing, and storage operations within PFP facilities, as described in the PFP FSAR, are acceptable, since the accident safety analyses associated with these activities meet the WHC risk acceptance guidelines and DOE safety goals in SEN-35-91

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

    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.

  15. Complementary safety assessments - Report by the French Nuclear Safety Authority

    2011-12-01

    As an immediate consequence of the Fukushima accident, the French Authority of Nuclear Safety (ASN) launched a campaign of on-site inspections and asked operators (mainly EDF, AREVA and CEA) to make complementary assessments of the safety of the nuclear facilities they manage. The approach defined by ASN for the complementary safety assessments (CSA) is to study the behaviour of nuclear facilities in severe accidents situations caused by an off-site natural hazard according to accident scenarios exceeding the current baseline safety requirements. This approach can be broken into 2 phases: first conformity to current design and secondly an approach to the beyond design-basis scenarios built around the principle of defence in depth. 38 inspections were performed on issues linked to the causes of the Fukushima crisis. It appears that some sites have to reinforce the robustness of the heat sink. The CSA confirmed that the processes put into place at EDF to detect non-conformities were satisfactory. The complementary safety assessments demonstrated that the current seismic margins on the EDF nuclear reactors are satisfactory. With regard to flooding, the complementary safety assessments show that the complete reassessment carried out following the flooding of the Le Blayais nuclear power plant in 1999 offers the installations a high level of protection against the risk of flooding. Concerning the loss of electrical power supplies and the loss of cooling systems, the analysis of EDF's CSA reports showed that certain heat sink and electrical power supply loss scenarios can, if nothing is done, lead to core melt in just a few hours in the most unfavourable circumstances. As for nuclear facilities that are not power or experimental reactors, some difficulties have appeared to implement the CSA approach that was initially devised for reactors. Generally speaking, ASN considers that the safety of nuclear facilities must be made more robust to improbable risks which are not

  16. Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis.

    2017-01-01

    A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies. The objective of this review was to address two research questions: (a) what are the barriers to and facilitators of successful adoption of a patient safety learning system reported by health professionals and (b) what design components maximize successful adoption and implementation? To answer the first question, we used a published systematic review. To answer the second question, we used scoping study methodology. Common barriers reported in the literature by health care professionals included fear of blame, legal penalties, the perception that incident reporting does not improve patient safety, lack of organizational support, inadequate feedback, lack of knowledge about incident reporting systems, and lack of understanding about what constitutes an error. Common facilitators included a non-accusatory environment, the perception that incident reporting improves safety, clarification of the route of reporting and of how the system uses reports, enhanced feedback, role models (such as managers) using and promoting reporting, legislated protection of those who report, ability to report anonymously, education and training opportunities, and clear guidelines on what to report. Components of a patient safety learning system that increased successful adoption and implementation were emphasis on a blame-free culture that encourages reporting and learning, clear guidelines on how and what to report, making sure the system is user-friendly, organizational development support for data analysis to generate meaningful learning outcomes

  17. Psychological safety and error reporting within Veterans Health Administration hospitals.

    Derickson, Ryan; Fishman, Jonathan; Osatuke, Katerine; Teclaw, Robert; Ramsel, Dee

    2015-03-01

    In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors. We conducted an ANOVA on psychological safety scores from a VHA employees census survey (n = 185,879), assessing variability of means across racial and supervisory levels. We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Psychological safety increased with supervisory level (P hospital (71% would report, 13% would not) were less willing to report an error than at the psychologically safe hospital (91% would, 0% would not). A substantial minority would not report an error and were willing to admit so in a private interview setting. Their stated reasons as well as higher psychological safety means for supervisory employees both suggest power as an important determinant. Intentions to report were associated with psychological safety, strongly suggesting this climate aspect as instrumental to improving patient safety and reducing costs.

  18. Annual safety research report, JFY 2012

    2013-08-01

    As for the regulatory issues the governments or JNES considered necessary, JNES had compiled 'safety research plan' in respective research areas necessary for solving the regulatory issues (safety research needs) and was conducting safety research to obtain the results, etc. Safety research areas, subjects and research projects were as follows: design review of nuclear power plant (5 subjects and each subject having several research projects totaled 20), control management of nuclear power plant (3 subjects and each subject having several research projects totaled 6), nuclear fuel cycle (2 subjects and each subject having several research projects totaled 4), nuclear fuel cycle backend (2 subjects and each subject having several research projects totaled 6), nuclear emergency preparedness and response (3 subjects and each subject having several research projects totaled 7) and bases of nuclear safety technology (3 subjects and each subject having several research projects totaled 6). In addition to these 49 research projects of 18 subjects in 6 areas, JNES worked on 19 research projects of 7 subjects in added areas (specific research projects on of the disaster at Fukushima Daiichi NPP accident and other challenges JNES considered necessary) in JFY 2012. This annual safety research report summarized respective achievements and state of regulatory tools necessary for solving regulatory issues according to the safety research plan, JFY 2012 Edition as well as the situation of the reflection for the safety regulations, and also described 16 research projects of 4 subjects: examination for new safety regulation (8 research projects), development of newly necessary evaluation methods (one research project), evaluation of the validity for the work for convergence at Fukushima Daiichi NPP accident (4 research project) and horizontal development to other nuclear power plants (3 research projects), and 3 research projects of 3 subjects as other challenges. A list of JNES

  19. The impact of health information technology on patient safety

    Yasser K. Alotaibi

    2017-12-01

    Full Text Available Since the original Institute of Medicine (IOM report was published there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety. This article is intended to review the current available scientific evidence on the impact of different health information technologies on improving patient safety outcomes. We conclude that health information technology improves patient’s safety by reducing medication errors, reducing adverse drug reactions, and improving compliance to practice guidelines. There should be no doubt that health information technology is an important tool for improving healthcare quality and safety. Healthcare organizations need to be selective in which technology to invest in, as literature shows that some technologies have limited evidence in improving patient safety outcomes.

  20. Safety Incident Management Team Report for NIMLT Case 50796

    2017-01-17

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

  1. Annual report ''nuclear safety in France''

    2001-01-01

    This document is the 2001 annual report of the French authority of nuclear safety (ASN). It summarizes the highlights of the year 2000 and details the following aspects: the nuclear safety in France, the organization of the control of nuclear safety, the regulation relative to basic nuclear facilities, the control of facilities, the information of the public, the international relations, the organisation of emergencies, the radiation protection, the transport of radioactive materials, the radioactive wastes, the PWR reactors, the experimental reactors and other laboratories and facilities, the nuclear fuel cycle facilities, and the shutdown and dismantling of nuclear facilities. (J.S.)

  2. Nuclear Safety Project - annual report 1980

    1981-08-01

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

  3. Health and Safety annual report 1993

    1994-01-01

    In the 1993 Health and Safety Report for BNFL, data showing improvements in radiological and conventional safety are given. Other aspects discussed are emergency planning, the level of incidents, occupational health services, litigation and the compensation scheme, the transport of radioactive materials, research covering transgenerational epidemiology, mortality and cancer studies, genetics and radiobiology, and dosimetry, and finally a summary of radioactive discharges and environmental data. (UK)

  4. Nuclear Safety Research Department annual report 2000

    Majborn, B.; Damkjaer, A.; Nielsen, S.P.; Nonboel, E.

    2001-08-01

    The report presents a summary of the work of the Nuclear Safety Research Department in 2000. The department's research and development activities were organized in two research programmes: 'Radiation Protection and Reactor Safety' and 'Radioecology and Tracer Studies'. In addition the department was responsible for the tasks 'Applied Health Physics and Emergency Preparedness', 'Dosimetry', 'Environmental Monitoring', and Irradiation and Isotope Services'. Lists of publications, committee memberships and staff members are included. (au)

  5. Program nuclear safety research: report 2000

    Muehl, B.

    2001-09-01

    The reactor safety R and D work of forschungszentrum karlsruhe (FZK) had been part of the nuclear safety research project (PSF) since 1990. In 2000, a new organisational structure was introduced and the Nuclear Safety Research Project was transferred into the nuclear safety research programme (NUKLEAR). In addition to the three traditional main topics - Light Water Reactor safety, Innovative systems, Studies related to the transmutation of actinides -, the new Programme NUKLEAR also covers Safety research related to final waste storage and Immobilisation of HAW. These new topics, however, will only be dealt with in the next annual report. Some tasks related to the traditional topics have been concluded and do no longer appear in the annual report; other tasks are new and are described for the first time. Numerous institutes of the research centre contribute to the work programme, as well as several external partners. The tasks are coordinated in agreement with internal and external working groups. The contributions to this report, which are either written in German or in English, correspond to the status of early/mid 2001. (orig.)

  6. 77 FR 25179 - Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute

    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...

  7. Patient Education May Improve Perioperative Safety.

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

    2016-01-01

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

  8. The effect of organisational culture on patient safety.

    Kaufman, Gerri; McCaughan, Dorothy

    This article explores the links between organisational culture and patient safety. The key elements associated with a safety culture, most notably effective leadership, good teamwork, a culture of learning and fairness, and fostering patient-centred care, are discussed. The broader aspects of a systems approach to promoting quality and safety, with specific reference to clinical governance, human factors, and ergonomics principles and methods, are also briefly explored, particularly in light of the report of the public inquiry into care failings at Mid Staffordshire NHS Foundation Trust.

  9. Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force

    Berner, Eta S; Dente, Mark A; Kaplan, Bonnie; Koppel, Ross; Rucker, Donald; Sands, Daniel Z; Winkelstein, Peter

    2010-01-01

    The current commercial health information technology (HIT) arena encompasses a number of competing firms that provide electronic health applications to hospitals, clinical practices, and other healthcare-related entities. Such applications collect, store, and analyze patient information. Some vendors incorporate contract language whereby purchasers of HIT systems, such as hospitals and clinics, must indemnify vendors for malpractice or personal injury claims, even if those events are not caused or fostered by the purchasers. Some vendors require contract clauses that force HIT system purchasers to adopt vendor-defined policies that prevent the disclosure of errors, bugs, design flaws, and other HIT-software-related hazards. To address this issue, the AMIA Board of Directors appointed a Task Force to provide an analysis and insights. Task Force findings and recommendations include: patient safety should trump all other values; corporate concerns about liability and intellectual property ownership may be valid but should not over-ride all other considerations; transparency and a commitment to patient safety should govern vendor contracts; institutions are duty-bound to provide ethics education to purchasers and users, and should commit publicly to standards of corporate conduct; and vendors, system purchasers, and users should encourage and assist in each others' efforts to adopt best practices. Finally, the HIT community should re-examine whether and how regulation of electronic health applications could foster improved care, public health, and patient safety. PMID:21075789

  10. Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.

    Goodman, Kenneth W; Berner, Eta S; Dente, Mark A; Kaplan, Bonnie; Koppel, Ross; Rucker, Donald; Sands, Daniel Z; Winkelstein, Peter

    2011-01-01

    The current commercial health information technology (HIT) arena encompasses a number of competing firms that provide electronic health applications to hospitals, clinical practices, and other healthcare-related entities. Such applications collect, store, and analyze patient information. Some vendors incorporate contract language whereby purchasers of HIT systems, such as hospitals and clinics, must indemnify vendors for malpractice or personal injury claims, even if those events are not caused or fostered by the purchasers. Some vendors require contract clauses that force HIT system purchasers to adopt vendor-defined policies that prevent the disclosure of errors, bugs, design flaws, and other HIT-software-related hazards. To address this issue, the AMIA Board of Directors appointed a Task Force to provide an analysis and insights. Task Force findings and recommendations include: patient safety should trump all other values; corporate concerns about liability and intellectual property ownership may be valid but should not over-ride all other considerations; transparency and a commitment to patient safety should govern vendor contracts; institutions are duty-bound to provide ethics education to purchasers and users, and should commit publicly to standards of corporate conduct; and vendors, system purchasers, and users should encourage and assist in each others' efforts to adopt best practices. Finally, the HIT community should re-examine whether and how regulation of electronic health applications could foster improved care, public health, and patient safety.

  11. Modeling patient safety incidents knowledge with the Categorial Structure method.

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

    2011-01-01

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

  12. A patient safety objective structured clinical examination.

    Singh, Ranjit; Singh, Ashok; Fish, Reva; McLean, Don; Anderson, Diana R; Singh, Gurdev

    2009-06-01

    There are international calls for improving education for health care workers around certain core competencies, of which patient safety and quality are integral and transcendent parts. Although relevant teaching programs have been developed, little is known about how best to assess their effectiveness. The objective of this work was to develop and implement an objective structured clinical examination (OSCE) to evaluate the impact of a patient safety curriculum. The curriculum was implemented in a family medicine residency program with 47 trainees. Two years after commencing the curriculum, a patient safety OSCE was developed and administered at this program and, for comparison purposes, to incoming residents at the same program and to residents at a neighboring residency program. All 47 residents exposed to the training, all 16 incoming residents, and 10 of 12 residents at the neighboring program participated in the OSCE. In a standardized patient case, error detection and error disclosure skills were better among trained residents. In a chart-based case, trained residents showed better performance in identifying deficiencies in care and described more appropriate means of addressing them. Third year residents exposed to a "Systems Approach" course performed better at system analysis and identifying system-based solutions after the course than before. Results suggest increased systems thinking and inculcation of a culture of safety among residents exposed to a patient safety curriculum. The main weaknesses of the study are its small size and suboptimal design. Much further investigation is needed into the effectiveness of patient safety curricula.

  13. Using Patient-Reported Outcome Measures (PROMs) to promote quality of care and safety in the management of patients with Advanced Chronic Kidney disease (PRO-trACK project): a mixed-methods project protocol.

    Aiyegbusi, Olalekan Lee; Kyte, Derek; Cockwell, Paul; Marshall, Tom; Dutton, Mary; Slade, Anita; Marklew, Neil; Price, Gary; Verdi, Rav; Waters, Judi; Sharpe, Keeley; Calvert, Melanie

    2017-06-30

    Advanced chronic kidney disease (CKD) has a major effect on the quality of life and health status of patients and requires accurate and responsive management. The use of electronic patient-reported outcome measures (ePROMs) could assist patients with advanced pre-dialysis CKD, and the clinicians responsible for their care, by identifying important changes in symptom burden in real time. We report the protocol for 'Using Patient-Reported Outcome measures (PROMs) to promote quality of care and safety in the management of patients with Advanced Chronic Kidney Disease' (PRO-trACK) project, which will explore the feasibility and validity of an ePROM system for use in patients with advanced CKD. The project will use a mixed-methods approach in three studies: (1) usability testing of the ePROM system involving up to 30 patients and focusing on acceptability and technical performance/stability; (2) ascertaining the views of patient and clinician stakeholders on the optimal use and administration of the CKD ePROM system-this will involve qualitative face-to-face/telephone interviewing with up to 30 patients or until saturation is achieved, focus groups with up to 15 clinical staff, management and IT team members; (3) psychometric assessment of the system, within a cohort of at least 180 patients with advanced CKD, to establish the measurement properties of the ePROM. This project was approved by the West Midlands Edgbaston Research Ethics Committee (Reference 17/WM/0010) and received Health Research Authority (HRA) approval on 24 February 2017.The findings from this project will be provided to clinicians at the Department of Renal Medicine, Queen Elizabeth Hospitals, Birmingham (QEHB), NHS England, presented at conferences and to the Kidney Patients' Association, British Kidney Patient Association and the British Renal Society. Articles based on the findings will be written and submitted for publication in peer-reviewed journals. © Article author(s) (or their employer

  14. Central Safety Department. Annual report 1986

    Kiefer, H.; Koenig, L.A.

    1987-03-01

    The Safety Officer and the Security Officer are responsible for radiation protection and technical safety, both conventional and nuclear, for the physical protection as well as the safeguards of nuclear materials and radioactive substances within the Kernforschungszentrum Karlsruhe GmbH (KfK). To fulfill these functions they rely on the assistance of the Central Safety Department. The Central Safety Department is responsible for handling all problems of radiation protection, safety and security of the institutes and departments of the Karlsruhe Nuclear Research Center, for waste water activity measurements and environmental monitoring of the whole area of the Center, and for research and development work mainly focusing on nuclear safety and radiation protection measures. The r+d work concentrates on the following aspects: physical and chemical behavior of biologically particularly active radionuclides, behavior of HT in the air/plant/soil system, biophysics of multicellular systems, improvement in radiation protection measurement and personnel dosimetry. The report gives details of the different duties, indicates the results of 1986 routine tasks and reports about results of investigations and developments of the working groups of the Department. (orig.) [de

  15. Saclay transparency and nuclear safety report 2009

    2006-01-01

    After a general presentation of the Saclay CEA Centre, this report presents the various safety arrangements in the different basic nuclear installations it possesses. These arrangements can be administrative, technical, or related to emergency situations or to inspections. It describes the organisation of radioprotection in the Saclay CEA Centre, indicates highlights for 2009, and gives results of dose measurements performed on the personnel. It reports significant events regarding nuclear safety and radioprotection in the various installations, gives and comments release measurements results and their impact on the environment (gaseous and liquid releases). It gives an overview of radioactive wastes stored in the different installations

  16. The Interagency Nuclear Safety Review Panel's Galileo safety evaluation report

    Nelson, R.C.; Gray, L.B.; Huff, D.A.

    1989-01-01

    The safety evaluation report (SER) for Galileo was prepared by the Interagency Nuclear Safety Review Panel (INSRP) coordinators in accordance with Presidential directive/National Security Council memorandum 25. The INSRP consists of three coordinators appointed by their respective agencies, the Department of Defense, the Department of Energy (DOE), and the National Aeronautics and Space Administration (NASA). These individuals are independent of the program being evaluated and depend on independent experts drawn from the national technical community to serve on the five INSRP subpanels. The Galileo SER is based on input provided by the NASA Galileo Program Office, review and assessment of the final safety analysis report prepared by the Office of Special Applications of the DOE under a memorandum of understanding between NASA and the DOE, as well as other related data and analyses. The SER was prepared for use by the agencies and the Office of Science and Technology Policy, Executive Office of the Present for use in their launch decision-making process. Although more than 20 nuclear-powered space missions have been previously reviewed via the INSRP process, the Galileo review constituted the first review of a nuclear power source associated with launch aboard the Space Transportation System

  17. Status of Ignalina's safety analysis reports

    Uspuras, E.

    1999-01-01

    Ignalina NPP is unique among RBMK type reactors in the scope and comprehensiveness of international studies which have been performed to verify its design parameters and analyze risk levels. International assistance took several forms, a very valuable mod of assistance utilized the knowledge of international experts in extensive international studies whose purpose was: collection, systematization and verification of plant design data; analysis of risk levels; recommendations leading to improvements in the safety lave; transfer of state of the art analytical methodology to Lithuanian specialists. The major large scale international studies include: probabilistic risk analysis; extensive international study meant to provide comprehensive overview of plant status with special emphasis on safety aspects; an extensive review of the Safety Analysis Report by an independent group of international experts. In spite of the safety improvements and analyses which have been performed at the Ignalina NPP, much remains to be done in the nearest future

  18. Health and safety annual report 1988

    1989-01-01

    This report on health and safety provides a review of the impact of the Comapny's activities on its workforce, the public and the environment. New sections include safety auditing, emergency planning and health and safety research. BNFL operates five sites in north west England and southern Scotland. The head office and Engineering Design Centre is at Risley, near Warrington. Fuel is manufactured at Springfields near Preston, uranium is enriched for modern nuclear power stations at Capenhurst near Chester and spent fuel is reprocessed at Sellafield. BNFL also operate Calder Hall (Sellafield) and Chapelcross (Scotland) power stations and a disposal site for low-level radioactive wastes at Drigg near Sellafield. Radiation sources and BNFL's radioactive discharge are first explained generally and then specifically for each BNFL site. Industrial and radiological safety within BNFL are described. (UK)

  19. The NASA Aviation Safety Reporting System

    1983-01-01

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

  20. Safety culture in design. Final report

    Macchi, L.; Pietikaeinen, E.; Liinasuo, M.; Savioja, P.; Reiman, T.; Wahlstroem, M.; Kahlbom, U.; Rollenhagen, C.

    2013-04-01

    In this report we approach design from a safety culture approach As this research area is new and understudied, we take a wide scope on the issue. Different theoretical perspectives that can be taken when improving safety of the design process are considered in this report. We suggest that in the design context the concept of safety culture should be expanded from an organizational level to the level of the network of organizations involved in the design activity. The implication of approaching the design process from a safety culture perspective are discussed and the results of the empirical part of the research are presented. In the interview study in Finland and Sweden we identified challenges and opportunities in the design process from safety culture perspective. Also, a small part of the interview study concentrated on state of the art human factors engineering (HFE) practices in Finland and the results relating to that are presented. This report provide a basis for future development of systematic good design practices and for providing guidelines that can lead to safe and robust technical solutions. (Author)

  1. Safety culture in design. Final report

    Macchi, L.; Pietikaeinen, E.; Liinasuo, M.; Savioja, P.; Reiman, T.; Wahlstroem, M. [VTT Technical Research Centre of Finland, Espoo (Finland); Kahlbom, U. [Risk Pilot AB, Stockholm (Sweden); Rollenhagen, C. [Vattenfall, Stockholm, (Sweden)

    2013-04-15

    In this report we approach design from a safety culture approach As this research area is new and understudied, we take a wide scope on the issue. Different theoretical perspectives that can be taken when improving safety of the design process are considered in this report. We suggest that in the design context the concept of safety culture should be expanded from an organizational level to the level of the network of organizations involved in the design activity. The implication of approaching the design process from a safety culture perspective are discussed and the results of the empirical part of the research are presented. In the interview study in Finland and Sweden we identified challenges and opportunities in the design process from safety culture perspective. Also, a small part of the interview study concentrated on state of the art human factors engineering (HFE) practices in Finland and the results relating to that are presented. This report provide a basis for future development of systematic good design practices and for providing guidelines that can lead to safe and robust technical solutions. (Author)

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

    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 ...

