WorldWideScience

Sample records for reliability safety patient

  1. Improving patient safety: patient-focused, high-reliability team training.

    Science.gov (United States)

    McKeon, Leslie M; Cunningham, Patricia D; Oswaks, Jill S Detty

    2009-01-01

    Healthcare systems are recognizing "human factor" flaws that result in adverse outcomes. Nurses work around system failures, although increasing healthcare complexity makes this harder to do without risk of error. Aviation and military organizations achieve ultrasafe outcomes through high-reliability practice. We describe how reliability principles were used to teach nurses to improve patient safety at the front line of care. Outcomes include safety-oriented, teamwork communication competency; reflections on safety culture and clinical leadership are discussed.

  2. Patient safety in anesthesia: learning from the culture of high-reliability organizations.

    Science.gov (United States)

    Wright, Suzanne M

    2015-03-01

    There has been an increased awareness of and interest in patient safety and improved outcomes, as well as a growing body of evidence substantiating medical error as a leading cause of death and injury in the United States. According to The Joint Commission, US hospitals demonstrate improvements in health care quality and patient safety. Although this progress is encouraging, much room for improvement remains. High-reliability organizations, industries that deliver reliable performances in the face of complex working environments, can serve as models of safety for our health care system until plausible explanations for patient harm are better understood. Copyright © 2015 Elsevier Inc. All rights reserved.

  3. 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...

  4. Operational safety reliability research

    International Nuclear Information System (INIS)

    Hall, R.E.; Boccio, J.L.

    1986-01-01

    Operating reactor events such as the TMI accident and the Salem automatic-trip failures raised the concern that during a plant's operating lifetime the reliability of systems could degrade from the design level that was considered in the licensing process. To address this concern, NRC is sponsoring the Operational Safety Reliability Research project. The objectives of this project are to identify the essential tasks of a reliability program and to evaluate the effectiveness and attributes of such a reliability program applicable to maintaining an acceptable level of safety during the operating lifetime at the plant

  5. Columbus safety and reliability

    Science.gov (United States)

    Longhurst, F.; Wessels, H.

    1988-10-01

    Analyses carried out to ensure Columbus reliability, availability, and maintainability, and operational and design safety are summarized. Failure modes/effects/criticality is the main qualitative tool used. The main aspects studied are fault tolerance, hazard consequence control, risk minimization, human error effects, restorability, and safe-life design.

  6. Safety and reliability criteria

    International Nuclear Information System (INIS)

    O'Neil, R.

    1978-01-01

    Nuclear power plants and, in particular, reactor pressure boundary components have unique reliability requirements, in that usually no significant redundancy is possible, and a single failure can give rise to possible widespread core damage and fission product release. Reliability may be required for availability or safety reasons, but in the case of the pressure boundary and certain other systems safety may dominate. Possible Safety and Reliability (S and R) criteria are proposed which would produce acceptable reactor design. Without some S and R requirement the designer has no way of knowing how far he must go in analysing his system or component, or whether his proposed solution is likely to gain acceptance. The paper shows how reliability targets for given components and systems can be individually considered against the derived S and R criteria at the design and construction stage. Since in the case of nuclear pressure boundary components there is often very little direct experience on which to base reliability studies, relevant non-nuclear experience is examined. (author)

  7. Safety and reliability assessment

    International Nuclear Information System (INIS)

    1979-01-01

    This report contains the papers delivered at the course on safety and reliability assessment held at the CSIR Conference Centre, Scientia, Pretoria. The following topics were discussed: safety standards; licensing; biological effects of radiation; what is a PWR; safety principles in the design of a nuclear reactor; radio-release analysis; quality assurance; the staffing, organisation and training for a nuclear power plant project; event trees, fault trees and probability; Automatic Protective Systems; sources of failure-rate data; interpretation of failure data; synthesis and reliability; quantification of human error in man-machine systems; dispersion of noxious substances through the atmosphere; criticality aspects of enrichment and recovery plants; and risk and hazard analysis. Extensive examples are given as well as case studies

  8. Reliability and safety of functional capacity evaluation in patients with whiplash associated disorders.

    Science.gov (United States)

    Trippolini, M A; Reneman, M F; Jansen, B; Dijkstra, P U; Geertzen, J H B

    2013-09-01

    Whiplash-associated disorders (WAD) are a burden for both individuals and society. It is recommended to evaluate patients with WAD at risk of chronification to enhance rehabilitation and promote an early return to work. In patients with low back pain (LBP), functional capacity evaluation (FCE) contributes to clinical decisions regarding fitness-for-work. FCE should have demonstrated sufficient clinimetric properties. Reliability and safety of FCE for patients with WAD is unknown. Thirty-two participants (11 females and 21 males; mean age 39.6 years) with WAD (Grade I or II) were included. The FCE consisted of 12 tests, including material handling, hand grip strength, repetitive arm movements, static arm activities, walking speed, and a 3 min step test. Overall the FCE duration was 60 min. The test-retest interval was 7 days. Interclass correlations (model 1) (ICCs) and limits of agreement (LoA) were calculated. Safety was assessed by a Pain Response Questionnaire, observation criteria and heart rate monitoring. ICCs ranged between 0.57 (3 min step test) and 0.96 (short two-handed carry). LoA relative to mean performance ranged between 15 % (50 m walking test) and 57 % (lifting waist to overhead). Pain reactions after WAD FCE decreased within days. Observations and heart rate measurements fell within the safety criteria. The reliability of the WAD FCE was moderate in two tests, good in five tests and excellent in five tests. Safety-criteria were fulfilled. Interpretation at the patient level should be performed with care because LoA were substantial.

  9. Safety and reliability of the insertable Reveal XT recorder in patients undergoing 3 Tesla brain magnetic resonance imaging.

    Science.gov (United States)

    Haeusler, Karl Georg; Koch, Lydia; Ueberreiter, Juliane; Coban, Nalan; Safak, Erdal; Kunze, Claudia; Villringer, Kersten; Endres, Matthias; Schultheiss, Heinz-Peter; Fiebach, Jochen B; Schirdewan, Alexander

    2011-03-01

    Up to now there is little evidence about the safety and reliability of insertable cardiac monitors (ICMs) in patients undergoing magnetic resonance imaging (MRI). The purpose of this prospective single-center study (MACPAF; clinicaltrials.govNCT01061931), which we are currently performing, was to evaluate these issues for the ICM Reveal XT at a 3 Tesla MRI scanner in patients undergoing serial brain MRI. We present an interim analysis including 62 brain MRI examinations in 24 patients with paroxysmal atrial fibrillation bearing the Reveal XT. All patients were interviewed for potential ICM-associated clinical symptoms during and after MRI examination. According to the study protocol, data from the Reveal XT were transmitted before and after the MRI examination. All patients were clinically asymptomatic during the MRI procedure. Moreover, the reliability (ability to detect signals, battery status) of the Reveal XT was unaffected, except for one MRI-induced artifact that was recorded by the ICM, mimicking a narrow complex tachycardia, as similarly recorded in a further study patient bearing the forerunner ICM Reveal DX. No loss of ICM data was observed after the MRI examination. The 3 Tesla brain MRI scanning is safe for patients bearing the ICM Reveal XT and does not alloy reliability of the Reveal XT itself. MRI-induced artifacts occur rarely but have to be taken into account. Copyright © 2011 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  10. Safety and reliability in Europe

    International Nuclear Information System (INIS)

    Colombo, A.G.

    1985-01-01

    This volume contains the papers presented at the ESRA Pre-Launching Meeting. The meeting was attended by about eighty European reliability and safety experts from industry, research organizations and universities. This meeting was dealing with the following subjects: the historical perspective of safety and reliability in Europe and to the aims of ESRA. Status and Trends in Research and Development; Codes, Standards and Regulations; Academic and Technical Training. National and international Organizations. Twenty six papers have been analyzed and abstracted for inclusion in the data base

  11. Requirements of safety and reliability

    International Nuclear Information System (INIS)

    Franzen, L.F.

    1977-01-01

    The safety strategy for nuclear power plants is characterized by the fact that the high level of safety was attained not as a result of experience, but on the basis of preventive accident analyses and the findings derived from such analyses. Although, in these accident analyses, the deterministic approach is predominant it is supplemented by reliability analyses. The accidents analyzed in nuclear licensing procedures cover a wide spectrum from minor incidents to the design basis accidents which determine the design of the safety devices. The initial and boundary conditions, which are essential for accident analyses, and the determination of the loads occuring in various states during regular operation and in accidents flow into the design of the individual systems and components. The inevitable residual risk and its origins are discussed. (orig./HP) [de

  12. Towards higher safety and reliability

    Energy Technology Data Exchange (ETDEWEB)

    Takekuro, I. [Tokyo Electric Power Company, Tokyo (Japan)

    2001-06-01

    Japanese electric power companies are now positioning themselves to gain a stronger position in the liberalised electricity market. Nuclear power in particular plays an important role in satisfying a large part of domestic electricity demand and its performance has continued to improve as a result of enhanced safety operation and tough maintenance programmes. Although the criticality accident which occurred in 1999 shocked not only the public but also the nuclear industry itself, the accident provided an opportunity for the industry and the regulators to learn lessons and look again at safety issues. Japanese electric power companies are now eager to be seen as front-runners in the safe, reliable, and efficient generation of nuclear power for the twenty-first century. (author)

  13. Are measurements of patient safety culture and adverse events valid and reliable? Results from a cross sectional study.

    Science.gov (United States)

    Farup, Per G

    2015-05-02

    The association between measurements of the patient safety culture and the "true" patient safety has been insufficiently documented, and the validity of the tools used for the measurements has been questioned. This study explored associations between the patient safety culture and adverse events, and evaluated the validity of the tools. In 2008/2009, a survey on patient safety culture was performed with Hospital Survey on Patient Safety Culture (HSOPSC) in two medical departments in two geographically separated hospitals of Innlandet Hospital Trust. Later, a retrospective analysis of adverse events during the same period was performed with the Global Trigger Tool (GTT). The safety culture and adverse events were compared between the departments. 185 employees participated in the study, and 272 patient records were analysed. The HSOPSC scores were lower and adverse events less prevalent in department 1 than in department 2. In departments 1 and 2 the mean HSOPSC scores (SD) were at the unit level 3.62 (0.42) and 3.90 (0.37) (p culture and adverse events. Until the criterion validity of the tools for measuring patient safety culture and tracking of adverse events have been further evaluated, measurement of patient safety culture could not be used as a proxy for the "true" safety.

  14. Space transportation main engine reliability and safety

    Science.gov (United States)

    Monk, Jan C.

    1991-01-01

    Viewgraphs are used to illustrate the reliability engineering and aerospace safety of the Space Transportation Main Engine (STME). A technology developed is called Total Quality Management (TQM). The goal is to develop a robust design. Reducing process variability produces a product with improved reliability and safety. Some engine system design characteristics are identified which improves reliability.

  15. Safety and reliability. V. 1. Proceedings

    International Nuclear Information System (INIS)

    Soares, C.G.

    1997-01-01

    Proceedings of a 1997 conference on industrial safety and reliability are reported. The first volume looks at risk management, probabilistic safety assessment and management styles in various industrial settings, including nuclear power plants. The second volume addresses safety and reliability in the offshore and transport industries, focusing on the role of staff training and appropriate maintenance routines to effectively reduce accidents and outages. (UK)

  16. Safety and reliability of automatization software

    Energy Technology Data Exchange (ETDEWEB)

    Kapp, K; Daum, R [Karlsruhe Univ. (TH) (Germany, F.R.). Lehrstuhl fuer Angewandte Informatik, Transport- und Verkehrssysteme

    1979-02-01

    Automated technical systems have to meet very high requirements concerning safety, security and reliability. Today, modern computers, especially microcomputers, are used as integral parts of those systems. In consequence computer programs must work in a safe and reliable mannter. Methods are discussed which allow to construct safe and reliable software for automatic systems such as reactor protection systems and to prove that the safety requirements are met. As a result it is shown that only the method of total software diversification can satisfy all safety requirements at tolerable cost. In order to achieve a high degree of reliability, structured and modular programming in context with high level programming languages are recommended.

  17. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare.

    Science.gov (United States)

    Van Spall, Harriette; Kassam, Alisha; Tollefson, Travis T

    2015-08-01

    Near-miss investigations in high reliability organizations (HROs) aim to mitigate risk and improve system safety. Healthcare settings have a higher rate of near-misses and subsequent adverse events than most high-risk industries, but near-misses are not systematically reported or analyzed. In this review, we will describe the strategies for near-miss analysis that have facilitated a culture of safety and continuous quality improvement in HROs. Near-miss analysis is routine and systematic in HROs such as aviation. Strategies implemented in aviation include the Commercial Aviation Safety Team, which undertakes systematic analyses of near-misses, so that findings can be incorporated into Standard Operating Procedures (SOPs). Other strategies resulting from incident analyses include Crew Resource Management (CRM) for enhanced communication, situational awareness training, adoption of checklists during operations, and built-in redundancy within systems. Health care organizations should consider near-misses as opportunities for quality improvement. The systematic reporting and analysis of near-misses, commonplace in HROs, can be adapted to health care settings to prevent adverse events and improve clinical outcomes.

  18. Reliability analysis of Angra I safety systems

    International Nuclear Information System (INIS)

    Oliveira, L.F.S. de; Soto, J.B.; Maciel, C.C.; Gibelli, S.M.O.; Fleming, P.V.; Arrieta, L.A.

    1980-07-01

    An extensive reliability analysis of some safety systems of Angra I, are presented. The fault tree technique, which has been successfully used in most reliability studies of nuclear safety systems performed to date is employed. Results of a quantitative determination of the unvailability of the accumulator and the containment spray injection systems are presented. These results are also compared to those reported in WASH-1400. (E.G.) [pt

  19. Improving the safety and reliability of Monju

    International Nuclear Information System (INIS)

    Itou, Kazumoto; Maeda, Hiroshi; Moriyama, Masatoshi

    1998-01-01

    Comprehensive safety review has been performed at Monju to determine why the Monju secondary sodium leakage accident occurred. We investigated how to improve the situation based on the results of the safety review. The safety review focused on five aspects of whether the facilities for dealing with the sodium leakage accident were adequate: the reliability of the detection method, the reliability of the method for preventing the spread of the sodium leakage accident, whether the documented operating procedures are adequate, whether the quality assurance system, program, and actions were properly performed and so on. As a result, we established for Monju a better method of dealing with sodium leakage accidents, rapid detection of sodium leakage, improvement of sodium drain facilities, and way to reduce damage to Monju systems after an accident. We also improve the operation procedures and quality assurance actions to increase the safety and reliability of Monju. (author)

  20. Reliability analysis of software based safety functions

    International Nuclear Information System (INIS)

    Pulkkinen, U.

    1993-05-01

    The methods applicable in the reliability analysis of software based safety functions are described in the report. Although the safety functions also include other components, the main emphasis in the report is on the reliability analysis of software. The check list type qualitative reliability analysis methods, such as failure mode and effects analysis (FMEA), are described, as well as the software fault tree analysis. The safety analysis based on the Petri nets is discussed. The most essential concepts and models of quantitative software reliability analysis are described. The most common software metrics and their combined use with software reliability models are discussed. The application of software reliability models in PSA is evaluated; it is observed that the recent software reliability models do not produce the estimates needed in PSA directly. As a result from the study some recommendations and conclusions are drawn. The need of formal methods in the analysis and development of software based systems, the applicability of qualitative reliability engineering methods in connection to PSA and the need to make more precise the requirements for software based systems and their analyses in the regulatory guides should be mentioned. (orig.). (46 refs., 13 figs., 1 tab.)

  1. Uncertainties and reliability theories for reactor safety

    International Nuclear Information System (INIS)

    Veneziano, D.

    1975-01-01

    What makes the safety problem of nuclear reactors particularly challenging is the demand for high levels of reliability and the limitation of statistical information. The latter is an unfortunate circumstance, which forces deductive theories of reliability to use models and parameter values with weak factual support. The uncertainty about probabilistic models and parameters which are inferred from limited statistical evidence can be quantified and incorporated rationally into inductive theories of reliability. In such theories, the starting point is the information actually available, as opposed to an estimated probabilistic model. But, while the necessity of introducing inductive uncertainty into reliability theories has been recognized by many authors, no satisfactory inductive theory is presently available. The paper presents: a classification of uncertainties and of reliability models for reactor safety; a general methodology to include these uncertainties into reliability analysis; a discussion about the relative advantages and the limitations of various reliability theories (specifically, of inductive and deductive, parametric and nonparametric, second-moment and full-distribution theories). For example, it is shown that second-moment theories, which were originally suggested to cope with the scarcity of data, and which have been proposed recently for the safety analysis of secondary containment vessels, are the least capable of incorporating statistical uncertainty. The focus is on reliability models for external threats (seismic accelerations and tornadoes). As an application example, the effect of statistical uncertainty on seismic risk is studied using parametric full-distribution models

  2. A reliability program approach to operational safety

    International Nuclear Information System (INIS)

    Mueller, C.J.; Bezella, W.A.

    1985-01-01

    A Reliability Program (RP) model based on proven reliability techniques is being formulated for potential application in the nuclear power industry. Methods employed under NASA and military direction, commercial airline and related FAA programs were surveyed and a review of current nuclear risk-dominant issues conducted. The need for a reliability approach to address dependent system failures, operating and emergency procedures and human performance, and develop a plant-specific performance data base for safety decision making is demonstrated. Current research has concentrated on developing a Reliability Program approach for the operating phase of a nuclear plant's lifecycle. The approach incorporates performance monitoring and evaluation activities with dedicated tasks that integrate these activities with operation, surveillance, and maintenance of the plant. The detection, root-cause evaluation and before-the-fact correction of incipient or actual systems failures as a mechanism for maintaining plant safety is a major objective of the Reliability Program. (orig./HP)

  3. SGHWR fuel performance, safety and reliability

    International Nuclear Information System (INIS)

    Pickman, D.O.; Inglis, G.H.

    1977-05-01

    The design principles involved in fuel pins and elements need to take account of the sometimes conflicting requirements of safety and reliability. The principal factors involved in this optimisation are discussed and it is shown from fuel irradiation experience in the Winfrith SGHWR that the necessary bias towards safety has not resulted in a reliability level lower than that shown by other successful water reactor designs. Reliability has important economic implications. By a detailed evaluation of SGHWR fuel defects it is shown that very few defects can be shown to be related to design, rating, or burn-up. This demonstrates that economic aspects have not over-ridden necessary criteria that most be met to achieve the desirable reliability level. It is possible that large scale experience on SGHWR fuel may eventually demonstrate that the balance is too much in favour of reliability and consideration may be given to whether design changes favouring economy could be achieved without compromising safety. The safety criteria applied to SGHWR fuel are designed to avoid any possibility of a temperature runaway in any credible accident situation. the philosophy and supporting experimental work programme are outlines and the fuel design features which particularly contribute to maximising safety margins are outlined. Reference is made to the new 60-pin fuel element to be used in the commercial SGHWRs and to its comparison in design and performance aspects with the 36-pin element that has been used to date in the Winfrith SGHWR. (author)

  4. Infusing Reliability Techniques into Software Safety Analysis

    Science.gov (United States)

    Shi, Ying

    2015-01-01

    Software safety analysis for a large software intensive system is always a challenge. Software safety practitioners need to ensure that software related hazards are completely identified, controlled, and tracked. This paper discusses in detail how to incorporate the traditional reliability techniques into the entire software safety analysis process. In addition, this paper addresses how information can be effectively shared between the various practitioners involved in the software safety analyses. The author has successfully applied the approach to several aerospace applications. Examples are provided to illustrate the key steps of the proposed approach.

  5. Reliability and safety of nuclear power stations

    International Nuclear Information System (INIS)

    Stepanek, S.

    1979-01-01

    The main problems are briefly discussed associated with the assessment of the safety and reliability of reactor pressure vessels. Two approaches are being applied to the assessment: one is based on the crack arrest temperature, the other on the determination of conditions corresponding to brittle fracture formation and on the determination of the critical defect size. The importance is stressed of continuous in-service inspection which may increase the factor of reliability by up to 10 4 times. (Z.M.)

  6. LOFT pressurizer safety: relief valve reliability

    International Nuclear Information System (INIS)

    Brown, E.S.

    1978-01-01

    The LOFT pressurizer self-actuating safety-relief valves are constructed to the present state-of-the-art and should have reliability equivalent to the valves in use on PWR plants in the U.S. There have been no NRC incident reports on valve failures to lift that would challenge the Technical Specification Safety Limit. Fourteen valves have been reported as lifting a few percentage points outside the +-1% Tech. Spec. surveillance tolerance (9 valves tested over and 5 valves tested under specification). There have been no incident reports on failures to reseat. The LOFT surveillance program for assuring reliability is equivalent to nuclear industry practice

  7. LOFT pressurizer safety: relief valve reliability

    Energy Technology Data Exchange (ETDEWEB)

    Brown, E.S.

    1978-01-18

    The LOFT pressurizer self-actuating safety-relief valves are constructed to the present state-of-the-art and should have reliability equivalent to the valves in use on PWR plants in the U.S. There have been no NRC incident reports on valve failures to lift that would challenge the Technical Specification Safety Limit. Fourteen valves have been reported as lifting a few percentage points outside the +-1% Tech. Spec. surveillance tolerance (9 valves tested over and 5 valves tested under specification). There have been no incident reports on failures to reseat. The LOFT surveillance program for assuring reliability is equivalent to nuclear industry practice.

  8. Swimming pool reactor reliability and safety analysis

    International Nuclear Information System (INIS)

    Li Zhaohuan

    1997-01-01

    A reliability and safety analysis of Swimming Pool Reactor in China Institute of Atomic Energy is done by use of event/fault tree technique. The paper briefly describes the analysis model, analysis code and main results. Meanwhile it also describes the impact of unassigned operation status on safety, the estimation of effectiveness of defense tactics in maintenance against common cause failure, the effectiveness of recovering actions on the system reliability, the comparison of occurrence frequencies of the core damage by use of generic and specific data

  9. Standards in reliability and safety engineering

    International Nuclear Information System (INIS)

    O'Connor, Patrick

    1998-01-01

    This article explains how the highest 'world class' levels of reliability and safety are achieved, by adherence to the basic principles of excellence in design, production, support and maintenance, by continuous improvement, and by understanding that excellence and improvement lead to reduced costs. These principles are contrasted with the methods that have been developed and standardised, particularly military standards for reliability, ISO9000, and safety case regulations. The article concludes that the formal, standardised approaches are misleading and counterproductive, and recommends that they be replaced by a philosophy based on the realities of human performance

  10. Patient safety

    African Journals Online (AJOL)

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

  11. Reliability on the move: safety and reliability in transportation

    International Nuclear Information System (INIS)

    Guy, G.B.

    1989-01-01

    The development of transportation has been a significant factor in the development of civilisation as a whole. Our technical ability to move people and goods now seems virtually limitless when one considers for example the achievements of the various space programmes. Yet our current achievements rely heavily on high standards of safety and reliability from equipment and the human component of transportation systems. Recent failures have highlighted our dependence on equipment and human reliability. This book represents the proceedings of the 1989 Safety and Reliability Society symposium held at Bath on 11-12 October 1989. The structure of the book follows the structure of the symposium itself and the papers selected represent current thinking the the wide field of transportation, and the areas of rail (6 papers, three on railway signalling), air including space (two papers), road (one paper), road and rail (two papers) and sea (three papers) are covered. There are four papers concerned with general transport issues. Three papers concerned with the transport of radioactive materials are indexed separately. (author)

  12. SGHWR fuel performance, safety and reliability

    International Nuclear Information System (INIS)

    Pickman, D.O.; Inglis, G.H.

    1977-01-01

    The design principles involved in fuel pins and elements need to take account of the sometimes conflicting requirements of performance, safety and reliability. The principal factors involved in this optimisation are discussed and it is shown from fuel irradiation experience in the Winfrith S.G.H.W.R. that the necessary bias toward safety has not resulted in a reliability level lower than that shown by other successful water reactor designs. Reliability has important economic implications and has to be paid for. By a detailed evaluation of S.G.H.W.R. fuel defects it is shown that very few defects can be shown to be related to design, rating or burn-up. This demonstrates that economic aspects have not over-ridden necessary criteria that must be met to achieve the desirable reliability level. It is possible that large-scale experience with S.G.H.W.R. fuel may eventually demonstrate that the balance is too much in favour of reliability and consideration may be given to whether design changes favouring economy could be achieved without compromising safety. The safety criteria applied to S.G.H.W.R. fuel are designed to avoid any possibility of a temperature runaway in any credible accident situation. The philosophy and supporting experimental work programme are outlined and the fuel design features which particularly contribute to maximising safety margins are outlined. Reference is made to new 60 pin fuel element to be used in the commercial S.G.H.W.R.'s and how it compares in design and performance aspects with the 36 pin element that has been used to date in the Winfrith S.G.H.W.R

  13. Software reliability for safety-critical applications

    International Nuclear Information System (INIS)

    Everett, B.; Musa, J.

    1994-01-01

    In this talk, the authors address the question open-quotes Can Software Reliability Engineering measurement and modeling techniques be applied to safety-critical applications?close quotes Quantitative techniques have long been applied in engineering hardware components of safety-critical applications. The authors have seen a growing acceptance and use of quantitative techniques in engineering software systems but a continuing reluctance in using such techniques in safety-critical applications. The general case posed against using quantitative techniques for software components runs along the following lines: safety-critical applications should be engineered such that catastrophic failures occur less frequently than one in a billion hours of operation; current software measurement/modeling techniques rely on using failure history data collected during testing; one would have to accumulate over a billion operational hours to verify failure rate objectives of about one per billion hours

  14. Reliability and safety analyses under fuzziness

    International Nuclear Information System (INIS)

    Onisawa, T.; Kacprzyk, J.

    1995-01-01

    Fuzzy theory, for example possibility theory, is compatible with probability theory. What is shown so far is that probability theory needs not be replaced by fuzzy theory, but rather that the former works much better in applications if it is combined with the latter. In fact, it is said that there are two essential uncertainties in the field of reliability and safety analyses: One is a probabilistic uncertainty which is more relevant for mechanical systems and the natural environment, and the other is fuzziness (imprecision) caused by the existence of human beings in systems. The classical probability theory alone is therefore not sufficient to deal with uncertainties in humanistic system. In such a context this collection of works will put a milestone in the arguments of probability theory and fuzzy theory. This volume covers fault analysis, life time analysis, reliability, quality control, safety analysis and risk analysis. (orig./DG). 106 figs

  15. Safety and reliability in superconducting MHD magnets

    International Nuclear Information System (INIS)

    Laverick, C.; Powell, J.; Hsieh, S.; Reich, M.; Botts, T.; Prodell, A.

    1979-07-01

    This compilation adapts studies on safety and reliability in fusion magnets to similar problems in superconducting MHD magnets. MHD base load magnet requirements have been identified from recent Francis Bitter National Laboratory reports and that of other contracts. Information relevant to this subject in recent base load magnet design reports for AVCO - Everett Research Laboratories and Magnetic Corporation of America is included together with some viewpoints from a BNL workshop on structural analysis needed for superconducting coils in magnetic fusion energy. A summary of design codes used in large bubble chamber magnet design is also included

  16. Human reliability in probabilistic safety assessments

    International Nuclear Information System (INIS)

    Nunez Mendez, J.

    1989-01-01

    Nowadays a growing interest in medioambiental aspects is detected in our country. It implies an assessment of the risk involved in the industrial processess and installations in order to determine if those are into the acceptable limits. In these safety assessments, among which PSA (Probabilistic Safety Assessments), can be pointed out the role played by the human being in the system is one of the more relevant subjects. (This relevance has been demostrated in the accidents happenned). However in Spain there aren't manuals specifically dedicated to asses the human contribution to risk in the frame of PSAs. This report aims to improve this situation providing: a) a theoretical background to help the reader in the understanding of the nature of the human error, b) a guide to carry out a Human Reliability Analysis and c) a selected overwiev of the techniques and methodologies currently applied in this area. (Author)

  17. Human Reliability in Probabilistic Safety Assessments

    International Nuclear Information System (INIS)

    Nunez Mendez, J.

    1989-01-01

    Nowadays a growing interest in environmental aspects is detected in our country. It implies an assessment of the risk involved in the industrial processes and installations in order to determine if those are into the acceptable limits. In these safety assessments, among which PSA (Probabilistic Safety Assessments), can be pointed out the role played by the human being in the system is one of the more relevant subjects (This relevance has been demonstrated in the accidents happened) . However, in Spain there aren't manuals specifically dedicated to asses the human contribution to risk in the frame of PSAs. This report aims to improve this situation providing: a) a theoretical background to help the reader in the understanding of the nature of the human error, b) a quid to carry out a Human Reliability Analysis and c) a selected overview of the techniques and methodologies currently applied in this area. (Author) 20 refs

  18. 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 ...

  19. Qualitative analysis in reliability and safety studies

    International Nuclear Information System (INIS)

    Worrell, R.B.; Burdick, G.R.

    1976-01-01

    The qualitative evaluation of system logic models is described as it pertains to assessing the reliability and safety characteristics of nuclear systems. Qualitative analysis of system logic models, i.e., models couched in an event (Boolean) algebra, is defined, and the advantages inherent in qualitative analysis are explained. Certain qualitative procedures that were developed as a part of fault-tree analysis are presented for illustration. Five fault-tree analysis computer-programs that contain a qualitative procedure for determining minimal cut sets are surveyed. For each program the minimal cut-set algorithm and limitations on its use are described. The recently developed common-cause analysis for studying the effect of common-causes of failure on system behavior is explained. This qualitative procedure does not require altering the fault tree, but does use minimal cut sets from the fault tree as part of its input. The method is applied using two different computer programs. 25 refs

  20. Reliability analysis of PLC safety equipment

    Energy Technology Data Exchange (ETDEWEB)

    Yu, J.; Kim, J. Y. [Chungnam Nat. Univ., Daejeon (Korea, Republic of)

    2006-06-15

    FMEA analysis for Nuclear Safety Grade PLC, failure rate prediction for nuclear safety grade PLC, sensitivity analysis for components failure rate of nuclear safety grade PLC, unavailability analysis support for nuclear safety system.

  1. Reliability analysis of PLC safety equipment

    International Nuclear Information System (INIS)

    Yu, J.; Kim, J. Y.

    2006-06-01

    FMEA analysis for Nuclear Safety Grade PLC, failure rate prediction for nuclear safety grade PLC, sensitivity analysis for components failure rate of nuclear safety grade PLC, unavailability analysis support for nuclear safety system

  2. 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...

  3. Trends in Control Area of PLC Reliability and Safety Parameters

    Directory of Open Access Journals (Sweden)

    Juraj Zdansky

    2008-01-01

    Full Text Available Extension of the PLC application possibilities is closely related to increase of reliability and safety parameters. If the requirement of reliability and safety parameters will be suitable, the PLC could by implemented to specific applications such the safety-related processes control. The goal of this article is to show the way which producers are approaching to increase PLC`s reliability and safety parameters. The second goal is to analyze these parameters for range of present choice and describe the possibility how the reliability and safety parameters can be affected.

  4. A reliability evaluation method for NPP safety DCS application software

    International Nuclear Information System (INIS)

    Li Yunjian; Zhang Lei; Liu Yuan

    2014-01-01

    In the field of nuclear power plant (NPP) digital i and c application, reliability evaluation for safety DCS application software is a key obstacle to be removed. In order to quantitatively evaluate reliability of NPP safety DCS application software, this paper propose a reliability evaluating method based on software development life cycle every stage's v and v defects density characteristics, by which the operating reliability level of the software can be predicted before its delivery, and helps to improve the reliability of NPP safety important software. (authors)

  5. Preliminary investigation on reliability assessment of passive safety system

    International Nuclear Information System (INIS)

    Huang Changfan; Kuang Bo

    2012-01-01

    The reliability evaluation of passive safety system plays an important part in probabilistic safety assessment (PSA) of nuclear power plant applying passive safety design, which depends quantitatively on reliabilities of passive safety system. According to the object of reliability assessment of passive safety system, relevant parameters are identified. Then passive system behavior during accident scenarios are studied. A practical example of this method is given for the case of reliability assessment of AP1000 passive heat removal system in loss of normal feedwater accident. Key and design parameters of PRHRS are identified and functional failure criteria are established. Parameter combinations acquired by Latin hyper~ cube sampling (LHS) in possible parametric ranges are input and calculations of uncertainty propagation through RELAP5/MOD3 code are carried out. Based on the calculations, sensitivity assessment on PRHRS functional criteria and reliability evaluation of the system are presented, which might provide further PSA with PRHR system reliability. (authors)

  6. Patient safety: Safety culture and patient safety ethics

    DEFF Research Database (Denmark)

    Madsen, Marlene Dyrløv

    2006-01-01

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

  7. Cernavoda NPP: Training for safety and reliability

    International Nuclear Information System (INIS)

    Postolache, Laura Lia

    2001-01-01

    The safe and reliable operation of NPP require successful integration of plant and system design (1), programmes and procedures (2) and qualified human resources (3). Of these three components, station personnel and management have capability to influence and improve programmes and competence of qualified personnel. Qualifying personnel includes selection, training and evaluation that meet the established performance standards. Training, therefore prepares people to achieve such competence. The critical role of operations personnel has been rightly emphasized by every country with a nuclear power programme. So far as operation team is concerned, they have to work, on the one hand with exacting safety rules and at the same time, they have to do the right thing at all times. In essence, they have to be prepared for new, emergency situations as well as for routine work. The plant operation in the Control Room is essentially a man - machine interaction and a safe and reliable operation requires them to take high quality decisions even under stressful conditions. Here lies therefore the need for high competent and licensed operations engineers who will ensure operation within the operating license of the station under the all conditions. The development of a long-term comprehensive training for Operation Staff is a requirement. The program addresses the qualification requirements of the various nuclear positions on shift, the outline content of the required training programs and the evaluation per the Systematic Approach to Training (SAT). A nuclear operator's training begins the moment he/she enters the station. It takes four to six years to develop the skills required to demonstrate that the candidate is an appropriate choice for the position. Then there's a further about two years of intense training at the Training Center on a simulator. After successful completion of the program, the candidate is authorized by the CNCAN (National Commission for Control of Nuclear

  8. Reliability Analysis for Safety Grade PLC(POSAFE-Q)

    International Nuclear Information System (INIS)

    Choi, Kyung Chul; Song, Seung Whan; Park, Gang Min; Hwang, Sung Jae

    2012-01-01

    Safety Grade PLC(Programmable Logic Controller), POSAFE-Q, was developed recently in accordance with nuclear regulatory and requirements. In this paper, describe reliability analysis for digital safety grade PLC (especially POSAFE-Q). Reliability analysis scope is Prediction, Calculation of MTBF (Mean Time Between Failure), FMEA (Failure Mode Effect Analysis), PFD (Probability of Failure on Demand). (author)

  9. The reliability of nuclear power plant safety systems

    International Nuclear Information System (INIS)

    Susnik, J.

    1978-01-01

    A criterion was established concerning the protection that nuclear power plant (NPP) safety systems should afford. An estimate of the necessary or adequate reliability of the total complex of safety systems was derived. The acceptable unreliability of auxiliary safety systems is given, provided the reliability built into the specific NPP safety systems (ECCS, Containment) is to be fully utilized. A criterion for the acceptable unreliability of safety (sub)systems which occur in minimum cut sets having three or more components of the analysed fault tree was proposed. A set of input MTBF or MTTF values which fulfil all the set criteria and attain the appropriate overall reliability was derived. The sensitivity of results to input reliability data values was estimated. Numerical reliability evaluations were evaluated by the programs POTI, KOMBI and particularly URSULA, the last being based on Vesely's kinetic fault tree theory. (author)

  10. STARS software tool for analysis of reliability and safety

    International Nuclear Information System (INIS)

    Poucet, A.; Guagnini, E.

    1989-01-01

    This paper reports on the STARS (Software Tool for the Analysis of Reliability and Safety) project aims at developing an integrated set of Computer Aided Reliability Analysis tools for the various tasks involved in systems safety and reliability analysis including hazard identification, qualitative analysis, logic model construction and evaluation. The expert system technology offers the most promising perspective for developing a Computer Aided Reliability Analysis tool. Combined with graphics and analysis capabilities, it can provide a natural engineering oriented environment for computer assisted reliability and safety modelling and analysis. For hazard identification and fault tree construction, a frame/rule based expert system is used, in which the deductive (goal driven) reasoning and the heuristic, applied during manual fault tree construction, is modelled. Expert system can explain their reasoning so that the analyst can become aware of the why and the how results are being obtained. Hence, the learning aspect involved in manual reliability and safety analysis can be maintained and improved

  11. Evaluation for nuclear safety-critical software reliability of DCS

    International Nuclear Information System (INIS)

    Liu Ying

    2015-01-01

    With the development of control and information technology at NPPs, software reliability is important because software failure is usually considered as one form of common cause failures in Digital I and C Systems (DCS). The reliability analysis of DCS, particularly qualitative and quantitative evaluation on the nuclear safety-critical software reliability belongs to a great challenge. To solve this problem, not only comprehensive evaluation model and stage evaluation models are built in this paper, but also prediction and sensibility analysis are given to the models. It can make besement for evaluating the reliability and safety of DCS. (author)

  12. Evaluation of reliability assurance approaches to operational nuclear safety

    International Nuclear Information System (INIS)

    Mueller, C.J.; Bezella, W.A.

    1984-01-01

    This report discusses the results of research to evaluate existing and/or recommended safety/reliability assurance activities among nuclear and other high technology industries for potential nuclear industry implementation. Since the Three Mile Island (TMI) accident, there has been increased interest in the use of reliability programs (RP) to assure the performance of nuclear safety systems throughout the plant's lifetime. Recently, several Nuclear Regulatory Commission (NRC) task forces or safety issue review groups have recommended RPs for assuring the continuing safety of nuclear reactor plants. 18 references

  13. Software reliability and safety in nuclear reactor protection systems

    International Nuclear Information System (INIS)

    Lawrence, J.D.

    1993-11-01

    Planning the development, use and regulation of computer systems in nuclear reactor protection systems in such a way as to enhance reliability and safety is a complex issue. This report is one of a series of reports from the Computer Safety and Reliability Group, Lawrence Livermore that investigates different aspects of computer software in reactor National Laboratory, that investigates different aspects of computer software in reactor protection systems. There are two central themes in the report, First, software considerations cannot be fully understood in isolation from computer hardware and application considerations. Second, the process of engineering reliability and safety into a computer system requires activities to be carried out throughout the software life cycle. The report discusses the many activities that can be carried out during the software life cycle to improve the safety and reliability of the resulting product. The viewpoint is primarily that of the assessor, or auditor

  14. Software reliability and safety in nuclear reactor protection systems

    Energy Technology Data Exchange (ETDEWEB)

    Lawrence, J.D. [Lawrence Livermore National Lab., CA (United States)

    1993-11-01

    Planning the development, use and regulation of computer systems in nuclear reactor protection systems in such a way as to enhance reliability and safety is a complex issue. This report is one of a series of reports from the Computer Safety and Reliability Group, Lawrence Livermore that investigates different aspects of computer software in reactor National Laboratory, that investigates different aspects of computer software in reactor protection systems. There are two central themes in the report, First, software considerations cannot be fully understood in isolation from computer hardware and application considerations. Second, the process of engineering reliability and safety into a computer system requires activities to be carried out throughout the software life cycle. The report discusses the many activities that can be carried out during the software life cycle to improve the safety and reliability of the resulting product. The viewpoint is primarily that of the assessor, or auditor.

  15. From reliability problems to nuclear safety problems

    International Nuclear Information System (INIS)

    Yastrebenetskij, M.A.

    2003-01-01

    The article is devoted to the 10-th anniversary of Kharkov Department (KhD) of SSTC NRS and reviews its creation prehistory (works on reliability of process automated control system carried out earlier by KhD scientists), basic results of KhD activities, and its future trends

  16. Advances in methods and applications of reliability and safety analysis

    International Nuclear Information System (INIS)

    Fieandt, J.; Hossi, H.; Laakso, K.; Lyytikaeinen, A.; Niemelae, I.; Pulkkinen, U.; Pulli, T.

    1986-01-01

    The know-how of the reliability and safety design and analysis techniques of Vtt has been established over several years in analyzing the reliability in the Finnish nuclear power plants Loviisa and Olkiluoto. This experience has been later on applied and developed to be used in the process industry, conventional power industry, automation and electronics. VTT develops and transfers methods and tools for reliability and safety analysis to the private and public sectors. The technology transfer takes place in joint development projects with potential users. Several computer-aided methods, such as RELVEC for reliability modelling and analysis, have been developed. The tool developed are today used by major Finnish companies in the fields of automation, nuclear power, shipbuilding and electronics. Development of computer-aided and other methods needed in analysis of operating experience, reliability or safety is further going on in a number of research and development projects

  17. 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...

  18. Safety and reliability analysis based on nonprobabilistic methods

    International Nuclear Information System (INIS)

    Kozin, I.O.; Petersen, K.E.

    1996-01-01

    Imprecise probabilities, being developed during the last two decades, offer a considerably more general theory having many advantages which make it very promising for reliability and safety analysis. The objective of the paper is to argue that imprecise probabilities are more appropriate tool for reliability and safety analysis, that they allow to model the behavior of nuclear industry objects more comprehensively and give a possibility to solve some problems unsolved in the framework of conventional approach. Furthermore, some specific examples are given from which we can see the usefulness of the tool for solving some reliability tasks

  19. Rational optimization of reliability and safety policies

    International Nuclear Information System (INIS)

    Melchers, Robert E.

