Report on the Personnel Dosimetry at AB Atomenergi during 1962

Energy Technology Data Exchange (ETDEWEB)

Edvardsson, K A; Hagsgaard, S

1964-07-15

This report presents the results of the personnel dosimetry at AB Atomenergi during 1963. No doses exceeding the recommendations of ICRP have been reported. The sum of the reported external total body doses during the year is for AB Atomenergi 64.2 manrem which, distributed over the whole company personnel, corresponds to about 40 mrem per year and person or about 1 % of the maximum permissible dose. 37800 gamma films and 6700 neutron films have been evaluated. The total number of urine analyses is 3603 and of whole body measurements 211.

Analysis of Medication Error Reports

Energy Technology Data Exchange (ETDEWEB)

Whitney, Paul D.; Young, Jonathan; Santell, John; Hicks, Rodney; Posse, Christian; Fecht, Barbara A.

2004-11-15

In medicine, as in many areas of research, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been, however, a corresponding lag in our abilities to analyze this overwhelming mass of data, and classic forms of statistical analysis may not allow researchers to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports has been carried out based on an approach of data comparison, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. Traditionally, USP has conducted an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.

Nurses' attitude and intention of medication administration error reporting.

Science.gov (United States)

Hung, Chang-Chiao; Chu, Tsui-Ping; Lee, Bih-O; Hsiao, Chia-Chi

2016-02-01

The Aims of this study were to explore the effects of nurses' attitudes and intentions regarding medication administration error reporting on actual reporting behaviours. Underreporting of medication errors is still a common occurrence. Whether attitude and intention towards medication administration error reporting connect to actual reporting behaviours remain unclear. This study used a cross-sectional design with self-administered questionnaires, and the theory of planned behaviour was used as the framework for this study. A total of 596 staff nurses who worked in general wards and intensive care units in a hospital were invited to participate in this study. The researchers used the instruments measuring nurses' attitude, nurse managers' and co-workers' attitude, report control, and nurses' intention to predict nurses' actual reporting behaviours. Data were collected from September-November 2013. Path analyses were used to examine the hypothesized model. Of the 596 nurses invited to participate, 548 (92%) completed and returned a valid questionnaire. The findings indicated that nurse managers' and co-workers' attitudes are predictors for nurses' attitudes towards medication administration error reporting. Nurses' attitudes also influenced their intention to report medication administration errors; however, no connection was found between intention and actual reporting behaviour. The findings reflected links among colleague perspectives, nurses' attitudes, and intention to report medication administration errors. The researchers suggest that hospitals should increase nurses' awareness and recognition of error occurrence. Regardless of nurse managers' and co-workers' attitudes towards medication administration error reporting, nurses are likely to report medication administration errors if they detect them. Management of medication administration errors should focus on increasing nurses' awareness and recognition of error occurrence. © 2015 John Wiley & Sons Ltd.

Burnout, engagement and resident physicians' self-reported errors.

Science.gov (United States)

Prins, J T; van der Heijden, F M M A; Hoekstra-Weebers, J E H M; Bakker, A B; van de Wiel, H B M; Jacobs, B; Gazendam-Donofrio, S M

2009-12-01

Burnout is a work-related syndrome that may negatively affect more than just the resident physician. On the other hand, engagement has been shown to protect employees; it may also positively affect the patient care that the residents provide. Little is known about the relationship between residents' self-reported errors and burnout and engagement. In our national study that included all residents and physicians in The Netherlands, 2115 questionnaires were returned (response rate 41.1%). The residents reported on burnout (Maslach Burnout Inventory-Health and Social Services), engagement (Utrecht Work Engagement Scale) and self-assessed patient care practices (six items, two factors: errors in action/judgment, errors due to lack of time). Ninety-four percent of the residents reported making one or more mistake without negative consequences for the patient during their training. Seventy-one percent reported performing procedures for which they did not feel properly trained. More than half (56%) of the residents stated they had made a mistake with a negative consequence. Seventy-six percent felt they had fallen short in the quality of care they provided on at least one occasion. Men reported more errors in action/judgment than women. Significant effects of specialty and clinical setting were found on both types of errors. Residents with burnout reported significantly more errors (p engaged residents reported fewer errors (p burnout and to keep residents engaged in their work.

Automated personnel data base system specifications, Task V. Final report

International Nuclear Information System (INIS)

Bartley, H.J.; Bocast, A.K.; Deppner, F.O.; Harrison, O.J.; Kraas, I.W.

1978-11-01

The full title of this study is 'Development of Qualification Requirements, Training Programs, Career Plans, and Methodologies for Effective Management and Training of Inspection and Enforcement Personnel.' Task V required the development of an automated personnel data base system for NRC/IE. This system is identified as the NRC/IE Personnel, Assignment, Qualifications, and Training System (PAQTS). This Task V report provides the documentation for PAQTS including the Functional Requirements Document (FRD), the Data Requirements Document (DRD), the Hardware and Software Capabilities Assessment, and the Detailed Implementation Schedule. Specific recommendations to facilitate implementation of PAQTS are also included

Personnel neutron dose assessment upgrade: Volume 1, Personnel neutron dosimetry assessment: [Final report

International Nuclear Information System (INIS)

Hadlock, D.E.; Brackenbush, L.W.; Griffith, R.V.; Hankins, D.E.; Parkhurst, M.A.; Stroud, C.M.; Faust, L.G.; Vallario, E.J.

1988-07-01

This report provides guidance on the characteristics, use, and calibration criteria for personnel neutron dosimeters. The report is applicable for neutrons with energies ranging from thermal to less than 20 MeV. Background for general neutron dosimetry requirements is provided, as is relevant federal regulations and other standards. The characteristics of personnel neutron dosimeters are discussed, with particular attention paid to passive neutron dosimetry systems. Two of the systems discussed are used at DOE and DOE-contractor facilities (nuclear track emulsion and thermoluminescent-albedo) and another (the combination TLD/TED) was recently developed. Topics discussed in the field applications of these dosimeters include their theory of operation, their processing, readout, and interpretation, and their advantages and disadvantages for field use. The procedures required for occupational neutron dosimetry are discussed, including radiation monitoring and the wearing of dosimeters, their exchange periods, dose equivalent evaluations, and the documenting of neutron exposures. The coverage of dosimeter testing, maintenance, and calibration includes guidance on the selection of calibration sources, the effects of irradiation geometries, lower limits of detectability, fading, frequency of calibration, spectrometry, and quality control. 49 refs., 6 figs., 8 tabs

Barriers to Medical Error Reporting for Physicians and Nurses.

Science.gov (United States)

Soydemir, Dilek; Seren Intepeler, Seyda; Mert, Hatice

2017-10-01

The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees' perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.

Pocket book {sup E}xpectations of operating personnel action and card criteria, previous meeting and precursor of error; Libro de bolsillo expectativas de actuacion del personal de operacion y tarjeta criterios reunion previa y precursores de error

Energy Technology Data Exchange (ETDEWEB)

Rodrigo Gonzalez, M.

2012-07-01

We have developed a pocket manual of performance expectations of operating personnel. Additionally, it has created a card pocket systematizing the application of previous meetings (pre-job) depending on the existence of error precursors and following the commission of an error. This manual serves to communicate expectations and performance expected to the Operation Staff. The results show a positive change in a short period of time working practices, both in training (simulator) and control room.

The Impact of Error-Management Climate, Error Type and Error Originator on Auditors’ Reporting Errors Discovered on Audit Work Papers

NARCIS (Netherlands)

A.H. Gold-Nöteberg (Anna); U. Gronewold (Ulfert); S. Salterio (Steve)

2010-01-01

textabstractWe examine factors affecting the auditor’s willingness to report their own or their peers’ self-discovered errors in working papers subsequent to detailed working paper review. Prior research has shown that errors in working papers are detected in the review process; however, such

Use of control room simulators for training of nuclear power plant personnel

International Nuclear Information System (INIS)

2004-09-01

Safety analysis and operational experience consistently indicate that human error is the greatest contributor to the risk of a severe accident in a nuclear power plant. Subsequent to the Three Mile Island accident, major changes were made internationally in reducing the potential for human error through improved procedures, information presentation, and training of operators. The use of full scope simulators in the training of operators is an essential element of these efforts to reduce human error. The operators today spend a large fraction of their time training and retraining on the simulator. As indicated in the IAEA Safety Guide on Recruitment, Qualification and Training of Personnel for Nuclear Power Plants, NS-G-2.8, 2002, representative simulator facilities should be used for training of control room operators and shift supervisors. Simulator training should incorporate normal, abnormal and accident conditions. The ability of the simulator to closely represent the actual conditions and environment that would be experienced in a real situation is critical to the value of the training received. The objective of this report is to provide nuclear power plant (NPP) managers, training centre managers and personnel involved with control room simulator training with practical information they can use to improve the performance of their personnel. While the emphasis in this publication is on simulator training of control room personnel using full scope simulators, information is also provided on how organizations have effectively used control room simulators for training of other NPP personnel, including simulators other than full-scope simulators

The Error Reporting in the ATLAS TDAQ system

CERN Document Server

Kolos, S; The ATLAS collaboration; Papaevgeniou, L

2014-01-01

The ATLAS Error Reporting feature, which is used in the TDAQ environment, provides a service that allows experts and shift crew to track and address errors relating to the data taking components and applications. This service, called the Error Reporting Service(ERS), gives software applications the opportunity to collect and send comprehensive data about errors, happening at run-time, to a place where it can be intercepted in real-time by any other system component. Other ATLAS online control and monitoring tools use the Error Reporting service as one of their main inputs to address system problems in a timely manner and to improve the quality of acquired data. The actual destination of the error messages depends solely on the run-time environment, in which the online applications are operating. When applications send information to ERS, depending on the actual configuration the information may end up in a local file, in a database, in distributed middle-ware, which can transport it to an expert system or dis...

The Error Reporting in the ATLAS TDAQ System

CERN Document Server

Kolos, S; The ATLAS collaboration; Papaevgeniou, L

2015-01-01

The ATLAS Error Reporting feature, which is used in the TDAQ environment, provides a service that allows experts and shift crew to track and address errors relating to the data taking components and applications. This service, called the Error Reporting Service(ERS), gives software applications the opportunity to collect and send comprehensive data about errors, happening at run-time, to a place where it can be intercepted in real-time by any other system component. Other ATLAS online control and monitoring tools use the Error Reporting service as one of their main inputs to address system problems in a timely manner and to improve the quality of acquired data. The actual destination of the error messages depends solely on the run-time environment, in which the online applications are operating. When applications send information to ERS, depending on the actual configuration the information may end up in a local file, in a database, in distributed middle-ware, which can transport it to an expert system or dis...

Learning from medication errors through a nationwide reporting programme

NARCIS (Netherlands)

Cheung, K.C.

2015-01-01

One of the strategies to enhance patient safety is the spontaneous reporting and analysis of medication errors. Sharing this information with other healthcare providers will help to prevent the reoccurrence of similar medication errors. In The Netherlands medication errors can be reported to a

Factors associated with reporting nursing errors in Iran: a qualitative study

Directory of Open Access Journals (Sweden)

Hashemi Fatemeh

2012-10-01

Full Text Available Abstract Background Reporting the professional errors for improving patient safety is considered essential not only in hospitals, but also in ambulatory care centers. Unfortunately, a great number of nurses, similar to most clinicians, do not report their errors. Therefore, the present study aimed to clarify the factors associated with reporting the nursing errors through the experiences of clinical nurses and nursing managers. Methods A total of 115 nurses working in the hospitals and specialized clinics affiliated to Tehran and Shiraz Universities of Medical Sciences, Iran participated in this qualitative study. The study data were collected through a semi-structured group discussion conducted in 17 sessions and analyzed by inductive content analysis approach. Results The main categories emerged in this study were: a general approaches of the nurses towards errors, b barriers in reporting the nursing errors, and c motivators in error reporting. Conclusion Error reporting provides extremely valuable information for preventing future errors and improving the patient safety. Overall, regarding motivators and barriers in reporting the nursing errors, it is necessary to enact regulations in which the ways of reporting the error and its constituent elements, such as the notion of the error, are clearly identified.

Performance estimates for personnel access control systems

International Nuclear Information System (INIS)

Bradley, R.G.

1980-10-01

Current performance estimates for personnel access control systems use estimates of Type I and Type II verification errors. A system performance equation which addresses normal operation, the insider, and outside adversary attack is developed. Examination of this equation reveals the inadequacy of classical Type I and II error evaluations which require detailed knowledge of the adversary threat scenario for each specific installation. Consequently, new performance measures which are consistent with the performance equation and independent of the threat are developed as an aid in selecting personnel access control systems

TITLE III EVALUATION REPORT FOR THE MATERIAL AND PERSONNEL HANDLING SYSTEM

International Nuclear Information System (INIS)

T. A. Misiak

1998-01-01

This Title III Evaluation Report (TER) provides the results of an evaluation that was conducted on the Material and Personnel Handling System. This TER has been written in accordance with the ''Technical Document Preparation Plan for the Mined Geologic Disposal System Title III Evaluation Reports'' (BA0000000-01717-4600-00005 REV 03). The objective of this evaluation is to provide recommendations to ensure consistency between the technical baseline requirements, baseline design, and the as-constructed Material and Personnel Handling System. Recommendations for resolving discrepancies between the as-constructed system, the technical baseline requirements, and the baseline design are included in this report. Cost and Schedule estimates are provided for all recommended modifications

Recognition of medical errors' reporting system dimensions in educational hospitals.

Science.gov (United States)

Yarmohammadian, Mohammad H; Mohammadinia, Leila; Tavakoli, Nahid; Ghalriz, Parvin; Haghshenas, Abbas

2014-01-01

Nowadays medical errors are one of the serious issues in the health-care system and carry to account of the patient's safety threat. The most important step for achieving safety promotion is identifying errors and their causes in order to recognize, correct and omit them. Concerning about repeating medical errors and harms, which were received via theses errors concluded to designing and establishing medical error reporting systems for hospitals and centers that are presenting therapeutic services. The aim of this study is the recognition of medical errors' reporting system dimensions in educational hospitals. This research is a descriptive-analytical and qualities' study, which has been carried out in Shahid Beheshti educational therapeutic center in Isfahan during 2012. In this study, relevant information was collected through 15 face to face interviews. That each of interviews take place in about 1hr and creation of five focused discussion groups through 45 min for each section, they were composed of Metron, educational supervisor, health officer, health education, and all of the head nurses. Concluded data interviews and discussion sessions were coded, then achieved results were extracted in the presence of clear-sighted persons and after their feedback perception, they were categorized. In order to make sure of information correctness, tables were presented to the research's interviewers and final the corrections were confirmed based on their view. The extracted information from interviews and discussion groups have been divided into nine main categories after content analyzing and subject coding and their subsets have been completely expressed. Achieved dimensions are composed of nine domains of medical error concept, error cases according to nurses' prospection, medical error reporting barriers, employees' motivational factors for error reporting, purposes of medical error reporting system, error reporting's challenges and opportunities, a desired system

Organizational safety culture and medical error reporting by Israeli nurses.

Science.gov (United States)

Kagan, Ilya; Barnoy, Sivia

2013-09-01

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

Syntactic and semantic errors in radiology reports associated with speech recognition software.

Science.gov (United States)

Ringler, Michael D; Goss, Brian C; Bartholmai, Brian J

2017-03-01

Speech recognition software can increase the frequency of errors in radiology reports, which may affect patient care. We retrieved 213,977 speech recognition software-generated reports from 147 different radiologists and proofread them for errors. Errors were classified as "material" if they were believed to alter interpretation of the report. "Immaterial" errors were subclassified as intrusion/omission or spelling errors. The proportion of errors and error type were compared among individual radiologists, imaging subspecialty, and time periods. In all, 20,759 reports (9.7%) contained errors, of which 3992 (1.9%) were material errors. Among immaterial errors, spelling errors were more common than intrusion/omission errors ( p reports, reports reinterpreting results of outside examinations, and procedural studies (all p < .001). Error rate decreased over time ( p < .001), which suggests that a quality control program with regular feedback may reduce errors.

Systematic Review of Errors in Inhaler Use

DEFF Research Database (Denmark)

Sanchis, Joaquin; Gich, Ignasi; Pedersen, Søren

2016-01-01

in these outcomes over these 40 years and when partitioned into years 1 to 20 and years 21 to 40. Analyses were conducted in accordance with recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Strengthening the Reporting of Observational Studies in Epidemiology. Results Data...... A systematic search for articles reporting direct observation of inhaler technique by trained personnel covered the period from 1975 to 2014. Outcomes were the nature and frequencies of the three most common errors; the percentage of patients demonstrating correct, acceptable, or poor technique; and variations...

Personnel selection and emotional stability certification: establishing a false negative error rate when clinical interviews

International Nuclear Information System (INIS)

Berghausen, P.E. Jr.

1987-01-01

The security plans of nuclear plants generally require that all personnel who are to have unescorted access to protected areas or vital islands be screened for emotional instability. Screening typically consists of first administering the MMPI and then conducting a clinical interview. Interviews-by-exception protocols provide for only those employees to be interviewed who have some indications of psychopathology in their MMPI results. A problem arises when the indications are not readily apparent: False negatives are likely to occur, resulting in employees being erroneously granted unescorted access. The present paper describes the development of a predictive equation which permits accurate identification, via analysis of MMPI results, of those employees who are most in need of being interviewed. The predictive equation also permits knowing probably maximum false negative error rates when a given percentage of employees is interviewed

Teamwork and clinical error reporting among nurses in Korean hospitals.

Science.gov (United States)

Hwang, Jee-In; Ahn, Jeonghoon

2015-03-01

To examine levels of teamwork and its relationships with clinical error reporting among Korean hospital nurses. The study employed a cross-sectional survey design. We distributed a questionnaire to 674 nurses in two teaching hospitals in Korea. The questionnaire included items on teamwork and the reporting of clinical errors. We measured teamwork using the Teamwork Perceptions Questionnaire, which has five subscales including team structure, leadership, situation monitoring, mutual support, and communication. Using logistic regression analysis, we determined the relationships between teamwork and error reporting. The response rate was 85.5%. The mean score of teamwork was 3.5 out of 5. At the subscale level, mutual support was rated highest, while leadership was rated lowest. Of the participating nurses, 522 responded that they had experienced at least one clinical error in the last 6 months. Among those, only 53.0% responded that they always or usually reported clinical errors to their managers and/or the patient safety department. Teamwork was significantly associated with better error reporting. Specifically, nurses with a higher team communication score were more likely to report clinical errors to their managers and the patient safety department (odds ratio = 1.82, 95% confidence intervals [1.05, 3.14]). Teamwork was rated as moderate and was positively associated with nurses' error reporting performance. Hospital executives and nurse managers should make substantial efforts to enhance teamwork, which will contribute to encouraging the reporting of errors and improving patient safety. Copyright © 2015. Published by Elsevier B.V.

Learning from Errors: Critical Incident Reporting in Nursing

Science.gov (United States)

Gartmeier, Martin; Ottl, Eva; Bauer, Johannes; Berberat, Pascal Oliver

2017-01-01

Purpose: The purpose of this paper is to conceptualize error reporting as a strategy for informal workplace learning and investigate nurses' error reporting cost/benefit evaluations and associated behaviors. Design/methodology/approach: A longitudinal survey study was carried out in a hospital setting with two measurements (time 1 [t1]:…

IAEA activities on NPP personnel training and qualification

International Nuclear Information System (INIS)

Kossilov, A.

1998-01-01

Activities of IAEA concerning training and qualification of NPP personnel consider the availability of sufficient number of competent personnel which is one of the most critical requirements for safe and reliable NPP operation and maintenance. Competence of personnel is essential for reducing the frequency of events connected to human errors and equipment failures. The IAEA Guidebook on Nuclear Power Plant Personnel Training and its Evaluation incorporates the experience gained worldwide and provides recommendations on the use of SAT being the best practice for attaining and maintaining the qualification and competence of NPP personnel and for quality assurance of training

Estimation of Total Error in DWPF Reported Radionuclide Inventories

International Nuclear Information System (INIS)

Edwards, T.B.

1995-01-01

This report investigates the impact of random errors due to measurement and sampling on the reported concentrations of radionuclides in DWPF's filled canister inventory resulting from each macro-batch. The objective of this investigation is to estimate the variance of the total error in reporting these radionuclide concentrations

Effects of Shame and Guilt on Error Reporting Among Obstetric Clinicians.

