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

Science.gov (United States)

Bishop, Andrea C; Macdonald, Marilyn

2017-06-01

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

Laboratory safety and the WHO World Alliance for Patient Safety.

Science.gov (United States)

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

2009-06-01

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

Patient safety culture in primary care

NARCIS (Netherlands)

Verbakel, N.J.

2015-01-01

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

Development of Surveillance and In-Service Inspection Programme for Indian Research Reactors Cirus and Dhruva

International Nuclear Information System (INIS)

Shukla, D.K.

2006-01-01

Many safety requirements for research reactors are quite similar to those of power reactors. For research reactors with a higher hazard potential, the use of safety codes and guides for power reactors is more appropriate. However, there are many important differences between power reactors and research reactors that must be taken into account to ensure that adequate safety margins are available in design and operation of the research reactor. Most research reactors may have small potential for hazard to the public compared to power reactors but may pose a greater potential hazard to the plant operators. The need for greater flexibility in use of research reactors for individual experiments requires a different safety approach. Safety rules for power reactors are required to be substantially modified for application to specific research reactor. Following the intent of the available safety guides for surveillance and In-Service Inspection of Nuclear Power Plants, guidelines were formulated to develop surveillance and In-Service Inspection programme for research reactors Cirus and Dhruva. Based on the specific design of these research reactors, regulatory requirements, the degree of sophistication and experience of the technical organization involved in operating the research reactor, guidelines were evolved for developing and implementing the surveillance and In-Service Inspection programme for research reactors Cirus (40 MWt) and Dhruva (100 MWt) located at Bhabha Atomic Research Centre, Trombay, Mumbai, India. Paper describes the approach adopted for formulation of surveillance and In-service Inspection programme for Dhruva reactor in detail. (author)

Risk informed In-service Inspection

International Nuclear Information System (INIS)

Corak, Z.

2003-01-01

Safety of nuclear power plants is one of the most important conditions for their acceptance. Safety is being acheived by numerous methods and techniques in phase of design, manufacturing and maintenance of the nuclear power plants. In-service Inspection (ISI) has a significant role in avoidances of failure in components of nuclear power plants just the same as in assurance of their integrity. Non-destructive examinations are performed periodically in accordance with 10 CFR 50 50.55a and ASME Boiler and Pressure Vessel Code section XI which is referenced by 10 CFR 50.55a. Nondestructive examinations provide information about a current condition of equipment at nuclear power plants and about any damage, defect or degradation mechanism. A lot of effort is often spent in situations in which the probability of failure and their effects on safety have a very low impact. Practical experience shows that failures can often occur at locations where the inspection has never been performed. Costs and expenses of in-service inspections are very high. Therefore, the accent has to be on locations with significant risk to safety. Many years of nuclear power plants' operation and maintenance have resulted in a more broad knowledge of degradation mechanism and the most susceptible locations and huge databases of different nuclear power plants' components. U.S. Nuclear Regulatory Commission (NRC) and the nuclear industry have recognized that probabilistic risk assessment (PRA) has developed and changed to be more useful in improvement of traditional engineering approaches in nuclear power plants regulation. After the publication of its policy statement on the use of PRA in nuclear regulatory activities, the Commission ordered the NRC staff to develop a regulatory framework that incorporated risk insights. The American Society of Mechanical Engineers (ASME) initiated Code Case N-560, N-577, and N-578 that address the importance of categorization and inspection of piping using risk

Patient safety culture among nurses.

Science.gov (United States)

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

2015-03-01

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

Applying reliability centered maintenance analysis principles to inservice testing

International Nuclear Information System (INIS)

Flude, J.W.

1994-01-01

Federal regulations require nuclear power plants to use inservice test (IST) programs to ensure the operability of safety-related equipment. IST programs are based on American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code requirements. Many of these plants also use Reliability Centered Maintenance (RCM) to optimize system maintenance. ASME Code requirements are hard to change. The process for requesting authority to use an alternate strategy is long and expensive. The difficulties of obtaining this authority make the use of RCM method on safety-related systems not cost effective. An ASME research task force on Risk Based Inservice Testing is investigating changing the Code. The change will allow plants to apply RCM methods to the problem of maintenance strategy selection for safety-related systems. The research task force is working closely with the Codes and Standards sections to develop a process related to the RCM process. Some day plants will be able to use this process to develop more efficient and safer maintenance strategies

Increase plant safety and reduce cost by implementing risk-informed in-service inspection programs

International Nuclear Information System (INIS)

Billington, A.; Monette, P.

2001-01-01

The idea behind the program is that it is possible to 'inspect less, but inspect better'. In other words, the risk-informed In-Service Inspection (ISI) process is used to improve the effectiveness of examination of piping components, i.e. concentrate inspection resources and enhance inspection strategies on high safety significant locations, and reduce inspection requirements on others. The Westinghouse Owners Group (WOG) risk-informed ISI process has already been applied for full scope (Millstone 3, Surry 1) and limited scope (Beznau, Ringhals 4, Asco, Turkey Point 3). By examining the high safety significant piping segments for the different fluid piping systems, the total piping core damage frequency is reduced. In addition, more than 80% of the risk associated with potential pressure boundary failures is addressed with the WOG risk-informed ISI process, while typically less that 50% of this same risk is addressed by the current inspection programs. The risk-informed ISI processes are used to improve the effectiveness of inspecting safety-significant piping components, to reduce inspection requirements on other piping components, to evaluate improvements to plant availability and enhanced safety measures, including reduction of personnel radiation exposure, and to reduce overall Operation and Maintenance (O and M) costs while maintaining regulatory compliance. A description of the process as well as benefits from past projects is presented, since the methodology is applicable for WWER plant design. (author)

Increase plant safety and reduce cost by implementing risk-informed In-Service Inspection programs

International Nuclear Information System (INIS)

Billington, A.; Monette, P.; Doumont, C.

2000-01-01

The idea behind the program is that it is possible to 'inspect less, but inspect better'. In other words, the risk-informed In-Service Inspection (ISI) process is used to improve the effectiveness of examination of piping components, i.e. concentrate inspection resources and enhance inspection strategies on high safety significant locations, and reduce inspection requirements on others. The Westinghouse Owners Group (WOG) risk-informed ISI process has already been applied for full scope (Millstone 3, Surry 1) and limited scope (Beznau, Ringhals 4, Asco, Turkey Point 3). By examining the high safety significant piping segments for the different fluid piping systems, the total piping core damage frequency is reduced. In addition, more than 80% of the risk associated with potential pressure boundary failures is addressed with the WOG risk-informed ISI process, while typically less than 50% of this same risk is addressed by the current inspection programs. The risk-informed ISI processes are used: to improve the effectiveness of inspecting safety-significant piping components; to reduce inspection requirements on other piping components; to evaluate improvements to plant availability and enhanced safety measures, including reduction of personnel radiation exposure; and to reduce overall Operation and Maintenance (O and M) costs while maintaining regulatory compliance. A description of the process as well as benefits of past projects is presented, since the methodology is applicable for VVER plant design. (author)

Evaluation of structural welds with respect to reliability and inservice inspection

International Nuclear Information System (INIS)

Marci, G.

1980-01-01

The ongoing developments with respect to large forgings for nuclear pressure vessels and the present philosophy of inservice inspection in the Federal Republic of Germany (FRG) (inspection of weld regions only) seem to be oriented towards a monolithic pressure vessel requiring no inservice inspection. This raises questions as to the task of inservice inspection in the framework of the total reliability of a nuclear pressure vessel. The inherent 'weak spots' associated with welds of ferritic low alloyed steels are the microstructural features of stress relief cracks and regions of coarse grains. An analysis as to the effects of stress relief cracks and regions of coarse grains in the heat affected zones of welds on subcritical crack growth is performed. It is shown that these 'weak spots' cannot be considered a particular safety hazard to vessel integrity. Therefore welds per se should not constitute the criteria for the performance of inservice inspection. Rather, the inservice inspection programme should check the regions where manufacturing history, loading conditions, and materials degradation are expected to enhance subcritical crack growth. (author)

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

Directory of Open Access Journals (Sweden)

Armitage Gerry

2011-05-01

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

Interaction between periodic in-service inspection requirements and design

International Nuclear Information System (INIS)

Prot, A.C.; Saglio, R.

1979-03-01

After reviewing the requirements specific of periodic In-Service Inspection related to safety problems, especially for the pressure vessels, and taking into account the experience gained with several PWR reactors, the authors show these requirements could lead to modify the primary circuit design

Increasing the Effectiveness of Inservice Training for Desegregation: A Synthesis of Current Research. Reference & Resource Series.

Science.gov (United States)

Smylie, Mark A.; Hawley, Willis D.

This report reviews recent research on strategies that have been found to promote useful and effective inservice training programs in desegregated schools. The first section presents approaches for planning and implementing inservice training for desegregation. The second section describes inservice desegregation training programs that focus on:…

In-service education and training as experienced by registered nurses.

Science.gov (United States)

Norushe, T F; Van Rooyen, D; Strumpher, J

2004-11-01

Nursing is a dynamic profession that is subject to rapid changes in health care provision, hence the need for in-service training programmes for nurses. Newly employed registered nurses require in-service training in order to update them regarding the latest developments in nursing practice. The researcher noted that some newly appointed registered nurses were not competent in all aspects relating to their tasks. This could have been due to a knowledge deficit relating to either new developments or of the procedure relating to a specific task. In some institutions newly-appointed registered nurses on probation reported not receiving in-service training for six months or longer, yet they were still expected to perform their tasks efficiently. The objectives of the study were to, firstly, explore and describe the experiences of registered nurses regarding in-service training programmes in their institutions and, secondly, to make recommendations to Nursing Service Managers relating to the development of effective in-service training programmes in their institutions. A qualitative, exploratory, descriptive design was implemented. Data was analysed using Tesch's descriptive approach (in Creswell, 1994:155). Two main themes emerged, namely that registered nurses experienced in-service training programmes as inadequate and reacted negatively towards them. This article focuses on the experiences of registered nurses relating to in-service training programmes, as well as the formulation of guidelines to assist nursing service managers in the development of effective in-service training programmes.

Improvement critical care patient safety: using nursing staff development strategies, at Saudi Arabia.

Science.gov (United States)

Basuni, Enas M; Bayoumi, Magda M

2015-01-13

Intensive care units (ICUs) provide lifesaving care for the critically ill patients and are associated with significant risks. Moreover complexity of care within ICUs requires that the health care professionals exhibit a trans-disciplinary level of competency to improve patient safety. This study aimed at using staff development strategies through implementing patient safety educational program that may minimize the medical errors and improve patient outcome in hospital. The study was carried out using a quasi experimental design. The settings included the intensive care units at General Mohail Hospital and National Mohail Hospital, King Khalid University, Saudi Arabia. The study was conducted from March to June 2012. A convenience sample of all prevalent nurses at three shifts in the aforementioned settings during the study period was recruited. The program was implemented on 50 staff nurses in different ICUs. Their age ranged between 25-40 years. Statistically significant relation was revealed between safety climate and job satisfaction among nurses in the study sample (p=0.001). The years of experiences in ICU ranged between one year 11 (16.4) to 10 years 20 (29.8), most of them (68%) were working in variable shift, while 32% were day shift only. Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on ICUs after implementing a safety program. On the heels of this improvement; nurses' total knowledge, skills and attitude were enhanced regarding patient safety dimensions. Continuous educational program for ICUs nursing staff through organized in-service training is needed to increase their knowledge and skills about the importance of improving patient safety measure. Emphasizing on effective collaborative system also will improve patient safety measures in ICUS.

In-Service Aircraft Transmission Life Modeling for Improved Flight Safety, Phase I

Data.gov (United States)

National Aeronautics and Space Administration — It is proposed to develop an accurate, in-service transmission life-estimation system for the prediction of remaining component and system life for a helicopter...

Study and discussion on management of nuclear island in-service inspection procedure system in nuclear power plant

International Nuclear Information System (INIS)

Zhang Xueliang; Fan Yancheng

2014-01-01

In-service inspection of nuclear island is the important way for keeping safety operation of nuclear power plant. Taking Daya Bay Nuclear Power Plant as example, the management problems of in-service inspection system was studied and discussed from the angle of references, contents, classifications etc. Based on comparison with French practice, some points of view on perfection of in-service inspection system and improvement of management ability under future multi-bases and multi-units management mode were presented. (authors)

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

Science.gov (United States)

Groves, Patricia S; Bunch, Jacinda L

2018-05-18

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

In-Service Aircraft Transmission Life Modeling for Improved Flight Safety, Phase II

Data.gov (United States)

National Aeronautics and Space Administration — It is proposed to develop an accurate, in-service transmission life-use estimation system for the prediction of remaining component and system life for a helicopter...

An In-Service: Microcomputers and Their Practical Application Levels in the Educational Process.

Science.gov (United States)

Webb, Rosanna M.; Karr-Kidwell, PJ

Intended for both preservice and inservice teachers at all levels, the inservice workshop detailed in this report focuses on the computer as an educational tool that can be utilized without gaining an expertise in the inner workings and technicalities associated with the machinery. Related equipment and terminology is introduced informally to…

Conceptual design of in-service inspection and maintenance for KALIMER

International Nuclear Information System (INIS)

Ju, Y. S.; Kim, S. H.; Koo, K. H.; You, B.

1999-01-01

In-service inspection and maintenance are very important for the safety and availability of nuclear power plants. The conceptual requirements of in-service inspection and maintenance should be reflected in the earlier design process for the verification of the plant operability and reliability. In this paper the fundamental approaches of the inspection and maintenance for KALIMER are established to ensure the structural integrity and operability for KALIMER. The general strategy and methodology of maintenance and inspection for the reactor system and components are proposed and described for satisfying the intents of the Section XI, Division 3, of ASME code and considering the design characteristics of KALIMER

Changes in Default Alarm Settings and Standard In-Service are Insufficient to Improve Alarm Fatigue in an Intensive Care Unit: A Pilot Project.

Science.gov (United States)

Sowan, Azizeh Khaled; Gomez, Tiffany Michelle; Tarriela, Albert Fajardo; Reed, Charles Calhoun; Paper, Bruce Michael

2016-01-11

Clinical alarm systems safety is a national concern, specifically in intensive care units (ICUs) where alarm rates are known to be the highest. Interventional projects that examined the effect of changing default alarm settings on overall alarm rate and on clinicians' attitudes and practices toward clinical alarms and alarm fatigue are scarce. To examine if (1) a change in default alarm settings of the cardiac monitors and (2) in-service nursing education on cardiac monitor use in an ICU would result in reducing alarm rate and in improving nurses' attitudes and practices toward clinical alarms. This quality improvement project took place in a 20-bed transplant/cardiac ICU with a total of 39 nurses. We implemented a unit-wide change of default alarm settings involving 17 parameters of the cardiac monitors. All nurses received an in-service education on monitor use. Alarm data were collected from the audit log of the cardiac monitors 10 weeks before and 10 weeks after the change in monitors' parameters. Nurses' attitudes and practices toward clinical alarms were measured using the Healthcare Technology Foundation National Clinical Alarms Survey, pre- and postintervention. Alarm rate was 87.86 alarms/patient day (a total of 64,500 alarms) at the preintervention period compared to 59.18 alarms/patient day (49,319 alarms) postintervention (P=.01). At baseline, Arterial Blood Pressure (ABP), Pair Premature Ventricular Contractions (PVCs), and Peripheral Capillary Oxygen Saturation (SpO2) alarms were the highest. ABP and SpO2 alarms remained among the top three at the postproject period. Out of the 39 ICU nurses, 24 (62%) provided complete pre- and postproject survey questionnaires. Compared to the preintervention survey, no remarkable changes in the postproject period were reported in nurses' attitudes. Themes in the narrative data were related to poor usability of cardiac monitors and the frequent alarms. The data showed great variation among nurses in terms of changing

Patient safety: break the silence.

Science.gov (United States)

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.

In-service inspection of nuclear power-plant pressure components

International Nuclear Information System (INIS)

Lautzenheiser, C.E.

1976-01-01

The early light-water-reactor systems for production of commercial power were designed and fabricated in accordance with the codes then being used for fossil-fired power-generating stations with some design changes for increased inspectability during fabrication. Over the past few years, major strides have been made in in-service inspection technology. Work has been under way to determine the reliability of nondestructive testing methods and to develop formal inspection programs throughout the world. The major problems associated with in-service inspection are the scarcity of qualified personnel, the variability in procedures and data recording between inspection agencies, and exposure of inspection personnel to radiation. Further work will be required to more completely mechanize piping inspections to reduce radiation exposure and to standardize inspection procedures, equipment, and certification of personnel. Worldwide attention to the requirements of the American Society of Mechanical Engineers' Boiler and Pressure Vessel Code, the size and integrity of inspection agencies, and efforts such as the development of personnel qualification and certification guides emphasize the importance of in-service inspection to nuclear safety

Evaluation and improvement in nondestructive examination (NDE) reliability for inservice inspection of light water reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Andersen, E.S.; Bowey, R.E.; Diaz, A.A.; Good, M.S.; Heasler, P.G.; Hockey, R.L.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.; Vo, T.V.

1991-01-01

This program is intended to establish the effectiveness, reliability and adequacy of inservice inspection of reactor pressure vessels and primary piping systems and the impact of ISI reliability on system integrity. The objectives of the program include: (a) determine the effectiveness and reliability of ultrasonic inservice inspection (ISI) performed on commercial, light water reactor pressure vessels and piping; (b) recommend Code changes to the inspection procedures to improve the reliability of ISI; (c) using fracture mechanics analysis, determine the impact of NDE unreliability on system safety and determine the level of inspection reliability required to assure a suitably low failure probability; (d) evaluate the degree of reliability improvement which could be achieved using improved NDE techniques; and (e) based on importance of component to safety, material properties, service conditions, and NDE uncertainties, formulate improved inservice inspection criteria (including sampling plan, frequency, and reliability of inspection) for revisions to ASME Section XI and regulatory requirements needed to assure suitably low failure probabilities

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

Science.gov (United States)

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

2016-10-01

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

In-service inspection of nuclear power plants

International Nuclear Information System (INIS)

1991-01-01

This Manual is intended to provide more comprehensive considerations on the management, organization, preparation, improvement and implementation of in-service inspection activities and the related surveillance. It also gives illustrative examples of good practices and recommendations from operating and other organizations that are consistent with the requirements and recommendations of the Code and Safety Guides. The Manual is directed primarily towards plant management. This Manual should be used in conjunction with the Code and the Safety Guides, in particular with IAEA Safety Series Nos. 50-C-O, 50-SG-O2, 50-SG-05, 50-SG-07, 50-SG-08 and 50-SG-D1, which contain recommendations of a general character about maintenance activities and radiation protection in an operating power plant, and with the 'Manual on the Maintenance of Systems and Components Important to Safety'. This Manual is divided into four technical sections. The first introduces the purpose, structure and main requirements of the programme. The second section describes constituents of the programme, recommending its scope, scheduling, acceptance standards and documentation of results. The following section goes into details of the inspection programme's contents, such as the selection of components, inspection locations, defect types, applicable techniques and procedures, and the evaluation of results. The last section specifies recommended methods and techniques for inspection, such as visual, ultrasonic, eddy current, magnetic particle and others. This main part of the Manual is complemented by a number of annexes which reproduce actual national examples of established procedures, ISI programme parts, acceptance standards, personnel training programmes, testing techniques and other aspects of in-service inspection, illustrating practical implementation of the recommendations of the Manual

Review of Savannah River Site K Reactor inservice inspection and testing restart program

International Nuclear Information System (INIS)

Anderson, M.T.; Hartley, R.S.; Kido, C.

1992-09-01

Inservice inspection (ISI) and inservice testing (IST) programs are used at commercial nuclear power plants to monitor the pressure boundary integrity and operability of components in important safety-related systems. The Department of Energy (DOE) - Office of Defense Programs (DP) operates a Category A (> 20 MW thermal) production reactor at the Savannah River Site (SRS). This report represents an evaluation of the ISI and IST practices proposed for restart of SRS K Reactor as compared, where applicable, to current ISI/IST activities of commercial nuclear power facilities

Addressing Adolescent Depression in Schools: Evaluation of an In-Service Training for School Staff in the United States

Science.gov (United States)

Valdez, Carmen R.; Budge, Stephanie L.

2012-01-01

This study evaluated an adolescent depression in-service training for school staff in the United States. A total of 252 school staff (e.g., teachers, principals, counselors) completed assessments prior to and following the in-service and a subsample of these staff participated in focus groups following the in-service and three months later.…

Pre-Service and In-Service Preschool Teachers' Views Regarding Creativity in Early Childhood Education

Science.gov (United States)

Alkus, Simge; Olgan, Refika

2014-01-01

This research investigated the views of pre-service and in-service preschool teachers concerning the developing of children's creativity in early childhood education by determining the similarities and/or differences among their views. The data were gathered from 10 pre-service and 11 in-service teachers through focus group meetings, and then from…

Safety, training focus of combined organization

Energy Technology Data Exchange (ETDEWEB)

Toop, L.

2006-03-15

This article presented details of Enform, a company that coordinates safety programs and training for new employees in the oil and gas industry. Enform was created when the Petroleum Industry Training Services merged with the Canadian Petroleum Safety Council. The aim of Enform is to ensure continuous improvements in health and safety within the industry by reducing working injuries and promoting health and safety practices. The companies merged to eliminate duplication of services and allow associates further opportunities for advanced training. In 2005, Enform trained an estimated 155,000 students, and a number of new courses were introduced and updated. A franchise program was extended and a training council was formed to offer direction and guidance to the oil industry. Enform focuses on sharing information among companies, as well as working to harmonize safety regulations across provincial borders. A task force was recently created by the company with a specific focus on drug and alcohol abuse. Other concerns include driver safety and driver interactions with wildlife. Enform is mainly focused on the traditional oil industry, and has had little entry into the oil sands industry. It was concluded that increased activity in the oil and gas industry will remain Enform's biggest challenge in the next few years. Plans for Enform's increased involvement in the offshore oil and gas industry were also discussed. 4 figs.

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

Science.gov (United States)

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

2015-01-01

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

Managing patient safety through NPSGs and employee performance.

Science.gov (United States)

Adair, Liberty

2010-01-01

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

GIS In-Service Teacher Training Based on TPACK

Science.gov (United States)

Hong, Jung Eun; Stonier, Francis

2015-01-01

This article introduces the geographic information systems (GIS) in-service teacher training, focusing on the intersection of technological, pedagogical, and content knowledge (TPACK) for successful implementation of GIS in the classroom. Eleven social studies teachers in Georgia learned GIS technologies, inquiry-based learning, and social studies…

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

Science.gov (United States)

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

2017-02-16

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

Pre- and in-Service Teachers Reading and Discussing Informational Texts

Directory of Open Access Journals (Sweden)

Theresa A. Deeney

2016-05-01

Full Text Available This study investigates U.S. elementary (kindergarten-Grade 6, ages 5-12 pre- and in-service teachers’ discussions of informational texts to understand current practices and identify needs with respect to how teachers support students in building knowledge from complex informational text as specified in the grade-level expectations of the Common Core State Standards adopted in many U.S. states. Transcripts and reflections from 17 in-service and 31 pre-service teachers’ informational text discussions were analyzed for teachers’ focus on the text, background knowledge, and text/background knowledge. In addition, transcripts were analyzed for the types of text ideas teachers targeted (details/main ideas, the comprehension demands placed on students, how teachers used follow-up moves to encourage higher level thinking, and how teachers use transcripts of their discussions to analyze and critique their own practice. Findings suggest that both pre- and in-service teachers draw heavily on students’ background knowledge and text details in their questioning; but differences exist in how pre- and in-service teachers use follow-up responses to promote knowledge building. Findings also suggest that both pre- and in-service teachers can use their transcripts to recognize areas of need, and offer themselves suggestions to better support students’ understanding. Implications are offered for teacher education and professional development.

Advanced In-Service Inspection Approaches Applied to the Phenix Fast Breeder Reactor

International Nuclear Information System (INIS)

Guidez, J.; Martin, L.; Dupraz, R.

2006-01-01

The safety upgrading of the Phenix plant undertaken between 1994 and 1997 involved a vast inspection programme of the reactor, the external storage drum and the secondary sodium circuits in order to meet the requirements of the defence-in-depth safety approach. The three lines of defence were analysed for every safety related component: demonstration of the quality of design and construction, appropriate in-service inspection and controlling the consequences of an accident. The in-service reactor block inspection programme consisted in controlling the core support structures and the high-temperature elements. Despite the fact that limited consideration had been given to inspection constraints during the design stage of the reactor in the 1960's, as compared to more recent reactor projects such as the European Fast Reactor (EFR), all the core support line elements were able to be inspected. The three following main operations are described: Ultrasonic inspection of the upper hangers of the main vessel, using small transducers able to withstand temperatures of 130 deg. C, Inspection of the conical shell supporting the core dia-grid. A specific ultrasonic method and a special implementation technique were used to control the under sodium structure welds, located up to several meters away from the scan surface. Remote inspection of the hot pool structures, particularly the core cover plug after partial sodium drainage of the reactor vessel. Other inspections are also summarized: control of secondary sodium circuit piping, intermediate heat exchangers, primary sodium pumps, steam generator units and external storage drum. The pool type reactor concept, developed in France since the 1960's, presents several favourable safety and operational features. The feedback from the Phenix plant also shows real potential for in-service inspection. The design of future generation IV sodium fast reactors will benefit from the experience acquired from the Phenix plant. (authors)

MIR: an in-service inspection device for Superphenix 1 vessels

International Nuclear Information System (INIS)

Asty, M.; Ceccato, S.; Lerat, B.; Viard, J.

1986-06-01

The main and safety vessels of SUPERPHENIX 1 were designed to allow in-service inspections. The remote controlled inspection device MIR was developed for this purpose. It allows both visual and ultrasonic examinations to be performed. Basically, MIR consists of a tetrahedral structure provided with four steering and traction wheels, two for each vessel. A computer assisted control system enables it to be driven to any position on either the main or safety vessels. Operating conditions are briefly reviewed and the main features of MIR presented

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

Directory of Open Access Journals (Sweden)

V. Karyadinata

2012-09-01

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

Educating future leaders in patient safety

Science.gov (United States)

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

2014-01-01

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

National Chemistry Teacher Safety Survey

Science.gov (United States)

Plohocki, Barbra A.

This study evaluated the status of secondary school instructional chemistry laboratory safety using a survey instrument which focused on Teacher background Information, Laboratory Safety Equipment, Facility Safety, General Safety, and a Safety Content Knowledge Survey. A fifty question survey instrument based on recent research and questions developed by the researcher was mailed to 500 secondary school chemistry teachers who participated in the 1993 one-week Woodrow Wilson National Fellowship Foundation Chemistry Institute conducted at Princeton University, New Jersey. The data received from 303 respondents was analyzed by t tests and Analysis of Variance (ANOVA). The level of significance for the study was set at ~\\ performance on the Safety Content Knowledge Survey and secondary school chemistry teachers who have had undergraduate and/or graduate safety training and those who have not had undergraduate and/or graduate safety training. Secondary school chemistry teachers who attended school district sponsored safety inservices did not score higher on the Safety Content Knowledge Survey than teachers who did not attend school district sponsored safety inservice sessions. The type of school district (urban, suburban, or rural) had no significant correlation to the type of laboratory safety equipment found in the instructional chemistry laboratory. The certification area (chemistry or other type of certificate which may or may not include chemistry) of the secondary school teacher had no significant correlation to the type of laboratory equipment found in the instructional chemistry laboratory. Overall, this study indicated a majority of secondary school chemistry teachers were interested in attending safety workshops applicable to chemistry safety. Throughout this research project, many teachers indicated they were not adequately instructed on the collegiate level in science safety and had to rely on common sense and self-study in their future teaching careers.