  3. Characterization report for the ferrocyanide safety issue

    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

  4. Patient safety trilogy: perspectives from clinical engineering.

    Gieras, Izabella; Sherman, Paul; Minsent, Dennis

    2013-01-01

    This article examines the role a clinical engineering or healthcare technology management (HTM) department can play in promoting patient safety from three different perspectives: a community hospital, a national government health system, and an academic medical center. After a general overview, Izabella Gieras from Huntington Hospital in Pasadena, CA, leads off by examining the growing role of human factors in healthcare technology, and describing how her facility uses clinical simulations in medical equipment evaluations. A section by Paul Sherman follows, examining patient safety initiatives from the perspective of the Veterans Health Administration with a focus on hazard alerts and recalls. Dennis Minsent from Oregon Health & Science University writes about patient safety from an academic healthcare perspective, and details how clinical engineers can engage in multidisciplinary safety opportunities.

  5. Fundamentals of a patient safety program

    Frush, Karen S.

    2008-01-01

    Thousands of people are injured or die from medical errors and adverse events each year, despite being cared for by hard-working, intelligent and well-intended health care professionals, working in the highly complex and high-risk environment of the American health care system. Patient safety leaders have described a need for health care organizations to make error prevention a major strategic objective while at the same time recognizing the importance of transforming the traditional health care culture. In response, comprehensive patient safety programs have been developed with the aim of reducing medical errors and adverse events and acting as a catalyst in the development of a culture of safety. Components of these programs are described, with an emphasis on strategies to improve pediatric patient safety. Physicians, as leaders of the health care team, have a unique opportunity to foster the culture and commitment required to address the underlying systems causes of medical error and harm. (orig.)

  6. Central Safety Department, annual report 1987

    Kiefer, H.; Koenig, L.A.

    1988-02-01

    The Central Safety Department is responsible for handling all problems of radiation protection, safety and security of the institutes and departments of the Karlsruhe Nuclear Research Center, for waste water activity measurements and environmental monitoring of the whole area of the Center, and for research and development work mainly focusing on nuclear safety and radiation protection measures. The r+d work concentrates on the following aspects: physical and chemical behaviour of biologically particularly active radionuclides, behaviour of HT in the air/plan/soil system, biophysics of multicellular systems, improvement in radiation protection measurement and personnel dosimetry. This report gives details of the different duties, indicates the results of 1987 routine tasks and reports about results of investigations and developments of the working groups of the Department. (orig./HP) [de

  7. Safety report on WWR-S reactor

    Horyna, J.; Kaisler, L.; Listik, E.

    1981-04-01

    The present Safety Report of the WWR-S reactor summarizes findings obtained during the trial and partially also permanent operation of the reactor after two stages of its reconstruction implemented between 1974 and 1976. Most data are presented necessary for assessing probable risks of possible accident conditions whose consequences pose health hazards to individuals of the population, radiation personnel and the facilities themselves. Attention is devoted to the description of the locality, to components and systems, heat removal from the core, design aspects, the quality of new and old parts of the technological circuits, the systems of protection and control, the emergency core cooling system, the problems of radiation safety, and to the safety analyses of the abnormal states envisaged. The Report was compiled with regard to IAEA and CMEA recommendations concerning safe operation of research reactors and to the recommendations and binding decisions of the Czechoslovak Atomic Energy Commission. (author)

  8. Healthcare professionals? views on feedback of a patient safety culture assessment

    Zwijnenberg, Nicolien C.; Hendriks, Michelle; Hoogervorst-Schilp, Janneke; Wagner, Cordula

    2016-01-01

    Background By assessing patient safety culture, healthcare providers can identify areas for improvement in patient safety culture. To achieve this, these assessment outcomes have to be relevant and presented clearly. The aim of our study was to explore healthcare professionals? views on the feedback of a patient safety culture assessment. Methods Twenty four hospitals participated in a patient safety culture assessment in 2012. Hospital departments received feedback in a report and on a websi...

  9. Improving patient safety: lessons from rock climbing.

    Robertson, Nic

    2012-02-01

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

  10. Surveillance on The Safety and Efficacy of Ambrisentan (Volibris Tablet 2.5 mg) in Patients with Pulmonary Arterial Hypertension in Real Clinical Practice: Post-marketing Surveillance (Interim Analysis Report).

    Takahashi, Tomohiko; Hayata, Satoru; Kobayashi, Akihiro; Onaka, Yuna; Ebihara, Takeshi; Hara, Terufumi

    2018-03-01

    Pulmonary arterial hypertension (PAH) is an intractable and rare disease and the accumulation of clinical evidence under real-world setting is needed. A post-marketing surveillance for the endothelin receptor antagonist ambrisentan (Volibris tablet) has been conducted by all-case investigation since September 2010. This paper is an interim report on the safety and efficacy of ambrisentan in 702 patients with PAH. PAH patients aged 15 years or older were subjected to the analysis. The safety analysis by overall cases or stratification of patient backgrounds and the efficacy analysis were investigated. Regarding patient characteristics, the 702 patients subjected to safety analysis included 543 (77.4%) women and 546 (77.8%) patients at WHO functional class II/III. The mean observational time was 392.7 days. A total of 324 adverse drug reaction (ADR) occurred in 204 (29.1%) patients. Common ADRs (≥ 2%) included anemia (4.6%), peripheral edema (4.1%), headache (3.6%), edema and face edema (2.6% each), abnormal hepatic function (2.3%), and epistaxis (2.1%). There were 82 serious ADRs occurring in 44 (6.3%) patients (385 serious adverse events in 184 (26.2%) patients). Although 11 (1.6%) interstitial lung disease (ILD) cases were reported, all were observed in patients with disease that may contribute to ILD and therefore it is difficult to assess if ambrisentan was associated with these events. There was no difference in safety in relation to the presence/absence of connective tissue disease-related PAH (CTD-PAH) or combination therapy. Among 677 patients subjected to efficacy analysis, those in whom hemodynamic status was determined before and after treatment showed improvement in the mean pulmonary arterial pressure and pulmonary vascular resistance after treatment. The interim results showed safety consistent with the known profile of ambrisentan in terms of the types and frequencies of ADRs in patients with PAH in real clinical practice, in comparison with

  11. 1982 annual status report: reactor safety

    1982-01-01

    This report presents the projects of the Reactor Safety Program at the JRC: 1) Reliability and risk evolution; 2) LWR loss of coolant accident studies; 3) Primary system integrity; 4) LMFBR core accident initiation and transition phase; and, 5) LMFBR accident post disassembly phase

  12. report transparency and nuclear safety 2007- CISBIO

    2007-01-01

    This report presents the activities of CISBIO, nuclear base installation, for the year 2007. CISBIO realizes at Saclay most of the radiopharmaceuticals and drugs distributed in France for the nuclear medicine. The actions concerning the safety, the radiation protection, the significant events, the release control and the environmental impacts and the wastes stored on the center are discussed. (A.L.B.)

  13. Preliminary safety analysis report for the TFTR

    Lind, K.E.; Levine, J.D.; Howe, H.J.

    A Preliminary Safety Analysis Report has been prepared for the Tokamak Fusion Test Reactor. No accident scenarios have been identified which would result in exposures to on-site personnel or the general public in excess of the guidelines defined for the project by DOE

  14. Bus safety study : a report to Congress.

    2013-11-01

    Section 20021(b) of the Moving Ahead for Progress for the 21st Century (MAP-21) legislation requires the Secretary of Transportation : to submit a report of the results of a Bus Safety Study to the Committee on Banking, Housing, and Urban Affai...

  15. Health and safety annual report 1989

    1989-01-01

    This 1989 annual report on Health and Safety in BNFL is intended to give the public a general review of the impact of the Company's activities on its workforce, the public and the environment. The activities at Sellafield, Springfields, Chapelcross, Drigg and Capenhurst are outlined, together with sections on medical services and transport, and radiation monitoring of workforce and the environment. (author)

  16. EURISOL MERCURY TARGET EXPERIMENT: CERN SAFETY REPORT

    J. Gulley (CERN SC/GS)

    Report on a visit to the mercury-handling lab at IPUL. The aim was to provide recommendations to IPUL on general health and safety issues relatring to the handling of mercury, the objective being to reduce exposure to acceptable levels, so far as is reasonably practical.

  17. Annual Report 1979 of the Safety Department

    Kiefer, H.; Koelzer, W.; Koenig, L.A.

    1980-04-01

    The Safety Officer and the Security Officer, respectively, are responsible for radiation protection and technical safety, both conventional and nuclear, for the physical protection as well as the security of nuclear materials and radioactive substances within the Kernforschungszentrum Karlsruhe GmbH. (KfK). To fulfill these functions they rely on the assistance of the Safety Department. The duties of this Department cover tasks relative to radiation protection, safety and security on behalf of the institutes and departments of KfK and environmental monitoring for the whole Karlsruhe Nuclear Research Center as well as research and development work, mainly performed under the Nuclear Safety Project and the Nuclear Safeguards Project. The centers of interest of r and d activities are: investigation of the atmospheric diffusion of nuclear pollutants on the micro- and meso-scales, evaluation of the radiological consequences of accidents in reactors under probabilistic aspects, studies of the physical and chemical behavior of radionuclides with particularly high biological effectiveness in the environment, implemantation of nuclear fuel safeguarding systems, improvements in radiation protection measurement technology. This report gives details of the different duties, indicates the results of 1979 routine tasks, and reports about results of investigations and developments of the working groups of the Department. (orig.) [de

  18. 1978 annual report of the safety department

    Kiefer, H.; Koelzer, W.

    1979-04-01

    The Safety Officer and the Security Officer, respectively, are responsible for radiation protection and technical safety, both conventional and nuclear, for the physical protection as well as the security of nuclear materials and radioactive substances within the Kernforschungszentrum Karlsruhe GmbH. (KfK). To fulfill these functions they rely on the assitance of the Safety Department. The duties of this Department cover tasks relative to radiation protection, safety and security on behalf of the institutes and departments of KfK and environmental monitoring for the whole Karlsruhe Nuclear Research Center as well as research and development work, mainly performed under the Nuclear Safety Project and the Nuclear Safeguards Project. The centers of interest of r and d activities are: investigation of the atmospheric diffusion of nuclear pollutants on the micro- and meso-scales, evaluation of the radiological consequences of accidents in reactors under probabilistic aspects, studies of the physical and chemical behavior of radionuclides with particularly high biological effectiveness in the environment, implementation of nuclear fuel safequarding systems, improvements in radiation protection measurement technology. This report gives details of the different duties, indicates the results of 1978 routine tasks, and reports about new results of investigations and developments of the working groups of the Department. (orig.) [de

  19. Fusion Safety Program. Annual report, FY 1982

    Crocker, J.G.; Cohen, S.

    1983-07-01

    The Fusion Safety Program major activities for Fiscal Year 1982 are summarized in this report. The program was started in FY-79, with the Idaho National Engineering Laboratory (INEL) designated as lead laboratory and EG and G Idaho, Inc., named as prime contractor to implement this role. The report contains four sections: EG and G Idaho, Inc., Activities at INEL includes major portions of papers dealing with ongoing work in tritium implantation experiments, tritium risk assessment, transient code development, heat transfer and fluid flow analysis, and high temperature oxidation and mobilization of structural material experiments. The section Outside Contracts includes studies of superconducting magnet safety conducted by Argonne National Laboratory, experiments concerning superconductor safety issues performed by the Francis Bitter Magnet Laboratory of the Massachusetts Institute of Technology (MIT) to verify analytical work, a continuation of safety and environmental studies by MIT, a summary of lithium safety experiments at Hanford Engineering Development Laboratory, and the results of tritium gas conversion to oxide experiments at Oak Ridge National Laboratory. A List of Publications and Proposed FY-83 Activities are also presented

  20. Waste Isolation Pilot Plant Safety Analysis Report

    1995-11-01

    The following provides a summary of the specific issues addressed in this FY-95 Annual Update as they relate to the CH TRU safety bases: Executive Summary; Site Characteristics; Principal Design and Safety Criteria; Facility Design and Operation; Hazards and Accident Analysis; Derivation of Technical Safety Requirements; Radiological and Hazardous Material Protection; Institutional Programs; Quality Assurance; and Decontamination and Decommissioning. The System Design Descriptions'' (SDDS) for the WIPP were reviewed and incorporated into Chapter 3, Principal Design and Safety Criteria and Chapter 4, Facility Design and Operation. This provides the most currently available final engineering design information on waste emplacement operations throughout the disposal phase up to the point of permanent closure. Also, the criteria which define the TRU waste to be accepted for disposal at the WIPP facility were summarized in Chapter 3 based on the WAC for the Waste Isolation Pilot Plant.'' This Safety Analysis Report (SAR) documents the safety analyses that develop and evaluate the adequacy of the Waste Isolation Pilot Plant Contact-Handled Transuranic Wastes (WIPP CH TRU) safety bases necessary to ensure the safety of workers, the public and the environment from the hazards posed by WIPP waste handling and emplacement operations during the disposal phase and hazards associated with the decommissioning and decontamination phase. The analyses of the hazards associated with the long-term (10,000 year) disposal of TRU and TRU mixed waste, and demonstration of compliance with the requirements of 40 CFR 191, Subpart B and 40 CFR 268.6 will be addressed in detail in the WIPP Final Certification Application scheduled for submittal in October 1996 (40 CFR 191) and the No-Migration Variance Petition (40 CFR 268.6) scheduled for submittal in June 1996. Section 5.4, Long-Term Waste Isolation Assessment summarizes the current status of the assessment

  1. Waste Isolation Pilot Plant Safety Analysis Report

    NONE

    1995-11-01

    The following provides a summary of the specific issues addressed in this FY-95 Annual Update as they relate to the CH TRU safety bases: Executive Summary; Site Characteristics; Principal Design and Safety Criteria; Facility Design and Operation; Hazards and Accident Analysis; Derivation of Technical Safety Requirements; Radiological and Hazardous Material Protection; Institutional Programs; Quality Assurance; and Decontamination and Decommissioning. The System Design Descriptions`` (SDDS) for the WIPP were reviewed and incorporated into Chapter 3, Principal Design and Safety Criteria and Chapter 4, Facility Design and Operation. This provides the most currently available final engineering design information on waste emplacement operations throughout the disposal phase up to the point of permanent closure. Also, the criteria which define the TRU waste to be accepted for disposal at the WIPP facility were summarized in Chapter 3 based on the WAC for the Waste Isolation Pilot Plant.`` This Safety Analysis Report (SAR) documents the safety analyses that develop and evaluate the adequacy of the Waste Isolation Pilot Plant Contact-Handled Transuranic Wastes (WIPP CH TRU) safety bases necessary to ensure the safety of workers, the public and the environment from the hazards posed by WIPP waste handling and emplacement operations during the disposal phase and hazards associated with the decommissioning and decontamination phase. The analyses of the hazards associated with the long-term (10,000 year) disposal of TRU and TRU mixed waste, and demonstration of compliance with the requirements of 40 CFR 191, Subpart B and 40 CFR 268.6 will be addressed in detail in the WIPP Final Certification Application scheduled for submittal in October 1996 (40 CFR 191) and the No-Migration Variance Petition (40 CFR 268.6) scheduled for submittal in June 1996. Section 5.4, Long-Term Waste Isolation Assessment summarizes the current status of the assessment.

  2. Are long physician working hours harmful to patient safety?

    Ehara, Akira

    2008-04-01

    Pediatricians of Japanese hospitals including not only residents but also attending physicians work long hours, and 8% work for >79 h per week. Most of them work consecutively for >or=32 h when they are on call. The aim of the present study was to evaluate the effect of long work hours on patient safety. The electronic databases MEDLINE and EMBASE to searched identify the English- and Japanese-language literature for studies on work hours, medical errors, patient safety, and malpractice for years 1966-2005. Studies that analyzed the relationship between physician work hours and outcomes directly related to patient safety were selected. Seven studies met the criteria. Four studies suggest that reduction of work hours has a favorable effect on patient safety indicators. In the other three studies no significant changes of the indicators were observed, but no report found that shorter work hours were harmful to patient safety. Decrease of physician work hours is not harmful but favorable to patient safety.

  3. Comparable long-term efficacy, as assessed by patient-reported outcomes, safety and pharmacokinetics, of CT-P13 and reference infliximab in patients with ankylosing spondylitis: 54-week results from the randomized, parallel-group PLANETAS study.

    Park, Won; Yoo, Dae Hyun; Jaworski, Janusz; Brzezicki, Jan; Gnylorybov, Andriy; Kadinov, Vladimir; Sariego, Irmgadt Goecke; Abud-Mendoza, Carlos; Escalante, William Jose Otero; Kang, Seong Wook; Andersone, Daina; Blanco, Francisco; Hong, Seung Suh; Lee, Sun Hee; Braun, Jürgen

    2016-01-20

    CT-P13 (Remsima®, Inflectra®) is a biosimilar of the infliximab reference product (RP; Remicade®) and is approved in Europe and elsewhere, mostly for the same indications as RP. The aim of this study was to compare the 54-week efficacy, immunogenicity, pharmacokinetics (PK) and safety of CT-P13 with RP in patients with ankylosing spondylitis (AS), with a focus on patient-reported outcomes (PROs). This was a multinational, double-blind, parallel-group study in patients with active AS. Participants were randomized (1:1) to receive CT-P13 (5 mg/kg) or RP (5 mg/kg) at weeks 0, 2, 6 and then every 8 weeks up to week 54. To assess responses, standardized assessment tools were used with an intention-to-treat analysis of observed data. Anti-drug antibodies (ADAs), PK parameters, and safety outcomes were also assessed. Of 250 randomized patients (n = 125 per group), 210 (84.0 %) completed 54 weeks of treatment, with similar completion rates between groups. At week 54, Assessment of Spondylo Arthritis international Society (ASAS)20 response, ASAS40 response and ASAS partial remission were comparable between treatment groups. Changes from baseline in PROs such as mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; CT-P13 -3.1 versus RP -2.8), Bath Ankylosing Spondylitis Functional Index (BASFI; -2.9 versus -2.7), and Short Form Health Survey (SF-36) scores (9.26 versus 10.13 for physical component summary; 7.30 versus 6.54 for mental component summary) were similar between treatment groups. At 54 weeks, 19.5 % and 23.0 % of patients receiving CT-P13 and RP, respectively, had ADAs. All observed PK parameters of CT-P13 and RP, including maximum and minimum serum concentrations, were similar through 54 weeks. The influence of ADAs on PK was similar in the two treatment groups. Most adverse events were mild or moderate in severity. There was no notable difference between treatment groups in the incidence of adverse events, serious adverse events

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

    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.

  5. IRSN - Annual Report 2013. Financial Report 2013. Enhancing nuclear safety

    Schuler, Matthieu; Marchal, Valerie; Albert, Marc-Gerard; Aurelle, Jacques; Bigot, Marie-Pierre; Bruna, Giovanni; Charron, Sylvie; Clavelle, Stephanie; Cousinou, Patrick; Deschamps, Patrice; Delattre, Aleth; Demeillers, Didier; Dumas, Agnes; Franquard, Dominique; Laloi, Patrick; Lorthioir, Stephane; Monti, Pascale; Rollinger, Francois; Rouyer, Veronique; Rutschkovsky, Nathalie; Scott De Martinville, Edouard; Tharaud, Christine; Verpeaux, Jean-Luc; Jaunet, Camille; Hedouin, Jean-Christophe; Pascal-Heuze, Charlotte

    2014-03-01

    IRSN, a public entity with industrial and commercial activities, is placed under the joint authority of the Ministries of Defense, Environment, Industry, Research, and Health. It is the nation's public service expert in nuclear and radiation risks, and its activities cover all the related scientific and technical issues. Its areas of specialization include the environment and radiological emergency response, human radiation protection in both a medical and professional capacity, and in both normal and post-accident situations, the prevention of major accidents, nuclear reactor safety, as well as safety in nuclear plants and laboratories, transport and waste treatment, and nuclear defense and security expertise. IRSN interacts with all parties concerned by these risks (public authorities, in particular nuclear safety and security authorities, local authorities, companies, research organizations, stakeholders' associations, etc.) to contribute to public policy issues relating to nuclear safety, human and environmental protection against ionizing radiation, and the protection of nuclear materials, facilities, and transport against the risk of malicious acts. This document is the 2013 issue of IRSN's activity report. Content: 1 - Organization, key figures; 2 - Strategy: Progress and main activities in 2013, Transparency and communications policy, Promoting a safety and radiation protection culture; 3 - Activities: Safety (Safety of existing facilities, Studies and researches, About defense, Conducting assessments of future facilities); Nuclear security and non-proliferation (Nuclear security activities, International non-proliferation controls); Radiation protection - environment and human health (Environmental and population exposure, Radiation protection in the workplace, Effects of chronic exposure, Protection in health care); Emergency and post-accident situations efficiency; 4 - Efficiency: Health, safety, environmental, protection and quality, Human resources

  6. Nuclear Safety Project. Annual report 1986

    1987-09-01

    The annual report 1986 is a detailed description of work within the Nuclear Safety Project performed in 1986 in the nuclear safety field by KfK institutes and departments and by external institutes on behalf of KfK. It includes individual research activities on dynamic loads and strains of reactor components under accident conditions, fuel behaviour under accident conditions, investigation and control of LWR core-meltdown accidents, improvement of fission product retention and reduction of radiation exposure, and on behaviour, impact and removal of released pollutants. (DG)

  7. Environment, safety, and health manual, closeout report

    1975-12-01

    A coordination draft of the Environment, Safety, and Health (ES and H) manual was submitted on 2 September 1975. Comments provided by Operational Safety personnel were being incorporated by a task team when the effort was terminated on 31 October 1975. This report documents the development history of the manual and provides a status of the manual up to the time the efforts were discontinued. Also discussed are issues which effect completion of the manual. Additionally a plan for completion of the manual is suggested

  8. Nuclear Safety Research Department annual report 2000

    Majborn, B.; Damkjaer, A.; Nielsen, S.P.; Nonboel, E

    2001-08-01

    The report presents a summary of the work of the Nuclear Safety Research Department in 2000. The department's research and development activities were organized in two research programmes: 'Radiation Protection and Reactor Safety' and 'Radioecology and Tracer Studies'. In addition the department was responsible for the tasks 'Applied Health Physics and Emergency Preparedness', 'Dosimetry', 'Environmental Monitoring', and Irradiation and Isotope Services'. Lists of publications, committee memberships and staff members are included. (au)

  9. Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

    Althans, Alison R; Brady, Justin T; Times, Melissa L; Keller, Deborah S; Harvey, Alexis R; Kelly, Molly E; Patel, Nilam D; Steele, Scott R

    2018-01-01

    Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. Comparative review of patients at 2 institutions in the same metropolitan area were conducted. The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. A total of 350 patients with colorectal cancer from each hospital were evaluated. Overall survival across hospital systems was measured. The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). This was a retrospective review, reporting from medical charts. Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused

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

    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.