Science.gov (United States)

Zabari, Mara Lynne; Southern, Nancy L

2018-04-17

To understand how the experiences of shame and guilt, coupled with organizational factors, affect error reporting by obstetric clinicians. Descriptive cross-sectional. A sample of 84 obstetric clinicians from three maternity units in Washington State. In this quantitative inquiry, a variant of the Test of Self-Conscious Affect was used to measure proneness to guilt and shame. In addition, we developed questions to assess attitudes regarding concerns about damaging one's reputation if an error was reported and the choice to keep an error to oneself. Both assessments were analyzed separately and then correlated to identify relationships between constructs. Interviews were used to identify organizational factors that affect error reporting. As a group, mean scores indicated that obstetric clinicians would not choose to keep errors to themselves. However, bivariate correlations showed that proneness to shame was positively correlated to concerns about one's reputation if an error was reported, and proneness to guilt was negatively correlated with keeping errors to oneself. Interview data analysis showed that Past Experience with Responses to Errors, Management and Leadership Styles, Professional Hierarchy, and Relationships With Colleagues were influential factors in error reporting. Although obstetric clinicians want to report errors, their decisions to report are influenced by their proneness to guilt and shame and perceptions of the degree to which organizational factors facilitate or create barriers to restore their self-images. Findings underscore the influence of the organizational context on clinicians' decisions to report errors. Copyright © 2018 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

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

Science.gov (United States)

Kim, Myoungsoo

2010-04-01

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

Error review: Can this improve reporting performance?

International Nuclear Information System (INIS)

Tudor, Gareth R.; Finlay, David B.

2001-01-01

AIM: This study aimed to assess whether error review can improve radiologists' reporting performance. MATERIALS AND METHODS: Ten Consultant Radiologists reported 50 plain radiographs, in which the diagnoses were established. Eighteen of the radiographs were normal, 32 showed an abnormality. The radiologists were shown their errors and then re-reported the series of radiographs after an interval of 4-5 months. The accuracy of the reports to the established diagnoses was assessed. Chi-square test was used to calculate the difference between the viewings. RESULTS: On re-reporting the radiographs, seven radiologists improved their accuracy score, two had a lower score and one radiologist showed no score difference. Mean accuracy pre-education was 82.2%, (range 78-92%) and post-education was 88%, (range 76-96%). Individually, two of the radiologists showed a statistically significant improvement post-education (P < 0.01,P < 0.05). Assessing the group as a whole, there was a trend for improvement post-education but this did not reach statistical significance. Assessing only the radiographs where errors were made on the initial viewing, for the group as a whole there was a 63% improvement post-education. CONCLUSION: We suggest that radiologists benefit from error review, although there was not a statistically significant improvement for the series of radiographs in total. This is partly explained by the fact that some radiologists gave incorrect responses post-education that had initially been correct, thus masking the effect of the educational intervention. Tudor, G.R. and Finlay, D.B. (2001

Human error in remote Afterloading Brachytherapy

International Nuclear Information System (INIS)

Quinn, M.L.; Callan, J.; Schoenfeld, I.; Serig, D.

1994-01-01

Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US. The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error

The Error Reporting in the ATLAS TDAQ System

Science.gov (United States)

Kolos, Serguei; Kazarov, Andrei; Papaevgeniou, Lykourgos

2015-05-01

The ATLAS Error Reporting provides a service that allows experts and shift crew to track and address errors relating to the data taking components and applications. This service, called the Error Reporting Service (ERS), gives to software applications the opportunity to collect and send comprehensive data about run-time errors, to a place where it can be intercepted in real-time by any other system component. Other ATLAS online control and monitoring tools use the ERS as one of their main inputs to address system problems in a timely manner and to improve the quality of acquired data. The actual destination of the error messages depends solely on the run-time environment, in which the online applications are operating. When an application sends information to ERS, depending on the configuration, it may end up in a local file, a database, distributed middleware which can transport it to an expert system or display it to users. Thanks to the open framework design of ERS, new information destinations can be added at any moment without touching the reporting and receiving applications. The ERS Application Program Interface (API) is provided in three programming languages used in the ATLAS online environment: C++, Java and Python. All APIs use exceptions for error reporting but each of them exploits advanced features of a given language to simplify the end-user program writing. For example, as C++ lacks language support for exceptions, a number of macros have been designed to generate hierarchies of C++ exception classes at compile time. Using this approach a software developer can write a single line of code to generate a boilerplate code for a fully qualified C++ exception class declaration with arbitrary number of parameters and multiple constructors, which encapsulates all relevant static information about the given type of issues. When a corresponding error occurs at run time, the program just need to create an instance of that class passing relevant values to one

Operating personnel error analysis during operation failures in the Kozloduj NPP

International Nuclear Information System (INIS)

Jonkova, A.

1990-01-01

The failures due to personnel errors are analyzed for 10 years period (1977-1986). Most of the results are presented in absolute values and are considered in dynamics. The indices for relative shares are compared by alternative analysis. One of the most important causes is the fluctuation of manpower. The failures distribution by months within the year and by hours of the day is given. The biggest number of failures occurred in the period April-October (without August - the month of the leaves), when the refueling and repair were taken place, and in January-February, due to heavy meteorological conditions and some fatigue and disconcentration because of multiple holidays. The failures during the day shifts had the greatest relative share - 42%, during the afternoon shifts - 26% and during the night shifts - 32% The most 'dangerous' time periods happened to be 11-12 h and 13-14 h (deteriorated attention after lunch), 20-22 h (physiological drop of the psychological activity), 0-3 h (the lowest level of physiological and psychological activity) and in the first and last hours of every shift. Three groups of causes are pointed out as the most frequent: improper actions connected with orders; improper independent actions; uncoordinated teamwork. The following measures are proposed for reducing the effect of the human factor: setting up the training centre; preliminary evaluation of the professional qualification of the operators; current dynamic control of their neuro-psychological fitness and occupational reliability. 1 fig, 2 tabs, 5 refs

Visual correlation analytics of event-based error reports for advanced manufacturing

OpenAIRE

Nazir, Iqbal

2017-01-01

With the growing digitalization and automation in the manufacturing domain, an increasing amount of process data and error reports become available. To minimize the number of errors and maximize the efficiency of the production line, it is important to analyze the generated error reports and find solutions that can reduce future errors. However, not all errors have the equal importance, as some errors may be the result of previously occurred errors. Therefore, it is important for domain exper...

Medication errors in anaesthetic practice: a report of two cases and ...

African Journals Online (AJOL)

EB

2013-09-03

Sep 3, 2013 ... Key words: Medication errors, anaesthetic practice, vigilance, safety .... reports in the Australian Incident Monitoring Study. (AIMS). ... contribute to systems failure and prescription errors were most ... being due to equipment error.17 Previous studies have ... errors reported occurred during day shifts and they.

THE INFLUENCE OF ACCOUNTANCY ERRORS ON FINANCIAL AND TAX REPORTS

Directory of Open Access Journals (Sweden)

Mariana GURĂU

2016-06-01

Full Text Available To make mistakes is human. An accountant may do mistakes, too. Accountancy errors are defined and classsified by accounting regulations. These set what is the accountant treatment for correcting accountancy errors. However, even though one of the objectives in accounting normalization is made by the disconnection between accountancy and taxation, the accountancy errors influence especially tax reports. We will further point the impact of accountancy errors on financial and tax reports. We will also approach the accountancy principles that impose the rules described for correcting the errors.

Voice recognition versus transcriptionist: error rated and productivity in MRI reporting

International Nuclear Information System (INIS)

Strahan, Rodney H.; Schneider-Kolsky, Michal E.

2010-01-01

Full text: Purpose: Despite the frequent introduction of voice recognition (VR) into radiology departments, little evidence still exists about its impact on workflow, error rates and costs. We designed a study to compare typographical errors, turnaround times (TAT) from reported to verified and productivity for VR-generated reports versus transcriptionist-generated reports in MRI. Methods: Fifty MRI reports generated by VR and 50 finalised MRI reports generated by the transcriptionist, of two radiologists, were sampled retrospectively. Two hundred reports were scrutinised for typographical errors and the average TAT from dictated to final approval. To assess productivity, the average MRI reports per hour for one of the radiologists was calculated using data from extra weekend reporting sessions. Results: Forty-two % and 30% of the finalised VR reports for each of the radiologists investigated contained errors. Only 6% and 8% of the transcriptionist-generated reports contained errors. The average TAT for VR was 0 h, and for the transcriptionist reports TAT was 89 and 38.9 h. Productivity was calculated at 8.6 MRI reports per hour using VR and 13.3 MRI reports using the transcriptionist, representing a 55% increase in productivity. Conclusion: Our results demonstrate that VR is not an effective method of generating reports for MRI. Ideally, we would have the report error rate and productivity of a transcriptionist and the TAT of VR.

Psychological safety and error reporting within Veterans Health Administration hospitals.

Science.gov (United States)

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

2015-03-01

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

Report on the Personnel Dosimetry at AB Atomenergi during 1965

Energy Technology Data Exchange (ETDEWEB)

Edvardsson, K A

1966-10-15

This report presents the results of the personnel dosimetry at AB Atomenergi during 1965. No doses exceeding the recommendations of ICRP were reported. For AB Atomenergi the average external total body dose during the year was 60 mrem which corresponds to 89.4 manrem. 31200 gamma films and 5850 neutron films were evaluated. 2067 urine analyses and 692 measurements of body activity were made.

Report on the Personnel Dosimetry at AB Atomenergi during 1965

International Nuclear Information System (INIS)

Edvardsson, K.A.

1966-10-01

This report presents the results of the personnel dosimetry at AB Atomenergi during 1965. No doses exceeding the recommendations of ICRP were reported. For AB Atomenergi the average external total body dose during the year was 60 mrem which corresponds to 89.4 manrem. 31200 gamma films and 5850 neutron films were evaluated. 2067 urine analyses and 692 measurements of body activity were made

Defense Forensic Enterprise: Assessment and Status Report Personnel Accounting Extract

Science.gov (United States)

2013-12-01

pathology , forensic anthropology, forensic toxicology, and DNA analysis to iden- tify human remains. Per DOD Directive 5205.15E, the stakeholders fall...Defense Forensic Enterprise Assessment and Status Report Personnel Accounting Extract Christine A. Hughes • Jeffrey E. Chilton John J. Clifford • C...community-related sections from a CNA report titled, “Defense Forensic Enterprise Assessment and Status Report” [1]. The first sec- tion within this

Report: Management Alert - EPA Has Not Initiated Required Background Investigations for Information Systems Contractor Personnel

Science.gov (United States)

Report #17-P-0409, September 27, 2017. Not vetting contractor personnel before granting them network access exposes the EPA to risks. Contractor personnel with potentially questionable backgrounds who access sensitive agency data could cause harm.

Voice recognition versus transcriptionist: error rates and productivity in MRI reporting.

Science.gov (United States)

Strahan, Rodney H; Schneider-Kolsky, Michal E

2010-10-01

Despite the frequent introduction of voice recognition (VR) into radiology departments, little evidence still exists about its impact on workflow, error rates and costs. We designed a study to compare typographical errors, turnaround times (TAT) from reported to verified and productivity for VR-generated reports versus transcriptionist-generated reports in MRI. Fifty MRI reports generated by VR and 50 finalized MRI reports generated by the transcriptionist, of two radiologists, were sampled retrospectively. Two hundred reports were scrutinised for typographical errors and the average TAT from dictated to final approval. To assess productivity, the average MRI reports per hour for one of the radiologists was calculated using data from extra weekend reporting sessions. Forty-two % and 30% of the finalized VR reports for each of the radiologists investigated contained errors. Only 6% and 8% of the transcriptionist-generated reports contained errors. The average TAT for VR was 0 h, and for the transcriptionist reports TAT was 89 and 38.9 h. Productivity was calculated at 8.6 MRI reports per hour using VR and 13.3 MRI reports using the transcriptionist, representing a 55% increase in productivity. Our results demonstrate that VR is not an effective method of generating reports for MRI. Ideally, we would have the report error rate and productivity of a transcriptionist and the TAT of VR. © 2010 The Authors. Journal of Medical Imaging and Radiation Oncology © 2010 The Royal Australian and New Zealand College of Radiologists.

Higher operational safety of nuclear power plants by evaluating the behaviour of operating personnel

International Nuclear Information System (INIS)

Mertins, M.; Glasner, P.

1990-01-01

In the GDR power reactors have been operated since 1966. Since that time operational experiences of 73 cumulative reactor years have been collected. The behaviour of operating personnel is an essential factor to guarantee the safety of operation of the nuclear power plant. Therefore a continuous analysis of the behaviour of operating personnel has been introduced at the GDR nuclear power plants. In the paper the overall system of the selection, preparation and control of the behaviour of nuclear power plant operating personnel is presented. The methods concerned are based on recording all errors of operating personnel and on analyzing them in order to find out the reasons. The aim of the analysis of reasons is to reduce the number of errors. By a feedback of experiences the nuclear safety of the nuclear power plant can be increased. All data necessary for the evaluation of errors are recorded and evaluated by a computer program. This method is explained thoroughly in the paper. Selected results of error analysis are presented. It is explained how the activities of the personnel are made safer by means of this analysis. Comparisons with other methods are made. (author). 3 refs, 4 figs

Report on the Personnel Dosimetry at AB Atomenergi during 1968

Energy Technology Data Exchange (ETDEWEB)

Carlsson, J; Wahlberg, T

1969-08-15

This report presents the results of personnel dosimetry at AB Atomenergi during 1968. 25600 gamma films and 3900 neutron films were evaluated. 1737 urine analyses and 1066 measurements of body activity were made. The external total body gamma dose for all employees (quarterly doses {<=} 100 mrem are not reported) corresponds to 136 manrem. The highest external total body gamma dose during 1968 to one person was 4,500 mrem.

Report on the Personnel Dosimetry at AB Atomenergi during 1967

International Nuclear Information System (INIS)

Carlsson, J.; Wahlberg, T.

1968-12-01

This report presents the results of personnel dosimetry at AB Atomenergi during 1967. The external total body gamma dose for all employees (quarterly doses ≤ 100 mrem are not reported) corresponds to 140 manrem. The highest external total body gamma dose during 1967 to one person was 5700 mrem. 24700 gamma films and 3900 neutron films were evaluated. 1988 urine analyses and 989 measurements of body activity were made

Report on the Personnel Dosimetry at AB Atomenergi during 1967

Energy Technology Data Exchange (ETDEWEB)

Carlsson, J; Wahlberg, T

1968-12-15

This report presents the results of personnel dosimetry at AB Atomenergi during 1967. The external total body gamma dose for all employees (quarterly doses {<=} 100 mrem are not reported) corresponds to 140 manrem. The highest external total body gamma dose during 1967 to one person was 5700 mrem. 24700 gamma films and 3900 neutron films were evaluated. 1988 urine analyses and 989 measurements of body activity were made.

Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time.

Science.gov (United States)

Hawkins, C M; Hall, S; Hardin, J; Salisbury, S; Towbin, A J

2012-08-01

Current speech recognition software allows exam-specific standard reports to be prepopulated into the dictation field based on the radiology information system procedure code. While it is thought that prepopulating reports can decrease the time required to dictate a study and the overall number of errors in the final report, this hypothesis has not been studied in a clinical setting. A prospective study was performed. During the first week, radiologists dictated all studies using prepopulated standard reports. During the second week, all studies were dictated after prepopulated reports had been disabled. Final radiology reports were evaluated for 11 different types of errors. Each error within a report was classified individually. The median time required to dictate an exam was compared between the 2 weeks. There were 12,387 reports dictated during the study, of which, 1,173 randomly distributed reports were analyzed for errors. There was no difference in the number of errors per report between the 2 weeks; however, radiologists overwhelmingly preferred using a standard report both weeks. Grammatical errors were by far the most common error type, followed by missense errors and errors of omission. There was no significant difference in the median dictation time when comparing studies performed each week. The use of prepopulated reports does not alone affect the error rate or dictation time of radiology reports. While it is a useful feature for radiologists, it must be coupled with other strategies in order to decrease errors.

Quantification of the reliability of personnel actions from the evaluation of actual German operational experience. Final report

International Nuclear Information System (INIS)

Preischl, W.; Fassmann, W.

2013-07-01

characterizing human reliability from data source ''reportable events'', - Methods to select samples characterizing human reliability from data source ''safety relevant, undoubtedly error free performed personnel actions'', - Mathematical proven methodology to derive probabilistic human performance data based on samples taken from OE, - 85 new probabilistic human performance data based on operational experience in German nuclear power plants, - Approach based on accepted behavioural knowledge to structure the obtained results and to link them to the new ''second generation'' human reliability assessment methodologies. The obtained data are forming the first data base on human reliability completely derived from operational experience of German nuclear power plants. Many subject matter experts from the plants supported the research project and contributed considerably to the research results.

Cardiopulmonary resuscitation; use, training and self-confidence in skills. A self-report study among hospital personnel

Directory of Open Access Journals (Sweden)

Hopstock Laila A

2008-12-01

Full Text Available Abstract Background Immediate start of basic cardiopulmonary resuscitation (CPR and early defibrillation have been highlighted as crucial for survival from cardiac arrest, but despite new knowledge, new technology and massive personnel training the survival rates from in-hospital cardiac arrest are still low. National guidelines recommend regular intervals of CPR training to make all hospital personnel able to perform basic CPR till advanced care is available. This study investigates CPR training, resuscitation experience and self-confidence in skills among hospital personnel outside critical care areas. Methods A cross-sectional study was performed at three Norwegian hospitals. Data on CPR training and CPR use were collected by self-reports from 361 hospital personnel. Results A total of 89% reported training in CPR, but only 11% had updated their skills in accordance with the time interval recommended by national guidelines. Real resuscitation experience was reported by one third of the respondents. Both training intervals and use of skills in resuscitation situations differed among the professions. Self-reported confidence decreased only after more than two years since last CPR training. Conclusion There is a gap between recommendations and reality in CPR training among hospital personnel working outside critical care areas.

Assessing explicit error reporting in the narrative electronic medical record using keyword searching.

Science.gov (United States)

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

Many types of medical errors occur in and outside of hospitals, some of which have very serious consequences and increase cost. Identifying errors is a critical step for managing and preventing them. In this study, we assessed the explicit reporting of medical errors in the electronic record. We used five search terms "mistake," "error," "incorrect," "inadvertent," and "iatrogenic" to survey several sets of narrative reports including discharge summaries, sign-out notes, and outpatient notes from 1991 to 2000. We manually reviewed all the positive cases and identified them based on the reporting of physicians. We identified 222 explicitly reported medical errors. The positive predictive value varied with different keywords. In general, the positive predictive value for each keyword was low, ranging from 3.4 to 24.4%. Therapeutic-related errors were the most common reported errors and these reported therapeutic-related errors were mainly medication errors. Keyword searches combined with manual review indicated some medical errors that were reported in medical records. It had a low sensitivity and a moderate positive predictive value, which varied by search term. Physicians were most likely to record errors in the Hospital Course and History of Present Illness sections of discharge summaries. The reported errors in medical records covered a broad range and were related to several types of care providers as well as non-health care professionals.

Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

Science.gov (United States)

Hobgood, Cherri; Weiner, Bryan; Tamayo-Sarver, Joshua H

2006-04-01

To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p error types, identification, disclosure, and reporting increased with increasing severity. Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

Report on the Personnel Dosimetry at AB Atomenergi during 1969

Energy Technology Data Exchange (ETDEWEB)

Carlsson, J; Wahlberg, T

1971-05-15

This report presents the results of personnel dosimetry at AB Atomenergi during 1969. 24,200 gamma films and 3,300 neutron films were evaluated. 770 urine analyses and 1,150 measurements of body activity were made. The external total body gamma dose for all employees (quarterly doses < 100 mrem are not reported) corresponds to 136 manrem. The highest external total body gamma dose during 1969 to one person was 4,800 mrem

Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals

Directory of Open Access Journals (Sweden)

Jee-In Hwang, PhD

2015-03-01

Conclusions: Teamwork was rated as moderate and was positively associated with nurses' error reporting performance. Hospital executives and nurse managers should make substantial efforts to enhance teamwork, which will contribute to encouraging the reporting of errors and improving patient safety.

Consistency errors in p-values reported in Spanish psychology journals.

Science.gov (United States)

Caperos, José Manuel; Pardo, Antonio

2013-01-01

Recent reviews have drawn attention to frequent consistency errors when reporting statistical results. We have reviewed the statistical results reported in 186 articles published in four Spanish psychology journals. Of these articles, 102 contained at least one of the statistics selected for our study: Fisher-F , Student-t and Pearson-c 2 . Out of the 1,212 complete statistics reviewed, 12.2% presented a consistency error, meaning that the reported p-value did not correspond to the reported value of the statistic and its degrees of freedom. In 2.3% of the cases, the correct calculation would have led to a different conclusion than the reported one. In terms of articles, 48% included at least one consistency error, and 17.6% would have to change at least one conclusion. In meta-analytical terms, with a focus on effect size, consistency errors can be considered substantial in 9.5% of the cases. These results imply a need to improve the quality and precision with which statistical results are reported in Spanish psychology journals.