Inservice inspection procedures and training according to the ASME code

International Nuclear Information System (INIS)

Greenwald, S.M.; Chockie, L.J.

1987-01-01

Mandatory training of the technical staff at a nuclear power plant is of paramount importance if we are to avoid costly plant shutdowns. This training should include the requirements for both Preservice and Inservice Inspection, in addition to Quality Assurance procedures as required by the American Society of Mechanical Engineers (ASME) Code. The training is best accomplished by utilizing instructors who are thoroughly familiar with plant operations and the ASME Code, as well as serving on one of the Code committees. This paper focuses on the Inservice Inspection procedures and the results of an intensive training effort to implement such procedures. (author)

Optimized periodic verification testing blended risk and performance-based MOV inservice test program an application of ASME code case OMN-1

Energy Technology Data Exchange (ETDEWEB)

Sellers, C.; Fleming, K.; Bidwell, D.; Forbes, P. [and others

1996-12-01

This paper presents an application of ASME Code Case OMN-1 to the GL 89-10 Program at the South Texas Project Electric Generating Station (STPEGS). Code Case OMN-1 provides guidance for a performance-based MOV inservice test program that can be used for periodic verification testing and allows consideration of risk insights. Blended probabilistic and deterministic evaluation techniques were used to establish inservice test strategies including both test methods and test frequency. Described in the paper are the methods and criteria for establishing MOV safety significance based on the STPEGS probabilistic safety assessment, deterministic considerations of MOV performance characteristics and performance margins, the expert panel evaluation process, and the development of inservice test strategies. Test strategies include a mix of dynamic and static testing as well as MOV exercising.

Optimized periodic verification testing blended risk and performance-based MOV inservice test program an application of ASME code case OMN-1

International Nuclear Information System (INIS)

Sellers, C.; Fleming, K.; Bidwell, D.; Forbes, P.

1996-01-01

This paper presents an application of ASME Code Case OMN-1 to the GL 89-10 Program at the South Texas Project Electric Generating Station (STPEGS). Code Case OMN-1 provides guidance for a performance-based MOV inservice test program that can be used for periodic verification testing and allows consideration of risk insights. Blended probabilistic and deterministic evaluation techniques were used to establish inservice test strategies including both test methods and test frequency. Described in the paper are the methods and criteria for establishing MOV safety significance based on the STPEGS probabilistic safety assessment, deterministic considerations of MOV performance characteristics and performance margins, the expert panel evaluation process, and the development of inservice test strategies. Test strategies include a mix of dynamic and static testing as well as MOV exercising

Use of expert judgment in the development and evaluation of risk-based inservice testing strategies for pumps and valves

International Nuclear Information System (INIS)

McAllister, W.J.; Perdue, R.K.; Balkey, K.R.; Closky, N.B.

1996-01-01

This paper describes a rigorous approach for quantitatively evaluating inservice testing effectiveness that evolved from two pilot plant studies. These studies prototyped methodologies for designing and selecting inservice testing (IST) strategies in a manner structured to insure that the targeted components will perform their required safety functions while minimizing life cycle inservice testing costs. The paper concentrates on the use of expert judgment in developing test effectiveness measures that move risk-based methods beyond ranking to optimization of plant IST programs. Selected results for check valves and pumps are shown to illustrate the practical significance of the approach

Use of expert judgment in the development and evaluation of risk-based inservice testing strategies for pumps and valves

Energy Technology Data Exchange (ETDEWEB)

McAllister, W.J.; Perdue, R.K.; Balkey, K.R.; Closky, N.B. [and others

1996-12-01

This paper describes a rigorous approach for quantitatively evaluating inservice testing effectiveness that evolved from two pilot plant studies. These studies prototyped methodologies for designing and selecting inservice testing (IST) strategies in a manner structured to insure that the targeted components will perform their required safety functions while minimizing life cycle inservice testing costs. The paper concentrates on the use of expert judgment in developing test effectiveness measures that move risk-based methods beyond ranking to optimization of plant IST programs. Selected results for check valves and pumps are shown to illustrate the practical significance of the approach.

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

Science.gov (United States)

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

2016-11-01

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

Nondestructive examination (NDE) Reliability for Inservice Inspection of Light Water Reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Good, M.S.; Heasler, P.G.; Hockey, R.L.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.; Vo, T.V.

1992-07-01

The Evaluation and Improvement of NDE reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to the Regulatory and ASME Code requirements, based on material properties, service conditions, and NDE uncertainties

Scientific foundation of in-service training for prevention of peer violence

Directory of Open Access Journals (Sweden)

Pavlović Miroslav V.

2016-01-01

Full Text Available The paper analyzes the compatibility of the continuous in-service teacher training for prevention of peer violence and modern scientific knowledge in this area. The first part of the paper summarizes the results of 12 systematic reviews and meta-analyses of the effectiveness of the studies of antibullying programs published since 2000. which relate to the effects of uni-modal and multi-modal programs, and the efficacy of interventions used in anti-bullying programs. The second part of the paper analyses the approved programs of in-service teacher training, in which priority is given to the prevention of violence, abuse and negligence. We analyzed 39 programs of continuous in-service teacher training, and focused on the empirical bases of the programs (researches which confirm the effectiveness of a program and the contents of the training (the level of preventive activity, modality, field, and interventions. The results of the analysis of the programs of continuous in-service training for peer violence prevention are discussed in the context of modern scientific knowledge of effectiveness of anti-bullying programs and of professional development of teachers and counsellors.

Application of phased arrays in basic and in-service inspection

International Nuclear Information System (INIS)

Gebhardt, W.; Schwarz, H.P.; Bonitz, F.; Woll, H.

1985-01-01

In the scope of the reactor safety research program of the Federal Ministry of Research and Technology a flexible microcomputer controlled phased array system was developed. Meanwhile, several industrial prototypes for simple and complicated applications are built up. The applicability of phased array systems in NDE for basic and inservice inspections of reactor pressure vessels is investigated. Methods for defect detection, reconstruction and classification are described

Preventing degradation and in-service inspection of NPP steam generator

International Nuclear Information System (INIS)

Ding Xunshen

1999-01-01

The author describes the degradation of steam generator tubes in initial operating stage of France NPP. The author emphatically presents the preventive measures to tackle degradation and In-service inspection of Daya Bay NPP 1 unit as a guarantee of safety operation, including secondary side water chemistry monitoring and controlling, leakage rate monitoring, eddy-current inspection, mechanical cleaning, cleanliness inspection, foreign objects removal and etc

Patient safety trilogy: perspectives from clinical engineering.

Science.gov (United States)

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.

Risk evaluation for motor operated valves in an Inservice Testing Program at a PWR nuclear power plant in Taiwan

International Nuclear Information System (INIS)

Li, Y.C.; Chen, K.T.; Su, Y.L.; Ting, K.; Chien, F.T.; Li, G.D.; Huang, S.H.

2012-01-01

Safety related valves such as Motor Operated Valves (MOV), Air Operated Valves (AOV) or Check Valves (CV) play an important role in nuclear power plant. Functioning of these valves mainly aim at emergency reactivity control, post-accident residue heat removal, post-accident radioactivity removal and containment isolation when a design basis accident occurred. In order to maintain these valves under operable conditions, an Inservice Testing Program (IST) is defined for routine testing tasks based on the ASME Boiler and Pressure Vessel Code section XI code requirements. Risk based Inservice Testing Programs have been studied and developed extensively in the nuclear energy industry since the 1990s. Risk Based evaluations of IST can bring positive advantages to the licensee such as identifying the vulnerability of the system, reducing unnecessary testing burden, concentrating testing resources on the critical pass oriented valves and saving plant’s personnel dose exposure. This risk evaluation is incorporated with quantitative and qualitative analyses to the Motor Operated Valves under current Inservice Testing Program for PWR nuclear power plant in Taiwan. With the outcome of the risk classifications for the safety related MOVs through numerical or deterministic analyses, a risk based testing frequency relief is suggested to demonstrate the benefits received from the risk based Inservice Testing Program. The goal made of this study, it could be as a reference and cornerstone for the licensee to perform overall scope Risk-Informed Inservice Testing Program (RI-IST) evaluation by referring relevant methodologies established in this study.

Application of risk-based methods to inservice testing of check valves

Energy Technology Data Exchange (ETDEWEB)

Closky, N.B.; Balkey, K.R.; McAllister, W.J. [and others

1996-12-01

Research efforts have been underway in the American Society of Mechanical Engineers (ASME) and industry to define appropriate methods for the application of risk-based technology in the development of inservice testing (IST) programs for pumps and valves in nuclear steam supply systems. This paper discusses a pilot application of these methods to the inservice testing of check valves in the emergency core cooling system of Georgia Power`s Vogtle nuclear power station. The results of the probabilistic safety assessment (PSA) are used to divide the check valves into risk-significant and less-risk-significant groups. This information is reviewed by a plant expert panel along with the consideration of appropriate deterministic insights to finally categorize the check valves into more safety-significant and less safety-significant component groups. All of the more safety-significant check valves are further evaluated in detail using a failure modes and causes analysis (FMCA) to assist in defining effective IST strategies. A template has been designed to evaluate how effective current and emerging tests for check valves are in detecting failures or in finding significant conditions that are precursors to failure for the likely failure causes. This information is then used to design and evaluate appropriate IST strategies that consider both the test method and frequency. A few of the less safety-significant check valves are also evaluated using this process since differences exist in check valve design, function, and operating conditions. Appropriate test strategies are selected for each check valve that has been evaluated based on safety and cost considerations. Test strategies are inferred from this information for the other check valves based on similar check valve conditions. Sensitivity studies are performed using the PSA model to arrive at an overall IST program that maintains or enhances safety at the lowest achievable cost.

The relationship between patient safety climate and occupational safety climate in healthcare - A multi-level investigation.

Science.gov (United States)

Pousette, Anders; Larsman, Pernilla; Eklöf, Mats; Törner, Marianne

2017-06-01

Patient safety climate/culture is attracting increasing research interest, but there is little research on its relation with organizational climates regarding other target domains. The aim of this study was to investigate the relationship between patient safety climate and occupational safety climate in healthcare. The climates were assessed using two questionnaires: Hospital Survey on Patient Safety Culture and Nordic Occupational Safety Climate Questionnaire. The final sample consisted of 1154 nurses, 886 assistant nurses, and 324 physicians, organized in 150 work units, within hospitals (117units), primary healthcare (5units) and elderly care (28units) in western Sweden, which represented 56% of the original sample contacted. Within each type of safety climate, two global dimensions were confirmed in a higher order factor analysis; one with an external focus relative the own unit, and one with an internal focus. Two methods were used to estimate the covariation between the global climate dimensions, in order to minimize the influence of bias from common method variance. First multilevel analysis was used for partitioning variances and covariances in a within unit part (individual level) and a between unit part (unit level). Second, a split sample technique was used to calculate unit level correlations based on aggregated observations from different respondents. Both methods showed associations similar in strength between the patient safety climate and the occupational safety climate domains. The results indicated that patient safety climate and occupational safety climate are strongly positively related at the unit level, and that the same organizational processes may be important for the development of both types of organizational climate. Safety improvement interventions should not be separated in different organizational processes, but be planned so that both patient safety and staff safety are considered concomitantly. Copyright © 2017 National Safety

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

Science.gov (United States)

Stewart, Lee; Usher, Kim

2010-11-01

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

Risk analysis of in-service pressure piping containing defects

International Nuclear Information System (INIS)

Lin, Y.C.; Xie, Y.J.; Wang, X.H.; Luo, H.

2004-01-01

The reliability of pressure piping containing defects is important in engineering. The failure probability of pressure piping containing defects may be used as a guide to the most economic deployment of resources on maintenance, inspection and repair. This paper presents a probabilistic assessment methodology for in-service pressure piping containing defects, which is especially designed for programming. It is based on three assessment codes, BS 7910, R6 and SAPV-99, considering uncertainties in operating loadings, flaw sizes, material fracture toughness and flow stress. A general sampling computation method of stress intensity factor (SIF), in the form of the relationship between SIF and axial force and bending moment and torsion, is adopted. This relationship has been successfully used in developing software, Safety Assessment System of In-service Pressure Piping Containing Flaws (SAPP-2003), to assess planar and non-planar flaws. A numerical example is presented to illustrate the application of SAPP-2003 for calculating the failure probabilities of separate defects and for the assessed pressure piping

Conceptual design and assessment of in-service inspection and maintenance of KALIMER

Energy Technology Data Exchange (ETDEWEB)

Joo, Young Sang; Kim, Seok Hun; Kim, Jong Bum; Lee, Jae Han [Korea Atomic Energy Research Institute, Taejeon (Korea)

2002-05-01

In the conceptual design stage of KALIMER, the philosophy and methodology of in-service inspection (ISI) and maintenance for the reactor system and components are proposed and described. The ISI and maintenance should be carried out throughout plant life to ensure the structural integrity and safety of KALIMER. The conceptual design of ISI and maintenance are performed for considering the design characteristics of KALIMER and the intents of the ASME XI Division 3. This report describes and summarizes the requirements and available methods of ISI and maintenance. The visual inspection and continuous monitoring play a great role in the in-service inspection of KALIMER. The major structures of KALIMER reactor system are designed for maintenance free operation for the plant life time and the maintenance philosophy is to replace major components rather than repair them. The assessment of the ISI accessibility and maintainability is performed and reviewed each major component. The postulated failure defects for each component are estimated and evaluated for KALIMER safety and reliability. 8 refs., 16 figs., 13 tabs. (Author)

S-TEAMS: A Truly Multiprofessional Course Focusing on Nontechnical Skills to Improve Patient Safety in the Operating Theater.

Science.gov (United States)

Stewart-Parker, Emma; Galloway, Robert; Vig, Stella

Possessing adequate nontechnical skills (NTS) in operating theaters is of increasing interest to health care professionals, yet these are rarely formally taught. Teams make human errors despite technical expertise and knowledge, compromising patient safety. We designed a 1-day, multiprofessional, multidisciplinary course to teach, practice, and apply these skills through simulation. The course, "S-TEAMS," comprised a morning of lectures, case studies, and interactive teamworking exercises. The afternoon divided the group into multiprofessional teams to rotate around simulated scenarios. During the scenarios, teams were encouraged to focus on NTS, including communication strategies, situational awareness, and prompts such as checklists. A thorough debrief with experienced clinician observers followed. Data was collected through self-assessments, immediate and 6-month feedback to assess whether skills continued to be used and their effect on safety. In total, 68 health care professionals have completed the course thus far. All participants felt the course had a clear structure and that learning objectives were explicit. Overall, 95% felt the scenarios had good or excellent relevance to clinical practice. Self-assessments revealed a 55% increase in confidence for "speaking up" in difficult situations. Long-term data revealed 97% of the participants continued to use the skills, with 88% feeling the course had prevented them from making errors. Moreover, 94% felt the course had directly improved patient safety. There is a real demand and enthusiasm for developing NTS within the modern theater team. The simple and easily reproducible format of S-TEAMS is sustainable and inclusive, and crucially, the skills taught continue to be used in long term to improve patient safety and teamworking. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The complexity of patient safety reporting systems in UK dentistry.

Science.gov (United States)

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.

Applying importance-performance analysis to patient safety culture.

Science.gov (United States)

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

2015-01-01

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

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

Science.gov (United States)

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

2015-04-22

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

Application of risk-informed in-service inspection approach. Pilot study on low pressure emergency core cooling system of NPP Temelin

International Nuclear Information System (INIS)

Horacek, L.; Palyza, J.; Zdarek, J.; Vizina, M.

2004-01-01

In-service inspection (ISI) programme of piping systems based on Riskinformed In-service Inspections (RI-ISI) approach represents for the WWER NPP licensee first overall systematic conceptual solution of the problems associated with design and design modifications of ISI programme for piping systems. The approach enables to consider possible savings and comparison of in-service inspection programmes according to more objective criteria including those calculated in PSA, in contrast to present much empiric experience collected by manufacturers, operators and ISI vendors in the past. Service experience has shown limited correlation between the deterministic ISI requirements and actual field failures or degradation mechanisms. Where field failures have been observed in piping, they have generally been due to either material concerns (e.g., Intergranular Stress Corrosion Cracking) or stress/cycling mechanisms not identified in the original design basis documents (e.g., thermal stratification), and therefore would not be selected for inspection under current requirements. Risk-informed in-service inspections represent integrated multidisciplinary approach to the in-service inspection programme fulfilling the enhanced requirements of the Czech Regulatory Body (SUJB) for defence in depth concept applied to weld joints of safety related components, application of qualified NDT methods/techniques and introducing of inspections for cause approach. Inspections for cause take into account analysis of both active and potential degradation mechanisms specific to piping system concerned. Simultaneously, this approach enables the licensee to reach, in cases justified from safety point of view, economic savings resulting from lowering of both number and extent of performed in-service inspections and optimisation of their performance. RI ISI pilot study based in majority on EPRI methodology implemented for WWER type reactors has been performed for LP ECCS (Low Pressure Emergency

International developments on implementation of Wog risk-informed inservice inspection methodology

International Nuclear Information System (INIS)

Balkey, K.R.; Bishop, B.A.; Canton, M.A.; Closky, N.B.; Haessler, R.L.; Kolonay, J.F.; Sharp, G.L.; Stevenson, P.R.

2001-01-01

The full text follows. The Westinghouse Owners Group (WOG) risk-informed inservice inspection (ISI) methodology was granted approval by the U.S. Nuclear Regulatory Commission in 1998 thereby providing an alternative to ASME Section XI Code requirements for the selection of examination locations in nuclear plant piping systems. This paper builds upon a technical paper presented at ICONE-8 that reported on the first wave of risk-informed ISI applications under development primarily focusing on those underway within the U.S. Since that time, many applications have continued within the U.S., however, much progress has been made in applying the WOG risk-informed ISI approach in several other countries. While a summary of results across the various applications will be provided, the paper will focus on the development and implementation of the WOG risk-informed ISI methodology across Europe and in Asia for both full scope and limited Class 1 scope applications. An update on future risk-informed applications, such as modifying requirements for augmented examinations for high energy line break exclusion regions and in risk-informing the safety classification of pressure boundary components in support of risk-informed regulation initiatives, will also be provided. (authors)

Examination of in-service risk management at the level of the draft project for Cigeo

International Nuclear Information System (INIS)

2014-01-01

This document reports the opinion of the IRSN on the issue of in-service risk management as it appears in the draft project of Cigeo. After having recalled the general context of the ASN request for this opinion, and presented the ANDRA file on in-service risk-management of the draft project for Cigeo, this report describes the underground installation and the different flows during the exploitation phase, and recalls the various evolutions of Cigeo general design from the 2009 file to the draft project. The next part reports the examination by the IRSN of the relevance of the in-service safety approach by the ANDRA. The next chapter reports the examination of the risk analysis made by the ANDRA on radioactive material dissemination, fire (protection measures, ventilation control, case of exothermal reactions), explosion, handling, co-activity, as well as ageing and maintenance of storage components, intervention in accidental and incidental situation and possibility of retrieval of waste packages

Risk-informed decision making a keystone in advanced safety assessment

International Nuclear Information System (INIS)

Reinhart, M.

2007-01-01

Probabilistic Safety Assessment (PSA) has provided extremely valuable complementary insight, perspective, comprehension, and balance to deterministic nuclear reactor safety assessment. This integrated approach of risk-informed management and decision making has been called Risk-Informed Decision Making (RIDM). RIDM provides enhanced safety, reliability, operational flexibility, reduced radiological exposure, and improved fiscal economy. Applications of RIDM continuously increase. Current applications are in the areas of design, construction, licensing, operations, and security. Operational phase safety applications include the following: technical specifications improvement, risk-monitors and configuration control, maintenance planning, outage planning and management, in-service inspection, inservice testing, graded quality assurance, reactor oversight and inspection, inspection finding significance determination, operational events assessment, and rulemaking. Interestingly there is a significant spectrum of approaches, methods, programs, controls, data bases, and standards. The quest of many is to assimilate the full compliment of PSA and RIDM information and to achieve a balanced international harmony. The goal is to focus the best of the best, so to speak, for the benefit of all. Accordingly, this presentation will address the principles, benefits, and applications of RIDM. It will also address some of the challenges and areas to improve. Finally it will highlight efforts by the IAEA and others to capture the international thinking, experience, successes, challenges, and lessons in RIDM. (authors)

Patient Safety Culture

DEFF Research Database (Denmark)

Kristensen, Solvejg

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

Targeted In-service Inspections Using Risk Insights

International Nuclear Information System (INIS)

Kulat, S.; Montgomery, B.; Robin Graybeal, M.

2012-01-01

This paper includes a discussion of the historical background and rationale for development of a targeted In-service Inspection (ISI) program using risk insights, known as Risk-Informed In-service Inspection (RI-ISI). RI-ISI programs are optimized inspection programs which target specific welds for inspection based upon potential degradation mechanisms and consequences of failure. Inspections are performed on those welds that are the highest contributors to plant risk. Additionally the inspections are tailored to detect the specific postulated degradation mechanisms. As a result, the numbers of inspections are reduced along with the associated cost and radiation exposure, while maintaining or improving the level of quality and safety. Provided in this paper are the basic principles of RI-ISI program development, and a summary of the impact of the implementation of such programs. For example, implementation of a Risk-Informed In-service Inspection program results in a reduction of both cost and radiation exposure. Cost savings are estimated at between USD 1,000,000 and USD 2,300,000 per unit per ten year interval for a Class 1 and2 RI-ISI application. Cost savings are estimated based on average cost per weld of USD 7600 for examination, including the following activities: erection and removal of scaffolding, removal and replacement of insulation, removal and replacement of interferences, weld preparation, examination, documentation, craft support. Reduction in radiation exposure is estimated at 75% to 90% for a Class 1 and2 RI-ISI application. Reduction in radiation exposure is due to the following factors: number of welds selected for examination decreases by 60% to 75%, surface examinations essentially eliminated, within a given risk category, welds can be selected for examination based on additional factors such as the minimization of radiation exposure.(author).

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

Science.gov (United States)

2011-11-17

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

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

Science.gov (United States)

2011-12-21

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

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

Science.gov (United States)

Parker, Dianne

2009-03-01

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

Psychodrama Techniques for Inservice Teacher Training

Science.gov (United States)

Kohut, Sylvester, Jr.

1976-01-01

By using psychodrama techniques in inservice programming, improvement in communication among members of the school community occurs. With modification the psychodrama approach can be used with inservice teachers and administrators to improve self-realization and communication. A program using psychodrama techniques is described in the article.…

Patient safety competency and educational needs of nursing educators in South Korea

Science.gov (United States)

2017-01-01

Background Nursing educators must be qualified to teach patient safety to nursing students to ensure patient safety in the clinical field. The purpose of this study was to assess nursing educators’ competencies and educational needs for patient safety in hospitals and nursing schools. Method A mixed-methods sequential explanatory design employed a survey and focus group interview with nursing educators (school clinical instructors and hospital nurse preceptors). Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analyzed to obtain quantitative data. Focus group interviews were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul. Results Nursing educators had higher levels of attitude compared with relatively lower levels of skill and knowledge regarding patient safety. They reported educational needs of “medication” and “infection prevention” as being higher and “human factors” and “complexity of systems” as being lower. Nursing educators desired different types of education for patient safety. Conclusion It is necessary to enhance nursing educators’ patient safety skills and knowledge by developing and providing an integrated program of patient safety, with various teaching methods to meet their educational needs. The findings of this study provide the basic information needed to reform patient safety education programs appropriately to fit nursing educators' needs and their patient safety competencies in both clinical practice and academia. Furthermore, the findings have revealed the importance of effective communication between clinical and academic settings in making patient safety education seamless. PMID:28873099

Patient safety competency and educational needs of nursing educators in South Korea.

Directory of Open Access Journals (Sweden)

Haena Jang

Full Text Available Nursing educators must be qualified to teach patient safety to nursing students to ensure patient safety in the clinical field. The purpose of this study was to assess nursing educators' competencies and educational needs for patient safety in hospitals and nursing schools.A mixed-methods sequential explanatory design employed a survey and focus group interview with nursing educators (school clinical instructors and hospital nurse preceptors. Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analyzed to obtain quantitative data. Focus group interviews were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul.Nursing educators had higher levels of attitude compared with relatively lower levels of skill and knowledge regarding patient safety. They reported educational needs of "medication" and "infection prevention" as being higher and "human factors" and "complexity of systems" as being lower. Nursing educators desired different types of education for patient safety.It is necessary to enhance nursing educators' patient safety skills and knowledge by developing and providing an integrated program of patient safety, with various teaching methods to meet their educational needs. The findings of this study provide the basic information needed to reform patient safety education programs appropriately to fit nursing educators' needs and their patient safety competencies in both clinical practice and academia. Furthermore, the findings have revealed the importance of effective communication between clinical and academic settings in making patient safety education seamless.

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

NARCIS (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

New Swedish regulations in the area of plant inspection and in-service inspection

International Nuclear Information System (INIS)

Hansson, B.

1998-01-01

History and present status od Swedish regulations in the field of NPP inspection and in-service inspection are described. The presentation focuses on the development of regulations and establishing new ones. A description of different organisations involved is included

Risk-informed inservice test activities at the NRC

International Nuclear Information System (INIS)

Fischer, D.; Cheok, M.; Hsia, A.

1996-01-01

The operational readiness of certain safety-related components is vital to the safe operation of nuclear power plants. Inservice testing (IST) is one of the mechanisms used by licensees to ensure this readiness. In the past, the type and frequency of IST have been based on the collective best judgment of the NRC and industry in an ASME Code consensus process and NRC rulemaking process. Furthermore, IST requirements have not explicitly considered unique component and system designs and contribution to overall plant risk. Because of the general nature of ASME Code test requirements and non-reliance on risk estimates, current IST requirements may not adequately emphasize testing those components that are most important to safety and may overly emphasize testing of less safety significant components. Nuclear power plant licensees are currently interested in optimizing testing by applying resources in more safety significant areas and, where appropriate, reducing measures in less safety-significant areas. They are interested in maintaining system availability and reducing overall maintenance costs in ways that do not adversely affect safety. The NRC has been interested in using probabilistic, as an adjunct to deterministic, techniques to help define the scope, type and frequency of IST. The development of risk-informed IST programs has the potential to optimize the use of NRC and industry resources without adverse affect on safety

Risk-informed inservice test activities at the NRC

Energy Technology Data Exchange (ETDEWEB)

Fischer, D.; Cheok, M.; Hsia, A.