    2001-01-01

    Optimization of structures for design has a long history, including optimization using numerical methods and optimality criteria. Much of this work has considered a subset of the complete design optimization problem--that of the technical issues alone. The more general problem must consider also non-technical issues and, importantly, the interplay between them and the parameters which influence them. Optimization involves optimal setting of design or acceptance criteria and, separately, optimal design within the criteria. In the modern context of probability based design codes this requires probabilistic acceptance criteria. The determination of such criteria involves more than the nominal code failure probability approach used for design code formulation. A more general view must be taken and a clear distinction must be made between those matters covered by technical reliability and non-technical reliability. The present paper considers this issue and outlines a framework for rational optimization of structural and other systems given the socio-economic and political systems within which optimization must be performed

  20. Engineering systems reliability, safety, and maintenance an integrated approach

    CERN Document Server

    Dhillon, B S

    2017-01-01

    Today, engineering systems are an important element of the world economy and each year billions of dollars are spent to develop, manufacture, operate, and maintain various types of engineering systems around the globe. Many of these systems are highly sophisticated and contain millions of parts. For example, a Boeing jumbo 747 is made up of approximately 4.5 million parts including fasteners. Needless to say, reliability, safety, and maintenance of systems such as this have become more important than ever before.  Global competition and other factors are forcing manufacturers to produce highly reliable, safe, and maintainable engineering products. Therefore, there is a definite need for the reliability, safety, and maintenance professionals to work closely during design and other phases. Engineering Systems Reliability, Safety, and Maintenance: An Integrated Approach eliminates the need to consult many different and diverse sources in the hunt for the information required to design better engineering syste...

  1. A Reliability Assessment Method for the VHTR Safety Systems

    International Nuclear Information System (INIS)

    Lee, Hyung Sok; Jae, Moo Sung; Kim, Yong Wan

    2011-01-01

    The Passive safety system by very high temperature reactor which has attracted worldwide attention in the last century is the reliability safety system introduced for the improvement in the safety of the next generation nuclear power plant design. The Passive system functionality does not rely on an external source of energy, but on an intelligent use of the natural phenomena, such as gravity, conduction and radiation, which are always present. Because of these features, it is difficult to evaluate the passive safety on the risk analysis methodology having considered the existing active system failure. Therefore new reliability methodology has to be considered. In this study, the preliminary evaluation and conceptualization are tried, applying the concept of the load and capacity from the reliability physics model, designing the new passive system analysis methodology, and the trial applying to paper plant.

  2. Human factors considerations for reliability and safety

    International Nuclear Information System (INIS)

    Carnino, A.

    1985-01-01

    Human factors in many industries have become an important issue, since the last few years. They should be considered during the whole life time of a plant: design, fabrication and construction, licensing, operation. Improvements have been performed in the field of man-machine interface such as procedures, control room lay-out, operator aids, training. In order to meet the needs of reliability and probabilistic risk studies, quantification of human errors has been developed but needs still improvements in the field of cognitive behaviour, diagnosis and representation errors. Data banks to support these quantifications are still in a development stage. This applies to nuclear power plants and several examples are given to illustrate the above ideas. In conclusion, human factors field is in a very quickly evolving process but the tendency is still to adapt the man to the machines whilst the reverse would be desirable

  3. Patient Safety, Present and Future

    International Nuclear Information System (INIS)

    Amalberti, R.

    2016-01-01

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

  4. Developing safety performance functions incorporating reliability-based risk measures.

    Science.gov (United States)

    Ibrahim, Shewkar El-Bassiouni; Sayed, Tarek

    2011-11-01

    Current geometric design guides provide deterministic standards where the safety margin of the design output is generally unknown and there is little knowledge of the safety implications of deviating from these standards. Several studies have advocated probabilistic geometric design where reliability analysis can be used to account for the uncertainty in the design parameters and to provide a risk measure of the implication of deviation from design standards. However, there is currently no link between measures of design reliability and the quantification of safety using collision frequency. The analysis presented in this paper attempts to bridge this gap by incorporating a reliability-based quantitative risk measure such as the probability of non-compliance (P(nc)) in safety performance functions (SPFs). Establishing this link will allow admitting reliability-based design into traditional benefit-cost analysis and should lead to a wider application of the reliability technique in road design. The present application is concerned with the design of horizontal curves, where the limit state function is defined in terms of the available (supply) and stopping (demand) sight distances. A comprehensive collision and geometric design database of two-lane rural highways is used to investigate the effect of the probability of non-compliance on safety. The reliability analysis was carried out using the First Order Reliability Method (FORM). Two Negative Binomial (NB) SPFs were developed to compare models with and without the reliability-based risk measures. It was found that models incorporating the P(nc) provided a better fit to the data set than the traditional (without risk) NB SPFs for total, injury and fatality (I+F) and property damage only (PDO) collisions. Copyright © 2011 Elsevier Ltd. All rights reserved.

  5. Prediction of safety critical software operational reliability from test reliability using testing environment factors

    International Nuclear Information System (INIS)

    Jung, Hoan Sung; Seong, Poong Hyun

    1999-01-01

    It has been a critical issue to predict the safety critical software reliability in nuclear engineering area. For many years, many researches have focused on the quantification of software reliability and there have been many models developed to quantify software reliability. Most software reliability models estimate the reliability with the failure data collected during the test assuming that the test environments well represent the operation profile. User's interest is however on the operational reliability rather than on the test reliability. The experiences show that the operational reliability is higher than the test reliability. With the assumption that the difference in reliability results from the change of environment, from testing to operation, testing environment factors comprising the aging factor and the coverage factor are developed in this paper and used to predict the ultimate operational reliability with the failure data in testing phase. It is by incorporating test environments applied beyond the operational profile into testing environment factors. The application results show that the proposed method can estimate the operational reliability accurately. (Author). 14 refs., 1 tab., 1 fig

  6. Human reliability analysis methods for probabilistic safety assessment

    International Nuclear Information System (INIS)

    Pyy, P.

    2000-11-01

    Human reliability analysis (HRA) of a probabilistic safety assessment (PSA) includes identifying human actions from safety point of view, modelling the most important of them in PSA models, and assessing their probabilities. As manifested by many incidents and studies, human actions may have both positive and negative effect on safety and economy. Human reliability analysis is one of the areas of probabilistic safety assessment (PSA) that has direct applications outside the nuclear industry. The thesis focuses upon developments in human reliability analysis methods and data. The aim is to support PSA by extending the applicability of HRA. The thesis consists of six publications and a summary. The summary includes general considerations and a discussion about human actions in the nuclear power plant (NPP) environment. A condensed discussion about the results of the attached publications is then given, including new development in methods and data. At the end of the summary part, the contribution of the publications to good practice in HRA is presented. In the publications, studies based on the collection of data on maintenance-related failures, simulator runs and expert judgement are presented in order to extend the human reliability analysis database. Furthermore, methodological frameworks are presented to perform a comprehensive HRA, including shutdown conditions, to study reliability of decision making, and to study the effects of wrong human actions. In the last publication, an interdisciplinary approach to analysing human decision making is presented. The publications also include practical applications of the presented methodological frameworks. (orig.)

  7. Reliability Improved Design for a Safety System Channel

    International Nuclear Information System (INIS)

    Oh, Eung Se; Kim, Yun Goo

    2016-01-01

    Nowadays, these systems are implemented with a same platform type, such as a qualified programmable logic controller (PLC). The platform intensively uses digital communication with fiber-optic links to reduce cabling costs and to achieve effective signal isolation. These communication interface and redundancies within a channel increase the complexness of an overall system design. This paper proposes a simpler channel architecture design to reduce the complexity and to enhance overall channel reliability. Simplified safety channel configuration is proposed and the failure probabilities are compared with baseline safety channel configuration using an estimated generic value. The simplified channel configuration achieves 40 percent failure reduction compare to baseline safety channel configuration. If this configuration can be implemented within a processor module, overall safety channel reliability is increase and costs of fabrication and maintenance will be greatly reduced

  8. Reliability Improved Design for a Safety System Channel

    Energy Technology Data Exchange (ETDEWEB)

    Oh, Eung Se; Kim, Yun Goo [KHNP, Daejeon (Korea, Republic of)

    2016-05-15

    Nowadays, these systems are implemented with a same platform type, such as a qualified programmable logic controller (PLC). The platform intensively uses digital communication with fiber-optic links to reduce cabling costs and to achieve effective signal isolation. These communication interface and redundancies within a channel increase the complexness of an overall system design. This paper proposes a simpler channel architecture design to reduce the complexity and to enhance overall channel reliability. Simplified safety channel configuration is proposed and the failure probabilities are compared with baseline safety channel configuration using an estimated generic value. The simplified channel configuration achieves 40 percent failure reduction compare to baseline safety channel configuration. If this configuration can be implemented within a processor module, overall safety channel reliability is increase and costs of fabrication and maintenance will be greatly reduced.

  9. Reliability Analysis of Public Survey in Satisfaction with Nuclear Safety

    Energy Technology Data Exchange (ETDEWEB)

    Park, Moon Soo; Moon, Joo Hyun; Kang, Chang Sun [Seoul National Univ., Seoul (Korea, Republic of)

    2005-07-01

    Korea Institute of Nuclear Safety (KINS) carried out a questionnaire survey on public's understanding nuclear safety and regulation in order to grasp public acceptance for nuclear energy. The survey was planned to help to analyze public opinion on nuclear energy and provide basic data for advertising strategy and policy development. In this study, based on results of the survey, the reliability of the survey was evaluated according to each nuclear site.

  10. Reliability Analysis of Public Survey in Satisfaction with Nuclear Safety

    International Nuclear Information System (INIS)

    Park, Moon Soo; Moon, Joo Hyun; Kang, Chang Sun

    2005-01-01

    Korea Institute of Nuclear Safety (KINS) carried out a questionnaire survey on public's understanding nuclear safety and regulation in order to grasp public acceptance for nuclear energy. The survey was planned to help to analyze public opinion on nuclear energy and provide basic data for advertising strategy and policy development. In this study, based on results of the survey, the reliability of the survey was evaluated according to each nuclear site

  11. Reliability model for common mode failures in redundant safety systems

    International Nuclear Information System (INIS)

    Fleming, K.N.

    1974-12-01

    A method is presented for computing the reliability of redundant safety systems, considering both independent and common mode type failures. The model developed for the computation is a simple extension of classical reliability theory. The feasibility of the method is demonstrated with the use of an example. The probability of failure of a typical diesel-generator emergency power system is computed based on data obtained from U. S. diesel-generator operating experience. The results are compared with reliability predictions based on the assumption that all failures are independent. The comparison shows a significant increase in the probability of redundant system failure, when common failure modes are considered. (U.S.)

  12. Development of reliability-based safety enhancement technology

    International Nuclear Information System (INIS)

    Kim, Kil Yoo; Han, Sang Hoon; Jang, Seung Cherl

    2002-04-01

    This project aims to develop critical technologies and the necessary reliability DB for maximizing the economics in the NPP operation with keeping the safety using the information of the risk (or reliability). For the research goal, firstly the four critical technologies(Risk Informed Tech. Spec. Optimization, Risk Informed Inservice Testing, On-line Maintenance, Maintenance Rule) for RIR and A have been developed. Secondly, KIND (Korea Information System for Nuclear Reliability Data) has been developed. Using KIND, YGN 3,4 and UCN 3,4 component reliability DB have been established. A reactor trip history DB for all NPP in Korea also has been developed and analyzed. Finally, a detailed reliability analysis of RPS/ESFAS for KNSP has been performed. With the result of the analysis, the sensitivity analysis also has been performed to optimize the AOT/STI of tech. spec. A statistical analysis procedure and computer code have been developed for the set point drift analysis

  13. International cooperation - a way to improve reliability and safety

    International Nuclear Information System (INIS)

    John, A.

    1998-01-01

    The mission of the World Association of Nuclear Operators (WANO) is highlighted, and WANO's Peer Review programme is described. At the Dukovany nuclear power plant, a Peer Review was undertaken in December 1997. The results gave evidence of a good level of safety, reliability and culture of operation of the plant. (P.A.)

  14. Safety, reliability and worker satisfaction during organizational change

    NARCIS (Netherlands)

    Zwetsloot, G.I.J.M.; Drupsteen, L.; Vroome, E.M.M. de

    2014-01-01

    The research presented in this paper was carried out in four process industry plants in the Netherlands, to identify factors that have the potential to increase safety and reliability while maintaining or improving job satisfaction. The data used were gathered as part of broader trajectories in

  15. An approach for assessing ALWR passive safety system reliability

    International Nuclear Information System (INIS)

    Hake, T.M.

    1991-01-01

    Many of the advanced light water reactor (ALWR) concepts proposed for the next generation of nuclear power plants rely on passive rather than active systems to perform safety functions. Despite the reduced redundancy of the passive systems as compared to active systems in current plants, the assertion is that the overall safety of the plant is enhanced due to the much higher expected reliability of the passive systems. In order to investigate this assertion, a study is being conducted at Sandia National Laboratories to evaluate the reliability of ALWR passive safety features in the context of probabilistic risk assessment (PRA). The purpose of this paper is to provide a brief overview of the approach to this study. The quantification of passive system reliability is not as straightforward as for active systems, due to the lack of operating experience, and to the greater uncertainty in the governing physical phenomena. Thus, the adequacy of current methods for evaluating system reliability must be assessed, and alternatives proposed if necessary. For this study, the Westinghouse Advanced Passive 600 MWe reactor (AP600) was chosen as the advanced reactor for analysis, because of the availability of AP600 design information. This study compares the reliability of AP600 emergency cooling system with that of corresponding systems in a current generation reactor

  16. 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.

  17. Modular reliability modeling of the TJNAF personnel safety system

    International Nuclear Information System (INIS)

    Cinnamon, J.; Mahoney, K.

    1997-01-01

    A reliability model for the Thomas Jefferson National Accelerator Facility (formerly CEBAF) personnel safety system has been developed. The model, which was implemented using an Excel spreadsheet, allows simulation of all or parts of the system. Modularity os the model's implementation allows rapid open-quotes what if open-quotes case studies to simulate change in safety system parameters such as redundancy, diversity, and failure rates. Particular emphasis is given to the prediction of failure modes which would result in the failure of both of the redundant safety interlock systems. In addition to the calculation of the predicted reliability of the safety system, the model also calculates availability of the same system. Such calculations allow the user to make tradeoff studies between reliability and availability, and to target resources to improving those parts of the system which would most benefit from redesign or upgrade. The model includes calculated, manufacturer's data, and Jefferson Lab field data. This paper describes the model, methods used, and comparison of calculated to actual data for the Jefferson Lab personnel safety system. Examples are given to illustrate the model's utility and ease of use

  18. Patient safety: lessons learned

    International Nuclear Information System (INIS)

    Bagian, James P.

    2006-01-01

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

  19. A SOFTWARE RELIABILITY ESTIMATION METHOD TO NUCLEAR SAFETY SOFTWARE

    Directory of Open Access Journals (Sweden)

    GEE-YONG PARK

    2014-02-01

    Full Text Available A method for estimating software reliability for nuclear safety software is proposed in this paper. This method is based on the software reliability growth model (SRGM, where the behavior of software failure is assumed to follow a non-homogeneous Poisson process. Two types of modeling schemes based on a particular underlying method are proposed in order to more precisely estimate and predict the number of software defects based on very rare software failure data. The Bayesian statistical inference is employed to estimate the model parameters by incorporating software test cases as a covariate into the model. It was identified that these models are capable of reasonably estimating the remaining number of software defects which directly affects the reactor trip functions. The software reliability might be estimated from these modeling equations, and one approach of obtaining software reliability value is proposed in this paper.

  20. Considerations concerning the reliability of reactor safety equipment

    International Nuclear Information System (INIS)

    Furet, J.; Guyot, Ch.

    1967-01-01

    A review is made of the circumstances which favor a good collection of maintenance data at the C.E.A. The large amount of data to be treated has made necessary the use of a computer for analyzing automatically the results collected. Here, only particular aspects of the reliability from the point of view of the electronics used for nuclear reactor control will be dealt with: sale and unsafe failures; probability of survival (in the case of reactor safety); availability. The general diagrams of the safety assemblies which have been drawn up for two types of reactor (power reactor and low power experimental reactor) are given. Results are presented of reliability analysis which could be applied to the use of functional modular elements, developed industrially in France. Improvement of this reliability appears to be fairly limited by an increase in the redundancy; on the other hand it is shown how it may be very markedly improved by the use of automatic tests with different frequencies for detecting unsafe failures rates of measurements for the sub-assemblies and for the logic sub-assemblies. Finally examples are given to show the incidence of the complexity and of the use of different technologies in reactor safety equipment on the reliability. (authors) [fr

  1. A reliability assessment methodology for the VHTR passive safety system

    International Nuclear Information System (INIS)

    Lee, Hyungsuk; Jae, Moosung

    2014-01-01

    The passive safety system of a VHTR (Very High Temperature Reactor), which has recently attracted worldwide attention, is currently being considered for the design of safety improvements for the next generation of nuclear power plants in Korea. The functionality of the passive system does not rely on an external source of an electrical support system, but on the intelligent use of natural phenomena. Its function involves an ultimate heat sink for a passive secondary auxiliary cooling system, especially during a station blackout such as the case of the Fukushima Daiichi reactor accidents. However, it is not easy to quantitatively evaluate the reliability of passive safety for the purpose of risk analysis, considering the existing active system failure since the classical reliability assessment method cannot be applied. Therefore, we present a new methodology to quantify the reliability based on reliability physics models. This evaluation framework is then applied to of the conceptually designed VHTR in Korea. The Response Surface Method (RSM) is also utilized for evaluating the uncertainty of the maximum temperature of nuclear fuel. The proposed method could contribute to evaluating accident sequence frequency and designing new innovative nuclear systems, such as the reactor cavity cooling system (RCCS) in VHTR to be designed and constructed in Korea.

  2. Quantitative reliability assessment for safety critical system software

    International Nuclear Information System (INIS)

    Chung, Dae Won; Kwon, Soon Man

    2005-01-01

    An essential issue in the replacement of the old analogue I and C to computer-based digital systems in nuclear power plants is the quantitative software reliability assessment. Software reliability models have been successfully applied to many industrial applications, but have the unfortunate drawback of requiring data from which one can formulate a model. Software which is developed for safety critical applications is frequently unable to produce such data for at least two reasons. First, the software is frequently one-of-a-kind, and second, it rarely fails. Safety critical software is normally expected to pass every unit test producing precious little failure data. The basic premise of the rare events approach is that well-tested software does not fail under normal routine and input signals, which means that failures must be triggered by unusual input data and computer states. The failure data found under the reasonable testing cases and testing time for these conditions should be considered for the quantitative reliability assessment. We will present the quantitative reliability assessment methodology of safety critical software for rare failure cases in this paper

  3. Reliability assessment for safety critical systems by statistical random testing

    International Nuclear Information System (INIS)

    Mills, S.E.

    1995-11-01

    In this report we present an overview of reliability assessment for software and focus on some basic aspects of assessing reliability for safety critical systems by statistical random testing. We also discuss possible deviations from some essential assumptions on which the general methodology is based. These deviations appear quite likely in practical applications. We present and discuss possible remedies and adjustments and then undertake applying this methodology to a portion of the SDS1 software. We also indicate shortcomings of the methodology and possible avenues to address to follow to address these problems. (author). 128 refs., 11 tabs., 31 figs

  4. Reliability assessment for safety critical systems by statistical random testing

    Energy Technology Data Exchange (ETDEWEB)

    Mills, S E [Carleton Univ., Ottawa, ON (Canada). Statistical Consulting Centre

    1995-11-01

    In this report we present an overview of reliability assessment for software and focus on some basic aspects of assessing reliability for safety critical systems by statistical random testing. We also discuss possible deviations from some essential assumptions on which the general methodology is based. These deviations appear quite likely in practical applications. We present and discuss possible remedies and adjustments and then undertake applying this methodology to a portion of the SDS1 software. We also indicate shortcomings of the methodology and possible avenues to address to follow to address these problems. (author). 128 refs., 11 tabs., 31 figs.

  5. A simple reliability block diagram method for safety integrity verification

    International Nuclear Information System (INIS)

    Guo Haitao; Yang Xianhui

    2007-01-01

    IEC 61508 requires safety integrity verification for safety related systems to be a necessary procedure in safety life cycle. PFD avg must be calculated to verify the safety integrity level (SIL). Since IEC 61508-6 does not give detailed explanations of the definitions and PFD avg calculations for its examples, it is difficult for common reliability or safety engineers to understand when they use the standard as guidance in practice. A method using reliability block diagram is investigated in this study in order to provide a clear and feasible way of PFD avg calculation and help those who take IEC 61508-6 as their guidance. The method finds mean down times (MDTs) of both channel and voted group first and then PFD avg . The calculated results of various voted groups are compared with those in IEC61508 part 6 and Ref. [Zhang T, Long W, Sato Y. Availability of systems with self-diagnostic components-applying Markov model to IEC 61508-6. Reliab Eng System Saf 2003;80(2):133-41]. An interesting outcome can be realized from the comparison. Furthermore, although differences in MDT of voted groups exist between IEC 61508-6 and this paper, PFD avg of voted groups are comparatively close. With detailed description, the method of RBD presented can be applied to the quantitative SIL verification, showing a similarity of the method in IEC 61508-6

  6. Probabilistic safety analysis and human reliability analysis. Proceedings. Working material

    International Nuclear Information System (INIS)

    1996-01-01

    An international meeting on Probabilistic Safety Assessment (PSA) and Human Reliability Analysis (HRA) was jointly organized by Electricite de France - Research and Development (EDF DER) and SRI International in co-ordination with the International Atomic Energy Agency. The meeting was held in Paris 21-23 November 1994. A group of international and French specialists in PSA and HRA participated at the meeting and discussed the state of the art and current trends in the following six topics: PSA Methodology; PSA Applications; From PSA to Dependability; Incident Analysis; Safety Indicators; Human Reliability. For each topic a background paper was prepared by EDF/DER and reviewed by the international group of specialists who attended the meeting. The results of this meeting provide a comprehensive overview of the most important questions related to the readiness of PSA for specific uses and areas where further research and development is required. Refs, figs, tabs

  7. Probabilistic safety analysis and human reliability analysis. Proceedings. Working material

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1997-12-31

    An international meeting on Probabilistic Safety Assessment (PSA) and Human Reliability Analysis (HRA) was jointly organized by Electricite de France - Research and Development (EDF DER) and SRI International in co-ordination with the International Atomic Energy Agency. The meeting was held in Paris 21-23 November 1994. A group of international and French specialists in PSA and HRA participated at the meeting and discussed the state of the art and current trends in the following six topics: PSA Methodology; PSA Applications; From PSA to Dependability; Incident Analysis; Safety Indicators; Human Reliability. For each topic a background paper was prepared by EDF/DER and reviewed by the international group of specialists who attended the meeting. The results of this meeting provide a comprehensive overview of the most important questions related to the readiness of PSA for specific uses and areas where further research and development is required. Refs, figs, tabs.

  8. The DYLAM approach to systems safety and reliability assessment

    International Nuclear Information System (INIS)

    Amendola, A.

    1988-01-01

    A survey of the principal features and applications of DYLAM (Dynamic Logical Analytical Methodology) is presented, whose basic principles can be summarized as follows: after a particular modelling of the component states, computerized heuristical procedures generate stochastic configurations of the system, whereas the resulting physical processes are simultaneously simulated to give account of the possible interactions between physics and states and, on the other hand, to search for system dangerous configurations and related probabilities. The association of probabilistic techniques for describing the states with physical equations for describing the process results in a very powerful tool for safety and reliability assessment of systems potentially subjected to dangerous incidental transients. A comprehensive picture of DYLAM capability for manifold applications can be obtained by the review of the study cases analyzed (LMFBR core accident, systems reliability assessment, accident simulation, man-machine interaction analysis, chemical reactors safety, etc.)

  9. Reliability of containment and safety-related structures

    International Nuclear Information System (INIS)

    Nessim, M.A.

    1995-09-01

    A research program on Reliability of Containment and Safety-related Structures has been developed and is described in this document. This program is designed to support AECB's regulatory activities aimed at ensuring the safety of these structures. These activities include evaluating submissions by operators and requesting special assessments when necessary. The results of the proposed research will also be useful in revising and enhancing the CSA design standards for containment and safety-related structures. The process of developing the research program started with an information collection and review phase. The sources of information included C-FER's previous work in the area, various recent research publications, regulatory documents and relevant design standards, and a detailed discussion with AECB staff. The second step was to outline the process of reliability evaluation, and identify the required models and parameters. Comparison between the required and available information was used to identify gaps in the state-of-the-art, and the research program was designed to fill these gaps. The program is organized in four major topics, namely: development of an approach for reliability analysis; compilation and development of the required analysis tools; application to specific problems related to design, assessment, maintenance and testing of structures; and testing and validation. It is suggested that the program should be supported by an on-going process of communication and consultation between AECB staff and industry experts. This will lend credibility to the results and facilitate their future application. (author). 1 fig

  10. Reliability of thermal-hydraulic passive safety systems

    International Nuclear Information System (INIS)

    D'Auria, F.; Araneo, D.; Pierro, F.; Galassi, G.

    2014-01-01

    The scholar will be informed of reliability concepts applied to passive system adopted for nuclear reactors. Namely, for classical components and systems the failure concept is associated with malfunction of breaking of hardware. In the case of passive systems the failure is associated with phenomena. A method for studying the reliability of passive systems is discussed and is applied. The paper deals with the description of the REPAS (Reliability Evaluation of Passive Safety System) methodology developed by University of Pisa (UNIPI) and with results from its application. The general objective of the REPAS methodology is to characterize the performance of a passive system in order to increase the confidence toward its operation and to compare the performances of active and passive systems and the performances of different passive systems

  11. Software Reliability Issues Concerning Large and Safety Critical Software Systems

    Science.gov (United States)

    Kamel, Khaled; Brown, Barbara

    1996-01-01

    This research was undertaken to provide NASA with a survey of state-of-the-art techniques using in industrial and academia to provide safe, reliable, and maintainable software to drive large systems. Such systems must match the complexity and strict safety requirements of NASA's shuttle system. In particular, the Launch Processing System (LPS) is being considered for replacement. The LPS is responsible for monitoring and commanding the shuttle during test, repair, and launch phases. NASA built this system in the 1970's using mostly hardware techniques to provide for increased reliability, but it did so often using custom-built equipment, which has not been able to keep up with current technologies. This report surveys the major techniques used in industry and academia to ensure reliability in large and critical computer systems.

  12. Reliability Analysis Multiple Redundancy Controller for Nuclear Safety Systems

    International Nuclear Information System (INIS)

    Son, Gwangseop; Kim, Donghoon; Son, Choulwoong

    2013-01-01

    This controller is configured for multiple modular redundancy (MMR) composed of dual modular redundancy (DMR) and triple modular redundancy (TMR). The architecture of MRC is briefly described, and the Markov model is developed. Based on the model, the reliability and Mean Time To Failure (MTTF) are analyzed. In this paper, the architecture of MRC for nuclear safety systems is described. The MRC is configured for multiple modular redundancy (MMR) composed of dual modular redundancy (DMR) and triple modular redundancy (TMR). Markov models for MRC architecture was developed, and then the reliability was analyzed by using the model. From the reliability analyses for the MRC, it is obtained that the failure rate of each module in the MRC should be less than 2 Χ 10 -4 /hour and the MTTF average increase rate depending on FCF increment, i. e. ΔMTTF/ΔFCF, is 4 months/0.1

  13. Transparent reliability model for fault-tolerant safety systems

    International Nuclear Information System (INIS)

    Bodsberg, Lars; Hokstad, Per

    1997-01-01

    A reliability model is presented which may serve as a tool for identification of cost-effective configurations and operating philosophies of computer-based process safety systems. The main merit of the model is the explicit relationship in the mathematical formulas between failure cause and the means used to improve system reliability such as self-test, redundancy, preventive maintenance and corrective maintenance. A component failure taxonomy has been developed which allows the analyst to treat hardware failures, human failures, and software failures of automatic systems in an integrated manner. Furthermore, the taxonomy distinguishes between failures due to excessive environmental stresses and failures initiated by humans during engineering and operation. Attention has been given to develop a transparent model which provides predictions which are in good agreement with observed system performance, and which is applicable for non-experts in the field of reliability

  14. 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...

  15. 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

  16. Proceedings of the Digital Systems Reliability and Nuclear Safety Workshop

    Energy Technology Data Exchange (ETDEWEB)

    Wallace, D. R.; Cuthill, B. B.; Ippolito, L. M. [National Inst. of Standards and Technology, Gaithersburg, MD (United States); Beltracchi, L. [Nuclear Regulatory Commission, Washington, DC (United States) ed.

    1994-03-01

    The United States Nuclear Regulatory Commission (NRC), in cooperation with the National Institute of Standards and Technology conducted the.Digital Systems Reliability and Nuclear Safety Workshop on September 13--14, 1993, in Rockville, Maryland. The workshop provided a forum for the exchange of information among experts within the nuclear industry, experts from other industries, regulators and academia. The information presented at this workshop provided in-depth exposure of the NRC staff and the nuclear industry to digital systems design safety issues and also provided feedback to the NRC from outside experts regarding identified safety issues, proposed regulatory positions, and intended research associated with the use of digital systems in nuclear power plants. Technical presentations provided insights on areas where current software engineering practices may be inadequate for safety-critical systems, on potential solutions for development issues, and on methods for reducing risk in safety-critical systems. This report contains an analysis of results of the workshop, the papers presented panel presentations, and summaries of, discussions at this workshop. The individual papers have been cataloged separately.

  17. Quantification of human reliability in probabilistic safety assessment

    International Nuclear Information System (INIS)

    Hirschberg, S.; Dankg, Vinh N.

    1996-01-01

    Human performance may substantially influence the reliability and safety of complex technical systems. For this reason, Human Reliability Analysis (HRA) constitutes an important part of Probabilistic Safety Assessment (PSAs) or Quantitative Risk Analyses (QRAs). The results of these studies as well as analyses of past accidents and incidents clearly demonstrate the importance of human interactions. The contribution of human errors to the core damage frequency (CDF), as estimated in the Swedish nuclear PSAs, are between 15 and 88%. A survey of the FRAs in the Swiss PSAs shows that also for the Swiss nuclear power plants the estimated HE contributions are substantial (49% of the CDF due to internal events in the case of Beznau and 70% in the case of Muehleberg; for the total CDF, including external events, 25% respectively 20%). Similar results can be extracted from the PSAs carried out for French, German, and US plants. In PSAs or QRAs, the adequate treatment of the human interactions with the system is a key to the understanding of accident sequences and their relative importance to overall risk. The main objectives of HRA are: first, to ensure that the key human interactions are systematically identified and incorporated into the safety analysis in a traceable manner, and second, to quantify the probabilities of their success and failure. Adopting a structured and systematic approach to the assessment of human performance makes it possible to provide greater confidence that the safety and availability of human-machine systems is not unduly jeopardized by human performance problems. Section 2 discusses the different types of human interactions analysed in PSAs. More generally, the section presents how HRA fits in the overall safety analysis, that is, how the human interactions to be quantified are identified. Section 3 addresses the methods for quantification. Section 4 concludes the paper by presenting some recommendations and pointing out the limitations of the

  18. 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 ...

  19. Remote patient monitoring: Information reliability challenges

    NARCIS (Netherlands)

    Petkovic, M.

    2009-01-01

    An increasing number of extramural applications in the personal healthcare domain pose new challenges regarding the security of medical data. In this paper, we focus on remote patient monitoring systems and the issues around information reliability. In these systems medical data is not collected by

  20. Component reliability data for use in probabilistic safety assessment

    International Nuclear Information System (INIS)

    1988-10-01

    Generic component reliability data is indispensable in any probabilistic safety analysis. It is not realistic to assume that all possible component failures and failure modes modeled in a PSA would be available from the operating experience of a specific plant in a statistically meaningful way. The degree that generic data is used in PSAs varies from case to case. Some studies are totally based on generic data while others use generic data as prior information to be specialized by plant specific data. Most studies, however, finally use a combination where data for certain components come from generic data sources and others from Bayesian updating. The IAEA effort to compile a generic component reliability data base aimed at facilitating the use of data available in the literature and at highlighting pitfalls which deserve special consideration. It was also intended to complement the fault tree and event tree package (PSAPACK) and to facilitate its use. Moreover, it should be noted, that the IAEA has recently initiated a Coordinated Research Program in Reliability Data Collection, Retrieval and Analysis. In this framework the issues identified as most affecting the quality of existing data bases would be addressed. This report presents the results of a compilation made from the specialized literature and includes reliability data for components usually considered in PSA

  1. 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.

  2. An approach for assessing ALWR passive safety system reliability

    International Nuclear Information System (INIS)

    Hake, T.M.

    1991-01-01

    Many advanced light water reactor designs incorporate passive rather than active safety features for front-line accident response. A method for evaluating the reliability of these passive systems in the context of probabilistic risk assessment has been developed at Sandia National Laboratories. This method addresses both the component (e.g. valve) failure aspect of passive system failure, and uncertainties in system success criteria arising from uncertainties in the system's underlying physical processes. These processes provide the system's driving force; examples are natural circulation and gravity-induced injection. This paper describes the method, and provides some preliminary results of application of the approach to the Westinghouse AP600 design

  3. The advantages of reliability centered maintenance for standby safety systems

    International Nuclear Information System (INIS)

    Dam, R.F.; Ayazzudin, S.; Nickerson, J.H.; DeLong, A.I.

    2002-01-01

    Full text: On standby safety systems, nuclear plants have to balance the requirements of demonstrating the reliability of each system, while maintaining the system and plant availability. With the goal of demonstrating statistical reliability, these systems have extensive testing programs, which often makes the system unavailable and this can impact the plant capacity. The inputs to the process are often safety and regulatory related, resulting in programs that provide a high level of scrutiny on the systems being considered. In such cases, the value of the application of a maintenance optimization strategy, such as Reliability Centered Maintenance (RCM), is questioned. Part of the question stems from the use of the word 'Reliability' in RCM, which implies a level of redundancy when applied to a system maintenance program driven by reliability requirements. A deeper look at the RCM process, however, shows that RCM has the goal of ensuring that the system operates 'reliably' through the application of an integrated maintenance strategy. This is a subtle, but important distinction. Although the system reliability requirements are an important part of the strategy evaluation, RCM provides a broader context where testing is only one part of an overall strategy focused on ensuring that component function is maintained through a combination of monitoring technologies (including testing), predictive techniques, and intrusive maintenance strategies. Each strategy is targeted to identify known component degradation mechanisms. The conclusion is that a maintenance program driven by reliability requirements will tend to have testing defined at a frequency intended to support the needed statistics. The testing demonstrates that the desired function is available today. Maintenance driven by functional requirements and known failure causes, as developed through an RCM assessment, will have frequencies tied to industry experience with components and rely on a higher degree of

  4. Partial Safety Factors and Target Reliability Level in Danish Structural Codes

    DEFF Research Database (Denmark)

    Sørensen, John Dalsgaard; Hansen, J. O.; Nielsen, T. A.

    2001-01-01

    The partial safety factors in the newly revised Danish structural codes have been derived using a reliability-based calibration. The calibrated partial safety factors result in the same average reliability level as in the previous codes, but a much more uniform reliability level has been obtained....... The paper describes the code format, the stochastic models and the resulting optimised partial safety factors....

  5. Improved reliability, maintainability and safety through elastomer upgrading

    International Nuclear Information System (INIS)

    Wensel, R.; Wittich, K.C.

    1995-01-01

    Equipment in nuclear plants has historically contained whatever elastomer each component supplier traditionally used for corresponding non-nuclear service. The resulting proliferation of elastomer compounds, many of which are far from optimal for the service conditions (e.g., pressure, temperature, radiation, etc.), has multiplied the costs to provide station reliability, maintainability and safety. Cost-effective improvements are being achieved in CANDU plants by upgrading and standardizing on a handful of high performing elastomer compounds. These upgraded materials offer significant gains in service life over the materials they replace (often by factors of 2 or more). This rationalization of elastomer compounds also facilitates the EQ process for safety-related equipment. Detailed test data on aging is currently being generated for these specific elastomers, encompassing the conditions and media (air, water, oil) common in CANDU service. Two key elements characterize this testing. First, each result is specific to the compound used in the test, and second, it is specific to the tested failure mode (e.g., compression set, extrusion, fracture, etc.). Having fewer, but more thoroughly tested compounds, avoids the penalty (associated with poorly characterized materials) of having to replace parts prematurely because of conservatism, while maintaining safe, reliable service. This paper provides an overview of this approach covering: the benefits of compound rationalization; and the how and why of establishing relevant failure criteria; appropriate quality assurance to maintain EQ; procurement, storage and handling guidelines; and monitoring and predicting in-service degradation. (author)

  6. 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

  7. An Organizational Learning Framework for Patient Safety.

    Science.gov (United States)

    Edwards, Marc T

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

  8. 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

  9. Systems Thinking and Patient Safety

    National Research Council Canada - National Science Library

    Schyve, Paul M

    2005-01-01

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

  10. Nuclear electric propulsion operational reliability and crew safety study

    International Nuclear Information System (INIS)

    Karns, J.J.; Fragola, J.R.; Kahan, L.; Pelaccio, D.

    1993-01-01

    The central purpose of this analysis is to assess the ''achievability'' of a nuclear electric propulsion (NEP) system in a given mission. ''Achievability'' is a concept introduced to indicate the extent to which a system that meets or achieves its design goals might be implemented using the existing technology base. In the context of this analysis, the objective is to assess the achievability of an NEP system for a manned Mars mission as it pertains to operational reliability and crew safety goals. By varying design parameters, then examining the resulting system achievability, the design and mission risk drivers can be identified. Additionally, conceptual changes in design approach or mission strategy which are likely to improve overall achievability of the NEP system can be examined

  11. Information about robustness, reliability and safety in early design phases

    DEFF Research Database (Denmark)

    Marini, Vinicius Kaster

    methods, and an industrial case to assess how the use of information about robustness, reliability and safety as practised by current methods influences concept development. Current methods cannot be used in early design phases due to their dependence on detailed design information for the identification...... alternatives. This prompts designers to reuse working principles that are inherently flawed, as they are liable to disturbances, failures and hazards. To address this issue, an approach based upon individual records of early design issues consists of comparing failures and benefits from prior working...... principles, before making a decision, and improving the more suitable alternatives through this feedback. Workshops were conducted with design practitioners to evaluate the potential of the approach and to simulate decision-making and gain feedback on a proof-of-concept basis. The evaluation has demonstrated...

  12. Increased nuclear safety and reliability through power beaming

    International Nuclear Information System (INIS)

    Coomes, E.P.; Widrig, R.D.

    1989-01-01

    Space satellites and platforms currently include self-contained power systems to supply the energy necessary to accomplish mission objectives. With power beaming, the power system is separate from the satellite and the two are connected by an energy beam. This approach is analogous to earth-based central station power generation and distribution over transmission lines to various customers. In space, power is produced by power satellites (central power generating stations) and transmitted via energy beams to individual users. Power beaming has the ability to provide an order of magnitude increase in power availability over solar-based power systems with less mass on orbit. The technologies needed for power beaming are being developed today under existing programs directed by the Strategic Defense Initiative Office, the National Aeronautics and Space Administration, and the US Department of Energy. A space power architecture based on power beaming would greatly increase the safety and reliability of employing nuclear power in space

  13. 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.

  14. Addressing Uniqueness and Unison of Reliability and Safety for a Better Integration

    Science.gov (United States)

    Huang, Zhaofeng; Safie, Fayssal

    2016-01-01

    Over time, it has been observed that Safety and Reliability have not been clearly differentiated, which leads to confusion, inefficiency, and, sometimes, counter-productive practices in executing each of these two disciplines. It is imperative to address this situation to help Reliability and Safety disciplines improve their effectiveness and efficiency. The paper poses an important question to address, "Safety and Reliability - Are they unique or unisonous?" To answer the question, the paper reviewed several most commonly used analyses from each of the disciplines, namely, FMEA, reliability allocation and prediction, reliability design involvement, system safety hazard analysis, Fault Tree Analysis, and Probabilistic Risk Assessment. The paper pointed out uniqueness and unison of Safety and Reliability in their respective roles, requirements, approaches, and tools, and presented some suggestions for enhancing and improving the individual disciplines, as well as promoting the integration of the two. The paper concludes that Safety and Reliability are unique, but compensating each other in many aspects, and need to be integrated. Particularly, the individual roles of Safety and Reliability need to be differentiated, that is, Safety is to ensure and assure the product meets safety requirements, goals, or desires, and Reliability is to ensure and assure maximum achievability of intended design functions. With the integration of Safety and Reliability, personnel can be shared, tools and analyses have to be integrated, and skill sets can be possessed by the same person with the purpose of providing the best value to a product development.

  15. 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.

  16. Assemblages of Patient Safety

    DEFF Research Database (Denmark)

    Balatsas Lekkas, Angelos

    2016-01-01

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

  17. 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.

  18. Pump performance and reliability follow-up by the French Safety Authorities

    International Nuclear Information System (INIS)

    Clausner, J.P.; De La Ronciere, X.; Scott de Martinville, E.; Courbiere, P.

    1990-12-01

    This paper will present, through actual examples, the methodology of the performance and reliability safety-related pumps evaluation applied by the French Safety Authorities and the lessons drawn from this evaluation

  19. Reliability analysis of diverse safety logic systems of fast breeder reactor

    International Nuclear Information System (INIS)

    Ravi Kumar, Bh.; Apte, P.R.; Srivani, L.; Ilango Sambasivan, S.; Swaminathan, P.