Estimation of total error in DWPF reported radionuclide inventories. Revision 1

International Nuclear Information System (INIS)

Edwards, T.B.

1995-01-01

The Defense Waste Processing Facility (DWPF) at the Savannah River Site is required to determine and report the radionuclide inventory of its glass product. For each macro-batch, the DWPF will report both the total amount (in curies) of each reportable radionuclide and the average concentration (in curies/gram of glass) of each reportable radionuclide. The DWPF is to provide the estimated error of these reported values of its radionuclide inventory as well. The objective of this document is to provide a framework for determining the estimated error in DWPF's reporting of these radionuclide inventories. This report investigates the impact of random errors due to measurement and sampling on the total amount of each reportable radionuclide in a given macro-batch. In addition, the impact of these measurement and sampling errors and process variation are evaluated to determine the uncertainty in the reported average concentrations of radionuclides in DWPF's filled canister inventory resulting from each macro-batch

Report on the Personnel Dosimetry at AB Atomenergi during 1962

International Nuclear Information System (INIS)

Edvardsson, K.A.; Hagsgaard, S.

1963-12-01

This report presents the results of the personnel dosimetry at AB Atomenergi during 1962. No doses exceeding the recommendations of ICRP have been reported. The sum of the reported external total body doses (≥ 100 mrem/quarter) is for the whole of AB Atomenergi during this year 74. 2 manrem corresponding to about 50 mrem/year and person or 1 % of the maximum permissible dose. 32500 gamma films and 6200 neutron films have been evaluated. The total number of urine analyses is 2700 and of whole body measurements 10

Report on the Personnel Dosimetry at AB Atomenergi during 1962

Energy Technology Data Exchange (ETDEWEB)

Edvardsson, K A; Hagsgaard, S

1963-12-15

This report presents the results of the personnel dosimetry at AB Atomenergi during 1962. No doses exceeding the recommendations of ICRP have been reported. The sum of the reported external total body doses ({>=} 100 mrem/quarter) is for the whole of AB Atomenergi during this year 74. 2 manrem corresponding to about 50 mrem/year and person or 1 % of the maximum permissible dose. 32500 gamma films and 6200 neutron films have been evaluated. The total number of urine analyses is 2700 and of whole body measurements 10.

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

Science.gov (United States)

McKaig, Donald; Collins, Christine; Elsaid, Khaled A

2014-09-01

A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.

The Impact of a Patient Safety Program on Medical Error Reporting

Science.gov (United States)

2005-05-01

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

Human error probability estimation using licensee event reports

International Nuclear Information System (INIS)

Voska, K.J.; O'Brien, J.N.

1984-07-01

Objective of this report is to present a method for using field data from nuclear power plants to estimate human error probabilities (HEPs). These HEPs are then used in probabilistic risk activities. This method of estimating HEPs is one of four being pursued in NRC-sponsored research. The other three are structured expert judgment, analysis of training simulator data, and performance modeling. The type of field data analyzed in this report is from Licensee Event reports (LERs) which are analyzed using a method specifically developed for that purpose. However, any type of field data or human errors could be analyzed using this method with minor adjustments. This report assesses the practicality, acceptability, and usefulness of estimating HEPs from LERs and comprehensively presents the method for use

Medication errors: prescribing faults and prescription errors.

Science.gov (United States)

Velo, Giampaolo P; Minuz, Pietro

2009-06-01

1. Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. 2. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. 3. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. 4. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. 5. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.

Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.

Science.gov (United States)

Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R

2017-01-30

Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.

Using incident reports to inform the prevention of medication administration errors.

Science.gov (United States)

Härkänen, Marja; Saano, Susanna; Vehviläinen-Julkunen, Katri

2017-11-01

To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health

"Why Don't They Report?" Hospital Personnel Working with Children at Risk

Science.gov (United States)

Svärd, Veronica

2017-01-01

Hospital personnel have been shown to report child maltreatment to social services less frequently than other professionals. This quantitative study shows that one-half of the respondents within the four largest Swedish children's hospitals had never made a report. However, nurses' and nurse assistants' odds of being low reporters were…

Medication errors of nurses and factors in refusal to report medication errors among nurses in a teaching medical center of iran in 2012.

Science.gov (United States)

Mostafaei, Davoud; Barati Marnani, Ahmad; Mosavi Esfahani, Haleh; Estebsari, Fatemeh; Shahzaidi, Shiva; Jamshidi, Ensiyeh; Aghamiri, Seyed Samad

2014-10-01

About one third of unwanted reported medication consequences are due to medication errors, resulting in one-fifth of hospital injuries. The aim of this study was determined formal and informal medication errors of nurses and the level of importance of factors in refusal to report medication errors among nurses. The cross-sectional study was done on the nursing staff of Shohada Tajrish Hospital, Tehran, Iran in 2012. The data was gathered through a questionnaire, made by the researchers. The questionnaires' face and content validity was confirmed by experts and for measuring its reliability test-retest was used. The data was analyzed by descriptive statistics. We used SPSS for related statistical analyses. The most important factors in refusal to report medication errors respectively were: lack of medication error recording and reporting system in the hospital (3.3%), non-significant error reporting to hospital authorities and lack of appropriate feedback (3.1%), and lack of a clear definition for a medication error (3%). There were both formal and informal reporting of medication errors in this study. Factors pertaining to management in hospitals as well as the fear of the consequences of reporting are two broad fields among the factors that make nurses not report their medication errors. In this regard, providing enough education to nurses, boosting the job security for nurses, management support and revising related processes and definitions are some factors that can help decreasing medication errors and increasing their report in case of occurrence.

Evaluation of a Web-based Error Reporting Surveillance System in a Large Iranian Hospital.

Science.gov (United States)

Askarian, Mehrdad; Ghoreishi, Mahboobeh; Akbari Haghighinejad, Hourvash; Palenik, Charles John; Ghodsi, Maryam

2017-08-01

Proper reporting of medical errors helps healthcare providers learn from adverse incidents and improve patient safety. A well-designed and functioning confidential reporting system is an essential component to this process. There are many error reporting methods; however, web-based systems are often preferred because they can provide; comprehensive and more easily analyzed information. This study addresses the use of a web-based error reporting system. This interventional study involved the application of an in-house designed "voluntary web-based medical error reporting system." The system has been used since July 2014 in Nemazee Hospital, Shiraz University of Medical Sciences. The rate and severity of errors reported during the year prior and a year after system launch were compared. The slope of the error report trend line was steep during the first 12 months (B = 105.727, P = 0.00). However, it slowed following launch of the web-based reporting system and was no longer statistically significant (B = 15.27, P = 0.81) by the end of the second year. Most recorded errors were no-harm laboratory types and were due to inattention. Usually, they were reported by nurses and other permanent employees. Most reported errors occurred during morning shifts. Using a standardized web-based error reporting system can be beneficial. This study reports on the performance of an in-house designed reporting system, which appeared to properly detect and analyze medical errors. The system also generated follow-up reports in a timely and accurate manner. Detection of near-miss errors could play a significant role in identifying areas of system defects.

Caffeine Use among Active Duty Navy and Marine Corps Personnel

Science.gov (United States)

Knapik, Joseph J.; Trone, Daniel W.; McGraw, Susan; Steelman, Ryan A.; Austin, Krista G.; Lieberman, Harris R.

2016-01-01

Data from the National Health and Nutrition Examination Survey (NHANES) indicate 89% of Americans regularly consume caffeine, but these data do not include military personnel. This cross-sectional study examined caffeine use in Navy and Marine Corps personnel, including prevalence, amount of daily consumption, and factors associated with use. A random sample of Navy and Marine Corps personnel was contacted and asked to complete a detailed questionnaire describing their use of caffeine-containing substances, in addition to their demographic, military, and lifestyle characteristics. A total of 1708 service members (SMs) completed the questionnaire. Overall, 87% reported using caffeinated beverages ≥1 time/week, with caffeine users consuming a mean ± standard error of 226 ± 5 mg/day (242 ± 7 mg/day for men, 183 ± 8 mg/day for women). The most commonly consumed caffeinated beverages (% users) were coffee (65%), colas (54%), teas (40%), and energy drinks (28%). Multivariable logistic regression modeling indicated that characteristics independently associated with caffeine use (≥1 time/week) included older age, white race/ethnicity, higher alcohol consumption, and participating in less resistance training. Prevalence of caffeine use in these SMs was similar to that reported in civilian investigations, but daily consumption (mg/day) was higher. PMID:27735834

Caffeine Use among Active Duty Navy and Marine Corps Personnel

Directory of Open Access Journals (Sweden)

Joseph J. Knapik

2016-10-01

Full Text Available Data from the National Health and Nutrition Examination Survey (NHANES indicate 89% of Americans regularly consume caffeine, but these data do not include military personnel. This cross-sectional study examined caffeine use in Navy and Marine Corps personnel, including prevalence, amount of daily consumption, and factors associated with use. A random sample of Navy and Marine Corps personnel was contacted and asked to complete a detailed questionnaire describing their use of caffeine-containing substances, in addition to their demographic, military, and lifestyle characteristics. A total of 1708 service members (SMs completed the questionnaire. Overall, 87% reported using caffeinated beverages ≥1 time/week, with caffeine users consuming a mean ± standard error of 226 ± 5 mg/day (242 ± 7 mg/day for men, 183 ± 8 mg/day for women. The most commonly consumed caffeinated beverages (% users were coffee (65%, colas (54%, teas (40%, and energy drinks (28%. Multivariable logistic regression modeling indicated that characteristics independently associated with caffeine use (≥1 time/week included older age, white race/ethnicity, higher alcohol consumption, and participating in less resistance training. Prevalence of caffeine use in these SMs was similar to that reported in civilian investigations, but daily consumption (mg/day was higher.

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Science.gov (United States)

Espin, Sherry; Levinson, Wendy; Regehr, Glenn; Baker, G Ross; Lingard, Lorelei

2006-01-01

Calls abound for a culture change in health care to improve patient safety. However, effective change cannot proceed without a clear understanding of perceptions and beliefs about error. In this study, we describe and compare operative team members' and patients' perceptions of error, reporting of error, and disclosure of error. Thirty-nine interviews of team members (9 surgeons, 9 nurses, 10 anesthesiologists) and patients (11) were conducted at 2 teaching hospitals using 4 scenarios as prompts. Transcribed responses to open questions were analyzed by 2 researchers for recurrent themes using the grounded-theory method. Yes/no answers were compared across groups using chi-square analyses. Team members and patients agreed on what constitutes an error. Deviation from standards and negative outcome were emphasized as definitive features. Patients and nurse professionals differed significantly in their perception of whether errors should be reported. Nurses were willing to report only events within their disciplinary scope of practice. Although most patients strongly advocated full disclosure of errors (what happened and how), team members preferred to disclose only what happened. When patients did support partial disclosure, their rationales varied from that of team members. Both operative teams and patients define error in terms of breaking the rules and the concept of "no harm no foul." These concepts pose challenges for treating errors as system failures. A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.

Identifying medication error chains from critical incident reports: a new analytic approach.

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Huckels-Baumgart, Saskia; Manser, Tanja

2014-10-01

Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.

Isolating Graphical Failure-Inducing Input for Privacy Protection in Error Reporting Systems

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Matos João

2016-04-01

Full Text Available This work proposes a new privacy-enhancing system that minimizes the disclosure of information in error reports. Error reporting mechanisms are of the utmost importance to correct software bugs but, unfortunately, the transmission of an error report may reveal users’ private information. Some privacy-enhancing systems for error reporting have been presented in the past years, yet they rely on path condition analysis, which we show in this paper to be ineffective when it comes to graphical-based input. Knowing that numerous applications have graphical user interfaces (GUI, it is very important to overcome such limitation. This work describes a new privacy-enhancing error reporting system, based on a new input minimization algorithm called GUIᴍɪɴ that is geared towards GUI, to remove input that is unnecessary to reproduce the observed failure. Before deciding whether to submit the error report, the user is provided with a step-by-step graphical replay of the minimized input, to evaluate whether it still yields sensitive information. We also provide an open source implementation of the proposed system and evaluate it with well-known applications.

Medication errors detected in non-traditional databases

DEFF Research Database (Denmark)

Perregaard, Helene; Aronson, Jeffrey K; Dalhoff, Kim

2015-01-01

AIMS: We have looked for medication errors involving the use of low-dose methotrexate, by extracting information from Danish sources other than traditional pharmacovigilance databases. We used the data to establish the relative frequencies of different types of errors. METHODS: We searched four...... errors, whereas knowledge-based errors more often resulted in near misses. CONCLUSIONS: The medication errors in this survey were most often action-based (50%) and knowledge-based (34%), suggesting that greater attention should be paid to education and surveillance of medical personnel who prescribe...

A description of medication errors reported by pharmacists in a neonatal intensive care unit.

Science.gov (United States)

Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila

2017-02-01

Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.

Defining Reported Errors on Web-based Reporting System Using ICPS From Nine Units in a Korean University Hospital

Directory of Open Access Journals (Sweden)

Chul-Hoon Kim, DDS, PhD

2009-12-01

Conclusion: The web-based error reporting system using ICPS proved to be an easy, feasible system for hospitals in Korea. This system will be helpful for inducing general agreement upon errors within clinical nursing practice and bring more attention to any errors made or near misses. Also, it will be able to ameliorate the punitive culture for errors and transform error reporting into a habit for healthcare providers.

Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals

OpenAIRE

Jee-In Hwang, PhD; Jeonghoon Ahn, PhD

2015-01-01

Purpose: To examine levels of teamwork and its relationships with clinical error reporting among Korean hospital nurses. Methods: The study employed a cross-sectional survey design. We distributed a questionnaire to 674 nurses in two teaching hospitals in Korea. The questionnaire included items on teamwork and the reporting of clinical errors. We measured teamwork using the Teamwork Perceptions Questionnaire, which has five subscales including team structure, leadership, situation monitori...

Analysis of error patterns in clinical radiotherapy

International Nuclear Information System (INIS)

Macklis, Roger; Meier, Tim; Barrett, Patricia; Weinhous, Martin

1996-01-01

Purpose: Until very recently, prescription errors and adverse treatment events have rarely been studied or reported systematically in oncology. We wished to understand the spectrum and severity of radiotherapy errors that take place on a day-to-day basis in a high-volume academic practice and to understand the resource needs and quality assurance challenges placed on a department by rapid upswings in contract-based clinical volumes requiring additional operating hours, procedures, and personnel. The goal was to define clinical benchmarks for operating safety and to detect error-prone treatment processes that might function as 'early warning' signs. Methods: A multi-tiered prospective and retrospective system for clinical error detection and classification was developed, with formal analysis of the antecedents and consequences of all deviations from prescribed treatment delivery, no matter how trivial. A department-wide record-and-verify system was operational during this period and was used as one method of treatment verification and error detection. Brachytherapy discrepancies were analyzed separately. Results: During the analysis year, over 2000 patients were treated with over 93,000 individual fields. A total of 59 errors affecting a total of 170 individual treated fields were reported or detected during this period. After review, all of these errors were classified as Level 1 (minor discrepancy with essentially no potential for negative clinical implications). This total treatment delivery error rate (170/93, 332 or 0.18%) is significantly better than corresponding error rates reported for other hospital and oncology treatment services, perhaps reflecting the relatively sophisticated error avoidance and detection procedures used in modern clinical radiation oncology. Error rates were independent of linac model and manufacturer, time of day (normal operating hours versus late evening or early morning) or clinical machine volumes. There was some relationship to

The frequency of diagnostic errors in radiologic reports depends on the patient's age

International Nuclear Information System (INIS)

Diaz, Sandra; Ekberg, Olle

2010-01-01

Background: Patients who undergo treatment may suffer preventable medical errors. Some of these errors are due to diagnostic imaging procedures. Purpose: To compare the frequency of diagnostic errors in different age groups in an urban European population. Material and Methods: A total of 19 129 reported radiologic examinations were included. During a 6-month period, the analyzed age groups were: children (aged 0-9 years), adults (40-49 years), and elderly (86-95 years). Results: The frequency of radiologic examinations per year was 0.3 in children, 0.6 in adults, and 1.1 in elderly. Significant errors were significantly more frequent in the elderly (1.7%) and children (1.4%) compared with adults (0.8%). There were 60 false-positive reports and 232 false-negative reports. Most errors were made by staff radiologists after hours when they reported on examinations outside their area of expertise. Conclusion: Diagnostic errors are more frequent in children and the elderly compared with middle-aged adults

Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital.

Science.gov (United States)

Farag, Amany; Blegen, Mary; Gedney-Lose, Amalia; Lose, Daniel; Perkhounkova, Yelena

2017-05-01

Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting. Published by Elsevier Inc.

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

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Lee, Eunjoo

2016-09-01

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

Proportion of medication error reporting and associated factors among nurses: a cross sectional study.

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Jember, Abebaw; Hailu, Mignote; Messele, Anteneh; Demeke, Tesfaye; Hassen, Mohammed

2018-01-01

A medication error (ME) is any preventable event that may cause or lead to inappropriate medication use or patient harm. Voluntary reporting has a principal role in appreciating the extent and impact of medication errors. Thus, exploration of the proportion of medication error reporting and associated factors among nurses is important to inform service providers and program implementers so as to improve the quality of the healthcare services. Institution based quantitative cross-sectional study was conducted among 397 nurses from March 6 to May 10, 2015. Stratified sampling followed by simple random sampling technique was used to select the study participants. The data were collected using structured self-administered questionnaire which was adopted from studies conducted in Australia and Jordan. A pilot study was carried out to validate the questionnaire before data collection for this study. Bivariate and multivariate logistic regression models were fitted to identify factors associated with the proportion of medication error reporting among nurses. An adjusted odds ratio with 95% confidence interval was computed to determine the level of significance. The proportion of medication error reporting among nurses was found to be 57.4%. Regression analysis showed that sex, marital status, having made a medication error and medication error experience were significantly associated with medication error reporting. The proportion of medication error reporting among nurses in this study was found to be higher than other studies.

Statistical Reporting Errors and Collaboration on Statistical Analyses in Psychological Science.

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Veldkamp, Coosje L S; Nuijten, Michèle B; Dominguez-Alvarez, Linda; van Assen, Marcel A L M; Wicherts, Jelte M

2014-01-01

Statistical analysis is error prone. A best practice for researchers using statistics would therefore be to share data among co-authors, allowing double-checking of executed tasks just as co-pilots do in aviation. To document the extent to which this 'co-piloting' currently occurs in psychology, we surveyed the authors of 697 articles published in six top psychology journals and asked them whether they had collaborated on four aspects of analyzing data and reporting results, and whether the described data had been shared between the authors. We acquired responses for 49.6% of the articles and found that co-piloting on statistical analysis and reporting results is quite uncommon among psychologists, while data sharing among co-authors seems reasonably but not completely standard. We then used an automated procedure to study the prevalence of statistical reporting errors in the articles in our sample and examined the relationship between reporting errors and co-piloting. Overall, 63% of the articles contained at least one p-value that was inconsistent with the reported test statistic and the accompanying degrees of freedom, and 20% of the articles contained at least one p-value that was inconsistent to such a degree that it may have affected decisions about statistical significance. Overall, the probability that a given p-value was inconsistent was over 10%. Co-piloting was not found to be associated with reporting errors.

Medication errors with the use of allopurinol and colchicine : A retrospective study of a national, anonymous Internet-accessible error reporting system

NARCIS (Netherlands)

Mikuls, TR; Curtis, [No Value; Allison, JJ; Hicks, RW; Saag, KG

Objectives. To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. Methods. We examined data from the MEDMARX (TM) database, covering the period from January 1, 1999 through December 31,

Patient identification errors: the detective in the laboratory.

Science.gov (United States)

Salinas, Maria; López-Garrigós, Maite; Lillo, Rosa; Gutiérrez, Mercedes; Lugo, Javier; Leiva-Salinas, Carlos

2013-11-01

The eradication of errors regarding patients' identification is one of the main goals for safety improvement. As clinical laboratory intervenes in 70% of clinical decisions, laboratory safety is crucial in patient safety. We studied the number of Laboratory Information System (LIS) demographic data errors registered in our laboratory during one year. The laboratory attends a variety of inpatients and outpatients. The demographic data of outpatients is registered in the LIS, when they present to the laboratory front desk. The requests from the primary care centers (PCC) are made electronically by the general practitioner. A manual step is always done at the PCC to conciliate the patient identification number in the electronic request with the one in the LIS. Manual registration is done through hospital information system demographic data capture when patient's medical record number is registered in LIS. Laboratory report is always sent out electronically to the patient's electronic medical record. Daily, every demographic data in LIS is manually compared to the request form to detect potential errors. Fewer errors were committed when electronic order was used. There was great error variability between PCC when using the electronic order. LIS demographic data manual registration errors depended on patient origin and test requesting method. Even when using the electronic approach, errors were detected. There was a great variability between PCC even when using this electronic modality; this suggests that the number of errors is still dependent on the personnel in charge of the technology. © 2013.