1996-12-01

The operational readiness of certain safety-related components is vital to the safe operation of nuclear power plants. Inservice testing (IST) is one of the mechanisms used by licensees to ensure this readiness. In the past, the type and frequency of IST have been based on the collective best judgment of the NRC and industry in an ASME Code consensus process and NRC rulemaking process. Furthermore, IST requirements have not explicitly considered unique component and system designs and contribution to overall plant risk. Because of the general nature of ASME Code test requirements and non-reliance on risk estimates, current IST requirements may not adequately emphasize testing those components that are most important to safety and may overly emphasize testing of less safety significant components. Nuclear power plant licensees are currently interested in optimizing testing by applying resources in more safety significant areas and, where appropriate, reducing measures in less safety-significant areas. They are interested in maintaining system availability and reducing overall maintenance costs in ways that do not adversely affect safety. The NRC has been interested in using probabilistic, as an adjunct to deterministic, techniques to help define the scope, type and frequency of IST. The development of risk-informed IST programs has the potential to optimize the use of NRC and industry resources without adverse affect on safety.

Nondestructive examination (NDE) reliability for inservice inspection of light water reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Deffenbaugh, J.D.; Good, M.S.; Green, E.R.; Heasler, P.G.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.

1989-10-01

The Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvement that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to ASME Code and Regulatory requirements based on material properties, service conditions, and NDE capabilities and uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other inspected components. This is a progress report covering the programmatic work from October 1987 through March 1988. 21 refs., 28 figs., 2 tabs

Nondestructive examination (NDE) reliability for inservice inspection of light waters reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Deffenbaugh, J.D.; Good, M.S.; Green, E.R.; Heasler, P.G.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.

1989-11-01

Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to ASME Code and Regulatory requirements, based on material properties, service conditions, and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other inspected components. This is a progress report covering the programmatic work from April 1988 through September 1988. 33 refs., 70 figs., 12 tabs

Nondestructive Examination (NDE) Reliability for Inservice Inspection of Light Water Reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Diaz, A.A.; Friley, J.R.

1993-09-01

The Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to ASME Code and Regulatory requirements, based on material properties, service conditions, and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other components inspected in accordance with Section XI of the ASME Code. This is a progress report covering the programmatic work from October 1991 through March 1992

Dimensions of patient safety culture in family practice.

Science.gov (United States)

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.

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

Science.gov (United States)

2011-09-29

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

Patient safety manifesto: a professional imperative for prelicensure nursing education.

Science.gov (United States)

Debourgh, Gregory A; Prion, Susan K

2012-01-01

Nurses in practice and students in training often fear hurting a patient or doing something wrong. Experienced nurses have developed assessment skills and clinical intuition to recognize and intervene to prevent patient risk and harm. Beginning nursing students have not yet had the opportunity to develop an awareness of patient risk, safety concerns, or a clear sense of their accountability in the nurse role as the primary advocate for patient safety. In this Safety Manifesto, the authors call for educators to critically review their prelicensure curricula for inclusion of teaching and learning activities that are focused on patient safety and offer recommendations for curricular changes with an emphasis on integration of instructional strategies that develop students' skills for clinical reasoning and judgment. Copyright © 2012 Elsevier Inc. All rights reserved.

Safety climate and firefighting: Focus group results.

Science.gov (United States)

DeJoy, David M; Smith, Todd D; Dyal, Mari-Amanda

2017-09-01

Firefighting is a hazardous occupation and there have been numerous calls for fundamental changes in how fire service organizations approach safety and balance safety with other operational priorities. These calls, however, have yielded little systematic research. As part of a larger project to develop and test a model of safety climate for the fire service, focus groups were used to identify potentially important dimensions of safety climate pertinent to firefighting. Analyses revealed nine overarching themes. Competency/professionalism, physical/psychological readiness, and that positive traits sometimes produce negative consequences were themes at the individual level; cohesion and supervisor leadership/support at the workgroup level; and politics/bureaucracy, resources, leadership, and hiring/promotion at the organizational level. A multi-level perspective seems appropriate for examining safety climate in firefighting. Safety climate in firefighting appears to be multi-dimensional and some dimensions prominent in the general safety climate literature also seem relevant to firefighting. These results also suggest that the fire service may be undergoing transitions encompassing mission, personnel, and its fundamental approach to safety and risk. These results help point the way to the development of safety climate measures specific to firefighting and to interventions for improving safety performance. Copyright © 2017 National Safety Council and Elsevier Ltd. All rights reserved.

The chatting gathering as a methodological strategy in in-service learning: moving along dialogical dynamics

Directory of Open Access Journals (Sweden)

María José Alonso

2008-04-01

Full Text Available This article focuses on an experience of in-service training carried out by a group of educators in literacy. The novelty of the undertaking lies in the methodological proposal analysed: using “chatting gatherings” as a methodological strategy, which supports critical reflection and the construction of knowledge, both in in-service training of professionals and in basic adult education. This experience reveals the nature of learning achieved through dialogical educational processes. Further, it allows us to observe the impact that they may have on the improvement of the professionals’ educational practices.

Inservice testing of vertical pumps

International Nuclear Information System (INIS)

Cornman, R.E. Jr.; Schumann, K.E.

1994-01-01

This paper focuses on the problems that may occur with vertical pumps while inservice tests are conducted in accordance with existing American Society of Mechanical Engineers Code, Section XI, standards. The vertical pump types discussed include single stage, multistage, free surface, and canned mixed flow pumps. Primary emphasis is placed on the hydraulic performance of the pump and the internal and external factors to the pump that impact hydraulic performance. In addition, the paper considers the mechanical design features that can affect the mechanical performance of vertical pumps. The conclusion shows how two recommended changes in the Code standards may increase the quality of the pump's operational readiness assessment during its service life

In-service inspection of nuclear power plants

International Nuclear Information System (INIS)

Asty, M.; Saglio, R.

1984-10-01

The French Commissariat a l'Energie Atomique (Atomic Energy Commission) developed two new non destructive control techniques, focused ultrasonics and multi-frequency eddy currents, which have been shown to allow a better detection and characterization of defects. We present here some of the in-service inspection devices which have been designed for field application of these techniques on the PWR reactors built by EDF, inspection devices of the PWR steam generator tubing and the now developing specific device for main tank and helicoidal tubing steam generator of Super-Phenix 1 [fr

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

Science.gov (United States)

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

2015-09-01

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

Patient safety in otolaryngology: a descriptive review.

Science.gov (United States)

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

Improving patient safety in Libya: insights from a British health system perspective.

Science.gov (United States)

Elmontsri, Mustafa; Almashrafi, Ahmed; Dubois, Elizabeth; Banarsee, Ricky; Majeed, Azeem

2018-04-16

Purpose Patient safety programmes aim to make healthcare safe for both patients and health professionals. The purpose of this paper is to explore the UK's patient safety improvement programmes over the past 15 years and explore what lessons can be learnt to improve Libyan healthcare patient safety. Design/methodology/approach Publications focusing on UK patient safety were searched in academic databases and content analysed. Findings Several initiatives have been undertaken over the past 15 years to improve British healthcare patient safety. Many stakeholders are involved, including regulatory and professional bodies, educational providers and non-governmental organisations. Lessons can be learnt from the British journey. Practical implications Developing a national patient safety strategy for Libya, which reflects context and needs is paramount. Above all, Libyan patient safety programmes should reference internationally approved guidelines, evidence, policy and learning from Britain's unique experience. Originality/value This review examines patient safety improvement strategies adopted in Britain to help developing country managers to progress local strategies based on lessons learnt from Britain's unique experience.

Development process of in-service training intended for teachers to perform teaching of mathematics with computer algebra systems

Science.gov (United States)

Ardıç, Mehmet Alper; Işleyen, Tevfik

2018-01-01

In this study, we deal with the development process of in-service training activities designed in order for mathematics teachers of secondary education to realize teaching of mathematics, utilizing computer algebra systems. In addition, the results obtained from the researches carried out during and after the in-service training were summarized. Last section focuses on suggestions any teacher can use to carry out activities aimed at using computer algebra systems in teaching environments.

Reactor safety through quality assurance and in-service inspection

International Nuclear Information System (INIS)

Bush, S.H.

The quality assurance is discussed of nuclear power plant equipment with respect to the following regulations: section 50 10 CFR - supplement B, section NA-400, ASME - section III and ANSI N-54.2. Quality assurance and reliability are assessed with regard to two aspects: all preoperational functions and all operating stages of the power plant. During the production of nuclear power plant components, increased attention should be devoted to the choice of material, materials testing, production programme and to the production process. During power plant operation, care should be given to periodical in-service inspections which guarantee the plant reliability; defects should immediately be remedied or the power plant shut down. Emphasis is put on the tests of reactor welded joints in compliance with the ASME code. The results of operating tests are used as feedback in the design and testing of the components during production. The probabilities were calculated of the occurrence and elimination of defects during the manufacture and operation of a nuclear reactor. (J.B.)

Attributes of Pre-Service and Inservice Teacher Satisfaction with Online Collaborative Mentoring

Science.gov (United States)

Dorner, Helga; Kumar, Swapna

2017-01-01

This study examines Hungarian pre-service and inservice teachers' satisfaction (n = 154) with the Mentored Innovation Model (MIM), an online collaborative mentoring model focused on technology integration. The Kano model was applied to results from two surveys to identify conditions in the MIM that most contribute to overall satisfaction with…

Launcher In-Service Workspace

Data.gov (United States)

Federal Laboratory Consortium — Purpose:Through Engineering Investigations (EIs), testing, development, evaluation and system integration of Aircraft Launch and Recovery Equipment (ALRE) in-service...

Safety and Efficacy of Focused Ultrasound Thalamotomy for Patients With Medication-Refractory, Tremor-Dominant Parkinson Disease: A Randomized Clinical Trial.

Science.gov (United States)

Bond, Aaron E; Shah, Binit B; Huss, Diane S; Dallapiazza, Robert F; Warren, Amy; Harrison, Madaline B; Sperling, Scott A; Wang, Xin-Qun; Gwinn, Ryder; Witt, Jennie; Ro, Susie; Elias, W Jeffrey

2017-12-01

Clinical trials have confirmed the efficacy of focused ultrasound (FUS) thalamotomy in essential tremor, but its effectiveness and safety for managing tremor-dominant Parkinson disease (TDPD) is unknown. To assess safety and efficacy at 12-month follow-up, accounting for placebo response, of unilateral FUS thalamotomy for patients with TDPD. Of the 326 patients identified from an in-house database, 53 patients consented to be screened. Twenty-six were ineligible, and 27 were randomized (2:1) to FUS thalamotomy or a sham procedure at 2 centers from October18, 2012, to January 8, 2015. The most common reasons for disqualification were withdrawal (8 persons [31%]), and not being medication refractory (8 persons [31%]). Data were analyzed using intention-to-treat analysis, and assessments were double-blinded through the primary outcome. Twenty patients were randomized to unilateral FUS thalamotomy, and 7 to sham procedure. The sham group was offered open-label treatment after unblinding. The predefined primary outcomes were safety and difference in improvement between groups at 3 months in the on-medication treated hand tremor subscore from the Clinical Rating Scale for Tremor (CRST). Secondary outcomes included descriptive results of Unified Parkinson's Disease Rating Scale (UPDRS) scores and quality of life measures. Of the 27 patients, 26 (96%) were male and the median age was 67.8 years (interquartile range [IQR], 62.1-73.8 years). On-medication median tremor scores improved 62% (IQR, 22%-79%) from a baseline of 17 points (IQR, 10.5-27.5) following FUS thalamotomy and 22% (IQR, -11% to 29%) from a baseline of 23 points (IQR, 14.0-27.0) after sham procedures; the between-group difference was significant (Wilcoxon P = .04). On-medication median UPDRS motor scores improved 8 points (IQR, 0.5-11.0) from a baseline of 23 points (IQR, 15.5-34.0) following FUS thalamotomy and 1 point (IQR, -5.0 to 9.0) from a baseline of 25 points (IQR, 15.0-33.0) after sham

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

Science.gov (United States)

2012-02-24

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

RIBA Project - Risk-Informed approach for In-Service Inspection of Nuclear Power Plant Components. Project summary

International Nuclear Information System (INIS)

Lidbury, D.; Smith, G.

2001-12-01

The need for a European review of a Risk-Informed Approach for In-Service Inspection of Nuclear Power Plant Components (RIBA) was identified in 1998. This was as a priority item in the programme of activities conducted in the framework of the Council Resolutions of 22 July 1975 and of 18 June 1992 on the Technological Problems of Nuclear Safety. The RIBA Project was established in November 1999 as a 24-month Study Contract funded by the European Commission within the frame of the former DG XI WGCS (Working Group on Codes and Standards). The Study Contract was subsequently managed for the EC by DG TREN. The participants in RIBA were Serco Assurance (project coordinator), Ringhals AB, EDF, Tecnatom SA and Westinghouse Electric Europe. The work is presented in a summary report with the detailed results contained in three companion reports as follows: main conclusions and recommendations, Review of Existing Risk-Informed Methodologies, A Comparative Study of Risk-Informed In-Service Inspection Applications, Conclusions and Recommendations for Risk-Informed in-service inspection methodology applied to Nuclear Power Plants in Europe. (author)

Challenges in using a probabilistic safety assessment in a risk informed process (illustrated using risk informed inservice inspection)

International Nuclear Information System (INIS)

Chapman, James R.; Dimitrijevic, Vesna B.

1999-01-01

Many of the ongoing and expected uses of Probabilistic Safety Assessment (PSA) create new challenges to ensuring that the resulting conclusions are valid. This paper provides a summary of some of these challenges. Work conducted by the authors on Risk-Informed Inservice Inspection (RI-ISI) is used to illustrate these challenges. Means to address all of the challenges are not provided in detail in this paper. Several earlier papers discuss how these challenges can be addressed. References are provided for the interested reader (Chapman JR et al. In: PSA '95, vol. 1, Seoul, 1995: 177-80; Chapman JR et al. In: ICONE-IV, New Orleans, 1996; Dimitrijevic VB et al. In: Croatian Nuclear Society International Conference, Opatija, 1996: 245-54; Dimitrijevic VB et al. In: Croatian Nuclear Society International Conference, Opatija, 1996: 255-62; Dimitrijevic VB. In: Yugoslav Nuclear Society Conference, Belgrade, 1996: 53-61; O'Regan PJ et al. In: PSA '95, Seoul, vol. 1, 1995: 403-5; O'Regan PJ. In: ICONE-IV, vol. 5, New Orleans, 1996: 277-80)

Assessing the In-Service Needs of Basic School Natural Science ...

African Journals Online (AJOL)

... that no significant associations existed. It was recommended among other things that in-service training courses be used as platforms in upgrading the teachers' knowledge and skills. Additionally, in-service course organizers should first assess the in-service needs of participants before providing the appropriate support ...

Aligning In-Service Training Examinations in Plastic Surgery and Orthopaedic Surgery With Competency-Based Education.

Science.gov (United States)

Ganesh Kumar, Nishant; Benvenuti, Michael A; Drolet, Brian C

2017-10-01

In-service training examinations (ITEs) are used to assess residents across specialties. However, it is not clear how they are integrated with the Accreditation Council for Graduate Medical Education Milestones and competencies. This study explored the distribution of specialty-specific milestones and competencies in ITEs for plastic surgery and orthopaedic surgery. In-service training examinations were publicly available for plastic surgery (PSITE) and orthopaedics (OITE). Questions on the PSITE for 2014-2016 and the OITE for 2013-2015 were mapped to the specialty-specific milestones and the 6 competencies. There was an uneven distribution of milestones and competencies in ITE questions. Nine of the 36 Plastic Surgery Milestones represented 52% (341 of 650) of questions, and 3 were not included in the ITE. Of 41 Orthopaedic Surgery Milestones, 7 represented 51% (201 of 394) of questions, and 5 had no representation on the ITE. Among the competencies, patient care was the most common (PSITE = 62% [403 of 650]; OITE = 59% [233 of 394]), followed by medical knowledge (PSITE = 34% [222 of 650]; OITE = 31% [124 of 394]). Distribution of the remaining competencies differed between the 2 specialties (PSITE = 4% [25 of 650]; OITE = 9% [37 of 394]). The ITEs tested slightly more than half of the milestones for the 2 specialties, and focused predominantly on patient care and medical knowledge competencies.

Patient safety and infection control: bases for curricular integration.

Science.gov (United States)

Silva, Andréa Mara Bernardes da; Bim, Lucas Lazarini; Bim, Felipe Lazarini; Sousa, Alvaro Francisco Lopes; Domingues, Pedro Castania Amadio; Nicolussi, Adriana Cristina; Andrade, Denise de

2018-05-01

To analyze curricular integration between teaching of patient safety and good infection prevention and control practices. Integrative review, designed to answer the question: "How does curricular integration of content about 'patient safety teaching' and content about 'infection prevention and control practices' occur in undergraduate courses in the health field?". The following databases were searched for primary studies: CINAHL, LILACS, ScienceDirect, Web of Science, Scopus, Europe PMC and MEDLINE. The final sample consisted of 13 studies. After content analysis, primary studies were grouped into two subject categories: "Innovative teaching practices" and "Curricular evaluation. Patient safety related to infection prevention and control practices is present in the curriculum of health undergraduate courses, but is not coordinated with other themes, is taught sporadically, and focuses mainly on hand hygiene.

Risk informed approach to the in-service inspection activities

International Nuclear Information System (INIS)

Korosec, D.; Vojvodic Tuma, J.

2004-01-01

In the present paper, the aspects of Risk Informed In-Service Inspection (RI-ISI) are discussed. Slovenian Nuclear Safety Administration (SNSA) and its authorized organization for the ISI activities, Institute of Metals and Technologies (IMT), are actually permanently involved in the ISI processes of the nuclear power plant (NPP) Krsko. Based on the previous experience on the ISI activities, evaluation of the results and review of the existing practice in nuclear world, the activities are started to asses the piping of systems in the light of probability of failure. This is so called Risk Informed approach. By the design established criteria, standards and practice gives good fundaments for the improvements implementation. Improvements can be done on the way that the more broad knowledge about safety important components of the systems shall bee added to the basic practice. It is necessary to identify conditions of the safety important components, such as realistic stress and fatigue conditions, material properties changes due aging processes, the temperature cycling effects, existing flaws characterization in the light of the previous detection and equipment technique used, assessment of the measurement accuracy on the results etc. In addition to this deterministic approach, the principles of risk evaluation methods should be used. NPP Krsko has, as practically majority of NPP's, probabilistic risk assessment (PRA) studies for all safety important systems and components. The methods and results from these studies can be efficiently used to upgrade classical deterministic results, based on which the in-service program as a whole is usually done. In addition to the above mentioned, risk assessment and evaluation of the piping shall be done, which is not covered by the existing PRA analysis. To do this it is necessary to made risk evaluation of the piping segments, based on previous structural element probability assessment. Probabilistic risk assessment is important

Integrated Framework for Patient Safety and Energy Efficiency in Healthcare Facilities Retrofit Projects.

Science.gov (United States)

Mohammadpour, Atefeh; Anumba, Chimay J; Messner, John I

2016-07-01

There is a growing focus on enhancing energy efficiency in healthcare facilities, many of which are decades old. Since replacement of all aging healthcare facilities is not economically feasible, the retrofitting of these facilities is an appropriate path, which also provides an opportunity to incorporate energy efficiency measures. In undertaking energy efficiency retrofits, it is vital that the safety of the patients in these facilities is maintained or enhanced. However, the interactions between patient safety and energy efficiency have not been adequately addressed to realize the full benefits of retrofitting healthcare facilities. To address this, an innovative integrated framework, the Patient Safety and Energy Efficiency (PATSiE) framework, was developed to simultaneously enhance patient safety and energy efficiency. The framework includes a step -: by -: step procedure for enhancing both patient safety and energy efficiency. It provides a structured overview of the different stages involved in retrofitting healthcare facilities and improves understanding of the intricacies associated with integrating patient safety improvements with energy efficiency enhancements. Evaluation of the PATSiE framework was conducted through focus groups with the key stakeholders in two case study healthcare facilities. The feedback from these stakeholders was generally positive, as they considered the framework useful and applicable to retrofit projects in the healthcare industry. © The Author(s) 2016.

2011 John M. Eisenberg Patient Safety and Quality Awards. The effect of a novel Housestaff Quality Council on quality and patient safety. Innovation in patient safety and quality at the local level.

Science.gov (United States)

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

2012-07-01

In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach--the Housestaff Quality Council (HQC)--to engaging house-staff in quality and patient safety activities. The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects--medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects--hand hygiene, central line-associated bloodstream infections, and patient handoffs--have been initiated. The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

Nondestructive Examination (NDE) Reliability for Inservice Inspection of Light Water Reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Diaz, A.A.; Friley, J.R.; Good, M.S.; Greenwood, M.S.; Heasler, P.G.; Hockey, R.L.; Kurtz, R.J.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.; Vo, T.V.

1992-07-01

The Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWR's); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to the Regulatory and ASME Code requirements, based on material properties, service conditions, and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other components inspected in accordance with Section XI of the ASME Code. This is a progress report covering the programmatic work from April 1991 through September 1991

Nondestructive Examination (NDE) Reliability for Inservice Inspection of Light Water Reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Diaz, A.A.; Friley, J.R.; Greenwood, M.S.; Heasler, P.G.; Kurtz, R.J.; Simonen, F.A.; Spanner, J.C.; Vo, T.V.

1993-11-01

The Evaluation and Improvement of NDE Reliability for Inservice inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs);using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to the Regulatory and ASME Code requirements, based on material properties, service conditions, and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel and other components inspected in accordance with Section XI of the ASME Code. This is a programs report covering the programmatic work from April 1992 through September 1992

Nondestructive examination (NDE) reliability for inservice inspection of light water reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Good, M.S.; Green, E.R.; Heasler, P.G.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.; Vo, T.V.

1991-08-01

The Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) Program at the Pacific Northwest Laboratory was established by the Nuclear Regulatory Commission to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to ASME Code and Regulatory requirements, based on material properties, service conditions, and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other components inspected in accordance with Section 6 of the ASME Code. This is a progress report covering the pro grammatic work from April 1989 through September 1989. 12 refs., 4 figs. 5 tabs

Patient Handoffs in Obstetrics and Gynecology: A Vital Link in Patient Safety

Directory of Open Access Journals (Sweden)

John Yeh

2009-01-01

Full Text Available Inadequate patient handoffs have been an area of focus for patient safety improvement. Insufficient communication and risks or “shortcuts” taken by staff members during handoffs could negatively affect the safety of patients in a department of obstetrics and gynecology. Other factors that contribute to inadequate handoffs are the caregiver feeling fatigued or stressed, level of urgency, volume of information, language barriers, noise, lighting, ambiguity of describing treatment, not allotting enough time for questions asked, and/or interruptions from other staff members. There have been several methods developed for improving the handoff process, such as the mnemonic devices SBAR, SHARQ, I PASS THE BATON, and the 5 P's. A new method for improving the quality of patient handoffs has been developed and presented in this article. It is a mnemonic device entitled “HANDOFFS”. It covers key aspects of what a handoff process should entail. Teamwork is essential to effective communication, and by using a mnemonic such as this, team members can work together in a more positive and accessible environment that will result in improved patient safety.

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

Science.gov (United States)

2011-11-17

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

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

Science.gov (United States)

2013-07-03

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

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

Science.gov (United States)

2011-02-11

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

Study on In-Service Inspection Program and Inspection Technologies for Commercialized Sodium-Cooled Fast Reactor

International Nuclear Information System (INIS)

Masato Ando; Shigenobu Kubo; Yoshio Kamishima; Toru Iitsuka

2006-01-01

The objective of in-service inspection of a nuclear power plant is to confirm integrity of function of components necessary to safety, and satisfy the needs to protect plant investment and to achieve high plant ability. The sodium-cooled fast reactor, which is designed in the feasibility study on commercialized fast reactor cycle systems in Japan, has two characteristics related to in-service inspection. The first is that all sodium coolant boundary structures have double-wall system. Continuous monitoring of the sodium coolant boundary structures are adopted for inspection. The second characteristic is the steam generator with double-wall-tubes. Volumetric testing is adopted to make sure that one of the tubes can maintain the boundary function in case of the other tube failure. A rational in-service inspection concept was developed taking these features into account. The inspection technologies were developed to implement in-service inspection plan. The under-sodium viewing system consisted of multi ultrasonic scanning transducers, which was used for imaging under-sodium structures. The under-sodium viewing system was mounted on the under-sodium vehicle and delivered to core internals. The prototype of under-sodium viewing system and vehicle were fabricated and performance tests were carried out under water. The laboratory experiments of volumetric testing for double-wall-tubes of steam generator, such as ultrasonic testing and remote-field eddy current testing, were performed and technical feasibility was assessed. (authors)

Ensuring a proactive, evidence-based, patient safety approach to patient assessment.

Science.gov (United States)

Considine, Julie; Currey, Judy

2015-01-01

To argue that if all nurses were to adopt the primary survey approach (assessment of airway, breathing, circulation and disability) as the first element of patient assessment, they would be more focused on active detection of clinical deterioration rather than passive collection of patient data. Nurses are the professional group that carry the highest level of responsibility for patient assessment, accurate data collection and interpretation. The timely recognition of, and response to deteriorating patients, is dependent on the measurement and interpretation of pertinent physiological data by nurses. Discursive paper. Traditionally taught and commonly used approaches to patient assessment such as 'vital signs' and 'body systems' are not evidence-based nor framed in patient safety. The primary survey approach as the first element in patient assessment has three major advantages: (1) data are collected according to clinical importance; (2) data are collected using the same framework as most organisation's rapid response system activation criteria; and (3) the primary survey acts as a patient safety checklist, thereby decreasing the risk of failure to recognise, and therefore respond to, deteriorating patients. The vital signs and body systems approaches to patient assessment have significant limitations in identifying clinical deterioration. The primary survey approach provides nurses with a consistent, evidence-based and sequenced approach to patient assessment in every clinical setting. All nurses should use a primary survey approach as the first element of patient assessment in every patient encounter as a patient safety strategy. © 2014 John Wiley & Sons Ltd.

Investigating the Information Technology Courses for Pre-service and In-service English Teachers in Hong Kong

Directory of Open Access Journals (Sweden)

Chi Cheung Ruby Yang

2011-07-01

Full Text Available This paper focuses on the views of twenty-six pre-service and eight in-service English teachers in Hong Kong concerning the information technology courses in their teacher education programmes. The findings of the study show that while both software applications and technological integration in teaching are highlighted in the course outline, the instructor focused more on the application aspect, with the technology integration being less emphasised. Another important finding is that PowerPoint was still the most commonly used application in teaching. Likewise, usually the involved pre-service and in-service teachers just simply used different computer applications as alternatives to traditional teaching resources. This may reflect the fact that the information technology courses are not adequate to prepare teachers to teach with it.

Measuring safety culture: Application of the Hospital Survey on Patient Safety Culture to radiation therapy departments worldwide.