    2006-01-01

    Safety Logic for Fast Breeder Reactor (FBR) is designed to initiate safety action against Design Basis Events. Based on the outputs of various processing circuits, Safety logic system drives the control rods of the shutdown system. So, Safety Logic system is classified as safety critical system. Therefore, reliability analysis has to be performed. This paper discusses the Reliability analysis of Diverse Safety logic systems of FBRs. For this literature survey on safety critical systems, system reliability approach and standards to be followed like IEC-61508 are discussed in detail. For Programmable Logic device based systems, Hardware Description Languages (HDL) are used. So this paper also discusses the Verification and Validation for HDLs. Finally a case study for the Reliability analysis of Safety logic is discussed. (author)

  20. Collection of methods for reliability and safety engineering

    International Nuclear Information System (INIS)

    Fussell, J.B.; Rasmuson, D.M.; Wilson, J.R.; Burdick, G.R.; Zipperer, J.C.

    1976-04-01

    The document presented contains five reports each describing a method of reliability and safety engineering. Report I provides a conceptual framework for the study of component malfunctions during system evaluations. Report II provides methods for locating groups of critical component failures such that all the component failures in a given group can be caused to occur by the occurrence of a single separate event. These groups of component failures are called common cause candidates. Report III provides a method for acquiring and storing system-independent component failure logic information. The information stored is influenced by the concepts presented in Report I and also includes information useful in locating common cause candidates. Report IV puts forth methods for analyzing situations that involve systems which change character in a predetermined time sequence. These phased missions techniques are applicable to the hypothetical ''accident chains'' frequently analyzed for nuclear power plants. Report V presents a unified approach to cause-consequence analysis, a method of analysis useful during risk assessments. This approach, as developed by the Danish Atomic Energy Commission, is modified to reflect the format and symbology conventionally used for other types of analysis of nuclear reactor systems

  1. 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.

  2. Proceedings of the SRESA national conference on reliability and safety engineering

    International Nuclear Information System (INIS)

    Varde, P.V.; Vaishnavi, P.; Sujatha, S.; Valarmathi, A.

    2014-01-01

    The objective of this conference was to provide a forum for technical discussions on recent developments in the area of risk based approach and Prognostic Health Management of critical systems in decision making. The reliability and safety engineering methods are concerned with the way which the product fails, and the effects of failure is to understand how a product works and assures acceptable levels of safety. The reliability engineering addresses all the anticipated and possibly unanticipated causes of failure to ensure the occurrence of failure is prevented or minimized. The topics discussed in the conference were: Reliability in Engineering Design, Safety Assessment and Management, Reliability analysis and Assessment , Stochastic Petri nets for reliability Modeling, Dynamic Reliability, Reliability Prediction, Hardware Reliability, Software Reliability in Safety Critical Issues, Probabilistic Safety Assessment, Risk Informed Approach, Dynamic Models for Reliability Analysis, Reliability based Design and Analysis, Prognostics and Health Management, Remaining Useful Life (RUL), Human Reliability Modeling, Risk Based Applications, Hazard and Operability Study (HAZOP), Reliability in Network Security and Quality Assurance and Management etc. The papers relevant to INIS are indexed separately

  3. 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...

  4. 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...

  5. 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

  6. RELOSS, Reliability of Safety System by Fault Tree Analysis

    International Nuclear Information System (INIS)

    Allan, R.N.; Rondiris, I.L.; Adraktas, A.

    1981-01-01

    1 - Description of problem or function: Program RELOSS is used in the reliability/safety assessment of any complex system with predetermined operational logic in qualitative and (if required) quantitative terms. The program calculates the possible system outcomes following an abnormal operating condition and the probability of occurrence, if required. Furthermore, the program deduces the minimal cut or tie sets of the system outcomes and identifies the potential common mode failures. 4. Method of solution: The reliability analysis performed by the program is based on the event tree methodology. Using this methodology, the program develops the event tree of a system or a module of that system and relates each path of this tree to its qualitative and/or quantitative impact on specified system or module outcomes. If the system being analysed is subdivided into modules the program assesses each module in turn as described previously and then combines the module information to obtain results for the overall system. Having developed the event tree of a module or a system, the program identifies which paths lead or do not lead to various outcomes depending on whether the cut or the tie sets of the outcomes are required and deduces the corresponding sets. Furthermore the program identifies for a specific system outcome, the potential common mode failures and the cut or tie sets containing potential dependent failures of some components. 5. Restrictions on the complexity of the problem: The present dimensions of the program are as follows. They can however be easily modified: Maximum number of modules (equivalent components): 25; Maximum number of components in a module: 15; Maximum number of levels of parentheses in a logical statement: 10 Maximum number of system outcomes: 3; Maximum number of module outcomes: 2; Maximum number of points in time for which quantitative analysis is required: 5; Maximum order of any cut or tie set: 10; Maximum order of a cut or tie of any

  7. Advancing Measurement of Patient Safety Culture

    Science.gov (United States)

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

    2009-01-01

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

  8. Validating the Danish adaptation of the World Health Organization's International Classification for Patient Safety classification of patient safety incident types

    DEFF Research Database (Denmark)

    Mikkelsen, Kim Lyngby; Thommesen, Jacob; Andersen, Henning Boje

    2013-01-01

    Objectives Validation of a Danish patient safety incident classification adapted from the World Health Organizaton's International Classification for Patient Safety (ICPS-WHO). Design Thirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types.......513 (range: 0.193–0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity...

  9. 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.

  10. Patient Safety and Organizational Learning

    DEFF Research Database (Denmark)

    Zinck Pedersen, Kirstine

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

  11. Procedures for controlling the risks of reliability, safety, and availability of technical systems

    International Nuclear Information System (INIS)

    1987-01-01

    The reference book covers four sections. Apart from the fundamental aspects of the reliability problem, of risk and safety and the relevant criteria with regard to reliability, the material presented explains reliability in terms of maintenance, logistics and availability, and presents procedures for reliability assessment and determination of factors influencing the reliability, together with suggestions for systems technical integration. The reliability assessment consists of diagnostic and prognostic analyses. The section on factors influencing reliability discusses aspects of organisational structures, programme planning and control, and critical activities. (DG) [de

  12. Technology development of maintenance optimization and reliability analysis for safety features in nuclear power plants

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Tae Woon; Choi, Seong Soo; Lee, Dong Gue; Kim, Young Il

    1999-12-01

    The reliability data management system (RDMS) for safety systems of PHWR type plants has been developed and utilized in the reliability analysis of the special safety systems of Wolsong Unit 1,2 with plant overhaul period lengthened. The RDMS is developed for the periodic efficient reliability analysis of the safety systems of Wolsong Unit 1,2. In addition, this system provides the function of analyzing the effects on safety system unavailability if the test period of a test procedure changes as well as the function of optimizing the test periods of safety-related test procedures. The RDMS can be utilized in handling the requests of the regulatory institute actively with regard to the reliability validation of safety systems. (author)

  13. Possibilities and Limitations of Applying Software Reliability Growth Models to Safety- Critical Software

    International Nuclear Information System (INIS)

    Kim, Man Cheol; Jang, Seung Cheol; Ha, Jae Joo

    2006-01-01

    As digital systems are gradually introduced to nuclear power plants (NPPs), the need of quantitatively analyzing the reliability of the digital systems is also increasing. Kang and Sung identified (1) software reliability, (2) common-cause failures (CCFs), and (3) fault coverage as the three most critical factors in the reliability analysis of digital systems. For the estimation of the safety-critical software (the software that is used in safety-critical digital systems), the use of Bayesian Belief Networks (BBNs) seems to be most widely used. The use of BBNs in reliability estimation of safety-critical software is basically a process of indirectly assigning a reliability based on various observed information and experts' opinions. When software testing results or software failure histories are available, we can use a process of directly estimating the reliability of the software using various software reliability growth models such as Jelinski- Moranda model and Goel-Okumoto's nonhomogeneous Poisson process (NHPP) model. Even though it is generally known that software reliability growth models cannot be applied to safety-critical software due to small number of expected failure data from the testing of safety-critical software, we try to find possibilities and corresponding limitations of applying software reliability growth models to safety critical software

  14. Software reliability growth model for safety systems of nuclear reactor

    International Nuclear Information System (INIS)

    Thirugnana Murthy, D.; Murali, N.; Sridevi, T.; Satya Murty, S.A.V.; Velusamy, K.

    2014-01-01

    The demand for complex software systems has increased more rapidly than the ability to design, implement, test, and maintain them, and the reliability of software systems has become a major concern for our, modern society.Software failures have impaired several high visibility programs in space, telecommunications, defense and health industries. Besides the costs involved, it setback the projects. The ways of quantifying it and using it for improvement and control of the software development and maintenance process. This paper discusses need for systematic approaches for measuring and assuring software reliability which is a major share of project development resources. It covers the reliability models with the concern on 'Reliability Growth'. It includes data collection on reliability, statistical estimation and prediction, metrics and attributes of product architecture, design, software development, and the operational environment. Besides its use for operational decisions like deployment, it includes guiding software architecture, development, testing and verification and validation. (author)

  15. 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.

  16. Can we improve patient safety?

    Science.gov (United States)

    Corbally, Martin Thomas

    2014-01-01

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

  17. A hybrid approach to quantify software reliability in nuclear safety systems

    International Nuclear Information System (INIS)

    Arun Babu, P.; Senthil Kumar, C.; Murali, N.

    2012-01-01

    Highlights: ► A novel method to quantify software reliability using software verification and mutation testing in nuclear safety systems. ► Contributing factors that influence software reliability estimate. ► Approach to help regulators verify the reliability of safety critical software system during software licensing process. -- Abstract: Technological advancements have led to the use of computer based systems in safety critical applications. As computer based systems are being introduced in nuclear power plants, effective and efficient methods are needed to ensure dependability and compliance to high reliability requirements of systems important to safety. Even after several years of research, quantification of software reliability remains controversial and unresolved issue. Also, existing approaches have assumptions and limitations, which are not acceptable for safety applications. This paper proposes a theoretical approach combining software verification and mutation testing to quantify the software reliability in nuclear safety systems. The theoretical results obtained suggest that the software reliability depends on three factors: the test adequacy, the amount of software verification carried out and the reusability of verified code in the software. The proposed approach may help regulators in licensing computer based safety systems in nuclear reactors.

  18. Aviation Fuel System Reliability and Fail-Safety Analysis. Promising Alternative Ways for Improving the Fuel System Reliability

    Directory of Open Access Journals (Sweden)

    I. S. Shumilov

    2017-01-01

    Full Text Available The paper deals with design requirements for an aviation fuel system (AFS, AFS basic design requirements, reliability, and design precautions to avoid AFS failure. Compares the reliability and fail-safety of AFS and aircraft hydraulic system (AHS, considers the promising alternative ways to raise reliability of fuel systems, as well as elaborates recommendations to improve reliability of the pipeline system components and pipeline systems, in general, based on the selection of design solutions.It is extremely advisable to design the AFS and AHS in accordance with Aviation Regulations АП25 and Accident Prevention Guidelines, ICAO (International Civil Aviation Association, which will reduce risk of emergency situations, and in some cases even avoid heavy disasters.ATS and AHS designs should be based on the uniform principles to ensure the highest reliability and safety. However, currently, this principle is not enough kept, and AFS looses in reliability and fail-safety as compared with AHS. When there are the examined failures (single and their combinations the guidelines to ensure the AFS efficiency should be the same as those of norm-adopted in the Regulations АП25 for AHS. This will significantly increase reliability and fail-safety of the fuel systems and aircraft flights, in general, despite a slight increase in AFS mass.The proposed improvements through the use of components redundancy of the fuel system will greatly raise reliability of the fuel system of a passenger aircraft, which will, without serious consequences for the flight, withstand up to 2 failures, its reliability and fail-safety design will be similar to those of the AHS, however, above improvement measures will lead to a slightly increasing total mass of the fuel system.It is advisable to set a second pump on the engine in parallel with the first one. It will run in case the first one fails for some reasons. The second pump, like the first pump, can be driven from the

  19. 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…

  20. 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

  1. Possibilities and limitations of applying software reliability growth models to safety-critical software

    International Nuclear Information System (INIS)

    Kim, Man Cheol; Jang, Seung Cheol; Ha, Jae Joo

    2007-01-01

    It is generally known that software reliability growth models such as the Jelinski-Moranda model and the Goel-Okumoto's Non-Homogeneous Poisson Process (NHPP) model cannot be applied to safety-critical software due to a lack of software failure data. In this paper, by applying two of the most widely known software reliability growth models to sample software failure data, we demonstrate the possibility of using the software reliability growth models to prove the high reliability of safety-critical software. The high sensitivity of a piece of software's reliability to software failure data, as well as a lack of sufficient software failure data, is also identified as a possible limitation when applying the software reliability growth models to safety-critical software

  2. 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.

  3. Reliability analysis of digital safety systems at nuclear power plants

    International Nuclear Information System (INIS)

    Sopira Vladimir; Kovacs, Zoltan

    2015-01-01

    Reliability analysis of digital reactor protection systems built on the basis of TELEPERM XS is described, and experience gained by the Slovak RELKO company during the past 20 years in this domain is highlighted. (orig.)

  4. Can we Improve Patient Safety?

    Directory of Open Access Journals (Sweden)

    Martin Thomas Corbally

    2014-09-01

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

  5. Collaborating with nurse leaders to develop patient safety practices.

    Science.gov (United States)

    Kanerva, Anne; Kivinen, Tuula; Lammintakanen, Johanna

    2017-07-03

    Purpose The organisational level and leadership development are crucial elements in advancing patient safety, because patient safety weaknesses are often caused by system failures. However, little is known about how frontline leader and director teams can be supported to develop patient safety practices. The purpose of this study is to describe the patient safety development process carried out by nursing leaders and directors. The research questions were: how the chosen development areas progressed in six months' time and how nursing leaders view the participatory development process. Design/methodology/approach Participatory action research was used to engage frontline nursing leaders and directors into developing patient safety practices. Semi-structured group interviews ( N = 10) were used in data collection at the end of a six-month action cycle, and data were analysed using content analysis. Findings The participatory development process enhanced collaboration and gave leaders insights into patient safety as a part of the hospital system and their role in advancing it. The chosen development areas advanced to different extents, with the greatest improvements in those areas with simple guidelines to follow and in which the leaders were most participative. The features of high-reliability organisation were moderately identified in the nursing leaders' actions and views. For example, acting as a change agent to implement patient safety practices was challenging. Participatory methods can be used to support leaders into advancing patient safety. However, it is important that the participants are familiar with the method, and there are enough facilitators to steer development processes. Originality/value Research brings more knowledge of how leaders can increase their effectiveness in advancing patient safety and promoting high-reliability organisation features in the healthcare organisation.

  6. Addressing Unison and Uniqueness of Reliability and Safety for Better Integration

    Science.gov (United States)

    Huang, Zhaofeng; Safie, Fayssal

    2015-01-01

    For a long time, both in theory and in practice, safety and reliability have not been clearly differentiated, which leads to confusion, inefficiency, and sometime counter-productive practices in executing each of these two disciplines. It is imperative to address the uniqueness and the unison of these two disciplines to help both disciplines become more effective and to promote a better integration of the two for enhancing safety and reliability in our products as an overall objective. There are two purposes of this paper. First, it will investigate the uniqueness and unison of each discipline and discuss the interrelationship between the two for awareness and clarification. Second, after clearly understanding the unique roles and interrelationship between the two in a product design and development life cycle, we offer suggestions to enhance the disciplines with distinguished and focused roles, to better integrate the two, and to improve unique sets of skills and tools of reliability and safety processes. From the uniqueness aspect, the paper identifies and discusses the respective uniqueness of reliability and safety from their roles, accountability, nature of requirements, technical scopes, detailed technical approaches, and analysis boundaries. It is misleading to equate unreliable to unsafe, since a safety hazard may or may not be related to the component, sub-system, or system functions, which are primarily what reliability addresses. Similarly, failing-to-function may or may not lead to hazard events. Examples will be given in the paper from aerospace, defense, and consumer products to illustrate the uniqueness and differences between reliability and safety. From the unison aspect, the paper discusses what the commonalities between reliability and safety are, and how these two disciplines are linked, integrated, and supplemented with each other to accomplish the customer requirements and product goals. In addition to understanding the uniqueness in

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

    Science.gov (United States)

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

    2016-07-11

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

  8. 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...

  9. 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...

  10. 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...

  11. Study on high reliability safety valve for railway vehicle

    Science.gov (United States)

    Zhang, Xuan; Chen, Ruikun; Zhang, Shixi; Xu, BuDu

    2017-09-01

    Now, the realization of most of the functions of the railway vehicles rely on compressed air, so the demand for compressed air is growing higher and higher. This safety valve is a protection device for pressure limitation and pressure relief in an air supply system of railway vehicles. I am going to introduce the structure, operating principle, research and development process of the safety valve designed by our company in this document.

  12. A survey on reliability and safety analysis techniques of robot systems in nuclear power plants

    Energy Technology Data Exchange (ETDEWEB)

    Eom, H S; Kim, J H; Lee, J C; Choi, Y R; Moon, S S

    2000-12-01

    The reliability and safety analysis techniques was surveyed for the purpose of overall quality improvement of reactor inspection system which is under development in our current project. The contents of this report are : 1. Reliability and safety analysis techniques suvey - Reviewed reliability and safety analysis techniques are generally accepted techniques in many industries including nuclear industry. And we selected a few techniques which are suitable for our robot system. They are falut tree analysis, failure mode and effect analysis, reliability block diagram, markov model, combinational method, and simulation method. 2. Survey on the characteristics of robot systems which are distinguished from other systems and which are important to the analysis. 3. Survey on the nuclear environmental factors which affect the reliability and safety analysis of robot system 4. Collection of the case studies of robot reliability and safety analysis which are performed in foreign countries. The analysis results of this survey will be applied to the improvement of reliability and safety of our robot system and also will be used for the formal qualification and certification of our reactor inspection system.

  13. A survey on reliability and safety analysis techniques of robot systems in nuclear power plants

    International Nuclear Information System (INIS)

    Eom, H.S.; Kim, J.H.; Lee, J.C.; Choi, Y.R.; Moon, S.S.

    2000-12-01

    The reliability and safety analysis techniques was surveyed for the purpose of overall quality improvement of reactor inspection system which is under development in our current project. The contents of this report are : 1. Reliability and safety analysis techniques suvey - Reviewed reliability and safety analysis techniques are generally accepted techniques in many industries including nuclear industry. And we selected a few techniques which are suitable for our robot system. They are falut tree analysis, failure mode and effect analysis, reliability block diagram, markov model, combinational method, and simulation method. 2. Survey on the characteristics of robot systems which are distinguished from other systems and which are important to the analysis. 3. Survey on the nuclear environmental factors which affect the reliability and safety analysis of robot system 4. Collection of the case studies of robot reliability and safety analysis which are performed in foreign countries. The analysis results of this survey will be applied to the improvement of reliability and safety of our robot system and also will be used for the formal qualification and certification of our reactor inspection system

  14. Safety and reliability in the 90s: will past experience or prediction meet our needs?

    International Nuclear Information System (INIS)

    Walter, M.H.; Cox, R.F.

    1990-01-01

    Twenty-six papers are presented in the proceedings of the 1990 Safety and Reliability Society Symposium. The papers selected provide current thinking on improved methods for identification, quantification and management of risks based on the safety culture developed across a range of industries during the last decade. In particular organizational and management factors feature in a large number of the papers. Two papers on the safety of all the operating plants at Sellafield's irradiated nuclear fuel handling and reprocessing site and the selection of field component reliability data for use in nuclear safety studies are selected and indexed separately. (author)

  15. Techniques, processes, and measures for software safety and reliability

    International Nuclear Information System (INIS)

    Sparkman, D.

    1992-01-01

    The purpose of this report is to provide a detailed survey of current recommended practices and measurement techniques for the development of reliable and safe software-based systems. This report is intended to assist the United States Nuclear Reaction Regulation (NRR) in determining the importance and maturity of the available techniques and in assessing the relevance of individual standards for application to instrumentation and control systems in nuclear power generating stations. Lawrence Livermore National Laboratory (LLNL) provides technical support for the Instrumentation and Control System Branch (ICSB) of NRRin advanced instrumentation and control systems, distributed digital systems, software reliability, and the application of verificafion and validafion for the development of software

  16. 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.

  17. Safety systems I/C equipment reliability analyses of the Kozloduy NPP units 3 and 4

    Energy Technology Data Exchange (ETDEWEB)

    Halev, G; Christov, N [Risk Engineering Ltd., Sofia (Bulgaria)

    1996-12-31

    The purpose of the analysis is to assess the safety systems I/C equipment reliability. The assessment includes: quantification of the safety systems unavailability due to component failures; definition of the minimal cut sets leading to the analysed safety systems failure; quantification of the I/C equipment importance measures of the dominant contribution components. The safety systems I/C equipment reliability has been analysed using PSAPACK (a code for probabilistic safety assessment). Fault trees for the following safety systems of the Kozloduy-3 and Kozloduy-4 reactors have been constructed: neutron flow control equipment, reactor protection system, main coolant pumps, pressurizer safety valves `Sempell`, steam dump systems, spray system, low pressure injection system, emergency feeding water system, essential service water system. THree separate reports have been issued containing the performed analyses and results. 1 ref.

  18. Global optimization of maintenance and surveillance testing based on reliability and probabilistic safety assessment. Research project

    International Nuclear Information System (INIS)

    Martorell, S.; Serradell, V.; Munoz, A.; Sanchez, A.

    1997-01-01

    Background, objective, scope, detailed working plan and follow-up and final product of the project ''Global optimization of maintenance and surveillance testing based on reliability and probabilistic safety assessment'' are described

  19. Laboratory errors and patient safety.

    Science.gov (United States)

    Miligy, Dawlat A

    2015-01-01

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

  20. 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.

  1. Assessing medical students' perceptions of patient safety: the medical student safety attitudes and professionalism survey.

    Science.gov (United States)

    Liao, Joshua M; Etchegaray, Jason M; Williams, S Tyler; Berger, David H; Bell, Sigall K; Thomas, Eric J

    2014-02-01

    To develop and test the psychometric properties of a survey to measure students' perceptions about patient safety as observed on clinical rotations. In 2012, the authors surveyed 367 graduating fourth-year medical students at three U.S. MD-granting medical schools. They assessed the survey's reliability and construct and concurrent validity. They examined correlations between students' perceptions of organizational cultural factors, organizational patient safety measures, and students' intended safety behaviors. They also calculated percent positive scores for cultural factors. Two hundred twenty-eight students (62%) responded. Analyses identified five cultural factors (teamwork culture, safety culture, error disclosure culture, experiences with professionalism, and comfort expressing professional concerns) that had construct validity, concurrent validity, and good reliability (Cronbach alphas > 0.70). Across schools, percent positive scores for safety culture ranged from 28% (95% confidence interval [CI], 13%-43%) to 64% (30%-98%), while those for teamwork culture ranged from 47% (32%-62%) to 74% (66%-81%). They were low for error disclosure culture (range: 10% [0%-20%] to 27% [20%-35%]), experiences with professionalism (range: 7% [0%-15%] to 23% [16%-30%]), and comfort expressing professional concerns (range: 17% [5%-29%] to 38% [8%-69%]). Each cultural factor correlated positively with perceptions of overall patient safety as observed in clinical rotations (r = 0.37-0.69, P safety behavioral intent item. This study provided initial evidence for the survey's reliability and validity and illustrated its applicability for determining whether students' clinical experiences exemplify positive patient safety environments.

  2. Engineering reliability in design phase: An application to AP-600 reactor passive safety system

    International Nuclear Information System (INIS)

    Majumdr, D.; Siahpush, A.S.; Hills, S.W.

    1992-01-01

    A computerized reliability enhancement methodology is described that can be used at the engineering design phase to help the designer achieve a desired reliability of the system. It can take into account the limitation imposed by a constraint such as budget, space, or weight. If the desired reliability of the system is known, it can determine the minimum reliabilities of the components, or how many redundant components are needed to achieve the desired reliability. This methodology is applied to examine the Automatic Depressurization System (ADS) of the new passively safe AP-600 reactor. The safety goal of a nuclear reactor dictates a certain reliability level of its components. It is found that a series parallel valve configuration instead of the parallel-series configuration of the four valves in one stage would improve the reliability of the ADS. Other valve characteristics and arrangements are explored to examine different reliability options for the system

  3. System safety and reliability using object-oriented programming techniques

    International Nuclear Information System (INIS)

    Patterson-Hine, F.A.; Koen, B.V.

    1987-01-01

    Direct evaluation fault tree codes have been written in recursive, list-processing computer languages such as PL/1 (PATREC-I) and LISP (PATREC-L). The pattern-matching strategy implemented in these codes has been used extensively in France to evaluate system reliability. Recent reviews of the risk management process suggest that a data base containing plant-specific information be integrated with a package of codes used for probabilistic risk assessment (PRA) to alleviate some of the difficulties that make a PRA so costly and time-intensive. A new programming paradigm, object-oriented programming, is uniquely suited for the development of such a software system. A knowledge base and fault tree evaluation algorithm, based on previous experience with PATREC-L, have been implemented using object-oriented techniques, resulting in a reliability assessment environment that is easy to develop, modify, and extend

  4. Relationships between safety and reliability in major hazard situations

    International Nuclear Information System (INIS)

    Farmer, F.R.

    1978-01-01

    Individual risk rates for various activities are presented and discussed. The concept of societal risk is introduced -the chance of hurting many people from one event. Major hazards present a possibility that an ensuing accident could have a very wide range of consequences from the trivial to a catastrophe. The techniques of assessing risks and consequences are being developed; these are closely related to the techniques of ensuring plant and system reliability. (author)

  5. Use of PRA methodology for enhancing operational safety and reliability

    International Nuclear Information System (INIS)

    Chu, B.; Rumble, E.; Najafi, B.; Putney, B.; Young, J.

    1985-01-01

    This paper describes a broad scope, on-going R and D study, sponsored by the Electric Power Research Institute (EPRI) to utilize key features of the state-of-the-art plant information management and system analysis techniques to develop and demonstrate a practical engineering tool for assisting plant engineering and operational staff to perform their activities more effectively. The study is foreseen to consist of two major activities: to develop a user-friendly, integrated software system; and to demonstrate the applications of this software on-site. This integrated software, Reliability Analysis Program with In-Plant Data (RAPID), will consist of three types of interrelated elements: an Executive Controller which will provide engineering and operations staff users with interface and control of the other two software elements, a Data Base Manager which can acquire, store, select, and transfer data, and Applications Modules which will perform the specific reliability-oriented functions. A broad range of these functions has been envisaged. The immediate emphasis will be focused on four application modules: a Plant Status Module, a Technical Specification Optimization Module, a Reliability Assessment Module, and a Utility Module for acquiring plant data

  6. Application of reliability analysis methods to the comparison of two safety circuits

    International Nuclear Information System (INIS)

    Signoret, J.-P.

    1975-01-01

    Two circuits of different design, intended for assuming the ''Low Pressure Safety Injection'' function in PWR reactors are analyzed using reliability methods. The reliability analysis of these circuits allows the failure trees to be established and the failure probability derived. The dependence of these results on test use and maintenance is emphasized as well as critical paths. The great number of results obtained may allow a well-informed choice taking account of the reliability wanted for the type of circuits [fr

  7. 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.).

  8. 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.)

  9. Reliability Analysis and Calibration of Partial Safety Factors for Redundant Structures

    DEFF Research Database (Denmark)

    Sørensen, John Dalsgaard

    1998-01-01

    Redundancy is important to include in the design and analysis of structural systems. In most codes of practice redundancy is not directly taken into account. In the paper various definitions of a deterministic and reliability based redundancy measure are reviewed. It is described how reundancy can...... be included in the safety system and how partial safety factors can be calibrated. An example is presented illustrating how redundancy is taken into account in the safety system in e.g. the Danish codes. The example shows how partial safety factors can be calibrated to comply with the safety level...

  10. Design measures to increase safety and reliability of power station control and protection systems

    International Nuclear Information System (INIS)

    Edelmann, J.; Spieth, W.

    1977-06-01

    The paper reviews a few criteria which exert a considerable influence on the safety and reliability of monitoring and control systems. When judging the safety and reliability of a system, it is of importance not only to look at the failures of just one part of a system but also to take into account the effect these failures have on the overall process. In this respect there is a marked difference between a centralized and a decentralized system. With the technical equipment nowadays at our disposal a high safety standard has been reached. Redundant and dynamic protection systems make the occurrence of a dangerous failure hypothetic. (Author)

  11. Demonstration of the reliability of the safety pumps

    International Nuclear Information System (INIS)

    Durand, J.M.

    1989-01-01

    POMPES GUINARD is supplying about 60% of the Nuclear pumps for the French Program. To become the specialist of Safety Related Pumps POMPES GUINARD made a lot of efforts and investments to acquire knowledge and experience. This was possible mainly with test on special loops as it is the only way for a pump manufacturer to progress by controlling hydraulics, components, bearings, mechanical seals, inducer, mechanical and hydraulic behaviour of the units in process of time. We will describe hereafter some of the typical tests which were performed during the last fifteen years

  12. 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.

  13. How to interpret safety critical failures in risk and reliability assessments

    International Nuclear Information System (INIS)

    Selvik, Jon Tømmerås; Signoret, Jean-Pierre

    2017-01-01

    Management of safety systems often receives high attention due to the potential for industrial accidents. In risk and reliability literature concerning such systems, and particularly concerning safety-instrumented systems, one frequently comes across the term ‘safety critical failure’. It is a term associated with the term ‘critical failure’, and it is often deduced that a safety critical failure refers to a failure occurring in a safety critical system. Although this is correct in some situations, it is not matching with for example the mathematical definition given in ISO/TR 12489:2013 on reliability modeling, where a clear distinction is made between ‘safe failures’ and ‘dangerous failures’. In this article, we show that different interpretations of the term ‘safety critical failure’ exist, and there is room for misinterpretations and misunderstandings regarding risk and reliability assessments where failure information linked to safety systems are used, and which could influence decision-making. The article gives some examples from the oil and gas industry, showing different possible interpretations of the term. In particular we discuss the link between criticality and failure. The article points in general to the importance of adequate risk communication when using the term, and gives some clarification on interpretation in risk and reliability assessments.

  14. 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

  15. 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.

  16. Development of a Reliability Program approach to assuring operational nuclear safety

    International Nuclear Information System (INIS)

    Mueller, C.J.; Bezella, W.A.

    1985-01-01

    A Reliability Program (RP) model based on proven reliability techniques used in other high technology industries is being formulated for potential application in the nuclear power industry. Research findings are discussed. The reliability methods employed under NASA and military direction, commercial airline and related FAA programs were surveyed with several reliability concepts (e.g., quantitative reliability goals, reliability centered maintenance) appearing to be directly transferable. Other tasks in the RP development effort involved the benchmarking and evaluation of the existing nuclear regulations and practices relevant to safety/reliability integration. A review of current risk-dominant issues was also conducted using results from existing probabilistic risk assessment studies. The ongoing RP development tasks have concentrated on defining a RP for the operating phase of a nuclear plant's lifecycle. The RP approach incorporates safety systems risk/reliability analysis and performance monitoring activities with dedicated tasks that integrate these activities with operating, surveillance, and maintenance of the plant. The detection, root-cause evaluation and before-the-fact correction of incipient or actual systems failures as a mechanism for maintaining plant safety is a major objective of the RP

  17. Human reliability analysis in Loviisa probabilistic safety analysis

    International Nuclear Information System (INIS)

    Illman, L.; Isaksson, J.; Makkonen, L.; Vaurio, J.K.; Vuorio, U.

    1986-01-01

    The human reliability analysis in the Loviisa PSA project is carried out for three major groups of errors in human actions: (A) errors made before an initiating event, (B) errors that initiate a transient and (C) errors made during transients. Recovery possibilities are also included in each group. The methods used or planned for each group are described. A simplified THERP approach is used for group A, with emphasis on test and maintenance error recovery aspects and dependencies between redundancies. For group B, task analyses and human factors assessments are made for startup, shutdown and operational transients, with emphasis on potential common cause initiators. For group C, both misdiagnosis and slow decision making are analyzed, as well as errors made in carrying out necessary or backup actions. New or advanced features of the methodology are described

  18. A region addresses patient safety.

    Science.gov (United States)

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

    2002-06-01

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

  19. 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

  20. Use of reliability analysis for the safety evaluation of technical facilities

    International Nuclear Information System (INIS)

    Balfanz, H.P.; Eggert, H.; Lindauer, E.

    1975-01-01

    Using examples from nuclear technology, the following is discussed: how efficient the present practical measures are for increasing reliability, which weak points can be recognized and what appears to be the most promising direction to take for improvements. The following are individually dealt with: 1) determination of the relevant parameters for the safety of a plant; 2) definition and fixing of reliability requirements; 3) process to prove the fulfilment of requirements; 4) measures to guarantee the reliability; 5) data feed-back to check and improve the reliability. (HP/LH) [de

  1. Reactor pressure vessels safety and reliability - certainty and uncertainty

    International Nuclear Information System (INIS)

    O'Neil, R.

    1977-01-01

    In the paper, it is suggested that the hazard to the population which would result from vessel failure rate of the order of 10 -6 to 10 -7 per vessel year could be acceptable to society on the basis of other natural and man-made risks. The paper considers the problems of demonstrating safety by calculation based on fracture mechanics, and indicates some of the uncertainties, and inconsistencies in the theory, particularly the effect of cracks in locally degraded volumes of material. The phenomenon of crack arrest is considered, and attention is drawn to the uncertainties as indicated at least by some tests. There is need for speedy resolution of this problem. The uncertainties in material properties, heat treatment and residual stresses are considered, and a proposed upper limit for residual defects ('original sin') is proposed. (orig.) [de

  2. Patient handover in orthopaedics, improving safety using Information Technology.

    Science.gov (United States)

    Pearkes, Tim

    2015-01-01

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

  3. Qualitative and quantitative reliability analysis of safety systems

    International Nuclear Information System (INIS)

    Karimi, R.; Rasmussen, N.; Wolf, L.

    1980-05-01

    A code has been developed for the comprehensive analysis of a fault tree. The code designated UNRAC (UNReliability Analysis Code) calculates the following characteristics of an input fault tree: (1) minimal cut sets; (2) top event unavailability as point estimate and/or in time dependent form; (3) quantitative importance of each component involved; and, (4) error bound on the top event unavailability. UNRAC can analyze fault trees, with any kind of gates (EOR, NAND, NOR, AND, OR), up to a maximum of 250 components and/or gates. The code is benchmarked against WAMCUT, MODCUT, KITT, BIT-FRANTIC, and PL-MODT. The results showed that UNRAC produces results more consistent with the KITT results than either BIT-FRANTIC or PL-MODT. Overall it is demonstrated that UNRAC is an efficient easy-to-use code and has the advantage of being able to do a complete fault tree analysis with this single code. Applications of fault tree analysis to safety studies of nuclear reactors are considered

  4. Safety, reliability, risk management and human factors: an integrated engineering approach applied to nuclear facilities

    Energy Technology Data Exchange (ETDEWEB)

    Vasconcelos, Vanderley de; Silva, Eliane Magalhaes Pereira da; Costa, Antonio Carlos Lopes da; Reis, Sergio Carneiro dos [Centro de Desenvolvimento da Tecnologia Nuclear (CDTN/CNEN-MG), Belo Horizonte, MG (Brazil)], e-mail: vasconv@cdtn.br, e-mail: silvaem@cdtn.br, e-mail: aclc@cdtn.br, e-mail: reissc@cdtn.br

    2009-07-01

    Nuclear energy has an important engineering legacy to share with the conventional industry. Much of the development of the tools related to safety, reliability, risk management, and human factors are associated with nuclear plant processes, mainly because the public concern about nuclear power generation. Despite the close association between these subjects, there are some important different approaches. The reliability engineering approach uses several techniques to minimize the component failures that cause the failure of the complex systems. These techniques include, for instance, redundancy, diversity, standby sparing, safety factors, and reliability centered maintenance. On the other hand system safety is primarily concerned with hazard management, that is, the identification, evaluation and control of hazards. Rather than just look at failure rates or engineering strengths, system safety would examine the interactions among system components. The events that cause accidents may be complex combinations of component failures, faulty maintenance, design errors, human actions, or actuation of instrumentation and control. Then, system safety deals with a broader spectrum of risk management, including: ergonomics, legal requirements, quality control, public acceptance, political considerations, and many other non-technical influences. Taking care of these subjects individually can compromise the completeness of the analysis and the measures associated with both risk reduction, and safety and reliability increasing. Analyzing together the engineering systems and controls of a nuclear facility, their management systems and operational procedures, and the human factors engineering, many benefits can be realized. This paper proposes an integration of these issues based on the application of systems theory. (author)

  5. Safety, reliability, risk management and human factors: an integrated engineering approach applied to nuclear facilities

    International Nuclear Information System (INIS)

    Vasconcelos, Vanderley de; Silva, Eliane Magalhaes Pereira da; Costa, Antonio Carlos Lopes da; Reis, Sergio Carneiro dos

    2009-01-01

    Nuclear energy has an important engineering legacy to share with the conventional industry. Much of the development of the tools related to safety, reliability, risk management, and human factors are associated with nuclear plant processes, mainly because the public concern about nuclear power generation. Despite the close association between these subjects, there are some important different approaches. The reliability engineering approach uses several techniques to minimize the component failures that cause the failure of the complex systems. These techniques include, for instance, redundancy, diversity, standby sparing, safety factors, and reliability centered maintenance. On the other hand system safety is primarily concerned with hazard management, that is, the identification, evaluation and control of hazards. Rather than just look at failure rates or engineering strengths, system safety would examine the interactions among system components. The events that cause accidents may be complex combinations of component failures, faulty maintenance, design errors, human actions, or actuation of instrumentation and control. Then, system safety deals with a broader spectrum of risk management, including: ergonomics, legal requirements, quality control, public acceptance, political considerations, and many other non-technical influences. Taking care of these subjects individually can compromise the completeness of the analysis and the measures associated with both risk reduction, and safety and reliability increasing. Analyzing together the engineering systems and controls of a nuclear facility, their management systems and operational procedures, and the human factors engineering, many benefits can be realized. This paper proposes an integration of these issues based on the application of systems theory. (author)

  6. 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...

  7. 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...

  8. 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...

  9. 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...

  10. 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...

  11. 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...

  12. Standardization of domestic human reliability analysis and experience of human reliability analysis in probabilistic safety assessment for NPPs under design

    International Nuclear Information System (INIS)

    Kang, D. I.; Jung, W. D.

    2002-01-01

    This paper introduces the background and development activities of domestic standardization of procedure and method for Human Reliability Analysis (HRA) to avoid the intervention of subjectivity by HRA analyst in Probabilistic Safety Assessment (PSA) as possible, and the review of the HRA results for domestic nuclear power plants under design studied by Korea Atomic Energy Research Institute. We identify the HRA methods used for PSA for domestic NPPs and discuss the subjectivity of HRA analyst shown in performing a HRA. Also, we introduce the PSA guidelines published in USA and review the HRA results based on them. We propose the system of a standard procedure and method for HRA to be developed

  13. Conceptual Software Reliability Prediction Models for Nuclear Power Plant Safety Systems

    International Nuclear Information System (INIS)

    Johnson, G.; Lawrence, D.; Yu, H.

    2000-01-01

    The objective of this project is to develop a method to predict the potential reliability of software to be used in a digital system instrumentation and control system. The reliability prediction is to make use of existing measures of software reliability such as those described in IEEE Std 982 and 982.2. This prediction must be of sufficient accuracy to provide a value for uncertainty that could be used in a nuclear power plant probabilistic risk assessment (PRA). For the purposes of the project, reliability was defined to be the probability that the digital system will successfully perform its intended safety function (for the distribution of conditions under which it is expected to respond) upon demand with no unintended functions that might affect system safety. The ultimate objective is to use the identified measures to develop a method for predicting the potential quantitative reliability of a digital system. The reliability prediction models proposed in this report are conceptual in nature. That is, possible prediction techniques are proposed and trial models are built, but in order to become a useful tool for predicting reliability, the models must be tested, modified according to the results, and validated. Using methods outlined by this project, models could be constructed to develop reliability estimates for elements of software systems. This would require careful review and refinement of the models, development of model parameters from actual experience data or expert elicitation, and careful validation. By combining these reliability estimates (generated from the validated models for the constituent parts) in structural software models, the reliability of the software system could then be predicted. Modeling digital system reliability will also require that methods be developed for combining reliability estimates for hardware and software. System structural models must also be developed in order to predict system reliability based upon the reliability

  14. Reliability and safety program plan outline for the operational phase of a waste isolation facility

    International Nuclear Information System (INIS)

    Ammer, H.G.; Wood, D.E.

    1977-01-01

    A Reliability and Safety Program plan outline has been prepared for the operational phase of a Waste Isolation Facility. The program includes major functions of risk assessment, technical support activities, quality assurance, operational safety, configuration monitoring, reliability analysis and support and coordination meetings. Detailed activity or task descriptions are included for each function. Activities are time-phased and presented in the PERT format for scheduling and interactions. Task descriptions include manloading, travel, and computer time estimates to provide data for future costing. The program outlined here will be used to provide guidance from a reliability and safety standpoint to design, procurement, construction, and operation of repositories for nuclear waste. These repositories are to be constructed under the National Waste Terminal Storage program under the direction of the Office of Waste Isolation, Union Carbide Corp. Nuclear Division

  15. Analysis of the reliability of the active injection safety systems of Angra I

    International Nuclear Information System (INIS)

    Frutuoso e Melo, P.F.F.