45 CFR 60.6 - Reporting errors, omissions, and revisions.

Science.gov (United States)

2010-10-01

... 45 Public Welfare 1 2010-10-01 2010-10-01 false Reporting errors, omissions, and revisions. 60.6 Section 60.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION NATIONAL PRACTITIONER DATA BANK FOR ADVERSE INFORMATION ON PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS Reporting of...

Pediatric echocardiograms performed at primary centers: Diagnostic errors and missing links!

International Nuclear Information System (INIS)

Saraf, Rahul P; Suresh, PV; Maheshwari, Sunita; Shah, Sejal S

2015-01-01

The present study was undertaken to assess the accuracy of pediatric echocardiograms done at non-tertiary centers and to evaluate the relationship of inaccurate interpretations with age, echocardiogram performer and complexity of congenital heart disease (CHD). The echocardiogram reports of 182 consecutive children with CHD (5 days-16 years) who were evaluated at a non-tertiary center and subsequently referred to our center were reviewed. Age of the child at echocardiogram, echocardiogram performer and complexity of CHD were noted. These reports were compared with echocardiogram done at our center. Discrepancies were noted and categorized. To assess our own error rate, we compared our echocardiogram reports with the findings obtained during surgery (n = 172), CT scan (n = 9) or cardiac catheterization reports (n = 1). Most of the children at the non-tertiary center (92%) underwent echocardiogram by personnel other than a pediatric cardiologist. Overall, diagnostic errors were found in 69/182 (38%) children. Moderate and major discrepancies affecting the final management were found in 42/182 (23%) children. Discrepancies were higher when the echocardiogram was done by personnel other than pediatric cardiologist (P < 0.01) and with moderate and high complexity lesions (P = 0.0001). There was no significant difference in proportion of these discrepancies in children ≤ 1 year vs. >1 year of age. A significant number of pediatric echocardiograms done at non-tertiary centers had discrepancies that affected the management of these children. More discrepancies were seen when the echocardiogram performer was not a pediatric cardiologist and with complex CHD

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Directory of Open Access Journals (Sweden)

Gabriella Rejane dos Santos Dalmolin

2013-12-01

Full Text Available Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%. Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.

A human error taxonomy for analysing healthcare incident reports: assessing reporting culture and its effects on safety perfomance

DEFF Research Database (Denmark)

Itoh, Kenji; Omata, N.; Andersen, Henning Boje

2009-01-01

The present paper reports on a human error taxonomy system developed for healthcare risk management and on its application to evaluating safety performance and reporting culture. The taxonomy comprises dimensions for classifying errors, for performance-shaping factors, and for the maturity...

The relationships among work stress, strain and self-reported errors in UK community pharmacy.

Science.gov (United States)

Johnson, S J; O'Connor, E M; Jacobs, S; Hassell, K; Ashcroft, D M

2014-01-01

Changes in the UK community pharmacy profession including new contractual frameworks, expansion of services, and increasing levels of workload have prompted concerns about rising levels of workplace stress and overload. This has implications for pharmacist health and well-being and the occurrence of errors that pose a risk to patient safety. Despite these concerns being voiced in the profession, few studies have explored work stress in the community pharmacy context. To investigate work-related stress among UK community pharmacists and to explore its relationships with pharmacists' psychological and physical well-being, and the occurrence of self-reported dispensing errors and detection of prescribing errors. A cross-sectional postal survey of a random sample of practicing community pharmacists (n = 903) used ASSET (A Shortened Stress Evaluation Tool) and questions relating to self-reported involvement in errors. Stress data were compared to general working population norms, and regressed on well-being and self-reported errors. Analysis of the data revealed that pharmacists reported significantly higher levels of workplace stressors than the general working population, with concerns about work-life balance, the nature of the job, and work relationships being the most influential on health and well-being. Despite this, pharmacists were not found to report worse health than the general working population. Self-reported error involvement was linked to both high dispensing volume and being troubled by perceived overload (dispensing errors), and resources and communication (detection of prescribing errors). This study contributes to the literature by benchmarking community pharmacists' health and well-being, and investigating sources of stress using a quantitative approach. A further important contribution to the literature is the identification of a quantitative link between high workload and self-reported dispensing errors. Copyright © 2014 Elsevier Inc. All rights

Personnel dose assignment practices

International Nuclear Information System (INIS)

Fix, J.J.

1993-04-01

Implementation of DOE N 5480.6 Radiological Control Manual Article 511(3) requirements, to minimize the assignment of personnel dosimeters, should be done only under a broader context ensuring that capabilities are in place to monitor and record personnel exposure both for compliance and for potential litigation. As noted in NCRP Report No. 114, personnel dosimetry programs are conducted to meet four major objectives: radiation safety program control and evaluation; regulatory compliance; epidemiological research; and litigation. A change to Article 511(3) is proposed that would require that minimizing the assignment of personnel dosimeters take place only following full evaluation of overall capabilities (e.g., access control, area dosimetry, etc.) to meet the NCRP objectives

Child Maltreatment Reporting by Educational Personnel: Implications for Racial Disproportionality in the Child Welfare System

Science.gov (United States)

Krase, Kathryn Suzanne

2015-01-01

African American children are disproportionally overrepresented in the U.S. child protection system. Because educational personnel are a significant source of reports of suspected child maltreatment across the country and in all states, the present study examines the impact of these reports on racial disproportionality and disparity at the…

Prevalence and reporting of recruitment, randomisation and treatment errors in clinical trials: A systematic review.

Science.gov (United States)

Yelland, Lisa N; Kahan, Brennan C; Dent, Elsa; Lee, Katherine J; Voysey, Merryn; Forbes, Andrew B; Cook, Jonathan A

2018-06-01

Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation

Variability in Threshold for Medication Error Reporting Between Physicians, Nurses, Pharmacists, and Families.

Science.gov (United States)

Keefer, Patricia; Kidwell, Kelley; Lengyel, Candice; Warrier, Kavita; Wagner, Deborah

2017-01-01

Voluntary medication error reporting is an imperfect resource used to improve the quality of medication administration. It requires judgment by front-line staff to determine how to report enough to identify opportunities to improve patients' safety but not jeopardize that safety by creating a culture of "report fatigue." This study aims to provide information on interpretability of medication error and the variability between the subgroups of caregivers in the hospital setting. Survey participants included nursing, physician (trainee and graduated), patient/families, pharmacist across a large academic health system, including an attached free-standing pediatric hospital. Demographics and survey questions were collected and analyzed using Fischer's exact testing with SAS v9.3. Statistically significant variability existed between the four groups for a majority of the questions. This included all cases designated as administration errors and many, but not all, cases of prescribing events. Commentary provided in the free-text portion of the survey was sub-analyzed and found to be associated with medication allergy reporting and lack of education surrounding report characteristics. There is significant variability in the threshold to report specific medication errors in the hospital setting. More work needs to be done to further improve the education surrounding error reporting in hospitals for all noted subgroups. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13...... (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between...

A Wireless Sensor Network Based Personnel Positioning Scheme in Coal Mines with Blind Areas

Science.gov (United States)

Liu, Zhigao; Li, Chunwen; Wu, Danchen; Dai, Wenhan; Geng, Shaobo; Ding, Qingqing

2010-01-01

This paper proposes a novel personnel positioning scheme for a tunnel network with blind areas, which compared with most existing schemes offers both low-cost and high-precision. Based on the data models of tunnel networks, measurement networks and mobile miners, the global positioning method is divided into four steps: (1) calculate the real time personnel location in local areas using a location engine, and send it to the upper computer through the gateway; (2) correct any localization errors resulting from the underground tunnel environmental interference; (3) determine the global three-dimensional position by coordinate transformation; (4) estimate the personnel locations in the blind areas. A prototype system constructed to verify the positioning performance shows that the proposed positioning system has good reliability, scalability, and positioning performance. In particular, the static localization error of the positioning system is less than 2.4 m in the underground tunnel environment and the moving estimation error is below 4.5 m in the corridor environment. The system was operated continuously over three months without any failures. PMID:22163446

A wireless sensor network based personnel positioning scheme in coal mines with blind areas.

Science.gov (United States)

Liu, Zhigao; Li, Chunwen; Wu, Danchen; Dai, Wenhan; Geng, Shaobo; Ding, Qingqing

2010-01-01

This paper proposes a novel personnel positioning scheme for a tunnel network with blind areas, which compared with most existing schemes offers both low-cost and high-precision. Based on the data models of tunnel networks, measurement networks and mobile miners, the global positioning method is divided into four steps: (1) calculate the real time personnel location in local areas using a location engine, and send it to the upper computer through the gateway; (2) correct any localization errors resulting from the underground tunnel environmental interference; (3) determine the global three-dimensional position by coordinate transformation; (4) estimate the personnel locations in the blind areas. A prototype system constructed to verify the positioning performance shows that the proposed positioning system has good reliability, scalability, and positioning performance. In particular, the static localization error of the positioning system is less than 2.4 m in the underground tunnel environment and the moving estimation error is below 4.5 m in the corridor environment. The system was operated continuously over three months without any failures.

Error Analysis of Brailled Instructional Materials Produced by Public School Personnel in Texas

Science.gov (United States)

Herzberg, Tina

2010-01-01

In this study, a detailed error analysis was performed to determine if patterns of errors existed in braille transcriptions. The most frequently occurring errors were the insertion of letters or words that were not contained in the original print material; the incorrect usage of the emphasis indicator; and the incorrect formatting of titles,…

The Relationship between Reports of Psychological Capital and Reports of Job Satisfaction among Administrative Personnel at a Private Institution of Higher Education

Science.gov (United States)

Mello, James A.

2012-01-01

The purpose of this single-site case study was to investigate the relationship between administrative personnel's reports of psychological capital (Luthans, Youssef, & Avolio, 2007) and their reports of job satisfaction (Hackman & Oldham, 1980). Specifically, two surveys, the Psychological Capital Questionnaire (Luthans, Youssef, &…

Factors affecting nursing students' intention to report medication errors: An application of the theory of planned behavior.

Science.gov (United States)

Ben Natan, Merav; Sharon, Ira; Mahajna, Marlen; Mahajna, Sara

2017-11-01

Medication errors are common among nursing students. Nonetheless, these errors are often underreported. To examine factors related to nursing students' intention to report medication errors, using the Theory of Planned Behavior, and to examine whether the theory is useful in predicting students' intention to report errors. This study has a descriptive cross-sectional design. Study population was recruited in a university and a large nursing school in central and northern Israel. A convenience sample of 250 nursing students took part in the study. The students completed a self-report questionnaire, based on the Theory of Planned Behavior. The findings indicate that students' intention to report medication errors was high. The Theory of Planned Behavior constructs explained 38% of variance in students' intention to report medication errors. The constructs of behavioral beliefs, subjective norms, and perceived behavioral control were found as affecting this intention, while the most significant factor was behavioral beliefs. The findings also reveal that students' fear of the reaction to disclosure of the error from superiors and colleagues may impede them from reporting the error. Understanding factors related to reporting medication errors is crucial to designing interventions that foster error reporting. Copyright © 2017 Elsevier Ltd. All rights reserved.

Outlier Removal and the Relation with Reporting Errors and Quality of Psychological Research

Science.gov (United States)

Bakker, Marjan; Wicherts, Jelte M.

2014-01-01

Background The removal of outliers to acquire a significant result is a questionable research practice that appears to be commonly used in psychology. In this study, we investigated whether the removal of outliers in psychology papers is related to weaker evidence (against the null hypothesis of no effect), a higher prevalence of reporting errors, and smaller sample sizes in these papers compared to papers in the same journals that did not report the exclusion of outliers from the analyses. Methods and Findings We retrieved a total of 2667 statistical results of null hypothesis significance tests from 153 articles in main psychology journals, and compared results from articles in which outliers were removed (N = 92) with results from articles that reported no exclusion of outliers (N = 61). We preregistered our hypotheses and methods and analyzed the data at the level of articles. Results show no significant difference between the two types of articles in median p value, sample sizes, or prevalence of all reporting errors, large reporting errors, and reporting errors that concerned the statistical significance. However, we did find a discrepancy between the reported degrees of freedom of t tests and the reported sample size in 41% of articles that did not report removal of any data values. This suggests common failure to report data exclusions (or missingness) in psychological articles. Conclusions We failed to find that the removal of outliers from the analysis in psychological articles was related to weaker evidence (against the null hypothesis of no effect), sample size, or the prevalence of errors. However, our control sample might be contaminated due to nondisclosure of excluded values in articles that did not report exclusion of outliers. Results therefore highlight the importance of more transparent reporting of statistical analyses. PMID:25072606

Compounded Pain Creams and Adverse Effects; Postanesthesia Care Unit ADC Selection Error; Docetaxel Product Has Unusual Concentration; Tragic Vaccine Diluent Mix-ups.

Science.gov (United States)

Cohen, Michael R; Smetzer, Judy L

2015-01-01

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Medication Errors in a Swiss Cardiovascular Surgery Department: A Cross-Sectional Study Based on a Novel Medication Error Report Method

Directory of Open Access Journals (Sweden)

Kaspar Küng

2013-01-01

Full Text Available The purpose of this study was (1 to determine frequency and type of medication errors (MEs, (2 to assess the number of MEs prevented by registered nurses, (3 to assess the consequences of ME for patients, and (4 to compare the number of MEs reported by a newly developed medication error self-reporting tool to the number reported by the traditional incident reporting system. We conducted a cross-sectional study on ME in the Cardiovascular Surgery Department of Bern University Hospital in Switzerland. Eligible registered nurses ( involving in the medication process were included. Data on ME were collected using an investigator-developed medication error self reporting tool (MESRT that asked about the occurrence and characteristics of ME. Registered nurses were instructed to complete a MESRT at the end of each shift even if there was no ME. All MESRTs were completed anonymously. During the one-month study period, a total of 987 MESRTs were returned. Of the 987 completed MESRTs, 288 (29% indicated that there had been an ME. Registered nurses reported preventing 49 (5% MEs. Overall, eight (2.8% MEs had patient consequences. The high response rate suggests that this new method may be a very effective approach to detect, report, and describe ME in hospitals.

Qualification of nuclear power plant operations personnel

International Nuclear Information System (INIS)

1984-01-01

With the ultimate aim of reducing the possibility of human error in nuclear power plant operations, the Guidebook discusses the organizational aspects, the staffing requirements, the educational systems and qualifications, the competence requirements, the ways to establish, preserve and verify competence, the specific aspects of personnel management and training for nuclear power plant operations, and finally the particular situations and difficulties to be overcome by utilities starting their first nuclear power plant. An important aspect presented in the Guidebook is the experience in training and qualification of nuclear power plant personnel in various countries: Argentina, Belgium, Canada, Czechoslovakia, France, Federal Republic of Germany, Spain, Sweden, United Kingdom and United States of America

Bounding quantum gate error rate based on reported average fidelity

International Nuclear Information System (INIS)

Sanders, Yuval R; Wallman, Joel J; Sanders, Barry C

2016-01-01

Remarkable experimental advances in quantum computing are exemplified by recent announcements of impressive average gate fidelities exceeding 99.9% for single-qubit gates and 99% for two-qubit gates. Although these high numbers engender optimism that fault-tolerant quantum computing is within reach, the connection of average gate fidelity with fault-tolerance requirements is not direct. Here we use reported average gate fidelity to determine an upper bound on the quantum-gate error rate, which is the appropriate metric for assessing progress towards fault-tolerant quantum computation, and we demonstrate that this bound is asymptotically tight for general noise. Although this bound is unlikely to be saturated by experimental noise, we demonstrate using explicit examples that the bound indicates a realistic deviation between the true error rate and the reported average fidelity. We introduce the Pauli distance as a measure of this deviation, and we show that knowledge of the Pauli distance enables tighter estimates of the error rate of quantum gates. (fast track communication)

Latency and mode of error detection as reflected in Swedish licensee event reports

Energy Technology Data Exchange (ETDEWEB)

Svenson, Ola; Salo, Ilkka [Stockholm Univ., (Sweden). Dept. of Psychology

2002-03-01

Licensee event reports (LERs) from an industry provide important information feedback about safety to the industry itself, the regulators and to the public. LERs from four nuclear power reactors were analyzed to find out about detection times, mode of detection and qualitative differences in reports from different reactors. The reliability of the coding was satisfactory and measured as the covariance between the ratings from two independent judges. The results showed differences in detection time across the reactors. On the average about ten percent of the errors remained undetected for 100 weeks or more, but the great majority of errors were detected soon after their first appearance in the plant. On the average 40 percent of the errors were detected in regular tests and 40 per cent through alarms. Operators found about 10 per cent of the errors through noticing something abnormal in the plant. The remaining errors were detected in various other ways. There were qualitative differences between the LERs from the different reactors reflecting the different conditions in the plants. The number of reports differed by a magnitude 1:2 between the different plants. However, a greater number of LERs can indicate both higher safety standards (e.g., a greater willingness to report all possible events to be able to learn from them) and lower safety standards (e.g., reporting as few events as possible to make a good impression). It was pointed out that LERs are indispensable in order to maintain safety of an industry and that the differences between plants found in the analyses of this study indicate how error reports can be used to initiate further investigations for improved safety.

Latency and mode of error detection as reflected in Swedish licensee event reports

International Nuclear Information System (INIS)

Svenson, Ola; Salo, Ilkka

2002-03-01

Licensee event reports (LERs) from an industry provide important information feedback about safety to the industry itself, the regulators and to the public. LERs from four nuclear power reactors were analyzed to find out about detection times, mode of detection and qualitative differences in reports from different reactors. The reliability of the coding was satisfactory and measured as the covariance between the ratings from two independent judges. The results showed differences in detection time across the reactors. On the average about ten percent of the errors remained undetected for 100 weeks or more, but the great majority of errors were detected soon after their first appearance in the plant. On the average 40 percent of the errors were detected in regular tests and 40 per cent through alarms. Operators found about 10 per cent of the errors through noticing something abnormal in the plant. The remaining errors were detected in various other ways. There were qualitative differences between the LERs from the different reactors reflecting the different conditions in the plants. The number of reports differed by a magnitude 1:2 between the different plants. However, a greater number of LERs can indicate both higher safety standards (e.g., a greater willingness to report all possible events to be able to learn from them) and lower safety standards (e.g., reporting as few events as possible to make a good impression). It was pointed out that LERs are indispensable in order to maintain safety of an industry and that the differences between plants found in the analyses of this study indicate how error reports can be used to initiate further investigations for improved safety

Personnel reliability impact on petrochemical facilities monitoring system's failure skipping probability

Science.gov (United States)

Kostyukov, V. N.; Naumenko, A. P.

2017-08-01

The paper dwells upon urgent issues of evaluating impact of actions conducted by complex technological systems operators on their safe operation considering application of condition monitoring systems for elements and sub-systems of petrochemical production facilities. The main task for the research is to distinguish factors and criteria of monitoring system properties description, which would allow to evaluate impact of errors made by personnel on operation of real-time condition monitoring and diagnostic systems for machinery of petrochemical facilities, and find and objective criteria for monitoring system class, considering a human factor. On the basis of real-time condition monitoring concepts of sudden failure skipping risk, static and dynamic error, monitoring systems, one may solve a task of evaluation of impact that personnel's qualification has on monitoring system operation in terms of error in personnel or operators' actions while receiving information from monitoring systems and operating a technological system. Operator is considered as a part of the technological system. Although, personnel's behavior is usually a combination of the following parameters: input signal - information perceiving, reaction - decision making, response - decision implementing. Based on several researches on behavior of nuclear powers station operators in USA, Italy and other countries, as well as on researches conducted by Russian scientists, required data on operator's reliability were selected for analysis of operator's behavior at technological facilities diagnostics and monitoring systems. The calculations revealed that for the monitoring system selected as an example, the failure skipping risk for the set values of static (less than 0.01) and dynamic (less than 0.001) errors considering all related factors of data on reliability of information perception, decision-making, and reaction fulfilled is 0.037, in case when all the facilities and error probability are under

Nuclear Test Personnel Review

Science.gov (United States)

FOIA Electronic Reading Room Privacy Impact Assessment DTRA No Fear Act Reporting Nuclear Test Personnel Review NTPR Fact Sheets NTPR Radiation Dose Assessment Documents US Atmospheric Nuclear Test History Documents US Underground Nuclear Test History Reports NTPR Radiation Exposure Reports Enewetak

Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative.