Science.gov (United States)

Leonard, Sarah; O'Donovan, Anita

Minimizing errors and improving patient safety has gained prominence worldwide in high-risk disciplines such as radiation therapy. Patient safety culture has been identified as an important factor in reducing the incidence of adverse events and improving patient safety in the health care setting. The aim of distributing the Hospital Survey on Patient Safety Culture (HSPSC) to radiation therapy departments worldwide was to assess the current status of safety culture, identify areas for improvement and areas that excel, examine factors that influence safety culture, and raise staff awareness. The safety culture in radiation therapy departments worldwide was evaluated by distributing the HSPSC. A total of 266 participants were recruited from radiation therapy departments and included radiation oncologists, radiation therapists, physicists, and dosimetrists. The positive percent scores for the 12 dimensions of the HSPSC varied from 50% to 79%. The highest composite score among the 12 dimensions was teamwork within units; the lowest composite score was handoffs and transitions. The results indicated that health care professionals in radiation therapy departments felt positively toward patient safety. The HSPSC was successfully applied to radiation therapy departments and provided valuable insight into areas of potential improvement such as teamwork across units, staffing, and handoffs and transitions. Managers and policy makers in radiation therapy may use this assessment tool for focused improvement efforts toward patient safety culture. Copyright © 2017 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Evaluation of the In-Service Education and Training Programme for Kuwait Army Instructors

Science.gov (United States)

Al-Mutawa, Najat; Al-Furaih, Suad

2005-01-01

This study evaluates the In-Service Education and Training (INSET) programme organised for Kuwait Army instructors. The focus is on their perceptual gain in related topics and skills, as they attended 10 courses at the College of Education--Kuwait University. Pre- and post-assessments involved 20 trainees. The analysis indicates significant…

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

Science.gov (United States)

2011-09-22

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

Non-technical skills training to enhance patient safety.

Science.gov (United States)

Gordon, Morris

2013-06-01

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

The Mechatronic System Design Of Ultrasonic Scanner For Inservice Inspection Of Research Reactor

Science.gov (United States)

Handono, Khairul; Kristedjo, K.; Awwaluddin, M.; Shobary, Ihsan

2018-02-01

The mechatronic system design of ultrasonic scanner for inservices inspection of Research Reactor has been conducted. The requirement designed must be reliable operated, safety to personnel and equipments, ease of maintenance and operation, protection of equipment mechanically, interchangeability of equipments and addition of the several model of probe immersion ultrasonic tranducer. In order to achieve the above goals and obtain the desired results, a mechatronic design based on mechanical and electronic practical experiences will be needed. In this paper consist of the mechanical design and the system mechanical movement using stepper motor control. The criteria and the methods of designs of mechanical and electronic equipments of the system have been discussed and investigated. A mechanical and instrumentation control system drawing and requirement of design will be presented as the outcome of the design. The designed of mechanical system is consequently simulated by solidwork software. The intention of the above research is to create solutions in different ways of inservice inspection of integrity of Reactor.

Feasibility of developing risk-based rankings of pressure boundary systems for inservice inspection

Energy Technology Data Exchange (ETDEWEB)

Vo, T.V.; Smith, B.W.; Simonen, F.A.; Gore, B.F.

1994-08-01

The goals of the Evaluation and Improvement of Non-destructive Examination Reliability for the In-service Inspection of Light Water Reactors Program sponsored by the Nuclear Regulatory Commission at Pacific Northwest Laboratory (PNL) are to (1) assess current ISI techniques and requirements for all pressure boundary systems and components, (2) determine if improvements to the requirements are needed, and (3) if necessary, develop recommendations for revising the applicable ASME Codes and regulatory requirements. In evaluating approaches that could be used to provide a technical basis for improved inservice inspection plans, PNL has developed and applied a method that uses results of probabilistic risk assessment (PRA) to establish piping system ISI requirements. In the PNL program, the feasibility of generic ISI requirements is being addressed in two phases. Phase I involves identifying and prioritizing the systems most relevant to plant safety. The results of these evaluations will be later consolidated into requirements for comprehensive inservice inspection of nuclear power plant components that will be developed in Phase II. This report presents Phase I evaluations for eight selected plants and attempts to compare these PRA-based inspection priorities with current ASME Section XI requirements for Class 1, 2 and 3 systems. These results show that there are generic insights that can be extrapolated from the selected plants to specific classes of light water reactors.

Feasibility of developing risk-based rankings of pressure boundary systems for inservice inspection

International Nuclear Information System (INIS)

Vo, T.V.; Smith, B.W.; Simonen, F.A.; Gore, B.F.

1994-08-01

The goals of the Evaluation and Improvement of Non-destructive Examination Reliability for the In-service Inspection of Light Water Reactors Program sponsored by the Nuclear Regulatory Commission at Pacific Northwest Laboratory (PNL) are to (1) assess current ISI techniques and requirements for all pressure boundary systems and components, (2) determine if improvements to the requirements are needed, and (3) if necessary, develop recommendations for revising the applicable ASME Codes and regulatory requirements. In evaluating approaches that could be used to provide a technical basis for improved inservice inspection plans, PNL has developed and applied a method that uses results of probabilistic risk assessment (PRA) to establish piping system ISI requirements. In the PNL program, the feasibility of generic ISI requirements is being addressed in two phases. Phase I involves identifying and prioritizing the systems most relevant to plant safety. The results of these evaluations will be later consolidated into requirements for comprehensive inservice inspection of nuclear power plant components that will be developed in Phase II. This report presents Phase I evaluations for eight selected plants and attempts to compare these PRA-based inspection priorities with current ASME Section XI requirements for Class 1, 2 and 3 systems. These results show that there are generic insights that can be extrapolated from the selected plants to specific classes of light water reactors

Inservice Teacher Education in Nigeria: A Case Study.

Science.gov (United States)

Esu, Akon E. O.

1991-01-01

Examines the current status of in-service teacher education in Nigeria, indicating three approaches: the central office approach; the long vacation program; and the Associateship Certificate in Education distance learning approach. Recommendations for planning and implementing in-service teacher education programs in Nigeria are noted. (SM)

Some reliability targets affecting the necessary provisions for in-service inspection and monitoring of LMFBR engineering components

International Nuclear Information System (INIS)

Bolt, P.R.

1980-01-01

The possible consequences of failure of primary and secondary sodium circuit components are discussed with particular reference to post incident fault diagnosis, remedial procedures and outage durations. The core support structures and steam generator units are identified as particularly important components in terms of economic consequence of their failure. Important safety considerations may also apply. Levels of reliability for core support and steam generator integrity, necessary to meet economic and certain safety criteria, are discussed and quantitative data is given. Possible failure and deterioration mechanisms which could result in unacceptable reductions in reliability are then identified for the core support and steam generator units. Following a consideration of the reliability targets and possible causes of loss of reliability, an appraisal is made of the necessary extent of in-service data to be obtained on component behaviour and condition. In-service inspection and monitoring methods that could be used to obtain this data are described. Consideration is given to UK and overseas inspection experience on LMFBR and other nuclear plant. (author)

Some reliability targets affecting the necessary provisions for in-service inspection and monitoring of LMFBR engineering components

Energy Technology Data Exchange (ETDEWEB)

Bolt, P R [Fast Reactor Engineering, Plant Engineering Department, CEGB, Barnwood, Gloucester (United Kingdom)

1980-11-01

The possible consequences of failure of primary and secondary sodium circuit components are discussed with particular reference to post incident fault diagnosis, remedial procedures and outage durations. The core support structures and steam generator units are identified as particularly important components in terms of economic consequence of their failure. Important safety considerations may also apply. Levels of reliability for core support and steam generator integrity, necessary to meet economic and certain safety criteria, are discussed and quantitative data is given. Possible failure and deterioration mechanisms which could result in unacceptable reductions in reliability are then identified for the core support and steam generator units. Following a consideration of the reliability targets and possible causes of loss of reliability, an appraisal is made of the necessary extent of in-service data to be obtained on component behaviour and condition. In-service inspection and monitoring methods that could be used to obtain this data are described. Consideration is given to UK and overseas inspection experience on LMFBR and other nuclear plant. (author)

Mapping patients' experiences after stroke onto a patient-focused intervention framework.

Science.gov (United States)

Donnellan, C; Martins, A; Conlon, A; Coughlan, T; O'Neill, D; Collins, D R

2013-03-01

Stroke patients' involvement in the rehabilitation process including decision making has made significant advances clinically over the past two decades. However, development of patient-focused interventions in stroke rehabilitation is a relatively under developed area of research. The aim of this study was to interpret the explanations that patients gave of their experience after stroke and how these may validate an already established patient-focused intervention framework - the Quest for quality and improved performance (QQUIP) (2006) that includes seven quality improvement goals. A random purposive sample of eight stroke patients was interviewed between 3 and 6 months following discharge. Patients' reports of their experience after stroke were obtained using in-dept semi-structured interviews and analysed using Qualitative Content Analysis. Explanations given by patients included both positive and negative reports of the stroke experience. Regardless of consequences as a result of physical, psychological and social impairments, there were other life style disruptions that were reported by all patients such as taking new medication and adverse effects of these, experiencing increasing fatigue, difficulties with social activities and situations and having to make changes in health behaviours and lifestyle. Some of the core themes that emerged reflected the aims of QQUIP improvement goals that include improving health literacy, clinical decision-making, self-care, patient safety, access to health advice, care experience and service development. Further recommendations based on the findings from this study would be to consider using the QQUIP framework for developing intervention studies in stroke rehabilitation care that are person-centred. This framework provides a template that is equipped to address some of the main concerns that people have following the experience of stroke and also focuses on improving quality of care.

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

Science.gov (United States)

Leonhardt, Kathryn Kraft

2010-01-01

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

Evaluation of inservice inspection examinatiions

International Nuclear Information System (INIS)

Aldrich, D.A.; Cook, J.F.

1990-05-01

In order to evaluate the effectiveness of Section 11, Division 1, ''Rules for Inservice Inspection of Nuclear Power Plant Components,'' of the American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code examinations, 26 inservice inspection (ISI) summary reports from 24 facilities were reviewed. It was found that these ASME Code examinations and tests are instrumental in revealing indications and defects in welds and plant components. In addition, this study uncovered that fact that some of the Section 11 requirements are apparently not clear and are misunderstood by some of the facilities. Also, the need for more stringent requirements was evaluated and some Code changes are recommended

Review of Section XI inservice inspection program effectiveness

International Nuclear Information System (INIS)

Cook, J.F. Sr.

1993-08-01

To evaluate the effectiveness of Section XI, Division 1, open-quotes Rules for Inservice Inspection of Nuclear Power Plant Components,close quotes of the American Society of Mechanical Engineers Boiler and Pressure Vessel Code, searches were performed of the Licensing Event Report and Nuclear Plant Reliability Data System computerized data bases, and a review was made of inservice inspection summary reports. It was found that the Section XI examinations and tests detect flaws in welds and plant components and result in subsequent corrective action. This study also shows that the format and topics of information provided in Section XI-prescribed inservice inspection summary reports vary widely

Review of Section XI inservice inspection program effectiveness

Energy Technology Data Exchange (ETDEWEB)

Cook, J.F. Sr.

1993-08-01

To evaluate the effectiveness of Section XI, Division 1, {open_quotes}Rules for Inservice Inspection of Nuclear Power Plant Components,{close_quotes} of the American Society of Mechanical Engineers Boiler and Pressure Vessel Code, searches were performed of the Licensing Event Report and Nuclear Plant Reliability Data System computerized data bases, and a review was made of inservice inspection summary reports. It was found that the Section XI examinations and tests detect flaws in welds and plant components and result in subsequent corrective action. This study also shows that the format and topics of information provided in Section XI-prescribed inservice inspection summary reports vary widely.

Technology Integration Support Levels for In-Service Teachers

Science.gov (United States)

Williams, Mable Evans

2017-01-01

In-service teachers across the globe are expected to integrate technology in their respective instructional content area. The purpose of this qualitative study was to explore the perceptions of in-service teachers concerning building-level support for technology integration. Participants in the study were asked to participate in semi-structured…

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

Science.gov (United States)

2013-09-25

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

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

Science.gov (United States)

2011-02-17

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

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.

Science.gov (United States)

Rhodes, Penny; Campbell, Stephen; Sanders, Caroline

2016-04-01

Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety. To explore patients' understandings of safety in primary care. Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio-demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison. Thirty-eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho-social aspects of professional-patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems-level tensions constraining safety. Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context-dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Patient safety goals for the proposed Federal Health Information Technology Safety Center.

Science.gov (United States)

Sittig, Dean F; Classen, David C; Singh, Hardeep

2015-03-01

The Office of the National Coordinator for Health Information Technology is expected to oversee creation of a Health Information Technology (HIT) Safety Center. While its functions are still being defined, the center is envisioned as a public-private entity focusing on promotion of HIT related patient safety. We propose that the HIT Safety Center leverages its unique position to work with key administrative and policy stakeholders, healthcare organizations (HCOs), and HIT vendors to achieve four goals: (1) facilitate creation of a nationwide 'post-marketing' surveillance system to monitor HIT related safety events; (2) develop methods and governance structures to support investigation of major HIT related safety events; (3) create the infrastructure and methods needed to carry out random assessments of HIT related safety in complex HCOs; and (4) advocate for HIT safety with government and private entities. The convening ability of a federally supported HIT Safety Center could be critically important to our transformation to a safe and effective HIT enabled healthcare system. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Involvement of patients with cancer in patient safety: a qualitative study of current practices, potentials and barriers.

Science.gov (United States)

Martin, Helle Max; Navne, Laura Emdal; Lipczak, Henriette

2013-10-01

Patient involvement in patient safety is widely advocated but knowledge regarding implementation of the concept in clinical practice is sparse. To investigate existing practices for patient involvement in patient safety, and opportunities and barriers for further involvement. A qualitative study of patient safety involvement practices in patient trajectories for prostate, uterine and colorectal cancer in Denmark. Observations from four hospital wards and interviews with 25 patients with cancer, 11 hospital doctors, 10 nurses, four general practitioners and two private practicing gynaecologists were conducted using ethnographic methodology. Patient safety was not a topic of attention for patients or dominant in communication between patients and healthcare professionals. The understanding of patient safety in clinical practice is almost exclusively linked to disease management. Involvement of patients is not systematic, but healthcare professionals and patients express willingness to engage. Invitation and encouragement of patients to become involved could be further systematised and developed. Barriers include limited knowledge of patient safety, of specific patient safety involvement techniques and concern regarding potential negative impact on doctor-patient relationship. Involvement of patients in patient safety must take into account that despite stated openness to the idea of involvement, patients and health professionals may not in practice show immediate concern. Lack of systematic involvement can also be attributed to limited knowledge about how to implement involvement beyond the focus of self-monitoring and compliance and a concern about the consequences of patient involvement for treatment outcomes. To realise the potential of patients' and health professionals' shared openness towards involvement, there is a need for more active facilitation and concrete guidance on how involvement can be practiced by both parties.

Understanding middle managers' influence in implementing patient safety culture.

Science.gov (United States)

Gutberg, Jennifer; Berta, Whitney

2017-08-22

The past fifteen years have been marked by large-scale change efforts undertaken by healthcare organizations to improve patient safety and patient-centered care. Despite substantial investment of effort and resources, many of these large-scale or "radical change" initiatives, like those in other industries, have enjoyed limited success - with practice and behavioural changes neither fully adopted nor ultimately sustained - which has in large part been ascribed to inadequate implementation efforts. Culture change to "patient safety culture" (PSC) is among these radical change initiatives, where results to date have been mixed at best. This paper responds to calls for research that focus on explicating factors that affect efforts to implement radical change in healthcare contexts, and focuses on PSC as the radical change implementation. Specifically, this paper offers a novel conceptual model based on Organizational Learning Theory to explain the ability of middle managers in healthcare organizations to influence patient safety culture change. We propose that middle managers can capitalize on their unique position between upper and lower levels in the organization and engage in 'ambidextrous' learning that is critical to implementing and sustaining radical change. This organizational learning perspective offers an innovative way of framing the mid-level managers' role, through both explorative and exploitative activities, which further considers the necessary organizational context in which they operate.

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

Science.gov (United States)

Yassi, Annalee; Hancock, Tina

2005-01-01

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

In-Service Teacher Education: Some Suggestions for Improvement ...

African Journals Online (AJOL)

This paper therefore examines teacher education, especially in-service teacher education and how it has been practised elsewhere. It is hoped that education policy makers will take note of some of the issues raised in this paper as the one day workshop which has hitherto been the most used strategy of in-service teacher ...

49 CFR 214.529 - In-service failure of primary braking system.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false In-service failure of primary braking system. 214... Maintenance Machines and Hi-Rail Vehicles § 214.529 In-service failure of primary braking system. (a) In the event of a total in-service failure of its primary braking system, an on-track roadway maintenance...

Software life after in-service

International Nuclear Information System (INIS)

Tseng, M.; Eng, P.

1993-01-01

Software engineers and designers tend to conclude a software project at the in-service milestone of the software life cycle. But the reality is that the 'life after in-service' is significantly longer than other phases of the life cycle, typically 20 years or more depending on the maintainability of the hardware platform and the designed life of the plant. During this period, the software asset (as with other physical assets in the plant) continues to be upgraded to correct deficiencies, meet new requirements, cope with obsolescence of equipment and so on. The software life cycle ends with a migration of the software to a different platform. It is typical in a software development project to put a great deal of emphasis on design methodologies, techniques, tools, development environment, standard procedures, and project management to ensure quality product is delivered on schedule and within budget. More often than not, a disproportion of emphasis is placed on the issues and needs of the in-service phase. Once the software is in-service, the designers move on to other projects, while the maintenance and support staff must manage the software. This paper examines the issues in three steps. First it presents a view of software from maintenance and support staff perspectives, including complexity of software, suitability of documentation, configuration management, training, difficulties and risks associated with making changes, required skills and knowledge. Second, it identifies the concerns raised from these viewpoints, including costs of maintaining the software, ability to meet additional requirements, availability of support tools, length of time required to engineer and install changes, and a strategy for the migration of software asset. Finally it discusses some approaches to deal with the concerns. (Author) 5 refs., fig

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

Science.gov (United States)

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

2015-01-01

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

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

Science.gov (United States)

Montoya, Isaac D

2008-07-01

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

RITES: Online (Reaching In-service Teachers with Earth Sciences Online)

Science.gov (United States)

Baptiste, H.

2003-12-01

The RITES: Online project team (Drs. H. Prentice Baptiste, Susan Brown, Jennifer Villa) believed that the power of technology could not be effectively utilized unless it was grounded in new models of teaching and learning based on a student centered and project based curriculum, that increased opportunities for active, hands-on learning and respect for multiculturalism. We subscribe to an inquiry approach to learning. Specifically, science teaching should actively engage the learners in activities that draw on multiple abilities and learning styles. Recent brain-based research has shown that human beings construct knowledge through actions and interactions within their environment. Learning occurs in communities, and new ideas are linked to previous knowledge and constructed by the learner. Knowledge is acquired by making connections. We believed the aforementioned ideas and points to be equally true for the teacher candidates and inservice teachers participating in the RITES: Online project as well as for their students. The ESSEA science courses were delivered by distance learning via the university WebCt distance education system to teacher candidates (preservice teachers) and inservice teachers. Teacher candidates and inservice teachers were encouraged to use technology when involving their students in science inquiry activities and to record their students' involvement in science activities with digital cameras. Teacher candidates and inservice teachers involve in the ESSEA courses are engaged in earth science inquiry activities relevant to the four spheres (atmosphere, lithosphere, biosphere, hydrosphere) with the students in their classes. This presentation will highlight teacher candidates and inservice teachers in the roles of designer, researcher, and collaborator. Examples of student works will also be a part of the Power point presentation. As a result of our courses our teachers have attained the following positive outcomes: 1) Teacher candidates and

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

Science.gov (United States)

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

2013-09-01

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

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

Science.gov (United States)

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.

Confrontation (A Human Relations Training Unit and Simulation Game for Teacher and Administrators in a Multi-Ethnic Elementary and High School). Description of Teacher Inservice Education Materials.

Science.gov (United States)

National Education Association, Washington, DC. Project on Utilization of Inservice Education R & D Outcomes.

The inservice teacher and administrator education program described here is intended to make teachers aware of the problems they may encounter in a multicultural, multiethnic school setting. The inservice topic is human relations, with the subject of black/white confrontation the main focus. This descriptive report provides additional information…

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

Science.gov (United States)

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

2015-01-01

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

Conceptions on the Teaching of Subtraction: A study Focused on an in-Service Teacher Training Course

Directory of Open Access Journals (Sweden)

Mario Martínez Silva

2004-05-01

Full Text Available This paper reports a research about a group of in-service teachers working in primary public schools in a poor urban zone in Monterrey city, Mexico. Its main aim was to study teachers’ conceptions about the teaching of subtraction and, in particular, to know more about the role that they assign to context and contextualizing in the teaching process. Broadly speaking, the research arose from the interest to know more about the relationship between the training and education in mathematics of primary teachers and how the teaching and learning of mathematics actually takes place at school.

Patient Safety Communication Among Differently Educated Nurses: Converging and Diverging Meaning Systems.

Science.gov (United States)

Anbari, Allison Brandt; Vogelsmeier, Amy; Dougherty, Debbie S

2017-12-01

Studies that suggest an increased number of bachelor's prepared nurses (BSNs) at the bedside improves patient safety do not stratify their samples into traditional bachelor's and associates (ADN) to BSN graduates. This qualitative study investigated potential differences in patient safety meaning among BSNs and ADN to BSN graduates. Guided by the theory of Language Convergence/Meaning Divergence, interview data from eight BSN and eight ADN to BSN graduates were analyzed. Findings indicate there are two meaning levels or systems, the local level and the systemic level. At the local level, the meaning of patient safety is focused at the patient's bedside and regulated by the nurse. The systemic level included the notion that health system factors such as policies and staffing are paramount to keeping patients safe. More frequently, ADN to BSN graduates' meaning of patient safety was at the local level, while BSNs' meaning centered at the systemic level.

A patient safety course for preclinical medical students.

Science.gov (United States)

Shekhter, Ilya; Rosen, Lisa; Sanko, Jill; Everett-Thomas, Ruth; Fitzpatrick, Maureen; Birnbach, David

2012-12-01

We developed a course to introduce incoming third-year medical students to the subject of patient safety, to focus their attention on teamwork and communication, and to create an awareness of patient-safe practices that will positively impact their performance as clinicians. The course, held prior to the start of clinical rotations, consisted of lectures, web-based didactic materials, small group activities and simulation exercises, with an emphasis on experiential learning. First, students inspected a 'room of horrors', which is a simulated clinical environment riddled with errors. Second, we used lenticular puzzles in small groups to elicit teamwork behaviours that parallel real-life interactions in health care. Each team was given 8 minutes to complete a 48-piece puzzle, with five pieces removed at random and given to other teams. The salient teaching point of this exercise is that for a team to complete the task, team members must communicate with members of their own team as well as with other teams. Last, simulation scenarios provided a clinical context to reinforce the skills introduced through the puzzle exercise and lectures. The students were split into groups of six or seven members and challenged with two scenarios. Both scenarios focused on a 56-year-old man in respiratory distress. The teams were debriefed on both clinical management and teamwork. The vast majority of the students (93%) agreed that the course improved their patient safety knowledge and skills. The positive response from students to the introductory course is an important step in fostering a culture of patient safety. © Blackwell Publishing Ltd 2012.

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

Science.gov (United States)

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

2013-04-01

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

Creating a Culture of Patient Safety through Innovative Hospital Design

National Research Council Canada - National Science Library

Reiling, John G

2005-01-01

When SynergyHealth, St. Joseph's Hospital of West Bend, Wisconsin, decided to relocate and build an 82-bed acute care facility, they recognized the opportunity to design a hospital that focused on patient safety...

Understanding the Knowledge Gap Experienced by U.S. Safety Net Patients in Teleretinal Screening.

Science.gov (United States)

George, Sheba M; Hayes, Erin Moran; Fish, Allison; Daskivich, Lauren Patty; Ogunyemi, Omolola I

2016-01-01

Safety-net patients' socioeconomic barriers interact with limited digital and health literacies to produce a "knowledge gap" that impacts the delivery of healthcare via telehealth technologies. Six focus groups (2 African- American and 4 Latino) were conducted with patients who received teleretinal screening in a U.S. urban safety-net setting. Focus groups were analyzed using a modified grounded theory methodology. Findings indicate that patients' knowledge gap is primarily produced at three points during the delivery of care: (1) exacerbation of patients' pre-existing personal barriers in the clinical setting; (2) encounters with technology during screening; and (3) lack of follow up after the visit. This knowledge gap produces confusion, potentially limiting patients' perceptions of care and their ability to manage their own care. It may be ameliorated through delivery of patient education focused on both disease pathology and specific role of telehealth technologies in disease management.

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

Directory of Open Access Journals (Sweden)

Elizabeth M. Borycki

2015-09-01

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

System safety education focused on flight safety

Science.gov (United States)

Holt, E.

1971-01-01

The measures necessary for achieving higher levels of system safety are analyzed with an eye toward maintaining the combat capability of the Air Force. Several education courses were provided for personnel involved in safety management. Data include: (1) Flight Safety Officer Course, (2) Advanced Safety Program Management, (3) Fundamentals of System Safety, and (4) Quantitative Methods of Safety Analysis.

Developing patient safety in dentistry.

Science.gov (United States)

Pemberton, M N

2014-10-01

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

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

Science.gov (United States)

Agnew, Cakil; Flin, Rhona; Mearns, Kathryn

2013-06-01

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

An in-service inspection method: the use of focused probes for the detection and sizing in DDT Plates 1 and 2

International Nuclear Information System (INIS)

Birac, A.M.; Pincemaille, G.; Saglio, R.; Cattiauz, G.; Morisseau, P.

1983-01-01

As part of the DDT programme to evaluate the nondestructive testing methods used during the in-service inspection (ISI) of PWR vessels, the UKAEA asked the CEA-STA-SCND to perform the ultrasonic examination of two test-plates. Each plate was bisected across its full width by a full-thickness butt-weld in which calibrated defects of various natures, dimensions, orientations have been inserted. It was required that the implementation of control, the equipment and the subsequent data analysis represent as nearly as possible the French procedure in force during the pre-service and in-service inspection of a PWR vessel. As suggested by the UKAEA, to evaluate the influence of examiners on the results, the examinations have been carried out twice by two independent teams: one from the CEA-STA-SCND and the second from INTERCONTROLE (a CEA subsidiary company). Procedure and results are given. (author)

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

Science.gov (United States)

2011-02-17

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

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

Science.gov (United States)

Elder, N C; Brungs, S M; Nagy, M; Kudel, I; Render, M L

2008-02-01

It is unknown if successful changes in specific safety practices in the intensive care unit (ICU) generalize to broader concepts of patient safety by staff nurses. To explore perceptions of patient safety among nursing staff in ICUs following participation in a safety project that decreased hospital acquired infections. After implementation of practices that reduced catheter-related bloodstream infections in ICUs at four community hospitals, ICU nurses participated in focus groups to discuss patient safety. Audiotapes from the focus groups were transcribed, and two independent reviewers categorised the data which were triangulated with responses from selected questions of safety climate surveys and with the safety checklists used by management leadership on walk rounds. Thirty-three nurses attended eight focus groups; 92 nurses and managers completed safety climate surveys, and three separate leadership checklists were reviewed. In focus groups, nurses predominantly related patient safety to dangers in the physical environment (eg, bed rails, alarms, restraints, equipment, etc.) and to medication administration. These areas also represented 47% of checklist items from leadership walk rounds. Nurses most frequently mentioned self-initiated "double checking" as their main safety task. Focus-group participants and survey responses both noted inconsistency between management's verbal and written commitment compared with their day-to-day support of patient safety issues. ICU nurses who participated in a project to decrease hospital acquired infections did not generalize their experience to other aspects of patient safety or relate it to management's interest in patient safety. These findings are consistent with many adult learning theories, where self-initiated tasks, combined with immediate, but temporary problem-solving, are stronger learning forces than management-led activities with delayed feedback.