  11. Institute for Safety Research. Annual report 1992

    Weiss, F.P.; Boehmert, J.

    1993-11-01

    The Institute is concerned with evaluating the design based safety and increasing the operational safety of technical systems which include serious sources of danger. It is further occupied with methods of mitigating the effects of incidents and accidents. For all these goals the institute does research work in the following fields: modelling and simulation of thermofluid dynamics and neutron kinetics in cases of accidents; two-phase measuring techniques; safety-related analyses and characterizing of mechanical behaviours of material; measurements and calculations of radiation fields; process and plant diagnostics; development and application of methods of decision analysis. This annual report gives a survey of projects and scientific contributions (e.g. Single rod burst tests with ZrNb1 cladding), lists publications, institute seminars and workshops, names the personal staff and describes the organizational structure. (orig./HP)

  12. Safety Analysis Report for Ignalina NPP

    Negrivoda, G.

    1997-01-01

    In December 1994 an agreement was signed between the European Bank for Reconstruction and Development and the Republic of Lithuania for the grant of 32.86 MECU for the safety Improvement at Ignalina NPP. One of the conditions for the provision of the grant, was a requirement for an in-depth analysis of the safety level at Ignalina NPP in the scope and according to the standards acceptable for a western nuclear power plant, and to publish a Safety Analysis Report (SAR). The report should investigate and analyze any factor that could limit a safe operation of the plant, and provide recommendations for actual safety improvements. According to the agreement, Lithuania had to finalize the SAR until 31 December, 1995. The bank has also organized and financed investigation of safety at Ignalina NPP and preparation of the SAR. EBRD made an agreement with Sweden's Vattenfall, which subcontracted well-known companies from Canada, USA, Germany, etc., and also the Russian Research and Development Institute of Power Engineering (NIKIET), reactor designer of Ignalina NPP. The SAR is a very comprehensive document and contains about 8000 pages of text, diagrams and tables. The main findings of the SAR are provided in the article. A large number of discrepancies with modern rules and western practices was detected, but they were not proved to be serious enough to require reactors shutdown. Based on the recommendations of the SAR Ignalina NPP has worked out Safety Improvement Program No. 2 (SIP-2), which is planned for three years and will cost 486 MLT. (author)

  13. Probabilistic safety goals. Phase 3 - Status report

    Holmberg, J.-E. (VTT (Finland)); Knochenhauer, M. (Relcon Scandpower AB, Sundbyberg (Sweden))

    2009-07-15

    The first phase of the project (2006) described the status, concepts and history of probabilistic safety goals for nuclear power plants. The second and third phases (2007-2008) have provided guidance related to the resolution of some of the problems identified, and resulted in a common understanding regarding the definition of safety goals. The basic aim of phase 3 (2009) has been to increase the scope and level of detail of the project, and to start preparations of a guidance document. Based on the conclusions from the previous project phases, the following issues have been covered: 1) Extension of international overview. Analysis of results from the questionnaire performed within the ongoing OECD/NEA WGRISK activity on probabilistic safety criteria, including participation in the preparation of the working report for OECD/NEA/WGRISK (to be finalised in phase 4). 2) Use of subsidiary criteria and relations between these (to be finalised in phase 4). 3) Numerical criteria when using probabilistic analyses in support of deterministic safety analysis (to be finalised in phase 4). 4) Guidance for the formulation, application and interpretation of probabilistic safety criteria (to be finalised in phase 4). (LN)

  14. Probabilistic safety goals. Phase 3 - Status report

    Holmberg, J.-E.; Knochenhauer, M.

    2009-07-01

    The first phase of the project (2006) described the status, concepts and history of probabilistic safety goals for nuclear power plants. The second and third phases (2007-2008) have provided guidance related to the resolution of some of the problems identified, and resulted in a common understanding regarding the definition of safety goals. The basic aim of phase 3 (2009) has been to increase the scope and level of detail of the project, and to start preparations of a guidance document. Based on the conclusions from the previous project phases, the following issues have been covered: 1) Extension of international overview. Analysis of results from the questionnaire performed within the ongoing OECD/NEA WGRISK activity on probabilistic safety criteria, including participation in the preparation of the working report for OECD/NEA/WGRISK (to be finalised in phase 4). 2) Use of subsidiary criteria and relations between these (to be finalised in phase 4). 3) Numerical criteria when using probabilistic analyses in support of deterministic safety analysis (to be finalised in phase 4). 4) Guidance for the formulation, application and interpretation of probabilistic safety criteria (to be finalised in phase 4). (LN)

  15. How to Improve Patient Safety Culture in Croatian Hospitals?

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

    2016-09-01

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

  16. From Safe Systems to Patient Safety

    Aarts, J.; Nøhr, C.

    2010-01-01

    for the third conference with the theme: The ability to design, implement and evaluate safe, useable and effective systems within complex health care organizations. The theme for this conference was "Designing and Implementing Health IT: from safe systems to patient safety". The contributions have reflected...... and implementation of safe systems and thus contribute to the agenda of patient safety? The contributions demonstrate how the health informatics community has contributed to the performance of significant research and to translating research findings to develop health care delivery and improve patient safety......This volume presents the papers from the fourth International Conference on Information Technology in Health Care: Socio-technical Approaches held in Aalborg, Denmark in June 2010. In 2001 the first conference was held in Rotterdam, The Netherlands with the theme: Sociotechnical' approaches...

  17. Safety first. Status reports on the IAEA's safety standards

    Webb, G.; Karbassioun, A.; Linsley, G.; Rawl, R.

    1998-01-01

    Documents in the IAEA's Safety Standards Series known as RASS (Radiation Safety Standards) are produced to develop an internally consistent set of regulatory-style publications that reflects an international consensus on the principles of radiation protection and safety and their application through regulation. In this article are briefly presented the Agency's programmes on Nuclear Safety Standards (NUSS), Radioactive Waste Safety Standards (RADWASS), and Safe Transport of Radioactive Materials

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

    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

  19. [Learning from aviation - how to increase patient safety in surgery].

    Renz, B; Angele, M K; Jauch, K-W; Kasparek, M S; Kreis, M; Müller, M H

    2012-04-01

    During the last years attempts have been made to draw lessons from aviation to increase patient safety in medicine. In particular similar conditions are present in surgery as pilots and surgeons may have to support high physical and mental pressure. The use of a few safety instruments from aviation is feasible in an attempt to increase safety in surgery. First a "root caused" accident research may be established. This is achievable by morbidity and mortality conferences and critical incident reporting systems (CIRS). Second, standard operating procedures may assure a uniform mental model of team members. Furthermore, crew resource management illustrates a strategy and attitude concept, which is applicable in all situations. Safety instruments from aviation, therefore, seem to have a high potential to increase safety in surgery when properly employed. © Georg Thieme Verlag KG Stuttgart ˙ New York.

  20. Is culture associated with patient safety in the emergency department? A study of staff perspectives.

    Verbeek-van Noord, I.; Wagner, C.; Dyck, C. van; Twisk, J.W.R.; Bruijne, M.C. de

    2014-01-01

    Objective: To describe the patient safety culture of Dutch emergency departments (EDs), to examine associations between safety culture dimensions and patient safety grades as reported by ED staff and to compare these associations between nurses and physicians. DESIGN: Cross-sectional survey

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

    Gaal, S.; Verstappen, W.H.J.M.; Wensing, M.J.P.

    2010-01-01

    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

  2. Safety of repetitive transcranial magnetic stimulation in patients with implanted cortical electrodes. An ex-vivo study and report of a case.

    Phielipp, Nicolás M; Saha, Utpal; Sankar, Tejas; Yugeta, Akihiro; Chen, Robert

    2017-06-01

    To evaluate the safety of repetitive transcranial magnetic stimulation (rTMS) in patients with implanted subdural cortical electrodes. We performed ex-vivo experiments to test the temperature, displacement and current induced in the electrodes with single pulse transcranial magnetic stimulation (TMS) from 10 to 100% of stimulator output and tested a typical rTMS protocol used in a clinical setting. We then used rTMS to the motor cortex to treat a patient with refractory post-herpetic neuralgia who had previously been implanted with a subdural motor cortical electrode for pain management. The rTMS protocol consisted of ten sessions of 2000 stimuli at 20Hz and 90% of resting motor threshold. The ex-vivo study showed an increase in the coil temperature of 2°C, a maximum induced charge density of 30.4μC/cm 2 /phase, and no electrode displacement with TMS. There was no serious adverse effect associated with rTMS treatment of the patient. Cortical tremor was observed in the intervals between trains of stimuli during one treatment session. TMS was safe in a patient with implanted Medtronic Resume II electrode (model 3587A) subdural cortical electrode. TMS may be used as a therapeutic, diagnostic or research tool in patients this type of with implanted cortical electrodes. Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

  3. Enhancing nuclear safety. Annual report 2014. Financial report 2014

    2015-01-01

    After some introductory texts proposed by several IRSN head managers, and a brief presentation of some key data illustrating the activity, the annual report presents the main strategic orientations, notably in the field of knowledge management, and of information and communication. After some images illustrating the past year, activities are presented. They first deal with safety: Reactor safety (operating experience feedback), From decommissioning old reactors to designing those of the future, Safety of laboratories and plants, Safety regarding risks due to infrastructure near nuclear facilities, Reactor aging, Fuel: research on corrosion and deformation, Research and assessments for improved understanding of accident situations, Earthquakes: research and assessments, About defense, Geological disposal of radioactive waste. They secondly deal with security and non-proliferation (nuclear security, nuclear non-proliferation, chemical weapon ban), thirdly with radiation protection for human and environment health (environment monitoring, radionuclide transfer in the environment, radon and polluted sites, human exposure, radiation protection in the workplace, effects of low-dose chronic exposures, Organization of radiation protection at the European level, protection in health care), and fourthly with emergency and post-accident situations (emergency and post-accident preparedness and response, Emergency response tools). The next part of the activity report addresses issues related to efficiency: Real estate program (construction projects get started), Hygiene, safety, social responsibility, Human resources, Organization chart, Board of directors, Steering committee for the nuclear defense expertise Division - CODEND, Scientific council, Ethics commission composition, Nuclear safety and radiation protection Research policy committee - COR. The financial report proposes a management report, financial statements with an appendix to annual accounts, and an auditor

  4. Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

    Mazurenko, Olena; Richter, Jason; Kazley, Abby Swanson; Ford, Eric

    2017-04-25

    The aim of this study was to explore the relationship between managers and clinicians' agreement on deeming the patient safety climate as high or low and the patients' satisfaction with those organizations. We used two secondary data sets: the Hospital Survey on Patient Safety Culture (2012) and the Hospital Consumer Assessment of Healthcare Providers and Systems (2012). We used ordinary least squares regressions to analyze the relationship between the extent of agreement between managers and clinicians' perceptions of safety climate in relationship to patient satisfaction. The dependent variables were four Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores: communication with nurses, communication with doctors, communication about medicines, and discharge information. The main independent variables were four groups that were formed based on the extent of managers and clinicians' agreement on four patient safety climate domains: communication openness, feedback and communication about errors, teamwork within units, and teamwork across units. After controlling for hospital and market-level characteristics, we found that patient satisfaction was significantly higher if managers and clinicians reported that patient safety climate is high or if only clinicians perceived the climate as high. Specifically, manager and clinician agreement on high levels of communication openness (β = 2.25, p = .01; β = 2.46, p = .05), feedback and communication about errors (β = 3.0, p = .001; β = 2.89, p = .01), and teamwork across units (β = 2.91, p = .001; β = 3.34, p = .01) was positively and significantly associated with patient satisfaction with discharge information and communication about medication. In addition, more favorable perceptions about patient safety climate by clinicians only yielded similar findings. Organizations should measure and examine patient safety climate from multiple perspectives and be aware that individuals

  5. Nurse working conditions and patient safety outcomes.

    Stone, Patricia W; Mooney-Kane, Cathy; Larson, Elaine L; Horan, Teresa; Glance, Laurent G; Zwanziger, Jack; Dick, Andrew W

    2007-06-01

    System approaches, such as improving working conditions, have been advocated to improve patient safety. However, the independent effect of many working condition variables on patient outcomes is unknown. To examine effects of a comprehensive set of working conditions on elderly patient safety outcomes in intensive care units. Observational study, with patient outcome data collected using the National Nosocomial Infection Surveillance system protocols and Medicare files. Several measures of health status and fixed setting characteristics were used to capture distinct dimensions of patient severity of illness and risk for disease. Working condition variables included organizational climate measured by nurse survey; objective measures of staffing, overtime, and wages (derived from payroll data); and hospital profitability and magnet accreditation. The sample comprised 15,846 patients in 51 adult intensive care units in 31 hospitals depending on the outcome analyzed; 1095 nurses were surveyed. Central line associated bloodstream infections (CLBSI), ventilator-associated pneumonia, catheter-associated urinary tract infections, 30-day mortality, and decubiti. Units with higher staffing had lower incidence of CLBSI, ventilator-associated pneumonia, 30-day mortality, and decubiti (P working conditions were associated with all outcomes measured. Improving working conditions will most likely promote patient safety. Future researchers and policymakers should consider a broad set of working condition variables.

  6. 78 FR 12065 - Patient Safety Organizations: Delisting for Cause for Independent Data Safety Monitoring, Inc.

    2013-02-21

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Safety Monitoring, Inc. due to its failure to correct a deficiency. The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the listing of PSOs, which are entities or component...

  7. An Organizational Learning Framework for Patient Safety.

    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.

  8. Environment, health and safety progress report 1997

    1998-01-01

    Imperial Oil is Canada's largest producer of crude oil and a major producer of natural gas. It is also the largest refiner and marketer of petroleum products, sold mainly under the Esso brand. Imperial Oil, in participation with Syncrude Canada, is also a major developer of the oil sands reserves in Cold Lake, Alberta. This review of environmental and health and safety performance in 1997 highlights the Company's comprehensive approach to risk management to reduce risk to safety, health and the environment. It is noted that in 1997, the Company's employee and contractor safety performance continued to be among the best in the industry. Potentially hazardous incidents decreased as a consequence of Imperial Oil's more stringent health and safety management system. Environmental compliance notifications fell by more than half in 1997. During the year there was a slight increase in hazardous wastes, due to the loss of outlets for recycling some materials. The National Pollutants Release Inventory indicates that Imperial has reduced emissions and offsite transfers by 25 per cent since 1993. Volatile organic compounds have been reduced by 60 per cent since 1993. According to the report all Imperial Oil facilities operate well within the guidelines for sulphur dioxide emissions. 1 tab., 10 figs

  9. Anesthesia Quality and Patient Safety in China: A Survey.

    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.

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

    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....

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

    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 ...

  12. Ethnic inequalities in patient safety in Dutch hospital care

    van Rosse, F.

    2015-01-01

    This thesis shows the first results of Dutch studies on the relation between ethnicity and patient safety. We used mixed methods to identify patient safety outcomes and patient safety risks in a cohort study in 4 urban hospitals among 763 Dutch patients and 576 ethnic minority patients. In a record

  13. Explaining Ethnic Disparities in Patient Safety: A Qualitative Analysis

    Suurmond, Jeanine; Uiters, Ellen; de Bruijne, Martine C.; Stronks, Karien; Essink-Bot, Marie-Louise

    2010-01-01

    Objectives. We explored characteristics of in-hospital care and treatment of immigrant patients to better understand the processes underlying ethnic disparities in patient safety. Methods. We conducted semistructured interviews with care providers regarding patient safety events involving immigrant

  14. Probabilistic safety goals. Phase 2 - Status report

    Holmberg, J.-E.; Bjoerkman, K.; Rossi, J.; Knochenhauer, M.; Xuhong He; Persson, A.; Gustavsson, H.

    2008-07-01

    The second phase of the project, the outcome of which is described in this project report has mainly dealt with four issues: 1) Consistency in the usage of safety goals 2) Criteria for assessment of results from PSA level 2 3) Overview of international safety goals and experiences from their use 4) Safety goals related to other man-made risks in society. Consistency in judgement over time has been perceived to be one of the main problems in the usage of safety goals. Safety goals defined in the 80ies were met in the beginning with PSA:s performed to the standards of that time, i.e., by PSA:s that were quite limited in scope and level of detail compared to today's state of the art. This issue was investigated by performing a comparative review was performed of three generations of the same PSA, focusing on the impact from changes over time in component failure data, IE frequency, and modelling of the plant, including plant changes and changes in success criteria. It proved to be very time-consuming and in some cases next to impossible to correctly identify the basic causes for changes in PSA results. A multitude of different sub-causes turned out to combined and difficult to differentiate. Thus, rigorous book-keeping is needed in order to keep track of how and why PSA results change. This is especially important in order to differentiate 'real' differences due to plant changes and updated component and IE data from differences that are due to general PSA development (scope, level of detail, modelling issues). (au)

  15. Probabilistic safety goals. Phase 2 - Status report

    Holmberg, J.-E.; Bjoerkman, K. Rossi, J. (VTT (Finland)); Knochenhauer, M.; Xuhong He; Persson, A.; Gustavsson, H. (Relcon Scandpower AB, Sundbyberg (Sweden))

    2008-07-15

    The second phase of the project, the outcome of which is described in this project report has mainly dealt with four issues: 1) Consistency in the usage of safety goals 2) Criteria for assessment of results from PSA level 2 3) Overview of international safety goals and experiences from their use 4) Safety goals related to other man-made risks in society. Consistency in judgement over time has been perceived to be one of the main problems in the usage of safety goals. Safety goals defined in the 80ies were met in the beginning with PSA:s performed to the standards of that time, i.e., by PSA:s that were quite limited in scope and level of detail compared to today's state of the art. This issue was investigated by performing a comparative review was performed of three generations of the same PSA, focusing on the impact from changes over time in component failure data, IE frequency, and modelling of the plant, including plant changes and changes in success criteria. It proved to be very time-consuming and in some cases next to impossible to correctly identify the basic causes for changes in PSA results. A multitude of different sub-causes turned out to combined and difficult to differentiate. Thus, rigorous book-keeping is needed in order to keep track of how and why PSA results change. This is especially important in order to differentiate 'real' differences due to plant changes and updated component and IE data from differences that are due to general PSA development (scope, level of detail, modelling issues). (au)

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

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

    2015-02-01

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

  17. Uncertainty analysis for Ulysses safety evaluation report

    Frank, M.V.

    1991-01-01

    As part of the effort to review the Ulysses Final Safety Analysis Report and to understand the risk of plutonium release from the Ulysses spacecraft General Purpose Heat Source---Radioisotope Thermal Generator (GPHS-RTG), the Interagency Nuclear Safety Review Panel (INSRP) and the author performed an integrated, quantitative analysis of the uncertainties of the calculated risk of plutonium release from Ulysses. Using state-of-art probabilistic risk assessment technology, the uncertainty analysis accounted for both variability and uncertainty of the key parameters of the risk analysis. The results show that INSRP had high confidence that risk of fatal cancers from potential plutonium release associated with calculated launch and deployment accident scenarios is low

  18. Safety regulations for radioisotopes, etc. (interim report)

    1980-01-01

    An (interim) report by an ad hoc expert committee to the Nuclear Safety Commission, on the safety regulations for radioisotopes, etc., was presented. For the utilization of radioisotopes, etc., there is the Law Concerning Prevention of Radiation Injury Due to Radioisotopes, etc. with the advances in this field and the improvement in international standards, the regulations by the law have been examined. After explaining the basic ideas of the regulations, the problems and countermeasures in the current regulations are described: legal system, rationalization in permission procedures and others, inspection on RI management, the system of the persons in charge of radiation handling, RI transport, low-level radioactive wastes, consumer goods, definitions of RIs, radiation and sealed sources, regulations by group partitioning, RI facilities, system of personnel exposure registration, entrusting of inspection, etc. to private firms, and reduction in the works for permission among governmental offices. (author)

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

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

    2009-01-01

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

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

    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.

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

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

    2012-01-01

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

  2. En Route Patient Safety: A Mixed-Methods Study

    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

  3. Safe patient care - safety culture and risk management in otorhinolaryngology.

    St Pierre, Michael

    2013-12-13

    Safety culture is positioned at the heart of an organization's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organization's maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organization's safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality. Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate stimulation based team trainings into their

  4. [Safe patient care: safety culture and risk management in otorhinolaryngology].

    St Pierre, M

    2013-04-01

    Safety culture is positioned at the heart of an organisation's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organizations maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organisation's "safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate simulation based team trainings into their curriculum

  5. 78 FR 5866 - Pipeline Safety: Annual Reports and Validation

    2013-01-28

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket ID PHMSA-2012-0319] Pipeline Safety: Annual Reports and Validation AGENCY: Pipeline and Hazardous Materials... 2012 gas transmission and gathering annual reports, remind pipeline owners and operators to validate...