Science.gov (United States)

Lobaugh, Lauren M Y; Martin, Lizabeth D; Schleelein, Laura E; Tyler, Donald C; Litman, Ronald S

2017-09-01

Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies. In September 2016, we analyzed approximately 6 years' worth of medication error events reported to Wake Up Safe. Medication errors were classified by: (1) medication category; (2) error type by phase of administration: prescribing, preparation, or administration; (3) bolus or infusion error; (4) provider type and level of training; (5) harm as defined by the National Coordinating Council for Medication Error Reporting and Prevention; and (6) perceived preventability. From 2010 to the time of our data analysis in September 2016, 32 institutions had joined and submitted data on 2087 adverse events during 2,316,635 anesthetics. These reports contained details of 276 medication errors, which comprised the third highest category of events behind cardiac and respiratory related events. Medication errors most commonly involved opioids and sedative/hypnotics. When categorized by phase of handling, 30 events occurred during preparation, 67 during prescribing, and 179 during administration. The most common error type was accidental administration of the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven (21%) reported medication errors involved medications prepared as infusions as opposed to 1 time bolus administrations. Medication errors were committed by all types of anesthesia providers, most commonly by attendings. Over 80% of reported medication errors reached the patient and more than half of these events caused patient harm. Fifteen events (5%) required a life sustaining intervention. Nearly all cases (97%) were judged to be either likely or certainly preventable. Our findings

Human errors related to maintenance and modifications

International Nuclear Information System (INIS)

Laakso, K.; Pyy, P.; Reiman, L.

1998-01-01

The focus in human reliability analysis (HRA) relating to nuclear power plants has traditionally been on human performance in disturbance conditions. On the other hand, some studies and incidents have shown that also maintenance errors, which have taken place earlier in plant history, may have an impact on the severity of a disturbance, e.g. if they disable safety related equipment. Especially common cause and other dependent failures of safety systems may significantly contribute to the core damage risk. The first aim of the study was to identify and give examples of multiple human errors which have penetrated the various error detection and inspection processes of plant safety barriers. Another objective was to generate numerical safety indicators to describe and forecast the effectiveness of maintenance. A more general objective was to identify needs for further development of maintenance quality and planning. In the first phase of this operational experience feedback analysis, human errors recognisable in connection with maintenance were looked for by reviewing about 4400 failure and repair reports and some special reports which cover two nuclear power plant units on the same site during 1992-94. A special effort was made to study dependent human errors since they are generally the most serious ones. An in-depth root cause analysis was made for 14 dependent errors by interviewing plant maintenance foremen and by thoroughly analysing the errors. A more simple treatment was given to maintenance-related single errors. The results were shown as a distribution of errors among operating states i.a. as regards the following matters: in what operational state the errors were committed and detected; in what operational and working condition the errors were detected, and what component and error type they were related to. These results were presented separately for single and dependent maintenance-related errors. As regards dependent errors, observations were also made

FRamework Assessing Notorious Contributing Influences for Error (FRANCIE): Perspective on Taxonomy Development to Support Error Reporting and Analysis

Energy Technology Data Exchange (ETDEWEB)

Lon N. Haney; David I. Gertman

2003-04-01

Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human error analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.

Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative

National Research Council Canada - National Science Library

Harris, Daniel M; Westfall, John M; Fernald, Douglas H; Duclos, Christine W; West, David R; Niebauer, Linda; Marr, Linda; Quintela, Javan; Main, Deborah S

2005-01-01

.... This paper presents a mixed methods approach to analyzing narrative error event reports. Mixed methods studies integrate one or more qualitative and quantitative techniques for data collection and analysis...

Educational Imperatives for Oral Health Personnel: Change or Decay? Report of a WHO Expert Committee. Technical Report Series 794.

Science.gov (United States)

World Health Organization, Geneva (Switzerland).

This report highlights trends in disease patterns and technological advances that call for sweeping changes in the education of oral health personnel. It first provides a brief history of the development of dental education. The second and most extensive section analyzes global trends for dental caries, periodontal conditions, tooth loss and…

Barriers to the medication error reporting process within the Irish National Ambulance Service, a focus group study.

Science.gov (United States)

Byrne, Eamonn; Bury, Gerard

2018-02-08

Incident reporting is vital to identifying pre-hospital medication safety issues because literature suggests that the majority of errors pre-hospital are self-identified. In 2016, the National Ambulance Service (NAS) reported 11 medication errors to the national body with responsibility for risk management and insurance cover. The Health Information and Quality Authority in 2014 stated that reporting of clinical incidents, of which medication errors are a subset, was not felt to be representative of the actual events occurring. Even though reporting systems are in place, the levels appear to be well below what might be expected. Little data is available to explain this apparent discrepancy. To identify, investigate and document the barriers to medication error reporting within the NAS. An independent moderator led four focus groups in March of 2016. A convenience sample of 18 frontline Paramedics and Advanced Paramedics from Cork City and County discussed medication errors and the medication error reporting process. The sessions were recorded and anonymised, and the data was analysed using a process of thematic analysis. Practitioners understood the value of reporting errors. Barriers to reporting included fear of consequences and ridicule, procedural ambiguity, lack of feedback and a perceived lack of both consistency and confidentiality. The perceived consequences for making an error included professional, financial, litigious and psychological. Staff appeared willing to admit errors in a psychologically safe environment. Barriers to reporting are in line with international evidence. Time constraints prevented achievement of thematic saturation. Further study is warranted.

The prevalence of statistical reporting errors in psychology (1985-2013)

NARCIS (Netherlands)

Nuijten, M.B.; Hartgerink, C.H.J.; van Assen, M.A.L.M.; Epskamp, S.; Wicherts, J.M.

2016-01-01

This study documents reporting errors in a sample of over 250,000 p-values reported in eight major psychology journals from 1985 until 2013, using the new R package “statcheck.” statcheck retrieved null-hypothesis significance testing (NHST) results from over half of the articles from this period.

Responsibility for reporting patient death due to hospital error in Japan when an error occurred at a referring institution.

Science.gov (United States)

Maeda, Shoichi; Starkey, Jay; Kamishiraki, Etsuko; Ikeda, Noriaki

2013-12-01

In Japan, physicians are required to report unexpected health care-associated patient deaths to the police. Patients needing to be transferred to another institution often have complex medical problems. If a medical error occurs, it may be either at the final or the referring institution. Some fear that liability will fall on the final institution regardless of where the error occurred or that the referring facility may oppose such reporting, leading to a failure to report to police or to recommend an autopsy. Little is known about the actual opinions of physicians and risk managers in this regard. The authors sent standardised, self-administered questionnaires to all hospitals in Japan that participate in the national general residency program. Most physicians and risk managers in Japan indicated that they would report a patient's death to the police where the patient has been transferred. Of those who indicated they would not report to the police, the majority still indicated they would recommend an autopsy

Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia.

Science.gov (United States)

Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi

2016-01-01

To explore and understand participants' perceptions and attitudes towards the reporting of medication errors (MEs). A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter's burden and benefit of reporting also were identified. Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

Event (error and near-miss) reporting and learning system for process improvement in radiation oncology.

Science.gov (United States)

Mutic, Sasa; Brame, R Scott; Oddiraju, Swetha; Parikh, Parag; Westfall, Melisa A; Hopkins, Merilee L; Medina, Angel D; Danieley, Jonathan C; Michalski, Jeff M; El Naqa, Issam M; Low, Daniel A; Wu, Bin

2010-09-01

The value of near-miss and error reporting processes in many industries is well appreciated and typically can be supported with data that have been collected over time. While it is generally accepted that such processes are important in the radiation therapy (RT) setting, studies analyzing the effects of organized reporting and process improvement systems on operation and patient safety in individual clinics remain scarce. The purpose of this work is to report on the design and long-term use of an electronic reporting system in a RT department and compare it to the paper-based reporting system it replaced. A specifically designed web-based system was designed for reporting of individual events in RT and clinically implemented in 2007. An event was defined as any occurrence that could have, or had, resulted in a deviation in the delivery of patient care. The aim of the system was to support process improvement in patient care and safety. The reporting tool was designed so individual events could be quickly and easily reported without disrupting clinical work. This was very important because the system use was voluntary. The spectrum of reported deviations extended from minor workflow issues (e.g., scheduling) to errors in treatment delivery. Reports were categorized based on functional area, type, and severity of an event. The events were processed and analyzed by a formal process improvement group that used the data and the statistics collected through the web-based tool for guidance in reengineering clinical processes. The reporting trends for the first 24 months with the electronic system were compared to the events that were reported in the same clinic with a paper-based system over a seven-year period. The reporting system and the process improvement structure resulted in increased event reporting, improved event communication, and improved identification of clinical areas which needed process and safety improvements. The reported data were also useful for the

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland.

Science.gov (United States)

Cassidy, Nicola; Duggan, Edel; Williams, David J P; Tracey, Joseph A

2011-07-01

Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland.

LENUS (Irish Health Repository)

Cassidy, Nicola

2012-02-01

INTRODUCTION: Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. AIM: The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. METHODS: A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. RESULTS: Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (>\\/= 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for

Experience from training of personnel abroad

International Nuclear Information System (INIS)

Otcenasek, P.

1983-01-01

In the first period of the development of nuclear technology specialists received mainly theoretical training in brief study courses and training sessions. These courses did not place high demands on training methods. In the subsequent period long-term, well-conceived and costly systems of training were developed placing emphasis on specialized knowledge and especially on practical training. The third stage has now been launched which is characterized by the departure from classical control rooms to data collection and processing in centralized information systems, selective recording according to situation and choice, etc. This stage is passing on to the system of the minimization of the human factor error. A significant problem of the human factor in nuclear technology is the time aspect. Schools specializing in the education and training of specialists, technical personnel and workers for the nuclear programme have been established. Following such education personnel are selected for specialized training in training centres which have been equipped with costly training equipment including simulators. With regard to the importance of the human factor in nuclear installations, control computers are being introduced to an increasing extent and individuals and groups of workers and personnel are trained in operation. (E.S.)

Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.

Science.gov (United States)

Patterson, Mark E; Pace, Heather A; Fincham, Jack E

2013-09-01

Although error-reporting systems enable hospitals to accurately track safety climate through the identification of adverse events, these systems may be underused within a work climate of poor communication. The objective of this analysis is to identify the extent to which perceived communication climate among hospital pharmacists impacts medical error reporting rates. This cross-sectional study used survey responses from more than 5000 pharmacists responding to the 2010 Hospital Survey on Patient Safety Culture (HSOPSC). Two composite scores were constructed for "communication openness" and "feedback and about error," respectively. Error reporting frequency was defined from the survey question, "In the past 12 months, how many event reports have you filled out and submitted?" Multivariable logistic regressions were used to estimate the likelihood of medical error reporting conditional upon communication openness or feedback levels, controlling for pharmacist years of experience, hospital geographic region, and ownership status. Pharmacists with higher communication openness scores compared with lower scores were 40% more likely to have filed or submitted a medical error report in the past 12 months (OR, 1.4; 95% CI, 1.1-1.7; P = 0.004). In contrast, pharmacists with higher communication feedback scores were not any more likely than those with lower scores to have filed or submitted a medical report in the past 12 months (OR, 1.0; 95% CI, 0.8-1.3; P = 0.97). Hospital work climates that encourage pharmacists to freely communicate about problems related to patient safety is conducive to medical error reporting. The presence of feedback infrastructures about error may not be sufficient to induce error-reporting behavior.

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

Science.gov (United States)

Wahr, Joyce A; Shore, Andrew D; Harris, Lindsay H; Rogers, Philippa; Panesar, Sukhmeet; Matthew, Linda; Pronovost, Peter J; Cleary, Kevin; Pham, Julius C

2014-01-01

The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

Improving patient safety in radiotherapy through error reporting and analysis

International Nuclear Information System (INIS)

Findlay, Ú.; Best, H.; Ottrey, M.

2016-01-01

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

Nuclear power plant personnel errors in decision-making as an object of probabilistic risk assessment

International Nuclear Information System (INIS)

Reer, B.

1993-09-01

The integration of human error - also called man-machine system analysis (MMSA) - is an essential part of probabilistic risk assessment (PRA). A new method is presented which allows for a systematic and comprehensive PRA inclusions of decision-based errors due to conflicts or similarities. For the error identification procedure, new question techniques are developed. These errors are shown to be identified by looking at retroactions caused by subordinate goals as components of the overall safety relevant goal. New quantification methods for estimating situation-specific probabilities are developed. The factors conflict and similarity are operationalized in a way that allows their quantification based on informations which are usually available in PRA. The quantification procedure uses extrapolations and interpolations based on a poor set of data related to decision-based errors. Moreover, for passive errors in decision-making a completely new approach is presented where errors are quantified via a delay initiating the required action rather than via error probabilities. The practicability of this dynamic approach is demonstrated by a probabilistic analysis of the actions required during the total loss of feedwater event at the Davis-Besse plant 1985. The extensions of the ''classical'' PRA method developed in this work are applied to a MMSA of the decay heat removal (DHR) of the ''HTR-500''. Errors in decision-making - as potential roots of extraneous acts - are taken into account in a comprehensive and systematic manner. Five additional errors are identified. However, the probabilistic quantification results a nonsignificant increase of the DHR failure probability. (orig.) [de

Management and Evaluation System on Human Error, Licence Requirements, and Job-aptitude in Rail and the Other Industries

Energy Technology Data Exchange (ETDEWEB)

Koo, In Soo; Suh, S. M.; Park, G. O. (and others)

2006-07-15

Rail system is a system that is very closely related to the public life. When an accident happens, the public using this system should be injured or even be killed. The accident that recently took place in Taegu subway system, because of the inappropriate human-side task performance, showed demonstratively how its results could turn out to be tragic one. Many studies have shown that the most cases of the accidents have occurred because of performing his/her tasks in inappropriate way. It is generally recognised that the rail system without human element could never be happened quite long time. So human element in rail system is going to be the major factor to the next tragic accident. This state of the art report studied the cases of the managements and evaluation systems related to human errors, license requirements, and job aptitudes in the areas of rail and the other industries for the purpose of improvement of the task performance of personnel which consists of an element and finally enhancement of rail safety. The human errors, license requirements, and evaluation system of the job aptitude on people engaged in agencies with close relation to rail do much for development and preservation their abilities. But due to various inside and outside factors, to some extent it may have limitations to timely reflect overall trends of society, technology, and a sense of value. Removal and control of the factors of human errors will have epochal roles in safety of the rail system through the case studies of this report. Analytical results on case studies of this report will be used in the project 'Development of Management Criteria on Human Error and Evaluation Criteria on Job-aptitude of Rail Safe-operation Personnel' which has been carried out as a part of 'Integrated R and D Program for Railway Safety'.

Management and Evaluation System on Human Error, Licence Requirements, and Job-aptitude in Rail and the Other Industries

International Nuclear Information System (INIS)

Koo, In Soo; Suh, S. M.; Park, G. O.

2006-07-01

Rail system is a system that is very closely related to the public life. When an accident happens, the public using this system should be injured or even be killed. The accident that recently took place in Taegu subway system, because of the inappropriate human-side task performance, showed demonstratively how its results could turn out to be tragic one. Many studies have shown that the most cases of the accidents have occurred because of performing his/her tasks in inappropriate way. It is generally recognised that the rail system without human element could never be happened quite long time. So human element in rail system is going to be the major factor to the next tragic accident. This state of the art report studied the cases of the managements and evaluation systems related to human errors, license requirements, and job aptitudes in the areas of rail and the other industries for the purpose of improvement of the task performance of personnel which consists of an element and finally enhancement of rail safety. The human errors, license requirements, and evaluation system of the job aptitude on people engaged in agencies with close relation to rail do much for development and preservation their abilities. But due to various inside and outside factors, to some extent it may have limitations to timely reflect overall trends of society, technology, and a sense of value. Removal and control of the factors of human errors will have epochal roles in safety of the rail system through the case studies of this report. Analytical results on case studies of this report will be used in the project 'Development of Management Criteria on Human Error and Evaluation Criteria on Job-aptitude of Rail Safe-operation Personnel' which has been carried out as a part of 'Integrated R and D Program for Railway Safety'

Errors in imaging patients in the emergency setting.

Science.gov (United States)

Pinto, Antonio; Reginelli, Alfonso; Pinto, Fabio; Lo Re, Giuseppe; Midiri, Federico; Muzj, Carlo; Romano, Luigia; Brunese, Luca

2016-01-01

Emergency and trauma care produces a "perfect storm" for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting.

The prevalence of statistical reporting errors in psychology (1985–2013)

NARCIS (Netherlands)

Nuijten, M.B.; Hartgerink, C.H.J.; van Assen, M.A.L.M.; Epskamp, S.; Wicherts, J.M.

2016-01-01

This study documents reporting errors in a sample of over 250,000 p-values reported in eight major psychology journals from 1985 until 2013, using the new R package “statcheck.” statcheck retrieved null-hypothesis significance testing (NHST) results from over half of the articles from this period.

Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

Science.gov (United States)

Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

2012-12-01

Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Standardizing Medication Error Event Reporting in the U.S. Department of Defense

National Research Council Canada - National Science Library

Nosek, Ronald A., Jr; McMeekin, Judy; Rake, Geoffrey W

2005-01-01

...) began an aggressive examination of medical errors and the strategies for minimizing them. A primary goal was the creation of a standardized medication event reporting system, including a central registry for the compilation of reported data...

Barriers to reporting medication errors and near misses among nurses: A systematic review.

Science.gov (United States)

Vrbnjak, Dominika; Denieffe, Suzanne; O'Gorman, Claire; Pajnkihar, Majda

2016-11-01

To explore barriers to nurses' reporting of medication errors and near misses in hospital settings. Systematic review. Medline, CINAHL, PubMed and Cochrane Library in addition to Google and Google Scholar and reference lists of relevant studies published in English between January 1981 and April 2015 were searched for relevant qualitative, quantitative or mixed methods empirical studies or unpublished PhD theses. Papers with a primary focus on barriers to reporting medication errors and near misses in nursing were included. The titles and abstracts of the search results were assessed for eligibility and relevance by one of the authors. After retrieval of the full texts, two of the authors independently made decisions concerning the final inclusion and these were validated by the third reviewer. Three authors independently assessed methodological quality of studies. Relevant data were extracted and findings were synthesised using thematic synthesis. From 4038 identified records, 38 studies were included in the synthesis. Findings suggest that organizational barriers such as culture, the reporting system and management behaviour in addition to personal and professional barriers such as fear, accountability and characteristics of nurses are barriers to reporting medication errors. To overcome reported barriers it is necessary to develop a non-blaming, non-punitive and non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and efficient reporting systems and supportive management behaviour that provides open feedback to nurses is needed. Nurses are accountable for patients' safety, so they need to be educated and skilled in error management. Lack of research into barriers to reporting of near misses' and low awareness of reporting suggests the need for further research and development of educational and management approaches to overcome these barriers. Copyright © 2016 Elsevier Ltd. All rights reserved.

Unique safety manual for experimental personnel

International Nuclear Information System (INIS)

Busick, D.D.; Warren, G.J.

1979-01-01

Within a few months of the discovery of x-rays the first radiation injuries were reported (ta71). During the past thirty years both the number and complexity of x-ray analytical units have increased markedly. The world-wide number of incidents leading to severe injury has also increased. For analytical x-ray machines the need for engineered and administrative safeguards has long been recognized. At Stanford Synchrotron Radiation Laboratory (SSRL) the personnel protection system has been carefully designed to maximize safety and minimize experimental interference. However, all possible experimental configurations cannot be anticipated and some interference is to be expected. There are means by which safeguards can be substituted as long as these substitutions do not degrade the existing degree of safety. any substitutions must be evaluated by the Radiation Safety Committee, the SSRL staff and Operational Health Physics. Some studies have indicated that between fifty and ninety percent of serious radiation accidents are directly related to human errors, i.e., ignoring administrative proccedures, by-passing engineered safeguards or by inadequate training. Lindell has estimated the annual probability of serious injury to be about 1:100 per macchine. No matter what the real probability of serious injury is the personnel protection system should reduce this risk to a value that approaches zero. It is hoped that this manual will bring into sharper focus some of the more serious results of unnecessary risk taking. We also hope that it will convey the very real necessity for safeguards which may at times appear to be arbitrary and unnecessary impediments to experimental purposes

Frequency and analysis of non-clinical errors made in radiology reports using the National Integrated Medical Imaging System voice recognition dictation software.