A plan for safety and integrity of research reactor components

International Nuclear Information System (INIS)

Moatty, Mona S. Abdel; Khattab, M.S.

2013-01-01

Highlights: ► A plan for in-service inspection of research reactor components is put. ► Section XI of the ASME Code requirements is applied. ► Components subjected to inspection and their classes are defined. ► Flaw evaluation and its acceptance–rejection criteria are reviewed. ► A plan of repair or replacement is prepared. -- Abstract: Safety and integrity of a research reactor that has been operated over 40 years requires frequent and thorough inspection of all the safety-related components of the facility. The need of increasing the safety is the need of improving the reliability of its systems. Diligent and extensive planning of in-service inspection (ISI) of all reactor components has been imposed for satisfying the most stringent safety requirements. The Safeguards Officer's responsibilities of Section XI of the American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code ASME Code have been applied. These represent the most extensive and time-consuming part of ISI program, and identify the components subjected to inspection and testing, methods of component classification, inspection and testing techniques, acceptance/rejection criteria, and the responsibilities. The paper focuses on ISI planning requirements for welded systems such as vessels, piping, valve bodies, pump casings, and control rod-housing parts. The weld in integral attachments for piping, pumps, and valves are considered too. These are taken in consideration of safety class (1, 2, 3, etc.), reactor age, and weld type. The parts involve in the frequency of inspection, the examination requirements for each inspection, the examination method are included. Moreover the flaw evaluation, the plan of repair or replacement, and the qualification of nondestructive examination personnel are considered

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

Science.gov (United States)

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

2008-10-01

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

In-Service Science Teachers' Attitude towards Information Communication Technology

Science.gov (United States)

Kibirige, I.

2011-01-01

The purpose of this study is to determine the attitude of in-service science teachers towards information communication technology (ICT) in education. The study explores the relationship between in-service teachers and four independent variables: their attitudes toward computers; their cultural perception of computers; their perceived computer…

Proceedings of the symposium on inservice testing of pumps and valves

International Nuclear Information System (INIS)

1990-10-01

The 1990 Symposium on Inservice Testing of Pumps and Valves, jointly sponsored by the Board on Nuclear Codes and Standards of the American Society of Mechanical Engineers and by the Nuclear Regulatory Commission, provided a forum for the discussion of current programs and methods for inservice testing at nuclear power plants. The symposium also provided an opportunity to discuss the need to improve inservice testing in order to ensure the reliable performance of pumps and valves. The participation of industry representatives, regulators, and consultants resulted in the discussion of a broad spectrum of ideas and perspectives regarding the improvement of inservice testing of pumps and valves at nuclear power plants

Proceedings of the symposium on inservice testing of pumps and valves

Energy Technology Data Exchange (ETDEWEB)

1990-10-01

The 1990 Symposium on Inservice Testing of Pumps and Valves, jointly sponsored by the Board on Nuclear Codes and Standards of the American Society of Mechanical Engineers and by the Nuclear Regulatory Commission, provided a forum for the discussion of current programs and methods for inservice testing at nuclear power plants. The symposium also provided an opportunity to discuss the need to improve inservice testing in order to ensure the reliable performance of pumps and valves. The participation of industry representatives, regulators, and consultants resulted in the discussion of a broad spectrum of ideas and perspectives regarding the improvement of inservice testing of pumps and valves at nuclear power plants.

Sociological refigurations of patient safety; ontologies of improvement and 'acting with' quality collaboratives in healthcare.

Science.gov (United States)

Zuiderent-Jerak, Teun; Strating, Mathilde; Nieboer, Anna; Bal, Roland

2009-12-01

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of 'usefulness' in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of 'usefulness', this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of 'effective care' are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study. In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like 'effectiveness' and 'client participation' are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many 'implementation problems' presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for 'acting with' quality improvement agents.

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

Science.gov (United States)

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

2014-10-01

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

The culture of patient safety from the perspective of the pediatric emergency nursing team

Directory of Open Access Journals (Sweden)

Taise Rocha Macedo

Full Text Available Abstract OBJECTIVE To identify the patient safety culture in pediatric emergencies from the perspective of the nursing team. METHOD A quantitative, cross-sectional survey research study with a sample composed of 75 professionals of the nursing team. Data was collected between September and November 2014 in three Pediatric Emergency units by applying the Hospital Survey on Patient Safety Culture instrument. Data were submitted to descriptive analysis. RESULTS Strong areas for patient safety were not found, with areas identified having potential being: Expectations and actions from supervisors/management to promote patient safety and teamwork. Areas identified as critical were: Non-punitive response to error and support from hospital management for patient safety. The study found a gap between the safety culture and pediatric emergencies, but it found possibilities of transformation that will contribute to the safety of pediatric patients. CONCLUSION Nursing professionals need to become protagonists in the process of replacing the current paradigm for a culture focused on safety. The replication of this study in other institutions is suggested in order to improve the current health care scenario.

Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

Science.gov (United States)

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

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

Science.gov (United States)

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

2016-07-01

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

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

Science.gov (United States)

2012-04-27

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

National Patient Safety Foundation

Science.gov (United States)

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

Safety for all: bringing together patient and employee safety.

Science.gov (United States)

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

2013-01-01

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

Review of inservice inspection and nondestructive examination practices at DOE Category A test and research reactors

International Nuclear Information System (INIS)

Anderson, M.T.; Aldrich, D.A.

1990-09-01

In-service inspection (ISI) programs are used at commercial nuclear power plants for monitoring the pressure boundary integrity of various systems and components to ensure their continued safe operation. The Department of Energy (DOE) operates several test and research reactors. This report represents an evaluation of the ISI and nondestructive examination (NDE) practices at five DOE Category A (> 20 MW thermal) reactors as compared, where applicable, to the current ISI activities of commercial nuclear power facilities. The purpose of an inservice inspection (ISI) program is to establish regular surveillance of safety-related components to ensure their safe and reliable operation. The integrity of materials comprising these components is generally monitored by means of periodic nondestructive examinations (NDE), which, if appropriately performed, provide methods for identifying degradation that could render components unable to perform their intended safety functions. The reactors evaluated during this review were the Experimental Breeder Reactor 2 and the Fast Flux Test Facility (liquid-metal cooled plants), the Advanced Test Reactor and the High Flux Isotopes Reactor (light-water cooled reactors), and the High Flux Beam Reactor (a heavy-water cooled facility). Although these facilities are extremely diverse in design and operation, they all have less stored energy, smaller inventories of radionuclides, and generally, more remote locations than commercial reactors. However, all DOE test and research facilities contain components similar to those of commercial reactors for which continued integrity is important to maintain plant safety. 10 refs., 6 tabs

IMPROVING PATIENT SAFETY:

DEFF Research Database (Denmark)

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

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

Challenging patient safety culture: survey results

NARCIS (Netherlands)

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

2007-01-01

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

Guidelines for inservice testing at nuclear power plants

International Nuclear Information System (INIS)

Campbell, P.

1995-04-01

The staff of the U.S. Nuclear Regulatory Commission (NRC) gives licensees guidelines and recommendations for developing and implementing programs for the inservice testing of pumps and valves at commercial nuclear power plants. The staff discusses the regulations; the components to be included in an inservice testing program; and the preparation and content of cold shutdown justifications, refueling outage justifications, and requests for relief from the American Society of Mechanical Engineers Code requirements. The staff also gives specific guidance on relief acceptable to the NRC and advises licensees in the use of this information at their facilities. The staff discusses the revised standard technical specifications for the inservice testing program requirements and gives guidance on the process a licensee may follow upon finding an instance of noncompliance with the Code

Evaluation and improvement in nondestructive examination (NDE) reliability for inservice inspection of light water reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Deffenbaugh, J.D.; Good, M.S.; Green, E.R.; Heasler, P.G.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.

1988-01-01

The Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactors (NDE Reliability) program at the Pacific Northwest Laboratory was established by the NRC to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to ASME Code and Regulatory requirements, based on material properties, service conditions and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other inspected components. This is a progress report covering the programmatic work from October 1986 through September 1987. (author)

Evaluation and improvement in nondestructive examination (NDE) reliability for inservice inspection of light water reactors

International Nuclear Information System (INIS)

Doctor, S.R.; Deffenbaugh, J.D.; Good, M.S.; Green, E.R.; Heasler, P.G.; Simonen, F.A.; Spanner, J.C.; Taylor, T.T.

1988-01-01

The Evaluation and Improvement of NDE Reliability for Inservice Inspection of Light Water Reactor (NDE Reliability) program at the Pacific Northwest Laboratory was established by the NRC to determine the reliability of current inservice inspection (ISI) techniques and to develop recommendations that will ensure a suitably high inspection reliability. The objectives of this program include determining the reliability of ISI performed on the primary systems of commercial light-water reactors (LWRs); using probabilistic fracture mechanics analysis to determine the impact of NDE unreliability on system safety; and evaluating reliability improvements that can be achieved with improved and advanced technology. A final objective is to formulate recommended revisions to ASME Code and Regulatory requirements, based on material properties, service conditions, and NDE uncertainties. The program scope is limited to ISI of the primary systems including the piping, vessel, and other inspected components. This is a progress report covering the programmatic work from October 1986 through September 1987

Study on practical application of risk informed inservice inspection

International Nuclear Information System (INIS)

Sato, Chikahiro; Machida, Hideo; Takeda, Shuhei; Miyata, Koichi; Nishino, Shoichiro

2009-01-01

This paper describes pilot study relevant to the application of risk informed inservice inspection (RI-ISI) to class 1 piping systems in a Japanese typical BWR5 plant. The benefits of making use of risk information are improvement in plant safety, quality of inspection and explanation of security activities in nuclear power plants. The current RI-ISI procedures and rules were developed to take advantage of lessons learned from PSA data and piping failure experiences, and are expected to rationalize of security activities for plant operation and maintenance. To introduce RI-ISI, it is necessary to collaborate with industry, academia and government. Development of the technical basis is one of the key issues to become practical of RI-ISI programs. (author)

Researchers' Roles in Patient Safety Improvement.

Science.gov (United States)

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

2016-03-01

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

Review of In-Service Inspection and Repair Technique Developments for French Liquid Metal Fast Reactors

International Nuclear Information System (INIS)

Baque, F.

2005-01-01

In-service monitoring of nuclear plants is indispensable for both the Operator and the Regulator. The notion of in-service monitoring ranges from the continuous monitoring of the reactor in operation to the thorough in-service reactor inspection during programmed shutdowns. However, the highly specific environment found in French liquid metal fast reactor plants - Phenix and Superphenix - makes monitoring and inspection complicated because of the use of a sodium coolant that is hot, opaque, and difficult to drain.The Commissariat a l'Energie Atomique, in collaboration with its traditional French partners, Electricite de France utilities and FRAMATOME/Novatome Engineering, decided to conduct a 6-yr research and development program (1994-2000) to explore this problem vis-a-vis Superphenix, as well as the possibilities of intervening within the reactor block or on components in a sodium environment. Furthermore, the safety reevaluation of Phenix, conducted between 1994 and 2003, represented an excellent 'test bench' during which the limits of inspection processes - applied to an integrated reactor concept - were surpassed using techniques such as fuel subassembly head scanning, ultrasonic examination of the core support, and visual inspection of the cover-gas plenum following a partial sodium draining. Repair techniques were investigated for cleaning of sodium wet structure surfaces, cutting of damaged parts, and welding in sodium aerosol atmosphere. Both conventional and laser processes were tested

Institutional Roles for In-Service Education of School Administrators.

Science.gov (United States)

Lynch, Patrick D., Ed.; Blackstone, Peggy L., Ed.

This document is a compilation of papers read at a 4-day conference attended by 60 participants from throughout the United States. Chapters include (1) "In-Service Education of School Administrators: Background, Present Status, and Problems," by Robert B. Howsam; (2) "Notes on Institutional Relationships in the In-Service Education of the…

In-service inspection robot for PFBR main vessel- concept

Energy Technology Data Exchange (ETDEWEB)

Rajendran, S; Ramakumar, M S [Bhabha Atomic Research Centre, Mumbai (India). Div. of Remote Handling and Robotics

1994-12-31

In-service inspection (ISI) of critical components in a nuclear reactor is one of the foremost and important tasks which reveals the state of health of the system, thereby ensuring the safety of the plant, personnel and environment. Prototype Fast Breeder Reactor (PFBR) is designed as a pool type reactor. A safety vessel is provided in the design which envelopes the main reactor vessel. The ISI of the main vessel is mandatory and will be carried out by a robot which will operate on this annular gap. The design of the robot is such that it can crawl around the vessel and into the gap at the bottom of the vessel relying on friction grip. The mobile robot will carry a CCTV camera and the inspection technique packages into the interspace, position and orient these to carry out the ISI of the main vessel. The paper discusses about the design features of the robot including the gripping mechanism and the crawling sequence to perform ISI of the reactor vessel. 3 figs.

In-service inspection robot for PFBR main vessel- concept

International Nuclear Information System (INIS)

Rajendran, S.; Ramakumar, M.S.

1994-01-01

In-service inspection (ISI) of critical components in a nuclear reactor is one of the foremost and important tasks which reveals the state of health of the system, thereby ensuring the safety of the plant, personnel and environment. Prototype Fast Breeder Reactor (PFBR) is designed as a pool type reactor. A safety vessel is provided in the design which envelopes the main reactor vessel. The ISI of the main vessel is mandatory and will be carried out by a robot which will operate on this annular gap. The design of the robot is such that it can crawl around the vessel and into the gap at the bottom of the vessel relying on friction grip. The mobile robot will carry a CCTV camera and the inspection technique packages into the interspace, position and orient these to carry out the ISI of the main vessel. The paper discusses about the design features of the robot including the gripping mechanism and the crawling sequence to perform ISI of the reactor vessel. 3 figs

The dual effects of leading for safety: The mediating role of employee regulatory focus.

Science.gov (United States)

Kark, Ronit; Katz-Navon, Tal; Delegach, Marianna

2015-09-01

This study examined the underlying mechanisms through which transformational and transactional leadership influence employee safety behaviors. Linking leadership theory with self-regulatory focus (SRF) theory, we examined a model of dual effects of leadership on safety initiative and safety compliance behaviors as mediated by promotion and prevention self-regulations. We conducted an experimental study (N = 107), an online study (N = 99) and a field study (N = 798 employees and 49 managers). Results demonstrated that followers' situational promotion focus mediated the positive relationship between transformational leadership and safety initiative behaviors. Through all 3 studies, transactional active leadership was positively associated with followers' situational prevention focus, however, the association between followers' prevention focus and safety compliance behaviors was inconsistent, showing the expected mediation relationships in the experimental setting, but not in the online and field studies. We discuss theoretical and practical implications of the findings. (c) 2015 APA, all rights reserved).

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

Science.gov (United States)

Chen, I-Chi; Li, Hung-Hui

2010-06-07

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

Safety aspects in radiology

International Nuclear Information System (INIS)

Silva, D.C. da.

1991-05-01

The development of a program for the evaluation of the physical installations and operational procedures in diagnostic radiology with respect to radiation-safety is described. In addition, a proposal for the quality analysis of X-ray equipment and film-processing is presented. The purpose is both to ensure quality and safety of the radiology service, as well as to aid in the initial and in-service training of the staff. Interviews with patients, staff practicing radiology at a wide range of levels and the controlling authorities were carried out in the State of Rio de Janeiro in order to investigate the existence and the effective use of personal radioprotection equipment as well as user's and staff's concern for radiation safety. Additionally physical measurements were carried out in University Hospitals in Rio de Janeiro to assess the quality of equipment in day-to-day use. It was found that in the locations which did not have routine maintenance the equipment was generally in a poor state which lead to a high incidence of repetition of examinations and the consequent financial loss. (author)

A Leadership Model for University Geology Department Teacher Inservice Programs.

Science.gov (United States)

Sheldon, Daniel S.; And Others

1983-01-01

Provides geology departments and science educators with a leadership model for developing earth science inservice programs. Model emphasizes cooperation/coordination among departments, science educators, and curriculum specialists at local/intermediate/state levels. Includes rationale for inservice programs and geology department involvement in…

"Nursing Students Assaulted": Considering Student Safety in Community-Focused Experiences.

Science.gov (United States)

Maneval, Rhonda E; Kurz, Jane

2016-01-01

Community nursing experiences for undergraduate students have progressed beyond community-based home visits to a wide array of community-focused experiences in neighborhood-based centers, clinics, shelters, and schools. Our Bachelor of Science in Nursing program chose to use sites situated within neighborhoods close to campus in order to promote student and faculty engagement in the local community. These neighborhood sites provide opportunities for students to deliver nursing services to underserved and vulnerable populations experiencing poverty and health disparities. Some of these neighborhoods are designated as high crime areas that may potentially increase the risk of harm to students and faculty. There is a need to acknowledge the risk to personal safety and to proactively create policies and guidelines to reduce potential harm to students engaged in community-focused experiences. When a group of baccalaureate nursing students was assaulted while walking to a neighborhood clinic, the faculty was challenged as how to respond given the lack of policies and guidelines. Through our experience, we share strategies to promote personal safety for students and recommend transparency by administrators regarding potential safety risks to students engaged in community-focused fieldwork activities. Copyright © 2016 Elsevier Inc. All rights reserved.

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

Science.gov (United States)

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

2018-04-01

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

[Karachi Nuclear Power Plant (KANUPP), Safety Management

Energy Technology Data Exchange (ETDEWEB)

Hasan, S M [Karachi Nuclear Power Plant (KANUPP), Karachi (Pakistan)

1997-12-01

The present regime for CANDU safety management in Pakistan has evolved in line with contemporary international practice, and is essential adequate to ensure the continued safety of KANUPP and other future CANDU reactors, as confirmed by international reviews as well. But the small size of Pakistan nuclear power program poses limitations in developing - expert judgment in analysis of in-service inspection data; and own methodology for CANDU safety analysis.

[Karachi Nuclear Power Plant (KANUPP), Safety Management

International Nuclear Information System (INIS)

Hasan, S.M.

1997-01-01

The present regime for CANDU safety management in Pakistan has evolved in line with contemporary international practice, and is essential adequate to ensure the continued safety of KANUPP and other future CANDU reactors, as confirmed by international reviews as well. But the small size of Pakistan nuclear power program poses limitations in developing - expert judgment in analysis of in-service inspection data; and own methodology for CANDU safety analysis

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

Science.gov (United States)

Vaismoradi, Mojtaba; Jordan, Sue; Kangasniemi, Mari

2015-03-01

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

Patient Safety and Healthcare Quality

Directory of Open Access Journals (Sweden)

Aikaterini Toska

2012-01-01

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

Scheduling and coordination for in-service inspection of nuclear power plant

International Nuclear Information System (INIS)

Li Songbai

1996-11-01

Based on the practice and experiences of pre-service and in-service inspections for Daya Bay Nuclear Power Plant (NPP) by Research Institute of Nuclear Power Operation (RINPO) following RSEM code, requirements of utility and actual situation in China, the in-service inspection preparation for organization, techniques and equipment/tooling, materials, personnel and documentation is briefly described. And the scheduling and coordinating consideration for planed in-service inspection activities during NPP outage is emphatically introduced. (2 refs., 4 figs.)

FOCUS: the Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

Science.gov (United States)

Barbeito, Atilio; Lau, William Travis; Weitzel, Nathaen; Abernathy, James H; Wahr, Joyce; Mark, Jonathan B

2014-10-01

The Society of Cardiovascular Anesthesiologists (SCA) introduced the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems) in 2005 in response to the need for a rigorous scientific approach to improve quality and safety in the cardiovascular operating room (CVOR). The goal of the project, which is supported by the SCA Foundation, is to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. A hazard is anything that has the potential to cause a preventable adverse event. Specifically, the strategic plan of FOCUS includes 3 goals: (1) identifying hazards in the CVOR, (2) prioritizing hazards and developing risk-reduction interventions, and (3) disseminating these interventions. Collectively, the FOCUS initiative, through the work of several groups composed of members from different disciplines such as clinical medicine, human factors engineering, industrial psychology, and organizational sociology, has identified and documented significant hazards occurring daily in our CVORs. Some examples of frequent occurrences that contribute to reduce the safety and quality of care provided to cardiac surgery patients include deficiencies in teamwork, poor OR design, incompatible technologies, and failure to adhere to best practices. Several projects are currently under way that are aimed at better understanding these hazards and developing interventions to mitigate them. The SCA, through the FOCUS initiative, has begun this journey of science-driven improvement in quality and safety. There is a long and arduous road ahead, but one we need to continue to travel.

Patient Safety and Healthcare Quality

OpenAIRE

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...

Acute care patients discuss the patient role in patient safety.

Science.gov (United States)

Rathert, Cheryl; Huddleston, Nicole; Pak, Youngju

2011-01-01

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

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

Science.gov (United States)

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.

Implementation of in-service inspection program for HANARO

International Nuclear Information System (INIS)

Wu, J.S.; Park, Y.C.; Cho, Y.G.; Jun, B.J.

2001-01-01

HANARO, a 30 MW multi-purpose research reactor in Korea has been successfully in operation for 6 years since its initial criticality in February 1995. It is mainly used for the research areas including nuclear fuel and material irradiation tests, radioisotope production, neutron beam application, neutron activation analysis and neutron transmutation doping. HANARO was designed to perform for at least 20 years under full power operating condition. It is expected that the actual reactor lifetime will be much more than the design lifetime, due to a safety reassessment based on realistic data, preventive maintenance and appropriate in-service inspections (ISI). Since ageing may affect the overall safety of the reactor facility, it is needed to detect and evaluate the effects on aged components and systems related to safety. During the lifetime of the reactor, structures, systems and components are subjected to environmental conditions of stress, temperature and irradiation that may lead to changes in the material properties and could result in unexpected failures. Evidence of ageing problems appears progressively. A rigorous inspection and visual examination based on a periodic ISI program should be established. It is desirable that the ageing surveillance activities is scheduled as early as possible and continued throughout the operating life of the reactor. An inspection plan for safety related structures, systems and components subjected to the ageing conditions is requested by the regulatory body to assess the safety status of reactor facility. A long-term ISI program for HANARO has been established for safety-related systems and components in the context of the overall reactor ageing management. The objective of this paper is to describe the ISI program and the result of the visual inspection as the first ISI. (orig.)

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

Science.gov (United States)

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

2011-12-01

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

Safeguarding the nuclear safety of WWER-440 reactor pressure vessels at SKODA Plzen

International Nuclear Information System (INIS)

Hrbek, Z.

1986-01-01

The approach is described of the SKODA enterprise to safety assurance and to providing the reliability of WWER-440 reactor pressure vessels. The philosophy is analyzed of in-service inspection and determination of the residual service life of pressure vessels. This follows up on the so-called conception of basic safety whose main aim is to preclude failures at production stage by the selection of suitable material, namely by optimizing the choice of raw materials, of metallurgical procedures such as will lead to high purity of the pressure vessel material, by introducing multiple inspection in production, reducing the sensitivity of materials to technological operations, and by high-quality welds. The quality of in-service inspections is given by the use of technical diagnostic instruments of peak quality and of modern methods of nondestructive materials testing. The instruments and methods used are described. It is stated that the experience gained with in-service inspection will make it possible to draw up operating regulations and safety criteria for nuclear installations and own inspection regulations, this with regard to technical and economic factors. (Z.M.)

A data fusion approach for track monitoring from multiple in-service trains

Science.gov (United States)

Lederman, George; Chen, Siheng; Garrett, James H.; Kovačević, Jelena; Noh, Hae Young; Bielak, Jacobo

2017-10-01

We present a data fusion approach for enabling data-driven rail-infrastructure monitoring from multiple in-service trains. A number of researchers have proposed using vibration data collected from in-service trains as a low-cost method to monitor track geometry. The majority of this work has focused on developing novel features to extract information about the tracks from data produced by individual sensors on individual trains. We extend this work by presenting a technique to combine extracted features from multiple passes over the tracks from multiple sensors aboard multiple vehicles. There are a number of challenges in combining multiple data sources, like different relative position coordinates depending on the location of the sensor within the train. Furthermore, as the number of sensors increases, the likelihood that some will malfunction also increases. We use a two-step approach that first minimizes position offset errors through data alignment, then fuses the data with a novel adaptive Kalman filter that weights data according to its estimated reliability. We show the efficacy of this approach both through simulations and on a data-set collected from two instrumented trains operating over a one-year period. Combining data from numerous in-service trains allows for more continuous and more reliable data-driven monitoring than analyzing data from any one train alone; as the number of instrumented trains increases, the proposed fusion approach could facilitate track monitoring of entire rail-networks.

New developments in containment in-service inspection requirements

International Nuclear Information System (INIS)

Staffiera, J.E.

1995-01-01

Section 11 of the ASME Boiler and Pressure Vessel Code contains requirements for inservice inspection of nuclear power plant components. Development of ASME Code requirements for containment inservice inspection was begun in 1977, and in 1979 the first such requirements were published in the form of Code Case N-236. Formal inclusion of these requirements in Section 11 of the ASME Code occurred with publication of Subsection IWE, ''Rules for inservice Inspection of Class MC Components of Nuclear Power Plants,'' in the 1980 Edition, Winter 1981 Addenda. At that time, inspection emphasis on nuclear power construction and operation activities was placed on welds and welding processes associated with steel containments and metallic liners of concrete containments. The need for repair-welding requirements was necessitated by containment design modifications for conditions not considered in several original plant designs. Welds in steel containments and metallic liners of concrete containments have not required significant amounts of repair, however, degradation of base metal in containments has become a major concern. Various degradation mechanisms have been identified as potential causes of damage to containment surfaces, including fatigue, corrosion and material embrittlement due to long-term radiation exposure. As a result of these concerns, and in response to comments generated by the Committee to Review Generic Requirements (CRGR) of the NRC in its review of Subsection IWE, emphasis on weld-based inservice inspection was redirected toward a containment-surface inservice inspection program. Significant changes were made to accommodate this re-emphasis. The majority of these changes were published in the 1992 Edition, with the 1992 Addenda, of Subsection IWE. The NRC Proposed Rulemaking was issued for a 75-day public comment period in January, 1994. This period was extended at the request of nuclear industry organizations to allow for meaningful evaluation

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

Science.gov (United States)

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

2012-01-01

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

Ten-year rollover of San Onofre inservice testing program for pumps and valves to OM-6 and OM-10

International Nuclear Information System (INIS)

Croy, P.A.; Fischetti, S.; Chiang, D.; Schofield, P.; Barney, D.

1994-01-01

The Pump and Valve Inservice Testing (IST) Program Sat San Onofre, Units 2 and 3, was updated for the second 120-month interval from August 1993 to April 1994. The U.S. Nuclear Regulatory Commission (USNRC) approved the OM-6 and OM-10 Codes in mid-1992. The project for the rollover to these new Codes included several elements: (a) a review of the differences between IWV/IWP and OM-6/OM-10, (b) a comprehensive audit of the IST Program scope for valves, (c) creation of the program and supporting basis documents, the Relief Requests, and implementing procedures, (d) interdivisional coordination, (e) submittal to the USNRC, and (f) training. Subsections IWV and IWP have been used and essentially unchanged for over a decade. The new Code (Parts 1, 6, and 10 called OM-1, OM-6, and OM-10) includes several significant changes from the old Code. Our group identified these differences and drafted revised and reorganized Inservice Testing (IST) Program documents. We also considered USNRC Generic Letter 89-04 (GL 89-04), open-quotes Guidance on Developing Acceptable Inservice Testing Programsclose quotes, and NUREG-1482, Guidelines for Inservice Testing at Nuclear Power Plants, while revising the program. There were six pump relief requires and 13 valve relief requests in the program for the first 10-year interval. For the revised program we needed only one pump relief request (and no valve relief requests). Converting to the 1989 edition of the ASME Code did not require changes to the technical specifications. We revised our Updated Final Safety Analysis Report (UFSAR) to reflect the IST Program for the second 10-year interval. UFSAR changes were minor, consisting of updated references to the Code edition and 10 CFR 50.55a(f), open-quotes Inservice Testing Requirementsclose quotes

'Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two scales.