    1981-01-01

    The reliability of the active emergency core cooling systems of Angra I nuclear power plant is evaluated. The fault tree analysis is employed. The unavailability of the above cited systems, is calculated. A parametric sensitivity analysis has been performed, due to the existing scattering in the failure and repair rate data of these system's components. The minimal cut sets were determined and, as a final step, a reliability importance analysis has been performed. This final step has required the development of a computer program. The methodology and data from the 'Reactor Safety Study' (Wash-1400) (in which the reliability of safety systems of a tipical PWR plant is calculated), is employed. The unavailability values for the safety systems analysed are too low, thus showing that in most cases the systems analysed are available to mitigate the effects of a loss-of-coolant accident. (Author) [pt

  16. High level issues in reliability quantification of safety-critical software

    International Nuclear Information System (INIS)

    Kim, Man Cheol

    2012-01-01

    For the purpose of developing a consensus method for the reliability assessment of safety-critical digital instrumentation and control systems in nuclear power plants, several high level issues in reliability assessment of the safety-critical software based on Bayesian belief network modeling and statistical testing are discussed. Related to the Bayesian belief network modeling, the relation between the assessment approach and the sources of evidence, the relation between qualitative evidence and quantitative evidence, how to consider qualitative evidence, and the cause-consequence relation are discussed. Related to the statistical testing, the need of the consideration of context-specific software failure probabilities and the inability to perform a huge number of tests in the real world are discussed. The discussions in this paper are expected to provide a common basis for future discussions on the reliability assessment of safety-critical software. (author)

  17. Identifying organizational cultures that promote patient safety.

    Science.gov (United States)

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

    2009-01-01

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

  18. Reliability

    OpenAIRE

    Condon, David; Revelle, William

    2017-01-01

    Separating the signal in a test from the irrelevant noise is a challenge for all measurement. Low test reliability limits test validity, attenuates important relationships, and can lead to regression artifacts. Multiple approaches to the assessment and improvement of reliability are discussed. The advantages and disadvantages of several different approaches to reliability are considered. Practical advice on how to assess reliability using open source software is provided.

  19. 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.

  20. Cognitive human reliability analysis for an assessment of the safety significance of complex transients

    International Nuclear Information System (INIS)

    Amico, P.J.; Hsu, C.J.; Youngblood, R.W.; Fitzpatrick, R.G.

    1989-01-01

    This paper reports that as part of a probabilistic assessment of the safety significance of complex transients at certain PWR power plants, it was necessary to perform a cognitive human reliability analysis. To increase the confidence in the results, it was desirable to make use of actual observations of operator response which were available for the assessment. An approach was developed which incorporated these observations into the human cognitive reliability (HCR) modeling approach. The results obtained provided additional insights over what would have been found using other approaches. These insights were supported by the observations, and it is suggested that this approach be considered for use in future probabilistic safety assessments

  1. First evidence on the validity and reliability of the Safety Organizing Scale-Nursing Home version (SOS-NH).

    Science.gov (United States)

    Ausserhofer, Dietmar; Anderson, Ruth A; Colón-Emeric, Cathleen; Schwendimann, René

    2013-08-01

    The Safety Organizing Scale is a valid and reliable measure on safety behaviors and practices in hospitals. This study aimed to explore the psychometric properties of the Safety Organizing Scale-Nursing Home version (SOS-NH). In a cross-sectional analysis of staff survey data, we examined validity and reliability of the 9-item Safety SOS-NH using American Educational Research Association guidelines. This substudy of a larger trial used baseline survey data collected from staff members (n = 627) in a variety of work roles in 13 nursing homes (NHs) in North Carolina and Virginia. Psychometric evaluation of the SOS-NH revealed good response patterns with low average of missing values across all items (3.05%). Analyses of the SOS-NH's internal structure (eg, comparative fit indices = 0.929, standardized root mean square error of approximation = 0.045) and consistency (composite reliability = 0.94) suggested its 1-dimensionality. Significant between-facility variability, intraclass correlations, within-group agreement, and design effect confirmed appropriateness of the SOS-NH for measurement at the NH level, justifying data aggregation. The SOS-NH showed discriminate validity from one related concept: communication openness. Initial evidence regarding validity and reliability of the SOS-NH supports its utility in measuring safety behaviors and practices among a wide range of NH staff members, including those with low literacy. Further psychometric evaluation should focus on testing concurrent and criterion validity, using resident outcome measures (eg, patient fall rates). Copyright © 2013 American Medical Directors Association, Inc. All rights reserved.

  2. Application of Cold Chain Logistics Safety Reliability in Fresh Food Distribution Optimization

    OpenAIRE

    Zou Yifeng; Xie Ruhe

    2013-01-01

    In view of the nature of fresh food’s continuous decrease of safety during distribution process, this study applied safety reliability of food cold chain logistics to establish fresh food distribution routing optimization model with time windows, and solved the model using MAX-MIN Ant System (MMAS) with case analysis. Studies have shown that the mentioned model and algorithm can better solve the problem of fresh food distribution routing optimization with time windows.

  3. 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

  4. Reliability estimation of safety-critical software-based systems using Bayesian networks

    International Nuclear Information System (INIS)

    Helminen, A.

    2001-06-01

    Due to the nature of software faults and the way they cause system failures new methods are needed for the safety and reliability evaluation of software-based safety-critical automation systems in nuclear power plants. In the research project 'Programmable automation system safety integrity assessment (PASSI)', belonging to the Finnish Nuclear Safety Research Programme (FINNUS, 1999-2002), various safety assessment methods and tools for software based systems are developed and evaluated. The project is financed together by the Radiation and Nuclear Safety Authority (STUK), the Ministry of Trade and Industry (KTM) and the Technical Research Centre of Finland (VTT). In this report the applicability of Bayesian networks to the reliability estimation of software-based systems is studied. The applicability is evaluated by building Bayesian network models for the systems of interest and performing simulations for these models. In the simulations hypothetical evidence is used for defining the parameter relations and for determining the ability to compensate disparate evidence in the models. Based on the experiences from modelling and simulations we are able to conclude that Bayesian networks provide a good method for the reliability estimation of software-based systems. (orig.)

  5. Is the Frontal Assessment Battery reliable in ALS patients?

    NARCIS (Netherlands)

    Raaphorst, J.; Beeldman, E.; Jaeger, B.; Schmand, B.A.; Berg, L.H. van den; Weikamp, J.G.; Schelhaas, H.J.; Visser, M. de; Haan, R.J. de

    2013-01-01

    The assessment of frontal functions in ALS patients is important because of the overlap with the behavioural variant of frontotemporal dementia (bvFTD). We investigated the applicability and reliability of the Frontal Assessment Battery (FAB) within a cohort of predominantly prevalent ALS patients.

  6. [Does simulator-based team training improve patient safety?].

    Science.gov (United States)

    Trentzsch, H; Urban, B; Sandmeyer, B; Hammer, T; Strohm, P C; Lazarovici, M

    2013-10-01

    Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

  7. Summary of component reliability data for probabilistic safety analysis of Korean standard nuclear power plant

    International Nuclear Information System (INIS)

    Choi, S. Y.; Han, S. H.

    2004-01-01

    The reliability data of Korean NPP that reflects the plant specific characteristics is necessary for PSA of Korean nuclear power plants. We have performed a study to develop the component reliability DB and S/W for component reliability analysis. Based on the system, we had have collected the component operation data and failure/repair data during plant operation data to 1998/2000 for YGN 3,4/UCN 3,4 respectively. Recently, we have upgraded the database by collecting additional data by 2002 for Korean standard nuclear power plants and performed component reliability analysis and Bayesian analysis again. In this paper, we supply the summary of component reliability data for probabilistic safety analysis of Korean standard nuclear power plant and describe the plant specific characteristics compared to the generic data

  8. Reliability Analysis on NPP's Safety-Related Control Module with Field Data

    International Nuclear Information System (INIS)

    Lee, Sang Yong; Jung, Jae Hyun; Kim, Seong Hun

    2006-01-01

    The automatic control systems used in nuclear power plant (NPP) consists of numerous control modules that can be considered to be a network of components various complex ways. The control modules require relatively high reliability than industrial electronic products. Reliability prediction provides the rational basis of system designs and also provides the safety significance of system operations. The aim of this paper is to minimize the deficiencies of the traditional reliability prediction method calculation using the available field return data. This way is possible to do more realistic reliability assessment. SAMCHANG Enterprise Company (SEC) has established database containing high quality data at the module and component level from module maintenance in NPP. On the basis of these, this paper compares results that add failure record (field data) to Telcordia-SR-332 reliability prediction model with MIL-HDBK-217F prediction results

  9. 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

  10. The engineering project and reliability research of the safety interlock slow control system in BESIII

    International Nuclear Information System (INIS)

    Zhang Yinhong; Zhao Jingwei; Li Xiaonan; Xie Xiaoxi; Gao Cuishan; Bai Jingzhi; Chen Xihui; Min Jian; Nie Zhendong

    2008-01-01

    The new safety interlock slow control system of BESIII is designed to ensure that the BESIII interior equipments and the accelerator control center to work in coordination, and to guarantee the safety of the operating staff and all the important equipments at the same time. This paper introduces the hardware and software design of safety interlock system from the engineering requirements angle, including a detailed research on the software implementation technique of the state machine on PLC and the reliability of the system. (authors)

  11. Nuclear power plant's safety and risk (requirements of safety and reliability)

    International Nuclear Information System (INIS)

    Franzen, L.F.

    1977-01-01

    Starting out from the given safety objectives as they have evolved during the past few years and from the present legal and regulatory provisions for the construction and operation of nuclear power plants, the hazards involved in regular operation, accidents and emergency situations are discussed. In compliance with the positive safety balance of nuclear power plants in the FRG, special attention is focused on the preventive safety analysis within the frame of the nuclear licensing procedure. Reference is made to the beginnings of a comprehensive hazard concept for an unbiased plant assessment. Emergency situations are discussed from the point of view of general hazard comparisons. (orig.) [de

  12. Use of reliability engineering tools in safety and risk assessment of nuclear facilities

    Energy Technology Data Exchange (ETDEWEB)

    Raso, Amanda Laureano; Vasconcelos, Vanderley de; Marques, Raíssa Oliveira; Soares, Wellington Antonio; Mesquita, Amir Zacarias, E-mail: amandaraso@hotmail.com, E-mail: vasconv@cdtn.br, E-mail: raissaomarques@gmail.com, E-mail: soaresw@cdtn.br, E-mail: amir@cdtn.br [Centro de Desenvolvimento da Tecnologia Nuclear (CDTN/CNEN-MG), Belo Horizonte, MG (Brazil). Serviço de Tecnologia de Reatores

    2017-07-01

    Safety, reliability and availability are fundamental criteria in design, construction and operation of nuclear facilities, as nuclear power plants. Deterministic and probabilistic risk assessments of such facilities are required by regulatory authorities in order to meet licensing regulations, contributing to assure safety, as well as reduce costs and environmental impacts. Probabilistic Risk Assessment has become an important part of licensing requirements of the nuclear power plants in Brazil and in the world. Risk can be defined as a qualitative and/or quantitative assessment of accident sequence frequencies (or probabilities) and their consequences. Risk management is a systematic application of management policies, procedures and practices to identify, analyze, plan, implement, control, communicate and document risks. Several tools and computer codes must be combined, in order to estimate both probabilities and consequences of accidents. Event Tree Analysis (ETA), Fault Tree Analysis (FTA), Reliability Block Diagrams (RBD), and Markov models are examples of evaluation tools that can support the safety and risk assessment for analyzing process systems, identifying potential accidents, and estimating consequences. Because of complexity of such analyzes, specialized computer codes are required, such as the reliability engineering software develop by Reliasoft® Corporation. BlockSim (FTA, RBD and Markov models), RENO (ETA and consequence assessment), Weibull++ (life data and uncertainty analysis), and Xfmea (qualitative risk assessment) are some codes that can be highlighted. This work describes an integrated approach using these tools and software to carry out reliability, safety, and risk assessment of nuclear facilities, as well as, and application example. (author)

  13. Use of reliability engineering tools in safety and risk assessment of nuclear facilities

    International Nuclear Information System (INIS)

    Raso, Amanda Laureano; Vasconcelos, Vanderley de; Marques, Raíssa Oliveira; Soares, Wellington Antonio; Mesquita, Amir Zacarias

    2017-01-01

    Safety, reliability and availability are fundamental criteria in design, construction and operation of nuclear facilities, as nuclear power plants. Deterministic and probabilistic risk assessments of such facilities are required by regulatory authorities in order to meet licensing regulations, contributing to assure safety, as well as reduce costs and environmental impacts. Probabilistic Risk Assessment has become an important part of licensing requirements of the nuclear power plants in Brazil and in the world. Risk can be defined as a qualitative and/or quantitative assessment of accident sequence frequencies (or probabilities) and their consequences. Risk management is a systematic application of management policies, procedures and practices to identify, analyze, plan, implement, control, communicate and document risks. Several tools and computer codes must be combined, in order to estimate both probabilities and consequences of accidents. Event Tree Analysis (ETA), Fault Tree Analysis (FTA), Reliability Block Diagrams (RBD), and Markov models are examples of evaluation tools that can support the safety and risk assessment for analyzing process systems, identifying potential accidents, and estimating consequences. Because of complexity of such analyzes, specialized computer codes are required, such as the reliability engineering software develop by Reliasoft® Corporation. BlockSim (FTA, RBD and Markov models), RENO (ETA and consequence assessment), Weibull++ (life data and uncertainty analysis), and Xfmea (qualitative risk assessment) are some codes that can be highlighted. This work describes an integrated approach using these tools and software to carry out reliability, safety, and risk assessment of nuclear facilities, as well as, and application example. (author)

  14. 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.

  15. 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

  16. A study on a reliability assessment methodology for the VHTR safety systems

    International Nuclear Information System (INIS)

    Lee, Hyung Sok

    2012-02-01

    The passive safety system of a 300MWt VHTR (Very High Temperature Reactor)which has attracted worldwide attention recently is actively considered for designing the improvement in the safety of the next generation nuclear power plant. The passive system functionality does not rely on an external source of the electrical support system,but on an intelligent use of the natural phenomena, such as convection, conduction, radiation, and gravity. It is not easy to evaluate quantitatively the reliability of the passive safety for the risk analysis considering the existing active system failure since the classical reliability assessment method could not be applicable. Therefore a new reliability methodology needs to be developed and applied for evaluating the reliability of the conceptual designed VHTR in this study. The preliminary evaluation and conceptualization are performed using the concept of the load and capacity theory related to the reliability physics model. The method of response surface method (RSM) is also utilized for evaluating the maximum temperature of nuclear fuel in this study. The significant variables and their correlation are considered for utilizing the GAMMA+ code. The proposed method might contribute to designing the new passive system of the VHTR

  17. Quantitative dynamic reliability evaluation of AP1000 passive safety systems by using FMEA and GO-FLOW methodology

    International Nuclear Information System (INIS)

    Hashim Muhammad; Yoshikawa, Hidekazu; Matsuoka, Takeshi; Yang Ming

    2014-01-01

    The passive safety systems utilized in advanced pressurized water reactor (PWR) design such as AP1000 should be more reliable than that of active safety systems of conventional PWR by less possible opportunities of hardware failures and human errors (less human intervention). The objectives of present study are to evaluate the dynamic reliability of AP1000 plant in order to check the effectiveness of passive safety systems by comparing the reliability-related issues with that of active safety systems in the event of the big accidents. How should the dynamic reliability of passive safety systems properly evaluated? And then what will be the comparison of reliability results of AP1000 passive safety systems with the active safety systems of conventional PWR. For this purpose, a single loop model of AP1000 passive core cooling system (PXS) and passive containment cooling system (PCCS) are assumed separately for quantitative reliability evaluation. The transient behaviors of these passive safety systems are taken under the large break loss-of-coolant accident in the cold leg. The analysis is made by utilizing the qualitative method failure mode and effect analysis in order to identify the potential failure mode and success-oriented reliability analysis tool called GO-FLOW for quantitative reliability evaluation. The GO-FLOW analysis has been conducted separately for PXS and PCCS systems under the same accident. The analysis results show that reliability of AP1000 passive safety systems (PXS and PCCS) is increased due to redundancies and diversity of passive safety subsystems and components, and four stages automatic depressurization system is the key subsystem for successful actuation of PXS and PCCS system. The reliability results of PCCS system of AP1000 are more reliable than that of the containment spray system of conventional PWR. And also GO-FLOW method can be utilized for reliability evaluation of passive safety systems. (author)

  18. Application of safety and reliability approaches in the power sector: Inside-sectoral overview

    DEFF Research Database (Denmark)

    Kozine, Igor

    2010-01-01

    This chapter summarizes the state-of-the-art and state-of-practice on the applications of safety and reliability approaches in the Power Sector. The nature and composition of this industrial sector including the characteristics of major hazards are summarized. The present situation with regard...... to a number of key technical aspects involved in the use of safety and reliability approaches in the power sector is discussed. Based on this review a Technology Maturity Matrix is synthesized. Barriers to the wider use of risk and reliability methods in the design and operation of power installations...... are identified and possible ways of overcoming these barriers are suggested. Key issues and priorities for research are identified....

  19. Software coding for reliable data communication in a reactor safety system

    International Nuclear Information System (INIS)

    Maghsoodi, R.

    1978-01-01

    A software coding method is proposed to improve the communication reliability of a microprocessor based fast-reactor safety system. This method which replaces the conventional coding circuitry, applies a program to code the data which is communicated between the processors via their data memories. The system requirements are studied and the suitable codes are suggested. The problems associated with hardware coders, and the advantages of software coding methods are discussed. The product code which proves a faster coding time over the cyclic code is chosen as the final code. Then the improvement of the communication reliability is derived for a processor and its data memory. The result is used to calculate the reliability improvement of the processing channel as the basic unit for the safety system. (author)

  20. An Assessment of the VHTR Safety Distance Using the Reliability Physics Model

    International Nuclear Information System (INIS)

    Lee, Joeun; Kim, Jintae; Jae, Moosung

    2015-01-01

    In Korea planning the production of hydrogen using high temperature from nuclear power is in progress. To produce hydrogen from nuclear plants, supplying temperature above 800 .deg. C is required. Therefore, Very High Temperature Reactor (VHTR) which is able to provide about 950 .deg. C is suitable. In situation of high temperature and corrosion where hydrogen might be released easily, hydrogen production facility using VHTR has a danger of explosion. Moreover explosion not only has a bad influence upon facility itself but also on VHTR. Those explosions result in unsafe situation that cause serious damage. However, In terms of thermal-hydraulics view, long distance makes low efficiency Thus, in this study, a methodology for the safety assessment of safety distance between the hydrogen production facilities and the VHTR is developed with reliability physics model. Based on the standard safety criteria which is a value of 1 x 10 -6 , the safety distance between the hydrogen production facilities and the VHTR using reliability physics model are calculated to be a value of 60m - 100m. In the future, assessment for characteristic of VHTR, the capacity to resist pressure from outside hydrogen explosion and the overpressure for the large amount of detonation volume in detail is expected to identify more precise safety distance using this reliability physics model

  1. Reliability and Maintainability Engineering - A Major Driver for Safety and Affordability

    Science.gov (United States)

    Safie, Fayssal M.

    2011-01-01

    The United States National Aeronautics and Space Administration (NASA) is in the midst of an effort to design and build a safe and affordable heavy lift vehicle to go to the moon and beyond. To achieve that, NASA is seeking more innovative and efficient approaches to reduce cost while maintaining an acceptable level of safety and mission success. One area that has the potential to contribute significantly to achieving NASA safety and affordability goals is Reliability and Maintainability (R&M) engineering. Inadequate reliability or failure of critical safety items may directly jeopardize the safety of the user(s) and result in a loss of life. Inadequate reliability of equipment may directly jeopardize mission success. Systems designed to be more reliable (fewer failures) and maintainable (fewer resources needed) can lower the total life cycle cost. The Department of Defense (DOD) and industry experience has shown that optimized and adequate levels of R&M are critical for achieving a high level of safety and mission success, and low sustainment cost. Also, lessons learned from the Space Shuttle program clearly demonstrated the importance of R&M engineering in designing and operating safe and affordable launch systems. The Challenger and Columbia accidents are examples of the severe impact of design unreliability and process induced failures on system safety and mission success. These accidents demonstrated the criticality of reliability engineering in understanding component failure mechanisms and integrated system failures across the system elements interfaces. Experience from the shuttle program also shows that insufficient Reliability, Maintainability, and Supportability (RMS) engineering analyses upfront in the design phase can significantly increase the sustainment cost and, thereby, the total life cycle cost. Emphasis on RMS during the design phase is critical for identifying the design features and characteristics needed for time efficient processing

  2. 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...

  3. Work Practice, Safety and Heedfulness. Studies of Organizational Reliability in Hospitals and Nuclear Power Plants

    International Nuclear Information System (INIS)

    Gauthereau, Vincent

    2003-01-01

    The study of safety in complex systems has focused on different issues over the past decades. This focus was often linked to the conclusions of previous accidents'/incidents' analyses. When accidents were attributed to technical causes, safety research focused on technical developments. When they were later attributed to 'human errors', safety research focused on this 'component'. And when, since the mid-eighties accidents have been attributed to 'organizational factors', safety research has focused on these very same 'organizational factors'. The present thesis argues for a 'practice view' over safety to be taken. This view is mainly drawn from the field of research on High Reliability Organizations (HRO). HRO theorists' point of view on safety is that we can operate complex systems safely despite the fact that we have made them so complex that they are prone to 'normal accidents'. Humans involved in the operation of our systems actually create safety. Safety is formed through the adaptation of work practice to local conditions, and this adaptation is part of safe operation. Safety is not only a substantial quality of our socio-technical systems: the discursive dimension of safety actually seems to be a central component of safety creation. However, the adaptive ability of HRO can sometimes become their downfall. Adaptation, which is the backbone of safety, can sometimes be a drawback as well. Consequently, the practice view of safety, proposed in the present work, argues that we need to further comprehend how work practice evolves over time, and more specifically what are the inherent characteristics of work practice that create this evolution. Empirical studies from health-care and nuclear power generation highlight different details about organizational reliability. For instance, one study of planning at a nuclear power plant draws our attention to the different roles of planning in the organization. Another study, within heath-care, underlines the evolution of

  4. Patient Education May Improve Perioperative Safety.

    NARCIS (Netherlands)

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

    2016-01-01

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

  5. Passive safety systems reliability and integration of these systems in nuclear power plant PSA

    International Nuclear Information System (INIS)

    La Lumia, V.; Mercier, S.; Marques, M.; Pignatel, J.F.

    2004-01-01

    Innovative nuclear reactor concepts could lead to use passive safety features in combination with active safety systems. A passive system does not need active component, external energy, signal or human interaction to operate. These are attractive advantages for safety nuclear plant improvements and economic competitiveness. But specific reliability problems, linked to physical phenomena, can conduct to stop the physical process. In this context, the European Commission (EC) starts the RMPS (Reliability Methods for Passive Safety functions) program. In this RMPS program, a quantitative reliability evaluation of the RP2 system (Residual Passive heat Removal system on the Primary circuit) has been realised, and the results introduced in a simplified PSA (Probabilistic Safety Assessment). The scope is to get out experience of definition of characteristic parameters for reliability evaluation and PSA including passive systems. The simplified PSA, using event tree method, is carried out for the total loss of power supplies initiating event leading to a severe core damage. Are taken into account: failures of components but also failures of the physical process involved (e.g. natural convection) by a specific method. The physical process failure probabilities are assessed through uncertainty analyses based on supposed probability density functions for the characteristic parameters of the RP2 system. The probabilities are calculated by MONTE CARLO simulation coupled to the CATHARE thermalhydraulic code. The yearly frequency of the severe core damage is evaluated for each accident sequence. This analysis has identified the influence of the passive system RP2 and propose a re-dimensioning of the RP2 system in order to satisfy the safety probabilistic objectives for reactor core severe damage. (authors)

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

    International Nuclear Information System (INIS)

    Hashim Muhammad; Yoshikawa, Hidekazu; Yang Ming

    2013-01-01

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

  7. 25. MPA-seminar: safety and reliability of plant technology with special emphasis on safety and reliability - integrity proofs, qualification of components, damage prevention. Vol. 1. Papers 1-29

    International Nuclear Information System (INIS)

    1999-01-01

    The proceedings of the 25th MPA Seminar on 'Safety and Reliability of Plant Technology' were issued in two volumes. The main topics of the first volume are: 1. Structural and safety analysis, 2. Reliability analysis, 3. Fracture mechanics, and 4. Nondestructive Testing. s

  8. Automatic creation of Markov models for reliability assessment of safety instrumented systems

    International Nuclear Information System (INIS)

    Guo Haitao; Yang Xianhui

    2008-01-01

    After the release of new international functional safety standards like IEC 61508, people care more for the safety and availability of safety instrumented systems. Markov analysis is a powerful and flexible technique to assess the reliability measurements of safety instrumented systems, but it is fallible and time-consuming to create Markov models manually. This paper presents a new technique to automatically create Markov models for reliability assessment of safety instrumented systems. Many safety related factors, such as failure modes, self-diagnostic, restorations, common cause and voting, are included in Markov models. A framework is generated first based on voting, failure modes and self-diagnostic. Then, repairs and common-cause failures are incorporated into the framework to build a complete Markov model. Eventual simplification of Markov models can be done by state merging. Examples given in this paper show how explosively the size of Markov model increases as the system becomes a little more complicated as well as the advancement of automatic creation of Markov models

  9. A patient safety objective structured clinical examination.

    Science.gov (United States)

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

    2009-06-01

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

  10. Digital System Reliability Test for the Evaluation of safety Critical Software of Digital Reactor Protection System

    Directory of Open Access Journals (Sweden)

    Hyun-Kook Shin

    2006-08-01

    Full Text Available A new Digital Reactor Protection System (DRPS based on VME bus Single Board Computer has been developed by KOPEC to prevent software Common Mode Failure(CMF inside digital system. The new DRPS has been proved to be an effective digital safety system to prevent CMF by Defense-in-Depth and Diversity (DID&D analysis. However, for practical use in Nuclear Power Plants, the performance test and the reliability test are essential for the digital system qualification. In this study, a single channel of DRPS prototype has been manufactured for the evaluation of DRPS capabilities. The integrated functional tests are performed and the system reliability is analyzed and tested. The results of reliability test show that the application software of DRPS has a very high reliability compared with the analog reactor protection systems.

  11. Reliability Analysis of Safety Grade PLC(POSAFE-Q) for Nuclear Power Plants

    International Nuclear Information System (INIS)

    Kim, J. Y.; Lyou, J.; Lee, D. Y.; Choi, J. G.; Park, W. M.

    2006-01-01

    The Part Count Method of the military standard MILHDK- 217F has been used for the reliability prediction of the nuclear field. This handbook determines the Programmable Logic Controller (PLC) failure rate by summing the failure rates of the individual component included in the PLC. Normally it is easily predictable that the components added for the fault detection improve the reliability of the PLC. But the application of this handbook is estimated with poor reliability because of the increased component number for the fault detection. To compensate this discrepancy, the quantitative reliability analysis method is suggested using the functional separation model in this paper. And it is applied to the Reactor Protection System (RPS) being developed in Korea to identify any design weak points from a safety point of view

  12. 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

  13. Reliability of scored patient generated subjective global assessment ...

    African Journals Online (AJOL)

    Objective: Establish the reliability of the scored Patient Generated-Subjective Global Assessment (PG-SGA) in determining nutritional status among Antiretroviral Therapy (ART) naive HIV-infected adults. Methods: A descriptive, cross sectional study among outpatient medical clinics, in The AIDS Support Organization ...

  14. 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 ...

  15. 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.

  16. 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.)

  17. A Regulatory Perspective on the Performance and Reliability of Nuclear Passive Safety Systems

    International Nuclear Information System (INIS)

    Quan, Pham Trung; Lee, Sukho

    2016-01-01

    Passive safety systems have been proven to enhance the safety of NPPs. When an accident such as station blackout occurs, these systems can perform the following functions: the decay heat removal, passive safety injection, containment cooling, and the retention of radioactive materials. Following the IAEA definitions, using passive safety systems reduces reliance on active components to achieve proper actuation and not requiring operator intervention in accident conditions. That leads to the deviations in boundary conditions of the critical process or geometric parameters, which activate and operate the system to perform accident prevention and mitigation functions. The main difficulties in evaluation of functional failure of passive systems arise because of (a) lack of plant operational experience; (b) scarcity of adequate experimental data from integral test facilities or from separate effect tests in order to understand the performance characteristics of these passive systems, not only at normal operation but also during accidents and transients; (c) lack of accepted definitions of failure modes for these systems; and (d) difficulty in modeling certain physical behavior of these systems. Reliability assessment of the PSS is still one of the important issues. Several reliability methodologies such as REPAS, RMPS and ASPRA have been applied to the reliability assessments. However, some issues are remained unresolved due to lack of understanding of the treatment of dynamic failure characteristics of components of the PSS, the treatment of dynamic variation of independence process parameters such as ambient temperature and the functional failure criteria of the PSS. Dynamic reliability methodologies should be integrated in the PSS reliability analysis to have a true estimate of system failure probability. The methodology should estimate the physical variation of the parameters and the frequency of the accident sequences when the dynamic effects are considered

  18. Efforts to improve safety and reliability of nuclear power plants in Kyushu Electric Power

    International Nuclear Information System (INIS)

    Yamamoto, Satoshi

    2014-01-01

    After the Fukushima accident, Kyushu Electric Power Co. took emergency safety measures requested by government to ensure power supply, coolant supply pumps and cooling water so as to keep cooling fuels in the reactor and spent fuel storage pool in case of losses of ordinary cooling capability caused by earthquake and tsunami. In order to improve safety and reliability of nuclear power plants, further efforts based on lessons learned from the Fukushima accident had been made to diversify corresponding equipment of safety measures in terms of prevention of core damage, prevention of containment failure, mitigation of radioactive materials release, cooling of spent fuel pit and ensurance of power supply, and to enhance emergency response capability so as to make operational management more complete. Additional safety measures applicable to new regulatory requirements against severe accidents were in progress. This article introduced details of such activities. (T. Tanaka)

  19. Reliability of histologic assessment in patients with eosinophilic oesophagitis.

    Science.gov (United States)

    Warners, M J; Ambarus, C A; Bredenoord, A J; Verheij, J; Lauwers, G Y; Walsh, J C; Katzka, D A; Nelson, S; van Viegen, T; Furuta, G T; Gupta, S K; Stitt, L; Zou, G; Parker, C E; Shackelton, L M; D Haens, G R; Sandborn, W J; Dellon, E S; Feagan, B G; Collins, M H; Jairath, V; Pai, R K

    2018-04-01

    The validity of the eosinophilic oesophagitis (EoE) histologic scoring system (EoEHSS) has been demonstrated, but only preliminary reliability data exist. Formally assess the reliability of the EoEHSS and additional histologic features. Four expert gastrointestinal pathologists independently reviewed slides from adult patients with EoE (N = 45) twice, in random order, using standardised training materials and scoring conventions for the EoEHSS and additional histologic features agreed upon during a modified Delphi process. Intra- and inter-rater reliability for scoring the EoEHSS, a visual analogue scale (VAS) of overall histopathologic disease severity, and additional histologic features were assessed using intra-class correlation coefficients (ICCs). Almost perfect intra-rater reliability was observed for the composite EoEHSS scores and the VAS. Inter-rater reliability was also almost perfect for the composite EoEHSS scores and substantial for the VAS. Of the EoEHSS items, eosinophilic inflammation was associated with the highest ICC estimates and consistent with almost perfect intra- and inter-rater reliability. With the exception of dyskeratotic epithelial cells and surface epithelial alteration, ICC estimates for the remaining EoEHSS items were above the benchmarks for substantial intra-rater, and moderate inter-rater reliability. Estimation of peak eosinophil count and number of lamina propria eosinophils were associated with the highest ICC estimates among the exploratory items. The composite EoEHSS and most component items are associated with substantial reliability when assessed by central pathologists. Future studies should assess responsiveness of the score to change after a therapeutic intervention to facilitate its use in clinical trials. © 2018 John Wiley & Sons Ltd.

  20. Development of reliability and probabilistic safety assessment program RiskA

    International Nuclear Information System (INIS)

    Wu, Yican

    2015-01-01

    Highlights: • There are four parts in the structure of RiskA. User input part lets users input the PSA model and some necessary data by GUI or model transformation tool. In calculation engine part, fault tree analysis, event tree analysis, uncertainty analysis, sensitivity analysis, importance analysis and failure mode and effects analysis are supplied. User output part outputs the analysis results, user customized reports and some other data. The last part includes reliability database, some other common tools and help documents. • RiskA has several advanced features. Extensible framework makes it easy to add any new functions, making RiskA to be a large platform of reliability and probabilistic safety assessment. It is very fast to analysis fault tree in RiskA because many advanced algorithm improvement were made. Many model formats can be imported and exported, which made the PSA model in the commercial software can be easily transformed to adapt RiskA platform. Web-based co-modeling let several users in different places work together whenever they are online. • The comparison between RiskA and other mature PSA codes (e.g. CAFTA, RiskSpectrum, XFTA) has demonstrated that the calculation and analysis of RiskA is correct and efficient. Based on the development of this code package, many applications of safety and reliability analysis of some research reactors and nuclear power plants were performed. The development of RiskA appears to be of realistic and potential value for academic research and practical operation safety management of nuclear power plants in China and abroad. - Abstract: PSA (probabilistic safety assessment) software, the indispensable tool in nuclear safety assessment, has been widely used. An integrated reliability and PSA program named RiskA has been developed by FDS Team. RiskA supplies several standard PSA modules including fault tree analysis, event tree analysis, uncertainty analysis, failure mode and effect analysis and reliability

  1. Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.

    Science.gov (United States)

    Singer, Sara J; Rosen, Amy; Zhao, Shibei; Ciavarelli, Anthony P; Gaba, David M

    2010-01-01

    Evidence of variation in safety climate suggests the need for improvement among at least some hospitals. However, comparisons only among hospitals may underestimate the improvement required. Comparison of hospitals with analogous industries may provide a broader perspective on the safety status of our nation's hospitals. The purpose of this study was to compare safety climate among hospital workers with personnel from naval aviation, an organization that operates with high reliability despite intrinsically hazardous conditions. We surveyed a random sample of health care workers in 67 U.S. hospitals and, for generalizability, 30 veterans affairs hospitals using questions comparable with those posed at approximately the same time (2007) to a census of personnel from 35 squadrons of U.S. naval aviators. We received 13,841 (41%) completed surveys in U.S. hospitals, 5,511 (50%) in veterans affairs hospitals, and 14,854 (82%) among naval aviators. We examined differences in respondents' perceptions of safety climate at their institution overall and for 16 individual items. Safety climate was three times better on average among naval aviators than among hospital personnel. Naval aviators perceived a safer climate (up to seven times safer) than hospital personnel with respect to each of the 16 survey items. Compared with hospital managers, naval commanders perceived climate more like frontline personnel did. When contrasting naval aviators with hospital personnel working in comparably hazardous areas, safety climate discrepancies increased rather than decreased. One individual hospital performed as well as naval aviation on average, and at least one hospital outperformed the Navy benchmark for all but three individual survey items. Results suggest that hospitals have not sufficiently created a uniform priority of safety. However, if each hospital performed as well as the top-performing hospital in each area measured, hospitals could achieve safety climate levels comparable

  2. Kilowatt isotope power system. Phase II plan. Volume V. Safety, quality assurance and reliability

    International Nuclear Information System (INIS)

    1978-01-01

    The development of a Kilowatt Isotope Power System (KIPS) was begun in 1975 for the purpose of satisfying the power requirements of satellites in the 1980's. The KIPS is a 238 PuO 2 -fueled organic Rankine cycle turbine power system to provide a design output of 500 to 2000 W. Included in this volume are: launch and flight safety considerations; quality assurance techniques and procedures to be followed through system fabrication, assembly and inspection; and the reliability program made up of reliability prediction analysis, failure mode analysis and criticality analysis

  3. 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.

  4. Technical feasibility and reliability of passive safety systems of AC600

    International Nuclear Information System (INIS)

    Niu, W.; Zeng, X.

    1996-01-01

    The first step conceptual design of the 600 MWe advanced PWR (AC-600) has been finished by the Nuclear Power Institute of China. Experiments on the passive system of AC-600 are being carried out, and are expected to be completed next year. The main research emphases of AC-600 conceptual design include the advanced core, the passive safety system and simplification. The design objective of AC-600 is that the safety, reliability, maintainability, operation cost and construction period are all improved upon compared to those of PWR plant. One of important means to achieve the objective is using a passive system, which has the following functions whenever its operation is required: providing the reactor core with enough coolant when others fail to make up the lost coolant; reactor residual heat removal; cooling and reducing pressure in the containment and preventing radioactive substances from being released into the environment after occurrence of accident (e.g. LOCA). The system should meet the single failure criterion, and keep operating when a single active component or passive component breaks down during the first 72 hour period after occurrence of accident, or in the long period following the 72 hour period. The passive safety system of AC-600 is composed of the primary safety injection system, the secondary emergency core residual heat removal system and the containment cooling system. The design of the system follows some relevant rules and criteria used by current PWR plant. The system has the ability to bear single failure, two complete separate subsystems are considered, each designed for 100% working capacity. Normal operation is separate from safety operation and avoids cross coupling and interference between systems, improves the reliability of components, and makes it easy to maintain, inspect and test the system. The paper discusses the technical feasibility and reliability of the passive safety system of AC-600, and some issues and test plans are also

  5. Technical feasibility and reliability of passive safety systems of AC600

    Energy Technology Data Exchange (ETDEWEB)

    Niu, W; Zeng, X [Nuclear Power Inst. of China, Chendu (China)

    1996-12-01

    The first step conceptual design of the 600 MWe advanced PWR (AC-600) has been finished. Experiments on the passive system of AC-600 are being carried out, and are expected to be completed next year. The main research emphases of AC-600 conceptual design include the advanced core, the passive safety system and simplification. The design objective of AC-600 is that the safety, reliability, maintainability, operation cost and construction period are all improved upon compared to those of PWR plant. One of important means to achieve the objective is using a passive system, which has the following functions whenever its operation is required: providing the reactor core with enough coolant when others fail to make up the lost coolant; reactor residual heat removal; cooling and reducing pressure in the containment and preventing radioactive substances from being released into the environment after occurrence of accident (e.g. LOCA). The system should meet the single failure criterion, and keep operating when a single active component or passive component breaks down during the first 72 hour period after occurrence of accident, or in the long period following the 72 hour period. The passive safety system of AC-600 is composed of the primary safety injection system, the secondary emergency core residual heat removal system and the containment cooling system. The design of the system follows some relevant rules and criteria used by current PWR plant. The system has the ability to bear single failure, two complete separate subsystems are considered, each designed for 100% working capacity. Normal operation is separate from safety operation and avoids cross coupling and interference between systems, improves the reliability of components, and makes it easy to maintain, inspect and test the system. The paper discusses the technical feasibility and reliability of the passive safety system of AC-600, and some issues and test plans are also involved. (author). 3 figs, 1 tab.

  6. [Creating a reliable therapeutic relationship with the patient].

    Science.gov (United States)

    Matsuki, Kunihiro

    2012-01-01

    The factors necessary to create a reliable therapeutic relationship are presented in this paper. They include a demeanor and calmness of temperament as a psychiatric professional, a feeling of respect for the patient that is based on our common sense as human beings, an attitude of listening attentively to what the patient is revealing, maintaining an attitude of receptive neutrality, the ability to withstand the emotional burdens imposed on one by the patient, patience with any difficulty on one's own part to understand the patient, the ability to communicate clearly, including on the patient's negative aspects, and the ability to end psychiatric consultation sessions in a friendly and intimate manner. Creating a beneficial therapeutic relationship is about the building of a trusting relationship, in which the patient can constructively endure being questioned by us, or cope with the tough burdens we may place on them. However, a reliable relationship such as this contains paradoxes. Patients are able to talk to us about their suspicions, anxieties, dissatisfactions or anger only if the therapeutic relationship is good or based on trust. In other words, just like our patients, psychiatrists, too, must deal with what that the patient brings and directs toward us. It is at this point that what we call a true therapeutic relationship starts.

  7. A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children's Hospital.

    Science.gov (United States)

    Saysana, Michele; McCaskey, Marjorie; Cox, Elaine; Thompson, Rachel; Tuttle, Lora K; Haut, Paul R

    2017-09-01

    Health care is a high-risk industry. To improve communication about daily events and begin the journey toward a high reliability organization, the Riley Hospital for Children at Indiana University Health implemented a daily safety brief. Various departments in our children's hospital were asked to participate in a daily safety brief, reporting daily events and unexpected outcomes within their scope of responsibility. Participants were surveyed before and after implementation of the safety brief about communication and awareness of events in the hospital. The length of the brief and percentage of departments reporting unexpected outcomes were measured. The analysis of the presurvey and the postsurvey showed a statistically significant improvement in the questions related to the awareness of daily events as well as communication and relationships between departments. The monthly mean length of time for the brief was 15 minutes or less. Unexpected outcomes were reported by 50% of the departments for 8 months. A daily safety brief can be successfully implemented in a children's hospital. Communication between departments and awareness of daily events were improved. Implementation of a daily safety brief is a step toward becoming a high reliability organization.

  8. Nordic perspectives on safety management in high reliability organizations: Theory and applications

    International Nuclear Information System (INIS)

    Svenson, Ola; Salo, I.; Sjerve, A.B.; Reiman, T.; Oedewald, P.