  6. Enhancing nuclear safety. Annual report 2015. Financial report 2015

    Le Guludec, Dominique; Niel, Jean-Christophe; Mouton, Georges-Henri; Repussard, Jacques; Schuler, Matthieu; Marchal, Valerie; Albert, Marc-Gerard; Bigot, Marie-Pierre; Brisset, Yves; Bruna, Giovanni; Charron, Sylvie; Clavelle, Stephanie; Deschamps, Patrice; Delattre, Aleth; Demeillers, Didier; Laloi, Patrick; Lorthioir, Stephane; Monti, Pascale; Rollinger, Francois; Rouyer, Veronique; Tharaud, Christine; Jaunet, Camille; Pascal-Heuze, Charlotte

    2016-01-01

    After some introductory texts proposed by several IRSN head managers, and a brief presentation of some key data illustrating the activity, the annual report presents the main strategic orientations, notably in the field of knowledge management, and of information and communication. After some images illustrating the past year, activities are presented. They first deal with safety: safety of civil nuclear facilities, from decommissioning old reactors to designing those of the future, reactor ageing, severe accidents, fuel, criticality and neutronics, fire and containment, safety and radiation protection of defence-related facilities and activities, geological disposal of radioactive wastes. They secondly deal with security and non-proliferation (nuclear security, nuclear non-proliferation, chemical weapon ban), thirdly with radiation protection for human and environment health (environment monitoring, radionuclide transfer in the environment, radon and polluted sites, human exposure, radiation protection in the workplace, effects of chronic exposures, protection in health care), and fourthly with emergency and post-accident situations (emergency and post-accident preparedness and response). The next part of the activity report addresses issues related to efficiency: improved economic and financial management, property, computer security, quality and corporate social responsibility, human resources, organisation chart. The financial report proposes a management report, financial statements with an appendix to annual accounts, and an auditor's report

  7. Nuclear Reactor RA Safety Report, Vol. 14, Safety protection measures

    1986-11-01

    Nuclear reactor accidents can be caused by three type of errors: failure of reactor components including (1) control and measuring instrumentation, (2) errors in operation procedure, (3) natural disasters. Safety during reactor operation are secured during its design and construction and later during operation. Both construction and administrative procedures are applied to attain safe operation. Technical safety features include fission product barriers, fuel elements cladding, primary reactor components (reactor vessel, primary cooling pipes, heat exchanger in the pump), reactor building. Safety system is the system for safe reactor shutdown and auxiliary safety system. RA reactor operating regulations and instructions are administrative acts applied to avoid possible human error caused accidents [sr

  8. The General Safety Group Annual Report 2001/2002

    Weingarten, W

    2003-01-01

    This report summarizes the main activities of the General Safety (GS) Group of the Technical Inspection and Safety Division during 2001 and 2002, and the results obtained. The different topics in which the group is active are covered: general safety inspections and ergonomics, electrical, chemical and gas safety, chemical pollution containment and control, industrial hygiene, the safety of civil engineering works and outside contractors, fire prevention and the safety aspects of the LHC experiments.

  9. 324 building safety analysis report supplement

    Dodd, A.O.; Wittenbrock, N.G.

    1977-01-01

    Process engineering designs, major equipment and plant facilities to be utilized in commercial nuclear waste preparation and vitrification in the 324 Radiochemical Engineering Building are reviewed with regard to accident potential and consequences. This Safety Analysis Report Supplement compares calculated environmental doses anticipated from the Commercial Nuclear Waste Vitrification Project (CNWVP) routine operations with the average doses from past waste management operations conducted at the Hanford Project and finds them to be significantly less. The calculated CNWVP environmental doses are found to be far below presently applicable ERDA standards and standards proposed by the EPA for nuclear power operations

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

    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

  11. [Innovative training for enhancing patient safety. Safety culture and integrated concepts].

    Rall, M; Schaedle, B; Zieger, J; Naef, W; Weinlich, M

    2002-11-01

    Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article. Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed. The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising. As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.

  12. Economic evaluation in patient safety: a literature review of methods.

    de Rezende, Bruna Alves; Or, Zeynep; Com-Ruelle, Laure; Michel, Philippe

    2012-06-01

    Patient safety practices, targeting organisational changes for improving patient safety, are implemented worldwide but their costs are rarely evaluated. This paper provides a review of the methods used in economic evaluation of such practices. International medical and economics databases were searched for peer-reviewed publications on economic evaluations of patient safety between 2000 and 2010 in English and French. This was complemented by a manual search of the reference lists of relevant papers. Grey literature was excluded. Studies were described using a standardised template and assessed independently by two researchers according to six quality criteria. 33 articles were reviewed that were representative of different patient safety domains, data types and evaluation methods. 18 estimated the economic burden of adverse events, 3 measured the costs of patient safety practices and 12 provided complete economic evaluations. Healthcare-associated infections were the most common subject of evaluation, followed by medication-related errors and all types of adverse events. Of these, 10 were selected that had adequately fulfilled one or several key quality criteria for illustration. This review shows that full cost-benefit/utility evaluations are rarely completed as they are resource intensive and often require unavailable data; some overcome these difficulties by performing stochastic modelling and by using secondary sources. Low methodological transparency can be a problem for building evidence from available economic evaluations. Investing in the economic design and reporting of studies with more emphasis on defining study perspectives, data collection and methodological choices could be helpful for strengthening our knowledge base on practices for improving patient safety.

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

    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.

  14. 242-A evaporator safety analysis report

    CAMPBELL, T.A.

    1999-01-01

    This report provides a revised safety analysis for the upgraded 242-A Evaporator (the Evaporator). This safety analysis report (SAR) supports the operation of the Evaporator following life extension upgrades and other facility and operations upgrades (e.g., Project B-534) that were undertaken to enhance the capabilities of the Evaporator. The Evaporator has been classified as a moderate-hazard facility (Johnson 1990). The information contained in this SAR is based on information provided by 242-A Evaporator Operations, Westinghouse Hanford Company, site maintenance and operations contractor from June 1987 to October 1996, and the existing operating contractor, Waste Management Hanford (WMH) policies. Where appropriate, a discussion address the US Department of Energy (DOE) Orders applicable to a topic is provided. Operation of the facility will be compared to the operating contractor procedures using appropriate audits and appraisals. The following subsections provide introductory and background information, including a general description of the Evaporator facility and process, a description of the scope of this SAR revision,a nd a description of the basic changes made to the original SAR

  15. 242-A evaporator safety analysis report

    CAMPBELL, T.A.

    1999-05-17

    This report provides a revised safety analysis for the upgraded 242-A Evaporator (the Evaporator). This safety analysis report (SAR) supports the operation of the Evaporator following life extension upgrades and other facility and operations upgrades (e.g., Project B-534) that were undertaken to enhance the capabilities of the Evaporator. The Evaporator has been classified as a moderate-hazard facility (Johnson 1990). The information contained in this SAR is based on information provided by 242-A Evaporator Operations, Westinghouse Hanford Company, site maintenance and operations contractor from June 1987 to October 1996, and the existing operating contractor, Waste Management Hanford (WMH) policies. Where appropriate, a discussion address the US Department of Energy (DOE) Orders applicable to a topic is provided. Operation of the facility will be compared to the operating contractor procedures using appropriate audits and appraisals. The following subsections provide introductory and background information, including a general description of the Evaporator facility and process, a description of the scope of this SAR revision,a nd a description of the basic changes made to the original SAR.

  16. Expediting Clinician Adoption of Safety Practices: The UCSF Venous Access Patient Safety Interdisciplinary Education Project

    Donaldson, Nancy E; Plank, Rosemary K; Williamson, Ann; Pearl, Jeffrey; Kellogg, Jerry; Ryder, Marcia

    2005-01-01

    ...) Venous Access Device (VAD) Patient Safety Interdisciplinary Education Project was to develop a 30-hour/one clinical academic unit VAD patient safety course with the aim of expediting clinician adoption of critical concepts...

  17. Safety

    1998-01-01

    A brief account of activities carried out by the Nuclear power plants Jaslovske Bohunice in 1997 is presented. These activities are reported under the headings: (1) Nuclear safety; (2) Industrial and health safety; (3) Radiation safety; and Fire protection

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

    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

  19. Improving patient safety through quality assurance.

    Raab, Stephen S

    2006-05-01

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

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

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

    2017-11-01

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

  1. Patient safety problem identification and solution sharing among rural community pharmacists.

    Galt, Kimberly A; Fuji, Kevin T; Faber, Jennifer

    2013-01-01

    To implement a communication network for safety problem identification and solution sharing among rural community pharmacists and to report participating pharmacists' perceived value and impact of the network on patient safety after 1 year of implementation. Action research study. Rural community pharmacies in Nebraska from January 2010 to April 2011. Rural community pharmacists who voluntarily agreed to join the Pharmacists for Patient Safety Network in Nebraska. Pharmacists reported errors, near misses, and safety concerns through Web-based event reporting. A rapid feedback process was used to provide patient safety solutions to consider implementing across the network. Qualitative interviews were conducted 1 year after program implementation with participating pharmacists to assess use of the reporting system, value of the disseminated safety solutions, and perceived impact on patient safety in pharmacies. 30 of 38 pharmacists participating in the project completed the interviews. The communication network improved pharmacist awareness, promoted open discussion and knowledge sharing, contributed to practice vigilance, and led to incorporation of proactive safety prevention practices. Despite low participation in error and near-miss reporting, a dynamic communication network designed to rapidly disseminate evidence-based patient safety strategies to reduce risk was valued and effective at improving patient safety practices in rural community pharmacies.

  2. Medical error disclosure and patient safety: legal aspects

    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.

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

    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.

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

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

    2017-01-18

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

  5. 78 FR 17212 - Patient Safety Organizations: Voluntary Relinquishment From Universal Safety Solution PSO

    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...

  6. Safety evaluation status report for the prototype license application safety analysis report

    1989-07-01

    The US Nuclear Regulatory Commission (NRC) staff and consultants reviewed a Prototype License Application Safety Analysis Report (PLASAR) submitted by the US Department of Energy (DOE) for the earth-mounded concrete bunker (EMCB) alternative method of low-level radioactive waste disposal. The NRC reviewers relied extensively on the Standard Review Plan (SRP), Rev.1 (NUREG-1200), to evaluate the acceptability of the information provided in the EMCB PLASAR. The NRC staff selected certain review areas in the PLASAR for development of safety evaluation report input to provide examples of safety assessments that are necessary as part of a licensing review. Because of the fictitious nature of the assumed disposal site, and the decision to limit the review to essentially first-round review status, the NRC staff report is labeled a ''Safety Evaluation Status Report'' (SESR). Appendix A comprises the NRC review comments and questions on the information that DOE submitted in the PLASAR. The NRC concentrated its review on the design and operations-related portions of the EMCB PLASAR

  7. Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

    McTiernan, Patricia; Wachter, Robert M; Meyer, Gregg S; Gandhi, Tejal K

    2015-02-01

    The opening keynote session of the 16th Annual National Patient Safety Foundation Patient Safety Congress, held 14-16 May 2014, featured a debate addressing the merits and challenges of accountability with respect to key issues in patient safety. The specific resolution debated was: Certain safety practices should be inviolable, and transgressions should result in penalties, potentially including fines, suspensions, and firing. The themes discussed in the debate are issues that healthcare professionals and leaders commonly struggle with in their day-to-day work. How do we draw a line between systems problems and personal failings? When should clinicians and staff be penalised for failing to follow a known safety protocol? The majority of those who listened to the live debate agreed that it is time to begin holding health professionals accountable when they wilfully or repeatedly violate policies or protocols put in place by their institutions to protect the safety of patients. This article summarises the debate as well as the questions and discussion generated by each side. A video of the original debate can be found at http://bit.ly/Npsf_debate. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  8. Patient Safety Movement: History and Future Directions.

    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.

  9. Advancing perinatal patient safety through application of safety science principles using health IT.

    Webb, Jennifer; Sorensen, Asta; Sommerness, Samantha; Lasater, Beth; Mistry, Kamila; Kahwati, Leila

    2017-12-19

    The use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety. Semi-structured interviews were conducted with L&D units participating in the Agency for Healthcare Research and Quality's (AHRQ's) Safety Program for Perinatal Care (SPPC) to assess units' experience with program implementation. Analysis of interview transcripts was used to characterize the process and experience of using health IT for applying safety science principles to L&D unit processes. Forty-six L&D units from 10 states completed participation in SPPC program implementation; thirty-two (70%) reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects. L&D units standardized care processes through use of electronic health record (EHR)-based order sets and use of smart pumps and other technology to improve medication safety. Units also standardized EHR documentation, particularly related to electronic fetal monitoring (EFM) and shoulder dystocia. Cognitive aids and tools were integrated into EHR and care workflows to create independent checks such as checklists, risk assessments, and communication handoff tools. Units also used data from EHRs to monitor processes of care to learn from defects. Units experienced several challenges incorporating health IT, including obtaining organization approval, working with their busy IT departments, and retrieving standardized data from health IT systems. Use of health IT played an integral part in the planning and implementation of SPPC for participating L&D units. Use of health IT is an encouraging approach for incorporating safety science principles into care to improve perinatal safety and should be incorporated

  10. Perspective of Nurses toward the Patient Safety Culture in Neonatal Intensive Care Units

    Saba Farzi

    2017-12-01

    Conclusion: According to the results, adherence to the dimensions of the patient safety culture was poor in the studied hospitals. Therefore, the patient safety culture requires special attention by providing proper facilities, adequate staff, developing checklists for handoffs and transitions, and surveillance and continuous monitoring by healthcare centers. Furthermore, a system-based approach should be implemented to deal with errors, while a persuasive reporting approach is needed to promote the patient safety culture in the NICUs of these hospitals.

  11. 76 FR 7855 - Patient Safety Organizations: Voluntary Delisting From Community Medical Foundation for Patient...

    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...

  12. 75 FR 57281 - Patient Safety Organizations: Voluntary delisting

    2010-09-20

    ... Organizations: Voluntary delisting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS ACTION: Notice... Patient Safety Corporation of its status as a Patient Safety Organization (PSO). The Patient Safety and... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

  13. Towards an international classification for patient safety : the conceptual framework

    Sherman, H.; Castro, G.; Fletcher, M.; Hatlie, M.; Hibbert, P.; Jakob, R.; Koss, R.; Lewalle, P.; Loeb, J.; Perneger, Th.; Runciman, W.; Thomson, R.; Schaaf, van der T.W.; Virtanen, M.

    2009-01-01

    Global advances in patient safety have been hampered by the lack of a uniform classification of patient safety concepts. This is a significant barrier to developing strategies to reduce risk, performing evidence-based research and evaluating existing healthcare policies relevant to patient safety.

  14. An international review of patient safety measures in radiotherapy practice

    Shafiq, Jesmin; Barton, Michael; Noble, Douglas; Lemer, Claire; Donaldson, Liam J.

    2009-01-01

    Errors from radiotherapy machine or software malfunction usually are well documented as they affect hundreds of patients, whereas random errors affecting individual patients are more difficult to be discovered and prevented. Although major clinical radiotherapy incidents have been reported, many more have remained unrecognised or have not been reported. The literature in this field is limited as it is mostly published as a result of investigation of major errors. We present a review of radiotherapy incidents internationally with the aim of identifying the domains where most errors occur through extensive review and synthesis of published reports, unpublished 'Grey literature' and departmental incident data. Our review of radiotherapy-related events in the last three decades (1976-2007) identified more than seven thousand (N = 7741) incidents and near misses. Three thousand one hundred and twenty-five incidents reported patient harm of variable intensity ranging from underdose increasing the risk of recurrence, to overdose causing toxicity, and even death for 1% (N = 38); 4616 events were near misses with no recognisable patient harm. Based on our review, a radiotherapy risk profile has been published by the WHO World Alliance for Patient Safety that highlights the role of communication, training and strict adherence to guidelines/protocols in improving the safety of radiotherapy process.

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

    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.

  16. An interprofessional course using human patient simulation to teach patient safety and teamwork skills.

    Vyas, Deepti; McCulloh, Russell; Dyer, Carla; Gregory, Gretchen; Higbee, Dena

    2012-05-10

    To assess the effectiveness of human patient simulation to teach patient safety, team-building skills, and the value of interprofessional collaboration to pharmacy students. Five scenarios simulating semi-urgent situations that required interprofessional collaboration were developed. Groups of 10 to 12 health professions students that included 1 to 2 pharmacy students evaluated patients while addressing patient safety hazards. Pharmacy students' scores on 8 of 30 items on a post-simulation survey of knowledge, skills, and attitudes improved over pre-simulation scores. Students' scores on 3 of 10 items on a team building and interprofessional communications survey also improved after participating in the simulation exercise. Over 90% of students reported that simulation increased their understanding of professional roles and the importance of interprofessional communication. Simulation training provided an opportunity to improve pharmacy students' ability to recognize and react to patient safety concerns and enhanced their interprofessional collaboration and communication skills.

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

    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.

  18. Assessment of patient safety culture in private and public hospitals in Peru.

    Arrieta, Alejandro; Suárez, Gabriela; Hakim, Galed

    2018-04-01

    To assess the patient safety culture in Peruvian hospitals from the perspective of healthcare professionals, and to test for differences between the private and public healthcare sectors. Patient safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of healthcare delivery. A non-random cross-sectional study conducted online. An online survey was administered from July to August 2016, in Peru. This study reports results from Lima and Callao, which are the capital and the port region of Peru. A total of 1679 healthcare professionals completed the survey. Participants were physicians, medical residents and nurses working in healthcare facilities from the private sector and public sector. Assessment of the degree of patient safety and 12 dimensions of patient safety culture in hospital units as perceived by healthcare professionals. Only 18% of healthcare professionals assess the degree of patient safety in their unit of work as excellent or very good. Significant differences are observed between the patient safety grades in the private sector (37%) compared to the public sub-sectors (13-15%). Moreover, in all patient safety culture dimensions, healthcare professionals from the private sector give more favorable responses for patient safety, than those from the public sub-systems. The most significant difference in support comes from patient safety administrators through communication and information about errors. Overall, the degree of patient safety in Peru is low, with significant gaps that exist between the private and the public sectors.

  19. Nurses' Perceptions of Patient Safety Culture in Three Hospitals in Saudi Arabia.

    Alquwez, Nahed; Cruz, Jonas Preposi; Almoghairi, Ahmed Mohammed; Al-Otaibi, Raid Salman; Almutairi, Khalid Obaid; Alicante, Jerico G; Colet, Paolo C

    2018-05-14

    To assess the present patient safety culture of three general hospitals in Saudi Arabia, as perceived by nurses. This study utilized a descriptive, cross-sectional design. A convenience sample of 351 nurses working in three general hospitals in the central region of Saudi Arabia was surveyed in this study using the Hospital Survey of Patients' Safety Culture (HSOPSC) from October 2016 to April 2017. From the 12 composites of the HSOPSC, the nurses perceived only the following two patient safety areas as strengths: teamwork within units and organizational learning-continuous improvement. Six areas of patient safety were identified as weaknesses, namely overall perception of patient safety, handoffs and transitions, communication openness, staffing, frequency of events reported, and nonpunitive response to errors. Nationality, educational attainment, hospital, length of service in the hospital, work area or unit, length of service in the current work area or unit, current position, and direct patient contact or interaction were significant predictors of the nurses' perceived patient safety culture. The findings in this study clarify the current status of patient safety culture in three hospitals in the Kingdom of Saudi Arabia. The present findings should be considered by policymakers, hospital leaders, and nurse executives in creating interventions aimed at improving the patient safety culture in hospitals. A multidimensional network intervention targeting the different dimensions of patient safety culture and involving different organizational levels should be implemented to improve patient safety. © 2018 Sigma Theta Tau International.

  20. HTGR safety research program. Progress report, April--June 1975

    Kirk, W.L.

    1975-09-01

    Progress in HTGR safety research is reported under the following headings: fission product technology; primary coolant impurities; structural investigation; safety instrumentation and control systems; phenomena modeling and systems analysis. (JWR)

  1. Applied Health Physics and Safety annual report for 1975

    1976-08-01

    This report describes and summarizes the activities of the applied sections and/or groups of the Health Physics Division. Projects and activities covered include personnel monitoring, environmental monitoring, radiation and safety surveys, and industrial safety

  2. Geosphere process report for the safety assessment SR-Site

    Skagius, Kristina

    2010-11-01

    This report documents geosphere processes identified as relevant to the long-term safety of a KBS-3 repository, and forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/

  3. Geosphere process report for the safety assessment SR-Site

    Skagius, Kristina (ed.) (Kemakta Konsult AB, Stockholm (Sweden))

    2010-11-15

    This report documents geosphere processes identified as relevant to the long-term safety of a KBS-3 repository, and forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/

  4. Manpower analysis in transportation safety. Final report

    Bauer, C.S.; Bowden, H.M.; Colford, C.A.; DeFilipps, P.J.; Dennis, J.D.; Ehlert, A.K.; Popkin, H.A.; Schrader, G.F.; Smith, Q.N.

    1977-05-01

    The project described provides a manpower review of national, state and local needs for safety skills, and projects future manning levels for transportation safety personnel in both the public and private sectors. Survey information revealed that there are currently approximately 121,000 persons employed directly in transportation safety occupations within the air carrier, highway and traffic safety, motor carrier, pipeline, rail carrier, and marine carrier transportation industry groups. The projected need for 1980 is over 145,000 of which over 80 percent will be in highway safety. An analysis of transportation tasks is included, and shows ten general categories about which the majority of safety activities are focused. A skills analysis shows a generally high level of educational background and several years of experience are required for most transportation safety jobs. An overall review of safety programs in the transportation industry is included, together with chapters on the individual transportation modes.

  5. Preliminary report of radiological safety to hydrology 1993 campaign

    Badano, A.; Suarez Antola, R.; Dellepere, A.; Barreiro, M.

    1993-01-01

    This report has been prepared based on the interaction between project managers and division radiological Protection and Nuclear Safety. In seeking to establish a basis for approval from the point of view of radiation safety practices . The idea for the audit has been provided at all times because the interest was the exchange of ideas and the use of common sense to improve the safety of radioactive substances, security of operators and public safety and environment.The above shows that in the planned radiation safety condition described in this report,the practice can be carried out according to the criteria of safety accepted .