Science.gov (United States)

Martinez, William; Etchegaray, Jason M; Thomas, Eric J; Hickson, Gerald B; Lehmann, Lisa Soleymani; Schleyer, Anneliese M; Best, Jennifer A; Shelburne, Julia T; May, Natalie B; Bell, Sigall K

2015-11-01

To develop and test the psychometric properties of two new survey scales aiming to measure the extent to which the clinical environment supports speaking up about (a) patient safety concerns and (b) unprofessional behaviour. Residents from six large US academic medical centres completed an anonymous, electronic survey containing questions regarding safety culture and speaking up about safety and professionalism concerns. Confirmatory factor analysis supported two separate, one-factor speaking up climates (SUCs) among residents; one focused on patient safety concerns (SUC-Safe scale) and the other focused on unprofessional behaviour (SUC-Prof scale). Both scales had good internal consistency (Cronbach's α>0.70) and were unique from validated safety and teamwork climate measures (rspeaking up behaviour about safety and professionalism concerns (r=0.21, pspeaking up behaviour among residents. These two scales may fill an existing gap in residency and safety culture assessments by measuring the openness of communication about safety and professionalism concerns, two important aspects of safety culture that are under-represented in existing metrics. 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.

In-service inspection of pressurized water reactors

International Nuclear Information System (INIS)

Rapin, M.; Saglio, R.

1983-01-01

French legislation, which is more demanding than in other countries, had led Electricite de France, the State-owned utility, to acquire better performance in-service inspection facilities than those which existed previously. This fact has spurred the industrial development of the new technical facilities which are used worldwide today. This article presents the ''in-service inspection machine'' (MIS) for the inspection of the welds of a PWR vessel, and the inspection device of steam generator tubes; the MIS allow a remote-viewing, ultrasonic and gamma-graphic inspection; Foucault currents are the only one method adapted to the inspection steam generator tubes [fr

Pre- and In-Service Preschool Teachers' Science Teaching Efficacy Beliefs

Science.gov (United States)

Aslan, Durmus; Tas, Isil; Ogul, Irem Gürgah

2016-01-01

In this study, pre- and in-service preschool teachers' science teaching efficacy beliefs were investigated. The sample included 100 pre-service (50 first grades and 50 last grades) and 73 in-service preschool teachers. As a data collection tool "Science Teaching Efficacy Belief Instrument" was used. Findings indicated that in-service…

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

Science.gov (United States)

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

2015-09-01

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

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

Science.gov (United States)

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

2017-08-02

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

Quality management, a directive approach to patient safety.

Science.gov (United States)

Ayuso-Murillo, Diego; de Andrés-Gimeno, Begoña; Noriega-Matanza, Concha; López-Suárez, Rafael Jesús; Herrera-Peco, Ivan

Nowadays the implementation of effective quality management systems and external evaluation in healthcare is a necessity to ensure not only transparency in activities related to health but also access to health and patient safety. The key to correctly implementing a quality management system is support from the managers of health facilities, since it is managers who design and communicate to health professionals the strategies of action involved in quality management systems. This article focuses on nursing managers' approach to quality management through the implementation of cycles of continuous improvement, participation of improvement groups, monitoring systems and external evaluation quality models (EFQM, ISO). The implementation of a quality management system will enable preventable adverse effects to be minimized or eliminated, and promote patient safety and safe practice by health professionals. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Inservice Inspection in the Fugen

OpenAIRE

1983-01-01

Pressure tube type reactors have specific components orstructures,compared with light water reactors.They are(1) steam drums(2) reactor inlet headers(3) reactor inlet and outlet pipies(4) pressure tubes.Much attention is paid upon Inservice Inspection (ISI)of the above components.

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

Science.gov (United States)

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

2017-07-01

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

Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm.

Science.gov (United States)

Lyren, Anne; Brilli, Richard J; Zieker, Karen; Marino, Miguel; Muething, Stephen; Sharek, Paul J

2017-09-01

To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs). A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions. Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; P collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm. Copyright © 2017 by the American Academy of Pediatrics.

RFID in the blood supply chain--increasing productivity, quality and patient safety.

Science.gov (United States)

Briggs, Lynne; Davis, Rodeina; Gutierrez, Alfonso; Kopetsky, Matthew; Young, Kassandra; Veeramani, Raj

2009-01-01

As part of an overall design of a new, standardized RFID-enabled blood transfusion medicine supply chain, an assessment was conducted for two hospitals: the University of Iowa Hospital and Clinics (UIHC) and Mississippi Baptist Health System (MBHS). The main objectives of the study were to assess RFID technological and economic feasibility, along with possible impacts to productivity, quality and patient safety. A step-by-step process analysis focused on the factors contributing to process "pain points" (errors, inefficiency, product losses). A process re-engineering exercise produced blueprints of RFID-enabled processes to alleviate or eliminate those pain-points. In addition, an innovative model quantifying the potential reduction in adverse patient effects as a result of RFID implementation was created, allowing improvement initiatives to focus on process areas with the greatest potential impact to patient safety. The study concluded that it is feasible to implement RFID-enabled processes, with tangible improvements to productivity and safety expected. Based on a comprehensive cost/benefit model, it is estimated for a large hospital (UIHC) to recover investment from implementation within two to three years, while smaller hospitals may need longer to realize ROI. More importantly, the study estimated that RFID technology could reduce morbidity and mortality effects substantially among patients receiving transfusions.

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

Science.gov (United States)

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

2009-01-01

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

Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide

Science.gov (United States)

Farley, Donna; Zheng, Hao; Rousi, Eirini; Leotsakos, Agnès

2015-01-01

Introduction Although the importance of training in patient safety has been acknowledged for over a decade, it remains under-utilized and under-valued in most countries. WHO developed the Multi-professional Patient Safety Curriculum Guide to provide schools with the requirements and tools for incorporating patient safety in education. It was field tested with 12 participating schools across the six WHO regions, to assess its effectiveness for teaching patient safety to undergraduate and graduate students in a global variety of settings. Methods The evaluation used a combined prospective/retrospective design to generate formative information on the experiences of working with the Guide and summative information on the impacts of the Guide. Using stakeholder interviews and student surveys, data were gathered from each participating school at three times: the start of the field test (baseline), soon after each school started teaching, and soon after each school finished teaching. Results Stakeholders interviewed were strongly positive about the Guide, noting that it emphasized universally important patient safety topics, was culturally appropriate for their countries, and gave credibility and created a focus on patient safety at their schools. Student perceptions and attitudes regarding patient safety improved substantially during the field test, and their knowledge of the topics they were taught doubled, from 10.7% to 20.8% of correct answers on the student survey. Discussion This evaluation documented the effectiveness of the Curriculum Guide, for both ease of use by schools and its impacts on improving the patient safety knowledge of healthcare students. WHO should be well positioned to refine the contents of the Guide and move forward in encouraging broader use of the Guide globally for teaching patient safety. PMID:26406893

Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide.

Science.gov (United States)

Farley, Donna; Zheng, Hao; Rousi, Eirini; Leotsakos, Agnès

2015-01-01

Although the importance of training in patient safety has been acknowledged for over a decade, it remains under-utilized and under-valued in most countries. WHO developed the Multi-professional Patient Safety Curriculum Guide to provide schools with the requirements and tools for incorporating patient safety in education. It was field tested with 12 participating schools across the six WHO regions, to assess its effectiveness for teaching patient safety to undergraduate and graduate students in a global variety of settings. The evaluation used a combined prospective/retrospective design to generate formative information on the experiences of working with the Guide and summative information on the impacts of the Guide. Using stakeholder interviews and student surveys, data were gathered from each participating school at three times: the start of the field test (baseline), soon after each school started teaching, and soon after each school finished teaching. Stakeholders interviewed were strongly positive about the Guide, noting that it emphasized universally important patient safety topics, was culturally appropriate for their countries, and gave credibility and created a focus on patient safety at their schools. Student perceptions and attitudes regarding patient safety improved substantially during the field test, and their knowledge of the topics they were taught doubled, from 10.7% to 20.8% of correct answers on the student survey. This evaluation documented the effectiveness of the Curriculum Guide, for both ease of use by schools and its impacts on improving the patient safety knowledge of healthcare students. WHO should be well positioned to refine the contents of the Guide and move forward in encouraging broader use of the Guide globally for teaching patient safety.

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

DEFF Research Database (Denmark)

Kristensen, Solvejg; Mainz, Jan; Bartels, Paul

2009-01-01

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

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

Science.gov (United States)

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

2012-02-01

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

Development of Heat-Affected Zone Hardness Limits for In-Service Welding

Science.gov (United States)

2009-09-29

Welding onto in-service pipelines is frequently required to facilitate a repair or to install a branch connection using the "hot tapping" technique. Welds made in-service cool at an accelerated rate as the result of the ability of the flowing content...

A Methodology for Evaluation of Inservice Test Intervals for Pumps and Motor Operated Valves

International Nuclear Information System (INIS)

McElhaney, K.L.

1999-01-01

The nuclear industry has begun efforts to reevaluate inservice tests (ISTs) for key components such as pumps and valves. At issue are two important questions--What kinds of tests provide the most meaningful information about component health, and what periodic test intervals are appropriate? In the past, requirements for component testing were prescribed by the American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code. The tests and test intervals specified in the Code were generic in nature and test intervals were relatively short. Operating experience has shown, however, that performance and safety improvements and cost savings could be realized by tailoring IST programs to similar components with comparable safety importance and service conditions. In many cases, test intervals may be lengthened, resulting in cost savings for utilities and their customers

Enhance pump reliability through improved inservice testing

International Nuclear Information System (INIS)

Healy, J.J.

1990-01-01

EPRI has undertaken a study to assess the effectiveness of existing testing programs to accurately monitor and predict performance changes before either pump performance degrades or an actual failure occurs. Anticipated changes in inservice testing techniques are directed towards enhancing the validity of test data, ensuring its repeatability, and avoiding deterioration of the pump assembly. There is a new-found interest in test programs of all types that has occurred, in part, because of an increase in reported pump degradation and pump failure. Inservice testing of pumps, which has long been a basis for assuring operability, has apparently produced an opposite effect; namely, the appearance of a reduction in reliability

Patient considerations in the management of chronic constipation: focus on prucalopride

Directory of Open Access Journals (Sweden)

Shin A

2016-07-01

Full Text Available Andrea Shin Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA Abstract: Chronic constipation is a common condition that significantly impacts health care utilization, productivity, and quality of life. Laxatives are commonly used, although often insufficient in restoring normal bowel function or providing adequate relief. There remains a significant need for the development of novel agents to optimize treatment of this condition. This review provides an overview of the preclinical and clinical trial data, supporting the efficacy and safety of prucalopride, a highly selective 5-HT4 receptor agonist that has been approved by the European Medicine Agency for the treatment of chronic constipation in adults who have failed standard laxative therapy. Unlike older 5-HT4 agonists, prucalopride has not been associated with adverse cardiovascular side effects or QT prolongation owing to its high selectivity and affinity for the 5-HT4 receptor without clinically significant cross-reactivity at the human ether-à-go-go-related gene (hERG potassium channel or 5-HT receptor subtypes that have previously been implicated in adverse cardiovascular events and arrhythmias. Careful safety assessments have documented the relative safety and tolerability of this agent in various patient groups. Focus has also been placed on demonstrating efficacy with regard to bowel function, symptoms, and patient-reported outcomes such as the Patient Assessment of Constipation-Symptoms and the Patient Assessment of Constipation Quality of Life scores to support the use of prucalopride as a safe and effective therapeutic option for the management of chronic constipation. Keywords: prucalopride, chronic constipation, 5-HT4 agonist, safety, prokinetic, PAC-QOL

An Examination of Technology Training Experiences from Teacher Candidacy to In-Service Professional Development

Science.gov (United States)

Williams, Mable Evans

2017-01-01

The purpose of this qualitative study was to explore the perceptions of in-service teachers concerning the effectiveness of technology training from a teacher education preparation program to in-service professional development. The findings of the study revealed that inservice teachers have had varying degrees of technology experiences from their…

Issues and Challenges of Providing Online Inservice Teacher Training: Korea's experience

Directory of Open Access Journals (Sweden)

Insung Jung

2001-07-01

Full Text Available To meet the need for flexible and interactive teacher training, the Korean government created a Cyber Teacher Training Center (CTTC in the summer of 1997. The CTTC project developed a software platform for managing online inservice teacher training, 11 general training courses, with plans to add more courses each year. This article examines the needs met through the introduction of online inservice teacher training and the strategies that have been employed in the process. This paper also analyzes the major impacts of online teacher training and looks at the challenges facing online inservice teacher training in the coming years.

Safety of diabetes drugs in patients with heart failure.

Science.gov (United States)

Carrasco-Sánchez, F J; Ostos-Ruiz, A I; Soto-Martín, M

2018-03-01

Heart failure (HF) and diabetes mellitus are 2 clinical conditions that often coexist, particularly in patients older than 65 years. Diabetes mellitus promotes the development of HF and confers a poorer prognosis. Hypoglycaemic agents (either by their mechanism of action, hypoglycaemic action or adverse effects) can be potentially dangerous for patients with HF. In this study, we performed a review of the available evidence on the safety of diabetes drugs in HF, focused on the main observational and experimental studies. Recent studies on cardiovascular safety have evaluated, although as a secondary objective, the impact of new hypoglycaemic agents on HF, helping us understand the neutrality, risks and potential benefits of these agents. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.

Research of nuclear power plant in-service maintenance based on virtual reality

International Nuclear Information System (INIS)

Wang Yong; Kuang Weijun

2015-01-01

This paper presents a method of constructing nuclear power plant in-service maintenance virtual simulation scene and virtual maintenance process. Taking air baffles dismantling process of CAP1400(China Advanced Passive 1400) nuclear power plant as an instance, this paper discusses ergonomics, space analysis, time assessment based on virtual reality in the process of in-service maintenance. It demonstrates the advantage of using VR technology to design and verify in-service maintenance process of nuclear power plant compared to the conventional way. (author)

Process management - critical safety issues with focus on risk management

International Nuclear Information System (INIS)

Sanne, Johan M.

2005-12-01

Organizational changes focused on process orientation are taking place among Swedish nuclear power plants, aiming at improving the operation. The Swedish Nuclear Power Inspectorate has identified a need for increased knowledge within the area for its regulatory activities. In order to analyze what process orientation imply for nuclear power plant safety a number of questions must be asked: 1. How is safety in nuclear power production created currently? What significance does the functional organization play? 2. How can organizational forms be analysed? What consequences does quality management have for work and for the enterprise? 3. Why should nuclear power plants be process oriented? Who are the customers and what are their customer values? Which customers are expected to contribute from process orientation? 4. What can one learn from process orientation in other safety critical systems? What is the effect on those features that currently create safety? 5. Could customer values increase for one customer without decreasing for other customers? What is the relationship between economic and safety interests from an increased process orientation? The deregulation of the electricity market have caused an interest in increased economic efficiency, which is the motivation for the interest in process orientation. among other means. It is the nuclear power plants' owners and the distributors (often the same corporations) that have the strongest interest in process orientation. If the functional organization and associated practices are decomposed, the prerequisites of the risk management regime changes, perhaps deteriorating its functionality. When nuclear power operators consider the introduction of process orientation, the Nuclear Power Inspectorate should require that 1. The operators perform a risk analysis beforehand concerning the potential consequences that process orientation might convey: the analysis should contain a model specifying how safety is currently

Integration of in-service inspection works in the objectives of nuclear power plants; Integracion de los trabajos de inspeccion en servicio en los objectivos de las centrales nucleares

Energy Technology Data Exchange (ETDEWEB)

Garcia, M.; Lopez, M.A.

1996-09-01

The present articles summarizes the objectives of Spanish NPPs and the in-service inspection aspect in these objectives. The Safety maintenance, lifetime of nuclear power plants, reduction of doses and wastes and the participation of main are evaluated.

Patient safety climate strength: a concept that requires more attention

Science.gov (United States)

Ginsburg, Liane; Gilin Oore, Debra

2016-01-01

Background When patient safety climate (PSC) surveys are used in healthcare, reporting typically focuses on PSC level (mean or per cent positive scores). This paper explores how an additional focus on PSC strength can enhance the utility of PSC survey data. Setting and participants 442 care providers from 24 emergency departments (EDs) across Canada. Methods We use anonymised data from the Can-PSCS PSC instrument collected in 2011 as part of the Qmentum accreditation programme. We examine differences in climate strength across EDs using the Rwg(j) and intraclass correlation coefficients measures of inter-rater agreement. Results Across the six survey dimensions, median Rwg(j) was sufficiently high to support shared climate perceptions (0.64–0.83), but varied widely across the 24 ED units. We provide an illustrative example showing vastly different climate strength (Rwg(j) range=0.17–0.86) for units with an equivalent level of PSC (eg, climate mean score=3). Conclusions Most PSC survey results focus solely on climate level. To facilitate improvement in PSC, we advocate a simple, holistic safety climate profile including three metrics: climate level (using mean or per cent positive climate scores), climate strength (using the Rwg(j), or SD as a proxy) and the shape of the distribution (using histograms to see the distribution of scores within units). In PSC research, we advocate paying attention to climate strength as an important variable in its own right. Focusing on PSC level and strength can further understanding of the extent to which PSC is a key variable in the domain of patient safety. PMID:26453636

Patient safety culture in Norwegian nursing homes.

Science.gov (United States)

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

2017-06-20

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

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

Science.gov (United States)

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

2018-06-04

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

Identifying research priorities for patient safety in mental health: an international expert Delphi study

Science.gov (United States)

Murray, Kevin; Thibaut, Bethan; Ramtale, Sonny Christian; Adam, Sheila; Darzi, Ara; Archer, Stephanie

2018-01-01

Objective Physical healthcare has dominated the patient safety field; research in mental healthcare is not as extensive but findings from physical healthcare cannot be applied to mental healthcare because it delivers specialised care that faces unique challenges. Therefore, a clearer focus and recognition of patient safety in mental health as a distinct research area is still needed. The study aim is to identify future research priorities in the field of patient safety in mental health. Design Semistructured interviews were conducted with the experts to ascertain their views on research priorities in patient safety in mental health. A three-round online Delphi study was used to ascertain consensus on 117 research priority statements. Setting and participants Academic and service user experts from the USA, UK, Switzerland, Netherlands, Ireland, Denmark, Finland, Germany, Sweden, Australia, New Zealand and Singapore were included. Main outcome measures Agreement in research priorities on a five-point scale. Results Seventy-nine statements achieved consensus (>70%). Three out of the top six research priorities were patient driven; experts agreed that understanding the patient perspective on safety planning, on self-harm and on medication was important. Conclusions This is the first international Delphi study to identify research priorities in safety in the mental field as determined by expert academic and service user perspectives. A reasonable consensus was obtained from international perspectives on future research priorities in patient safety in mental health; however, the patient perspective on their mental healthcare is a priority. The research agenda for patient safety in mental health identified here should be informed by patient safety science more broadly and used to further establish this area as a priority in its own right. The safety of mental health patients must have parity with that of physical health patients to achieve this. PMID:29502096

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

Science.gov (United States)

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

Effects on in-service education on improving science teaching in Swaziland

NARCIS (Netherlands)

Stronkhorst, Robert; van den Akker, Jan

2006-01-01

This paper discusses the findings of an evaluative and interpretive study into the potential of in-service education to improve science education in Swaziland. Short-term and long-term effects of an in-service intervention are evaluated in terms of changes in classroom processes. The teaching

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

Directory of Open Access Journals (Sweden)

Wensing Michel

2010-01-01

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

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

Science.gov (United States)

Gaal, Sander; Verstappen, Wim; Wensing, Michel

2010-01-21

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

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

OpenAIRE

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

2017-01-01

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

Reliability and safety engineering

CERN Document Server

Verma, Ajit Kumar; Karanki, Durga Rao

2016-01-01

Reliability and safety are core issues that must be addressed throughout the life cycle of engineering systems. Reliability and Safety Engineering presents an overview of the basic concepts, together with simple and practical illustrations. The authors present reliability terminology in various engineering fields, viz.,electronics engineering, software engineering, mechanical engineering, structural engineering and power systems engineering. The book describes the latest applications in the area of probabilistic safety assessment, such as technical specification optimization, risk monitoring and risk informed in-service inspection. Reliability and safety studies must, inevitably, deal with uncertainty, so the book includes uncertainty propagation methods: Monte Carlo simulation, fuzzy arithmetic, Dempster-Shafer theory and probability bounds. Reliability and Safety Engineering also highlights advances in system reliability and safety assessment including dynamic system modeling and uncertainty management. Cas...

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Science.gov (United States)

Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A

2006-11-01

Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.

[Improving patient safety through voluntary peer review].

Science.gov (United States)

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.

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

Directory of Open Access Journals (Sweden)

Predrag Dašić

2017-03-01

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

Patient safety culture assessment in oman.

Science.gov (United States)

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

2014-07-01

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

Patient Safety Culture Assessment in Oman

Science.gov (United States)

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

2014-01-01

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

Guidelines for inservice testing at nuclear power plants. Draft report for comment

International Nuclear Information System (INIS)

Campbell, P.

1993-11-01

In this report, the staff gives licensees guidelines for developing and implementing programs for the inservice testing of pumps and valves at commercial nuclear power plants. The report includes U.S. Nuclear Regulatory Commission (NRC) guidance and recommendations on inservice testing issues. The staff discusses the regulations, the components to be included in an inservice testing program, and the preparation and content of cold shutdown and refueling outage justifications and requests for relief from the American Society of Mechanical Engineers Code requirements. The staff also gives specific guidance on relief acceptable to the NRC and advises licensees in the use of this information for application at their facilities. The staff discusses the revised standard technical specifications for the inservice testing program requirements and gives guidance on the process a licensee may follow upon finding an instance of noncompliance with the Code

In-Service Education of Teachers: Overview, Problems and the Way Forward

Science.gov (United States)

Osamwonyi, Eduwen Friday

2016-01-01

The need for in-service education of teachers cannot be underestimated. It is a necessity in enhancing work performance and motivation of teachers in the field. Absence of in-service training of teachers will retard professional growth of teachers as well as "missing gaps" between demands and actual achievement levels. Inservice…

Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.

Science.gov (United States)

Auerbach, Andrew D; Sehgal, Niraj L; Blegen, Mary A; Maselli, Judith; Alldredge, Brian K; Vittinghoff, Eric; Wachter, Robert M

2012-02-01

Improving communication between caregivers is an important approach to improving safety. To implement teamwork and communication interventions and evaluate their impact on patient outcomes. A prospective, interrupted time series of a three-phase a run-in period (phase 1), during which a training programme was given to providers and staff on each unit; phase 2, which focused on unit-based safety teams to identify and address care problems using skills from phase 1; and phase 3, which focused on engaging patients in communication efforts. General medical inpatient units at three northern California hospitals. Administrative data were collected from all adults admitted to the target units, and a convenience sample of patients interviewed during and after hospitalisation. Readmission, length of stay and patient reports of teamwork, problems with care, and overall satisfaction. 10 977 patients were admitted; 581 patients (5.3% of total sample) were interviewed in hospital, and 313 (2.9% overall, 53.8% of interviewed patients) completed 1-month surveys. No phase of the study was associated with adjusted differences in readmission or length of stay. The phase 2 intervention appeared to be associated with improvement in reports of whether physicians treated them with respect, whether nurses treated them with respect or understood their needs (pcommunication may improve patients' perception of team functions, but may also increase patients' perception of safety gaps.

On-line monitoring and inservice inspection in codes

International Nuclear Information System (INIS)

Bartonicek, J.; Zaiss, W.; Bath, H.R.

1999-01-01

The relevant regulatory codes determine the ISI tasks and the time intervals for recurrent components testing for evaluation of operation-induced damaging or ageing in order to ensure component integrity on the basis of the last available quality data. In-service quality monitoring is carried out through on-line monitoring and recurrent testing. The requirements defined by the engineering codes elaborated by various institutions are comparable, with the KTA nuclear engineering and safety codes being the most complete provisions for quality evaluation and assurance after different, defined service periods. German conventional codes for assuring component integrity provide exclusively for recurrent inspection regimes (mainly pressure tests and optical testing). The requirements defined in the KTA codes however always demanded more specific inspections relying on recurrent testing as well as on-line monitoring. Foreign codes for ensuring component integrity concentrate on NDE tasks at regular time intervals, with time intervals scope of testing activities being defined on the basis of the ASME code, section XI. (orig./CB) [de

Kirkpatrick evaluation model for in-service training on cardiopulmonary resuscitation

Directory of Open Access Journals (Sweden)

Safoura Dorri

2016-01-01

Full Text Available Background: There are several evaluation models that can be used to evaluate the effect of in-service training; one of them is the Kirkpatrick model. The aim of the present study is to assess the in-service training of cardiopulmonary resuscitation (CPR for nurses based on the Kirkpatrick′s model. Materials and Methods: This study is a cross-sectional study based on the Kirkpatrick′s model in which the efficacy of in-service training of CPR to nurses was assessed in the Shahadaye Lenjan Hospital in Isfahan province in 2014. 80 nurses and Nurse′s aides participated in the study after providing informed consent. The in-service training course was evaluated in reaction, learning, behavior, and results level of the Kirkpatrick model. Data were collected through a researcher-made questionnaire. Results: The mean age of the participants was 35 ± 8.5 years. The effectiveness score obtained in the reaction level (first level in the Kirkpatrick model was 4.2 ± 0.32. The effectiveness score in the second level of model or the learning level was 4.70 ± 0.09, which is statistically significant (P < 0.001. The effectiveness score at the third and fourth level were 4.1 ± 0.34 and 4.3 ± 0.12, respectively. Total effectiveness score was 4.35. Conclusions: The results of this study showed that CPR in-service training has a favorable effect on all four levels of the Kirkpatrick model for nurses and nurse′s aides.

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

OpenAIRE

Ballangrud, Randi

2013-01-01

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

Developing a patient-led electronic feedback system for quality and safety within Renal PatientView.