    2006-04-01

    The chapters in this volume are written on a stand-alone basis meaning that the chapters can be read in any order. The first 4 chapters focus on theory and method in general with some applied examples illustrating the methods and theories. Chapters 5 and 6 are about safety management in the aviation industry with some additional information about incident reporting in the aviation industry and the health care sector. Chapters 7 through 9 cover safety management with applied examples from the nuclear power industry and with considerable validity for safety management in any industry. Chapters 10 through 12 cover generic safety issues with examples from the oil industry and chapter 13 presents issues related to organizations with different internal organizational structures. Although the many of the chapters use a specific industry to illustrate safety management, the messages in all the chapters are of importance for safety management in any high reliability industry or risky activity. The interested reader is also referred to, e.g., a document by an international NEA group (SEGHOF), who is about to publish a state of the art report on Systematic Approaches to Safety Management (cf., CSNI/NEA/SEGHOF, home page: www.nea.fr). (au)

  9. Nordic perspectives on safety management in high reliability organizations: Theory and applications

    Energy Technology Data Exchange (ETDEWEB)

    Svenson, Ola; Salo, I; Sjerve, A B; Reiman, T; Oedewald, P [Stockholm Univ. (Sweden)

    2006-04-15

    The chapters in this volume are written on a stand-alone basis meaning that the chapters can be read in any order. The first 4 chapters focus on theory and method in general with some applied examples illustrating the methods and theories. Chapters 5 and 6 are about safety management in the aviation industry with some additional information about incident reporting in the aviation industry and the health care sector. Chapters 7 through 9 cover safety management with applied examples from the nuclear power industry and with considerable validity for safety management in any industry. Chapters 10 through 12 cover generic safety issues with examples from the oil industry and chapter 13 presents issues related to organizations with different internal organizational structures. Although the many of the chapters use a specific industry to illustrate safety management, the messages in all the chapters are of importance for safety management in any high reliability industry or risky activity. The interested reader is also referred to, e.g., a document by an international NEA group (SEGHOF), who is about to publish a state of the art report on Systematic Approaches to Safety Management (cf., CSNI/NEA/SEGHOF, home page: www.nea.fr). (au)

  10. Reliability of diabetic patients' gait parameters in a challenging environment.

    Science.gov (United States)

    Allet, L; Armand, S; de Bie, R A; Golay, A; Monnin, D; Aminian, K; de Bruin, E D

    2008-11-01

    Activities of daily life require us to move about in challenging environments and to walk on varied surfaces. Irregular terrain has been shown to influence gait parameters, especially in a population at risk for falling. A precise portable measurement system would permit objective gait analysis under such conditions. The aims of this study are to (a) investigate the reliability of gait parameters measured with the Physilog in diabetic patients walking on different surfaces (tar, grass, and stones); (b) identify the measurement error (precision); (c) identify the minimal clinical detectable change. 16 patients with Type 2 diabetes were measured twice within 8 days. After clinical examination patients walked, equipped with a Physilog, on the three aforementioned surfaces. ICC for each surface was excellent for within-visit analyses (>0.938). Inter-visit ICC's (0.753) were excellent except for the knee range parameter (>0.503). The coefficient of variation (CV) was lower than 5% for most of the parameters. Bland and Altman Plots, SEM and SDC showed precise values, distributed around zero for all surfaces. Good reliability of Physilog measurements on different surfaces suggests that Physilog could facilitate the study of diabetic patients' gait in conditions close to real-life situations. Gait parameters during complex locomotor activities (e.g. stair-climbing, curbs, slopes) have not yet been extensively investigated. Good reliability, small measurement error and values of minimal clinical detectable change recommend the utilization of Physilog for the evaluation of gait parameters in diabetic patients.

  11. Validity evidence and reliability of a simulated patient feedback instrument.

    Science.gov (United States)

    Schlegel, Claudia; Woermann, Ulrich; Rethans, Jan-Joost; van der Vleuten, Cees

    2012-01-27

    In the training of healthcare professionals, one of the advantages of communication training with simulated patients (SPs) is the SP's ability to provide direct feedback to students after a simulated clinical encounter. The quality of SP feedback must be monitored, especially because it is well known that feedback can have a profound effect on student performance. Due to the current lack of valid and reliable instruments to assess the quality of SP feedback, our study examined the validity and reliability of one potential instrument, the 'modified Quality of Simulated Patient Feedback Form' (mQSF). Content validity of the mQSF was assessed by inviting experts in the area of simulated clinical encounters to rate the importance of the mQSF items. Moreover, generalizability theory was used to examine the reliability of the mQSF. Our data came from videotapes of clinical encounters between six simulated patients and six students and the ensuing feedback from the SPs to the students. Ten faculty members judged the SP feedback according to the items on the mQSF. Three weeks later, this procedure was repeated with the same faculty members and recordings. All but two items of the mQSF received importance ratings of > 2.5 on a four-point rating scale. A generalizability coefficient of 0.77 was established with two judges observing one encounter. The findings for content validity and reliability with two judges suggest that the mQSF is a valid and reliable instrument to assess the quality of feedback provided by simulated patients.

  12. Development of advanced methods and related software for human reliability evaluation within probabilistic safety analyses

    International Nuclear Information System (INIS)

    Kosmowski, K.T.; Mertens, J.; Degen, G.; Reer, B.

    1994-06-01

    Human Reliability Analysis (HRA) is an important part of Probabilistic Safety Analysis (PSA). The first part of this report consists of an overview of types of human behaviour and human error including the effect of significant performance shaping factors on human reliability. Particularly with regard to safety assessments for nuclear power plants a lot of HRA methods have been developed. The most important of these methods are presented and discussed in the report, together with techniques for incorporating HRA into PSA and with models of operator cognitive behaviour. Based on existing HRA methods the concept of a software system is described. For the development of this system the utilization of modern programming tools is proposed; the essential goal is the effective application of HRA methods. A possible integration of computeraided HRA within PSA is discussed. The features of Expert System Technology and examples of applications (PSA, HRA) are presented in four appendices. (orig.) [de

  13. Good performance in Japan is proof of continuing safety and reliability improvement practice

    International Nuclear Information System (INIS)

    Sumi, Y.

    1987-01-01

    Nuclear power is a vital energy supply source for both security and economy for such countries as Japan whose sources of energy are dependent on imported materials. This is the very reason why Japan gives her national priority to the improvement of nuclear power safety and reliability. As of the end of 1986, total nuclear power capacity owned and operated by private utility companies in Japan amounted to 24521 MW with 32 units sharing -- 19% of the total generating capacity. Moreover, during 1986 these units scored a remarkably high capacity factor of 76.2% and shared almost 28% of the nationwide electric power production, thereby contributing to a considerable saving of imported sources of energy. This outstanding record has been achieved by the parties concerned who dedicated themselves to furthering nuclear plant safety and reliability improvement. In this connection, this paper summarizes those key factors contributing to the good nuclear power plant performance of the Kansai Electric Power Company

  14. Reliability analysis of repairable safety systems of a reprocessing plant allowing for tolerable system downtimes

    International Nuclear Information System (INIS)

    Schaefer, H.

    1987-01-01

    GRS has been engaged in safety analysises of the German Reprocessing Plant for several years. The development and verification of appropriate reliability analysis methods, the generation of data as well as the search for an adequate structural presentation of the results to form a basis of recommendations for technical or administrative measures or contributions to risk oriented evaluations have been or are in the process of being established. In contrast to NPP-studies, the reliability assessment of safety systems of a reprocessing plant is applied to repairable and often relatively small systems allowing for tolerable system downtimes. A sketch of the diverse cooling systems of a vessel containing a selfheating solution is given. The interruption of the cooling function for about one day might be tolerable before boiling will be reached. This interval is suitable for transfer of the solution to a spare vessel or for repairing the failed components, thus restoring the cooling function

  15. Study of evaluation techniques of software safety and reliability in nuclear power plants

    Energy Technology Data Exchange (ETDEWEB)

    Youn, Cheong; Baek, Y. W.; Kim, H. C.; Park, N. J.; Shin, C. Y. [Chungnam National Univ., Taejon (Korea, Republic of)

    1999-04-15

    Software system development process and software quality assurance activities are examined in this study. Especially software safety and reliability requirements in nuclear power plant are investigated. For this purpose methodologies and tools which can be applied to software analysis, design, implementation, testing, maintenance step are evaluated. Necessary tasks for each step are investigated. Duty, input, and detailed activity for each task are defined to establish development process of high quality software system. This means applying basic concepts of software engineering and principles of system development. This study establish a guideline that can assure software safety and reliability requirements in digitalized nuclear plant systems and can be used as a guidebook of software development process to assure software quality many software development organization.

  16. 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.

  17. SAFETY CRITERION IN ASSESSING THE IMPORTANCE OF AN ELEMENT IN THE COMPLEX TECHNOLOGICAL SYSTEM RELIABILITY STRUCTURE

    Directory of Open Access Journals (Sweden)

    Leszek CHYBOWSKI

    2012-01-01

    Full Text Available The paper presents the need to develop a description of the importance of the technological systems reliability structure elements in terms of security of the system. Basic issues related to the exploration of weak links and important elements in the system as well as a proposal to develop the current approach to assessing the importance of the system components have been presented. Moreover, the differences between the unreliability of suitability and unreliability of safety have been pointed out.

  18. The computer vision in the service of safety and reliability in steam generators inspection services

    International Nuclear Information System (INIS)

    Pineiro Fernandez, P.; Garcia Bueno, A.; Cabrera Jordan, E.

    2012-01-01

    The actual computational vision has matured very quickly in the last ten years by facilitating new developments in various areas of nuclear application allowing to automate and simplify processes and tasks, instead or in collaboration with the people and equipment efficiently. The current computer vision (more appropriate than the artificial vision concept) provides great possibilities of also improving in terms of the reliability and safety of NPPS inspection systems.

  19. John F. Kennedy Space Center, Safety, Reliability, Maintainability and Quality Assurance, Survey and Audit Program

    Science.gov (United States)

    1994-01-01

    This document is the product of the KSC Survey and Audit Working Group composed of civil service and contractor Safety, Reliability, and Quality Assurance (SR&QA) personnel. The program described herein provides standardized terminology, uniformity of survey and audit operations, and emphasizes process assessments rather than a program based solely on compliance. The program establishes minimum training requirements, adopts an auditor certification methodology, and includes survey and audit metrics for the audited organizations as well as the auditing organization.

  20. Selected problems and results of the transient event and reliability analyses for the German safety study

    International Nuclear Information System (INIS)

    Hoertner, H.

    1977-01-01

    For the investigation of the risk of nuclear power plants loss-of-coolant accidents and transients have to be analyzed. The different functions of the engineered safety features installed to cope with transients are explained. The event tree analysis is carried out for the important transient 'loss of normal onsite power'. Preliminary results of the reliability analyses performed for quantitative evaluation of this event tree are shown. (orig.) [de

  1. Safeprops: A Software for Fast and Reliable Estimation of Safety and Environmental Properties for Organic Compounds

    DEFF Research Database (Denmark)

    Jones, Mark Nicholas; Frutiger, Jerome; Abildskov, Jens

    We present a new software tool called SAFEPROPS which is able to estimate major safety-related and environmental properties for organic compounds. SAFEPROPS provides accurate, reliable and fast predictions using the Marrero-Gani group contribution (MG-GC) method. It is implemented using Python...... as the main programming language, while the necessary parameters together with their correlation matrix are obtained from a SQLite database which has been populated using off-line parameter and error estimation routines (Eq. 3-8)....

  2. 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.

  3. Design and reliability, availability, maintainability, and safety analysis of a high availability quadruple vital computer system

    Institute of Scientific and Technical Information of China (English)

    Ping TAN; Wei-ting HE; Jia LIN; Hong-ming ZHAO; Jian CHU

    2011-01-01

    With the development of high-speed railways in China,more than 2000 high-speed trains will be put into use.Safety and efficiency of railway transportation is increasingly important.We have designed a high availability quadruple vital computer (HAQVC) system based on the analysis of the architecture of the traditional double 2-out-of-2 system and 2-out-of-3 system.The HAQVC system is a system with high availability and safety,with prominent characteristics such as fire-new internal architecture,high efficiency,reliable data interaction mechanism,and operation state change mechanism.The hardware of the vital CPU is based on ARM7 with the real-time embedded safe operation system (ES-OS).The Markov modeling method is designed to evaluate the reliability,availability,maintainability,and safety (RAMS) of the system.In this paper,we demonstrate that the HAQVC system is more reliable than the all voting triple modular redundancy (AVTMR) system and double 2-out-of-2 system.Thus,the design can be used for a specific application system,such as an airplane or high-speed railway system.

  4. Current activities and future trends in reliability analysis and probabilistic safety assessment in Hungary

    International Nuclear Information System (INIS)

    Hollo, E.; Toth, J.

    1986-01-01

    In Hungary reliability analysis (RA) and probabilistic safety assessment (PSA) of nuclear power plants was initiated 3 years ago. First, computer codes for automatic fault tree analysis (CAT, PREP) and numerical evaluation (REMO, KITT1,2) were adapted. Two main case studies - detailed availability/reliability calculation of diesel sets and analysis of safety systems influencing event sequences induced by large LOCA - were performed. Input failure data were taken from publications, a need for failure and reliability data bank was revealed. Current and future activities involves: setup of national data bank for WWER-440 units; full-scope level-I PSA of PAKS NPP in Hungary; operational safety assessment of particular problems at PAKS NPP. In the present article the state of RA and PSA activities in Hungary, as well as the main objectives of ongoing work are described. A need for international cooperation (for unified data collection of WWER-440 units) and for IAEA support (within Interregional Program INT/9/063) is emphasized. (author)

  5. 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.

  6. Reliability analysis of the reconstructed safety systems of the Kozloduy-2 WWER-440/V-230 reactor

    International Nuclear Information System (INIS)

    Kalchev, B.

    1995-01-01

    The Unit 2 of the Kozloduy NPP started operations in 1975. As it is designed according to safety standards of the middle sixties, it needs reconstruction in order to prolong its operational life up to the design age of 30 years, in agreement with the increased safety requirements in Bulgaria. The reliability analyses of front line systems of the unit are performed to this end. The approach taken in the study is the fault tree methodology to determine the unavailability of each system. Common mode failures are considered for the pumps and valves using the beta factor method. The mission time for each system is 24 hours and the test period is 720 hours. Support systems and human errors are also included. All the systems control and instrumentation signals are modelled explicitly in the fault trees. The generic IDEA reliability data base is used for all quantifications. The initiating events that would require the system operation are presented and on this basis the thermohydraulic analysis success criteria for each system are determined. The code for probabilistic safety assessment PSAPACK is used. Fault trees for the following front line safety systems are constructed: the high pressure injection system, the spray system and the auxiliary feed water system. The analysis consider some proposed decisions for reconstruction. The results show that the reliability of these systems has increased after reconstruction and the safety has been upgraded. This decrease the core damage frequency from 3.53E -3 , 1/RY to 1.07E -3 , 1/RY. 5 refs., 2 tabs., 5 figs

  7. Reliability analysis of the reconstructed safety systems of the Kozloduy-2 WWER-440/V-230 reactor

    Energy Technology Data Exchange (ETDEWEB)

    Kalchev, B [Energoproekt, Sofia (Bulgaria)

    1996-12-31

    The Unit 2 of the Kozloduy NPP started operations in 1975. As it is designed according to safety standards of the middle sixties, it needs reconstruction in order to prolong its operational life up to the design age of 30 years, in agreement with the increased safety requirements in Bulgaria. The reliability analyses of front line systems of the unit are performed to this end. The approach taken in the study is the fault tree methodology to determine the unavailability of each system. Common mode failures are considered for the pumps and valves using the beta factor method. The mission time for each system is 24 hours and the test period is 720 hours. Support systems and human errors are also included. All the systems control and instrumentation signals are modelled explicitly in the fault trees. The generic IDEA reliability data base is used for all quantifications. The initiating events that would require the system operation are presented and on this basis the thermohydraulic analysis success criteria for each system are determined. The code for probabilistic safety assessment PSAPACK is used. Fault trees for the following front line safety systems are constructed: the high pressure injection system, the spray system and the auxiliary feed water system. The analysis consider some proposed decisions for reconstruction. The results show that the reliability of these systems has increased after reconstruction and the safety has been upgraded. This decrease the core damage frequency from 3.53E{sup -3}, 1/RY to 1.07E{sup -3}, 1/RY. 5 refs., 2 tabs., 5 figs.

  8. System principles, mathematical models and methods to ensure high reliability of safety systems

    Science.gov (United States)

    Zaslavskyi, V.

    2017-04-01

    Modern safety and security systems are composed of a large number of various components designed for detection, localization, tracking, collecting, and processing of information from the systems of monitoring, telemetry, control, etc. They are required to be highly reliable in a view to correctly perform data aggregation, processing and analysis for subsequent decision making support. On design and construction phases of the manufacturing of such systems a various types of components (elements, devices, and subsystems) are considered and used to ensure high reliability of signals detection, noise isolation, and erroneous commands reduction. When generating design solutions for highly reliable systems a number of restrictions and conditions such as types of components and various constrains on resources should be considered. Various types of components perform identical functions; however, they are implemented using diverse principles, approaches and have distinct technical and economic indicators such as cost or power consumption. The systematic use of different component types increases the probability of tasks performing and eliminates the common cause failure. We consider type-variety principle as an engineering principle of system analysis, mathematical models based on this principle, and algorithms for solving optimization problems of highly reliable safety and security systems design. Mathematical models are formalized in a class of two-level discrete optimization problems of large dimension. The proposed approach, mathematical models, algorithms can be used for problem solving of optimal redundancy on the basis of a variety of methods and control devices for fault and defects detection in technical systems, telecommunication networks, and energy systems.

  9. Operational safety performance indicator system - a management tool for the self assessment of safety and reliability of nuclear power plants

    International Nuclear Information System (INIS)

    Anil Kumar; Mandowara, S.L.; Mittal, S.

    2006-01-01

    Operational Safety Performance Indicator system is one of the self assessment tools for station management to monitor safety and reliability of nuclear power plants. It provides information to station management about the performance of various areas of the plants by means of different colours of relevant performance indicators. Such systems have been implemented at many nuclear power plants in the world and have been considered as strength during WANO Peer Review. IAEA had a Coordinated Research Programme (CRP) on this with several countries participating including India. In NPCIL this system has been implemented in KAPS about a year back and found very useful in identifying areas which needs to be given more attention. Based on the KAPS feedback Implementation of this system has been taken up in RAPS-3 and 4 and KGS-l and 2. (author)

  10. Human reliability analysis in probabilistic safety assessment for nuclear power plants. A Safety Practice. A publication within the NUSS programme

    International Nuclear Information System (INIS)

    1995-01-01

    Probabilistic safety assessment (PSA) is playing an increasingly important role in the safe operation of nuclear power plants throughout the world. In order to establish a consistent framework for conducting PSA studies, for promoting technology transfer of the state of the art, and for encouraging uniformity in the way PSA is carried out, the IAEA is preparing a set of publications which gives guidance on various aspects of PSA. This document presents a practical approach for incorporating human reliability analysis (HRA) into PSA. It describes the steps needed and the documentation that should be provided both to support the PSA itself and to ensure effective communication of important information arising from the studies. It also describes a framework for analysing those human actions which could affect safety and for relating such human influences to specific parts of a PSA. This Safety Practice also addresses the limitations of PSA in taking account of human factors in relation to safety and risk. Refs, figs and tabs

  11. From Safe Systems to Patient Safety

    DEFF Research Database (Denmark)

    Aarts, J.; Nøhr, C.

    2010-01-01

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

  12. Improving patient safety in radiation oncology

    International Nuclear Information System (INIS)

    Hendee, William R.; Herman, Michael G.

    2011-01-01

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

  13. Operator reliability study for Probabilistic Safety Analysis of an operating research reactor

    International Nuclear Information System (INIS)

    Mohamed, F.; Hassan, A.; Yahaya, R.; Rahman, I.; Maskin, M.; Praktom, P.; Charlie, F.

    2015-01-01

    Highlights: • Human Reliability Analysis (HRA) for Level 1 Probabilistic Safety Analysis (PSA) is performed on research nuclear reactor. • Implemented qualitative HRA framework is addressed. • Human Failure Events of significant impact to the reactor safety are derived. - Abstract: A Level 1 Probabilistic Safety Analysis (PSA) for the TRIGA Mark II research reactor of Malaysian Nuclear Agency has been developed to evaluate the potential risk in its operation. In conjunction to this PSA development, Human Reliability Analysis (HRA) is performed in order to determine human contribution to the risk. The aim of this study is to qualitatively analyze human actions (HAs) involved in the operation of this reactor according to the qualitative part of the HRA framework for PSA which is namely the identification, qualitative screening and modeling of HAs. By performing this framework, Human Failure Events (HFEs) of significant impact to the reactor safety are systematically analyzed and incorporated into the PSA structure. A part of the findings in this study will become the input for the subsequent quantitative part of the HRA framework, i.e. the Human Error Probability (HEP) quantification

  14. Mobile phone radiation health risk controversy: the reliability and sufficiency of science behind the safety standards.

    Science.gov (United States)

    Leszczynski, Dariusz; Xu, Zhengping

    2010-01-27

    There is ongoing discussion whether the mobile phone radiation causes any health effects. The International Commission on Non-Ionizing Radiation Protection, the International Committee on Electromagnetic Safety and the World Health Organization are assuring that there is no proven health risk and that the present safety limits protect all mobile phone users. However, based on the available scientific evidence, the situation is not as clear. The majority of the evidence comes from in vitro laboratory studies and is of very limited use for determining health risk. Animal toxicology studies are inadequate because it is not possible to "overdose" microwave radiation, as it is done with chemical agents, due to simultaneous induction of heating side-effects. There is a lack of human volunteer studies that would, in unbiased way, demonstrate whether human body responds at all to mobile phone radiation. Finally, the epidemiological evidence is insufficient due to, among others, selection and misclassification bias and the low sensitivity of this approach in detection of health risk within the population. This indicates that the presently available scientific evidence is insufficient to prove reliability of the current safety standards. Therefore, we recommend to use precaution when dealing with mobile phones and, whenever possible and feasible, to limit body exposure to this radiation. Continuation of the research on mobile phone radiation effects is needed in order to improve the basis and the reliability of the safety standards.

  15. Mobile phone radiation health risk controversy: the reliability and sufficiency of science behind the safety standards

    Directory of Open Access Journals (Sweden)

    Leszczynski Dariusz

    2010-01-01

    Full Text Available Abstract There is ongoing discussion whether the mobile phone radiation causes any health effects. The International Commission on Non-Ionizing Radiation Protection, the International Committee on Electromagnetic Safety and the World Health Organization are assuring that there is no proven health risk and that the present safety limits protect all mobile phone users. However, based on the available scientific evidence, the situation is not as clear. The majority of the evidence comes from in vitro laboratory studies and is of very limited use for determining health risk. Animal toxicology studies are inadequate because it is not possible to "overdose" microwave radiation, as it is done with chemical agents, due to simultaneous induction of heating side-effects. There is a lack of human volunteer studies that would, in unbiased way, demonstrate whether human body responds at all to mobile phone radiation. Finally, the epidemiological evidence is insufficient due to, among others, selection and misclassification bias and the low sensitivity of this approach in detection of health risk within the population. This indicates that the presently available scientific evidence is insufficient to prove reliability of the current safety standards. Therefore, we recommend to use precaution when dealing with mobile phones and, whenever possible and feasible, to limit body exposure to this radiation. Continuation of the research on mobile phone radiation effects is needed in order to improve the basis and the reliability of the safety standards.

  16. Reliability and safety of a new upper cervical spine injury treatment algorithm

    Directory of Open Access Journals (Sweden)

    Andrei Fernandes Joaquim

    Full Text Available ABSTRACT In the present study, we evaluated the reliability and safety of a new upper cervical spine injury treatment algorithm to help in the selection of the best treatment modality for these injuries. Methods Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer using the Kappa index. Results The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons’ personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agreement with the treatment actually performed was obtained in more than 89% of the cases. Conclusion The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.

  17. 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

  18. CONSIDERING TRAVEL TIME RELIABILITY AND SAFETY FOR EVALUATION OF CONGESTION RELIEF SCHEMES ON EXPRESSWAY SEGMENTS

    Directory of Open Access Journals (Sweden)

    Babak MEHRAN

    2009-01-01

    Full Text Available Evaluation of the efficiency of congestion relief schemes on expressways has generally been based on average travel time analysis. However, road authorities are much more interested in knowing the possible impacts of improvement schemes on safety and travel time reliability prior to implementing them in real conditions. A methodology is presented to estimate travel time reliability based on modeling travel time variations as a function of demand, capacity and weather conditions. For a subject expressway segment, patterns of demand and capacity were generated for each 5-minute interval over a year by using the Monte-Carlo simulation technique, and accidents were generated randomly according to traffic conditions. A whole year analysis was performed by comparing demand and available capacity for each scenario and shockwave analysis was used to estimate the queue length at each time interval. Travel times were estimated from refined speed-flow relationships and buffer time index was estimated as a measure of travel time reliability. it was shown that the estimated reliability measures and predicted number of accidents are very close to observed values through empirical data. After validation, the methodology was applied to assess the impact of two alternative congestion relief schemes on a subject expressway segment. one alternative was to open the hard shoulder to traffic during the peak period, while the other was to reduce the peak period demand by 15%. The extent of improvements in travel conditions and safety, likewise the reduction in road users' costs after implementing each improvement scheme were estimated. it was shown that both strategies can result in up to 23% reduction in the number of occurred accidents and significant improvements in travel time reliability. Finally, the advantages and challenging issues of selecting each improvement scheme were discussed.

  19. Nurse working conditions and patient safety outcomes.

    Science.gov (United States)

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

    2007-06-01

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

  20. 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...

  1. On the complex analysis of the reliability, safety, and economic efficiency of atomic electric power stations

    International Nuclear Information System (INIS)

    Emel'yanov, I.Ya.; Klemin, A.I.; Polyakov, E.F.

    1977-01-01

    The problem is posed of effectively increasing the engineering performance of nuclear electric power stations (APS). The principal components of the engineering performance of modern large APS are considered: economic efficiency, radiation safety, reliability, and their interrelationship. A nomenclature is proposed for the quantitative indices which most completely characterize the enumerated properties and are convenient for the analysis of the engineering performance. The urgent problem of developing a methodology for the complex analysis and optimization of the principal performance components is considered; this methodology is designed to increase the efficiency of the work on high-performance competitive APS. The principle of complex optimization of the reliability, safety, and economic-efficiency indices is formulated; specific recommendations are made for the practical realization of this principle. The structure of the complex quantiative analysis of the enumerated performance components is given. The urgency and promise of the complex approach to solving the problem of APS optimization is demonstrated, i.e., the solution of the problem of creating optimally reliable, fairly safe, and maximally economically efficient stations

  2. Patient Safety in Pediatrics: a Developing Discipline

    NARCIS (Netherlands)

    C. van der Starre (Cynthia)

    2011-01-01

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

  3. Assessment of reliability of a safety culture questionnaire in the cleanser and washer industries

    Directory of Open Access Journals (Sweden)

    2012-09-01

    Full Text Available Introduction: Occupational injuries and accidents as one of the problems have always been considered important in occupational environments. Domino model that Heinrich was formed to pursue the idea of the cause of the accident is the man. Thus one of the effective way to reduce accidents will be control by the unsafe behaviors among workers by promoting safety culture. .Material and Method: In this descriptive - analytical study, the reliability and exploratory factor analysis was used to evaluate the reliability of the questionnaire. In total 303 questionnaires were analyzed using SPSS 17 software. . Result: The alpha crumbed, coefficient was 0/86. Structural factor of the questionnaire was evaluated using factor analysis. KMO and Bartlett’s sphericity test coefficient were 0/909 and 9785/057, respectively. The varimax rotation showed that all test questions are based on factors. .Conclusion: The results indicated favorable validity of this questionnaire for use in detergents and cleaners industries within the country. Considering the load factor safety culture in detergents and cleaners industries, contained 5 factors including “management commitment”, “education and information exchange,” “supportive environment”, “barriers” and “priority to safety”. The obtained the correlations, the highest positive correlation was belong to the “management commitment” (r=0/952, as the strongest correlation with the safety culture.

  4. Architecture for interlock systems: reliability analysis with regard to safety and availability

    International Nuclear Information System (INIS)

    Wagner, S.; Apollonio, A.; Schmidt, R.; Zerlauth, M.; Vergara-Fernandez, A.

    2012-01-01

    For particle accelerators like LHC and other large experimental physics facilities like ITER, the machine protection relies on complex interlock systems. In the design of interlock loops for the signal exchange in machine protection systems, the choice of the hardware architecture impacts on machine safety and availability. The reliable performance of a machine stop (leaving the machine in a safe state) in case of an emergency, is an inherent requirement. The constraints in terms of machine availability on the other hand may differ from one facility to another. Spurious machine stops, lowering machine availability, may to a certain extent be tolerated in facilities where they do not cause undue equipment wear-out. In order to compare various interlock loop architectures in terms of safety and availability, the occurrence frequencies of related scenarios have been calculated in a reliability analysis, using a generic analytical model. This paper presents the results and illustrates the potential of the analysis method for supporting the choice of interlock system architectures. The results show the advantages of a 2003 (3 redundant lines with 2-out-of-3 voting) over the 6 architectures under consideration for systems with high requirements in both safety and availability

  5. 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....

  6. 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 ...

  7. A study on the quantitative evaluation of the reliability for safety critical software using Bayesian belief nets

    International Nuclear Information System (INIS)

    Eom, H. S.; Jang, S. C.; Ha, J. J.

    2003-01-01

    Despite the efforts to avoid undesirable risks, or at least to bring them under control in the world, new risks that are highly difficult to manage continue to emerge from the use of new technologies, such as the use of digital instrumentation and control (I and C) components in nuclear power plant. Whenever new risk issues came out by now, we have endeavored to find the most effective ways to reduce risks, or to allocate limited resources to do this. One of the major challenges is the reliability analysis of safety-critical software associated with digital safety systems. Though many activities such as testing, verification and validation (V and V) techniques have been carried out in the design stage of software, however, the process of quantitatively evaluating the reliability of safety-critical software has not yet been developed because of the irrelevance of the conventional software reliability techniques to apply for the digital safety systems. This paper focuses on the applicability of Bayesian Belief Net (BBN) techniques to quantitatively estimate the reliability of safety-critical software adopted in digital safety system. In this paper, a typical BBN model was constructed using the dedication process of the Commercial-Off-The-Shelf (COTS) installed by KAERI. In conclusion, the adoption of BBN technique can facilitate the process of evaluating the safety-critical software reliability in nuclear power plant, as well as provide very useful information (e.g., 'what if' analysis) associated with software reliability in the viewpoint of practicality

  8. 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

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

    NARCIS (Netherlands)

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

    2010-01-01

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

  10. The contribution of quality assurance to safety and reliability in nuclear power plants

    International Nuclear Information System (INIS)

    Raisic, N.

    1978-01-01

    The potential contribution of quality assurance to nuclear power plant safety and reliability is analysed. An attempt is made to establish a relationship between quality and reliability. The reliability may be expressed in quantitative terms as ''the probability that an item will perform a required function for a stated period of time''. Quality, however, cannot be expressed in simple quantitative terms but only as a set of required properties which an item should have for a specific application. The achievement of quality and additional reliability objectives is a task of project activities such as design, construction, installation, operation, etc. The elements of a quality assurance system and its functions in nuclear power projects are presented in some detail. Confidence in plant quality, which should be a basis for the regulatory body issuing the construction permit or operation licence, should be based on the capability of quality assurance activities to prevent errors and correct deficiencies in nuclear power plants. An analysis is made of those errors in plant design, manufacture, construction and operation which contribute most frequently to plant outages. It is concluded that these errors can be avoided or corrected by strict adherence to quality assurance principles and by the efficient functioning of quality assurance systems. In fact, quality assurance may be considered an effective defence against common cause failures originating in errors in the design, manufacture, installation or operation of a nuclear power plant

  11. Reliability analysis of the recirculation phase of the safety injection system of Angra-1

    International Nuclear Information System (INIS)

    Rivera, R.R.J.M.

    1981-09-01

    The calculation of several reliability parameters-failure probability, unavailability and unreliability - of the recirculation phase of the safety injection system of Angra-1, was done. This system has two distinct modes of operation (short term and long term) which were fault tree analysed both separately and as a whole. To obtain quantitative results the computer codes SAMPLE and PRET-KITT were utilized. The former was used to consider the uncertainties in the failure data (drawn integrally from WASH-1400) and the latter to obtain time dependent unreliability values. Hardware failures and common-mode failures were considered. Altough the analysis methods employed here differ somewhat from those used in WASH-1400, the results which could be compared were found to have the order of magnitude. A viability study of some suggestions of system's modifications was performed, and it has shown that some significant reliability improvements can be achieved with reasonably simple changes. (Author) [pt

  12. Analysis and recommendations for a reliable programming of software based safety systems

    International Nuclear Information System (INIS)

    Nunez McLeod, J.; Nunez McLeod, J.E.; Rivera, S.S.

    1997-01-01

    The present paper summarizes the results of several studies performed for the development of high software on i486 microprocessors, towards its utilization for control and safety systems for nuclear power plants. The work is based on software programmed in C language. Several recommendations oriented to high reliability software are analyzed, relating the requirements on high level language to its influence on assembler level. Several metrics are implemented, that allow for the quantification of the results achieved. New metrics were developed and other were adapted, in order to obtain more efficient indexes for the software description. Such metrics are helpful to visualize the adaptation of the software under development to the quality rules under use. A specific program developed to assist the reliability analyst on this quantification is also present in the paper. It performs the analysis of an executable program written in C language, disassembling it and evaluating its inter al structures. (author)

  13. Increasing nuclear safety and operational reliability by upgrading the charging pump mechanical sealing system

    Energy Technology Data Exchange (ETDEWEB)

    Loenhout, Gerard van [Flowserve Corporation, Etten-Leur (Netherlands); Nilsson, Peter [Flowsys Technologies AB, Moelndal (Sweden); Jehander, Magnus [Ringhals AB, Vaeroebacka (Sweden)

    2016-07-01

    For the Ringhals-2 nuclear power plant, three installed centrifugal pumps were designated to have a combined High Head Safety Injection function, as well as a Chemical Volume Control System function. The pumps were originally installed with rubber bellow type mechanical seals, which over time had demonstrated an unreliable sealing performance by displaying high leakages. In 2002, the Ringhals Maintenance engineers initiated to identify a more reliable and robust shaft sealing solution. In 2007, the project was launched and the installation of the first, new mechanical sealing solution took place in the autumn of 2011. In October 2014, these mechanical seals were dismantled and inspected. The inspection confirmed the expected reliability of the new solution.

  14. Increasing nuclear safety and operational reliability by upgrading the charging pump mechanical sealing system

    Energy Technology Data Exchange (ETDEWEB)

    Loenhout, Gerard van [Flowserve Corporation, Etten-Leur (Netherlands); Nilsson, Peter [Flowsys Technologies AB, Moelndal (Sweden); Jehander, Magnus [Ringhals AB, Vaeroebacka (Sweden)

    2016-03-15

    For the Ringhals-2 nuclear power plant, three installed centrifugal pumps were designated to have a combined High Head Safety Injection function, as well as a Chemical Volume Control System function. The pumps were originally installed with rubber bellow type mechanical seals, which over time had demonstrated an unreliable sealing performance by displaying high leakages. In 2002, the Ringhals Maintenance engineers initiated to identify a more reliable and robust shaft sealing solution. In 2007, the project was launched and the installation of the first, new mechanical sealing solution took place in the autumn of 2011. In October 2014, these mechanical seals were dismantled and inspected. The inspection confirmed the expected reliability of the new solution.

  15. Increasing nuclear safety and operational reliability by upgrading the charging pump mechanical sealing system

    International Nuclear Information System (INIS)

    Loenhout, Gerard van; Nilsson, Peter; Jehander, Magnus

    2016-01-01

    For the Ringhals-2 nuclear power plant, three installed centrifugal pumps were designated to have a combined High Head Safety Injection function, as well as a Chemical Volume Control System function. The pumps were originally installed with rubber bellow type mechanical seals, which over time had demonstrated an unreliable sealing performance by displaying high leakages. In 2002, the Ringhals Maintenance engineers initiated to identify a more reliable and robust shaft sealing solution. In 2007, the project was launched and the installation of the first, new mechanical sealing solution took place in the autumn of 2011. In October 2014, these mechanical seals were dismantled and inspected. The inspection confirmed the expected reliability of the new solution.

  16. 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.

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

    Science.gov (United States)

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

    2012-01-01

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

  18. Reliability analysis of safety systems of nuclear power plant and utility experience with reliability safeguarding of systems during specified normal operation

    International Nuclear Information System (INIS)

    Balfanz, H.P.

    1989-01-01

    The paper gives an outline of the methods applied for reliability analysis of safety systems in nuclear power plant. The main tasks are to check the system design for detection of weak points, and to find possibilities of optimizing the strategies for inspection, inspection intervals, maintenance periods. Reliability safeguarding measures include the determination and verification of the broundary conditions of the analysis with regard to the reliability parameters and maintenance parameters used in the analysis, and the analysis of data feedback reflecting the plant response during operation. (orig.) [de

  19. Feasibility of AmbulanCe-Based Telemedicine (FACT study: safety, feasibility and reliability of third generation in-ambulance telemedicine.

    Directory of Open Access Journals (Sweden)

    Laetitia Yperzeele

    Full Text Available Telemedicine is currently mainly applied as an in-hospital service, but this technology also holds potential to improve emergency care in the prehospital arena. We report on the safety, feasibility and reliability of in-ambulance teleconsultation using a telemedicine system of the third generation.A routine ambulance was equipped with a system for real-time bidirectional audio-video communication, automated transmission of vital parameters, glycemia and electronic patient identification. All patients ( ≥ 18 years transported during emergency missions by a Prehospital Intervention Team of the Universitair Ziekenhuis Brussel were eligible for inclusion. To guarantee mobility and to facilitate 24/7 availability, the teleconsultants used lightweight laptop computers to access a dedicated telemedicine platform, which also provided functionalities for neurological assessment, electronic reporting and prehospital notification of the in-hospital team. Key registrations included any safety issue, mobile connectivity, communication of patient information, audiovisual quality, user-friendliness and accuracy of the prehospital diagnosis.Prehospital teleconsultation was obtained in 41 out of 43 cases (95.3%. The success rates for communication of blood pressure, heart rate, blood oxygen saturation, glycemia, and electronic patient identification were 78.7%, 84.8%, 80.6%, 64.0%, and 84.2%. A preliminary prehospital diagnosis was formulated in 90.2%, with satisfactory agreement with final in-hospital diagnoses. Communication of a prehospital report to the in-hospital team was successful in 94.7% and prenotification of the in-hospital team via SMS in 90.2%. Failures resulted mainly from limited mobile connectivity and to a lesser extent from software, hardware or human error. The user acceptance was high.Ambulance-based telemedicine of the third generation is safe, feasible and reliable but further research and development, especially with regard to high

  20. Survey of bayesian belif nets for quantitative reliability assessment of safety critical software used in nuclear power plants

    Energy Technology Data Exchange (ETDEWEB)

    Eom, H.S.; Sung, T.Y.; Jeong, H.S.; Park, J.H.; Kang, H.G.; Lee, K

    2001-03-01

    As part of the Probabilistic Safety Assessment of safety grade digital systems used in Nuclear Power plants research, measures and methodologies applicable to quantitative reliability assessment of safety critical software were surveyed. Among the techniques proposed in the literature we selected those which are in use widely and investigated their limitations in quantitative software reliability assessment. One promising methodology from the survey is Bayesian Belief Nets (BBN) which has a formalism and can combine various disparate evidences relevant to reliability into final decision under uncertainty. Thus we analyzed BBN and its application cases in digital systems assessment area and finally studied the possibility of its application to the quantitative reliability assessment of safety critical software.

  1. Survey of bayesian belif nets for quantitative reliability assessment of safety critical software used in nuclear power plants

    International Nuclear Information System (INIS)

    Eom, H. S.; Sung, T. Y.; Jeong, H. S.; Park, J. H.; Kang, H. G.; Lee, K.

    2001-03-01

    As part of the Probabilistic Safety Assessment of safety grade digital systems used in Nuclear Power plants research, measures and methodologies applicable to quantitative reliability assessment of safety critical software were surveyed. Among the techniques proposed in the literature we selected those which are in use widely and investigated their limitations in quantitative software reliability assessment. One promising methodology from the survey is Bayesian Belief Nets (BBN) which has a formalism and can combine various disparate evidences relevant to reliability into final decision under uncertainty. Thus we analyzed BBN and its application cases in digital systems assessment area and finally studied the possibility of its application to the quantitative reliability assessment of safety critical software

  2. Design, construction, qualification and reliability of main components, from the safety aspect

    International Nuclear Information System (INIS)

    Crette, J.P.