  6. Safety climate and self-reported injury: assessing the mediating role of employee safety control.

    Huang, Yueng-Hsiang; Ho, Michael; Smith, Gordon S; Chen, Peter Y

    2006-05-01

    To further reduce injuries in the workplace, companies have begun focusing on organizational factors which may contribute to workplace safety. Safety climate is an organizational factor commonly cited as a predictor of injury occurrence. Characterized by the shared perceptions of employees, safety climate can be viewed as a snapshot of the prevailing state of safety in the organization at a discrete point in time. However, few studies have elaborated plausible mechanisms through which safety climate likely influences injury occurrence. A mediating model is proposed to link safety climate (i.e., management commitment to safety, return-to-work policies, post-injury administration, and safety training) with self-reported injury through employees' perceived control on safety. Factorial evidence substantiated that management commitment to safety, return-to-work policies, post-injury administration, and safety training are important dimensions of safety climate. In addition, the data support that safety climate is a critical factor predicting the history of a self-reported occupational injury, and that employee safety control mediates the relationship between safety climate and occupational injury. These findings highlight the importance of incorporating organizational factors and workers' characteristics in efforts to improve organizational safety performance.

  7. Influence of workplace demands on nurses' perception of patient safety.

    Ramanujam, Rangaraj; Abrahamson, Kathleen; Anderson, James G

    2008-06-01

    Patient safety is an ongoing challenge in the design and delivery of health-care services. As registered nurses play an integral role in patient safety, further examination of the link between nursing work and patient safety is warranted. The present study examines the relationship between nurses' perceptions of job demands and nurses' perceptions of patient safety. Structural equation modeling is used to analyze the data collected from a survey of 430 registered nurses at two community hospitals in the USA. As hypothesized, nurses' perception of patient safety decreases as the job demands increase. The level of personal control over practice directly affects nurses' perception of the ability to assure patient well-being. Nurses who work full-time and are highly educated have a decreased perception of patient safety, as well. The significant relationship between job demands and patient safety confirms that nurses make a connection between their working conditions and the ability to deliver safe care.

  8. Device-associated infections among neonatal intensive care unit patients: incidence and associated pathogens reported to the National Healthcare Safety Network, 2006-2008.

    Hocevar, Susan N; Edwards, Jonathan R; Horan, Teresa C; Morrell, Gloria C; Iwamoto, Martha; Lessa, Fernanda C

    2012-12-01

    To describe rates and pathogen distribution of device-associated infections (DAIs) in neonatal intensive care unit (NICU) patients and compare differences in infection rates by hospital type (children's vs general hospitals). Neonates in NICUs participating in the National Healthcare Safety Network from 2006 through 2008. We analyzed central line-associated bloodstream infections (CLABSIs), umbilical catheter-associated bloodstream infections (UCABs), and ventilator-associated pneumonia (VAP) among 304 NICUs. Differences in pooled mean incidence rates were examined using Poisson regression; nonparametric tests for comparing medians and rate distributions were used. Pooled mean incidence rates by birth weight category (750 g or less, 751-1,000 g, 1,001-1,500 g, 1,501-2,500 g, and more than 2,500 g, respectively) were 3.94, 3.09, 2.25, 1.90, and 1.60 for CLABSI; 4.52, 2.77, 1.70, 0.91, and 0.92 for UCAB; and 2.36, 2.08, 1.28, 0.86, and 0.72 for VAP. When rates of infection between hospital types were compared, only pooled mean VAP rates were significantly lower in children's hospitals than in general hospitals among neonates weighing 1,000 g or less; no significant differences in medians or rate distributions were noted. Pathogen frequencies were coagulase-negative staphylococci (28%), Staphylococcus aureus (19%), and Candida species (13%) for bloodstream infections and Pseudomonas species (16%), S. aureus (15%), and Klebsiella species (14%) for VAP. Of 673 S. aureus isolates with susceptibility results, 33% were methicillin resistant. Neonates weighing 750 g or less had the highest DAI incidence. With the exception of VAP, pooled mean NICU incidence rates did not differ between children's and general hospitals. Pathogens associated with these infections can pose treatment challenges; continued efforts at prevention need to be applied to all NICU settings.

  9. The Patient's Voice in Pharmacovigilance: Pragmatic Approaches to Building a Patient-Centric Drug Safety Organization.

    Smith, Meredith Y; Benattia, Isma

    2016-09-01

    Patient-centeredness has become an acknowledged hallmark of not only high-quality health care but also high-quality drug development. Biopharmaceutical companies are actively seeking to be more patient-centric in drug research and development by involving patients in identifying target disease conditions, participating in the design of, and recruitment for, clinical trials, and disseminating study results. Drug safety departments within the biopharmaceutical industry are at a similar inflection point. Rising rates of per capita prescription drug use underscore the importance of having robust pharmacovigilance systems in place to detect and assess adverse drug reactions (ADRs). At the same time, the practice of pharmacovigilance is being transformed by a host of recent regulatory guidances and related initiatives which emphasize the importance of the patient's perspective in drug safety. Collectively, these initiatives impact the full range of activities that fall within the remit of pharmacovigilance, including ADR reporting, signal detection and evaluation, risk management, medication error assessment, benefit-risk assessment and risk communication. Examples include the fact that manufacturing authorization holders are now expected to monitor all digital sources under their control for potential reports of ADRs, and the emergence of new methods for collecting, analysing and reporting patient-generated ADR reports for signal detection and evaluation purposes. A drug safety department's ability to transition successfully into a more patient-centric organization will depend on three defining attributes: (1) a patient-centered culture; (2) deployment of a framework to guide patient engagement activities; and (3) demonstrated proficiency in patient-centered competencies, including patient engagement, risk communication and patient preference assessment. Whether, and to what extent, drug safety departments embrace the new patient-centric imperative, and the methods and

  10. Health innovation for patient safety improvement

    Renukha Sellappans

    2013-01-01

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

  11. Health innovation for patient safety improvement.

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

    2013-01-01

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

  12. Effects of a team-based assessment and intervention on patient safety culture in general practice

    Hoffmann, B; Müller, V; Rochon, J

    2014-01-01

    Background: The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations....... In this study we assessed the effects of FraTrix on safety culture in general practice. Methods: We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12...... months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. Results: During the team sessions, practice teams reflected on their safety...

  13. Advancing Measurement of Patient Safety Culture

    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

  14. Measurement equivalence of patient safety climate in Chinese hospitals: can we compare across physicians and nurses?

    Zhu, Junya

    2018-06-11

    Self-report instruments have been widely used to better understand variations in patient safety climate between physicians and nurses. Research is needed to determine whether differences in patient safety climate reflect true differences in the underlying concepts. This is known as measurement equivalence, which is a prerequisite for meaningful group comparisons. This study aims to examine the degree of measurement equivalence of the responses to a patient safety climate survey of Chinese hospitals and to demonstrate how the measurement equivalence method can be applied to self-report climate surveys for patient safety research. Using data from the Chinese Hospital Survey of Patient Safety Climate from six Chinese hospitals in 2011, we constructed two groups: physicians and nurses (346 per group). We used multiple-group confirmatory factor analyses to examine progressively more stringent restrictions for measurement equivalence. We identified weak factorial equivalence across the two groups. Strong factorial equivalence was found for Organizational Learning, Unit Management Support for Safety, Adequacy of Safety Arrangements, Institutional Commitment to Safety, Error Reporting and Teamwork. Strong factorial equivalence, however, was not found for Safety System, Communication and Peer Support and Staffing. Nevertheless, further analyses suggested that nonequivalence did not meaningfully affect the conclusions regarding physician-nurse differences in patient safety climate. Our results provide evidence of at least partial equivalence of the survey responses between nurses and physicians, supporting mean comparisons of its constructs between the two groups. The measurement equivalence approach is essential to ensure that conclusions about group differences are valid.

  15. Safety climate and attitude toward medication error reporting after hospital accreditation in South Korea.

    Lee, Eunjoo

    2016-09-01

    This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. This study employed a longitudinal, descriptive design. Data were collected using questionnaires. A tertiary acute hospital in South Korea undergoing a hospital accreditation program. Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively. Hospital accreditation program. Perceived safety climate and attitude toward medication error reporting. The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants' perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program. Improving hospitals' safety climate increased nurses' medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses' fear of penalties. Administration and managers should support nurses who report their own errors. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  16. 77 FR 42738 - Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient...

    2012-07-20

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient Safety of Chicagoland (CQPS.... SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41,42...

  17. FAA National Aviation Safety Inspection Program. Annual Report FY90

    1991-06-01

    This report was undertaken to document, analyze, and place : into national perspective the findings from the 1990 National : Aviation Safety Inspection Program (NASIP). This report is the : fifth in a series of annual reports covering the results of ...

  18. Culture influence and predictors for behavioral involvement in patient safety among hospital nurses in Taiwan.

    Chiang, Hui-Ying; Lin, Shu-Yuan; Hsiao, Ya-Chu; Chang, Yuanmay

    2012-01-01

    This study explored the effects of incident reporting culture and willingness of incident reporting on behavioral involvement in patient safety (BIPS) by surveying 1049 hospital nurses in Taiwan. The highest areas of BIPS were handoff communication and discussion on error prevention. Yet, sharing information about human factors toward safety awareness was less frequent. Results indicated that the reporting culture, willingness to report, tenure of work, and reporting rate contributed positively to BIPS.

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

    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.

  20. Radiation safety and care of patients

    Das, B.K.; Noreen Norfaraheen Lee Abdullah

    2012-01-01

    The objective of this chapter is to acquaint the reader with radiation safety measures which can be pursued to minimize radiation load to the patient and staff. The basic principle is that all unnecessary administration should be avoided and a number of simple techniques be used to reduce radiation dose. For example, the kidney excretes many radionuclides. Drinking plenty of fluid and frequent bladder emptying can minimize absorbed dose to the bladder. Thyroid blocking agents must be used if radioactive iodine is being administered to avoid unnecessary radiation exposure to the thyroid gland. When it is necessary to administer radioactive substances to a female of childbearing age, the radiation exposure should be minimum and information whether the patient is pregnant or not must be obtained. Alternatives techniques, which do not involve ionizing radiation, should also be considered. (author)

  1. [Electronic patient record as the tool for better patient safety].

    Schneider, Henning

    2015-01-01

    Recent studies indicate again that there is a deficit in the use of electronic health records (EHR) in German hospitals. Despite good arguments in favour of their use, such as the rapid availability of data, German hospitals shy away from a wider implementation. The reason is the high cost of installing and maintaining the EHRs, for the benefit is difficult to evaluate in monetary terms for the hospital. Even if a benefit can be shown it is not necessarily evident within the hospital, but manifests itself only in the health system outside. Many hospitals only manage to partly implement EHR resulting in increased documentation requirements which reverse their positive effect.In the United States, electronic medical records are also viewed in light of their positive impact on patient safety. In particular, electronic medication systems prove the benefits they can provide in the context of patient safety. As a result, financing systems have been created to promote the digitalisation of hospitals in the United States. This has led to a large increase in the use of IT systems in the United States in recent years. The Universitätsklinikum Eppendorf (UKE) introduced electronic patient records in 2009. The benefits, in particular as regards patient safety, are numerous and there are many examples to illustrate this position. These positive results are intended to demonstrate the important role EHR play in hospitals. A financing system of the ailing IT landscape based on the American model is urgently needed to benefit-especially in terms of patient safety-from electronic medical records in the hospital.

  2. Improving ICU risk management and patient safety.

    Kielty, Lucy Ann

    2017-06-12

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

  3. [Improving patient safety through voluntary peer review].

    Kluge, S; Bause, H

    2015-01-01

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

  4. Preparing a Safety Analysis Report using the building block approach

    Herrington, C.C.

    1990-01-01

    The credibility of the applicant in a licensing proceeding is severely impacted by the quality of the license application, particularly the Safety Analysis Report. To ensure the highest possible credibility, the building block approach was devised to support the development of a quality Safety Analysis Report. The approach incorporates a comprehensive planning scheme that logically ties together all levels of the investigation and provides the direction necessary to prepare a superior Safety Analysis Report

  5. 21 CFR 312.88 - Safeguards for patient safety.

    2010-04-01

    ... 21 Food and Drugs 5 2010-04-01 2010-04-01 false Safeguards for patient safety. 312.88 Section 312... Severely-debilitating Illnesses § 312.88 Safeguards for patient safety. All of the safeguards incorporated within parts 50, 56, 312, 314, and 600 of this chapter designed to ensure the safety of clinical testing...

  6. Safety evaluation report of the Waste Isolation Pilot Plant safety analysis report: Contact-handled transuranic waste disposal operations

    1997-02-01

    DOE 5480.23, Nuclear Safety Analysis Reports, requires that the US Department of Energy conduct an independent, defensible, review in order to approve a Safety Analysis Report (SAR). That review and the SAR approval basis is documented in this formal Safety Evaluation Report (SER). This SER documents the DOE's review of the Waste Isolation Pilot Plant SAR and provides the Carlsbad Area Office Manager, the WIPP SAR approval authority, with the basis for approving the safety document. It concludes that the safety basis documented in the WIPP SAR is comprehensive, correct, and commensurate with hazards associated with planned waste disposal operations

  7. AMNT 2014. Key Topic: Reactor operation, safety - report. Pt. 1

    Schaffrath, Andreas

    2014-01-01

    Summary report on one session of the Annual Conference on Nuclear Technology held in Frankfurt, 6 to 8 May 2014: - Safety of Nuclear Installations - Methods, Analysis, Results: Backfittings for the Improvement of Safety and Efficiency. The other Sessions of the Key Topics 'Reactor Operation, Safety', 'Competence, Innovation, Regulation' and 'Fuel, Decommissioning and Disposal' will be covered in further issues of atw.

  8. Industrial safety and applied health physics. Annual report for 1977

    Auxier, J.A.; Davis, D.M.

    1978-06-01

    Progress is reported on the following: radiation monitoring with regard to personnel monitoring and health physics instrumentation; environs surveillance with regard to atmospheric monitoring, water monitoring, radiation background measurements, and soil and grass samples; radiation and safety surveys with regard to laboratory operations monitoring, radiation incidents, and laundry monitoring; industrial safety and special projects with regard to accident analysis, disabling injuries, and safety awards

  9. Strengthening the Global Nuclear Safety Regime. INSAG-21. A report by the International Nuclear Safety Group

    2014-01-01

    The Global Nuclear Safety Regime is the framework for achieving the worldwide implementation of a high level of safety at nuclear installations. Its core is the activities undertaken by each country to ensure the safety and security of the nuclear installations within its jurisdiction. But national efforts are and should be augmented by the activities of a variety of international enterprises that facilitate nuclear safety - intergovernmental organizations, multinational networks among operators, multinational networks among regulators, the international nuclear industry, multinational networks among scientists, international standards setting organizations and other stakeholders such as the public, news media and non-governmental organizations (NGOs) that are engaged in nuclear safety. All of these efforts should be harnessed to enhance the achievement of safety. The existing Global Nuclear Safety Regime is functioning at an effective level today. But its impact on improving safety could be enhanced by pursuing some measured change. This report recommends action in the following areas: - Enhanced use of the review meetings of the Convention on Nuclear Safety as a vehicle for open and critical peer review and a source for learning about the best safety practices of others; - Enhanced utilization of IAEA Safety Standards for the harmonization of national safety regulations, to the extent feasible; - Enhanced exchange of operating experience for improving operating and regulatory practices; and - Multinational cooperation in the safety review of new nuclear power plant designs. These actions, which are described more fully in this report, should serve to enhance the effectiveness of the Global Nuclear Safety Regime

  10. Improving Patient Safety in Anesthesia: A Success Story?

    Botney, Richard

    2008-01-01

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

  11. Safety assessment of research reactors and preparation of the safety analysis report

    1994-01-01

    This Safety Guide presents guidelines, approved by international consensus, for the preparation, review and assessment of safety documentation for research reactors such as the Safety Analysis Report. While the Guide is most applicable to research reactors in the design and construction stage, it is also recommended for use during relicensing or reassessment of existing reactors

  12. Report on safety and the environment 1992-93

    1993-09-01

    The steps taken by AEA Technology to implement high safety and environmental standards and performance levels achieved are summarized. AEA's policy on safety and the environment is stated. The way that safety is organised, how plant safety cases are made, plant operations and safety 1992-93 and decommissioning work at several of AEA's plants are reported. Radiological doses for AEA plants are shown to have fallen since 1990. General industrial and office safety, what is learned from accidents and incidents, how the environment is protected, the occupational health services provided and the emergency arrangements in operation are also mentioned briefly. (UK)

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

    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.

  14. Current status of safety analysis report for ANPP

    Amirjanyan, A.

    1999-01-01

    Current situation concerning Armenian NPP safety analysis report is considered within the frame of accepted safety practice. Licensing procedure is being developed. Technical support group was established in the Armenian Nuclear Regulatory Authority (ANRA). The task of the group is to study modern methods of NPP in depth safety analysis for technical assistance for the ANRA, and perform independent safety assessments. ANRA will be obliged to demand assistance from various foreign organisations for preparation of different parts of the Safety Analysis Report like determination though certain parts can be prepared in Armenia

  15. Safety of Magnetic Resonance Imaging in Patients with Cardiac Devices.

    Nazarian, Saman; Hansford, Rozann; Rahsepar, Amir A; Weltin, Valeria; McVeigh, Diana; Gucuk Ipek, Esra; Kwan, Alan; Berger, Ronald D; Calkins, Hugh; Lardo, Albert C; Kraut, Michael A; Kamel, Ihab R; Zimmerman, Stefan L; Halperin, Henry R

    2017-12-28

    Patients who have pacemakers or defibrillators are often denied the opportunity to undergo magnetic resonance imaging (MRI) because of safety concerns, unless the devices meet certain criteria specified by the Food and Drug Administration (termed "MRI-conditional" devices). We performed a prospective, nonrandomized study to assess the safety of MRI at a magnetic field strength of 1.5 Tesla in 1509 patients who had a pacemaker (58%) or an implantable cardioverter-defibrillator (42%) that was not considered to be MRI-conditional (termed a "legacy" device). Overall, the patients underwent 2103 thoracic and nonthoracic MRI examinations that were deemed to be clinically necessary. The pacing mode was changed to asynchronous mode for pacing-dependent patients and to demand mode for other patients. Tachyarrhythmia functions were disabled. Outcome assessments included adverse events and changes in the variables that indicate lead and generator function and interaction with surrounding tissue (device parameters). No long-term clinically significant adverse events were reported. In nine MRI examinations (0.4%; 95% confidence interval, 0.2 to 0.7), the patient's device reset to a backup mode. The reset was transient in eight of the nine examinations. In one case, a pacemaker with less than 1 month left of battery life reset to ventricular inhibited pacing and could not be reprogrammed; the device was subsequently replaced. The most common notable change in device parameters (>50% change from baseline) immediately after MRI was a decrease in P-wave amplitude, which occurred in 1% of the patients. At long-term follow-up (results of which were available for 63% of the patients), the most common notable changes from baseline were decreases in P-wave amplitude (in 4% of the patients), increases in atrial capture threshold (4%), increases in right ventricular capture threshold (4%), and increases in left ventricular capture threshold (3%). The observed changes in lead parameters

  16. Ignalina Safety Analysis Group's report for the year 1998

    Uspuras, E.; Augutis, J.; Bubelis, E.; Cesna, B.; Kaliatka, A.

    1999-02-01

    Results of Ignalina NPP Safety Analysis Group's research are presented. The main fields of group's activities in 1998 were following: safety analysis of reactor's cooling system, safety analysis of accident localization system, investigation of the problem graphite - fuel channel, reactor core modelling, assistance to the regulatory body VATESI in drafting regulations and reviewing safety reports presented by Ignalina NPP during the process of licensing of unit 1

  17. Fusion safety program annual report fiscal year 1997

    Longhurst, G.R.; Anderl, R.A.; Cadwallader, L.C.

    1998-01-01

    This report summarizes the major activities of the Fusion Safety Program in FY 1997. The Idaho National Engineering and Environmental Laboratory (INEEL) is the designated lead laboratory, and Lockheed Martin Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in FY 1979 to perform research and develop data needed to ensure safety in fusion facilities. Activities include experiments, analysis, code development and application, and other forms of research. These activities are conducted at the INEEL, different DOE laboratories, and other institutions. The technical areas covered in this report include chemical reactions and activation product release, tritium safety, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER) project. Work done for ITER this year has focused on developing the needed information for the Non-site Specific Safety Report (NSSR-2)

  18. Fusion safety program annual report fiscal year 1997

    Longhurst, G.R.; Anderl, R.A.; Cadwallader, L.C. [and others

    1998-01-01

    This report summarizes the major activities of the Fusion Safety Program in FY 1997. The Idaho National Engineering and Environmental Laboratory (INEEL) is the designated lead laboratory, and Lockheed Martin Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in FY 1979 to perform research and develop data needed to ensure safety in fusion facilities. Activities include experiments, analysis, code development and application, and other forms of research. These activities are conducted at the INEEL, different DOE laboratories, and other institutions. The technical areas covered in this report include chemical reactions and activation product release, tritium safety, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER) project. Work done for ITER this year has focused on developing the needed information for the Non-site Specific Safety Report (NSSR-2).

  19. Health, safety and environment : annual report 2000

    2000-01-01

    A natural gas transmission and power services company, TransCanada Pipelines Limited operates approximately 38,000 kilometers of pipeline, thereby supplying the majority of natural gas production facilities in Western Canada. The company is also involved in the power generation industry by building, operating and owning interests in electric power plants. Located in Rhode Island, United States, the largest plant operated by TransCanada is a combined-cycle plant that generates in excess of 500 MW. TransCanada is committed to its health, safety and environment management system. The system is modeled after the elements of the International Organization for Standardization (ISO) 14001 which sets the standard for environmental management systems. Considerable efforts were expanded to implement programs and initiatives to protect the environment, such as the pipeline reclamation criteria, the hazardous materials and waste management, and proposed polychlorinated biphenyl (PCB) regulations, which are currently under consideration by Environment Canada. TransCanada PipeLines Limited has also set up an environmental research program to enable management and workers to minimize the environmental impacts of the business. Its objectives are the enhancement of the health and safety of employees and their communities, the mitigation of effects on lands, air and water. The topics covered by the research are: vegetation and wildlife with several sub-categories. The company is concerned about the effects on climate change, and developed plans and strategies to manage the emissions of greenhouse gases. In the process, it was awarded several awards for its commitment, action and leadership on voluntary reduction program of greenhouse gases. Full-time resources are dedicated to illness prevention and health promotion, employee assistance programs, short and long term disability management and others. During the year 2000, TransCanada invested 4 million dollars in communities

  20. Applying importance-performance analysis to patient safety culture.

    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.