Science.gov (United States)

Giles, Sally J; Reynolds, Caroline; Heyhoe, Jane; Armitage, Gerry

2017-03-01

It is increasingly acknowledged that patients can provide direct feedback about the quality and safety of their care through patient reporting systems. The aim of this study was to explore the feasibility of patients, healthcare professionals and researchers working in partnership to develop a patient-led quality and safety feedback system within an existing electronic health record (EHR), known as Renal PatientView (RPV). Phase 1 (inception) involved focus groups (n = 9) and phase 2 (requirements) involved cognitive walkthroughs (n = 34) and 1:1 qualitative interviews (n = 34) with patients and healthcare professionals. A Joint Services Expert Panel (JSP) was convened to review the findings from phase 1 and agree the core principles and components of the system prototype. Phase 1 data were analysed using a thematic approach. Data from phase 1 were used to inform the design of the initial system prototype. Phase 2 data were analysed using the components of heuristic evaluation, resulting in a list of core principles and components for the final system prototype. Phase 1 identified four main barriers and facilitators to patients feeding back on quality and safety concerns. In phase 2, the JSP agreed that the system should be based on seven core principles and components. Stakeholders were able to work together to identify core principles and components for an electronic patient quality and safety feedback system in renal services. Tensions arose due to competing priorities, particularly around anonymity and feedback. Careful consideration should be given to the feasibility of integrating a novel element with differing priorities into an established system with existing functions and objectives. © 2016 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Mentorship for newly appointed physicians: a strategy for enhancing patient safety?

Science.gov (United States)

Harrison, Reema; McClean, Serwaa; Lawton, Rebecca; Wright, John; Kay, Clive

2014-09-01

Mentorship is an increasingly popular innovation from business and industry that is being applied in health-care contexts. This paper explores the concept of mentorship for newly appointed physicians in their first substantive senior post, and specifically its utilization to enhance patient safety. Semi-structured face to face and telephone interviews with Medical Directors (n = 5), Deputy Medical Directors (n = 4), and Clinical Directors (n = 6) from 9 acute NHS Trusts in the Yorkshire and Humber region in the north of England. A focused thematic analysis was used. A number of beneficial outcomes were associated with mentorship for newly appointed physicians including greater personal and professional support, organizational commitment, and general well-being. Providing newly appointed senior physicians with support through mentorship was considered to enhance the safety of patient care. Mentorship may prevent or reduce active failures, be used to identify threats in the local working environment, and in the longer term, address latent threats to safety within the organization by encouraging a healthier safety culture. Offering mentorship to all newly appointed physicians in their first substantive post in health care may be a useful strategy to support the development of their clinical, professional, and personal skills in this transitional period that may also enhance the safety of patient care.

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

Science.gov (United States)

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.

The enhancement of Ignalina NPP in design and operational safety

International Nuclear Information System (INIS)

Negrivoda, G.

1999-01-01

Enhancement of Ignalina NPP design include: core design improvements; fuel channel integrity (multiple pressure tube rupture); improvements of shutdown systems; improvements of instrumentation and control devices; containment strength and tightness; design basis accident analysis; improvements of safety and support systems; seismic safety enhancement; Year 2000 project; cracks in pipes. Enhancement of operational safety includes: quality assurance; configuration management; safety management and safety culture; emergency operating procedures; training and full scope simulator; in-service inspection; fire protection and ageing monitoring and management

Beijing In-Service Teachers' Self-Efficacy and Attitudes towards Inclusive Education

Science.gov (United States)

Malinen, Olli-Pekka; Savolainen, Hannu; Xu, Jiacheng

2012-01-01

Four-hundred-and-fifty-one in-service teachers from the Beijing municipality filled in a questionnaire containing a Teacher Efficacy for Inclusive Practices (TEIP) scale. The aim was to examine the factor structure of the TEIP scale among mainland Chinese in-service teachers, and to investigate the relationship between self-efficacy for inclusive…

Relationships between needle and syringe programs and police: An exploratory analysis of the potential role of in-service training.

Science.gov (United States)

Strike, Carol; Watson, Tara Marie

2017-06-01

Training police on the public health benefits of needle and syringe programs (NSPs) is viewed as a best practice to facilitate more collaborative relationships between police and these programs. To date, while the limited published literature contains promising cases of harm reduction in-service training for police, evaluative evidence is preliminary. Using an online survey, we asked NSP managers across Canada about their programs and the quality of their NSP-police relationships. We analyzed data from the responses of 75 program managers among whom 69% reported that their program had a "positive" or "mostly positive" relationship with the police. In-service training about topics such as needle-stick injury prevention and NSP effectiveness was provided by less than 50% of the programs surveyed. Seventy-five percent reported no established protocols to resolve conflicts between NSP staff and police. Four variables, all related to in-service training, were significantly related to positive NSP-police relationships, including training about: NSP program goals (OR 7.7; 95% CI 2.0, 33.1); needle-stick injury prevention and basics of blood-borne virus transmission (OR 4.0; 95% CI 1.1, 15.34); the health and social concerns of people who use drugs (OR 3.9; 95% CI 1.1, 13.5); and evidence about the impact of injection equipment distribution (OR 3.9; 95% CI 1.1, 13.5). Development of in-service training for police that is focused on harm reduction goals and initiatives is a new and evolving area. We highly encourage NSPs to offer and evaluate any such in-service training programs. Copyright © 2017 Elsevier B.V. All rights reserved.

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

Science.gov (United States)

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

2010-06-01

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

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

Science.gov (United States)

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

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

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

Science.gov (United States)

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

2002-12-01

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

17. meeting of the Society for Reactor Safety. Proceedings

International Nuclear Information System (INIS)

1994-06-01

An autonomous and independent reactor safety research in Germany is indispensable. Three out of the four papers of the meeting deal with the protective aim concept of NPP. Deterministic safety assessment during periodic in-service inspections, a new generation of information engineering, and the incorporation of serious accidents in the containment design of new reactors are considered in detail. (DG) [de

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

NARCIS (Netherlands)

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

2015-01-01

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

ASN takes position in the in-service follow-up programs of primary and secondary loops of EdF's nuclear power plants

International Nuclear Information System (INIS)

2002-01-01

This decision from the French authority of nuclear safety (ASN) aims at fixing the conditions to be respected by Electricite de France (EdF) during its in-service follow-up programs for the monitoring and preventive maintenance of the primary and secondary cooling loops of EdF's PWR reactors. The components and the particular points to be controlled are listed in appendixes. (J.S.)

Surveillance and in-service inspection (SISI) program at FFTF

International Nuclear Information System (INIS)

Conrads, T.J.

1980-01-01

Assurance of the integrity of the sodium coolant pressure boundaries of the Fast Flux Test Facility systems and components is essential for safe operation. A program has been developed to monitor the integrity of the coolant boundaries and certain plant conditions. Specific equipment and features have been designed into the plant for monitoring. The purpose of SISI is to prevent failures or minimize their consequences through early detection. The program which administers the requirements for monitoring applicable plant conditions whose integrity is necessary to protect public health and safety is known as the Surveillance and In-service Inspection (SISI) Program. The SISI program utilizes a wide range of monitoring techniques to ensure that material degradation or structural deficiencies will not result in the loss of the ability to shut down the reactor, cool the reactor core, or cause the release of radioactive material to the environment

Implementing Patient Safety Initiatives in Rural Hospitals

Science.gov (United States)

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

2009-01-01

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

Patient safety in surgical environments: Cross-countries comparison of psychometric properties and results of the Norwegian version of the Hospital Survey on Patient Safety

Directory of Open Access Journals (Sweden)

Nortvedt Monica W

2010-09-01

theatre personnel perceived their hospital's patient safety climate far more negatively than the health care personnel in hospitals in the United States and with perceptions more comparable to those of health care personnel in hospitals in the Netherlands. In fact, the surgical personnel in our hospital may perceive that patient safety climate is less focused in our hospital, at least compared with the results from hospitals in the United States.

A case-mix in-service education program.

Science.gov (United States)

Arons, R R

1985-01-01

The new case-mix in-service education program at the Presbyterian Hospital in the City of New York is a fine example of physicians and administration working together to achieve success under the new prospective pricing system. The hospital's office of Case-Mix Studies has developed an accurate computer-based information system with historical, clinical, and demographic data for patients discharged from the hospital over the past five years. Reports regarding the cases, diagnoses, finances, and characteristics are shared in meetings with the hospital administration and directors of sixteen clinical departments, their staff, attending physicians, and house officers in training. The informative case-mix reports provide revealing sociodemographic summaries and have proven to be an invaluable tool for planning, marketing, and program evaluation.

Multi-Canister overpack inservice inspection and maintenance

International Nuclear Information System (INIS)

SMITH, K.E.

1998-01-01

The factors to be considered in establishing inservice inspection and maintenance requirements for the Multi-Canister Overpack (MCO) include evaluating the likelihood of degradation to the MCO pressure boundary due to erosion and corrosion, reviewing commercial practice for NRC licensed spent nuclear fuel storage systems, and examining the individual MCO components for maintenance needs. Reviews of the potential for MCO erosion and corrosion conclude that neither will pose a threat to the MCO pressure boundary. Consistent with commercial practice for spent fuel storage systems, the MCO closure weld will be helium leak tested prior to placement in interim storage. Beyond the CSB facility related monitoring plans (radiological monitoring, emissions monitoring, vault cooling data, etc.), no inservice inspection or maintenance of the MCO is required during interim storage

ASME N511-19XX, Standard for periodic in-service testing of nuclear air treatment, heating, ventilating and air conditioning systems

Energy Technology Data Exchange (ETDEWEB)

NONE

1997-08-01

A draft version of the Standard is presented in this document. The Standard covers the requirements for periodic in-service testing of nuclear safety-related air treatment, heating, ventilating, and air conditioning systems in nuclear facilities. The Standard provides a basis for the development of test programs and does not include acceptance criteria, except in cases where the results of one test influence the performance of other tests. The Standard covers general inspection and test requirements, reference values, inspection and test requirements, generic tests, acceptance criteria, in-service test requirements, testing following an abnormal incident, corrective action requirements, and quality assurance. Mandatory appendices provide a visual inspection checklist and four test procedures. Non-mandatory appendices provide additional information and guidance on mounting frame pressure leak test procedure, corrective action, challenge gas substitute selection criteria, and test program development. 8 refs., 10 tabs.

ASME N511-19XX, Standard for periodic in-service testing of nuclear air treatment, heating, ventilating and air conditioning systems

International Nuclear Information System (INIS)

1997-01-01

A draft version of the Standard is presented in this document. The Standard covers the requirements for periodic in-service testing of nuclear safety-related air treatment, heating, ventilating, and air conditioning systems in nuclear facilities. The Standard provides a basis for the development of test programs and does not include acceptance criteria, except in cases where the results of one test influence the performance of other tests. The Standard covers general inspection and test requirements, reference values, inspection and test requirements, generic tests, acceptance criteria, in-service test requirements, testing following an abnormal incident, corrective action requirements, and quality assurance. Mandatory appendices provide a visual inspection checklist and four test procedures. Non-mandatory appendices provide additional information and guidance on mounting frame pressure leak test procedure, corrective action, challenge gas substitute selection criteria, and test program development. 8 refs., 10 tabs

Applicability of PSA Issues for Risk Assessment during Optimisation of In-Service Inspection

International Nuclear Information System (INIS)

Kolykhanov, V.; Skalozubov, V.; Kovrigkin, Y.

2006-01-01

The current codes determining periodicity of in-service inspection of the NPP equipment have been formed using deterministic approaches and have an unnecessary degree of conservatism. A perspective direction of perfection of normative base is decision making on a basis of risk-informed methodologies. It allows to increase safety of NPP equipment's operation and to optimise programs on inspection of the equipment subject to limited resources by focusing efforts on the most safety significant elements of the equipment. It is internationally accepted that methodology of the probabilistic safety analysis (PSA) is the most universal and comprehensive tool focused on the general assessment of safety of NPP as a whole. By now, PSA Level 1 is fulfilled for all pilot units of the Ukrainian NPPs that is a valuable result, which should be taken into account at an assessment of reliability of the equipment. However, specificity of PSA methodology should be taken into account at the decision of the particular tasks aimed at optimisation of maintenance of the equipment within individual systems. The estimation of the contribution to core damage frequency (CDF) is a PSA issue usually used to assess the significance of consequences of failure of a system/equipment during risk-informed decision-making. This work shows that above factor is only a part of assessment of the significance of consequences as core damage can be expressed in different amount of the damaged fuel elements and, hence, severity of consequences. Besides CDF is directly affected only by active elements which failure can be an initiating event. PSA methodology uses averaged reliability factors of the equipment for all possible operating modes occurring at transitive accident process. Here, there are limited opportunities to account impact of periodicity of maintenance of the equipment on reliability and to predict impact of change of the inspection program. PSA methodology does not allow taking into account

Industry standards catch up with in-service welding

Energy Technology Data Exchange (ETDEWEB)

Bruce, W.A.

1999-11-01

Welding onto a pipeline after it has been put into service, a practice commonly referred to as hot tap welding, is frequently required for several reasons. Repair sleeves are installed to reinforce areas of corrosion or mechanical damage, and branch connections are made for system modifications. There are often significant economic incentives to perform this welding without removing the system from service. Operations are maintained during welding and the pipe's contents are not vented into the atmosphere. Due to technological advances in in-service welding, industry needed an update to standards and recommended practices. This year, the American Petroleum Institute (API) hopes to meet that need. The 19th edition of API Standard 1104--Welding of Pipelines and Related Facilities, includes a new appendix that pertains to in-service welding. Appendix B, In-Service Welding, is intended to eventually replace API Recommended Practice 1107--Pipeline Maintenance Welding Practices. API 1107, which was introduced in 1966 and updated in 1987 and 1991, is intended to provide recommended practices for pipeline maintenance welding. The current third edition approached its mandatory five-year review in 1996 by the API-AGA Joint Committee on Oil and Gas Pipeline Field Welding Practices, which also maintains API 1104. The committee saw 11078 needed to reflect the updates that had been made to 1104 as well as the technological advances for in-service welding. To alleviate redundancy between the two documents, and to alleviate lag time between updates, the committee approved a proposal to update and incorporate requirements of API 1107 into an appendix of API 1104. In the meantime, the third edition of API 1107 was reapproved for another five-year review cycle.

A practical approach for implementing risk-based inservice testing of pumps at nuclear power plants

International Nuclear Information System (INIS)

Hartley, R.S.; Maret, D.; Seniuk, P.; Smith, L.

1996-01-01

The American Society of Mechanical Engineers (ASME) Center for Research and Technology Development's (CRTD) Research Task Force on Risk-Based Inservice Testing has developed guidelines for risk-based inservice testing (IST) of pumps and valves. These guidelines are intended to help the ASME Operation and Maintenance (OM) Committee to enhance plant safety while focussing appropriate testing resources on critical components. This paper describes a practical approach for implementing those guidelines for pumps at nuclear power plants. The approach, as described in this paper, relies on input, direction, and assistance from several entities such as the ASME Code Committees, United States Nuclear Regulatory Commission (NRC), and the National Laboratories, as well as industry groups and personnel with applicable expertise. Key parts of the risk-based IST process that are addressed here include: identification of important failure modes, identification of significant failure causes, assessing the effectiveness of testing and maintenance activities, development of alternative testing and maintenance strategies, and assessing the effectiveness of alternative testing strategies with present ASME Code requirements. Finally, the paper suggests a method of implementing this process into the ASME OM Code for pump testing

A practical approach for implementing risk-based inservice testing of pumps at nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Hartley, R.S. [Idaho National Engineering Lab., Idaho Falls, ID (United States); Maret, D.; Seniuk, P.; Smith, L.

1996-12-01

The American Society of Mechanical Engineers (ASME) Center for Research and Technology Development`s (CRTD) Research Task Force on Risk-Based Inservice Testing has developed guidelines for risk-based inservice testing (IST) of pumps and valves. These guidelines are intended to help the ASME Operation and Maintenance (OM) Committee to enhance plant safety while focussing appropriate testing resources on critical components. This paper describes a practical approach for implementing those guidelines for pumps at nuclear power plants. The approach, as described in this paper, relies on input, direction, and assistance from several entities such as the ASME Code Committees, United States Nuclear Regulatory Commission (NRC), and the National Laboratories, as well as industry groups and personnel with applicable expertise. Key parts of the risk-based IST process that are addressed here include: identification of important failure modes, identification of significant failure causes, assessing the effectiveness of testing and maintenance activities, development of alternative testing and maintenance strategies, and assessing the effectiveness of alternative testing strategies with present ASME Code requirements. Finally, the paper suggests a method of implementing this process into the ASME OM Code for pump testing.

Emotions at work: what is the link to patient and staff safety? Implications for nurse managers in the NHS.

Science.gov (United States)

Smith, Pam; Pearson, Pauline H; Ross, Fiona

2009-03-01

This paper sets the discussion of emotions at work within the modern NHS and the current prioritisation of creating a safety culture within the service. The paper focuses on the work of students, frontline nurses and their managers drawing on recent studies of patient safety in the curriculum, and governance and incentives in the care of patients with complex long term conditions. The primary research featured in the paper combined a case study design with focus groups, interviews and observation. In the patient safety research the importance of physical and emotional safety emerged as a key finding both for users and professionals. In the governance and incentives research, risk emerged as a key concern for managers, frontline workers and users. The recognition of emotions and the importance of emotional labour at an individual and organizational level managed by emotionally intelligent leaders played an important role in promoting worker and patient safety and reducing workplace risk. Nurse managers need to be aware of the emotional complexities of their organizations in order to set up systems to support the emotional wellbeing of professionals and users which in turn ensures safety and reduces risk.

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

Directory of Open Access Journals (Sweden)

Afrisya Iriviranty

2016-07-01

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

Risk informed in-service inspection and testing in Spain

International Nuclear Information System (INIS)

Bros, Juan; Marcelles, Ignacio

2002-01-01

The Spanish nuclear regulatory authority, the Consejo de Seguridad Nuclear (CSN), requires the use of codes and standards in force in the country of origin of the plant technology. For this reason, the in-service inspection and testing programs applied at Spanish nuclear power plants basically adhere to the requirements of the ASME XI and ASME OM Codes. It is not surprising that when the earliest developments aimed at drawing up risk informed inservice inspection and testing programs were initiated within the framework of ASME, the Spanish industry should follows such developments very closely. In fact, persons within the Spanish nuclear industry joined different ASME committees involved in the development and approval of the various code cases encompassing these developments. Developments specific to the Spanish nuclear power plants were initiated at a time when the aforementioned reference documentation was in a very advanced stage of development/approval. Two clearly differentiated lines of work got under way: On the one hand, and as regards risk informed in-service testing programs, the American standards were used as the sole reference. In the case of risk informed in-service inspection programs, the Spanish nuclear power plant-owning utilities and the Consejo de Seguridad Nuclear decided to draw up a Spanish guideline that, although using the ASME developments as a reference, would have its own specific characteristics. In relation to the above, and referring to the chronology of the events, the activities performed to date in Spain are described

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

Science.gov (United States)

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

2014-10-01

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

Patient safety in maternal healthcare at secondary and tertiary level facilities in Delhi, India

Directory of Open Access Journals (Sweden)

Chandrakant Lahariya

2015-01-01

Full Text Available Background: There is insufficient information on causes of unsafe care at facility levels in India. This study was conducted to understand the challenges in government hospitals in ensuring patient safety and to propose solutions to improve patient care. Materials and Methods: Desk review, in-depth interviews, and focused group discussions were conducted between January and March 2014. Healthcare providers and nodal persons for patient safety in Gynecology and Obstetrics Departments of government health facilities from Delhi state of India were included. Data were analyzed using qualitative research methods and presented adopting the "health system approach." Results: The patient safety was a major concern among healthcare providers. The key challenges identified were scarcity of resources, overcrowding at health facilities, poor communications, patient handovers, delay in referrals, and the limited continuity of care. Systematic attention on the training of care providers involved in service delivery, prescription audits, peer reviews, facility level capacity building plan, additional financial resources, leadership by institutional heads and policy makers were suggested as possible solutions. Conclusions: There is increasing awareness and understanding about challenges in patient safety. The available local information could be used for selection, designing, and implementation of measures to improve patient safety at facility levels. A systematic and sustained approach with attention on all functions of health systems could be beneficial. Patient safety could be used as an entry point to improve the quality of health care services in India.

Laboratory test requesting appropriateness and patient safety

CERN Document Server

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

2016-01-01

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

The interplay between teamwork, clinicians' emotional exhaustion, and clinician-rated patient safety: a longitudinal study.

Science.gov (United States)

Welp, Annalena; Meier, Laurenz L; Manser, Tanja

2016-04-19

Effectively managing patient safety and clinicians' emotional exhaustion are important goals of healthcare organizations. Previous cross-sectional studies showed that teamwork is associated with both. However, causal relationships between all three constructs have not yet been investigated. Moreover, the role of different dimensions of teamwork in relation to emotional exhaustion and patient safety is unclear. The current study focused on the long-term development of teamwork, emotional exhaustion, and patient safety in interprofessional intensive care teams by exploring causal relationships between these constructs. A secondary objective was to disentangle the effects of interpersonal and cognitive-behavioral teamwork. We employed a longitudinal study design. Participants were 2100 nurses and physicians working in 55 intensive care units. They answered an online questionnaire on interpersonal and cognitive-behavioral aspects of teamwork, emotional exhaustion, and patient safety at three time points with a 3-month lag. Data were analyzed with cross-lagged structural equation modeling. We controlled for professional role. Analyses showed that emotional exhaustion had a lagged effect on interpersonal teamwork. Furthermore, interpersonal and cognitive-behavioral teamwork mutually influenced each other. Finally, cognitive-behavioral teamwork predicted clinician-rated patient safety. The current study shows that the interrelations between teamwork, clinician burnout, and clinician-rated patient safety unfold over time. Interpersonal and cognitive-behavioral teamwork play specific roles in a process leading from clinician emotional exhaustion to decreased clinician-rated patient safety. Emotionally exhausted clinicians are less able to engage in positive interpersonal teamwork, which might set in motion a vicious cycle: negative interpersonal team interactions negatively affect cognitive-behavioral teamwork and vice versa. Ultimately, ineffective cognitive

Evaluation of effectiveness of inservice inspection in aging PWR plants based on PSA

Energy Technology Data Exchange (ETDEWEB)

Hanafusa, Hidemitsu; Irie, Takashi; Suyama, Takeshi [Institute of Nuclear Safety Systems Inc., Mihama, Fukui (Japan); Morota, Hidetsugu [Computer Software Development Co., Ltd., Tokyo (Japan)

2001-09-01

By making use of a probabilistic fracture mechanics (PFM) code which had been improved to be able to evaluate the influence of thermal aging embrittlement of cast stainless steel, we evaluated the fracture probability of welding parts of the piping of the pressurized water reactor plants in Japan and the core damage frequency by the fracture. In addition, we ranked the welding parts by the safety significance and evaluated the effectiveness of inservice inspection (ISI). As a result, it is seen that the risk increases about 25% for extending the plant life from 40 to 60 years without ISI. However, the influence of the risk on the plant life becomes negligible, when the ISI is performed adequately. This assessment is useful to plan efficient inspection and test programs of a plant under limited resources, because it is available to rank piping segments by the safety significance and to evaluate the effectiveness of inspection and test quantitatively. (author)

Radiation Safety Management Guidelines for PET-CT: Focus on Behavior and Environment

International Nuclear Information System (INIS)

Jung, Jin Wook; Han, Eun Ok

2011-01-01

Our purpose is to specify behavior and environmental factors aimed at reducing the exposed dosage caused by PET-CT and to develop radiation safety management guidelines adequate for domestic circumstances. We have used a multistep-multimethod as the methodological approach to design and to carry out the research both in quality and quantity, including an analysis on previous studies, professional consultations and a survey. The survey includes responses from 139 practitioners in charged of 109 PET-CTs installed throughout Korea(reported by the Korean Society of Nuclear Medicine, 2010). The research use 156 questions using Cronbach's α (alpha) coefficients which were: 0.818 for 'the necessity of setting and installing the radiation protective environment'; 0.916 for 'the necessity of radiation protection', 'setting and installing the radiation protective environment'; and 0.885 for 'radiation protection'. The check list, derived from the radiation safety management guidelines focused on behavior and environment, was composed of 20 items for the radiation protective environment: including 5 items for the patient; 4 items for the guardian; 3 items for the radiologist; and 8 items applied to everyone involved; for a total of 26 items for the radiation protective behavior including: 12 items for the patient; 1 item for the guardian, 7 items for the radiologist; and 6 items applied to everyone involved. The specific check list is shown in (Table 5-6). Since our country has no safety management guidelines of its own to reduce the exposed dosage caused by PET-CTs, we believe the guidelines developed through this study means great deal to the field as it is not only appropriate for domestic circumstances, but also contains specific check lists for each target who may be exposed to radiation in regards to behavior and environment.

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

Directory of Open Access Journals (Sweden)

Renata Mahfuz Daud-Gallotti

2011-01-01

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

Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members.

Science.gov (United States)

Jeffs, Lianne; Abramovich, Ilona Alex; Hayes, Chris; Smith, Orla; Tregunno, Deborah; Chan, Wai-Hin; Reeves, Scott

2013-11-01

Effective teamwork and interprofessional collaboration are vital for healthcare quality and safety; however, challenges persist in creating interprofessional teamwork and resilient professional teams. A study was undertaken to delineate perceptions of individuals involved with the implementation of an interprofessional patient safety competency-based intervention and intervention participants. The study employed a qualitative study design that triangulated data from interviews with six steering committee members and five members of the project team who developed and monitored the intervention and six focus groups with clinical team members who participated in the intervention and implemented local patient safety projects within a large teaching hospital in Canada. Our study findings reveal that healthcare professionals and support staff acquired patient safety competencies in an interprofessional context that can result in improved patient and work flow processes. However, key challenges exist including managing projects amidst competing priorities, lacking physician engagement and sustaining projects. Our findings point to leaders to provide opportunities for healthcare teams to engage in interprofessional teamwork and patient safety projects to improve quality of patient care. Further research efforts should examine the sustainability of interprofessional safety projects and how leaders can more fully engage the participation of all professions, specifically physicians.

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

Science.gov (United States)

2013-03-20

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

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

DEFF Research Database (Denmark)

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

2005-01-01

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

Focused ultrasound subthalamotomy in patients with asymmetric Parkinson's disease: a pilot study.

Science.gov (United States)

Martínez-Fernández, Raul; Rodríguez-Rojas, Rafael; Del Álamo, Marta; Hernández-Fernández, Frida; Pineda-Pardo, Jose A; Dileone, Michele; Alonso-Frech, Fernando; Foffani, Guglielmo; Obeso, Ignacio; Gasca-Salas, Carmen; de Luis-Pastor, Esther; Vela, Lydia; Obeso, José A

2018-01-01

Ablative neurosurgery has been used to treat Parkinson's disease for many decades. MRI-guided focused ultrasound allows focal lesions to be made in deep brain structures without skull incision. We investigated the safety and preliminary efficacy of unilateral subthalamotomy by focused ultrasound in Parkinson's disease. This prospective, open-label pilot study was done at CINAC (Centro Integral de Neurociencias), University Hospital HM Puerta del Sur in Madrid, Spain. Eligible participants had Parkinson's disease with markedly asymmetric parkinsonism. Patients with severe dyskinesia, history of stereotactic surgery or brain haemorrhage, a diagnosis of an unstable cardiac or psychiatric disease, or a skull density ratio of 0·3 or less were excluded. Enrolled patients underwent focused ultrasound unilateral subthalamotomy. The subthalamic nucleus was targeted by means of brain images acquired with a 3-Tesla MRI apparatus. Several sonications above the definitive ablation temperature of 55°C were delivered and adjusted according to clinical response. The primary outcomes were safety and a change in the motor status of the treated hemibody as assessed with part III of the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS III) in both off-medication and on-medication states at 6 months. Adverse events were monitored up to 48 h after treatment and at scheduled clinic visits at 1, 3, and 6 months after treatment. The study is registered with ClinicalTrials.gov, number NCT02912871. Between April 26 and June 14, 2016, ten patients with markedly asymmetric parkinsonism that was poorly controlled pharmacologically were enrolled for focused ultrasound unilateral subthalamotomy. By 6 months follow-up, 38 incidents of adverse events had been recorded, none of which were serious or severe. Seven adverse events were present at 6 months. Three of these adverse events were directly related to subthalamotomy: off-medication dyskinesia in the treated arm

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

Science.gov (United States)

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

2017-07-01

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

Periodic and in-service inspection programs

International Nuclear Information System (INIS)

Dinu, M.