    1982-01-01

    In FRANCE, the design and construction of reliable components, which condition the safe operation and availability of breeder plants, is based on the experience acquired during the operation of RAPSODIE, PHENIX and the various test facilities. The technical progress achieved on all main components is illustrated by examples taken from the CREYS-MALVILLE plant. In parallel with the development of these components, an extensive program covering research, development and the definition of design, construction and inspection rules, together with scheduling and quality assurance methods, prepares the industrialization of this reactor system, in compliance with the rules and recommendations issued by the pertinent safety authorities

  3. Human Reliability in Probabilistic Safety Assessments; Fiabilidad Humana en los Analisis Probabilisticos de Seguridad

    Energy Technology Data Exchange (ETDEWEB)

    Nunez Mendez, J

    1989-07-01

    Nowadays a growing interest in environmental aspects is detected in our country. It implies an assessment of the risk involved in the industrial processes and installations in order to determine if those are into the acceptable limits. In these safety assessments, among which PSA (Probabilistic Safety Assessments), can be pointed out the role played by the human being in the system is one of the more relevant subjects (This relevance has been demonstrated in the accidents happened) . However, in Spain there aren't manuals specifically dedicated to asses the human contribution to risk in the frame of PSAs. This report aims to improve this situation providing: a) a theoretical background to help the reader in the understanding of the nature of the human error, b) a quid to carry out a Human Reliability Analysis and c) a selected overview of the techniques and methodologies currently applied in this area. (Author) 20 refs.

  4. Human Reliability in Probabilistic Safety Assessments; Fiabilidad Humana en los Analisis Probabilisticos de Seguridad

    Energy Technology Data Exchange (ETDEWEB)

    Nunez Mendez, J.

    1989-07-01

    Nowadays a growing interest in environmental aspects is detected in our country. It implies an assessment of the risk involved in the industrial processes and installations in order to determine if those are into the acceptable limits. In these safety assessments, among which PSA (Probabilistic Safety Assessments), can be pointed out the role played by the human being in the system is one of the more relevant subjects (This relevance has been demonstrated in the accidents happened) . However, in Spain there aren't manuals specifically dedicated to asses the human contribution to risk in the frame of PSAs. This report aims to improve this situation providing: a) a theoretical background to help the reader in the understanding of the nature of the human error, b) a quid to carry out a Human Reliability Analysis and c) a selected overview of the techniques and methodologies currently applied in this area. (Author) 20 refs.

  5. 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.

  6. New design of engineered safety features-component control system to improve performance and reliability

    International Nuclear Information System (INIS)

    Kim, S.T.; Jung, H.W.; Lee, S.J.; Cho, C.H.; Kim, D.H.; Kim, H.

    2006-01-01

    Full text: Full text: The Engineered Safety Features-Component Control System (ESF-CCS) controls the engineered safety features of a Nuclear Power Plant such as Solenoid Operated Valves (SOV), Motor Operated Valves (MOV), pumps, dampers, etc. to mitigate the effects of a Design Basis Accident (DBA) or an abnormal operation. ESF-CCS serves as an interface system between the Plant Protection System (PPS) and remote actuation devices. ESF-CCS is composed of fault tolerant Group Controllers GC, Loop Controllers (LC), ESF-CCS Test and Interface Processor (ETIP) and Cabinet Operator Module (COM) and Control Channel Gateway (CCG) etc. GCs in each division are designed to be fully independent triple configuration, which perform system level NSSS and BOP ESFAS logic (2-out-of-4 logic and l-out-of-2 logic, respectively) making it possible to test each GC individually during normal operation. In the existing configuration, the safety-related plant component control is part of the Plant Control System (PCS) non-safety system. For increased safety and reliability, this design change incorporates this part into the LCs, and is therefore designed according to the safety-critical system procedures. The test and diagnosis capabilities of ETIP and COM are reinforced. By means of an automatic periodic test for all main functions of the system, it is possible to quickly determine an abnormal status of the system, and to decrease the elapsed time for tests, thus effectively increasing availability. ESF-CCS consists of four independent divisions (A, B, C, and D) in the Advanced Power Reactor 1400 (APR1400). One prototype division is being manufactured and will be tested

  7. 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...

  8. Reliability study: digital engineered safety feature actuation system of Korean Standard Nuclear Power Plant

    International Nuclear Information System (INIS)

    Sudarno; Kang, H. G.; Jang, S. C.; Eom, H. S.; Ha, J. J.

    2003-04-01

    The usage of digital Instrumentation and Control (I and C) in a nuclear power plant becomes more extensive, including safety related systems. The PSA application of these new designs are very important in order to evaluate their reliability. In particular, Korean Standard Nuclear Power Plants (KSNPPs), typically Ulchin 5 and 6 (UCN 5 and 6) reactor units, adopted the digital safety-critical systems such as Digital Plant Protection System (DPPS) and Digital Engineered Safety Feature Actuation System (DESFAS). In this research, we developed fault tree models for assessing the unavailability of the DESFAS functions. We also performed an analysis of the quantification results. The unavailability results of different DESFAS functions showed that their values are comprised from 5.461E-5 to 3.14E-4. The system unavailability of DESFAS AFAS-1 is estimated as 5.461E-5, which is about 27% less than that of analog system if we consider the difference of human failure probability estimation between both analyses. The results of this study could be utilized in risk-effect analysis of KSNPP. We expect that the safety analysis result will contribute to design feedback

  9. Performance and Reliability of DSRC Vehicular Safety Communication: A Formal Analysis

    Directory of Open Access Journals (Sweden)

    2009-02-01

    Full Text Available IEEE- and ASTM-adopted dedicated short range communications (DSRC standard toward 802.11p is a key enabling technology for the next generation of vehicular safety communication. Broadcasting of safety messages is one of the fundamental services in DSRC. There have been numerous publications addressing design and analysis of such broadcast ad hoc system based on the simulations. For the first time, an analytical model is proposed in this paper to evaluate performance and reliability of IEEE 802.11a-based vehicle-to-vehicle (V2V safety-related broadcast services in DSRC system on highway. The proposed model takes two safety services with different priorities, nonsaturated message arrival, hidden terminal problem, fading transmission channel, transmission range, IEEE 802.11 backoff counter process, and highly mobile vehicles on highway into account. Based on the solutions to the proposed analytic model, closed-form expressions of channel throughput, transmission delay, and packet reception rates are derived. From the obtained numerical results under various offered traffic and network parameters, new insights and enhancement suggestions are given.

  10. Application of REPAS Methodology to Assess the Reliability of Passive Safety Systems

    Directory of Open Access Journals (Sweden)

    Franco Pierro

    2009-01-01

    Full Text Available The paper deals with the presentation of the Reliability Evaluation of Passive Safety System (REPAS methodology developed by University of Pisa. The general objective of the REPAS is to characterize in an analytical way the performance of a passive system in order to increase the confidence toward its operation and to compare the performances of active and passive systems and the performances of different passive systems. The REPAS can be used in the design of the passive safety systems to assess their goodness and to optimize their costs. It may also provide numerical values that can be used in more complex safety assessment studies and it can be seen as a support to Probabilistic Safety Analysis studies. With regard to this, some examples in the application of the methodology are reported in the paper. A best-estimate thermal-hydraulic code, RELAP5, has been used to support the analyses and to model the selected systems. Probability distributions have been assigned to the uncertain input parameters through engineering judgment. Monte Carlo method has been used to propagate uncertainties and Wilks' formula has been taken into account to select sample size. Failure criterions are defined in terms of nonfulfillment of the defined design targets.

  11. Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.

    Science.gov (United States)

    Singer, Sara; Meterko, Mark; Baker, Laurence; Gaba, David; Falwell, Alyson; Rosen, Amy

    2007-10-01

    To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity. Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate. Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers. We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA). We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89. It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

  12. Reliable scar scoring system to assess photographs of burn patients.

    Science.gov (United States)

    Mecott, Gabriel A; Finnerty, Celeste C; Herndon, David N; Al-Mousawi, Ahmed M; Branski, Ludwik K; Hegde, Sachin; Kraft, Robert; Williams, Felicia N; Maldonado, Susana A; Rivero, Haidy G; Rodriguez-Escobar, Noe; Jeschke, Marc G

    2015-12-01

    Several scar-scoring scales exist to clinically monitor burn scar development and maturation. Although scoring scars through direct clinical examination is ideal, scars must sometimes be scored from photographs. No scar scale currently exists for the latter purpose. We modified a previously described scar scale (Yeong et al., J Burn Care Rehabil 1997) and tested the reliability of this new scale in assessing burn scars from photographs. The new scale consisted of three parameters as follows: scar height, surface appearance, and color mismatch. Each parameter was assigned a score of 1 (best) to 4 (worst), generating a total score of 3-12. Five physicians with burns training scored 120 representative photographs using the original and modified scales. Reliability was analyzed using coefficient of agreement, Cronbach alpha, intraclass correlation coefficient, variance, and coefficient of variance. Analysis of variance was performed using the Kruskal-Wallis test. Color mismatch and scar height scores were validated by analyzing actual height and color differences. The intraclass correlation coefficient, the coefficient of agreement, and Cronbach alpha were higher for the modified scale than those of the original scale. The original scale produced more variance than that in the modified scale. Subanalysis demonstrated that, for all categories, the modified scale had greater correlation and reliability than the original scale. The correlation between color mismatch scores and actual color differences was 0.84 and between scar height scores and actual height was 0.81. The modified scar scale is a simple, reliable, and useful scale for evaluating photographs of burn patients. Copyright © 2015 Elsevier Inc. All rights reserved.

  13. [Examination of safety improvement by failure record analysis that uses reliability engineering].

    Science.gov (United States)

    Kato, Kyoichi; Sato, Hisaya; Abe, Yoshihisa; Ishimori, Yoshiyuki; Hirano, Hiroshi; Higashimura, Kyoji; Amauchi, Hiroshi; Yanakita, Takashi; Kikuchi, Kei; Nakazawa, Yasuo

    2010-08-20

    How the maintenance checks of the medical treatment system, including start of work check and the ending check, was effective for preventive maintenance and the safety improvement was verified. In this research, date on the failure of devices in multiple facilities was collected, and the data of the trouble repair record was analyzed by the technique of reliability engineering. An analysis of data on the system (8 general systems, 6 Angio systems, 11 CT systems, 8 MRI systems, 8 RI systems, and the radiation therapy system 9) used in eight hospitals was performed. The data collection period assumed nine months from April to December 2008. Seven items were analyzed. (1) Mean time between failures (MTBF) (2) Mean time to repair (MTTR) (3) Mean down time (MDT) (4) Number found by check in morning (5) Failure generation time according to modality. The classification of the breakdowns per device, the incidence, and the tendency could be understood by introducing reliability engineering. Analysis, evaluation, and feedback on the failure generation history are useful to keep downtime to a minimum and to ensure safety.

  14. Establishing the Appropriate Attributes in Current Human Reliability Assessment Techniques for Nuclear Safety

    International Nuclear Information System (INIS)

    Bowie, Jane; Munley, Gary; Dang, Vinh; Wreathall, John; Bye, Andreas; Cooper, Susan; Marble, Julie; Peters, Sean; Xing, Jing; Fauchille, Veronique; Fiset, Jean Yves; Haage, Monica; Johanson, Gunnar; Jung, Won Dae; Kim, Jaewhan; Lee, Seung Jung; Kubicek, Jan; Le Bot, Pierre; Pesme, Helene; Preischl, Wolfgang; Salway, Alice; Amri, Abdallah; Lamarre, Greg; White, Andrew; )

    2015-03-01

    This report presents the results of a joint task of the Working Groups on Risk Assessment (WGRISK) and on Human and Organisational Factors (WGHOF) of the OECD/NEA CSNI, to identify desirable attributes of Human Reliability Assessment (HRA) methods, and to evaluate a range of HRA methods used in OECD member countries against those attributes. The purpose of this project is to provide information that will support regulators and operators of nuclear facilities when making judgements about the appropriateness of HRA methods for conducting assessments in support of Probabilistic Safety Assessments (PSA). The task was performed by an international team of Human Factors, HRA and PSA experts from a broad range of OECD member countries. As in other reviews of HRA methods, the study did not set out to recommend or promote the use of any particular HRA method. Rather the study aims to identify the strengths and limitations of commonly used and developing methods to aid those responsible for production of HRAs in selecting appropriate tools for specific HRA applications. The study also aims to assist regulators when making judgements on the appropriateness of the application of an HRA technique within nuclear-related probabilistic safety assessments. The report is aimed at practitioners in the field of human reliability assessment, human factors, and risk assessment more generally

  15. Quantitative software-reliability analysis of computer codes relevant to nuclear safety

    International Nuclear Information System (INIS)

    Mueller, C.J.

    1981-12-01

    This report presents the results of the first year of an ongoing research program to determine the probability of failure characteristics of computer codes relevant to nuclear safety. An introduction to both qualitative and quantitative aspects of nuclear software is given. A mathematical framework is presented which will enable the a priori prediction of the probability of failure characteristics of a code given the proper specification of its properties. The framework consists of four parts: (1) a classification system for software errors and code failures; (2) probabilistic modeling for selected reliability characteristics; (3) multivariate regression analyses to establish predictive relationships among reliability characteristics and generic code property and development parameters; and (4) the associated information base. Preliminary data of the type needed to support the modeling and the predictions of this program are described. Illustrations of the use of the modeling are given but the results so obtained, as well as all results of code failure probabilities presented herein, are based on data which at this point are preliminary, incomplete, and possibly non-representative of codes relevant to nuclear safety

  16. The selection of field component reliability data for use in nuclear safety studies

    International Nuclear Information System (INIS)

    Coxson, B.A.; Tabaie, Mansour

    1990-01-01

    The paper reviews the user requirements for field component failure data in nuclear safety studies, and the capability of various data sources to satisfy these requirements. Aspects such as estimating the population of items exposed to failure, incompleteness, and under-reporting problems are discussed. The paper takes as an example the selection of component reliability data for use in the Pre-Operational Safety Report (POSR) for Sizewell 'B' Power Station, where field data has in many cases been derived from equipment other than that to be procured and operated on site. The paper concludes that the main quality sought in the available data sources for such studies is the ability to examine failure narratives in component reliability data systems for equipment performing comparable duties to the intended plant application. The main benefit brought about in the last decade is the interactive access to data systems which are adequately structured with regard to the equipment covered, and also provide a text-searching capability of quality-controlled event narratives. (author)

  17. 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.

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

    National Research Council Canada - National Science Library

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

    2005-01-01

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

  19. 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

  20. Improving patient safety through quality assurance.

    Science.gov (United States)

    Raab, Stephen S

    2006-05-01

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

  1. Failure Modes Effects and Criticality Analysis, an Underutilized Safety, Reliability, Project Management and Systems Engineering Tool

    Science.gov (United States)

    Mullin, Daniel Richard

    2013-09-01

    The majority of space programs whether manned or unmanned for science or exploration require that a Failure Modes Effects and Criticality Analysis (FMECA) be performed as part of their safety and reliability activities. This comes as no surprise given that FMECAs have been an integral part of the reliability engineer's toolkit since the 1950s. The reasons for performing a FMECA are well known including fleshing out system single point failures, system hazards and critical components and functions. However, in the author's ten years' experience as a space systems safety and reliability engineer, findings demonstrate that the FMECA is often performed as an afterthought, simply to meet contract deliverable requirements and is often started long after the system requirements allocation and preliminary design have been completed. There are also important qualitative and quantitative components often missing which can provide useful data to all of project stakeholders. These include; probability of occurrence, probability of detection, time to effect and time to detect and, finally, the Risk Priority Number. This is unfortunate as the FMECA is a powerful system design tool that when used effectively, can help optimize system function while minimizing the risk of failure. When performed as early as possible in conjunction with writing the top level system requirements, the FMECA can provide instant feedback on the viability of the requirements while providing a valuable sanity check early in the design process. It can indicate which areas of the system will require redundancy and which areas are inherently the most risky from the onset. Based on historical and practical examples, it is this author's contention that FMECAs are an immense source of important information for all involved stakeholders in a given project and can provide several benefits including, efficient project management with respect to cost and schedule, system engineering and requirements management

  2. A holistic framework of degradation modeling for reliability analysis and maintenance optimization of nuclear safety systems

    International Nuclear Information System (INIS)

    Lin, Yanhui

    2016-01-01

    Components of nuclear safety systems are in general highly reliable, which leads to a difficulty in modeling their degradation and failure behaviors due to the limited amount of data available. Besides, the complexity of such modeling task is increased by the fact that these systems are often subject to multiple competing degradation processes and that these can be dependent under certain circumstances, and influenced by a number of external factors (e.g. temperature, stress, mechanical shocks, etc.). In this complicated problem setting, this PhD work aims to develop a holistic framework of models and computational methods for the reliability-based analysis and maintenance optimization of nuclear safety systems taking into account the available knowledge on the systems, degradation and failure behaviors, their dependencies, the external influencing factors and the associated uncertainties.The original scientific contributions of the work are: (1) For single components, we integrate random shocks into multi-state physics models for component reliability analysis, considering general dependencies between the degradation and two types of random shocks. (2) For multi-component systems (with a limited number of components):(a) a piecewise-deterministic Markov process modeling framework is developed to treat degradation dependency in a system whose degradation processes are modeled by physics-based models and multi-state models; (b) epistemic uncertainty due to incomplete or imprecise knowledge is considered and a finite-volume scheme is extended to assess the (fuzzy) system reliability; (c) the mean absolute deviation importance measures are extended for components with multiple dependent competing degradation processes and subject to maintenance; (d) the optimal maintenance policy considering epistemic uncertainty and degradation dependency is derived by combining finite-volume scheme, differential evolution and non-dominated sorting differential evolution; (e) the

  3. Electric Power quality Analysis in research reactor: Impacts on nuclear safety assessment and electrical distribution reliability

    International Nuclear Information System (INIS)

    Touati, Said; Chennai, Salim; Souli, Aissa

    2015-01-01

    The increased requirements on supervision, control, and performance in modern power systems make power quality monitoring a common practise for utilities. Large databases are created and automatic processing of the data is required for fast and effective use of the available information. Aim of the work presented in this paper is the development of tools for analysis of monitoring power quality data and in particular measurements of voltage and currents in various level of electrical power distribution. The study is extended to evaluate the reliability of the electrical system in nuclear plant. Power Quality is a measure of how well a system supports reliable operation of its loads. A power disturbance or event can involve voltage, current, or frequency. Power disturbances can originate in consumer power systems, consumer loads, or the utility. The effect of power quality problems is the loss power supply leading to severe damage to equipments. So, we try to track and improve system reliability. The assessment can be focused on the study of impact of short circuits on the system, harmonics distortion, power factor improvement and effects of transient disturbances on the Electrical System during motor starting and power system fault conditions. We focus also on the review of the Electrical System design against the Nuclear Directorate Safety Assessment principles, including those extended during the last Fukushima nuclear accident. The simplified configuration of the required system can be extended from this simple scheme. To achieve these studies, we have used a demo ETAP power station software for several simulations. (authors)

  4. Electric Power quality Analysis in research reactor: Impacts on nuclear safety assessment and electrical distribution reliability

    Energy Technology Data Exchange (ETDEWEB)

    Touati, Said; Chennai, Salim; Souli, Aissa [Nuclear Research Centre of Birine, Ain Oussera, Djelfa Province (Algeria)

    2015-07-01

    The increased requirements on supervision, control, and performance in modern power systems make power quality monitoring a common practise for utilities. Large databases are created and automatic processing of the data is required for fast and effective use of the available information. Aim of the work presented in this paper is the development of tools for analysis of monitoring power quality data and in particular measurements of voltage and currents in various level of electrical power distribution. The study is extended to evaluate the reliability of the electrical system in nuclear plant. Power Quality is a measure of how well a system supports reliable operation of its loads. A power disturbance or event can involve voltage, current, or frequency. Power disturbances can originate in consumer power systems, consumer loads, or the utility. The effect of power quality problems is the loss power supply leading to severe damage to equipments. So, we try to track and improve system reliability. The assessment can be focused on the study of impact of short circuits on the system, harmonics distortion, power factor improvement and effects of transient disturbances on the Electrical System during motor starting and power system fault conditions. We focus also on the review of the Electrical System design against the Nuclear Directorate Safety Assessment principles, including those extended during the last Fukushima nuclear accident. The simplified configuration of the required system can be extended from this simple scheme. To achieve these studies, we have used a demo ETAP power station software for several simulations. (authors)

  5. A probabilistic approach to safety/reliability of space nuclear power systems

    International Nuclear Information System (INIS)

    Medford, G.; Williams, K.; Kolaczkowski, A.

    1989-01-01

    An ongoing effort is investigating the feasibility of using probabilistic risk assessment (PRA) modeling techniques to construct a living model of a space nuclear power system. This is being done in conjunction with a traditional reliability and survivability analysis of the SP-100 space nuclear power system. The initial phase of the project consists of three major parts with the overall goal of developing a top-level system model and defining initiating events of interest for the SP-100 system. The three major tasks were performing a traditional survivability analysis, performing a simple system reliability analysis, and constructing a top-level system fault-tree model. Each of these tasks and their interim results are discussed in this paper. Initial results from the study support the conclusion that PRA modeling techniques can provide a valuable design and decision-making tool for space reactors. The ability of the model to rank and calculate relative contributions from various failure modes allows design optimization for maximum safety and reliability. Future efforts in the SP-100 program will see data development and quantification of the model to allow parametric evaluations of the SP-100 system. Current efforts have shown the need for formal data development and test programs within such a modeling framework

  6. [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.

  7. IAEA TC Project 'Strengthening safety and reliability of fuel and materials in nuclear power plants'

    International Nuclear Information System (INIS)

    Makihara, Y.

    2008-01-01

    The Regional TC Project in Europe RER9076 'Strengthening Safety and Reliability of Fuel and Materials in Nuclear Power Plants' was launched in 2003 as a four-year project and was subsequently extended in 2006 to run through 2008. The purpose of the Project is to support the Central and Eastern European countries with the necessary tools to fulfill their own fuel and material licensing needs. The main objective will be to provide quality data on fuel and materials irradiated in power reactors and in dedicated experiments carried out in material test reactors (MTRs). Within the framework of the Project, ten tasks were implemented. These included experiments performed at the test facilities in the region, training courses and workshops related to fuel safety. While several tasks are expected to be completed by the end of RER9076, some remain. It would be desirable to initiate a new RER Project from the next TC cycle (2009-2011) in order to take over RER9076 and to implement new tasks required for enhancing fuel safety in the region. (author)

  8. 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...

  9. 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.

  10. Patient Safety Movement: History and Future Directions.

    Science.gov (United States)

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

    2018-02-01

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

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

    OpenAIRE

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

    2016-01-01

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

  12. 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...

  13. The REPAS approach to the evaluation of passive safety systems reliability

    International Nuclear Information System (INIS)

    Bianchi, F.; Burgazzi, L.; D'Auria, F.; Ricotti, M.E.

    2002-01-01

    Scope of this research, carried out by ENEA in collaboration with University of Pisa and Polytechnic of Milano since 1999, is the identification of a methodology allowing the evaluation of the reliability of passive systems as a whole, in a more physical and phenomenal way. The paper describe the study, named REPAS (Reliability Evaluation of Passive Safety systems), carried out by the partners and finalised to the development and validation of such a procedure. The strategy of engagement moves from the consideration that a passive system should be theoretically more reliable than an active one. In fact it does not need any external input or energy to operate and it relies only upon natural physical laws (e.g. gravity, natural circulation, internally stored energy, etc.) and/or 'intelligent' use of the energy inherently available in the system (e.g. chemical reaction, decay heat, etc.). Nevertheless the passive system may fail its mission not only as a consequence of classical mechanical failure of components, but also for deviation from the expected behaviour, due to physical phenomena mainly related to thermal-hydraulics or due to different boundary and initial conditions. The main sources of physical failure are identified and a probability of occurrence is assigned. The reliability analysis is performed on a passive system which operates in two-phase, natural circulation. The selected system is a loop including a heat source and a heat sink where the condensation occurs. The system behaviour under different configurations has been simulated via best-estimate code (Relap5 mod3.2). The results are shown and can be treated in such a way to give qualitative and quantitative information on the system reliability. Main routes of development of the methodology are also depicted. The analysis of the results shows that the procedure is suitable to evaluate the performance of a passive system on a probabilistic / deterministic basis. Important information can also be

  14. Studying Patient Safety Culture from the Viewpoint of Nurse in educational hospitals Ilam City

    Directory of Open Access Journals (Sweden)

    Milad Borji

    2016-12-01

    Full Text Available Introduction: Patient safety culture is the first necessary step to reduce medical errors and improve patient's condition. In this context, this article aims at studying the condition of patient safety culture in hospitals in Elam in 2016. Materials and Methods: In this cross-sectional study, 150 nurses in Ilam were randomly selected. The Culture Hospital Survey on Patient Safety (HSOPSC was used and its reliability and validity had been confirmed by the previous studies. The data were analyzed by SPSS17. Results: The results showed that the nurses' safety was at positive(62.37± 8.70 and there could be found no significant difference in patient safety among the studied hospitals in this article (P<.05. Extra-organizational teamwork and non-punitive response, among the aspects of patient safety, had the lowest means and organizational learning and general understanding had the highest. Conclusion: Considering the importance of patient safety, the interventions need to be performed in order to improve the patient safety condition among nurses, especially in two aspects of extra-organizational teamwork and non-punitive response that had the lowest means.

  15. 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...

  16. 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...

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

    NARCIS (Netherlands)

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

    2009-01-01

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

  18. Notes on human factors problems in process plant reliability and safety prediction

    International Nuclear Information System (INIS)

    Rasmussen, J.; Taylor, J.R.

    1976-09-01

    The basis for plant operator reliability evaluation is described. Principles for plant design, necessary to permit reliability evaluation, are outlined. Five approaches to the plant operator reliability problem are described. Case stories, illustrating operator reliability problems, are given. (author)

  19. The collection, storage and use of equipment performance data for the safety and reliability assessment of nuclear power plants

    International Nuclear Information System (INIS)

    Fothergill, C.D.H.

    1975-01-01

    It has been characteristic of the Nuclear Industry that it should grow up in an atmosphere where reliability and operational safety considerations have been of vital importance. Consequently all aspects of Nuclear Power Reactor design, construction and operation (in the U.K.A.E.A.) are subjected to rigorous reliability assessments, beginning with the automatic protective devices and the safety shut-down systems. This has resulted in the setting up of large and small private data stores to support this upsurgence of Safety and Reliability assessment work. Unfortunately, much of the information being stored and published falls short of the minimum requirements of Safety Assessors and Reliability Analysts who need to make use of it. That there is still an urgent need for more work to be done in the Reliability Data field is universally acknowledged. The characteristics which make up good quality reliability data must be defined and achievable minimum standards must be set for its identification, collection, storage and retrieval. To this end the United Kingdom Atomic Energy Authority have set up the Systems Reliability Service Data Bank. This includes a computerized storage facility comprised of two principal data stores: (i) Reliability Data Store, (ii) Event Data Store. The figures available in the Reliability Data Store range from those relating to the lifetimes of minute components to those obtained from the assessment of whole plants and complete assemblies. These data have been accumulated from many reliable sources both inside and outside the Nuclear Industry, including the transfer of 'live' data generated from the results of reliability surveillance exercises associated with Event Data collection. Computer techniques developed specifically for the Reliability Data Store enable further 'processing' of these data to be carried out. The Event Data Store consists of three discrete computerized data stores, each one providing the necessary storage, retrieval and

  20. Comparative analysis of different configurations of PLC-based safety systems from reliability point of view

    Science.gov (United States)

    Tapia, Moiez A.

    1993-01-01

    The study of a comparative analysis of distinct multiplex and fault-tolerant configurations for a PLC-based safety system from a reliability point of view is presented. It considers simplex, duplex and fault-tolerant triple redundancy configurations. The standby unit in case of a duplex configuration has a failure rate which is k times the failure rate of the standby unit, the value of k varying from 0 to 1. For distinct values of MTTR and MTTF of the main unit, MTBF and availability for these configurations are calculated. The effect of duplexing only the PLC module or only the sensors and the actuators module, on the MTBF of the configuration, is also presented. The results are summarized and merits and demerits of various configurations under distinct environments are discussed.

  1. Reliability Quantification Method for Safety Critical Software Based on a Finite Test Set

    International Nuclear Information System (INIS)

    Shin, Sung Min; Kim, Hee Eun; Kang, Hyun Gook; Lee, Seung Jun

    2014-01-01

    Software inside of digitalized system have very important role because it may cause irreversible consequence and affect the whole system as common cause failure. However, test-based reliability quantification method for some safety critical software has limitations caused by difficulties in developing input sets as a form of trajectory which is series of successive values of variables. To address these limitations, this study proposed another method which conduct the test using combination of single values of variables. To substitute the trajectory form of input using combination of variables, the possible range of each variable should be identified. For this purpose, assigned range of each variable, logical relations between variables, plant dynamics under certain situation, and characteristics of obtaining information of digital device are considered. A feasibility of the proposed method was confirmed through an application to the Reactor Protection System (RPS) software trip logic

  2. Insights from the interim reliability evaluation program pertinent to reactor safety issues

    International Nuclear Information System (INIS)

    Carlson, D.D.

    1983-01-01

    The Interim Reliability Evaluation Program (IREP) consisted of concurrent probabilistic analyses of four operating nuclear power plants. This paper presents and integrated view of the results of the analyses drawing insights pertinent to reactor safety. The importance to risk of accident sequences initiated by transients and small loss-of-coolant accidents was confirmed. Support systems were found to contribute significantly to the sets of dominant accident sequences, either due to single failures which could disable one or more mitigating systems or due to their initiating plant transients. Human errors in response to accidents also were important risk contributors. Consideration of operator recovery actions influences accident sequence frequency estimates, the list of accident sequences dominating core melt, and the set of dominant risk contributors. Accidents involving station blackout, reactor coolant pump seal leaks and ruptures, and loss-of-coolant accidents requiring manual initiation of coolant injection were found to be risk significant

  3. Human reliability analysis for probabilistic safety assessments - review of methods and issues

    International Nuclear Information System (INIS)

    Srinivas, G.; Guptan, Rajee; Malhotra, P.K.; Ghadge, S.G.; Chandra, Umesh

    2011-01-01

    It is well known that the two major events in World Nuclear Power Plant Operating history, namely the Three Mile Island and Chernobyl, were Human failure events. Subsequent to these two events, several significant changes have been incorporated in Plant Design, Control Room Design and Operator Training to reduce the possibility of Human errors during plant transients. Still, human error contribution to Risk in Nuclear Power Plant operations has been a topic of continued attention for research, development and analysis. Probabilistic Safety Assessments attempt to capture all potential human errors with a scientifically computed failure probability, through Human Reliability Analysis. Several methods are followed by different countries to quantify the Human error probability. This paper reviews the various popular methods being followed, critically examines them with reference to their criticisms and brings out issues for future research. (author)

  4. Numerical methods for reliability and safety assessment multiscale and multiphysics systems

    CERN Document Server

    Hami, Abdelkhalak

    2015-01-01

    This book offers unique insight on structural safety and reliability by combining computational methods that address multiphysics problems, involving multiple equations describing different physical phenomena, and multiscale problems, involving discrete sub-problems that together  describe important aspects of a system at multiple scales. The book examines a range of engineering domains and problems using dynamic analysis, nonlinear methods, error estimation, finite element analysis, and other computational techniques. This book also: ·       Introduces novel numerical methods ·       Illustrates new practical applications ·       Examines recent engineering applications ·       Presents up-to-date theoretical results ·       Offers perspective relevant to a wide audience, including teaching faculty/graduate students, researchers, and practicing engineers

  5. Safety related maintenance in the framework of the reliability centered maintenance concept

    International Nuclear Information System (INIS)

    1992-07-01

    Elevated safety requirements and ever increasing costs of maintenance of nuclear power plants stimulate the interest in different methods and approaches to optimize maintenance activities. Among different concepts, the Reliability Centered Maintenance (RCM) as an approach to improve Preventive Maintenance (PM) programmes is being widely discussed an applied in several IAEA Member States. In order to summarize basic principles and current implementation of the RCM, the IAEA organized a Consultants Meeting in November 1990. The report prepared during that meeting was discussed during the Technical Committee Meeting (TCM) held in May 1991. Numerous technical presentations as well as panel and plenary discussions took place at the TCM. This document contains the report of the Consultants Meeting (modified to include comments of the TCM), a summary of the most important discussions as well as all 14 papers presented at the TCM

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

    Science.gov (United States)

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

    2008-06-01

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

  7. Health innovation for patient safety improvement

    Directory of Open Access Journals (Sweden)

    Renukha Sellappans

    2013-01-01

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

  8. Health innovation for patient safety improvement.

    Science.gov (United States)

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

    2013-01-01

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

  9. Overview of the NKS/RAK-1 project 'Strategies for reactor safety' and linkages to piping reliability studies

    International Nuclear Information System (INIS)

    Andersson, Kjell

    1997-01-01

    The NKS/RAK-1 project forms part of a four-year research program (1994-97) in the Nordic countries. The general objective of NKS/RAK-1 project is to explore strategies for reactor safety: to investigate and evaluate the safety work, to increase realism and reliability of safety analysis; and to increase the safety of nuclear installations in selected areas. The project has done extensive interview work at utilities and authorities, and analysed a number of case studies. Brief highlights and overviews of the sub-projects are presented in this paper

  10. Assessment of ALWR passive safety system reliability. Phase 1: Methodology development and component failure quantification

    International Nuclear Information System (INIS)

    Hake, T.M.; Heger, A.S.

    1995-04-01

    Many advanced light water reactor (ALWR) concepts proposed for the next generation of nuclear power plants rely on passive systems to perform safety functions, rather than active systems as in current reactor designs. These passive systems depend to a great extent on physical processes such as natural circulation for their driving force, and not on active components, such as pumps. An NRC-sponsored study was begun at Sandia National Laboratories to develop and implement a methodology for evaluating ALWR passive system reliability in the context of probabilistic risk assessment (PRA). This report documents the first of three phases of this study, including methodology development, system-level qualitative analysis, and sequence-level component failure quantification. The methodology developed addresses both the component (e.g. valve) failure aspect of passive system failure, and uncertainties in system success criteria arising from uncertainties in the system's underlying physical processes. Traditional PRA methods, such as fault and event tree modeling, are applied to the component failure aspect. Thermal-hydraulic calculations are incorporated into a formal expert judgment process to address uncertainties in selected natural processes and success criteria. The first phase of the program has emphasized the component failure element of passive system reliability, rather than the natural process uncertainties. Although cursory evaluation of the natural processes has been performed as part of Phase 1, detailed assessment of these processes will take place during Phases 2 and 3 of the program

  11. Engaging Employees: The Importance of High-Performance Work Systems for Patient Safety.

    Science.gov (United States)

    Etchegaray, Jason M; Thomas, Eric J

    2015-12-01

    To develop and test survey items that measure high-performance work systems (HPWSs), report psychometric characteristics of the survey, and examine associations between HPWSs and teamwork culture, safety culture, and overall patient safety grade. We reviewed literature to determine dimensions of HPWSs and then asked executives to tell us which dimensions they viewed as most important for safety and quality. We then created a HPWSs survey to measure the most important HPWSs dimensions. We administered an anonymous, electronic survey to employees with direct patient care working at a large hospital system in the Southern United States and looked for linkages between HPWSs, culture, and outcomes. Similarities existed for the HPWS practices viewed as most important by previous researchers and health-care executives. The HPWSs survey was found to be reliable, distinct from safety culture and teamwork culture based on a confirmatory factor analysis, and was the strongest predictor of the extent to which employees felt comfortable speaking up about patient safety problems as well as patient safety grade. We used information from a literature review and executive input to create a reliable and valid HPWSs survey. Future research needs to examine whether HPWSs is associated with additional safety and quality outcomes.

  12. 77 FR 42738 - Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient...

    Science.gov (United States)

    2012-07-20

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

  13. Reliability modeling of safety-critical network communication in a digitalized nuclear power plant

    International Nuclear Information System (INIS)

    Lee, Sang Hun; Kim, Hee Eun; Son, Kwang Seop; Shin, Sung Min; Lee, Seung Jun; Kang, Hyun Gook

    2015-01-01

    The Engineered Safety Feature-Component Control System (ESF-CCS), which uses a network communication system for the transmission of safety-critical information from group controllers (GCs) to loop controllers (LCs), was recently developed. However, the ESF-CCS has not been applied to nuclear power plants (NPPs) because the network communication failure risk in the ESF-CCS has yet to be fully quantified. Therefore, this study was performed to identify the potential hazardous states for network communication between GCs and LCs and to develop quantification schemes for various network failure causes. To estimate the risk effects of network communication failures in the ESF-CCS, a fault-tree model of an ESF-CCS signal failure in the containment spray actuation signal condition was developed for the case study. Based on a specified range of periodic inspection periods for network modules and the baseline probability of software failure, a sensitivity study was conducted to analyze the risk effect of network failure between GCs and LCs on ESF-CCS signal failure. This study is expected to provide insight into the development of a fault-tree model for network failures in digital I&C systems and the quantification of the risk effects of network failures for safety-critical information transmission in NPPs. - Highlights: • Network reliability modeling framework for digital I&C system in NPP is proposed. • Hazardous states of network protocol between GC and LC in ESF-CCS are identified. • Fault-tree model of ESF-CCS signal failure in ESF actuation condition is developed. • Risk effect of network failure on ESF-CCS signal failure is analyzed.

  14. Use of standard reliability levels in design and safety assessment of in-pile loops

    International Nuclear Information System (INIS)

    Bogani, G.; Verre, A.; Balestreri, S.; Colombo, A.G.; Luisi, T.

    1975-01-01

    This paper describes a logic-probabilistic analysis technique for a critical design review and safety assessment of in-pile loops. The examples in this paper refer to the analysis performed for the experimental loops already constructed or under construction in the ESSOR reactor of the Joint Research Centre of Ispra, as irradiation facilities for fuel element research and development tests. The proposed technique is based on the classification into categories of components and protective device malfunctions. Such subdivision into categories was agreed upon by the Italian Safety Authority and Euratom JRC, and adopted for the safety assessment of the ESSOR reactor in-pile loops. For each category, the method makes a link with a corresponding malfunction probability range (probability level). This probability level is defined taking into account design, construction, inspection and maintenance criteria as well as periodic controls; therefore the quality level and consequently the reliability level are thus also defined. The analysis is developed in the following stages: (1) definition of the analysis object (top event) and drawing of the relative fault-tree; (2) loop design analysis and preliminary optimization based on logic criteria; (3) classification into categories of the fault-tree primary events; (4) final loop design analysis and optimization based on defined component quality requirements. Stages 2 and 4 are quite different since stage 2 mainly consists of a redundance optimization, while stage 4 acts on the component quality level in such a way that each minimum cut-set leading to the top has an acceptable probability level. During analysis development, use is made of computer codes which, among other things enable the verification of fault-tree logic makeup, the listing of the minimum cut-sets with and without event categorization, and the evaluation of each cut-set order. (author)

  15. Test tools of physics radiography children as a support for safety radiation and safety patients

    International Nuclear Information System (INIS)

    Siti Masrochah; Yeti Kartikasari; Ardi Soesilo Wibowo

    2013-01-01

    Radiographic examination of the thorax children aged 1-3 years have a high sufficiently failure. This failure is caused by the movement and difficulty positioning the patient, resulting in the risk of repeat radiographs to patient safety particularly unnecessary radiation risks. It is therefore necessary to develop research on children design fixation devices. This research aims to create a design tool fixation on radiographs children to support radiation safety and patient safety. This research is a descriptive exploratory approach to tool design. The independent variables were the design tools, variable tool function test results, and radiographic variables controlled thorax. The procedure is done by designing data collection tools, further trials with 20 samples. Processing and analysis of data is done by calculating the performance assessment tool scores with range 1-3. The results showed that the design tool of fixation in the form of standard radiographic cassette equipped with chairs and some form of seat belt fixation. The procedure uses a tool fixation is routine radiographic follow thorax child in an upright position. Function test results aids fixation is to have an average score of 2.66, which means good. While the test results for each component, the majority of respondents stated that the reliability of the device is quite good with a score of 2.45 (60 %), convenience tool with a score of 2.60 (70 %), quality of the radiographs did not incontinence of the thorax radiograph with a score 2.55 (85 %), the child protection (security) with a score of 2.70 (70 %), good design aesthetic design with a score of 2.80 (80 %), addition of radiation from the others on the use of these tools do not need with a score of 2.80 (80 %), and there is no additional radiation due to repetitions with a score of 2.85 (90 %). (author)

  16. Radiation safety and care of patients

    International Nuclear Information System (INIS)

    Das, B.K.; Noreen Norfaraheen Lee Abdullah

    2012-01-01

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

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

    Science.gov (United States)

    Schneider, Henning

    2015-01-01

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

  18. Improving ICU risk management and patient safety.

    Science.gov (United States)

    Kielty, Lucy Ann

    2017-06-12

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

  19. [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.

  20. 21 CFR 312.88 - Safeguards for patient safety.

    Science.gov (United States)

    2010-04-01

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

  1. Development of reliability database for safety-related I and C component based on operating experience of KSNP

    International Nuclear Information System (INIS)

    Jang, S. C.; Han, S. H.; Min, K. R.

    2001-01-01

    Reliability database for safety-related I and C components has been developed, based on domestic operating experience of total 8.63 years from four units-Yonggwang Units 3 and 4, and Ulchin Units 3 and 4. This plant-specific data of safety-related I and C components has compared with operating experience for CE-supplied plants in U.S.A. As a results, we found that on the whole the domestic reliability data was similar to CE-supplied plants in USA, through lots of failures occurred early in the commercial operation were included in our analyses without percolation

  2. Probabilistic safety assessment of Tehran Research Reactor using systems analysis programs for hands-on integrated reliability evaluations

    International Nuclear Information System (INIS)

    Hosseini, M.H.; Nematollahi, M.R.; Sepanloo, K.