Science.gov (United States)

Motyer, R E; Liddy, S; Torreggiani, W C; Buckley, O

2016-11-01

Voice recognition (VR) dictation of radiology reports has become the mainstay of reporting in many institutions worldwide. Despite benefit, such software is not without limitations, and transcription errors have been widely reported. Evaluate the frequency and nature of non-clinical transcription error using VR dictation software. Retrospective audit of 378 finalised radiology reports. Errors were counted and categorised by significance, error type and sub-type. Data regarding imaging modality, report length and dictation time was collected. 67 (17.72 %) reports contained ≥1 errors, with 7 (1.85 %) containing 'significant' and 9 (2.38 %) containing 'very significant' errors. A total of 90 errors were identified from the 378 reports analysed, with 74 (82.22 %) classified as 'insignificant', 7 (7.78 %) as 'significant', 9 (10 %) as 'very significant'. 68 (75.56 %) errors were 'spelling and grammar', 20 (22.22 %) 'missense' and 2 (2.22 %) 'nonsense'. 'Punctuation' error was most common sub-type, accounting for 27 errors (30 %). Complex imaging modalities had higher error rates per report and sentence. Computed tomography contained 0.040 errors per sentence compared to plain film with 0.030. Longer reports had a higher error rate, with reports >25 sentences containing an average of 1.23 errors per report compared to 0-5 sentences containing 0.09. These findings highlight the limitations of VR dictation software. While most error was deemed insignificant, there were occurrences of error with potential to alter report interpretation and patient management. Longer reports and reports on more complex imaging had higher error rates and this should be taken into account by the reporting radiologist.

A comparative study of voluntarily reported medication errors among ...

African Journals Online (AJOL)

errors among adult patients in intensive care (IC) and non-. IC settings in Riyadh, ... safety “To err is human: Building a safer health care system” .... regression analysis was used to identify factors affecting the .... that work in non-ICU areas are less likely to report such ... ve.org/read), which permit unrestricted use, distribution ...

Perceptual learning eases crowding by reducing recognition errors but not position errors.

Science.gov (United States)

Xiong, Ying-Zi; Yu, Cong; Zhang, Jun-Yun

2015-08-01

When an observer reports a letter flanked by additional letters in the visual periphery, the response errors (the crowding effect) may result from failure to recognize the target letter (recognition errors), from mislocating a correctly recognized target letter at a flanker location (target misplacement errors), or from reporting a flanker as the target letter (flanker substitution errors). Crowding can be reduced through perceptual learning. However, it is not known how perceptual learning operates to reduce crowding. In this study we trained observers with a partial-report task (Experiment 1), in which they reported the central target letter of a three-letter string presented in the visual periphery, or a whole-report task (Experiment 2), in which they reported all three letters in order. We then assessed the impact of training on recognition of both unflanked and flanked targets, with particular attention to how perceptual learning affected the types of errors. Our results show that training improved target recognition but not single-letter recognition, indicating that training indeed affected crowding. However, training did not reduce target misplacement errors or flanker substitution errors. This dissociation between target recognition and flanker substitution errors supports the view that flanker substitution may be more likely a by-product (due to response bias), rather than a cause, of crowding. Moreover, the dissociation is not consistent with hypothesized mechanisms of crowding that would predict reduced positional errors.

Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions

Science.gov (United States)

2018-03-20

within report documents. The information presented was obtained through a request to use the U.S. Army Combat Readiness Center’s Risk Management ...controlled flight into terrain (13 accidents), fueling errors by improper techniques (7 accidents), and a variety of maintenance errors (10 accidents). The...and 9 of the 10 maintenance accidents. Table 4. Frequencies Based on Source of Human Error Human error source Presence Poor Planning

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.

Science.gov (United States)

Westbrook, Johanna I; Li, Ling; Lehnbom, Elin C; Baysari, Melissa T; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O

2015-02-01

To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. Two major academic teaching hospitals in Sydney, Australia. Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. © The Author 2015. Published by Oxford University Press in association

Authorization of nuclear power plant control room personnel: Methods and practices with emphasis on the use of simulators

International Nuclear Information System (INIS)

2006-07-01

In 2002 the IAEA published a revision to Safety Guide NS-G-2.8, Recruitment, Qualification and Training of Personnel for Nuclear Power Plants. This Safety Guide provides recommendations on the authorization of designated personnel who have a direct impact on nuclear safety. The IAEA Technical Working Group on Training and Qualification of Nuclear Power Plant Personnel recommended that an additional report be prepared that provided information on the practices in Member States on the use of simulators in the authorization of control room staff. This publication has been prepared in response to that recommendation. In gathering information for the report, Member States were asked to: respond to a survey on the use of simulators and the involvement of regulatory body in operator authorization; and to complete a questionnaire on their practices in authorizing control room staff. Safety analysis and operating experience consistently indicate that human error is a major contributor to nuclear power plant (NPP) accident risk. With the recent world wide emphasis and implementation of full scope simulators for nuclear power plant personnel training, operators spend a large portion of their training time on simulators. As described in the foreword to IAEA-TECDOC-1411, Use of Control Room Simulators for Training of Nuclear Power Plant Personnel, simulators provide operators an opportunity to learn and practice the abilities that are required in accident and infrequently used plant evolutions. Because of their fidelity, full scope simulators are now used by most Member States in the authorization examinations of control room personnel. This situation is becoming more common as more plants acquire modern full scope plant referenced simulators. This publication provides information and examples based upon experience in a variety of Member States. The body of the report provides general information that represents the practices of the Member States that contributed to the

A Human Error Analysis Procedure for Identifying Potential Error Modes and Influencing Factors for Test and Maintenance Activities

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2010-01-01

Periodic or non-periodic test and maintenance (T and M) activities in large, complex systems such as nuclear power plants (NPPs) are essential for sustaining stable and safe operation of the systems. On the other hand, it also has been raised that human erroneous actions that might occur during T and M activities has the possibility of incurring unplanned reactor trips (RTs) or power derate, making safety-related systems unavailable, or making the reliability of components degraded. Contribution of human errors during normal and abnormal activities of NPPs to the unplanned RTs is known to be about 20% of the total events. This paper introduces a procedure for predictively analyzing human error potentials when maintenance personnel perform T and M tasks based on a work procedure or their work plan. This procedure helps plant maintenance team prepare for plausible human errors. The procedure to be introduced is focusing on the recurrent error forms (or modes) in execution-based errors such as wrong object, omission, too little, and wrong action

Error Detection and Error Classification: Failure Awareness in Data Transfer Scheduling

Energy Technology Data Exchange (ETDEWEB)

Louisiana State University; Balman, Mehmet; Kosar, Tevfik

2010-10-27

Data transfer in distributed environment is prone to frequent failures resulting from back-end system level problems, like connectivity failure which is technically untraceable by users. Error messages are not logged efficiently, and sometimes are not relevant/useful from users point-of-view. Our study explores the possibility of an efficient error detection and reporting system for such environments. Prior knowledge about the environment and awareness of the actual reason behind a failure would enable higher level planners to make better and accurate decisions. It is necessary to have well defined error detection and error reporting methods to increase the usability and serviceability of existing data transfer protocols and data management systems. We investigate the applicability of early error detection and error classification techniques and propose an error reporting framework and a failure-aware data transfer life cycle to improve arrangement of data transfer operations and to enhance decision making of data transfer schedulers.

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

International Nuclear Information System (INIS)

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

2001-01-01

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

Simulators for training nuclear power plant personnel

International Nuclear Information System (INIS)

1993-01-01

Simulator training and retraining of operations personnel is essential for their acquiring the necessary knowledge, skills and qualification for operating a nuclear power plant, and for effective feedback of experience including human based operating errors. Simulator training is the most effective way by far of training operations personnel in co-operation and communication in a team, which also involves instilling attitudes and approaches for achieving excellence and individual responsibility and alertness. This technical document provides guidance to Member States on the procurement, setting up and utilization of a simulator training centre; it will also be useful for organizations with previous experience in the use of simulators for training. The document is the result of a series of advisory and consultants meetings held in the framework of the International Working Group on Nuclear Power Plant Control and Instrumentation in 1989-1992. 17 refs, 2 tabs

Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event.

Science.gov (United States)

Meurier, C E

2000-07-01

Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.

Recruitment into diabetes prevention programs: what is the impact of errors in self-reported measures of obesity?

Science.gov (United States)

Hernan, Andrea; Philpot, Benjamin; Janus, Edward D; Dunbar, James A

2012-07-08

Error in self-reported measures of obesity has been frequently described, but the effect of self-reported error on recruitment into diabetes prevention programs is not well established. The aim of this study was to examine the effect of using self-reported obesity data from the Finnish diabetes risk score (FINDRISC) on recruitment into the Greater Green Triangle Diabetes Prevention Project (GGT DPP). The GGT DPP was a structured group-based lifestyle modification program delivered in primary health care settings in South-Eastern Australia. Between 2004-05, 850 FINDRISC forms were collected during recruitment for the GGT DPP. Eligible individuals, at moderate to high risk of developing diabetes, were invited to undertake baseline tests, including anthropometric measurements performed by specially trained nurses. In addition to errors in calculating total risk scores, accuracy of self-reported data (height, weight, waist circumference (WC) and Body Mass Index (BMI)) from FINDRISCs was compared with baseline data, with impact on participation eligibility presented. Overall, calculation errors impacted on eligibility in 18 cases (2.1%). Of n = 279 GGT DPP participants with measured data, errors (total score calculation, BMI or WC) in self-report were found in n = 90 (32.3%). These errors were equally likely to result in under- or over-reported risk. Under-reporting was more common in those reporting lower risk scores (Spearman-rho = -0.226, p-value recruit participants at moderate to high risk of diabetes, accurately categorising levels of overweight and obesity using self-report data. The results could be generalisable to other diabetes prevention programs using screening tools which include self-reported levels of obesity.

Study of the adequacy of personnel for the US nuclear program

International Nuclear Information System (INIS)

1981-11-01

The report will emphasize fission topics relative to fusion because of the relative number of personnel involved. However, the commonality of types of personnel and their required educational background are such that the health of the fission educational infrastructure will affect the future supply of fusion technologists. Alternatively, the attractive aspects of some closely related fusion research in universities can help attract the high quality personnel needed in the fission field. The report's recommendations are therefore based on the needs of both programs. A separate study of the detailed requirements for fusion scientific and engineering personnel has been prepared by the Office of Fusion Energy. In this report, the present status of nuclear power, historic personnel requirements, future requirements, and constraints on future supply are analyzed. The intent of this report is to provide a context for conclusions and recommendation of Government actions leading to an adequate supply of nuclear manpower both for the industrial and Government components of the nuclear enterprise

Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières.

Directory of Open Access Journals (Sweden)

Leslie Shanks

Full Text Available To analyse the results from the first 3 years of implementation of a medical error reporting system in Médecins Sans Frontières-Operational Centre Amsterdam (MSF programs.A medical error reporting policy was developed with input from frontline workers and introduced to the organisation in June 2010. The definition of medical error used was "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." All confirmed error reports were entered into a database without the use of personal identifiers.179 errors were reported from 38 projects in 18 countries over the period of June 2010 to May 2013. The rate of reporting was 31, 42, and 106 incidents/year for reporting year 1, 2 and 3 respectively. The majority of errors were categorized as dispensing errors (62 cases or 34.6%, errors or delays in diagnosis (24 cases or 13.4% and inappropriate treatment (19 cases or 10.6%. The impact of the error was categorized as no harm (58, 32.4%, harm (70, 39.1%, death (42, 23.5% and unknown in 9 (5.0% reports. Disclosure to the patient took place in 34 cases (19.0%, did not take place in 46 (25.7%, was not applicable for 5 (2.8% cases and not reported for 94 (52.5%. Remedial actions introduced at headquarters level included guideline revisions and changes to medical supply procedures. At field level improvements included increased training and supervision, adjustments in staffing levels, and adaptations to the organization of the pharmacy.It was feasible to implement a voluntary reporting system for medical errors despite the complex contexts in which MSF intervenes. The reporting policy led to system changes that improved patient safety and accountability to patients. Challenges remain in achieving widespread acceptance of the policy as evidenced by the low reporting and disclosure rates.

Medication administration error reporting and associated factors among nurses working at the University of Gondar referral hospital, Northwest Ethiopia, 2015.

Science.gov (United States)

Bifftu, Berhanu Boru; Dachew, Berihun Assefa; Tiruneh, Bewket Tadesse; Beshah, Debrework Tesgera

2016-01-01

Medication administration is the final step/phase of medication process in which its error directly affects the patient health. Due to the central role of nurses in medication administration, whether they are the source of an error, a contributor, or an observer they have the professional, legal and ethical responsibility to recognize and report. The aim of this study was to assess the prevalence of medication administration error reporting and associated factors among nurses working at The University of Gondar Referral Hospital, Northwest Ethiopia. Institution based quantitative cross - sectional study was conducted among 282 Nurses. Data were collected using semi-structured, self-administered questionnaire of the Medication Administration Errors Reporting (MAERs). Binary logistic regression with 95 % confidence interval was used to identify factors associated with medication administration errors reporting. The estimated medication administration error reporting was found to be 29.1 %. The perceived rates of medication administration errors reporting for non-intravenous related medications were ranged from 16.8 to 28.6 % and for intravenous-related from 20.6 to 33.4 %. Education status (AOR =1.38, 95 % CI: 4.009, 11.128), disagreement over time - error definition (AOR = 0.44, 95 % CI: 0.468, 0.990), administrative reason (AOR = 0.35, 95 % CI: 0.168, 0.710) and fear (AOR = 0.39, 95 % CI: 0.257, 0.838) were factors statistically significant for the refusal of reporting medication administration errors at p-value definition, administrative reason and fear were factors statistically significant for the refusal of errors reporting at p-value definition of reportable errors and strengthen the educational status of nurses by the health care organization.

Error Analysis in Mathematics. Technical Report #1012

Science.gov (United States)

Lai, Cheng-Fei

2012-01-01

Error analysis is a method commonly used to identify the cause of student errors when they make consistent mistakes. It is a process of reviewing a student's work and then looking for patterns of misunderstanding. Errors in mathematics can be factual, procedural, or conceptual, and may occur for a number of reasons. Reasons why students make…

Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention.

Science.gov (United States)

Goedecke, Thomas; Ord, Kathryn; Newbould, Victoria; Brosch, Sabine; Arlett, Peter

2016-06-01

A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article

Task Force Report, Safety of Personnel in LHC underground areas following the accident of 19th September 2008

CERN Document Server

Delille, B; Inigo-Golfin, J; Lindell, G; Roy, G; Tavian, L; Thomas, E; Trant, R; Völlinger, C

2009-01-01

In January 2009, the Task Force on Safety of Personnel in the LHC underground areas following the accident in sector 3-4 of 19th September 2008 (Safety Task Force) received from the CERN Director General the mandate to investigate the impact of the accident of 19th September 2008 on the safety of personnel working in the LHC underground areas. This mandate includes the elaboration of preventive and/or corrective measures, if deemed necessary. This report gives the conclusions and recommendations of the Safety Task Force which have been reviewed by an external advisory committee of safety experts.

Perofrmance testing of personnel dosimetry services. Final report of a two-year pilot study, October 1977-September 1979

International Nuclear Information System (INIS)

Plato, P.; Hudson, G.

1980-01-01

A two-year pilot study was conducted of the Health Physics Society Standards Committee (HPSSC) Standard titled, Criteria for Testing Personnel Dosimetry Performance. The objectives of the pilot study were: to give processors an opportunity to correct any problems that are uncovered; to develop operational and administrative prodedures to be used later by a permanent testing laboratory; and to determine whether the proposed HPSSC Standard provides an adequate and practical test of dosimetry performance. Fifty-nine dosimetry processors volunteered to submit dosimeters for test irradiations according to the requirements of the HPSSC Standard. The feasibility of using the HPSSC Standard for a future mandatory testing program for personnel dosimetry processors is discussed. This report shows the results of the pilot study and contains recommendations for revisions in the Standard that will make a mandatory testing program useful to regulatory agencies, dosimetry processors, and radiation workers that use personnel dosimeters

Measurement error and timing of predictor values for multivariable risk prediction models are poorly reported.

Science.gov (United States)

Whittle, Rebecca; Peat, George; Belcher, John; Collins, Gary S; Riley, Richard D

2018-05-18

Measurement error in predictor variables may threaten the validity of clinical prediction models. We sought to evaluate the possible extent of the problem. A secondary objective was to examine whether predictors are measured at the intended moment of model use. A systematic search of Medline was used to identify a sample of articles reporting the development of a clinical prediction model published in 2015. After screening according to a predefined inclusion criteria, information on predictors, strategies to control for measurement error and intended moment of model use were extracted. Susceptibility to measurement error for each predictor was classified into low and high risk. Thirty-three studies were reviewed, including 151 different predictors in the final prediction models. Fifty-one (33.7%) predictors were categorised as high risk of error, however this was not accounted for in the model development. Only 8 (24.2%) studies explicitly stated the intended moment of model use and when the predictors were measured. Reporting of measurement error and intended moment of model use is poor in prediction model studies. There is a need to identify circumstances where ignoring measurement error in prediction models is consequential and whether accounting for the error will improve the predictions. Copyright © 2018. Published by Elsevier Inc.

Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana, Cuba.

Science.gov (United States)

Swanson, Randel L; Hampton, Stephen; Green-McKenzie, Judith; Diaz-Arrastia, Ramon; Grady, M Sean; Verma, Ragini; Biester, Rosette; Duda, Diana; Wolf, Ronald L; Smith, Douglas H

2018-03-20

From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n�

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Method Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions......Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13...

New classification of operators' human errors at overseas nuclear power plants and preparation of easy-to-use case sheets

International Nuclear Information System (INIS)

Takagawa, Kenichi

2004-01-01

At nuclear power plants, plant operators examine other human error cases, including those that occurred at other plants, so that they can learn from such experiences and avoid making similar errors again. Although there is little data available on errors made at domestic plants, nuclear operators in foreign countries are reporting even minor irregularities and signs of faults, and a large amount of data on human errors at overseas plants could be collected and examined. However, these overseas data have not been used effectively because most of them are poorly organized or not properly classified and are often hard to understand. Accordingly, we carried out a study on the cases of human errors at overseas power plants in order to help plant personnel clearly understand overseas experiences and avoid repeating similar errors, The study produced the following results, which were put to use at nuclear power plants and other facilities. (1) ''One-Point-Advice'' refers to a practice where a leader gives pieces of advice to his team of operators in order to prevent human errors before starting work. Based on this practice and those used in the aviation industry, we have developed a new method of classifying human errors that consists of four basic actions and three applied actions. (2) We used this new classification method to classify human errors made by operators at overseas nuclear power plants. The results show that the most frequent errors caused not by operators themselves but due to insufficient team monitoring, for which superiors and/or their colleagues were responsible. We therefore analyzed and classified possible factors contributing to insufficient team monitoring, and demonstrated that the frequent errors have also occurred at domestic power plants. (3) Using the new classification formula, we prepared a human error case sheets that is easy for plant personnel to understand. The sheets are designed to make data more understandable and easier to remember

Using Personnel and Financial Data for Reporting Purposes: What Are the Challenges to Using Such Data Accurately?

Science.gov (United States)

Valcik, Nicolas A.; Stigdon, Andrea D.

2008-01-01

Although institutional researchers devote a great deal of time mining and using student data to fulfill mandatory federal and state reports and analyze institutional effectiveness, financial and personnel information is also necessary for such endeavors. In this article, the authors discuss the challenges that arise from extracting data from…

WAYS TO INCREASE ACCURACY AND RELIABILITY OF INDIVIDUAL DOSES ASSESSMENTS IN PERSONNEL WITHIN THERMOLUMINESCENCE TECHNIQUE

Directory of Open Access Journals (Sweden)

G. N. Kaydanovskiy

2012-01-01

Full Text Available The paper analyses the main sources of measurement errors of individual doses in personnel performed within the thermoluminescence technique and gives recommendations to minimize these errors. The reasons that reduce reliability of effective dose assessments derived from measured values of personal dose equivalent are imperfections of guidance documents. Changes to the Guidelines «Organization and implementation of individual dosimetric control. Staff of health institutions» are justified.