  1. Efficacy, patient-reported outcomes and safety profile of ATX-101 (deoxycholic acid), an injectable drug for the reduction of unwanted submental fat: results from a phase III, randomized, placebo-controlled study.

    Ascher, B; Hoffmann, K; Walker, P; Lippert, S; Wollina, U; Havlickova, B

    2014-12-01

    Unwanted submental fat (SMF) may result in an unattractive chin profile and dissatisfaction with appearance. An approved and rigorously tested non-surgical method for SMF reduction is lacking. To evaluate the efficacy and safety of ATX-101 for the pharmacological reduction of unwanted SMF in a phase III randomized, double-blind, placebo-controlled study. Patients (n = 360) with moderate or severe SMF were randomized to receive ATX-101 1 or 2 mg/cm(2) or placebo injected into their SMF for up to four treatments ~28 days apart, with a 12-week follow-up. Coprimary efficacy endpoints were the proportions of treatment responders, defined as a ≥1-point reduction in SMF on the Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), and those satisfied with their appearance in association with their face and chin after treatment on the Subject Self-Rating Scale (SSRS score ≥4). Secondary efficacy endpoints included a ≥1-point improvement in SMF on the Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and changes in the Patient-Reported Submental Fat Impact Scale (PR-SMFIS). Additional patient-reported outcomes and changes in the Skin Laxity Rating Scale were recorded. Adverse events (AEs) and laboratory test results were monitored. Compared with placebo, a greater proportion of patients treated with ATX-101 1 and 2 mg/cm(2) showed a ≥1-point improvement in CR-SMFRS (58.3% and 62.3%, respectively, vs. 34.5% with placebo; P < 0.001) and patient satisfaction (SSRS score ≥4) with the appearance of their face and chin (68.3% and 64.8%, respectively, vs. 29.3%; P < 0.001). Patient-reported secondary efficacy endpoints showed significant improvements in SMF severity (PR-SMFRS; P = 0.009 for ATX-101 1 mg/cm(2) , P < 0.001 for ATX-101 2 mg/cm(2) vs. placebo) and emotions and perceived self-image (PR-SMFIS; P < 0.001). No overall worsening of skin laxity was observed. AEs were mostly transient, mild to moderate in intensity and localized to the treatment area. ATX

  2. Strategies for reactor safety. Final report

    Andersson, K

    1997-12-01

    The NKS/RAK-1 project formed part of a four-year nuclear research program (1994-1997) in the Nordic countries, the NKS Programme. The project aims were to investigate and evaluate the safety work, to increase realism and reliability of the safety analysis, and to give ideas for how safety can be improved in selected areas. An evaluation of the safety work in nuclear installations in Finland and Sweden was made, and a special effort was devoted to plant modernisation and to see how modern safety standards can be met up with. A combination of more resources and higher efficiency is recommended to meet requirements from plant modernisation and plant renovations. Both the utilities and the safety authorities are recommended to actively follow the evolving safety standards for new reactors. Various approaches to estimating LOCA frequencies have been explored. In particular, a probabilistic model for pipe ruptures due to intergranular stress corrosion has been developed. A survey has been done over methodologies for integrated sequence analysis (ISA), and different approaches have been developed and tested on four sequences. Structured frameworks for integration between PSA and behavioural sciences have been developed, which e.g. have improved PSA. The status of maintenance strategies in Finland and Sweden has been studied and a new maintenance data information system has been developed. (au) 41 refs.

  3. Strategies for reactor safety. Final report

    Andersson, K.

    1997-12-01

    The NKS/RAK-1 project formed part of a four-year nuclear research program (1994-1997) in the Nordic countries, the NKS Programme. The project aims were to investigate and evaluate the safety work, to increase realism and reliability of the safety analysis, and to give ideas for how safety can be improved in selected areas. An evaluation of the safety work in nuclear installations in Finland and Sweden was made, and a special effort was devoted to plant modernisation and to see how modern safety standards can be met up with. A combination of more resources and higher efficiency is recommended to meet requirements from plant modernisation and plant renovations. Both the utilities and the safety authorities are recommended to actively follow the evolving safety standards for new reactors. Various approaches to estimating LOCA frequencies have been explored. In particular, a probabilistic model for pipe ruptures due to intergranular stress corrosion has been developed. A survey has been done over methodologies for integrated sequence analysis (ISA), and different approaches have been developed and tested on four sequences. Structured frameworks for integration between PSA and behavioural sciences have been developed, which e.g. have improved PSA. The status of maintenance strategies in Finland and Sweden has been studied and a new maintenance data information system has been developed. (au)

  4. Safety of Monopolar Electrocautery in Patients With Cochlear Implants.

    Tien, Duc A; Woodson, Erika A; Anne, Samantha

    2016-09-01

    The outcomes of 2 patients with cochlear implants (CIs) who underwent adenotonsillectomy (AT) with inadvertent use of monopolar cautery are presented. The safety data regarding monopolar cautery use in CI recipients is also reviewed. This is a retrospective case series of 2 CI recipients that underwent AT with monopolar cautery and literature review of electrocautery safety in the setting of CI. Two patients with CIs underwent AT with use of monopolar cautery inadvertently by surgeons that do not routinely perform cochlear implants as part of his or her clinical practice. Patient 1 was a 9-year-old female who had AT for obstructive sleep apnea (OSA) after undergoing unilateral CI for profound congenital sensorineural hearing loss (SNHL) 8 years ago. Patient 2 was a 7-year-old female who underwent AT for OSA 4 months after undergoing unilateral CI for congenital SNHL. Both patients had no immediate signs of complications with their CI use postoperatively. Both patients demonstrated unchanged postoperative neural response telemetry and behavioral audiometric testing. Patient 1 continues to have no CI-related complications 3.5 years after the procedure. Patient 2 has been followed for at least 3 months by audiometric testing and 10 months by otolaryngologist with no CI-related complications. Although animal and cadaveric studies suggest that monopolar cautery may be safely used in patients with cochlear implants, there have been no in vivo human studies that have evaluated the risk to the patient or implant. This is a report of a small, unintended experience with 2 patients, both of whom exhibit no complications or changes to CI function thus far. © The Author(s) 2016.

  5. Research on patient safety: falls and medications.

    Boddice, Sandra Dawn; Kogan, Polina

    2009-10-01

    Below you will find summaries of published research describing investigations into patient safety issues related to falls and medications. The first summary provides details on the incidence of falls associated with the use of walkers and canes. This is followed by a summary of a fall-prevention intervention study that evaluated the effectiveness of widespread dissemination of evidence-based strategies in a community in Connecticut. The third write up provides information on three classes of medications that are associated with a significant number of emergency room visits. The last summary describes a pharmacist-managed medication reconciliation intervention pilot program. For additional details about the study findings and interventions, we encourage readers to review the original articles.

  6. Patient Safety Incidents and Nursing Workload 1

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

    2017-01-01

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

  7. Patient Safety Incidents and Nursing Workload

    Katya Cuadros Carlesi

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

  8. Patients' perceptions of safety and quality of maternity clinical handover

    Chin Georgiana SM

    2011-08-01

    Full Text Available Abstract Background Maternity clinical handover serves to address the gaps in knowledge existing when transitions between individuals or groups of clinicians occur throughout the antenatal, intra-partum and postnatal period. There are limited published studies on maternity handover and a paucity of information about patients' perceptions of the same. This paper reports postnatal patients' perceptions of how maternity handover contributes to the quality and safety of maternity care. Methods This paper reports on a mixed-methods study consisting of qualitative interviews and quantitative medical record analysis. Thirty English-speaking postnatal patients who gave birth at an Australian tertiary maternity hospital participated in a semi-structured interview prior to discharge from hospital. Interview data were coded thematically using the constant comparative method and managed via NVivo software; this data set was supplemented by medical record data analysed using STATA. Results Almost half of the women were aware of a handover process. Clinician awareness of patient information was seen as evidence that handover had taken place and was seen as representing positive aspects of teamwork, care and communication by participants, all important factors in the perception of quality health care. Collaborative cross-checking, including the use of cognitive artefacts such as hand held antenatal records and patient-authored birth plans, and the involvement of patients and their support people in handover were behaviours described by participants to be protective mechanisms that enhanced quality and safety of care. These human factors also facilitated team situational awareness (TSA, shared decision making and patient motivation in labour. Conclusions This study illustrates that many patients are aware of handover processes. For some patients, evidence of handover, through clinician awareness of information, represented positive aspects of teamwork, care and

  9. Safety-related LWR research. Annual report 1993

    Hueper, R.

    1994-06-01

    The reactor safety R and D work of the Karlsruhe Nuclear Research Centre (KfK) has been part of the Nuclear Safety Research Project (PSF) since 1990. The present annual report 1993 summarizes the results on LWR safety. The research tasks are coordinated in agreement with internal and external working groups. The contributions to this report correspond to the status at the end of 1993. (orig./HP) [de

  10. Safety analysis report for the Waste Storage Facility. Revision 2

    Bengston, S.J.

    1994-05-01

    This safety analysis report outlines the safety concerns associated with the Waste Storage Facility located in the Radioactive Waste Management Complex at the Idaho National Engineering Laboratory. The three main objectives of the report are: define and document a safety basis for the Waste Storage Facility activities; demonstrate how the activities will be carried out to adequately protect the workers, public, and environment; and provide a basis for review and acceptance of the identified risk that the managers, operators, and owners will assume.

  11. Health and safety annual report 1987

    1988-01-01

    The principal activities and organisation of BNFL are reviewed in relation to the impact these activities have on the workforce, members of the general public and the environment, together with services for occupational safety within the company. (author)

  12. Using Addenda in Documented Safety Analysis Reports

    Swanson, D.S.; Thieme, M.A.

    2003-01-01

    This paper discusses the use of addenda to the Radioactive Waste Management Complex (RWMC) Documented Safety Analysis (DSA) located at the Idaho National Engineering and Environmental Laboratory (INEEL). Addenda were prepared for several systems and processes at the facility that lacked adequate descriptive information and hazard analysis in the DSA. They were also prepared for several new activities involving unreviewed safety questions (USQs). Ten addenda to the RWMC DSA have been prepared since the last annual update

  13. 78 FR 14877 - Pipeline Safety: Incident and Accident Reports

    2013-03-07

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

  14. The President's Report on Occupational Safety and Health.

    Department of Health, Education, and Welfare, Washington, DC.

    This report describes what has been done to implement the Occupational Safety and Health Act of 1970 during its first year of operation. The report examines the responsibilities of the Department of Labor for setting safety and health standards and also explores the activities of the Department of Health, Education, and Welfare in research and…

  15. Report on nuclear and radiation safety in Slovenia in 1999

    Lovincic, D.

    2000-09-01

    The Slovenian Nuclear Safety Administration (SNSA) has prepared Report on Nuclear and Radiation Safety in Slovenia in 1999. This is one of the regular forms of reporting on the work of the Administration to the Government and National Assembly of the Republic of Slovenia.

  16. New Automated System Available for Reporting Safety Concerns | Poster

    A new system has been developed for reporting safety issues in the workplace. The Environment, Health, and Safety’s (EHS’) Safety Inspection and Issue Management System (SIIMS) is an online resource where any employee can report a problem or issue, said Siobhan Tierney, program manager at EHS.

  17. Patient safety: knowledge between multiprofessional residents.

    Oliveira, João Lucas Campos de; Silva, Simone Viana da; Santos, Pamela Regina Dos; Matsuda, Laura Misue; Tonini, Nelsi Salete; Nicola, Anair Lazzari

    2017-01-01

    To assess the knowledge of multiprofesional residents in health about the security of the patient theme. Cross-sectional study, quantitative, developed with graduate courses/residence specialties of health in a public university of Paraná, Brazil. Participants (n=78) answered a questionnaire containing nine objective questions related to patient safety. Data were analyzed using descriptive statistics, in proportion measures. The minimum 75% of correct answers was considered the cutoff for positive evaluation. The sample was predominantly composed of young people from medical programs. Almost half of the items evaluated (n=5) achieved the established positive pattern, especially those who dealt with the hand hygiene moments (98.8%) and goal of the Patient Safety National Program (92.3%). The identification of the patient was the worst rated item (37.7%). In the analysis by professional areas, only the Nursing reached the standard of hits established. Knowledge of the residents was threshold. Verificar o conhecimento de residentes multiprofissionais na área da saúde sobre o tema segurança do paciente. Estudo transversal, quantitativo, desenvolvido com pós-graduandos dos cursos/especialidades de residência da área da saúde de uma universidade pública do Paraná. Os participantes (n=78) responderam um questionário contendo nove questões objetivas relacionadas com a segurança do paciente. Os dados foram analisados por estatística descritiva, em medidas de proporção. O mínimo de 75% de acertos foi considerado ponto de corte para avaliação positiva. A amostra foi composta por profissionais predominantemente jovens, oriundos de programas médicos. Quase metade dos itens avaliados (n=5) alcançou o padrão de positividade estabelecido, com destaque para os que trataram dos momentos de higienização das mãos (98,8%) e o objetivo do Programa Nacional de Segurança do Paciente (92,3%). A identificação do paciente foi o pior item avaliado (37,7%). Na an

  18. Transit safety & security statistics & analysis 2002 annual report (formerly SAMIS)

    2004-12-01

    The Transit Safety & Security Statistics & Analysis 2002 Annual Report (formerly SAMIS) is a compilation and analysis of mass transit accident, casualty, and crime statistics reported under the Federal Transit Administrations (FTAs) National Tr...

  19. Transit safety & security statistics & analysis 2003 annual report (formerly SAMIS)

    2005-12-01

    The Transit Safety & Security Statistics & Analysis 2003 Annual Report (formerly SAMIS) is a compilation and analysis of mass transit accident, casualty, and crime statistics reported under the Federal Transit Administrations (FTAs) National Tr...

  20. Social capital and knowledge sharing: effects on patient safety.

    Chang, Chia-Wen; Huang, Heng-Chiang; Chiang, Chi-Yun; Hsu, Chiu-Ping; Chang, Chia-Chen

    2012-08-01

    This article is a report on a study that empirically examines the influence of social capital on knowledge sharing and the impact of knowledge sharing on patient safety. Knowledge sharing is linked to many desirable managerial outcomes, including learning and problem-solving, which are essential for patient safety. Rather than studying the tangible effects of rewards, this study examines whether social capital (including social interaction, trust and shared vision) directly supports individual knowledge sharing in an organization. This cross-sectional study analysed data collected through a questionnaire survey of nurses from a major medical centre in northern Taiwan. The data were collected over a 9-month period from 2008 to 2009. The data analysis was conducted using the Partial Least Squares Graph v3.0 program to evaluate the measurement properties and the structural relationships specified in the research model. Based on a large-scale survey, empirical results indicate that Registered Nurses' perceptions of trust and shared vision have statistically significant and direct effects on knowledge sharing. In addition, knowledge sharing is significantly and positively associated with patient safety. The findings suggest that hospital administrators should foster group trust and initiate a common vision among Registered Nurses. In addition, administrators and chief knowledge officers of hospitals should encourage positive intentions towards knowledge sharing. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

  1. Patient Safety Outcomes in Small Urban and Small Rural Hospitals

    Vartak, Smruti; Ward, Marcia M.; Vaughn, Thomas E.

    2010-01-01

    Purpose: To assess patient safety outcomes in small urban and small rural hospitals and to examine the relationship of hospital and patient factors to patient safety outcomes. Methods: The Nationwide Inpatient Sample and American Hospital Association annual survey data were used for analyses. To increase comparability, the study sample was…

  2. Supplement to safety analysis report. 306-W building operations safety requirement

    Richey, C.R.

    1979-08-01

    The operations safety requirements (OSRs) presented in this report define the conditions, safe boundaries, and management control needed for safely conducting operations with radioactive materials in the Pacific Northwest Laboratory (PNL) 306-W building. The safety requirements are organized in five sections. Safety limits are safety-related process variables that are observable and measurable. Limiting conditions cover: equipment and technical conditions and characteristics of the facility and operations necessary for continued safe operation. Surveillance requirements prescribe the requirements for checking systems and components that are essential to safety. Equipment design controls require that changes to process equipment and systems be independently checked and approved to assure that the changes will have no adverse effect on safety. Administrative controls describe and discuss the organization and administrative systems and procedures to be used for safe operation of the facility. Details of the implementation of the operations safety requirements are prescribed by internal PNL documents such as criticality safety specifications and radiation work procedures

  3. Assessment of Patient Safety Culture in an Adult Oncology Department in Saudi Arabia

    Waleed Alharbi

    2018-05-01

    Full Text Available Objectives: We sought to evaluate patient safety culture across different healthcare professionals from different countries of origin working in an adult oncology department in a medical facility in Saudi Arabia. Methods: This cross-sectional survey of 130 healthcare staff (doctors, pharmacists, nurses was conducted in February 2017. We used the Hospital Survey of Patient Safety Culture (HSOPSC to examine healthcare staff perceptions of safety culture. Results: A total of 127 questionnaires were returned, yielding a response rate of 97.7%. Eight out of 12 HSOPSC composites were considered areas for improvement (percent positivity < 50.0%. Significantly different mean scores were observed across the three professional groups in all 12 HSOPSC composites. Doctors tended to rate patient safety culture significantly more positively than nurses or pharmacists. Nurses scored significantly lower than pharmacists in the majority of HSOPSC composites. No significant differences in patient safety culture composite scores were observed between Saudi/Gulf Cooperation Council (GCC and non-Saudi/GCC groups. Regression analysis showed that the frequency of reported events is predicted by feedback and communication about errors, and teamwork across units. Perception of patient safety is associated with respondents’ profession and teamwork across units. Conclusions: This study brings to the fore the assumption that all healthcare professionals have a shared understanding of patient safety. We urge healthcare leaders and policy makers to look at patient safety culture at this granular level in their contexts and use this information to develop strategies and training to improve patient safety culture.

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

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

    2018-04-01

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

  5. Communication barriers in counselling foreign-language patients in public pharmacies: threats to patient safety?

    Schwappach, David L B; Meyer Massetti, Carla; Gehring, Katrin

    2012-10-01

    Foreign-language (FL) patients are at increased risk for adverse drug events. Evidence regarding communication barriers and the safety of pharmaceutical care of FL patients in European countries is scarce despite large migrant populations. To investigate Swiss public pharmacists' experiences and current practices in counselling FL patients with a focus on patient safety. In a cross-sectional study heads of public pharmacies in Switzerland were surveyed using an electronic questionnaire. The survey assessed the frequency of communication barriers encountered in medication counselling of FL patients, perceptions of risks for adverse drug events, satisfaction with the quality of counselling provided to FL patients, current strategies to reduce risks, and preferences towards tools to improve safety for FL patients. 498 pharmacists completed the survey (43 % response rate). More than every second pharmacist reported at least weekly encounters at which they cannot provide good medication counselling to FL patients in the regional Swiss language. Ad-hoc interpreting by minors is also common at a considerable number of pharmacies (26.5 % reported at least one weekly occurrence). Approximately 10 % of pharmacies reported that they fail at least weekly to explain the essentials of drug therapy (e.g. dosing of children's medications) to FL patients. 79.8 % perceived the risk of FL patients for adverse drug events to be somewhat or much higher compared to other patients. 22.5 % of pharmacists reported being concerned at least monthly about medication safety when FL patients leave their pharmacy. However, the majority of pharmacists were satisfied with the quality of care provided to FL patients in their pharmacy [78.6 % (very) satisfied]. The main strategy used to improve counselling for FL patients was the employment of multilingual staff. Participants would use software for printing foreign-language labels (41.2 %) and multilingual package inserts (42.0 %) if these were

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

    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

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

    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.

  8. The sociotechnical configuration of the problem of Patient Safety

    Danholt, Peter

    2010-01-01

    Abstract. This paper presents and discusses two approaches to “the sociotechnical”, one coming from the Tavistock tradition and the other from actor network theory. These two differ in important ways and from the latter it follows that what patient safety means must be scrutinized and unpacked....... The paper thus rudimentarily discusses central contributions to the problematization of patient safety. Last it is argued that research that provide data on the processes of medical interventions where events, decisions and entities become transformed through their interactions is needed in order to further...... nuance the problem of patient safety. Keywords. Sociotechnical, patient safety, actor network theory, adverse events....

  9. The Role of Patient Safety in the Device Purchasing Process

    Johnson, Todd R; Zhang, Jiajie; Patel, Vimla L; Keselman, Alla; Tang, Xiaozhou; Brixey, Juliana J; Paige, Danielle; Turley, James P

    2005-01-01

    To examine how patient safety considerations are incorporated into medical device purchase decisions, individuals involved in recent infusion pump purchasing decisions at three different health care...

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

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

    2013-04-01

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

  11. The role of the ward manager in promoting patient safety.

    Pinnock, David

    In this article the role of the ward manager in promoting patient safety is explored. The background to the development of the patient safety agenda is briefly discussed and the relationship between quality and safety is illustrated. The pivotal importance of the role of the ward manager in delivering services to patients is underlined and literature on patient safety is examined to identify what a ward manager can do to make care safer. Possible actions of the ward manager to improve safety discussed in the literature are structured around the Leadership Framework. This framework identifies seven domains for the leadership of service delivery. Ward managers use their personal qualities, and network and work within teams, while managing performance and facilitating innovation, change and measurement for improvement. The challenge of promoting patient safety for ward managers is briefly explored and recommendations for further research are made.