    2004-01-01

    Probabilistic safety assessment application is found to be a practical tool for research reactor safety due to intense involvement of human interactions in an experimental facility. In this document the application of the probabilistic safety assessment to the Tehran Research Reactor is presented. The level 1 practicabilities safety assessment application involved: Familiarization with the plant, selection of accident initiators, mitigating functions and system definitions, event tree constructions and quantifications, fault tree constructions and quantification, human reliability, component failure data base development and dependent failure analysis. Each of the steps of the analysis given above is discussed with highlights from the selected results. Quantification of the constructed models is done using systems analysis programs for hands-on integrated reliability evaluations software

  3. 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.

  4. The importance of the reliability study for the safety operation of chemical plants. Application in heavy water plants

    International Nuclear Information System (INIS)

    Dumitrescu, Maria; Lazar, Roxana Elena; Preda, Irina Aida; Stefanescu, Ioan

    1999-01-01

    Heavy water production in Romania is based on H 2 O-H 2 S isotopic exchange process followed by vacuum isotopic distillation. The heavy water plant are complex chemical systems, characterized by an ensemble of static and dynamic equipment, AMC components, enclosures. Such equipment must have a high degree of reliability, a maximum safety in technological operation and a high availability index. Safety, reliable and economical operation heavy water plants need to maintain the systems and the components at adequate levels of reliability. The paper is a synthesis of the qualitative and quantitative assessment reliability studies for heavy water plants. The operation analysis on subsystems, each subsystems being a well-defined unit, is required by the plant complexity. For each component the reliability indicators were estimated by parametric and non-parametric methods based on the plant operation data. Also, the reliability qualitative and quantitative assessment was done using the fault tree technique. For the dual temperature isotopic exchange plants the results indicate an increase of the MTBF after the first years of operation, illustrating both the operation experience increasing and maintenance improvement. Also a high degree of availability was illustrated by the reliability studies of the vacuum distillation plant. The establishment of the reliability characteristics for heavy water plant represents an important step, a guide for highlighting the elements and process liable to failure being at the same time a planning modality to correlate the control times with the maintenance operations. This is the way to minimise maintenance, control and costs. The main purpose of the reliability study was the safety increase of the plant operation and the support for decision making. (authors)

  5. 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

    Full Text Available Abstract Background How hospital health care personnel perceive safety climate has been assessed in several countries by using the Hospital Survey on Patient Safety (HSOPS. Few studies have examined safety climate factors in surgical departments per se. This study examined the psychometric properties of a Norwegian translation of the HSOPS and also compared safety climate factors from a surgical setting to hospitals in the United States, the Netherlands and Norway. Methods This survey included 575 surgical personnel in Haukeland University Hospital in Bergen, an 1100-bed tertiary hospital in western Norway: surgeons, operating theatre nurses, anaesthesiologists, nurse anaesthetists and ancillary personnel. Of these, 358 returned the HSOPS, resulting in a 62% response rate. We used factor analysis to examine the applicability of the HSOPS factor structure in operating theatre settings. We also performed psychometric analysis for internal consistency and construct validity. In addition, we compared the percent of average positive responds of the patient safety climate factors with results of the US HSOPS 2010 comparative data base report. Results The professions differed in their perception of patient safety climate, with anaesthesia personnel having the highest mean scores. Factor analysis using the original 12-factor model of the HSOPS resulted in low reliability scores (r = 0.6 for two factors: "adequate staffing" and "organizational learning and continuous improvement". For the remaining factors, reliability was ≥ 0.7. Reliability scores improved to r = 0.8 by combining the factors "organizational learning and continuous improvement" and "feedback and communication about error" into one six-item factor, supporting an 11-factor model. The inter-item correlations were found satisfactory. Conclusions The psychometric properties of the questionnaire need further investigations to be regarded as reliable in surgical environments. The operating

  6. 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.

  7. A measurement tool to assess culture change regarding patient safety in hospital obstetrical units.

    Science.gov (United States)

    Kenneth Milne, J; Bendaly, Nicole; Bendaly, Leslie; Worsley, Jill; FitzGerald, John; Nisker, Jeff

    2010-06-01

    Clinical error in acute care hospitals can only be addressed by developing a culture of safety. We sought to develop a cultural assessment survey (CAS) to assess patient safety culture change in obstetrical units. Interview prompts and a preliminary questionnaire were developed through a literature review of patient safety and "high reliability organizations," followed by interviews with members of the Managing Obstetrical Risk Efficiently (MOREOB) Program of the Society of Obstetricians and Gynaecologists of Canada. Three hundred preliminary questionnaires were mailed, and 21 interviews and 9 focus groups were conducted with the staff of 11 hospital sites participating in the program. To pilot test the CAS, 350 surveys were mailed to staff in participating hospitals, and interviews were conducted with seven nurses and five physicians who had completed the survey. Reliability analysis was conducted on four units that completed the CAS prior to and following the implementation of the first MOREOB module. Nineteen values and 105 behaviours, practices, and perceptions relating to patient safety were identified and included in the preliminary questionnaire, of which 143 of 300 (47.4%) were returned. Among the 220 cultural assessment surveys returned (62.9%), six cultural scales emerged: (1) patient safety as everyone's priority; (2) teamwork; (3) valuing individuals; (4) open communication; (5) learning; and (6) empowering individuals. The reliability analysis found all six scales to have internal reliability (Cronbach alpha), ranging from 0.72 (open communication) to 0.84 (valuing individuals). The CAS developed for this study may enable obstetrical units to assess change in patient safety culture.

  8. 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.

  9. Three suggestions on the definition of terms for the safety and reliability analysis of digital systems

    International Nuclear Information System (INIS)

    Kim, Man Cheol; Smidts, Carol S.

    2015-01-01

    As digital instrumentation and control systems are being progressively introduced into nuclear power plants, a growing number of related technical issues are coming to light needing to be resolved. As a result, an understanding of relevant terms and basic concepts becomes increasingly important. Under the framework of the OECD/NEA WGRISK DIGREL Task Group, the authors were involved in reviewing definitions of terms forming the supporting vocabulary for addressing issues related to the safety and reliability analysis of digital instrumentation and control (SRA of DI and C). These definitions were extracted from various standards regulating the disciplines that form the technical and scientific basis of SRA DI and C. The authors discovered that different definitions are provided by different standards within a common discipline and used differently across various disciplines. This paper raises the concern that a common understanding of terms and basic concepts has not yet been established to address the very specific technical issues facing SRA DI and C. Based on the lessons learned from the review of the definitions of interest and the analysis of dependency relationships existing between these definitions, this paper establishes a set of recommendations for the development of a consistent terminology for SRA DI and C. - Highlights: ●We reviewed definitions of terms used in reliability analysis of digital systems. ●Different definitions are provided by different standards within a common discipline. ●Acyclic and cyclic structures of dependency in defining terms are compared. ●Three recommendations for the development of a consistent terminology provided

  10. Autonomous safety and reliability features of the K-1 avionics system

    Energy Technology Data Exchange (ETDEWEB)

    Mueller, G.E.; Kohrs, D.; Bailey, R.; Lai, G. [Kistler Aerospace Corp., Kirkland, WA (United States)

    2004-03-01

    Kistler Aerospace Corporation is developing the K-1, a fully reusable, two-stage-to-orbit launch vehicle. Both stages return to the launch site using parachutes and airbags. Initial flight operations will occur from Woomera, Australia. K-1 guidance is performed autonomously. Each stage of the K- 1 employs a triplex, fault tolerant avionics architecture, including three fault tolerant computers and three radiation hardened Embedded GPS/INS units with a hardware voter. The K-1 has an Integrated Vehicle Health Management (IVHM) system on each stage residing in the three vehicle computers based on similar systems in commercial aircraft. During first-stage ascent, the IVHM system performs an Instantaneous Impact Prediction (IIP) calculation 25 times per second, initiating an abort in the event the vehicle is outside a predetermined safety corridor for at least three consecutive calculations. In this event, commands are issued to terminate thrust, separate the stages, dump all propellant in the first-stage, and initiate a normal landing sequence. The second-stage flight computer calculates its ability to reach orbit along its state vector, initiating an abort sequence similar to the first stage if it cannot. On a nominal mission, following separation, the second-stage also performs calculations to assure its impact point is within a safety corridor. The K-1's guidance and control design is being tested through simulation with hardware-in-the-loop at Draper Laboratory. Kistler's verification strategy assures reliable and safe operation of the K-1. (author)

  11. Research on patient safety: falls and medications.

    Science.gov (United States)

    Boddice, Sandra Dawn; Kogan, Polina

    2009-10-01

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

  12. Patient Safety Incidents and Nursing Workload 1

    Science.gov (United States)

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

    2017-01-01

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

  13. Patient Safety Incidents and Nursing Workload

    Directory of Open Access Journals (Sweden)

    Katya Cuadros Carlesi

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

  14. Suitability review of FMEA and reliability analysis for digital plant protection system and digital engineered safety features actuation system

    Energy Technology Data Exchange (ETDEWEB)

    Kim, I. S.; Kim, T. K.; Kim, M. C.; Kim, B. S.; Hwang, S. W.; Ryu, K. C. [Hanyang Univ., Seoul (Korea, Republic of)

    2000-11-15

    Of the many items that should be checked out during a review stage of the licensing application for the I and C system of Ulchin 5 and 6 units, this report relates to a suitability review of the reliability analysis of Digital Plant Protection System (DPPS) and Digital Engineered Safety Features Actuation System (DESFAS). In the reliability analysis performed by the system designer, ABB-CE, fault tree analysis was used as the main methods along with Failure Modes and Effect Analysis (FMEA). However, the present regulatory technique dose not allow the system reliability analysis and its results to be appropriately evaluated. Hence, this study was carried out focusing on the following four items ; development of general review items by which to check the validity of a reliability analysis, and the subsequent review of suitability of the reliability analysis for Ulchin 5 and 6 DPPS and DESFAS L development of detailed review items by which to check the validity of an FMEA, and the subsequent review of suitability of the FMEA for Ulchin 5 and 6 DPPS and DESFAS ; development of detailed review items by which to check the validity of a fault tree analysis, and the subsequent review of suitability of the fault tree for Ulchin 5 and 6 DPPS and DESFAS ; an integrated review of the safety and reliability of the Ulchin 5 and 6 DPPS and DESFAS based on the results of the various reviews above and also of a reliability comparison between the digital systems and the comparable analog systems, i.e., and analog Plant Protection System (PPS) and and analog Engineered Safety Features Actuation System (ESFAS). According to the review mentioned above, the reliability analysis of Ulchin 5 and 6 DPPS and DESFAS generally satisfies the review requirements. However, some shortcomings of the analysis were identified in our review such that the assumed test periods for several equipment were not properly incorporated in the analysis, and failures of some equipment were not included in the

  15. 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.

  16. Reliability of patient-reported outcomes in rheumatoid arthritis patients: an observational prospective study.

    Science.gov (United States)

    Studenic, Paul; Stamm, Tanja; Smolen, Josef S; Aletaha, Daniel

    2016-01-01

    Patient-reported outcomes (PROs) such as pain, patient global assessment (PGA) and fatigue are regularly assessed in RA patients. In the present study, we aimed to explore the reliability and smallest detectable differences (SDDs) of these PROs, and whether the time between assessments has an impact on reliability. Forty RA patients on stable treatment reported the three PROs daily over two subsequent months. We assessed the reliability of these measures by calculating intraclass correlation coefficients (ICCs) and the SDDs for 1-, 7-, 14- and 28-day test-retest intervals. Overall, SDD and ICC were 25 mm and 0.67 for pain, 25 mm and 0.71 for PGA and 30 mm and 0.66 for fatigue, respectively. SDD was higher with longer time period between assessments, ranging from 19 mm (1-day intervals) to 30 mm (28-day intervals) for pain, 19 to 33 mm for PGA, and 26 to 34 mm for fatigue; correspondingly, ICC was smaller with longer intervals, and ranged between the 1- and the 28-day interval from 0.80 to 0.50 for pain, 0.83 to 0.57 for PGA and 0.76 to 0.58 for fatigue. The baseline simplified disease activity index did not have any influence on reliability. Lower baseline PRO scores led to smaller SDDs. Reliability of pain, PGA and fatigue measurements is dependent on the tested time interval and the baseline levels. The relatively high SDDs, even for patients in the lowest tertiles of their PROs, indicate potential issues for assessment of the presence of remission. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  17. Feasibility of AmbulanCe-Based Telemedicine (FACT) Study : Safety, Feasibility and Reliability of Third Generation Ambulance Telemedicine

    NARCIS (Netherlands)

    Yperzeele, Laetitia; Van Hooff, Robbert-Jan; De Smedt, Ann; Espinoza, Alexis Valenzuela; Van Dyck, Rita; Van de Casseye, Rohny; Convents, Andre; Hubloue, Ives; Lauwaert, Door; De Keyser, Jacques; Brouns, Raf

    2014-01-01

    Background: Telemedicine is currently mainly applied as an in-hospital service, but this technology also holds potential to improve emergency care in the prehospital arena. We report on the safety, feasibility and reliability of in-ambulance teleconsultation using a telemedicine system of the third

  18. How to use an optimization-based method capable of balancing safety, reliability, and weight in an aircraft design process

    Energy Technology Data Exchange (ETDEWEB)

    Johansson, Cristina [Mendeley, Broderna Ugglasgatan, Linkoping (Sweden); Derelov, Micael; Olvander, Johan [Linkoping University, IEI, Dept. of Machine Design, Linkoping (Sweden)

    2017-03-15

    In order to help decision-makers in the early design phase to improve and make more cost-efficient system safety and reliability baselines of aircraft design concepts, a method (Multi-objective Optimization for Safety and Reliability Trade-off) that is able to handle trade-offs such as system safety, system reliability, and other characteristics, for instance weight and cost, is used. Multi-objective Optimization for Safety and Reliability Trade-off has been developed and implemented at SAAB Aeronautics. The aim of this paper is to demonstrate how the implemented method might work to aid the selection of optimal design alternatives. The method is a three-step method: step 1 involves the modelling of each considered target, step 2 is optimization, and step 3 is the visualization and selection of results (results processing). The analysis is performed within Architecture Design and Preliminary Design steps, according to the company's Product Development Process. The lessons learned regarding the use of the implemented trade-off method in the three cases are presented. The results are a handful of solutions, a basis to aid in the selection of a design alternative. While the implementation of the trade-off method is performed for companies, there is nothing to prevent adapting this method, with minimal modifications, for use in other industrial applications.

  19. How to use an optimization-based method capable of balancing safety, reliability, and weight in an aircraft design process

    International Nuclear Information System (INIS)

    Johansson, Cristina; Derelov, Micael; Olvander, Johan

    2017-01-01

    In order to help decision-makers in the early design phase to improve and make more cost-efficient system safety and reliability baselines of aircraft design concepts, a method (Multi-objective Optimization for Safety and Reliability Trade-off) that is able to handle trade-offs such as system safety, system reliability, and other characteristics, for instance weight and cost, is used. Multi-objective Optimization for Safety and Reliability Trade-off has been developed and implemented at SAAB Aeronautics. The aim of this paper is to demonstrate how the implemented method might work to aid the selection of optimal design alternatives. The method is a three-step method: step 1 involves the modelling of each considered target, step 2 is optimization, and step 3 is the visualization and selection of results (results processing). The analysis is performed within Architecture Design and Preliminary Design steps, according to the company's Product Development Process. The lessons learned regarding the use of the implemented trade-off method in the three cases are presented. The results are a handful of solutions, a basis to aid in the selection of a design alternative. While the implementation of the trade-off method is performed for companies, there is nothing to prevent adapting this method, with minimal modifications, for use in other industrial applications

  20. 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.

  1. 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.

  2. Patient safety: knowledge between multiprofessional residents.

    Science.gov (United States)

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

    2017-01-01

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

  3. Patient safety competence for final-year health professional students: Perceptions of effectiveness of an interprofessional education course.

    Science.gov (United States)

    Hwang, Jee-In; Yoon, Tai-Young; Jin, Hyeon-Jeong; Park, Yikyun; Park, Ju-Young; Lee, Beom-Joon

    2016-11-01

    As final-year medical and nursing students will soon play key roles in frontline patient care, their preparedness for safe, reliable care provision is of special importance. We assessed patient safety competencies of final-year health profession students, and the effect of a 1-day patient safety education programme on these competencies. A cross-sectional survey was conducted with 233 students in three colleges of medicine, nursing, and traditional medicine in Seoul. A before-and-after study followed to evaluate the effectiveness of the curriculum. Patient safety competency was measured using the Health-Professional Education for Patients Safety Survey (H-PEPSS) and an objective patient safety knowledge test. The mean scores were 3.4 and 1.7 out of 5.0, respectively. The communication domain was rated the highest and the teamwork domain was rated the lowest. H-PEPSS scores significantly differed between the students from three colleges. The 1-day patient safety education curriculum significantly improved H-PEPSS and knowledge test scores. These results indicated that strengthening patient safety competencies, especially teamwork, of students is required in undergraduate healthcare curricula. A 1-day interprofessional patient safety education programme may be a promising strategy. The findings suggest that interprofessional patient safety education needs to be implemented as a core undergraduate course to improve students' safety competence.

  4. Probabilistic Analysis of Passive Safety System Reliability in Advanced Small Modular Reactors: Methodologies and Lessons Learned

    Energy Technology Data Exchange (ETDEWEB)

    Grabaskas, David; Bucknor, Matthew; Brunett, Acacia; Grelle, Austin

    2015-06-28

    Many advanced small modular reactor designs rely on passive systems to fulfill safety functions during accident sequences. These systems depend heavily on boundary conditions to induce a motive force, meaning the system can fail to operate as intended due to deviations in boundary conditions, rather than as the result of physical failures. Furthermore, passive systems may operate in intermediate or degraded modes. These factors make passive system operation difficult to characterize with a traditional probabilistic framework that only recognizes discrete operating modes and does not allow for the explicit consideration of time-dependent boundary conditions. Argonne National Laboratory has been examining various methodologies for assessing passive system reliability within a probabilistic risk assessment for a station blackout event at an advanced small modular reactor. This paper describes the most promising options: mechanistic techniques, which share qualities with conventional probabilistic methods, and simulation-based techniques, which explicitly account for time-dependent processes. The primary intention of this paper is to describe the strengths and weaknesses of each methodology and highlight the lessons learned while applying the two techniques while providing high-level results. This includes the global benefits and deficiencies of the methods and practical problems encountered during the implementation of each technique.

  5. A study of adopting maintenance rule under the periodic safety review and reliability centered maintenance program

    International Nuclear Information System (INIS)

    Kilyoo, Kim

    2001-01-01

    U.S Maintenance Rule (MR) has three main functions. One is to monitor the performance changes of SSCs (Structure, System, and Component) caused by risk informed applications. Periodic Safety Review (PSR) program is widely adopted in Europe while it is not adopted in U. S. A where MR and new oversight program are instead used. Recently, in Korea, it was determined to adopt PSR, and the first PSR program has started this year for Kori unit 1 as a pilot plant. Also, a traditional Reliability Centered Maintenance (RCM) has been performed for 4 systems of YGN unit 1 and 2 and it will be applied to the other nuclear power plants in Korea. However, since MR is adopting many useful concept of RCM, traditional RCM could not be further performed without being associated with MR. Thus, MR, RCM and PSR have recently become hot issue policies which should be well associated each other in Korea, and this paper suggests a desirable new maintenance process which would embrace the concepts of the three policies, and also discusses whether U.S. MR is necessary even though a PSR program is already adopted, and if necessary, then how cost-effectively it can be introduced to. (author)

  6. Development of a Method for Quantifying the Reliability of Nuclear Safety-Related Software

    International Nuclear Information System (INIS)

    Yi Zhang; Golay, Michael W.

    2003-01-01

    The work of our project is intended to help introducing digital technologies into nuclear power into nuclear power plant safety related software applications. In our project we utilize a combination of modern software engineering methods: design process discipline and feedback, formal methods, automated computer aided software engineering tools, automatic code generation, and extensive feasible structure flow path testing to improve software quality. The tactics include ensuring that the software structure is kept simple, permitting routine testing during design development, permitting extensive finished product testing in the input data space of most likely service and using test-based Bayesian updating to estimate the probability that a random software input will encounter an error upon execution. From the results obtained the software reliability can be both improved and its value estimated. Hopefully our success in the project's work can aid the transition of the nuclear enterprise into the modern information world. In our work, we have been using the proprietary sample software, the digital Signal Validation Algorithm (SVA), provided by Westinghouse. Also our work is being done with their collaboration. The SVA software is used for selecting the plant instrumentation signal set which is to be used as the input the digital Plant Protection System (PPS). This is the system that automatically decides whether to trip the reactor. In our work, we are using -001 computer assisted software engineering (CASE) tool of Hamilton Technologies Inc. This tool is capable of stating the syntactic structure of a program reflecting its state requirements, logical functions and data structure

  7. Materials technology and the energy problem : application to the reliability and safety of nuclear pressure vessels

    International Nuclear Information System (INIS)

    Garrett, G.G.

    1975-01-01

    In the U.S.A. over the past few months, widespread plant shutdowns because of cracking problems has produced considerable public pressure for a reappraisal of the reliability and safety of nuclear reactors. The awareness of such problems, and their solution, is particularly relevant to South Africa at this time. Some materials problems related to nuclear plant failure are examined in this paper. Since catastrophic failure (without prior warning from slow leakage) is in principle possible for light water (pressurised) reactors under operating conditions, it is essential to maintain rigorous manufacturing and quality control procedures, in conjunction with thorough and frequent examination by non-destructive testing methods. Although tests currently in progress in the U.S.A. on large-scale model reactors suggest that mathematical stress and failure analyses, for simple geometries at least, are sound, current in situ surveillance programmes aimed at categorizing the effects of irradiation are inadequate. In addition, the effects on materials properties and subsequent fracture resistance of the combined effects of irradiation and thermal shock (arising from the injection of emergency cooling water during a loss-of coolant accident) are unknown. The problem of stress corrosion cracking in stainless steel pipelines is considerable, and at present virtually impossible to predict. Much of the available laboratory data is inapplicable in that it cannot account for the complex interactions of stress state, temperature, material variations and segregation effects, and water chemistry, especially in conjunction with irradiation effects, that are experienced in an operating environment

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

    Science.gov (United States)

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

    2010-01-01

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

  9. 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

  10. Journey Toward High Reliability: A Comprehensive Safety Program to Improve Quality of Care and Safety Culture in a Large, Multisite Radiation Oncology Department.

    Science.gov (United States)

    Woodhouse, Kristina Demas; Volz, Edna; Maity, Amit; Gabriel, Peter E; Solberg, Timothy D; Bergendahl, Howard W; Hahn, Stephen M

    2016-05-01

    High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology. In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade. Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Postintervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P safety framework. Our multifaceted initiatives, focusing on culture and system changes, can be successfully implemented in a large academic radiation oncology department to yield measurable improvements in SC and outcomes. Copyright © 2016 by American Society of Clinical Oncology.

  11. The sociotechnical configuration of the problem of Patient Safety

    DEFF Research Database (Denmark)

    Danholt, Peter

    2010-01-01

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

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

    National Research Council Canada - National Science Library

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

    2005-01-01

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

  13. 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

  14. Development of a patient safety climate survey for Chinese hospitals: cross-national adaptation and psychometric evaluation.

    Science.gov (United States)

    Zhu, Junya; Li, Liping; Zhao, Hailei; Han, Guangshu; Wu, Albert W; Weingart, Saul N

    2014-10-01

    Existing patient safety climate instruments, most of which have been developed in the USA, may not accurately reflect the conditions in the healthcare systems of other countries. To develop and evaluate a patient safety climate instrument for healthcare workers in Chinese hospitals. Based on a review of existing instruments, expert panel review, focus groups and cognitive interviews, we developed items relevant to patient safety climate in Chinese hospitals. The draft instrument was distributed to 1700 hospital workers from 54 units in six hospitals in five Chinese cities between July and October 2011, and 1464 completed surveys were received. We performed exploratory and confirmatory factor analyses and estimated internal consistency reliability, within-unit agreement, between-unit variation, unit-mean reliability, correlation between multi-item composites, and association between the composites and two single items of perceived safety. The final instrument included 34 items organised into nine composites: institutional commitment to safety, unit management support for safety, organisational learning, safety system, adequacy of safety arrangements, error reporting, communication and peer support, teamwork and staffing. All composites had acceptable unit-mean reliabilities (≥0.74) and within-unit agreement (Rwg ≥0.71), and exhibited significant between-unit variation with intraclass correlation coefficients ranging from 9% to 21%. Internal consistency reliabilities ranged from 0.59 to 0.88 and were ≥0.70 for eight of the nine composites. Correlations between composites ranged from 0.27 to 0.73. All composites were positively and significantly associated with the two perceived safety items. The Chinese Hospital Survey on Patient Safety Climate demonstrates adequate dimensionality, reliability and validity. The integration of qualitative and quantitative methods is essential to produce an instrument that is culturally appropriate for Chinese hospitals

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

    Science.gov (United States)

    Pinnock, David

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

  16. A Spanish-language patient safety questionnaire to measure medical and nursing students' attitudes and knowledge.

    Science.gov (United States)

    Mira, José J; Navarro, Isabel M; Guilabert, Mercedes; Poblete, Rodrigo; Franco, Astolfo L; Jiménez, Pilar; Aquino, Margarita; Fernández-Trujillo, Francisco J; Lorenzo, Susana; Vitaller, Julián; de Valle, Yohana Díaz; Aibar, Carlos; Aranaz, Jesús M; De Pedro, José A

    2015-08-01

    To design and validate a questionnaire for assessing attitudes and knowledge about patient safety using a sample of medical and nursing students undergoing clinical training in Spain and four countries in Latin America. In this cross-sectional study, a literature review was carried out and total of 786 medical and nursing students were surveyed at eight universities from five countries (Chile, Colombia, El Salvador, Guatemala, and Spain) to develop and refine a Spanish-language questionnaire on knowledge and attitudes about patient safety. The scope of the questionnaire was based on five dimensions (factors) presented in studies related to patient safety culture found in PubMed and Scopus. Based on the five factors, 25 reactive items were developed. Composite reliability indexes and Cronbach's alpha statistics were estimated for each factor, and confirmatory factor analysis was conducted to assess validity. After a pilot test, the questionnaire was refined using confirmatory models, maximum-likelihood estimation, and the variance-covariance matrix (as input). Multiple linear regression models were used to confirm external validity, considering variables related to patient safety culture as dependent variables and the five factors as independent variables. The final instrument was a structured five-point Likert self-administered survey (the "Latino Student Patient Safety Questionnaire") consisting of 21 items grouped into five factors. Compound reliability indexes (Cronbach's alpha statistic) calculated for the five factors were about 0.7 or higher. The results of the multiple linear regression analyses indicated good model fit (goodness-of-fit index: 0.9). Item-total correlations were higher than 0.3 in all cases. The convergent-discriminant validity was adequate. The questionnaire designed and validated in this study assesses nursing and medical students' attitudes and knowledge about patient safety. This instrument could be used to indirectly evaluate whether or

  17. Effects of Implemented Initiatives on Patient Safety Culture in Fateme Al-zahra Hospital in Najafabad

    Directory of Open Access Journals (Sweden)

    Ahmadreza Izadi

    2015-01-01

    Full Text Available Introduction: Patient safety improvement requires ongoing culture. This cultural change is the most important challenge that managers are faced with in creation of a safe system. This study aims to show the results of initiatives to improvement in patient safety culture in Fateme Al-zahra hospital. Method: In the quasi-experimental research, patient safety culture was measured using the Persian questionnaire on adaptation of the hospital survey on patient safety culture in 12 dimensions. The research was conducted before (January 2010 and after (September 2012 the improvement initiatives. In this study, all units were determined and no sampling method was used. Reliability of the questionnaire was tested by Alpha Chronbakh (0.83. Data were analyzed using descriptive statistics indices and Independent T-Test by SPSS Software (version 18. Results: 350 questionnaires were distributed in each phaseand overall response rate was 58 and 56 percent, respectively. According to Independent T-test, Management expectations and actions, Organizational learning, Management support, Feedback and communication about error, Communication openness, Overall Perceptions of Safety, Non-punitive Response to Error, Frequency of Event Reporting, and Patient safety culture showed significant differences (P-value0.05. The mean score of Patient safety culture was 2.27 (from 5 and it was increased to 2.46 after initiatives that showed a significant difference (P-value<0.05. Conclusion: Although, improvement in patient safety culture needs teamwork and continuous attempts, the study showed that initiatives implemented in the case hospital had been effective in some dimensions. However, Teamwork within hospital units, Teamwork across units, Hospital handoffs and transitions, and Staffing dimensions were recognized for further intervention. Hospital could improve the patient safety culture with planning and measures in these dimensions.

  18. IEEE standard requirements for reliability analysis in the design and operation of safety systems for nuclear power generating stations

    International Nuclear Information System (INIS)

    Anon.

    1976-01-01

    The purpose of this standard is to provide uniform, minimum acceptable requirements for the performance of reliability analyses for safety-related systems found in nuclear-power generating stations, but not to define the need for an analysis. The need for reliability analysis has been identified in other standards which expand the requirements of regulations (e.g., IEEE Std 379-1972 (ANSI N41.2-1972), ''Guide for the Application of the Single-Failure Criterion to Nuclear Power Generating Station Protection System,'' which describes the application of the single-failure criterion). IEEE Std 352-1975, ''Guide for General Principles of Reliability Analysis of Nuclear Power Generating Station Protection Systems,'' provides guidance in the application and use of reliability techniques referred to in this standard

  19. 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...

  20. The Surgical Safety Checklist and Teamwork Coaching Tools: a study of inter-rater reliability.

    Science.gov (United States)

    Huang, Lyen C; Conley, Dante; Lipsitz, Stu; Wright, Christopher C; Diller, Thomas W; Edmondson, Lizabeth; Berry, William R; Singer, Sara J

    2014-08-01

    To assess the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork. Data surgical safety checklists can promote adherence to standards of care and improve teamwork in the operating room. Their use has been associated with reductions in mortality and other postoperative complications. However, checklist effectiveness depends on how well they are performed. Authors from the Safe Surgery 2015 initiative developed a pair of novel observation tools through literature review, expert consultation and end-user testing. In one South Carolina hospital participating in the initiative, two observers jointly attended 50 surgical cases and independently rated surgical teams using both tools. We used descriptive statistics to measure checklist performance and teamwork at the hospital. We assessed IRR by measuring percent agreement, Cohen's κ, and weighted κ scores. The overall percent agreement and κ between the two observers was 93% and 0.74 (95% CI 0.66 to 0.79), respectively, for the Checklist Coaching Tool and 86% and 0.84 (95% CI 0.77 to 0.90) for the Surgical Teamwork Tool. Percent agreement for individual sections of both tools was 79% or higher. Additionally, κ scores for six of eight sections on the Checklist Coaching Tool and for two of five domains on the Surgical Teamwork Tool achieved the desired 0.7 threshold. However, teamwork scores were high and variation was limited. There were no significant changes in the percent agreement or κ scores between the first 10 and last 10 cases observed. Both tools demonstrated substantial IRR and required limited training to use. These instruments may be used to observe checklist performance and teamwork in the operating room. However, further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools. Published by the BMJ Publishing Group Limited. For permission to use (where not already

  1. The Patient Safety Attitudes among the Operating Room Personnel

    Directory of Open Access Journals (Sweden)

    Cherdsak Iramaneerat

    2016-07-01

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

  2. 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.

  3. Development of a Method for Quantifying the Reliability of Nuclear Safety-Related Software

    Energy Technology Data Exchange (ETDEWEB)

    Yi Zhang; Michael W. Golay

    2003-10-01

    The work of our project is intended to help introducing digital technologies into nuclear power into nuclear power plant safety related software applications. In our project we utilize a combination of modern software engineering methods: design process discipline and feedback, formal methods, automated computer aided software engineering tools, automatic code generation, and extensive feasible structure flow path testing to improve software quality. The tactics include ensuring that the software structure is kept simple, permitting routine testing during design development, permitting extensive finished product testing in the input data space of most likely service and using test-based Bayesian updating to estimate the probability that a random software input will encounter an error upon execution. From the results obtained the software reliability can be both improved and its value estimated. Hopefully our success in the project's work can aid the transition of the nuclear enterprise into the modern information world. In our work, we have been using the proprietary sample software, the digital Signal Validation Algorithm (SVA), provided by Westinghouse. Also our work is being done with their collaboration. The SVA software is used for selecting the plant instrumentation signal set which is to be used as the input the digital Plant Protection System (PPS). This is the system that automatically decides whether to trip the reactor. In our work, we are using -001 computer assisted software engineering (CASE) tool of Hamilton Technologies Inc. This tool is capable of stating the syntactic structure of a program reflecting its state requirements, logical functions and data structure.

  4. 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.

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

    DEFF Research Database (Denmark)

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

    2016-01-01

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

  6. Linguistic Validation and Cultural Adaptation of Bulgarian Version of Hospital Survey on Patient Safety Culture (HSOPSC).

    Science.gov (United States)

    Stoyanova, Rumyana; Dimova, Rositsa; Tarnovska, Miglena; Boeva, Tatyana

    2018-05-20

    Patient safety (PS) is one of the essential elements of health care quality and a priority of healthcare systems in most countries. Thus the creation of validated instruments and the implementation of systems that measure patient safety are considered to be of great importance worldwide. The present paper aims to illustrate the process of linguistic validation, cross-cultural verification and adaptation of the Bulgarian version of the Hospital Survey on Patient Safety Culture (B-HSOPSC) and its test-retest reliability. The study design is cross-sectional. The HSOPSC questionnaire consists of 42 questions, grouped in 12 different subscales that measure patient safety culture. Internal con-sistency was assessed using Cronbach's alpha. The Wilcoxon signed-rank test and the split-half method were used; the Spear-man-Brown coefficient was calculated. The overall Cronbach's alpha for B-HSOPSC is 0.918. Subscales 7 Staffing and 12 Overall perceptions of safety had the lowest coefficients. The high reliability of the instrument was confirmed by the Split-half method (0.97) and ICC-coefficient (0.95). The lowest values of Spearmen-Broun coefficients were found in items A13 and A14. The study offers an analysis of the results of the linguistic validation of the B-HSOPSC and its test-retest reliability. The psychometric characteristics of the questions revealed good validity and reliability, except two questions. In the future, the instrument will be administered to the target population in the main study so that the psychometric properties of the instrument can be verified.

  7. Improving Patient Safety With the Military Electronic Health Record

    National Research Council Canada - National Science Library

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

    2005-01-01

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

  8. Reliability testing of tendon disease using two different scanning methods in patients with rheumatoid arthritis

    DEFF Research Database (Denmark)

    Bruyn, George A W; Möller, Ingrid; Garrido, Jesus

    2012-01-01

    To assess the intra- and interobserver reliability of musculoskeletal ultrasonography (US) in detecting inflammatory and destructive tendon abnormalities in patients with RA using two different scanning methods.......To assess the intra- and interobserver reliability of musculoskeletal ultrasonography (US) in detecting inflammatory and destructive tendon abnormalities in patients with RA using two different scanning methods....

  9. Reliability of in-Shoe Plantar Pressure Measurements in Rheumatoid Arthritis Patients

    Science.gov (United States)

    Vidmar, Gaj; Novak, Primoz

    2009-01-01

    Plantar pressures measurement is a frequently used method in rehabilitation and related research. Metric characteristics of the F-Scan system have been assessed from different standpoints and in different patients, but not its reliability in rheumatoid arthritis patients. Therefore, our objective was to assess reliability of the F-Scan plantar…

  10. High inter-tester reliability of the new mobility score in patients with hip fracture

    DEFF Research Database (Denmark)

    Kristensen, M.T.; Bandholm, T.; Foss, N.B.

    2008-01-01

    OBJECTIVE: To assess the inter-tester reliability of the New Mobility Score in patients with acute hip fracture. DESIGN: An inter-tester reliability study. SUBJECTS: Forty-eight consecutive patients with acute hip fracture at a median age of 84 (interquartile range, 76-89) years; 40 admitted from...

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

    Science.gov (United States)

    Maqueda Palau, M; Pérez Juan, E

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

  12. Assessing patient safety culture in hospitals across countries

    NARCIS (Netherlands)

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

    2013-01-01

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

  13. Assessing patient safety culture in hospitals across countries.

    NARCIS (Netherlands)

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

    2013-01-01

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

  14. Assessing patient safety culture in hospitals across countries

    NARCIS (Netherlands)

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

    2013-01-01

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

  15. 75 FR 57477 - Patient Safety Organizations: Voluntary Delisting

    Science.gov (United States)

    2010-09-21

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

  16. 75 FR 75473 - Patient Safety Organizations: Voluntary Delisting

    Science.gov (United States)

    2010-12-03

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

  17. 75 FR 75471 - Patient Safety Organizations: Voluntary Delisting

    Science.gov (United States)

    2010-12-03

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

  18. 75 FR 75472 - Patient Safety Organizations: Voluntary Delisting

    Science.gov (United States)

    2010-12-03

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

  19. 75 FR 57048 - Patient Safety Organizations: Voluntary Delisting

    Science.gov (United States)

    2010-09-17

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

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

    LENUS (Irish Health Repository)

    Cullen, Garret

    2010-09-01

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

  1. 75 FR 63498 - Patient Safety Organizations: Voluntary Delisting

    Science.gov (United States)

    2010-10-15

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

  2. Using safety crosses for patient self-reflection.

    Science.gov (United States)

    Silverton, Sarah

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

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

    NARCIS (Netherlands)

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

    2016-01-01

    Background: By assessing patient safety culture, healthcare providers can identify areas for improvement in patient safety culture. To achieve this, these assessment outcomes have to be relevant and presented clearly. The aim of our study was to explore healthcare professionals’ views on the

  4. Improving Patient Safety Culture in Primary Care: A Systematic Review

    NARCIS (Netherlands)

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

    Background: Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which

  5. Patient Safety and Workplace Bullying: An Integrative Review.

    Science.gov (United States)

    Houck, Noreen M; Colbert, Alison M

    Workplace bullying is strongly associated with negative nursing outcomes, such as work dissatisfaction, turnover, and intent to leave; however, results of studies examining associations with specific patient safety outcomes are limited or nonspecific. This integrative review explores and synthesizes the published articles that address the impact of workplace nurse bullying on patient safety.

  6. 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

  7. 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.

  8. reliability reliability

    African Journals Online (AJOL)

    eobe

    Corresponding author, Tel: +234-703. RELIABILITY .... V , , given by the code of practice. However, checks must .... an optimization procedure over the failure domain F corresponding .... of Concrete Members based on Utility Theory,. Technical ...

  9. 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.

  10. Simulated patient training: Using inter-rater reliability to evaluate simulated patient consistency in nursing education.

    Science.gov (United States)

    MacLean, Sharon; Geddes, Fiona; Kelly, Michelle; Della, Phillip

    2018-03-01

    Simulated patients (SPs) are frequently used for training nursing students in communication skills. An acknowledged benefit of using SPs is the opportunity to provide a standardized approach by which participants can demonstrate and develop communication skills. However, relatively little evidence is available on how to best facilitate and evaluate the reliability and accuracy of SPs' performances. The aim of this study is to investigate the effectiveness of an evidenced based SP training framework to ensure standardization of SPs. The training framework was employed to improve inter-rater reliability of SPs. A quasi-experimental study was employed to assess SP post-training understanding of simulation scenario parameters using inter-rater reliability agreement indices. Two phases of data collection took place. Initially a trial phase including audio-visual (AV) recordings of two undergraduate nursing students completing a simulation scenario is rated by eight SPs using the Interpersonal Communication Assessments Scale (ICAS) and Quality of Discharge Teaching Scale (QDTS). In phase 2, eight SP raters and four nursing faculty raters independently evaluated students' (N=42) communication practices using the QDTS. Intraclass correlation coefficients (ICC) were >0.80 for both stages of the study in clinical communication skills. The results support the premise that if trained appropriately, SPs have a high degree of reliability and validity to both facilitate and evaluate student performance in nurse education. Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.

  11. Use of F.M.E.A. for reliability analysis of safety systems in nuclear power plants

    International Nuclear Information System (INIS)

    Barbet, J.F.; Llory, M.; Villemeur, A.

    1982-01-01

    In the framework of the French nuclear power plant program, reliability studies of safety systems have been carried out at the Electricite de France since 1975. The main results of the studies are examined; about the methodological aspects it appears useful to develop an inductive approach such as the Failure Modes and Effects Analysis (F.M.E.A.). The method is described with its advantages and limitations; the possibilities of use of F.M.E.A. to solve specific safety problems are investigated. To conclude, the future trends of research and development in this field at Electricite de France are pointed out [fr

  12. Variability of patient safety culture in Belgian acute hospitals.

    Science.gov (United States)

    Vlayen, Annemie; Schrooten, Ward; Wami, Welcome; Aerts, Marc; Barrado, Leandro Garcia; Claes, Neree; Hellings, Johan

    2015-06-01

    The aim of this study was to measure differences in safety culture perceptions within Belgian acute hospitals and to examine variability based on language, work area, staff position, and work experience. The Hospital Survey on Patient Safety Culture was distributed to hospitals participating in the national quality and safety program (2007-2009). Hospitals were invited to participate in a comparative study. Data of 47,136 respondents from 89 acute hospitals were used for quantitative analysis. Percentages of positive response were calculated on 12 dimensions. Generalized estimating equations models were fitted to explore differences in safety culture. Handoffs and transitions, staffing, and management support for patient safety were considered as major problem areas. Dutch-speaking hospitals had higher odds of positive perceptions for most dimensions in comparison with French-speaking hospitals. Safety culture scores were more positive for respondents working in pediatrics, psychiatry, and rehabilitation compared with the emergency department, operating theater, and multiple hospital units. We found an important gap in safety culture perceptions between leaders and assistants within disciplines. Administration and middle management had lower perceptions toward patient safety. Respondents working less than 1 year in the current hospital had more positive safety culture perceptions in comparison with all other respondents. Large comparative databases provide the opportunity to identify distinct high and low scoring groups. In our study, language, work area, and profession were identified as important safety culture predictors. Years of experience in the hospital had only a small effect on safety culture perceptions.