Assuring the competence of nuclear power plant contractor personnel

International Nuclear Information System (INIS)

2001-07-01

This report was prepared in response to a recommendation by the IAEA International Working Group on Training and Qualification of NPP Personnel (JWG-T and Q) and supported by a number of IAEA meetings on NPP personnel training. IAEA publications on NPP training are the only international documents available to all Member States with nuclear programmes. This report complements the following IAEA publications on NPP personnel training: Technical Reports Series No. 380, Nuclear Power Plant Personnel Training and its Evaluation, A Guidebook; IAEA-TECDOC-1057, Experience in the Use of Systematic Approach to Training (SAT) for Nuclear Power Plant Personnel and IAEA-TECDOC-1063, IAEA World Survey on Nuclear Power Plant Personnel Training. This TECDOC also supplements the IAEA Safety Guide 50-SG-O1 (Rev. 1), Staffing of Nuclear Power Plants and the Recruitment Training and Authorization of Operating Personnel and Safety Standards Series No. NS-R-2, Safety of Nuclear Power Plants. Operation. Within the context of this report NPP contractors are defined as any personnel working for a nuclear power plant who are not directly employed by the nuclear power plant. Competence is the ability to perform to identified standards; it comprises skills, knowledge and attitudes and may be developed through education, experience and training. Qualification is a formal statement of achievement, resulting from an auditable assessment; if competence is assessed, the qualification becomes a formal statement of competence and may be shown on a certificate, diploma, etc. It is recognized that personnel are used to perform tasks that are of a specialised or temporary nature where it is not feasible to hire or maintain a full-time NPP employee. Accordingly, contractors may be used in a variety of situations to support NPPs. Typical situations include: supplies and services being delivered by the contractors that are subject to different quality standards based on a graded approach to assuring

Assuring the competence of nuclear power plant contractor personnel

Energy Technology Data Exchange (ETDEWEB)

NONE

2001-07-01

This report was prepared in response to a recommendation by the IAEA International Working Group on Training and Qualification of NPP Personnel (JWG-T and Q) and supported by a number of IAEA meetings on NPP personnel training. IAEA publications on NPP training are the only international documents available to all Member States with nuclear programmes. This report complements the following IAEA publications on NPP personnel training: Technical Reports Series No. 380, Nuclear Power Plant Personnel Training and its Evaluation, A Guidebook; IAEA-TECDOC-1057, Experience in the Use of Systematic Approach to Training (SAT) for Nuclear Power Plant Personnel and IAEA-TECDOC-1063, IAEA World Survey on Nuclear Power Plant Personnel Training. This TECDOC also supplements the IAEA Safety Guide 50-SG-O1 (Rev. 1), Staffing of Nuclear Power Plants and the Recruitment Training and Authorization of Operating Personnel and Safety Standards Series No. NS-R-2, Safety of Nuclear Power Plants. Operation. Within the context of this report NPP contractors are defined as any personnel working for a nuclear power plant who are not directly employed by the nuclear power plant. Competence is the ability to perform to identified standards; it comprises skills, knowledge and attitudes and may be developed through education, experience and training. Qualification is a formal statement of achievement, resulting from an auditable assessment; if competence is assessed, the qualification becomes a formal statement of competence and may be shown on a certificate, diploma, etc. It is recognized that personnel are used to perform tasks that are of a specialised or temporary nature where it is not feasible to hire or maintain a full-time NPP employee. Accordingly, contractors may be used in a variety of situations to support NPPs. Typical situations include: supplies and services being delivered by the contractors that are subject to different quality standards based on a graded approach to assuring

A method for analysing incidents due to human errors on nuclear installations

International Nuclear Information System (INIS)

Griffon, M.

1980-01-01

This paper deals with the development of a methodology adapted to a detailed analysis of incidents considered to be due to human errors. An identification of human errors and a search for their eventual multiple causes is then needed. They are categorized in eight classes: education and training of personnel, installation design, work organization, time and work duration, physical environment, social environment, history of the plant and performance of the operator. The method is illustrated by the analysis of a handling incident generated by multiple human errors. (author)

Error forecasting schemes of error correction at receiver

International Nuclear Information System (INIS)

Bhunia, C.T.

2007-08-01

To combat error in computer communication networks, ARQ (Automatic Repeat Request) techniques are used. Recently Chakraborty has proposed a simple technique called the packet combining scheme in which error is corrected at the receiver from the erroneous copies. Packet Combining (PC) scheme fails: (i) when bit error locations in erroneous copies are the same and (ii) when multiple bit errors occur. Both these have been addressed recently by two schemes known as Packet Reversed Packet Combining (PRPC) Scheme, and Modified Packet Combining (MPC) Scheme respectively. In the letter, two error forecasting correction schemes are reported, which in combination with PRPC offer higher throughput. (author)

Personnel monitoring

International Nuclear Information System (INIS)

1965-01-01

This film stresses the need for personnel monitoring in work areas where there is a hazard of exposure to radiation. It illustrates the use of personnel monitoring devices (specially the film dosimeter), the assessment of exposure to radiation and the detailed recording of the results on personnel filing cards

Personnel monitoring

Energy Technology Data Exchange (ETDEWEB)

NONE

1966-12-31

This film stresses the need for personnel monitoring in work areas where there is a hazard of exposure to radiation. It illustrates the use of personnel monitoring devices (specially the film dosimeter), the assessment of exposure to radiation and the detailed recording of the results on personnel filing cards

Quantification of the reliability of personnel actions from the evaluation of actual German operational experience. Final report; Quantifizierung der Zuverlaessigkeit von Personalhandlungen durch Auswertung der aktuellen deutschen Betriebserfahrung. Abschlussbericht

Energy Technology Data Exchange (ETDEWEB)

Preischl, W.; Fassmann, W.

2013-07-15

characterizing human reliability from data source ''reportable events'', - Methods to select samples characterizing human reliability from data source ''safety relevant, undoubtedly error free performed personnel actions'', - Mathematical proven methodology to derive probabilistic human performance data based on samples taken from OE, - 85 new probabilistic human performance data based on operational experience in German nuclear power plants, - Approach based on accepted behavioural knowledge to structure the obtained results and to link them to the new ''second generation'' human reliability assessment methodologies. The obtained data are forming the first data base on human reliability completely derived from operational experience of German nuclear power plants. Many subject matter experts from the plants supported the research project and contributed considerably to the research results.

5 CFR 1605.22 - Claims for correction of Board or TSP record keeper errors; time limitations.

Science.gov (United States)

2010-01-01

... record keeper errors; time limitations. 1605.22 Section 1605.22 Administrative Personnel FEDERAL... § 1605.22 Claims for correction of Board or TSP record keeper errors; time limitations. (a) Filing claims... after that time, the Board or TSP record keeper may use its sound discretion in deciding whether to...

Residents' Ratings of Their Clinical Supervision and Their Self-Reported Medical Errors: Analysis of Data From 2009.

Science.gov (United States)

Baldwin, DeWitt C; Daugherty, Steven R; Ryan, Patrick M; Yaghmour, Nicholas A; Philibert, Ingrid

2018-04-01

Medical errors and patient safety are major concerns for the medical and medical education communities. Improving clinical supervision for residents is important in avoiding errors, yet little is known about how residents perceive the adequacy of their supervision and how this relates to medical errors and other education outcomes, such as learning and satisfaction. We analyzed data from a 2009 survey of residents in 4 large specialties regarding the adequacy and quality of supervision they receive as well as associations with self-reported data on medical errors and residents' perceptions of their learning environment. Residents' reports of working without adequate supervision were lower than data from a 1999 survey for all 4 specialties, and residents were least likely to rate "lack of supervision" as a problem. While few residents reported that they received inadequate supervision, problems with supervision were negatively correlated with sufficient time for clinical activities, overall ratings of the residency experience, and attending physicians as a source of learning. Problems with supervision were positively correlated with resident reports that they had made a significant medical error, had been belittled or humiliated, or had observed others falsifying medical records. Although working without supervision was not a pervasive problem in 2009, when it happened, it appeared to have negative consequences. The association between inadequate supervision and medical errors is of particular concern.

Guidelines for the calibration of personnel dosimeters

International Nuclear Information System (INIS)

Roberson, P.L.; Holbrook, K.L.

1984-01-01

This guide describes minimum acceptable performance levels for personnel dosimetry systems used at Department of Energy (DOE) facilities. The goal is to improve both the quality of radiological calibrations and the methods of comparing reported occupational doses between DOE facilities. Reference calibration techniques are defined. A standard for evaluation of personnel dosimetry systems and recommended design parameters for personnel dosimeters are also included. Approximate intervals for the radiation energies for which these guidelines are appropriate are 15 keV to 2 MeV for photons; above 0.3 MeV for beta particles; and 1 keV to 2 MeV for neutrons. An analysis of ANSI N13.11 was completed using performance evaluations of selected personnel dosimetry systems in use at DOE facilities. The results of this analysis are incorporated in the guidelines

Personnel dosimetry: specialized industrial services. Jan 1997-Aug 2001

International Nuclear Information System (INIS)

Guillen, J.A.

2001-09-01

The purpose of this report is to evaluate data from personnel dosimetry of the Servicios Industriales Especializados, that is a licensee with gamma sources for non destructive testing. Data of the period Jan-97 to Aug-01 are evaluated in terms of collective doses. This report was made according to the national regulations that stablish to control that annual limits and reference levels in personnel dosimetry must be controlled

75 FR 13287 - Proposed Collection; Comment Request for an Unmodified SF 278 Executive Branch Personnel Public...

Science.gov (United States)

2010-03-19

.... SUPPLEMENTARY INFORMATION: Title: Executive Branch Personnel Public Financial Disclosure Report. Form Number: SF... Executive Branch Personnel Public Financial Disclosure Report AGENCY: Office of Government Ethics (OGE... 278 Executive Branch Personnel Public Financial Disclosure Report to the Office of Management and...

Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers, and Institutions.

Science.gov (United States)

Bell, Sigall K; White, Andrew A; Yi, Jean C; Yi-Frazier, Joyce P; Gallagher, Thomas H

2017-12-01

Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about transparent communication with patients, peers, and the institution after error were related. Physician attitudes about disclosing errors to patients, peers, and institutions were correlated (all P's transparent communication with patients and peers/institution included female sex, US (vs Canadian) doctors, academic (vs private) practice, the belief that disclosure decreased likelihood of litigation, and the belief that system changes occur after error reporting. In addition, younger physicians, surgeons, and those with previous experience disclosing a serious error were more likely to agree with disclosure to patients. In comparison, doctors who believed that disclosure would decrease patient trust were less likely to agree with error disclosure to patients. Previous disclosure education was associated with attitudes supporting greater transparency with peers/institution. Physician attitudes about discussing errors with patients, colleagues, and institutions are related. Several predictors of transparency affect all 3 practices and are potentially modifiable by educational and institutional strategies.

New Employee Orientation, Division of Personnel and Labor Relations,

Science.gov (United States)

understanding work rules and procedures, provide you with the resources you need, as well as guide you through Employee Training Exit Survey HR Forms New Employee Orientation For Admin Staff Classification Form Packets Personnel Memoranda Personnel Rules Policies and Procedures Recruitment Services Reports Sections Director's

45 CFR 98.100 - Error Rate Report.

Science.gov (United States)

2010-10-01

... Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND... the total dollar amount of payments made in the sample); the average amount of improper payment; and... not received. (e) Costs of Preparing the Error Rate Report—Provided the error rate calculations and...

Personnel Selection Method Based on Personnel-Job Matching

OpenAIRE

Li Wang; Xilin Hou; Lili Zhang

2013-01-01

The existing personnel selection decisions in practice are based on the evaluation of job seeker's human capital, and it may be difficult to make personnel-job matching and make each party satisfy. Therefore, this paper puts forward a new personnel selection method by consideration of bilateral matching. Starting from the employment thoughts of ¡°satisfy¡±, the satisfaction evaluation indicator system of each party are constructed. The multi-objective optimization model is given according to ...

Errors in abdominal computed tomography

International Nuclear Information System (INIS)

Stephens, S.; Marting, I.; Dixon, A.K.

1989-01-01

Sixty-nine patients are presented in whom a substantial error was made on the initial abdominal computed tomography report. Certain features of these errors have been analysed. In 30 (43.5%) a lesion was simply not recognised (error of observation); in 39 (56.5%) the wrong conclusions were drawn about the nature of normal or abnormal structures (error of interpretation). The 39 errors of interpretation were more complex; in 7 patients an abnormal structure was noted but interpreted as normal, whereas in four a normal structure was thought to represent a lesion. Other interpretive errors included those where the wrong cause for a lesion had been ascribed (24 patients), and those where the abnormality was substantially under-reported (4 patients). Various features of these errors are presented and discussed. Errors were made just as often in relation to small and large lesions. Consultants made as many errors as senior registrar radiologists. It is like that dual reporting is the best method of avoiding such errors and, indeed, this is widely practised in our unit. (Author). 9 refs.; 5 figs.; 1 tab

Errors in self-reports of health services use: impact on alzheimer disease clinical trial designs.

Science.gov (United States)

Callahan, Christopher M; Tu, Wanzhu; Stump, Timothy E; Clark, Daniel O; Unroe, Kathleen T; Hendrie, Hugh C

2015-01-01

Most Alzheimer disease clinical trials that compare the use of health services rely on reports of caregivers. The goal of this study was to assess the accuracy of self-reports among older adults with Alzheimer disease and their caregiver proxy respondents. This issue is particularly relevant to Alzheimer disease clinical trials because inaccuracy can lead both to loss of power and increased bias in study outcomes. We compared respondent accuracy in reporting any use and in reporting the frequency of use with actual utilization data as documented in a comprehensive database. We next simulated the impact of underreporting and overreporting on sample size estimates and treatment effect bias for clinical trials comparing utilization between experimental groups. Respondents self-reports have a poor level of accuracy with κ-values often below 0.5. Respondents tend to underreport use even for rare events such as hospitalizations and nursing home stays. In analyses simulating underreporting and overreporting of varying magnitude, we found that errors in self-reports can increase the required sample size by 15% to 30%. In addition, bias in the reported treatment effect ranged from 3% to 18% due to both underreporting and overreporting errors. Use of self-report data in clinical trials of Alzheimer disease treatments may inflate sample size needs. Even when adequate power is achieved by increasing sample size, reporting errors can result in a biased estimate of the true effect size of the intervention.

Optimising the education of responsible shift personnel in nuclear power plants. Volume 2 for Chapter 4: General areas of staff education

International Nuclear Information System (INIS)

1985-01-01

Themes are discussed which have not in fact become learning objectives, but which nevertheless influence the education of shift personnel. This volume contains articles on the following: the influence factors of human error; the demands on a simulator for the education of shift personnel; technical aids for supporting stuff and principles of leadership and motivation. (DG) [de

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.

Science.gov (United States)

Hutchinson, Alison M; Sales, Anne E; Brotto, Vanessa; Bucknall, Tracey K

2015-05-19

Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change

Hand dermatitis and symptoms from the fingers among Swedish dental personnel.

Science.gov (United States)

Lönnroth, E C; Shahnavaz, H

1998-01-01

Hand dermatitis among dental personnel has been an issue in recent years. Dental personnel manually handle polymer materials which are known to irritate skin, and also cause allergy. In addition, dental personnel wash their hands frequently, and use latex gloves, and are therefore at risk to develop hand dermatitis. To survey the occurrence of hand dermatitis among dental personnel, questionnaires were sent to all dental teams (dentist + chair assistant) working in the two northern Swedish counties. Referents were; researchers, teachers, and secretaries from a university and high schools, from the same geographical area. The response rate was 76% for dental teams, and 66% for referents. The results show that male dentists reported a significantly higher prevalence of hand dermatitis than male reference. In contrast to chair assistants and referents, dentists (both male and female) reported a higher extent of hand dermatitis on the left than on the right hand. There was an association between hand dermatitis among dental personnel and; age, eczema in childhood, and hay fever but, not with; sex, asthma, frequent washing of the hands, and glove use. Whitening of the fingers increased with increasing age among dental personnel. Pricking was also associated with frequent glove use. Pricking of the fingers was associated with sex, and 3.5 times more common among female dental personnel than male dentists. Numbness of the fingers, and finger pain was reported by more dentists than chair assistants and referents.

A Review of Mercury Exposure and Health of Dental Personnel

Directory of Open Access Journals (Sweden)

Natasha Nagpal

2017-03-01

Full Text Available Considerable effort has been made to address the issue of occupational health and environmental exposure to mercury. This review reports on the current literature of mercury exposure and health impacts on dental personnel. Citations were searched using four comprehensive electronic databases for articles published between 2002 and 2015. All original articles that evaluated an association between the use of dental amalgam and occupational mercury exposure in dental personnel were included. Fifteen publications from nine different countries met the selection criteria. The design and quality of the studies showed significant variation, particularly in the choice of biomarkers as an indicator of mercury exposure. In several countries, dental personnel had higher mercury levels in biological fluids and tissues than in control groups; some work practices increased mercury exposure but the exposure levels remained below recommended guidelines. Dental personnel reported more health conditions, often involving the central nervous system, than the control groups. Clinical symptoms reported by dental professionals may be associated with low-level, long-term exposure to occupational mercury, but may also be due to the effects of aging, occupational overuse, and stress. It is important that dental personnel, researchers, and educators continue to encourage and monitor good work practices by dental professionals.

Medication errors in anaesthetic practice: A report of two cases and ...

African Journals Online (AJOL)

Background: Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications. Objective: To highlight the significance of medication errors in our practice and ...

Preventing Errors in Laterality

OpenAIRE

Landau, Elliot; Hirschorn, David; Koutras, Iakovos; Malek, Alexander; Demissie, Seleshie

2014-01-01

An error in laterality is the reporting of a finding that is present on the right side as on the left or vice versa. While different medical and surgical specialties have implemented protocols to help prevent such errors, very few studies have been published that describe these errors in radiology reports and ways to prevent them. We devised a system that allows the radiologist to view reports in a separate window, displayed in a simple font and with all terms of laterality highlighted in sep...

Perceived effect of deployment on families of UK military personnel.

Science.gov (United States)

Thandi, G; Greenberg, N; Fear, N T; Jones, N

2017-10-01

In the UK, little is known about the perceived effects of deployment, on military families, from military personnel in theatre. To investigate military personnel's perceptions of the impact of deployment on intimate relationships and children. Deployed service personnel who were in a relationship, and who had children, completed a survey while deployed on combat operations. Data were taken from four mental health surveys carried out in Iraq in 2009 and Afghanistan in 2010, 2011 and 2014. Among 4265 participants, after adjusting for military and social-demographic covariates, perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress, and traumatic stress symptoms. Military personnel who reported being in danger of being injured or killed during deployment, were more likely to report a perceived negative effect of deployment on their intimate relationships. Reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars. Military personnel who themselves planned to separate from their partner were more likely to report psychological distress, and stressors at home. Perceived insufficient support from the Ministry of Defence was associated with poor mental health, and holding a junior rank. Deployed UK military personnel with symptoms of psychological distress, who experienced stressors at home, were especially likely to perceive that their family were inadequately supported by the military. Those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed. © The Author 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Radiation exposure of non-monitored hospital personnel

International Nuclear Information System (INIS)

Renaud, L.; Blanchette, J.; Galand, C.

1993-02-01

This addendum to report INFO--0437-1 reports the raw results of phase 2 of the survey of medical personnel exposed to nuclear medicine patients. It also presents floor plans of the three hospitals surveyed. (L.L.) (42 tabs., 36 figs.)

List of Error-Prone Abbreviations, Symbols, and Dose Designations

Science.gov (United States)

... Analysis and Coaching Report an Error Report a Medication Error Report a Vaccine Error Consumer Error Reporting Search ... which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) as being frequently misinterpreted ...

The training of the operation personnel

International Nuclear Information System (INIS)

Martin, H.D.

1975-01-01

A survey about training places and the volume of the training program for reactor personnel in the Federal Republic of Germany is given. Paragraph 7 of the atomic energy act, which imposes on the operators of nuclear energy plants the qualifired training of the personnel, is refered to. Positive experiences with the use of simulation equipment for training have led to the planning of a simulator-centre which is expected to be ready for operation in 1977. The versatile program of this centre is briefly reported. (ORU) [de

Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem.

Science.gov (United States)

Perez, Bianca; Knych, Stephen A; Weaver, Sallie J; Liberman, Aaron; Abel, Eileen M; Oetjen, Dawn; Wan, Thomas T H

2014-03-01

The issues of medical errors and medical malpractice have stimulated significant interest in establishing transparency in health care, in other words, ensuring that medical professionals formally report medical errors and disclose related outcomes to patients and families. However, research has amply shown that transparency is not a universal practice among physicians. A review of the literature was carried out using the search terms "transparency," "patient safety," "disclosure," "medical error," "error reporting," "medical malpractice," "doctor-patient relationship," and "physician" to find articles describing physician barriers to transparency. The current literature underscores that a complex Web of factors influence physician reluctance to engage in transparency. Specifically, 4 domains of barriers emerged from this analysis: intrapersonal, interpersonal, institutional, and societal. Transparency initiatives will require vigorous, interdisciplinary efforts to address the systemic and pervasive nature of the problem. Several ethical and social-psychological barriers suggest that medical schools and hospitals should collaborate to establish continuity in education and ensure that knowledge acquired in early education is transferred into long-term learning. At the institutional level, practical and cultural barriers suggest the creation of supportive learning environments and private discussion forums where physicians can seek moral support in the aftermath of an error. To overcome resistance to culture transformation, incremental change should be considered, for example, replacing arcane transparency policies and complex reporting mechanisms with clear, user-friendly guidelines.

Interim status report of the TMI personnel-dosimetry project

International Nuclear Information System (INIS)

Rich, B.L.; Alvarez, J.L.; Adams, S.R.