2000-01-01

Periodic and in-service inspection programs for Cernavoda NPP consists of periodic inspections of CANDU NPP components CSAN N-285.4 and CSAN N-285.4, in-service inspections and repair and modifications general inspection. Periodic inspection program document (PIPD) determines the systems and components subject to inspection, the category of the inspection, techniques, areas and other details.The current status of the inspection programs is presented, including containment , erosion/corrosion, pressure vessel support and snubbers, main steam lines inspection programs. Qualification program in Cernavoda NPP involves equipment qualification in the on-site laboratory, yearly certification, special equipment qualification in the National Institute of Metrology. All procedures are approved by the ISCIR (regulatory body for pressure vessel and lifting equipment) and CNCAN (National Commission on Nuclear Activities Control). Qualification of the personnel is performed according to the ISCIR Technical prescription CR 11/82 for up to 3 year period. Final qualification and licensing is performed by CNCAN

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

Science.gov (United States)

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

2015-01-01

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

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

Science.gov (United States)

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

2015-09-01

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

Proceedings of the international symposium on safety and reliability systems of PWRs and BWRs

Energy Technology Data Exchange (ETDEWEB)

NONE

1996-05-01

Out of 33 contributions presented at the conference, 30 were submitted to INIS. The conference programme was divided into three sections: (i) Diagnostics and in-service inspection; (ii) Safety and reliability of NPP operation; (iii) Experience of NPP operation and new approaches to nuclear safety. (J.B.).

Proceedings of the international symposium on safety and reliability systems of PWRs and BWRs

International Nuclear Information System (INIS)

1996-02-01

Out of 33 contributions presented at the conference, 30 were submitted to INIS. The conference programme was divided into three sections: (i) Diagnostics and in-service inspection; (ii) Safety and reliability of NPP operation; (iii) Experience of NPP operation and new approaches to nuclear safety. (J.B.)

Preliminary safety and efficacy results with robotic high-intensity focused ultrasound : A single center Indian experience

Directory of Open Access Journals (Sweden)

Shashikant Mishra

2011-01-01

Full Text Available Background : There are no Indian data of high-intensity focused ultrasound (HIFU. Being an alternative, still experimental modality, reporting short-term safety outcome is paramount. Aims : This study was aimed at to assess the safety and short-term outcome in patients with prostate cancer treated by HIFU. Settings and Design : A retrospective study of case records of 30 patients undergoing HIFU between January 2008 to September 2010 was designed and conducted. Materials and Methods : The procedural safety was analyzed at 3 months. Follow-up consisted of 3 monthly prostate-specific antigen (PSA levels and transrectal biopsy if indicated. All the patients had a minimum follow-up of 6 months. Results : A mean prostate volume of 26.9 ± 8.5 cm 3 was treated in a mean time of 115 ± 37.4 min. There was no intraoperative complication. The postoperative pain visual analogue score at day 0 was 2.1 ± 1.9 and at day 1 was 0.4 ± 0.8 on a scale of 1-10. Mean duration of perurethral catheter removal was 3.9 days. The complications after treatment were: LUTS in seven patients, stress incontinence in two, stricture in two, and symptomatic urinary tract infection in five. Average follow-up duration was 10.4 months (range, 6-20 months. Mean time to obtain PSA nadir was 6 ± 3 months with a median PSA nadir value of 0.3 ng/ml. Two patients had positive prostatic biopsy in the localized (high risk group. Conclusions : HIFU was safe in carcinoma prostate patients. The short-term results were efficacious in localized disease. The low complication rates and favorable functional outcome support the planning of further larger studies.

Emotional influences in patient safety.

Science.gov (United States)

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

2010-12-01

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

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

Science.gov (United States)

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

2015-10-01

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

In-service inspection program for the NCS-80 reactor pressure vessel

International Nuclear Information System (INIS)

Scharge, J.; Wehowsky, P.; Zeibig, H.

1978-01-01

The in-service inspection program of reactor pressure vessels is mainly based on the ultra-sonic method, visual checking of inner and outer surfaces as well as pressure and leak tests. The test procedure require a design of the pressure vessel suitable for the test methods and the possibility to remove the pressure vessel internals. For the outside inspection a gap of sufficient width is mandatory. The present status of the ultra-sonic method and of the inner and outer manipulators affords to conduct the in-service inspection program in form of automatic checkings. The in-service inspection program for NCS-80, the Nuclear Container-Ship design of 80,000 shp, is integrated in the refueling periods due to the request for a high availability of the ship and reactor plant

Culture matters: indigenizing patient safety in Bhutan.

Science.gov (United States)

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

2017-09-01

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

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

Science.gov (United States)

2011-02-11

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

Advanced Approach of Reactor Pressure Vessel In-service Inspection

International Nuclear Information System (INIS)

Matokovic, A.; Picek, E.; Pajnic, M.

2006-01-01

The most important task of every utility operating a nuclear power plant is the continuously keeping of the desired safety and reliability level. This is achieved by the performance of numerous inspections of the components, equipment and system of the nuclear power plant in operation and in particular during the scheduled maintenance periods at re-fueling time. Periodic non-destructive in-service inspections provide most relevant criteria of the integrity of primary circuit pressure components. The task is to reliably detect defects and realistically size and characterize them. One of most important and the most extensive examination is a reactor pressure vessel in-service inspection. That inspection demand high standards of technology and quality and continual innovation in the field of non-destructive testing (NDT) advanced technology as well as regarding reactor pressure vessel tool and control systems. A remote underwater contact ultrasonic technique is employed for the examination of the defined sections (reactor welds), whence eddy current method is applied for clad surface examinations. Visual inspection is used for examination of the vessel inner surface. The movement of probes and data positioning are assured by using new reactor pressure vessel tool concept that is fully integrated with NDT systems. The successful performance is attributed thorough pre-outage planning, training and successful performance demonstration qualification of chosen NDT techniques on the specimens with artificial and/or real defects. Furthermore, use of advanced approach of inspection through implementation the state of the art examination equipment significantly reduced the inspection time, radiation exposure to examination personnel, shortening nuclear power plant outage and cutting the total inspection costs. The advanced approach as presented in this paper offer more flexibility of application (non-destructive tests, local grinding action as well as taking of boat samples

Apparative developments for inservice inspections of reactor pressure vessels

International Nuclear Information System (INIS)

Bohn, H.; Ruthrof, K.; Barbian, O.A.; Kappes, W.; Neumann, R.; Stanger, H.K.

1987-01-01

Emphasizing PWR pressure vessel (RPV) inspections, recent developments of new generations of automated and mechanized ultrasonic inspection equipment are presented. Starting from general equipment design and inservice implenentation criteria, specific examples are given. Main attention is directed to equipment realization of phased array and ALOK inspection techniques, especially in their combination. Refined aspects of subsequent computer processing and evaluation of defect detection data are described. Analytical features and potential for further developments become evident. Remote controlled RPV inspections are stressed by describing a new generation of central mast manipulators, forming an integral part of total inservice inspection system. (orig./HP)

A report on developing a checklist to assess company plans focused on improving safety awareness, safe behaviour and safety culture: final report

NARCIS (Netherlands)

Steijger, N.; Starren, H.; Keus, M.; Gort, J.; Vervoort, M.

2003-01-01

This report describes the process of developing a checklist to asses company plans focused on improving safety awareness, safe behaviour and safety culture. These plans are part of a programme initiated by the Ministry of Social Affairs and Employment aiming at improving the safety performance of

Identifying primary care patient safety research priorities in the UK: a James Lind Alliance Priority Setting Partnership.

Science.gov (United States)

Morris, Rebecca Lauren; Stocks, Susan Jill; Alam, Rahul; Taylor, Sian; Rolfe, Carly; Glover, Steven William; Whitcombe, Joanne; Campbell, Stephen M

2018-02-28

To identify the top 10 unanswered research questions for primary care patient safety research. A modified nominal group technique. UK. Anyone with experience of primary care including: patients, carers and healthcare professionals. 341 patients and 86 healthcare professionals submitted questions. A top 10, and top 30, future research questions for primary care patient safety. 443 research questions were submitted by 341 patients and 86 healthcare professionals, through a national survey. After checking for relevance and rephrasing, a total of 173 questions were collated into themes. The themes were largely focused on communication, team and system working, interfaces across primary and secondary care, medication, self-management support and technology. The questions were then prioritised through a national survey, the top 30 questions were taken forward to the final prioritisation workshop. The top 10 research questions focused on the most vulnerable in society, holistic whole-person care, safer communication and coordination between care providers, work intensity, continuity of care, suicide risk, complex care at home and confidentiality. This study was the first national prioritisation exercise to identify patient and healthcare professional priorities for primary care patient safety research. The research priorities identified a range of important gaps in the existing evidence to inform everyday practice to address primary care patient safety. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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

Science.gov (United States)

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...

75 FR 57281 - Patient Safety Organizations: Voluntary delisting

Science.gov (United States)

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...

Implementation of patient safety strategies in European hospitals.

Science.gov (United States)

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.

French developments and experience in the field of inservice inspection

International Nuclear Information System (INIS)

Saglio, Robert; Destribats, M.-T.; Pigeon, Michel; Roule, Maurice; Touffait, A.-M.

1979-01-01

The French PWR nuclear plant program was at the origin of a large amount of R and D work in the field of inservice inspection. The actions which were undertaken may be split up into different levels: - the regulatory level, the R and D level, the design level, the flaw evaluation level. The first results of pre and inservice inspections are presented. The experience gained by French Atomic Energy Commission with new techniques like focussed ultrasonics transducers and multi frequencies Eddy current apparatus are discussed

42 CFR 3.212 - Nonidentification of patient safety work product.

Science.gov (United States)

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Nonidentification of patient safety work product. 3... PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.212 Nonidentification of patient safety work product. (a...

Effects of perioperative briefing and debriefing on patient safety: a prospective intervention study.

NARCIS (Netherlands)

Leong, K.B.M.S.L.; Hanskamp-Sebregts, M.E.; Wal, R.A. van der; Wolff, AP

2017-01-01

OBJECTIVES: This study was carried out to improve patient safety in the operating theatre by the introduction of perioperative briefing and debriefing, which focused on an optimal collaboration between surgical team members. DESIGN: A prospective intervention study with one pretest and two post-test

Changing patient safety culture in China: a case study of an experimental Chinese hospital from a comparative perspective

Science.gov (United States)

Gu, Yong Hong; Ng, Chui Shan; Cai, Xiao; Xu, Jun; Zhang, Xin Shi; Ke, Dong Ge; Yu, Qian Hui; Chan, Chi Kuen

2018-01-01

Background The World Health Organization highlights that patient safety interventions are not lacking but that the local context affects their successful implementation. Increasing attention is being paid to patient safety in Mainland China, yet few studies focus on patient safety in organizations with mixed cultures. This paper evaluates the current patient safety culture in an experimental Chinese hospital with a Hong Kong hospital management culture, and it aims to explore the application of Hong Kong’s patient safety strategies in the context of Mainland China. Methods A quantitative survey of 307 hospital staff members was conducted using the Hospital Survey on Patient Safety Culture questionnaire. The findings were compared with a similar study on general Chinese hospitals and were appraised with reference to the Manchester Patient Safety Framework. Results Lower scores were observed among participants with the following characteristics: males, doctors, those with more work experience, those with higher education, and those from the general practice and otolaryngology departments. However, the case study hospital achieved better scores in management expectations, actions and support for patient safety, incident reporting and communication, and teamwork within units. Its weaknesses were related to non-punitive responses to errors, teamwork across units, and staffing. Conclusions The case study hospital contributes to a changing patient safety culture in Mainland China, yet its patient safety culture remains mostly bureaucratic. Further efforts could be made to deepen the staff’s patient safety culture mind-set, to realize a “bottom-up” approach to cultural change, to build up a comprehensive and integrated incident management system, and to improve team building and staffing for patient safety. PMID:29750061

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

Directory of Open Access Journals (Sweden)

Wensing Michel

2010-12-01

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

42 CFR 3.204 - Privilege of patient safety work product.

Science.gov (United States)

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Privilege of patient safety work product. 3.204... PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.204 Privilege of patient safety work product. (a) Privilege...

Improving Patient Safety: Improving Communication.

Science.gov (United States)

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.

High-intensity focused ultrasound to treat primary hyperparathyroidism: a feasibility study in four patients

DEFF Research Database (Denmark)

Kovatcheva, Roussanka D; Vlahov, Jordan D; Shinkov, Alexander D

2010-01-01

Many patients with primary hyperparathyroidism either decline or are not candidates for surgical parathyroidectomy. There are drawbacks to medical therapy as well as percutaneous ethanol injection as alternative therapies for primary hyperparathyroidism. Therefore, in this pilot study, our aim...... was to test the feasibility, safety, and efficacy of a newly developed noninvasive high-intensity focused ultrasound (HIFU) technique for the nonsurgical management of primary hyperparathyroidism....

Valve testing for UK PWR safety applications

International Nuclear Information System (INIS)

George, P.T.; Bryant, S.

1989-01-01

Extensive testing and development has been done by the Central Electricity Generating Board (CEGB) to support the design, construction and operation of Sizewell B, the UK's first PWR. A Blowdown Rig for the Assessment of Valve Operability - (BRAVO) has been constructed at the CEGB Marchwood Engineering Laboratory to reproduce PWR Pressurizer fluid conditions for the full scale testing of Pressurizer Relief System (PRS) valves. A full size tandem pair of Pilot Operated Safety Relief Valves (POSRVs) is being tested under the full range of pressurizer fluid conditions. Tests to date have produced important data on the performance of the valve in its Cold Overpressure protection mode of operation and on methods for the in-service testing of the valve. Also, a full size pressurizer safety valve has been tested under full PRS fluid conditions to develop a methodology for the pre-service testing of the Sizewell valves. Further work will be carried out to develop procedures for the in-service testing of the valve. In the Main Steam Safety Valve test program carried out at the Siemens-KWU Test Facilities, a single MSSV from three potential suppliers was tested under full secondary system conditions. The test results have been analyzed and are reflected in the CEGB's arrangements for the pre-service and in-service testing of the Sizewell MSSVs. Valves required to interrupt pipebreak flow must be qualified for this duty by testing or a combination of testing and analysis. To obtain guidance on the performance of such tests gate and globe valves have been subjected to simulated pipebreaks under PWR primary circuit conditions. In the light of problems encountered with gate valve closure under these conditions, further tests are currently being carried out on the BRAVO facility on a gate valve, in preparation for the full scale flow interruption qualification testing of the Sizewell main steam isolation valve

In-service inspection guidelines for composite aerospace structures

International Nuclear Information System (INIS)

Heida, Jaap H.; Platenkamp, Derk J.

2012-01-01

The in-service inspection of composite aerospace structures is reviewed, using the results of a evaluation of promising, mobile non-destructive inspection (NDI) methods. The evaluation made use of carbon fibre reinforced specimens representative for primary composite aerospace structures, including relevant damage types such as impact damage, delaminations and disbonds. A range of NDI methods were evaluated such as visual inspection, vibration analysis, phased array ultrasonic inspection, shearography and thermography inspection. Important aspects of the evaluation were the capability for defect detection and characterization, portability of equipment, field of view, couplant requirements, speed of inspection, level of training required and the cost of equipment. The paper reviews the damage tolerance design approach for composites, and concludes with guidelines for the in-service inspection of composite aerospace structures.

Methodology for qualification of in-service inspection systems for WWER nuclear power plants. A publication of the extrabudgetary programme on the safety of WWER and RBMK nuclear power plants

International Nuclear Information System (INIS)

1998-03-01

Program was initiated by IAEA in 1990 with the aim to assist the countries of Central and Eastern Europe and former Soviet Union in evaluating the safety of their first generation WWER-440/230 nuclear power plants. The main objectives were: to identify major design and operational safety issues; to establish international consensus on priorities for safety improvements; and to provide assistance in the review of the competence and and adequacy of safety improvement programs. The scope was extended in 1992 to include RBMK, WWER-440/312 and WWER-1000 plants in operation and under construction. Integrity of primary circuit is fundamental for the safe operation of any nuclear power plant. In-service inspection (ISI) in general terms and in particular, non-destructive tests (NDT) play a key role in maintaining primary circuit integrity. This report provides a methodology for qualification of ISI systems which might be used by WWER operating countries as a commonly accepted basis for further development of the necessary qualification related infrastructures. It also provides several qualification principles defining the administrative framework needed for the practical implementation of the methodology, a description of the process of qualification of an inspection system, specifying its minimum technical and documentation related requirements, as well as specific requirements with regard to the NDT procedures, equipment and personnel to be qualified and the test specimen to be used in practical trials. Finally, the report suggests an appropriate distribution of responsibilities among all the parties involved in a qualification process, based on international practice

Culture, language, and patient safety: Making the link.

Science.gov (United States)

Johnstone, Megan-Jane; Kanitsaki, Olga

2006-10-01

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a 'resident pathogen' within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture-language-patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

Nurses' perceptions of patient safety culture in Jordanian hospitals.

Science.gov (United States)

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

Alternate Welding Processes for In-Service Welding

Science.gov (United States)

2009-04-24

Conducting weld repairs and attaching hot tap tees onto pressurized pipes has the advantage of avoiding loss of service and revenue. However, the risks involved with in-service welding need to be managed by ensuring that welding is performed in a rep...

Speaking up for patient safety by hospital-based health care professionals: a literature review.

NARCIS (Netherlands)

Okuyama, A.; Wagner, C.; Bijnen, B.

2014-01-01

Background: Speaking up is important for patient safety, but often, health care professionals hesitate to voice concerns. Understanding the influencing factors can help to improve speaking-up behaviour and team communication. This review focused on health care professionals’ speaking-up behaviour

Speaking up for patient safety by hospital-based health care professionals: a literature review

NARCIS (Netherlands)

Okuyama, A.; Wagner, C.; Bijnen, A.B.

2014-01-01

Background: Speaking up is important for patient safety, but often, health care professionals hesitate to voice concerns. Understanding the influencing factors can help to improve speaking-up behaviour and team communication. This review focused on health care professionals' speaking-up behaviour

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

Directory of Open Access Journals (Sweden)

Schwappach David LB

2008-03-01

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

The Victorian State Computer Education Committee’s Seeding Pair In-Service Program: Two Case Studies

OpenAIRE

Keane , William ,

2014-01-01

International audience; Following the introduction of microcomputers into schools in the late 1970s, National Policy was developed which focused on the use of computers in non-computing subjects. The Victorian strategy for the implementation of the National Computers in Education Program was the development of a week-long in-service course which aimed to develop seeding pairs of teachers who would act as change agents when they returned to school. This chapter looks back at the case studies o...

Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety

DEFF Research Database (Denmark)

Mbonye, Anthony K; Buregyeya, Esther; Rutebemberwa, Elizeus

2016-01-01

OBJECTIVES: The main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to provide data for policy discussions aimed at improving quality of care and patient safety......-line drug for treatment of pneumonia in children according to the guidelines. CONCLUSIONS: There is urgent need to regulate drug shop practices of prescribing and selling antibiotics, for the safety of patients seeking care at these outlets....

Ethnic inequalities in patient safety in Dutch hospital care

NARCIS (Netherlands)

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

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

Science.gov (United States)

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

2016-04-01

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

Measuring and improving patient safety through health information technology: The Health IT Safety Framework.

Science.gov (United States)

Singh, Hardeep; Sittig, Dean F

2016-04-01

Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety

Improving patient safety: lessons from rock climbing.

Science.gov (United States)

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.

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

Science.gov (United States)

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...

Automatic examination of nuclear reactor vessels with focused search units. Status and typical application to inspections performed in accordance with ASME code

International Nuclear Information System (INIS)

Verger, B.; Saglio, R.

1981-05-01

The use of focused search units in nuclear reactor vessel examinations has significantly increased the capability of flaw indication detection and characterization. These search units especially allow a more accurate sizing of indications and a more efficient follow up of their history. In this aspect, they are a unique tool in the area of safety and reliability of installations. It was this type of search unit which was adopted to perform the examinations required within the scope of inservice inspections of all P.W.R. reactors of the French nuclear program. This paper summarizes the results gathered through the 4l examinations performed over the last five years. A typical application of focused search units in automated inspections performed in accordance with ASME code requirements on P.W.R. nuclear reactor vessels is then described

The Impact of Patient Safety Training on Oral and Maxillofacial Surgery Residents' Attitudes and Knowledge: A Mixed Method Case Study

Science.gov (United States)

Buhrow, Suzanne

2013-01-01

It is estimated that in the United States, more than 40,000 patients are injured each day because of preventable medical errors. Patient safety experts and graduate medical education accreditation leaders recognize that medical education reform must include the integration of safety training focused on error causation, system engineering, and…

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

Science.gov (United States)

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

2017-02-10

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

Effects of the Smartphone Application "Safe Patients" on Knowledge of Patient Safety Issues Among Surgical Patients.

Science.gov (United States)

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.

Physics teachers' nuclear in-service training in Hungary

International Nuclear Information System (INIS)

Ujvari, Sandor

2005-01-01

Teaching of science subjects, specifically physics among others, is important in Hungarian schools. The paper starts with some historical aspects on how the modern physics reached Hungarian schools, what kinds of methods the physics teachers use for their in-service training and what is their success. In 1985 Hungarian Government introduced the system of physics teacher's in-service training for a year. The courses end with a thesis and examination. Teachers have a possibility to join the nuclear physics intensive course of Nuclear Physics Department at Eottvos University. Curriculum and topics of laboratory practice are given together with some dissertations of the course. Moreover, several competition (Leo Szilard competition) is mentioned with starting that in each year the 5 best students get free entrance to the Hungarian universities. (S. Ohno)

Qualifying in-service education of Science Teachers (QUEST)

DEFF Research Database (Denmark)

Nielsen, Keld; Nielsen, Birgitte Lund; Pontoppidan, Birgitte

The Danish QUEST-project is a large-scale (450 teachers), long-term (4 years) professional development project for science teachers. The project aims at closing the gap between the present inconsequential practice in in-service education and recent research results documenting conditions for effe......The Danish QUEST-project is a large-scale (450 teachers), long-term (4 years) professional development project for science teachers. The project aims at closing the gap between the present inconsequential practice in in-service education and recent research results documenting conditions...... and peer involvement in collaborative practices in the school science teacher group is specifically addressed and targeted throughout the project. A special way of working (the QUEST-Rhythm) has been developed to increase the degree of teacher collaboration and networking over the 4 years. The accompanying...

Knowledge Representation in Patient Safety Reporting: An Ontological Approach

OpenAIRE

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...

Patient Safety Threat - Syringe Reuse

Science.gov (United States)

... 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 ...

76 FR 60494 - Patient Safety Organizations: Voluntary Relinquishment From HPI-PSO

Science.gov (United States)

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...

New graduate registered nurses' knowledge of patient safety and practice: A literature review.

Science.gov (United States)

Murray, Melanie; Sundin, Deborah; Cope, Vicki

2018-01-01

To critically appraise available literature and summarise evidence pertaining to the patient safety knowledge and practices of new graduate registered nurses. Responsibility for patient safety should not be limited to the practice of the bedside nurses, rather the responsibility of all in the healthcare system. Previous research identified lapses in safety across the health care, more specifically with new practitioners. Understanding these gaps and what may be employed to counteract them is vital to ensuring patient safety. A focused review of research literature. The review used key terms and Boolean operators across a 5-year time frame in CINAHL, Medline, psycINFO and Google Scholar for research articles pertaining to the area of enquiry. Eighty-four articles met the inclusion criteria, 39 discarded due to irrelevant material and 45 articles were included in the literature review. This review acknowledges that nursing has different stages of knowledge and practice capabilities. A theory-practice gap for new graduate registered nurses exists, and transition to practice is a key learning period setting new nurses on the path to becoming expert practitioners. Within the literature, there was little to no acknowledgement of patient safety knowledge of the newly registered nurse. Issues raised in the 1970s remain a concern for today's new graduate registered nurses. Research has recognised several factors affecting transition from nursing student to new graduate registered nurse. These factors are leaving new practitioners open to potential errors and risking patient safety. Understanding the knowledge of a new graduate registered nurse upon entering clinical practice may assist in organisations providing appropriate clinical and theoretical support to these nurses during their transition. © 2017 John Wiley & Sons Ltd.

S/He Who Pays the Piper Calls the Tune? Professionalism, Developmentalism, and the Paucity of In-Service Education within the Research Profession

Science.gov (United States)

Evans, Linda

2009-01-01

This paper focuses on the research-related, in-service professional development of social science academic researchers. It identifies as a gap in provision the paucity of provision of career-long training in the "creative" elements of research practice--specifically the methodological skills that have the potential to enhance individuals' research…

Patient safety in the operating room: an intervention study on latent risk factors

Directory of Open Access Journals (Sweden)

van Beuzekom Martie

2012-06-01

Full Text Available Abstract Background Patient safety is one of the greatest challenges in healthcare. In the operating room errors are frequent and often consequential. This article describes an approach to a successful implementation of a patient safety program in the operating room, focussing on latent risk factors that influence patient safety. We performed an intervention to improve these latent risk factors (LRFs and increase awareness of patient safety issues amongst OR staff. Methods Latent risk factors were studied using a validated questionnaire applied to the OR staff before and after an intervention. A pre-test/post-test control group design with repeated measures was used to evaluate the effects of the interventions. The staff from one operating room of an university hospital acted as the intervention group. Controls consisted of the staff of the operating room in another university hospital. The outcomes were the changes in LRF scores, perceived incident rate, and changes in incident reports between pre- and post-intervention. Results Based on pre-test scores and participants’ key concerns about organizational factors affecting patient safety in their department the intervention focused on the following LRFs: Material Resources, Training and Staffing Recourses. After the intervention, the intervention operating room - compared to the control operating room - reported significantly fewer problems on Material Resources and Staffing Resources and a significantly lower score on perceived incident rate. The contribution of technical factors to incident causation decreased significantly in the intervention group after the intervention. Conclusion The change of state of latent risk factors can be measured using a patient safety questionnaire aimed at these factors. The change of the relevant risk factors (Material and Staffing resources concurred with a decrease in perceived and reported incident rates in the relevant categories. We conclude that

In-Service Education: A Blueprint for Action

Science.gov (United States)

Keller, Arnold J.

1978-01-01

Inservice teacher education is the logical catalyst to any process of school improvement but school board members and school administrators must insure that their forthcoming efforts fulfill three important criteria: (1) Shared decision-making responsibilities with recognized representatives of the teaching staff, preferably at the individual…

Fundamentals of a patient safety program

International Nuclear Information System (INIS)

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.)

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

African Journals Online (AJOL)

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