  13. 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...

  14. 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.

  15. Method for assessing reliability of a network considering probabilistic safety assessment

    International Nuclear Information System (INIS)

    Cepin, M.

    2005-01-01

    A method for assessment of reliability of the network is developed, which uses the features of the fault tree analysis. The method is developed in a way that the increase of the network under consideration does not require significant increase of the model. The method is applied to small examples of network consisting of a small number of nodes and a small number of their connections. The results give the network reliability. They identify equipment, which is to be carefully maintained in order that the network reliability is not reduced, and equipment, which is a candidate for redundancy, as this would improve network reliability significantly. (author)

  16. Importance of independent and dependent human error to system reliability and plant safety

    International Nuclear Information System (INIS)

    Dach, K.

    1988-08-01

    Uncertainty analysis of the quantification of the unavailability for the emergency core cooling system was made. The reliability analysis of the low pressure injection system (LPIS) of the ECCS of WWER-440 reactor was also performed. Results of reliability analysis proved that LPIS reliability under normal conditions is sufficient and can be increased by two orders of magnitude. This increase in reliability can be achieved by means of simple changes such as securing an opening of the quick-acting fittings at LPIS discharge line. A method for analysis of systems uncertainty with periodic inspected components was elaborated and verified by performing an analysis of the medium size system. Refs, figs and tabs

  17. Optimized work control process to improve safety and reliability in a risk-based and deregulated environment

    International Nuclear Information System (INIS)

    Anderson, Jon G.; Jeffries, Jeffrey D. E.; Mairs, Todd P.; Rahn, Frank J.

    1999-01-01

    This paper provides an overview of strategic models to assist power generating plants to improve their work control processes. These models include mechanisms to continually keep the process up to date. Included in the work control process are elements for system cost/performance analysis, life-cycle maintenance planning, on-line scheduling and look-ahead techniques, and schedule implementation to conduct work on the asset. The paper also discusses how risk management associated with work control issues that effect the safety and reliability, as well as O and M costs, is integrated into this strategy. The work control process is a pervasive and critical element in the successful implementation of operations and work management programs. While providing a method to implement maintenance activities in a cost-effective manner, the work control process improves plant safety and system reliability

  18. A study of digital hardware architectures for nuclear reactors protection systems applications - reliability and safety analysis methods

    International Nuclear Information System (INIS)

    Benko, Pedro Luiz

    1997-01-01

    A study of digital hardware architectures, including experience in many countries, topologies and solutions to interface circuits for protection systems of nuclear reactors is presented. Methods for developing digital systems architectures based on fault tolerant and safety requirements is proposed. Directives for assessing such conditions are suggested. Techniques and the most common tools employed in reliability, safety evaluation and modeling of hardware architectures is also presented. Markov chain modeling is used to evaluate the reliability of redundant architectures. In order to estimate software quality, several mechanisms to be used in design, specification, and validation and verification (V and V) procedures are suggested. A digital protection system architecture has been analyzed as a case study. (author)

  19. Reliability analysis and computation of computer-based safety instrumentation and control used in German nuclear power plant. Final report

    International Nuclear Information System (INIS)

    Ding, Yongjian; Krause, Ulrich; Gu, Chunlei

    2014-01-01

    The trend of technological advancement in the field of safety instrumentation and control (I and C) leads to increasingly frequent use of computer-based (digital) control systems which consisting of distributed, connected bus communications computers and their functionalities are freely programmable by qualified software. The advantages of the new I and C system over the old I and C system with hard-wired technology are e.g. in the higher flexibility, cost-effective procurement of spare parts, higher hardware reliability (through higher integration density, intelligent self-monitoring mechanisms, etc.). On the other hand, skeptics see the new technology with the computer-based I and C a higher potential by influences of common cause failures (CCF), and the easier manipulation by sabotage (IT Security). In this joint research project funded by the Federal Ministry for Economical Affaires and Energy (BMWi) (2011-2014, FJZ 1501405) the Otto-von-Guericke-University Magdeburg and Magdeburg-Stendal University of Applied Sciences are therefore trying to develop suitable methods for the demonstration of the reliability of the new instrumentation and control systems with the focus on the investigation of CCF. This expertise of both houses shall be extended to this area and a scientific contribution to the sound reliability judgments of the digital safety I and C in domestic and foreign nuclear power plants. First, the state of science and technology will be worked out through the study of national and international standards in the field of functional safety of electrical and I and C systems and accompanying literature. On the basis of the existing nuclear Standards the deterministic requirements on the structure of the new digital I and C system will be determined. The possible methods of reliability modeling will be analyzed and compared. A suitable method called multi class binomial failure rate (MCFBR) which was successfully used in safety valve applications will be

  20. 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

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

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

    Science.gov (United States)

    Alotaibi, Yasser K; Federico, Frank

    2017-12-01

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

  3. High-reliability logic system evaluation of a programmed multiprocessor solution. Application in the nuclear reactor safety field

    International Nuclear Information System (INIS)

    Lallement, Dominique.

    1979-01-01

    Nuclear reactors are monitored by several systems combined. The hydraulic and mechanical limitations on the equipment and the heat transfer requirements in the core set a reliable working range for the boiler defined with certain safety margins. The control system tends to keep the power plant within this working range. The protection system covers all the electrical and mechanical equipment needed to safeguard the boiler in the event of abnormal transients or accidents accounted for in the design of the plant. On units in service protection is handled by cabled automatic systems. For better reliability and safety operation, greater flexibility of use (modularity, adaptability) and improved start-up criteria by data processing the tendency is to use digital programmed systems. Computers are already present in control systems but their introduction into protection systems meets with some reticence on the part of the nuclear safety authorities. A study on the replacement of conventional by digital protection systems is presented. From choices partly made on the principles which should govern the hardware and software of a protection system the reliability of different structures and elements was examined and an experimental model built with its simulator and test facilities. A prototype based on these options and studies is being built and is to be set up on one of the CEN-G reactors for tests [fr

  4. Improving the Efficiency of Administrative Decision-Making when Monitoring Reliability and Safety of Oil and Gas Equipment

    Directory of Open Access Journals (Sweden)

    Zemenkova Maria

    2016-01-01

    Full Text Available Methodology of rapid assessment of reliability index was developed based on system analysis of technological parameters. Within functioning of on-line monitoring system of reliability index of industrial facility this method allows to increase efficiency of making managerial decisions on technical and preventive maintenance. The technique is based on the analysis of technological parameters of operational modes of pipeline transport facilities registered by dispatcher controls. The created technique can be used by the operating, research, design institutes and oil and gas transport enterprises when declaring industrial safety. The received mathematical models allow federal services of supervision, the independent expert organizations to predict the development of reliability in the registered block of dispatching data either in real time mode, or taking into account the dynamics of service conditions of the object.

  5. Focusing on patient safety in the Neonatal Intensive Care Unit environment

    Directory of Open Access Journals (Sweden)

    Ilias Chatziioannidis

    2017-02-01

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

  6. Patient safety culture at neonatal intensive care units: perspectives of the nursing and medical team 1

    Science.gov (United States)

    Tomazoni, Andréia; Rocha, Patrícia Kuerten; de Souza, Sabrina; Anders, Jane Cristina; de Malfussi, Hamilton Filipe Correia

    2014-01-01

    OBJECTIVE: to verify the assessment of the patient safety culture according to the function and length of experience of the nursing and medical teams at Neonatal Intensive Care Units. METHOD: quantitative survey undertaken at four Neonatal Intensive Care Units in Florianópolis, Brazil. The sample totaled 141 subjects. The data were collected between February and April 2013 through the application of the Hospital Survey on Patient Safety Culture. For analysis, the Kruskal-Wallis and Chi-Square tests and Cronbach's Alpha coefficient were used. Approval for the research project was obtained from the Ethics Committee, CAAE: 05274612.7.0000.0121. RESULTS: differences in the number of positive answers to the Hospital Survey on Patient Safety Culture, the safety grade and the number of reported events were found according to the professional characteristics. A significant association was found between a shorter Length of work at the hospital and Length of work at the unit and a larger number of positive answers; longer length of experience in the profession represented higher grades and less reported events. The physicians and nursing technicians assessed the patient safety culture more positively. Cronbach's alpha demonstrated the reliability of the instrument. CONCLUSION: the differences found reveal a possible relation between the assessment of the safety culture and the subjects' professional characteristics at the Neonatal Intensive Care Units. PMID:25493670

  7. Organizational culture and climate for patient safety in Intensive Care Units.

    Science.gov (United States)

    Santiago, Thaiana Helena Roma; Turrini, Ruth Natalia Teresa

    2015-02-01

    Objective To assess the perception of health professionals about patient safety climate and culture in different intensive care units (ICUs) and the relationship between scores obtained on the Hospital Survey on Patient Safety Culture (HSOPSC) and the Safety Attitudes Questionnaire (SAQ). Method A cross-sectional study conducted at a teaching hospital in the state of São Paulo, Brazil, in March and April 2014. As data gathering instruments, the HSOPSC, SAQ and a questionnaire with sociodemographic and professional information about the staff working in an adult, pediatric and neonatal ICU were used. Data analysis was conducted with descriptive statistics. Results The scales presented good reliability. Greater weaknesses in patient safety were observed in the Working conditions andPerceptions of management domains of the SAQ and in the Nonpunitive response to error domain of the HSOPSC. The strengths indicated by the SAQ wereTeamwork climate and Job satisfactionand by the HSOPC, Supervisor/manager expectations and actions promoting safety and Organizational learning-continuous improvement. Job satisfaction was higher among neonatal ICU workers when compared with the other ICUs. The adult ICU presented lower scores for most of the SAQ and HSOPSC domains. The scales presented moderate correlation between them (r=0.66). Conclusion There were differences in perception regarding patient safety among ICUs, which corroborates the existence of local microcultures. The study did not demonstrate equivalence between the SAQ and the HSOPSC.

  8. Leader communication approaches and patient safety: An integrated model.

    Science.gov (United States)

    Mattson, Malin; Hellgren, Johnny; Göransson, Sara

    2015-06-01

    Leader communication is known to influence a number of employee behaviors. When it comes to the relationship between leader communication and safety, the evidence is more scarce and ambiguous. The aim of the present study is to investigate whether and in what way leader communication relates to safety outcomes. The study examines two leader communication approaches: leader safety priority communication and feedback to subordinates. These approaches were assumed to affect safety outcomes via different employee behaviors. Questionnaire data, collected from 221 employees at two hospital wards, were analyzed using structural equation modeling. The two examined communication approaches were both positively related to safety outcomes, although leader safety priority communication was mediated by employee compliance and feedback communication by organizational citizenship behaviors. The findings suggest that leader communication plays a vital role in improving organizational and patient safety and that different communication approaches seem to positively affect different but equally essential employee safety behaviors. The results highlights the necessity for leaders to engage in one-way communication of safety values as well as in more relational feedback communication with their subordinates in order to enhance patient safety. Copyright © 2015 Elsevier Ltd. and National Safety Council. Published by Elsevier Ltd. All rights reserved.

  9. Enhancing Safety of Artificially Ventilated Patients Using Ambient Process Analysis.

    Science.gov (United States)

    Lins, Christian; Gerka, Alexander; Lüpkes, Christian; Röhrig, Rainer; Hein, Andreas

    2018-01-01

    In this paper, we present an approach for enhancing the safety of artificially ventilated patients using ambient process analysis. We propose to use an analysis system consisting of low-cost ambient sensors such as power sensor, RGB-D sensor, passage detector, and matrix infrared temperature sensor to reduce risks for artificially ventilated patients in both home and clinical environments. We describe the system concept and our implementation and show how the system can contribute to patient safety.

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

    Directory of Open Access Journals (Sweden)

    Liang Chen

    2016-10-01

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

  11. [Patient safety in home care - A review of international recommendations].

    Science.gov (United States)

    Czakert, Judith; Lehmann, Yvonne; Ewers, Michael

    2018-06-08

    In recent years there has been a growing trend towards nursing care at home in general as well as towards intensive home care being provided by specialized home care services in Germany. However, resulting challenges for patient safety have rarely been considered. Against this background we aimed to explore whether international recommendations for patient safety in home care in general and in intensive home care in particular already exist and how they can stimulate further practice development in Germany. A review of online English documents containing recommendations for patient safety in intensive home care was conducted. Available documents were analyzed and compared in terms of their form and content. Overall, a small number of relevant documents could be identified. None of these documents exclusively refer to the intensive home care sector. Despite their differences, however, the analysis of four selected documents showed similarities, e. g., regarding specific topics of patient safety (communication, involvement of patients and their relatives, risk assessment, medication management, qualification). Furthermore, strengths and weaknesses of the documents became apparent: e. g., an explicit understanding of patient safety, a literature-based introduction to safety topics or an adaptation of the recommendations to the specific features of home care were occasionally lacking. This document analysis provides interesting input to the formal and content-related development of specific recommendations and to practice development in Germany to improve patient safety in home care. Copyright © 2018. Published by Elsevier GmbH.

  12. Research on the evaluation model of the software reliability in nuclear safety class digital instrumentation and control system

    International Nuclear Information System (INIS)

    Liu Ying; Yang Ming; Li Fengjun; Ma Zhanguo; Zeng Hai

    2014-01-01

    In order to analyze the software reliability (SR) in nuclear safety class digital instrumentation and control system (D-I and C), firstly, the international software design standards were analyzed, the standards' framework was built, and we found that the D-I and C software standards should follow the NUREG-0800 BTP7-14, according to the NRC NUREG-0800 review of requirements. Secondly, the quantitative evaluation model of SR using Bayesian Belief Network and thirteen sub-model frameworks were established. Thirdly, each sub-models and the weight of corresponding indexes in the evaluation model were analyzed. Finally, the safety case was introduced. The models lay a foundation for review and quantitative evaluation on the SR in nuclear safety class D-I and C. (authors)

  13. 42 CFR 3.208 - Continued protection of patient safety work product.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 1 2010-10-01 2010-10-01 false Continued protection of patient safety work product... GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.208 Continued protection of patient safety work...

  14. 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...

  15. 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...

  16. Leadership style and patient safety: implications for nurse managers.

    Science.gov (United States)

    Merrill, Katreena Collette

    2015-06-01

    The purpose of this study was to explore the relationship between nurse manager (NM) leadership style and safety climate. Nursing leaders are needed who will change the environment and increase patient safety. Hospital NMs are positioned to impact day-to-day operations. Therefore, it is essential to inform nurse executives regarding the impact of leadership style on patient safety. A descriptive correlational study was conducted in 41 nursing departments across 9 hospitals. The hospital unit safety climate survey and multifactorial leadership questionnaire were completed by 466 staff nurses. Bivariate and regression analyses were conducted to determine how well leadership style predicted safety climate. Transformational leadership style was demonstrated as a positive contributor to safety climate, whereas laissez-faire leadership style was shown to negatively contribute to unit socialization and a culture of blame. Nursing leaders must concentrate on developing transformational leadership skills while also diminishing negative leadership styles.

  17. Reliability analysis of microcomputer boards and computer based systems important to safety of nuclear plants

    International Nuclear Information System (INIS)

    Shrikhande, S.V.; Patil, V.K.; Ganesh, G.; Biswas, B.; Patil, R.K.

    2010-01-01

    Computer Based Systems (CBS) are employed in Indian nuclear plants for protection, control and monitoring purpose. For forthcoming CBS, Reactor Control Division has designed and developed a new standardized family of microcomputer boards qualified to stringent requirements of nuclear industry. These boards form the basic building blocks of CBS. Reliability analysis of these boards is being carried out using analysis package based on MIL-STD-217Plus methodology. The estimated failure rate values of these standardized microcomputer boards will be useful for reliability assessment of these systems. The paper presents reliability analysis of microcomputer boards and case study of a CBS system built using these boards. (author)

  18. 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.

  19. Surgical resident education in patient safety: where can we improve?

    Science.gov (United States)

    Putnam, Luke R; Levy, Shauna M; Kellagher, Caroline M; Etchegaray, Jason M; Thomas, Eric J; Kao, Lillian S; Lally, Kevin P; Tsao, KuoJen

    2015-12-01

    Effective communication and patient safety practices are paramount in health care. Surgical residents play an integral role in the perioperative team, yet their perceptions of patient safety remain unclear. We hypothesized that surgical residents perceive the perioperative environment as more unsafe than their faculty and operating room staff despite completing a required safety curriculum. Surgeons, anesthesiologists, and perioperative nurses in a large academic children's hospital participated in multifaceted, physician-led workshops aimed at enhancing communication and safety culture over a 3-y period. All general surgery residents from the same academic center completed a hospital-based online safety curriculum only. All groups subsequently completed the psychometrically validated safety attitudes questionnaire to evaluate three domains: safety culture, teamwork, and speaking up. Results reflect the percent of respondents who slightly or strongly agreed. Chi-square analysis was performed. Sixty-three of 84 perioperative personnel (75%) and 48 of 52 surgical residents (92%) completed the safety attitudes questionnaire. A higher percentage of perioperative personnel perceived a safer environment than the surgical residents in all three domains, which was significantly higher for safety culture (68% versus 46%, P = 0.03). When stratified into two groups, junior residents (postgraduate years 1-2) and senior residents (postgraduate years 3-5) had lower scores for all three domains, but the differences were not statistically significant. Surgical residents' perceptions of perioperative safety remain suboptimal. With an enhanced safety curriculum, perioperative staff demonstrated higher perceptions of safety compared with residents who participated in an online-only curriculum. Optimal surgical education on patient safety remains unknown but should require a dedicated, systematic approach. Copyright © 2015 Elsevier Inc. All rights reserved.

  20. Patient safety - the role of human factors and systems engineering.

    Science.gov (United States)

    Carayon, Pascale; Wood, Kenneth E

    2010-01-01

    Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.

  1. Patient Safety: The Role of Human Factors and Systems Engineering

    Science.gov (United States)

    Carayon, Pascale; Wood, Kenneth E.

    2011-01-01

    Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety. PMID:20543237

  2. Aspects of safety and reliability for fusion magnet systems first annual report

    International Nuclear Information System (INIS)

    Powell, J.

    1976-01-01

    General systems aspects of fusion magnet safety are examined first, followed by specific detailed analyses covering structural, thermal, electrical, and other aspects of fusion magnet safety. The design examples chosen for analysis are illustrative and are not intended to be definitive, since fusion magnet designs are rapidly evolving. Included is a comprehensive collection of design and operating data relating to the safety of existing superconducting magnet systems. The remainder of the overview lists the main conclusions developed from the work to date. These should be regarded as initial steps. Since this study has concentrated on examining potential safety concerns, it may tend to overemphasize the problems of fusion magnets. In fact, many aspects of fusion magnets are well developed and are consistent with good safety practice. A short summary of the findings of this study is given

  3. Inter- and intrarater reliability of goniometry and hand held dynamometry for patients with subacromial impingement syndrome.

    Science.gov (United States)

    Fieseler, Georg; Laudner, Kevin G; Irlenbusch, Lars; Meyer, Henrike; Schulze, Stephan; Delank, Karl-Stefan; Hermassi, Souhail; Bartels, Thomas; Schwesig, René

    2017-12-01

    The purpose of this study was to examine the intra- and interrater reliability of measuring shoulder range of motion (ROM) and strength among patients diagnosed with subacromial impingement syndrome (SAIS). Twenty-five patients (14 female patients; mean age, 60.4± 7.84 years) diagnosed with SAIS were assessed to determine the intrarater reliability for glenohumeral ROM. Twenty-five patients (16 female patients; mean age, 60.4± 7.80 years) and 76 asymptomatic volunteers (52 female volunteers; mean age, 29.4± 14.1 years) were assessed for interrater reliability. Dependent variables were active shoulder ROM and isometric strength. Intrarater reliability was fair-to-excellent for the SAIS patients (intraclass correlation coefficient [ICC], 0.52-0.97; standard error of measurement [SEM], 4.4°-9.9° N; coefficient of variation [CV], 7.1%-44.9%). Based on the ICC, 11 of 12 parameters (92%) displayed an excellent reliability (ICC> 0.75). The interrater reliability showed fair-to-excellent results (SAIS patients: ICC, 0.13-0.98; SEM, 2.3°-8.8°; CV, 3.6%-37.0%; controls: ICC, 0.11-0.96; SEM, 3.0°-35.4°; CV, 5.6%-26.4%). In accordance with the intrarater reliability, glenohumeral adduction ROM was the only parameter with an ICC below 0.75 for both samples. Painful shoulder ROM in the SAIS patients showed no influence on the quality of reliability for measurement. Therefore, these protocols should be considered reliable assessment techniques in the prevention, diagnosis, and treatment of painful shoulder conditions such as SAIS.

  4. The impact of health information technology on patient safety

    Directory of Open Access Journals (Sweden)

    Yasser K. Alotaibi

    2017-12-01

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

  5. Focus on patient safety all day, every day.

    Science.gov (United States)

    2015-06-01

    Case managers may think their job doesn't involve patient safety, but they promote safety by ensuring a safe discharge and are in a position to see safety breaches and mistakes all over the hospital. CMS includes discharge planning in its worksheets for surveyors to use to assess a hospital's compliance with Medicare Conditions of Participation. Because they work with patients from admission to discharge, case managers know which clinicians are competent, those who are not, and may observe safety breaches like failure to wash hands and leaving the catheter in too long. Case managers should spend enough time with their patients to know their situations at home and their support systems and use the information to create workable and safe discharge plans. Hospitals should create an environment and a culture where case managers and other clinicians feel comfortable speaking up when they see safety breaches.

  6. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain

    NARCIS (Netherlands)

    Boonstra, Anne M.; Schiphorst Preuper, Henrica R.; Reneman, Michiel F.; Posthumus, Jitze B.; Stewart, Roy E.

    To determine the reliability and concurrent validity of a visual analogue scale (VAS) for disability as a single-item instrument measuring disability in chronic pain patients was the objective of the study. For the reliability study a test-retest design and for the validity study a cross-sectional

  7. Life Satisfaction Questionnaire (Lisat-9): Reliability and Validity for Patients with Acquired Brain Injury

    Science.gov (United States)

    Boonstra, Anne M.; Reneman, Michiel F.; Stewart, Roy E.; Balk, Gerlof A.

    2012-01-01

    The aim of this study was to determine the reliability and discriminant validity of the Dutch version of the life satisfaction questionnaire (Lisat-9 DV) to assess patients with an acquired brain injury. The reliability study used a test-retest design, and the validity study used a cross-sectional design. The setting was the general rehabilitation…

  8. Reliability analyses of safety systems for WWER-440 nuclear power plants

    International Nuclear Information System (INIS)

    Dusek, J.; Hojny, V.

    1985-01-01

    The UJV in Rez near Prague studied the reliability of the system of emergency core cooling and of the system for suppressing pressure in the sealed area of the nuclear power plant in the occurrence of a loss-of-coolant accident. The reliability of the systems was evaluated by failure tree analysis. Simulation and analytical calculation programs were developed and used for the reliability analysis. The results are briefly presented of the reliability analyses of the passive system for the immediate short-term flooding of the reactor core, of the active low-pressure system of emergency core cooling, the spray system, the bubble-vacuum system and the system of emergency supply of the steam generators. (E.S.)

  9. Reliability-based evaluation of bridge components for consistent safety margins.

    Science.gov (United States)

    2010-10-01

    The Load and Resistant Factor Design (LRFD) approach is based on the concept of structural reliability. The approach is more : rational than the former design approaches such as Load Factor Design or Allowable Stress Design. The LRFD Specification fo...

  10. 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.

  11. A Primer for DoD Reliability, Maintainability, Safety, and Logistics Standards, 1992

    Science.gov (United States)

    1991-10-01

    Application of Reliability-Centered Maintenance to Naval Aircraft Weapon Systems and Support Equipment "* FMD -91 Failure Mode/Mechanism...Distributions ( FMD -91) available from the Reliability Analysis Center, HIT Research Institute, 201 Mill St., Rome, NY 13440-8200. 14.4 PHYSICAL...Fault Tree Analysis ( FTA ) (9) Sneak Circuit Analysis (10) Design Reviews Items (1) and (2) are addressed in Section 7 largely by reference to MIL

  12. 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

  13. 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.

  14. Monitoring of operational reliability of safety-related I and C subsystems at the Dukovany NPP

    International Nuclear Information System (INIS)

    Fuchs, P.; Sagl, P.; Zlamal, P.

    2007-01-01

    First, the situation existing in the data base in 1999, i.e. before the monitoring and the operational reliability monitoring concept were introduced, is highlighted. The technique of data processing is described with focus on the assessment of the relevancy of the records, component failure rate monitoring, estimation of basic statistical parameters, evaluation of the feasibility of component failure (or failure latency) detection, assessment of the mean time to repair, FMEA of the basic components (relays end measuring chains) to establish spurious signals and dangerous failure ratio. The reliability assessment of the system functions is based on structural reliability calculations (common cause failures not included). The outcomes from the operational reliability monitoring are presented in the form of a representative set of data, graphic charts and results of system function reliability assessment. Prospects for upgrading the I and C operational reliability monitoring system to the benefit of NPP Dukovany operating economy (life cycle costs evaluation, spare parts planning, RCM application) are outlined. (author)

  15. Brief history of patient safety culture and science.

    Science.gov (United States)

    Ilan, Roy; Fowler, Robert

    2005-03-01

    The science of safety is well established in such disciplines as the automotive and aviation industry. In this brief history of safety science as it pertains to patient care, we review remote and recent publications that have guided the maturation of this field that has particular relevance to the complex structure of systems, personnel, and therapies involved in caring for the critically ill.

  16. Development and applicability of Hospital Survey on Patient Safety Culture (HSOPS) in Japan.

    Science.gov (United States)

    Ito, Shinya; Seto, Kanako; Kigawa, Mika; Fujita, Shigeru; Hasegawa, Toshihiko; Hasegawa, Tomonori

    2011-02-07

    Patient safety culture at healthcare organizations plays an important role in guaranteeing, improving and promoting overall patient safety. Although several conceptual frameworks have been proposed in the past, no standard measurement tool has yet been developed for Japan. In order to examine possibilities to introduce the Hospital Survey on Patient Safety Culture (HSOPS) in Japan, the authors of this study translated the HSOPS into Japanese, and evaluated its factor structure, internal consistency, and construct validity. Healthcare workers (n = 6,395) from 13 acute care general hospitals in Japan participated in this survey. Confirmatory factor analysis indicated that the Japanese HSOPS' 12-factor model was selected as the most pertinent, and showed a sufficiently high standard partial regression coefficient. The internal reliability of the subscale scores was 0.46-0.88. The construct validity of each safety culture sub-dimension was confirmed by polychoric correlation, and by an ordered probit analysis. The results of the present study indicate that the factor structures of the Japanese and the American HSOPS are almost identical, and that the Japanese HSOPS has acceptable levels of internal reliability and construct validity. This shows that the HSOPS can be introduced in Japan.

  17. 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

  18. Treatment of Passive Component Reliability in Risk-Informed Safety Margin Characterization FY 2010 Report

    Energy Technology Data Exchange (ETDEWEB)

    Robert W Youngblood

    2010-09-01

    The Risk-Informed Safety Margin Characterization (RISMC) pathway is a set of activities defined under the U.S. Department of Energy (DOE) Light Water Reactor Sustainability Program. The overarching objective of RISMC is to support plant life-extension decision-making by providing a state-of-knowledge characterization of safety margins in key systems, structures, and components (SSCs). A technical challenge at the core of this effort is to establish the conceptual and technical feasibility of analyzing safety margin in a risk-informed way, which, unlike conventionally defined deterministic margin analysis, is founded on probabilistic characterizations of SSC performance.

  19. Relationship between patient safety and accountability of nurses in Al-Zahra Gilangharb Hospital in 2015.

    Science.gov (United States)

    Esfandnia, F; Mohammadi, E; Mohammadi, M; Cheraghi, R; Esfandnia, N; Esfandnia, A

    2015-01-01

    Introduction. The purpose of this research was to investigate the connection between the patient safety and the accountability of nurses in Gilangharb Hospital in 2015. Methods. This research was a cross-sectional study conducted in Al-Gilangharb, in 2015. The data needed for research was taken from the library and an internet search and was gathered by using standard questionnaireThe professional and caring nurses' questionnaire was based on the extension evaluation office Nursing Care, Ministry of Health and Medical Education and demographic information and questions about 4 different roles of nurses were prepared and included. Moreover, patient safety was highlighted in a validation questionnaire, validated by experts judging group of teachers and academics, which was established. Cronbach's alpha test was used to assess the reliability. Finally, the reliability and professional standards of nursing care, patient safety questionnaire 093. 86/ 0 percent calculated the population of Gilangharb Hospital nurses (n = 70) and, in the strata selected, a statistical analysis using data from the questionnaires included in the SPSS statistical software, version 21, took place. Results. The patients' safety and accountability was observed at the level of 95 percent by using the Spearman correlation (SIG = .000). The correlation coefficient was (R=.768). Also, the dimensions of responsibility between the patient's safety (regarding the role of the nurse teacher, manager, researcher, and clinician) at 95 percent and the positive use of Spearman correlation was found (SIG = .000). Conclusions. Given the correlation among the patient protection and accountability, it can be said that the nurses in all roles (educator, researcher, administrator, and clinical specialist) have been successful, so, we suggested that given the experience, expertise and abilities, they have made an efficient use of their lifting power.

  20. 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...

  1. Patient Safety Data Sharing and Protection From Legal Discovery

    National Research Council Canada - National Science Library

    Suydam, Steven; Liang, Bryan A; Anderson, Storm; Weinger, Matthew B

    2004-01-01

    .... Nevertheless, existing State and Federal law may offer some protection. The most promising source of existing protection for all members of patient safety collaboratives is 42 U.S.C. SS299c-3(c...

  2. 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...

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

    Science.gov (United States)

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

    2011-01-01

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

  4. TEL4Health – Mobile tools to improve patient safety

    NARCIS (Netherlands)

    Drachsler, Hendrik; Kalz, Marco; Specht, Marcus

    2013-01-01

    Drachsler, H., Kalz, M., & Specht, M. (2013, 10 October). TEL4Health – Mobile tools to improve patient safety. Presentation given at the blended learning platform of the Netherlands Organisation for Hospitals (Nederlandse Vereniging van Ziekenhuizen), Utrecht, The Netherlands.

  5. Establishing a culture for patient safety - the role of education.

    Science.gov (United States)

    Milligan, Frank J

    2007-02-01

    This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).

  6. Teamwork, organizational learning, patient safety and job outcomes.

    Science.gov (United States)

    Goh, Swee C; Chan, Christopher; Kuziemsky, Craig

    2013-01-01

    This article aims to encourage healthcare administrators to consider the learning organization concept and foster collaborative learning among teams in their attempt to improve patient safety. Relevant healthcare, organizational behavior and human resource management literature was reviewed. A patient safety culture, fostered by healthcare leaders, should include an organizational culture that encourages collaborative learning, replaces the blame culture, prioritizes patient safety and rewards individuals who identify serious mistakes. As healthcare institution staffs are being asked to deliver more complex medical services with fewer resources, there is a need to understand how hospital staff can learn from other organizational settings, especially the non-healthcare sectors. The paper provides suggestions for improving patient safety which are drawn from the health and business management literature.

  7. Patients' experiences of safety during haemodialysis treatment - a qualitative study

    NARCIS (Netherlands)

    Lovink, M.H.; Kars, M.C.; Man-van Ginkel, J.M. de; Schoonhoven, L.

    2015-01-01

    AIM: To explore the experiences of safety of adult patients during their haemodialysis treatment. BACKGROUND: Haemodialysis is a complex treatment with a risk for harm that causes anxiety among many patients. To date, no in-depth study of haemodialysis patients' emotional responses to conditions of

  8. High-temperature gas-cooled reactor safety-reliability program plan

    Energy Technology Data Exchange (ETDEWEB)

    1981-03-01

    The purpose of this document is to present a safety plan as part of an overall program plan for the design and development of the High Temperature Gas-Cooled Reactor (HTGR). This plan is intended to establish a logical framework for identifying the technology necessary to demonstrate that the requisite degree of public risk safety can be achieved economically. This plan provides a coherent system safety approach together with goals and success criterion as part of a unifying strategy for licensing a lead reactor plant in the near term. It is intended to provide guidance to program participants involved in producing a technology base for the HTGR that is fully responsive to safety consideration in the design, evaluation, licensing, public acceptance, and economic optimization of reactor systems.

  9. Reliability evaluation of the power supply of an electrical power net for safety-relevant applications

    International Nuclear Information System (INIS)

    Dominguez-Garcia, Alejandro D.; Kassakian, John G.; Schindall, Joel E.

    2006-01-01

    In this paper, we introduce a methodology for the dependability analysis of new automotive safety-relevant systems. With the introduction of safety-relevant electronic systems in cars, it is necessary to carry out a thorough dependability analysis of those systems to fully understand and quantify the failure mechanisms in order to improve the design. Several system level FMEAs are used to identify the different failure modes of the system and, a Markov model is constructed to quantify their probability of occurrence. A new power net architecture with application to new safety-relevant automotive systems, such as Steer-by-Wire or Brake-by-Wire, is used as a case study. For these safety-relevant loads, loss of electric power supply means loss of control of the vehicle. It is, therefore, necessary and critical to develop a highly dependable power net to ensure power to these loads under all circumstances

  10. Research activities of MPA, Stuttgart University, for enhanced safety and reliability of components under complex load

    International Nuclear Information System (INIS)

    Herter, K.H.; Roos, E.; Schuler, X.; Maile, K.

    2004-01-01

    MPA research activities focus on fracture prevention and on the development of a generally applicable method of component integrity testing which, independent of the safety relevance of the components involved, is also part of ageing management. (orig.) [de

  11. Reliability-based approaches for safety margin assessment in the French nuclear industry

    International Nuclear Information System (INIS)

    Ardillon, E.; Barthelet, B.; Meister, E.; Cambefort, P.; Hornet, P.; Le Delliou, P.

    2003-01-01

    The prevention of the fast fracture damage of the mechanical equipment important for the safety of nuclear islands of the French PWR relies on deterministic rules. These rules include flaw acceptance criteria involving safety factors applied to characteristic values (implicit margins) of the physical variables. The sets of safety factors that are currently under application in the industrial analyses with the agreement of the Safety Authority, are distributed across the two main physical parameters and have partly been based on a semi-probabilistic approach. After presenting the generic probabilistic pro-codification approach this paper shows its application to the evaluation of the performances of the existing regulatory flaw acceptance criteria. This application can be carried out in a realistic manner or in a more simplified one. These two approaches are applied to representative mechanical components. Their results are consistent. (author)

  12. 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

  13. Safety and reliability of pressure components with special emphasis on advanced methods of NDT. Vol. 2

    International Nuclear Information System (INIS)

    1986-01-01

    The 12 papers discuss topics of strength and safety in the field of materials technology and engineering. Conclusions for NPP component safety and materials are drawn. Measurements and studies relate to fracture mechanics methods (oscillation, burst, material strength, characteristics). The dynamic analysis of the behaviour of large test specimens, the influence of load velocity on crack resistance curve and the development of forged parts from austenitic steel for fast breeder reactors are presented. (DG) [de

  14. Mobile phone radiation health risk controversy: the reliability and sufficiency of science behind the safety standards

    OpenAIRE

    Leszczynski Dariusz; Xu Zhengping

    2010-01-01

    Abstract There is ongoing discussion whether the mobile phone radiation causes any health effects. The International Commission on Non-Ionizing Radiation Protection, the International Committee on Electromagnetic Safety and the World Health Organization are assuring that there is no proven health risk and that the present safety limits protect all mobile phone users. However, based on the available scientific evidence, the situation is not as clear. The majority of the evidence comes from in ...

  15. Quantitative assessment of probability of failing safely for the safety instrumented system using reliability block diagram method

    International Nuclear Information System (INIS)

    Jin, Jianghong; Pang, Lei; Zhao, Shoutang; Hu, Bin

    2015-01-01

    Highlights: • Models of PFS for SIS were established by using the reliability block diagram. • The more accurate calculation of PFS for SIS can be acquired by using SL. • Degraded operation of complex SIS does not affect the availability of SIS. • The safe undetected failure is the largest contribution to the PFS of SIS. - Abstract: The spurious trip of safety instrumented system (SIS) brings great economic losses to production. How to ensure the safety instrumented system is reliable and available has been put on the schedule. But the existing models on spurious trip rate (STR) or probability of failing safely (PFS) are too simplified and not accurate, in-depth studies of availability to obtain more accurate PFS for SIS are required. Based on the analysis of factors that influence the PFS for the SIS, using reliability block diagram method (RBD), the quantitative study of PFS for the SIS is carried out, and gives some application examples. The results show that, the common cause failure will increase the PFS; degraded operation does not affect the availability of the SIS; if the equipment was tested and repaired one by one, the unavailability of the SIS can be ignored; the corresponding occurrence time of independent safe undetected failure should be the system lifecycle (SL) rather than the proof test interval and the independent safe undetected failure is the largest contribution to the PFS for the SIS

  16. Implementation of a patient safety program at a tertiary health system: A longitudinal analysis of interventions and serious safety events.

    Science.gov (United States)

    Cropper, Douglas P; Harb, Nidal H; Said, Patricia A; Lemke, Jon H; Shammas, Nicolas W

    2018-04-01

    We hypothesize that implementation of a safety program based on high reliability organization principles will reduce serious safety events (SSE). The safety program focused on 7 essential elements: (a) safety rounding, (b) safety oversight teams, (c) safety huddles, (d) safety coaches, (e) good catches/safety heroes, (f) safety education, and (g) red rule. An educational curriculum was implemented focusing on changing high-risk behaviors and implementing critical safety policies. All unusual occurrences were captured in the Midas system and investigated by risk specialists, the safety officer, and the chief medical officer. A multidepartmental committee evaluated these events, and a root cause analysis (RCA) was performed. Events were tabulated and serious safety event (SSE) recorded and plotted over time. Safety success stories (SSSs) were also evaluated over time. A steady drop in SSEs was seen over 9 years. Also a rise in SSSs was evident, reflecting on staff engagement in the program. The parallel change in SSEs, SSSs, and the implementation of various safety interventions highly suggest that the program was successful in achieving its goals. A safety program based on high-reliability organization principles and made a core value of the institution can have a significant positive impact on reducing SSEs. © 2018 American Society for Healthcare Risk Management of the American Hospital Association.

  17. Stochastic models and reliability parameter estimation applicable to nuclear power plant safety

    International Nuclear Information System (INIS)

    Mitra, S.P.

    1979-01-01

    A set of stochastic models and related estimation schemes for reliability parameters are developed. The models are applicable for evaluating reliability of nuclear power plant systems. Reliability information is extracted from model parameters which are estimated from the type and nature of failure data that is generally available or could be compiled in nuclear power plants. Principally, two aspects of nuclear power plant reliability have been investigated: (1) The statistical treatment of inplant component and system failure data; (2) The analysis and evaluation of common mode failures. The model inputs are failure data which have been classified as either the time type of failure data or the demand type of failure data. Failures of components and systems in nuclear power plant are, in general, rare events.This gives rise to sparse failure data. Estimation schemes for treating sparse data, whenever necessary, have been considered. The following five problems have been studied: 1) Distribution of sparse failure rate component data. 2) Failure rate inference and reliability prediction from time type of failure data. 3) Analyses of demand type of failure data. 4) Common mode failure model applicable to time type of failure data. 5) Estimation of common mode failures from 'near-miss' demand type of failure data

  18. Patient Safety Incidents and Nursing Workload.

    Science.gov (United States)

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

    2017-04-06

    to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile. quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation. 879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload. the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload. identificar a relação entre a carga de trabalho da equipe de enfermagem e a ocorrência de incidentes de segurança dos pacientes ligados aos cuidados de enfermagem de um hospital público no Chile. pesquisa transversal analítica quantitativa através de revisão de prontuários médicos. A estimativa da carga de trabalho em Unidade de Terapia Intensiva (UTI) foi realizada utilizando o Índice de Intervenções Terapêuticas-TISS-28 e para os outros serviços, foram utilizados os cocientes enfermeira/paciente e auxiliar de enfermagem/ paciente. Foram feitas análises univariada descritiva e multivariada. Para a análise multivariada utilizou-se análise de componentes principais e correlação de Pearson. foram analisados 879 prontuáriosclínicos de pós-alta e a carga de trabalho de 85 enfermeiros e 157

  19. Reliability and validity of the Beck depression inventory in patients with Parkinson's disease

    NARCIS (Netherlands)

    Visser, Martine; Leentjens, Albert F. G.; Marinus, Johan; Stiggelbout, Anne M.; van Hilten, Jacobus J.

    2006-01-01

    We evaluated the validity, reliability, and potential responsiveness of the Beck Depression Inventory (BDI) in patients with Parkinson's disease (PD). In part 1 of the study, 92 patients with PD underwent a structured clinical interview for DSM major depression and based on this patients were

  20. Validity evidence and reliability of a simulated patient feedback instrument.

    NARCIS (Netherlands)

    Schlegel, C.; Woermann, U.; Rethans, J.J.; Vleuten, C.P.M. van der

    2012-01-01

    BACKGROUND: In the training of healthcare professionals, one of the advantages of communication training with simulated patients (SPs) is the SP's ability to provide direct feedback to students after a simulated clinical encounter. The quality of SP feedback must be monitored, especially because it