  12. Nuclear and radiation safety in Slovenia. Annual report 1997

    1998-01-01

    The Slovenian Nuclear Safety Administration (SNSA), in co-operation with the Health Inspectorate of the Republic of Slovenia, the Administration for Civil Protection and Disaster Relief and the Ministry of the Interior, has prepared a Report on Nuclear and Radiation Safety in the Republic of Slovenia for 1997. This is one of the regular forms of reporting on the work of the Administration to the Government and National Assembly of the Republic of Slovenia. Contributions to the report were furthermore prepared by competent authorities in the field of nuclear safety: the Agency for Radwaste Management (ARAO), the Milan Copic Nuclear Training Centre, etc. The report contains 17 chapters. (author)

  13. Report on nuclear and radiation safety in Slovenia in 1997

    1998-06-01

    The Slovenian Nuclear Safety Administration (SNSA), in co-operation with the Health Inspectorate of the Republic of Slovenia, the Administration for Civil Protection and Disaster Relief and the Ministry of the Interior, has prepared a Report on Nuclear and Radiation Safety in the Republic of Slovenia for 1997. This is one of the regular forms of reporting on the work of the Administration to the Government and National Assembly of the Republic of Slovenia. Contributions to the report were furthermore prepared by competent authorities in the field of nuclear safety: the Agency for Radwaste Management (ARAO), the Milan Copic Nuclear Training Centre, etc. The report contains 19 chapters.

  14. Toward introduction of risk informed safety regulation. Nuclear Safety Commission taskforce's interim report

    2006-01-01

    Nuclear Safety Commission's taskforce on 'Introduction of Safety Regulation Utilizing Risk Information' completed the interim report on its future subjects and directions in December 2005. Although current safety regulatory activities have been based on deterministic approach, this report shows the risk informed approach is expected to be very useful for making nuclear safety regulation and assurance activities reasonable and also for appropriate allocation of regulatory resources. For introduction of risk informed regulation, it also recommends pileups of experiences with gradual introduction and trial of the risk informed approach, improvement of plant maintenance rules and regulatory requirements utilizing risk information, and establishment of framework to assure quality of risk evaluation. (T. Tanaka)

  15. Fusion safety program Annual report, Fiscal year 1995

    Longhurst, G.R.; Cadwallader, L.C.; Carmack, W.J.

    1995-12-01

    This report summarizes the major activities of the Fusion Safety Program in FY-95. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory, and Lockheed Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL, at other DOE laboratories, and at other institutions. Among the technical areas covered in this report are tritium safety, beryllium safety, chemical reactions and activation product release, safety aspects of fusion magnet systems, plasma disruptions, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Also included in the report are summaries of the safety and environmental studies performed by the Fusion Safety Program for the Tokamak Physics Experiment and the Tokamak Fusion Test Reactor and the technical support for commercial fusion facility conceptual design studies. A final activity described is work to develop DOE Technical Standards for Safety of Fusion Test Facilities

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

    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.

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

    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.

  18. A 2-year study of patient safety competency assessment in 29 clinical laboratories.

    Reed, Robyn C; Kim, Sara; Farquharson, Kara; Astion, Michael L

    2008-06-01

    Competency assessment is critical for laboratory operations and is mandated by the Clinical Laboratory Improvement Amendments of 1988. However, no previous reports describe methods for assessing competency in patient safety. We developed and implemented a Web-based tool to assess performance of 875 laboratory staff from 29 laboratories in patient safety. Question categories included workplace culture, categorizing error, prioritization of patient safety interventions, strength of specific interventions, and general patient safety concepts. The mean score was 85.0%, with individual scores ranging from 56% to 100% and scores by category from 81.3% to 88.6%. Of the most difficult questions (laboratory technologists. Computer-based competency assessments help laboratories identify topics for continuing education in patient safety.

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

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

    2015-01-01

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

  20. 76 FR 7854 - Patient Safety Organizations: Voluntary Delisting From Lumetra PSO

    2011-02-11

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act... delivery. The Patient Safety and Quality Improvement Final Rule (Patient Safety Rule), 42 CFR part 3...

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

    2013-01-01

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

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

    2011-01-01

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

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

    NONE

    2014-07-01

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

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

    2015-01-01

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

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

    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.

  6. Safety oriented LWR research. Annual report 1990

    1991-07-01

    The contributions describe phenomenons of severe fuel damage and aspects of core meltdown accidents. These accidents deal with aerosol behaviour and ventilation systems and the methods for assessing and reducing the radiological concequences of nuclear accidents. Other contributions describe selected questions of safety of HCLWR type reactors. (DG)

  7. The Patient Safety Attitudes among the Operating Room Personnel

    Cherdsak Iramaneerat

    2016-07-01

    Full Text Available Background: The first step in cultivating the culture of safety in the operating room is the assessment of safety culture among operating room personnel. Objective: To assess the patient safety culture of operating room personnel at the Department of Surgery, Faculty of Medicine Siriraj Hospital, and compare attitudes among different groups of personnel, and compare them with the international standards. Methods: We conducted a cross-sectional survey of safety attitudes among 396 operating room personnel, using a short form of the Safety Attitudes Questionnaire (SAQ. The SAQ employed 30 items to assess safety culture in six dimensions: teamwork climate, safety climate, stress recognition, perception of hospital management, working conditions, and job satisfaction. The subscore of each dimension was calculated and converted to a scale score with a full score of 100, where higher scores indicated better safety attitudes. Results: The response rate was 66.4%. The overall safety culture score of the operating room personnel was 65.02, higher than an international average (61.80. Operating room personnel at Siriraj Hospital had safety attitudes in teamwork climate, safety climate, and stress recognition lower than the international average, but had safety attitudes in the perception of hospital management, working conditions, and job satisfaction higher than the international average. Conclusion: The safety culture attitudes of operating room personnel at the Department of Surgery, Siriraj Hospital were comparable to international standards. The safety dimensions that Siriraj Hospital operating room should try to improve were teamwork climate, safety climate, and stress recognition.

  8. Non-technical skills training to enhance patient safety.

    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.

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

    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.

  10. Strengthening leadership as a catalyst for enhanced patient safety culture

    Kristensen, Solvejg; Christensen, Karl Bang; Jaquet, Annette

    2016-01-01

    OBJECTIVES: Current literature emphasises that clinical leaders are in a position to enable a culture of safety, and that the safety culture is a performance mediator with the potential to influence patient outcomes. This paper aims to investigate staff's perceptions of patient safety culture...... in a Danish psychiatric department before and after a leadership intervention. METHODS: A repeated cross-sectional experimental study by design was applied. In 2 surveys, healthcare staff were asked about their perceptions of the patient safety culture using the 7 patient safety culture dimensions...... in the Safety Attitudes Questionnaire. To broaden knowledge and strengthen leadership skills, a multicomponent programme consisting of academic input, exercises, reflections and discussions, networking, and action learning was implemented among the clinical area level leaders. RESULTS: In total, 358 and 325...

  11. Learning Patient Safety in Academic Settings: A Comparative Study of Finnish and British Nursing Students' Perceptions.

    Tella, Susanna; Smith, Nancy-Jane; Partanen, Pirjo; Turunen, Hannele

    2015-06-01

    Globalization of health care demands nursing education programs that equip students with evidence-based patient safety competences in the global context. Nursing students' entrance into clinical placements requires professional readiness. Thus, evidence-based learning activities about patient safety must be provided in academic settings prior to students' clinical placements. To explore and compare Finnish and British nursing students' perceptions of learning about patient safety in academic settings to inform nursing educators about designing future education curriculum. A purpose-designed instrument, Patient Safety in Nursing Education Questionnaire (PaSNEQ) was used to examine the perceptions of Finnish (n = 195) and British (n = 158) nursing students prior to their final year of registration. Data were collected in two Finnish and two English nursing schools in 2012. Logistic regressions were used to analyze the differences. British students reported more inclusion (p motivation" related to patient safety in their programs. Both student groups considered patient safety education to be more valuable for their own learning than what their programs had provided. Training patient safety skills in the academic settings were the strongest predictors for differences (odds ratio [OR] = 34.69, 95% confidence interval [CI] 7.39-162.83), along with work experience in the healthcare sector (OR = 3.02, 95% CI 1.39-6.58). To prepare nursing students for practical work, training related to clear communication, reporting errors, systems-based approaches, interprofessional teamwork, and use of simulation in academic settings requires comprehensive attention, especially in Finland. Overall, designing patient safety-affirming nursing curricula in collaboration with students may enhance their positive experiences on teaching and learning about patient safety. An international collaboration between educators could help to develop and harmonize patient safety education and to better

  12. AMNT 2014. Key Topic: Reactor operation, safety - report. Pt. 1

    Schaffrath, Andreas [Gesellschaft fuer Anlagen- und Reaktorsicherheit mbH (GRS), Garching (Germany). Forschungszentrum

    2014-10-15

    Summary report on one session of the Annual Conference on Nuclear Technology held in Frankfurt, 6 to 8 May 2014: - Safety of Nuclear Installations - Methods, Analysis, Results: Backfittings for the Improvement of Safety and Efficiency. The other Sessions of the Key Topics 'Reactor Operation, Safety', 'Competence, Innovation, Regulation' and 'Fuel, Decommissioning and Disposal' will be covered in further issues of atw.

  13. Forschungszentrum Rossendorf, Institute for Safety Research. Annual report 1995

    Weiss, F.P.; Rindelhardt, U.

    1996-09-01

    The scientific work of the Institute of Safety Research covers a wide range of safety related investigations. During 1995 important results on thermo-fluid dynamic single effects, thermalhydraulics and neutron kinetics for accident analysis, materials safety, simulation of radiation and particle transport, mechanical integrity of technical systems and process monitoring, risk management for waste deposits, magneto-hydrodynamics of conductive fluids, and of renewable energies were reached. The annual report presents also lists of publications, conference contributions, meetings, and workshops. (DG)

  14. Safety Assessment for Research Reactors and Preparation of the Safety Analysis Report. Specific Safety Guide

    NONE

    2011-11-15

    The IAEA's Statute authorizes the Agency to 'establish or adopt' standards of safety for protection of health and minimization of danger to life and property' - standards that the IAEA must use in its own operations, and which States can apply by means of their regulatory provisions for nuclear and radiation safety. The IAEA does this in consultation with the competent organs of the United Nations and with the specialized agencies concerned. A comprehensive set of high quality standards under regular review is a key element of a stable and sustainable global safety regime, as is the IAEA's assistance in their application. The IAEA commenced its safety standards programme in 1958. The emphasis placed on quality, fitness for purpose and continuous improvement has led to the widespread use of the IAEA standards throughout the world. The Safety Standards Series now includes unified Fundamental Safety Principles, which represent an international consensus on what must constitute a high level of protection and safety. With the strong support of the Commission on Safety Standards, the IAEA is working to promote the global acceptance and use of its standards. Standards are only effective if they are properly applied in practice. The IAEA's safety services encompass design, siting and engineering safety, operational safety, radiation safety, safe transport of radioactive material and safe management of radioactive waste, as well as governmental organization, regulatory matters and safety culture in organizations. These safety services assist Member States in the application of the standards and enable valuable experience and insights to be shared. Regulating safety is a national responsibility, and many States have decided to adopt the IAEA's standards for use in their national regulations. For parties to the various international safety conventions, IAEA standards provide a consistent, reliable means of ensuring the effective fulfilment of obligations under the conventions

  15. Safety Assessment for Research Reactors and Preparation of the Safety Analysis Report. Specific Safety Guide

    2011-01-01

    The IAEA's Statute authorizes the Agency to 'establish or adopt' standards of safety for protection of health and minimization of danger to life and property' - standards that the IAEA must use in its own operations, and which States can apply by means of their regulatory provisions for nuclear and radiation safety. The IAEA does this in consultation with the competent organs of the United Nations and with the specialized agencies concerned. A comprehensive set of high quality standards under regular review is a key element of a stable and sustainable global safety regime, as is the IAEA's assistance in their application. The IAEA commenced its safety standards programme in 1958. The emphasis placed on quality, fitness for purpose and continuous improvement has led to the widespread use of the IAEA standards throughout the world. The Safety Standards Series now includes unified Fundamental Safety Principles, which represent an international consensus on what must constitute a high level of protection and safety. With the strong support of the Commission on Safety Standards, the IAEA is working to promote the global acceptance and use of its standards. Standards are only effective if they are properly applied in practice. The IAEA's safety services encompass design, siting and engineering safety, operational safety, radiation safety, safe transport of radioactive material and safe management of radioactive waste, as well as governmental organization, regulatory matters and safety culture in organizations. These safety services assist Member States in the application of the standards and enable valuable experience and insights to be shared. Regulating safety is a national responsibility, and many States have decided to adopt the IAEA's standards for use in their national regulations. For parties to the various international safety conventions, IAEA standards provide a consistent, reliable means of ensuring the effective fulfilment of obligations under the conventions

  16. Improving Patient Safety With the Military Electronic Health Record

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

    2005-01-01

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

  17. Ethics of safety reporting of a clinical trial

    Amrita Sil

    2017-01-01

    Full Text Available Clinical trial related injury and serious adverse events (SAE are a major area of concern. In all such scenarios the investigator is responsible for medical care of the trial participant and also ethically bound to report the event to all the stakeholders of the clinical trial. The trial sponsor is responsible for ongoing safety evaluation of the investigational product, reporting and compensating the participant in case of any SAE. The Ethics Committee and regulatory body of the country are to uphold the ethical principles of beneficence, justice, non-maleficence in such cases. Any unwanted and noxious effect of a drug when used in recommended doses is an adverse drug reaction (ADR whereas if causal association is not yet established it is termed adverse event (AE. An AE or ADR that is associated with death, in-patient hospitalization, prolongation of hospitalization, persistent or significant disability or incapacity, a congenital anomaly, or is otherwise life threatening is termed as an SAE. The principal investigator reports the event to the licensing authority (DCGI, sponsor and Chairperson of the Ethics Committee (EC within 24 hours of occurrence of the SAE. This report is furthered by a detailed report by both the investigator and the EC and given to the DCGI who then gives a final decision on the amount of compensation to be given by the sponsor or the sponsor's representative to the grieving party.

  18. [Patient safety in antibiotics administration: Risk assessment].

    Maqueda Palau, M; Pérez Juan, E

    To determine the level of risk in the preparation and administration of antibiotics frequently used in the Intensive Care Unit using a risk matrix. A study was conducted using situation analysis and literature review of databases, protocols and good practice guidelines on intravenous therapy, drugs, and their administration routes. The most used antibiotics in the ICU registered in the ENVIN-HELICS program from 1 April to 30 June 2015 were selected. In this period, 257 patients received antimicrobial treatment and 26 antibiotics were evaluated. Variables studied: A risk assessment of each antibiotic using the scale Risk Assessment Tool, of the National Patient Safety Agency, as well as pH, osmolarity, type of catheter recommended for administration, and compatibility and incompatibility with other antibiotics studied. Almost two-thirds (65.3%) of antibiotics had more than 3 risk factors (represented by a yellow stripe), with the remaining 34.7% of antibiotics having between 0 and 2 risk factors (represented by a green stripe). There were no antibiotics with 6 or more risk factors (represented by a red stripe). Most drugs needed reconstitution, additional dilution, and the use of part of the vial to administer the prescribed dose. More than half of the antibiotics studied had a moderate risk level; thus measures should be adopted in order to reduce it. The risk matrix is a useful tool for the assessment and detection of weaknesses associated with the preparation and administration of intravenous antibiotics. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

  19. Fusion Safety Program annual report, fiscal year 1994

    Longhurst, G.R.; Cadwallader, L.C.; Dolan, T.J.; Herring, J.S.; McCarthy, K.A.; Merrill, B.J.; Motloch, C.G.; Petti, D.A.

    1995-03-01

    This report summarizes the major activities of the Fusion Safety Program in fiscal year 1994. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory and Lockheed Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL, at other DOE laboratories, and at other institutions, including the University of Wisconsin. The technical areas covered in this report include tritium safety, beryllium safety, chemical reactions and activation product release, safety aspects of fusion magnet systems, plasma disruptions, risk assessment failure rate data base development, and thermalhydraulics code development and their application to fusion safety issues. Much of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Also included in the report are summaries of the safety and environmental studies performed by the Fusion Safety Program for the Tokamak Physics Experiment and the Tokamak Fusion Test Reactor and of the technical support for commercial fusion facility conceptual design studies. A major activity this year has been work to develop a DOE Technical Standard for the safety of fusion test facilities

  20. Report on nuclear and radiological safety in 1994

    Lovincic, D.

    1995-01-01

    The Slovenian Nuclear Safety Administration (SNSA) in cooperation with the Health Inspectorate, prepared the Report on Nuclear and Radiological Safety in the Republic of Slovenia for 1994 as part of its regular practice of reporting on its activities to the Government and the Parliament of the Republic of Slovenia. The report is divided into seven thematic chapters covering the activities of the SNSA, the operation of nuclear facilities in Slovenia, the activities of the Agency for Radwaste Management (ARAO), the activities of international safety missions in Slovenia, environmental radioactivity monitoring in Slovenia, ionizing radiation sources control by Slovenian Health Inspectorate and review of the operation of nuclear facilities around the world.

  1. Improving the safety of LWR power plants. Final report

    1980-04-01

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

  2. Fusion Safety Program annual report: Fiscal year 1986

    Holland, D.F.; Merrill, B.J.; Herring, J.S.; Piet, S.J.; Longhurst, G.R.

    1987-06-01

    This report summarizes the Fusion Safety Program's (FSP) major activities in fiscal year 1986. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory, and EG and G Idaho, Inc., is the prime contractor for FSP, which was initiated in 1979. Activities are conducted at the INEL and in participating facilities, including the Hanford Engineering Development Laboratory (HEDL), the Massachusetts Institute of Technology (MIT), and the University of Wisconsin. The technical areas covered in this report include tritium safety, activation product release, reactions involving lithium breeding materials, safety of fusion magnet systems, plasma disruption, risk assessment methodology, and computer code development for reactor transients. Contributions to the Technical Planning Activity (TPA) and the ''white paper'' study by the Environmental, Safety,and Economics Committee (ESECOM) are summarized. The report also includes a summary of the safety and environmental analysis and documentation performed by the INEL for the Compact Ignition Tokamak (CIT) design project

  3. Summary report on safety objectives in nuclear power plants

    1989-01-01

    The special Task Force on Safety Objectives of the Commission of the European Communities (CEC) Working Group on the Safety of Light Water Reactors reported in May 1983 on its review of existing overall safety objectives in nuclear power plants. Since then much relevant worlwide activity has taken place. This report reviews those activities that have taken place since 1983 in European Community Member States, including more recent Members, as well as in Sweden and Finland. The report confines itself to issues related to probabilistic safety objectives, and concludes that significant progress has been made in many areas. Mutual understanding of safety objectives is leading to a convergence of views and approaches, but it is noted that much work remains to be completed

  4. Studying the Relationship between Individual and Organizational Factors and Nurses' Perception of Patient Safety Culture

    Farahnaz Abdolahzadeh

    2012-11-01

    Full Text Available Introduction: Safety culture is considered as an important factor in improving patient safety. Therefore, identifying individual and organizational factors affecting safety culture is crucial. This study was carried out to determine individual and organizational factors associated with nurses' perception of patient safety culture. Methods: The present descriptive study included 940 nurses working in four training hospitals affiliated with Urmia University of Medical Sciences (Iran. Data was collected through the self-report questionnaire of patient safety culture. Descriptive (number, percent, mean, and standard deviation and inferential (t-test and analysis of variance statistics were used to analyze the data in SPSS. Results: Nurses' perception of patient safety culture was significantly correlated with marital status, workplace, and overtime hours. Conclusion: The results of this study revealed that some individual and organizational factors can impact on nurses' perception of patient safety culture. Nursing authorities should thus pay more attention to factors which promote patient safety culture and ultimately the safety of provided services.

  5. Assessing patient safety culture in hospitals across countries

    Wagner, C.; Smits, M.; Sorra, J.; Huang, C.C.

    2013-01-01

    Objective. It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries:

  6. Assessing patient safety culture in hospitals across countries.

    Wagner, C.; Smits, M.; Sorra, J.; Huang, C.C.

    2013-01-01

    Objective: It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries:

  7. Assessing patient safety culture in hospitals across countries

    Wagner, C.; Smits, M.; Sorra, J.; Huang, C.C.

    2013-01-01

    OBJECTIVE: It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries:

  8. 75 FR 57477 - Patient Safety Organizations: Voluntary Delisting

    2010-09-21

    ... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION... Creighton Center for Health Services Research and Patient Safety (CHRP) Patient Safety Organization (PSO... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

  9. 75 FR 75473 - Patient Safety Organizations: Voluntary Delisting

    2010-12-03

    ... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality, HHS. ACTION: Notice of... entity of Harbor Medical, Inc., of its status as a Patient Safety Organization (PSO). The Patient Safety... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

  10. 75 FR 75471 - Patient Safety Organizations: Voluntary Delisting

    2010-12-03

    ... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality, HHS. ACTION: Notice of..., LLC of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement... or component organizations whose mission and primary activity is to conduct activities to improve...

  11. 75 FR 75472 - Patient Safety Organizations: Voluntary Delisting

    2010-12-03

    ... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality, HHS. ACTION: Notice of.... Patient Safety Group (A Component of Helmet Fire, Inc. of its status as a Patient Safety Organization (PSO... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

  12. 75 FR 57048 - Patient Safety Organizations: Voluntary Delisting

    2010-09-17

    ... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION... Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

  13. Perceptions of medication safety among patients with inflammatory bowel disease.

    Cullen, Garret

    2010-09-01

    The aim of this study was to assess attitudes towards and knowledge of medication safety in inflammatory bowel disease (IBD). IBD patients frequently require long-term treatment with potentially toxic medications. Techniques are employed to improve patient awareness of medication safety, but there are sparse data on their effectiveness.

  14. 75 FR 63498 - Patient Safety Organizations: Voluntary Delisting

    2010-10-15

    ... Healthcare Technology Foundation of its status as a Patient Safety Organization (PSO). The Patient Safety and... notification from the ACCE Healthcare Technology Foundation, PSO number P0017, to voluntarily relinquish its status as a PSO. Accordingly, the ACCE Healthcare Technology Foundation was delisted effective at 12:00...

  15. Using safety crosses for patient self-reflection.

    Silverton, Sarah

    The Productive Mental Health Ward programme has been developed to improve efficiency and safety in the NHS. Patients in a medium-secure mental health unit used patient safety crosses as a tool for self-reflection as part of their recovery journey. This article describes how the project was set up as well as initial findings.

  16. Healthcare professionals’ views of feedback on patient safety culture assessment.

    Zwijnenberg, N.C.; Hendriks, M.; Hoogervorst-Schilp, J.; Wagner, C.

    2016-01-01

    Background: By assessing patient safety culture, healthcare providers can identify areas for improvement in patient safety culture. To achieve this, these assessment outcomes have to be relevant and presented clearly. The aim of our study was to explore healthcare professionals’ views on the

  17. Improving Patient Safety Culture in Primary Care: A Systematic Review

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

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

  18. Patient Safety and Workplace Bullying: An Integrative Review.

    Houck, Noreen M; Colbert, Alison M

    Workplace bullying is strongly associated with negative nursing outcomes, such as work dissatisfaction, turnover, and intent to leave; however, results of studies examining associations with specific patient safety outcomes are limited or nonspecific. This integrative review explores and synthesizes the published articles that address the impact of workplace nurse bullying on patient safety.

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

    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

  20. N Reactor updated safety analysis report, NUSAR

    1978-01-01

    An update of the N Reactor safety analysis is presented to reconfirm that the continued operation does not pose undue risk to DOE personnel and property, the public, or the environment. A reanalysis of LOCA and reactivity transients utilizing current codes and methods is made. The principal aspects of the overall submission, a general description, and site characteristics including geography and demography, nearby industrial, transportation and military facilities, meteorology, hydraulic engineering, and geology and seismology are described

  1. The PEC reactor. Safety analysis: Detailed reports

    1988-01-01

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

  2. Progress report: 1996 Radiation Safety Systems Division

    Bhagwat, A.M.; Sharma, D.N.; Abani, M.C.; Mehta, S.K.

    1997-01-01

    The activities of Radiation Safety Systems Division include (i) development of specialised monitoring systems and radiation safety information network, (ii) radiation hazards control at the nuclear fuel cycle facilities, the radioisotope programmes at Bhabha Atomic Research Centre (BARC) and for the accelerators programme at BARC and Centre for Advanced Technology (CAT), Indore. The systems on which development and upgradation work was carried out during the year included aerial gamma spectrometer, automated environment monitor using railway network, radioisotope package monitor and air monitors for tritium and alpha active aerosols. Other R and D efforts at the division included assessment of risk for radiation exposures and evaluation of ICRP 60 recommendations in the Indian context, shielding evaluation and dosimetry for the new upcoming accelerator facilities and solid state nuclear track detector techniques for neutron measurements. The expertise of the divisional members was provided for 36 safety committees of BARC and Atomic Energy Regulatory Board (AERB). Twenty three publications were brought out during the year 1996. (author)

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

    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.

  4. Report of safety of the characterizing system of radioactive waste

    Angeles C, A.; Jimenez D, J.; Reyes L, J.

    1998-09-01

    Report of safety of the system of radioactive waste of the ININ: Installation, participant personnel, selection of the place, description of the installation, equipment. Proposed activities: operations with radioactive material, calibration in energy, calibration in efficiency, types of waste. Maintenance: handling of radioactive waste, physical safety. Organization: radiological protection, armor-plating, personal dosemeter, risks and emergency plan, environmental impact, medical exams. (Author)

  5. Review of safety reports involving electronic flight bags

    2009-04-27

    Electronic Flight Bags (EFBs) are a relatively new device used by pilots. Even so, 37 safety-related events involving EFBs were identified from the public online Aviation Safety Reporting System (ASRS) database as of June 2008. In addition, two accid...

  6. Environmental and Occupational Safety Division annual progress report for 1983

    1984-11-01

    This report presents summaries of activities conducted during 1983 in the following areas: radiation monitoring; health physics instrumentation development; environmental management; atmospheric monitoring; water monitoring; background radiation measurements; soil and grass samples; deer samples; calculation of potential radiation dose to the public; industrial safety; and operational safety

  7. Training Course for Compliance Safety and Health Officers. Final Report.

    McKnight, A. James; And Others

    The report describes revision of the Compliance Safety and Health Officers (CSHO) course for the Department of Labor, Occupational Safety and Health Administration (OSHA). The CSHO's job was analyzed in depth, in accord with OSHA standards, policies, and procedures. A listing of over 1,700 violations of OSHA standards was prepared, and specialists…

  8. Preliminary report in radiological safety for 1993 hydrology campaign

    Badano, A.; Suraez, R.; Dellepere, A.; Barreiro, M.

    1993-01-01

    The purpose of this report is to provide a study about industrial effluents influence on water pollution of Montevideo coastal beaches. The methods which have been considered are nuclear tracer techniques with a special attention in the radioprotection supervision. Three points are considered as evaluation: handling of radioactive tracers and safety, radiation protection workers, environment and public safety. tabs

  9. Effects of the Smartphone Application "Safe Patients" on Knowledge of Patient Safety Issues Among Surgical Patients.

    Cho, Sumi; Lee, Eunjoo

    2017-12-01

    Recently, the patient's role in preventing adverse events has been emphasized. Patients who are more knowledgeable about safety issues are more likely to engage in safety initiatives. Therefore, nurses need to develop techniques and tools that increase patients' knowledge in preventing adverse events. For this reason, an educational smartphone application for patient safety called "Safe Patients" was developed through an iterative process involving a literature review, expert consultations, and pilot testing of the application. To determine the effect of "Safe Patients," it was implemented for patients in surgical units in a tertiary hospital in South Korea. The change in patients' knowledge about patient safety was measured using seven true/false questions developed in this study. A one-group pretest and posttest design was used, and a total of 123 of 190 possible participants were tested. The percentage of correct answers significantly increased from 64.5% to 75.8% (P effectively improve patients' knowledge of safety issues. This will ultimately empower patients to engage in safe practices and prevent adverse events related to surgery.

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

    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.

  11. Variability of patient safety culture in Belgian acute hospitals.

    Vlayen, Annemie; Schrooten, Ward; Wami, Welcome; Aerts, Marc; Barrado, Leandro Garcia; Claes, Neree; Hellings, Johan

    2015-06-01

    The aim of this study was to measure differences in safety culture perceptions within Belgian acute hospitals and to examine variability based on language, work area, staff position, and work experience. The Hospital Survey on Patient Safety Culture was distributed to hospitals participating in the national quality and safety program (2007-2009). Hospitals were invited to participate in a comparative study. Data of 47,136 respondents from 89 acute hospitals were used for quantitative analysis. Percentages of positive response were calculated on 12 dimensions. Generalized estimating equations models were fitted to explore differences in safety culture. Handoffs and transitions, staffing, and management support for patient safety were considered as major problem areas. Dutch-speaking hospitals had higher odds of positive perceptions for most dimensions in comparison with French-speaking hospitals. Safety culture scores were more positive for respondents working in pediatrics, psychiatry, and rehabilitation compared with the emergency department, operating theater, and multiple hospital units. We found an important gap in safety culture perceptions between leaders and assistants within disciplines. Administration and middle management had lower perceptions toward patient safety. Respondents working less than 1 year in the current hospital had more positive safety culture perceptions in comparison with all other respondents. Large comparative databases provide the opportunity to identify distinct high and low scoring groups. In our study, language, work area, and profession were identified as important safety culture predictors. Years of experience in the hospital had only a small effect on safety culture perceptions.

  12. 76 FR 60494 - Patient Safety Organizations: Voluntary Relinquishment From HPI-PSO

    2011-09-29

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient... delivery. The Patient Safety and Quality Improvement Final Rule (Patient Safety Rule), 42 CFR Part 3...

  13. AMNT 2014. Key topic: Reactor operation, safety - report. Pt. 2

    Fischer, Klaus-Christian; Willschuetz, Hans-Georg; Wortmann, Birgit

    2014-01-01

    Summary report on the following sessions of the Annual Conference on Nuclear Technology held in Frankfurt, 6 to 8 May 2014: - Thermo Dynamics and Fluid Dynamics: Experiments and Backfittings for the Improvement of Safety and Efficiency; - Safety of Nuclear Installations - Methods, Analyses, Results: In-Vessel Phenomena; Ex-Vessel Phenomena; - Standards and Regulations; Hazard and Safety Analysis; and Validation and Uncertainty Analysis. The other Sessions of the Key Topics 'Reactor Operation, Safety', 'Competence, Innovation, Regulation' and 'Fuel, Decommissioning and Disposal' have been covered in atw 10 (2014) and will be covered in further issues of atw.

  14. DOE Defense Program (DP) safety programs. Final report, Task 003

    1998-01-01

    The overall objective of the work on Task 003 of Subcontract 9-X52-W7423-1 was to provide LANL with support to the DOE Defense Program (DP) Safety Programs. The effort included the identification of appropriate safety requirements, the refinement of a DP-specific Safety Analysis Report (SAR) Format and Content Guide (FCG) and Comprehensive Review Plan (CRP), incorporation of graded approach instructions into the guidance, and the development of a safety analysis methodologies document. All tasks which were assigned under this Task Order were completed. Descriptions of the objectives of each task and effort performed to complete each objective is provided here

  15. Preliminary Safety Analysis Report for the Tokamak Physics Experiment

    Motloch, C.G.; Bonney, R.F.; Levine, J.D.; Masson, L.S.; Commander, J.C.

    1995-04-01

    This Preliminary Safety Analysis Report (PSAR), includes an indication of the magnitude of facility hazards, complexity of facility operations, and the stage of the facility life-cycle. It presents the results of safety analyses, safety assurance programs, identified vulnerabilities, compensatory measures, and, in general, the rationale describing why the Tokamak Physics Experiment (TPX) can be safely operated. It discusses application of the graded approach to the TPX safety analysis, including the basis for using Department of Energy (DOE) Order 5480.23 and DOE-STD-3009-94 in the development of the PSAR

  16. Safety Review Committee - Annual Report 1991-1992

    1993-01-01

    During the year under review. The Safety Review Committee (SRC) assessed the safety of ANSTO's operations. This was done by site visits, examination of documentation and briefing by ANSTO officers responsible for particular operations, and includes HIFAR and Moata reactors, radioisotope production, packing and dispatch, radioactive waste management practices, occupational health and safety activities and ANSTO's arrangements for public health and safety beyond the site. This report describes the activities and findings of the SRC during the year ending 30 June 1992. 8 figs., ills

  17. Dimensions of patient safety culture in family practice.

    Palacios-Derflingher, Luz; O'Beirne, Maeve; Sterling, Pam; Zwicker, Karen; Harding, Brianne K; Casebeer, Ann

    2010-01-01

    Safety culture has been shown to affect patient safety in healthcare. While the United States and United Kingdom have studied the dimensions that reflect patient safety culture in family practice settings, to date, this has not been done in Canada. Differences in the healthcare systems between these countries and Canada may affect the dimensions found to be relevant here. Thus, it is important to identify and compare the dimensions from the United States and the United Kingdom in a Canadian context. The objectives of this study were to explore the dimensions of patient safety culture that relate to family practice in Canada and to determine if differences and similarities exist between dimensions found in Canada and those found in previous studies undertaken in the United States and the United Kingdom. A qualitative study was undertaken applying thematic analysis using focus groups with family practice offices and supplementary key stakeholders. Analysis of the data indicated that most of the dimensions from the United States and United Kingdom are appropriate in our Canadian context. Exceptions included owner/managing partner/leadership support for patient safety, job satisfaction and overall perceptions of patient safety and quality. Two unique dimensions were identified in the Canadian context: disclosure and accepting responsibility for errors. Based on this early work, it is important to consider differences in care settings when understanding dimensions of patient safety culture. We suggest that additional research in family practice settings is critical to further understand the influence of context on patient safety culture.

  18. Implementation of patient safety and patient-centeredness strategies in Iranian hospitals.

    Asgar Aghaei Hashjin

    Full Text Available OBJECTIVE: To examine the extent of implementation for patient safety (PS and patient-centeredness (PC strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade in Iran. METHODS: A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009-2010. RESULTS: The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO, and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient's diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals. CONCLUSIONS: Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.

  19. Implementation of patient safety and patient-centeredness strategies in Iranian hospitals.

    Aghaei Hashjin, Asgar; Kringos, Dionne S; Manoochehri, Jila; Ravaghi, Hamid; Klazinga, Niek S

    2014-01-01

    To examine the extent of implementation for patient safety (PS) and patient-centeredness (PC) strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade) in Iran. A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009-2010. The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO), and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient's diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals. Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.

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

    Howanitz, Peter J

    2005-10-01

    , specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented. Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.

  1. NPP Temelin safety analysis reports and PSA status

    Mlady, O.

    1999-01-01

    To enhance the safety level of Temelin NPP, recommendations of the international reviews were implemented into the design as well as into organization of the plant construction and preparation for operation. The safety assessment of these design changes has been integrated and reflected in the Safety Analysis Reports, which follow the internationally accepted guidelines. All safety analyses within Safety Analysis Reports were repeated carefully considering technical improvements and replacements to complement preliminary safety documentation. These analyses were performed by advanced western computer codes to the depth and in the structure required by western standards. The Temelin NPP followed a systematic approach in the functional design of the Reactor Protection System and related safety analyses. Modifications of reactor protection system increase defense in depth and facilitate demonstrating that LOCA and radiological limits are met for non-LOCA events. The rigorous safety analysis methodology provides assurance that LOCA and radiological limits are met. Established and accepted safety analysis methodology and accepted criteria were applied to Temelin NPP meeting US NRC and Czech Republic requirements. IAEA guidelines and recommendations

  2. West Valley Reprocessing Plant. Safety analysis report, supplement 21

    1976-01-01

    Supplement No. 21 contains responses to USNRC questions on quality assurance contained in USNRC letter to NFS dated January 22, 1976, revised pages for the safety analysis report, and Appendix IX ''Quality Assurance Manual--West Valley Construction Projects.''

  3. Annual technical progress report: reactor safety, Government fiscal year 1978

    1978-01-01

    Progress in LMFBR safety studies on accident debris behavior is reported under the following subtask titles: high-temperature-concentration aerosols, large-scale molten fuel tests, sodium release tests, and risk analysis

  4. 77 FR 34457 - Pipeline Safety: Mechanical Fitting Failure Reports

    2012-06-11

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... notice provides clarification to owners and operators of gas distribution pipeline facilities when... of a gas distribution pipeline facility to file a written report for any mechanical fitting failure...

  5. Applied health physics and safety annual report for 1976

    Auxier, J.A.; Davis, D.M.

    1977-08-01

    Progress is reported in the following areas of research: personnel monitoring; health physics instrumentation; atmospheric monitoring; water monitoring; radiation background measurements; soil samples; laboratory operations monitoring; radiation incidents; laundry monitoring; accident analysis; and industrial safety

  6. Early fluid loading for septic patients: Any safety limit needed?

    Gong, Yi-Chun; Liu, Jing-Tao; Ma, Peng-Lin

    2018-02-01

    Early adequate fluid loading was the corner stone of hemodynamic optimization for sepsis and septic shock. Meanwhile, recent recommended protocol for fluid resuscitation was increasingly debated on hemodynamic stability vs risk of overloading. In recent publications, it was found that a priority was often given to hemodynamic stability rather than organ function alternation in the early fluid resuscitation of sepsis. However, no safety limits were used at all in most of these reports. In this article, the rationality and safety of early aggressive fluid loading for septic patients were discussed. It was concluded that early aggressive fluid loading improved hemodynamics transitorily, but was probably traded off with a follow-up organ function impairment, such as worsening oxygenation by reduction of lung aeration, in a part of septic patients at least. Thus, a safeguard is needed against unnecessary excessive fluids in early aggressive fluid loading for septic patients. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

  7. Rankine bottoming cycle safety analysis. Final report

    Lewandowski, G.A.

    1980-02-01

    Vector Engineering Inc. conducted a safety and hazards analysis of three Rankine Bottoming Cycle Systems in public utility applications: a Thermo Electron system using Fluorinal-85 (a mixture of 85 mole % trifluoroethanol and 15 mole % water) as the working fluid; a Sundstrand system using toluene as the working fluid; and a Mechanical Technology system using steam and Freon-II as the working fluids. The properties of the working fluids considered are flammability, toxicity, and degradation, and the risks to both plant workers and the community at large are analyzed.

  8. Fusion Safety Program Annual Report, Fiscal Year 1996

    Longhurst, G.R.; Anderl, R.A.; Cadwallader, L.C.

    1996-12-01

    This report summarizes the major activities of the Fusion Safety Program in FY 1996. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory, and Lockheed Martin Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. The objective is to perform research and develop data needed to ensure safety in fusion facilities. Activities include experiments, analysis, code development and application, and other forms of research. These activities are conducted at the INEL, at other DOE laboratories, and at other institutions. Among the technical areas covered in this report are tritium safety, chemical reactions and activation product release, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Work done for ITER this year has focused on developing the needed information for the Non- Site- Specific Safety Report (NSSR-1). A final area of activity described is development of the new DOE Technical Standards for Safety of Magnetic Fusion Facilities

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

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

    2016-01-01

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

  10. KfK Nuclear Safety Project. First semiannual report 1985

    1985-11-01

    The semiannual progress report 1985/1 is a description of work within the Nuclear Safety Project performed in the first six month of 1985 in the nuclear safety field by KfK institutes and departements and by external institutions on behalf of KfK. The chosen kind of this report is that of short summaries, containing the topics: work performed, results obtained and plans for future work. (orig./HP) [de

  11. Report on nuclear and radiation safety in Slovenia in 2000

    Lovincic, D.

    2001-09-01

    The Slovenian Nuclear Safety Administration (SNSA), in co-operation with the Health Inspectorate of the Republic of Slovenia, the Administration for Civil Protection and Disaster Relief and the Ministry of the Interior, has prepared a Report on Nuclear and Radiation Safety in the Republic of Slovenia for 2000. This is one of the regular forms of reporting on the work of the Administration to the Government and National Assembly of the Republic of Slovenia.

  12. Nuclear and radiological safety in Slovenia in 1998, Annual report

    Lovincic, D.

    1999-09-01

    The Slovenian Nuclear Safety Administration (SNSA), in cooperation with Health Inspectorate of the Republic of Slovenia and the Administration for Civil Protection and Disaster Relief, has prepared a Report of Nuclear and Radiological Safety in the Republic of Slovenia for 1998. The report presents activities of the SNSA, operation of nuclear facilities, activities of the Agency of Radwaste Management, work of international missions, emergency plan, authorized organizations, monitoring of radioactivity, control of ionizing radiation and nuclear electricity generation

  13. Nuclear and Radiological Safety in Slovenia. Annual Report 1996

    Lovincic, D.

    1997-08-01

    The Slovenian Nuclear Safety Administration (SNSA), in cooperation with Health Inspectorate of the Republic of Slovenia, the Administration for Civil Protection and Disaster Relief and the Ministry of the Interior, has prepared a Report on Nuclear and Radiological Safety in the Republic of Slovenia for 1996. The report presents activities of the SNSA; operation of nuclear facilities; activities of the Agency for Radwaste Management; work of international missions; emergency plan; authorized organizations; monitoring of radioactivity; control of ionizing radiation and nuclear electricity generation

  14. Report on nuclear and radiological safety in 1995

    Lovincic, D.

    1996-07-01

    The Slovenian Nuclear Safety Administration (SNSA) in cooperation with the Health Inspectorate of the Republic of Slovenia and the Administration for Rescue and Disaster Relief (URSZR) has prepared a Report on Nuclear and Radiological Safety in the Republic of Slovenia for 1995. The report is presenting: the activities of the SNSA; the operation of nuclear facilities; monitoring of radioactivity; control of ionizing radiation and nuclear electricity generation.

  15. Nuclear and radiation safety in Slovenia. Annual report 2000

    Lovincic, D.

    2001-09-01

    The Slovenian Nuclear Safety Administration (SNSA), in co-operation with the Health Inspectorate of the Republic of Slovenia, the Administration for Civil Protection and Disaster Relief and the Ministry of the Interior, has prepared a Report on Nuclear and Radiation Safety in the Republic of Slovenia for 2000. This is one of the regular forms of reporting on the work of the Administration to the Government and National Assembly of the Republic of Slovenia. (author)

  16. Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events.

    Whitehurst, Julie M; Schroder, John; Leonard, Dave; Horvath, Monica M; Cozart, Heidi; Ferranti, Jeffrey

    2012-05-18

    Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined. To address this problem, we sought to create a "best-of-breed" patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint. A

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

    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

  18. Research program on regulatory safety research - Synthesis report 2008

    Mailaender, R

    2009-06-01

    This report for the Swiss Federal Office of Energy (SFOE) summarises the program's main points of interest, work done in the year 2008 and the results obtained. The main points of the research program, which is co-ordinated by the Swiss Federal Nuclear Safety Inspectorate ENSI, are discussed. Topics covered concern reactor safety as well as human, organisational and safety aspects. Work done in several areas concerning reactor safety and materials as well as interactions in severe accidents in light-water reactors is described. Radiation protection, the transport and disposal of radioactive wastes and safety culture are also looked at. Finally, national and international co-operation is briefly looked at and work to be done in 2009 is reviewed. The report is completed with a list of research and development projects co-ordinated by ENSI

  19. Bowtie Risk Management methodology and Modern Nuclear Safety Reports

    Ilizastigui Pérez, F.

    2016-01-01

    The Safety Report (SR) plays a crucial role within the nuclear licensing regime as the principal means for demonstrating the adequacy of safety analysis for a nuclear facility to ensure that it can be constructed, operated, maintained, shut down, and decommissioned safely and in compliance with applicable laws and regulations. It serves as the basis for granting authorizations for the commencement of the main stages of the facility’s life cycle as well as decision-making processes related to safety. Historically, the majority of nuclear safety reports have operated under rather prescriptive regimes, with emphasis placed on demonstrations of the robustness of the facility’s design (design safety) against prescriptive technical requirements set by the regulatory body, and less attention paid to demonstrating the adequacy and effectiveness of Operator’s management system for managing risks to daily operation.

  20. An analysis of electronic health record-related patient safety incidents.

    Palojoki, Sari; Mäkelä, Matti; Lehtonen, Lasse; Saranto, Kaija

    2017-06-01

    The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.