1981-06-01

The current 2-chip TLD personnel dosimeter in use at Three Mile Island (TMI) has been shown inadequate for the anticipated high beta/gamma fields during TMI recovery operations in some areas. This project surveyed the available dosimeter systems, set up an Idaho National Engineering Laboratory (INEL) prototype system, and compared this system with those commercial systems that could be made immediately available for comparison. Of the systems tested, the new INEL personnel dosimeter was found to produce the most accurate results for use in recovery operations at TMI-2. The other multiple-chip or multiple-filter systems were found less desirable at present. The most prominent deficiencies in the INEL dosimeter stem from the fact that it lacks a completely automated reader and its x-ray and thermal neutron responses require additional development. A automated prototype reader system may be in operation by the end of CY-1981. Three alternatives for operational dosimetry are discussed. A combination of a modified version of the presently used Harshaw 2-chip dosimeter and the INEL dosimeter is recommended

Pre-Departure Clearance (PDC): An Analysis of Aviation Safety Reporting System Reports Concerning PDC Related Errors

Science.gov (United States)

Montalyo, Michael L.; Lebacqz, J. Victor (Technical Monitor)

1994-01-01

Airlines operating in the United States are required to operate under instrument flight rules (EFR). Typically, a clearance is issued via voice transmission from clearance delivery at the departing airport. In 1990, the Federal Aviation Administration (FAA) began deployment of the Pre-Departure Clearance (PDC) system at 30 U.S. airports. The PDC system utilizes aeronautical datalink and Aircraft Communication and Reporting System (ACARS) to transmit departure clearances directly to the pilot. An objective of the PDC system is to provide an immediate reduction in voice congestion over the clearance delivery frequency. Participating airports report that this objective has been met. However, preliminary analysis of 42 Aviation Safety Reporting System (ASRS) reports has revealed problems in PDC procedures and formatting which have caused errors in the proper execution of the clearance. It must be acknowledged that this technology, along with other advancements on the flightdeck, is adding more responsibility to the crew and increasing the opportunity for error. The present study uses these findings as a basis for further coding and analysis of an additional 82 reports obtained from an ASRS database search. These reports indicate that clearances are often amended or exceptions are added in order to accommodate local ATC facilities. However, the onboard ACARS is limited in its ability to emphasize or highlight these changes which has resulted in altitude and heading deviations along with increases in ATC workload. Furthermore, few participating airports require any type of PDC receipt confirmation. In fact, 35% of all ASRS reports dealing with PDC's include failure to acquire the PDC at all. Consequently, this study examines pilots' suggestions contained in ASRS reports in order to develop recommendations to airlines and ATC facilities to help reduce the amount of incidents that occur.

Errors in otology.

Science.gov (United States)

Kartush, J M

1996-11-01

Practicing medicine successfully requires that errors in diagnosis and treatment be minimized. Malpractice laws encourage litigators to ascribe all medical errors to incompetence and negligence. There are, however, many other causes of unintended outcomes. This article describes common causes of errors and suggests ways to minimize mistakes in otologic practice. Widespread dissemination of knowledge about common errors and their precursors can reduce the incidence of their occurrence. Consequently, laws should be passed to allow for a system of non-punitive, confidential reporting of errors and "near misses" that can be shared by physicians nationwide.

Self-Reported and Observed Punitive Parenting Prospectively Predicts Increased Error-Related Brain Activity in Six-Year-Old Children.

Science.gov (United States)

Meyer, Alexandria; Proudfit, Greg Hajcak; Bufferd, Sara J; Kujawa, Autumn J; Laptook, Rebecca S; Torpey, Dana C; Klein, Daniel N

2015-07-01

The error-related negativity (ERN) is a negative deflection in the event-related potential (ERP) occurring approximately 50 ms after error commission at fronto-central electrode sites and is thought to reflect the activation of a generic error monitoring system. Several studies have reported an increased ERN in clinically anxious children, and suggest that anxious children are more sensitive to error commission--although the mechanisms underlying this association are not clear. We have previously found that punishing errors results in a larger ERN, an effect that persists after punishment ends. It is possible that learning-related experiences that impact sensitivity to errors may lead to an increased ERN. In particular, punitive parenting might sensitize children to errors and increase their ERN. We tested this possibility in the current study by prospectively examining the relationship between parenting style during early childhood and children's ERN approximately 3 years later. Initially, 295 parents and children (approximately 3 years old) participated in a structured observational measure of parenting behavior, and parents completed a self-report measure of parenting style. At a follow-up assessment approximately 3 years later, the ERN was elicited during a Go/No-Go task, and diagnostic interviews were completed with parents to assess child psychopathology. Results suggested that both observational measures of hostile parenting and self-report measures of authoritarian parenting style uniquely predicted a larger ERN in children 3 years later. We previously reported that children in this sample with anxiety disorders were characterized by an increased ERN. A mediation analysis indicated that ERN magnitude mediated the relationship between harsh parenting and child anxiety disorder. Results suggest that parenting may shape children's error processing through environmental conditioning and thereby risk for anxiety, although future work is needed to confirm this

Self-reported and observed punitive parenting prospectively predicts increased error-related brain activity in six-year-old children

Science.gov (United States)

Meyer, Alexandria; Proudfit, Greg Hajcak; Bufferd, Sara J.; Kujawa, Autumn J.; Laptook, Rebecca S.; Torpey, Dana C.; Klein, Daniel N.

2017-01-01

The error-related negativity (ERN) is a negative deflection in the event-related potential (ERP) occurring approximately 50 ms after error commission at fronto-central electrode sites and is thought to reflect the activation of a generic error monitoring system. Several studies have reported an increased ERN in clinically anxious children, and suggest that anxious children are more sensitive to error commission—although the mechanisms underlying this association are not clear. We have previously found that punishing errors results in a larger ERN, an effect that persists after punishment ends. It is possible that learning-related experiences that impact sensitivity to errors may lead to an increased ERN. In particular, punitive parenting might sensitize children to errors and increase their ERN. We tested this possibility in the current study by prospectively examining the relationship between parenting style during early childhood and children’s ERN approximately three years later. Initially, 295 parents and children (approximately 3 years old) participated in a structured observational measure of parenting behavior, and parents completed a self-report measure of parenting style. At a follow-up assessment approximately three years later, the ERN was elicited during a Go/No-Go task, and diagnostic interviews were completed with parents to assess child psychopathology. Results suggested that both observational measures of hostile parenting and self-report measures of authoritarian parenting style uniquely predicted a larger ERN in children 3 years later. We previously reported that children in this sample with anxiety disorders were characterized by an increased ERN. A mediation analysis indicated that ERN magnitude mediated the relationship between harsh parenting and child anxiety disorder. Results suggest that parenting may shape children’s error processing through environmental conditioning and thereby risk for anxiety, although future work is needed to

Improving Mental Health Reporting Practices in Between Personnel Security Investigations

Science.gov (United States)

2017-06-01

derogatory information, unfavorable administrative actions, and adverse actions to the appropriate personnel security, human resources , and...national security clearance? What type of clearances do people typically have (e.g., Secret, Top Secret, TS/SCI, SAP , etc.)? (2) Does [the

EPIC: an Error Propagation/Inquiry Code

International Nuclear Information System (INIS)

Baker, A.L.

1985-01-01

The use of a computer program EPIC (Error Propagation/Inquiry Code) will be discussed. EPIC calculates the variance of a materials balance closed about a materials balance area (MBA) in a processing plant operated under steady-state conditions. It was designed for use in evaluating the significance of inventory differences in the Department of Energy (DOE) nuclear plants. EPIC rapidly estimates the variance of a materials balance using average plant operating data. The intent is to learn as much as possible about problem areas in a process with simple straightforward calculations assuming a process is running in a steady-state mode. EPIC is designed to be used by plant personnel or others with little computer background. However, the user should be knowledgeable about measurement errors in the system being evaluated and have a limited knowledge of how error terms are combined in error propagation analyses. EPIC contains six variance equations; the appropriate equation is used to calculate the variance at each measurement point. After all of these variances are calculated, the total variance for the MBA is calculated using a simple algebraic sum of variances. The EPIC code runs on any computer that accepts a standard form of the BASIC language. 2 refs., 1 fig., 6 tabs

Training of nuclear power plant personnel in Canada

International Nuclear Information System (INIS)

Tennant, D.

1993-01-01

All of the utilities, Ontario Hydro, Hydro Quebec and New Brunswick Power, operating Nuclear Power Plants in Canada have Training Centres which provide training for all of their plant personnel whose job activities could affect plant and personnel safety. This report points out the methods used for training, which generally conform to that described by the IAEA as a Systematic Approach to Training (SAT)

Effects of changed working methods on personnel doses at a I-131 and afterloading therapy ward

International Nuclear Information System (INIS)

Lange, D.; Wolf, G.; Georgi, P.; Bauer, M.

1985-01-01

The external load of the personnel from I-131 therapy can be kept small (almost 'neglectable') by appropriate behaviour without keeping patients 'under-lock and key'. The marked decrease in personnel doses is due to improved radiation protection for afterloading therapy (gynecological Ra-therapy, Cs-137-therapy) by technical equipment. This therapy is now possible but with the door of the application room closed; when the door is opened, the instruments automatically go back to their original position. From 1975 through 1982, there were remote control errors forcing the personnel to withdraw the instruments to the safe manually. Despite working regulations the personnel was able to go into the room without prior instrument withdrawal. The personnel doses so received were within the tolerance limits, however markedly above the inevitable values. Because of regular thyroid gland examination of the personnel there is proof for the fact that the radiation load of this organ from I-131 is probably smaller than 2% (6 mSv/a=600 mrem/a) of the annual limit value of 0.3 Sv (30 rem) which corresponds to 6 times the value of normal load. (orig./HP) [de

Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.

Science.gov (United States)

Scobie, Andrea

2011-04-01

To identify risk factors associated with self-reported medical, medication and laboratory error in eight countries. The Commonwealth Fund's 2008 International Health Policy Survey of chronically ill patients in eight countries. None. A multi-country telephone survey was conducted between 3 March and 30 May 2008 with patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA who self-reported being chronically ill. A bivariate analysis was performed to determine significant explanatory variables of medical, medication and laboratory error (P error: age 65 and under, education level of some college or less, presence of two or more chronic conditions, high prescription drug use (four+ drugs), four or more doctors seen within 2 years, a care coordination problem, poor doctor-patient communication and use of an emergency department. Risk factors with the greatest ability to predict experiencing an error encompassed issues with coordination of care and provider knowledge of a patient's medical history. The identification of these risk factors could help policymakers and organizations to proactively reduce the likelihood of error through greater examination of system- and organization-level practices.

Error in laboratory report data for platelet count assessment in patients suspicious for dengue: a note from observation

Directory of Open Access Journals (Sweden)

Somsri Wiwanitkit

2016-08-01

Full Text Available Dengue is a common tropical infection that is still a global health threat. An important laboratory parameter for the management of dengue is platelet count. Platelet count is an useful test for diagnosis and following up on dengue. However, errors in laboratory reports can occur. This study is a retrospective analysis on laboratory report data of complete blood count in cases with suspicious dengue in a medical center within 1 month period during the outbreak season on October, 2015. According to the studied period, there were 184 requests for complete blood count for cases suspected for dengue. From those 184 laboratory report records, errors can be seen in 12 reports (6.5%. This study demonstrates that there are considerable high rate of post-analytical errors in laboratory reports. Interestingly, the platelet count in those erroneous reports can be unreliable and ineffective or problematic when it is used for the management of dengue suspicious patients.

Medication errors: an analysis comparing PHICO's closed claims data and PHICO's Event Reporting Trending System (PERTS).

Science.gov (United States)

Benjamin, David M; Pendrak, Robert F

2003-07-01

Clinical pharmacologists are all dedicated to improving the use of medications and decreasing medication errors and adverse drug reactions. However, quality improvement requires that some significant parameters of quality be categorized, measured, and tracked to provide benchmarks to which future data (performance) can be compared. One of the best ways to accumulate data on medication errors and adverse drug reactions is to look at medical malpractice data compiled by the insurance industry. Using data from PHICO insurance company, PHICO's Closed Claims Data, and PHICO's Event Reporting Trending System (PERTS), this article examines the significance and trends of the claims and events reported between 1996 and 1998. Those who misread history are doomed to repeat the mistakes of the past. From a quality improvement perspective, the categorization of the claims and events is useful for reengineering integrated medication delivery, particularly in a hospital setting, and for redesigning drug administration protocols on low therapeutic index medications and "high-risk" drugs. Demonstrable evidence of quality improvement is being required by state laws and by accreditation agencies. The state of Florida requires that quality improvement data be posted quarterly on the Web sites of the health care facilities. Other states have followed suit. The insurance industry is concerned with costs, and medication errors cost money. Even excluding costs of litigation, an adverse drug reaction may cost up to $2500 in hospital resources, and a preventable medication error may cost almost $4700. To monitor costs and assess risk, insurance companies want to know what errors are made and where the system has broken down, permitting the error to occur. Recording and evaluating reliable data on adverse drug events is the first step in improving the quality of pharmacotherapy and increasing patient safety. Cost savings and quality improvement evolve on parallel paths. The PHICO data

Oral health survey of the military personnel deployed to the southernmost provinces of Thailand.

Science.gov (United States)

Sutthavong, Sirikarn; Ukritchon, Supak; Rangsin, Ram

2014-02-01

Dental problems are some of the major health problems of deployed miilitaly personnel. There have been no systematically reports of oral health information survey among the deployed military personnel in Thailand. The present study was to determine the oral health problems of the deployed military personnel and effects on personnel fitness. A cross-sectional study and a cluster sampling were conducted during April 2011 and March 2013. The Royal Thai Army (RTA) personnel 12 out of21 task forces in southern most provinces were invited to participate in the study. A standardized questionnaire was used. In total, 2,884 RTA deployed personnel voluntarily participated and completed the questionnaire infonnrmation. Their mean age was 27.8 +/- 9.4 years old. Fifty percent admitted that they had oral problems during the past six months and the most common ones were toothache/hypersensitivity (32.4%), and dental caries (21.5%). The majority of the participants (60.7%) reported that they experienced oral health problems less than 3 times and 2.8% reported sick leave during deployment because of oral conditions. 64.4% reported that their oral problems affected their quality of life and disturbed their duties. A relatively high prevalence oforal health problems was reported by the deployed RTA personnel. The problems affected their quality of life and assigned duties. Most ofthe problems were neglected. In order to keep the RTApersonnel fit for deployment, an effective dental health program should be developed.

A relational database for personnel radiation exposure management

International Nuclear Information System (INIS)

David, W.; Miller, P.D.

1993-01-01

In-house utility personnel developed a relational data base for personnel radiation exposure management computer system during a 2 1/2 year period. The (PREM) Personnel Radiation Exposure Management System was designed to meet current Nuclear Regulatory Commission (NRC) requirements related to radiological access control, Radiation Work Permits (RWP) management, automated personnel dosimetry reporting, ALARA planning and repetitive job history dose archiving. The system has been operational for the past 18 months which includes a full refueling outage at Clinton Power Station. The Radiation Protection Department designed PREM to establish a software platform for implementing future revisions to 10CFR20 in 1993. Workers acceptance of the system has been excellent. Regulatory officials have given the system high marks as a radiological tool because of the system's ability to track the entire job from start to finish

Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

2008-02-01

This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants

Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

2008-02-15

This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants.

Effects of human performance methods of the radiation exposure of the task personnel during the inspection of steam generator heat tubes

International Nuclear Information System (INIS)

Wilkes, Bernd; Bienentreu, Robert

2008-01-01

Westinghouse has implemented the so called human performance philosophy for specific scopes of work. Human performance is supposed to establish and support personnel behavior aimed to a safe and reliable operation of the plant. The overall goal is the prevention of errors. Every action deviating from the expected behavior is defined as an error, independent of the consequences. The accident statistics has shown that every severe accident was preceded by hundreds of events without consequences. The implementation of these techniques is demonstrated using the process of steam generator heat tube inspection. According to the ALARA principle a lot of effort was concentrated on dose reduction for the personnel, including constructive (improved testing probes, improved manipulator, etc.) and administrative measures.

National synchrotron light source medical personnel protection interlock

International Nuclear Information System (INIS)

Buda, S.; Gmur, N.F.; Larson, R.; Thomlinson, W.

1998-01-01

This report is founded on reports written in April 1987 by Robert Hettel for angiography operations at the Stanford Synchrotron Research Laboratory (SSRL) and a subsequent report covering angiography operations at the National Synchrotron Light Source (NSLS); BNL Informal Report 47681, June 1992. The latter report has now been rewritten in order to accurately reflect the design and installation of a new medical safety system at the NSLS X17B2 beamline Synchrotron Medical Research Facility (SMERF). Known originally as the Angiography Personnel Protection Interlock (APPI), this system has been modified to incorporate other medical imaging research programs on the same beamline and thus the name has been changed to the more generic Medical Personnel Protection Interlock (MPPI). This report will deal almost exclusively with the human imaging (angiography, bronchography, mammography) aspects of the safety system, but will briefly explain the modular aspects of the system allowing other medical experiments to be incorporated

NATIONAL SYNCHROTRON LIGHT SOURCE MEDICAL PERSONNEL PROTECTION INTERLOCK

Energy Technology Data Exchange (ETDEWEB)

BUDA,S.; GMUR,N.F.; LARSON,R.; THOMLINSON,W.

1998-11-03

This report is founded on reports written in April 1987 by Robert Hettel for angiography operations at the Stanford Synchrotron Research Laboratory (SSRL) and a subsequent report covering angiography operations at the National Synchrotron Light Source (NSLS); BNL Informal Report 47681, June 1992. The latter report has now been rewritten in order to accurately reflect the design and installation of a new medical safety system at the NSLS X17B2 beamline Synchrotron Medical Research Facility (SMERF). Known originally as the Angiography Personnel Protection Interlock (APPI), this system has been modified to incorporate other medical imaging research programs on the same beamline and thus the name has been changed to the more generic Medical Personnel Protection Interlock (MPPI). This report will deal almost exclusively with the human imaging (angiography, bronchography, mammography) aspects of the safety system, but will briefly explain the modular aspects of the system allowing other medical experiments to be incorporated.

Nurse perceptions of organizational culture and its association with the culture of error reporting: a case of public sector hospitals in Pakistan.

Science.gov (United States)

Jafree, Sara Rizvi; Zakar, Rubeena; Zakar, Muhammad Zakria; Fischer, Florian

2016-01-05

There is an absence of formal error tracking systems in public sector hospitals of Pakistan and also a lack of literature concerning error reporting culture in the health care sector. Nurse practitioners have front-line knowledge and rich exposure about both the organizational culture and error sharing in hospital settings. The aim of this paper was to investigate the association between organizational culture and the culture of error reporting, as perceived by nurses. The authors used the "Practice Environment Scale-Nurse Work Index Revised" to measure the six dimensions of organizational culture. Seven questions were used from the "Survey to Solicit Information about the Culture of Reporting" to measure error reporting culture in the region. Overall, 309 nurses participated in the survey, including female nurses from all designations such as supervisors, instructors, ward-heads, staff nurses and student nurses. We used SPSS 17.0 to perform a factor analysis. Furthermore, descriptive statistics, mean scores and multivariable logistic regression were used for the analysis. Three areas were ranked unfavorably by nurse respondents, including: (i) the error reporting culture, (ii) staffing and resource adequacy, and (iii) nurse foundations for quality of care. Multivariable regression results revealed that all six categories of organizational culture, including: (1) nurse manager ability, leadership and support, (2) nurse participation in hospital affairs, (3) nurse participation in governance, (4) nurse foundations of quality care, (5) nurse-coworkers relations, and (6) nurse staffing and resource adequacy, were positively associated with higher odds of error reporting culture. In addition, it was found that married nurses and nurses on permanent contract were more likely to report errors at the workplace. Public healthcare services of Pakistan can be improved through the promotion of an error reporting culture, reducing staffing and resource shortages and the

Exploring behavioural determinants relating to health professional reporting of medication errors: a qualitative study using the Theoretical Domains Framework.

Science.gov (United States)

Alqubaisi, Mai; Tonna, Antonella; Strath, Alison; Stewart, Derek

2016-07-01

Effective and efficient medication reporting processes are essential in promoting patient safety. Few qualitative studies have explored reporting of medication errors by health professionals, and none have made reference to behavioural theories. The objective was to describe and understand the behavioural determinants of health professional reporting of medication errors in the United Arab Emirates (UAE). This was a qualitative study comprising face-to-face, semi-structured interviews within three major medical/surgical hospitals of Abu Dhabi, the UAE. Health professionals were sampled purposively in strata of profession and years of experience. The semi-structured interview schedule focused on behavioural determinants around medication error reporting, facilitators, barriers and experiences. The Theoretical Domains Framework (TDF; a framework of theories of behaviour change) was used as a coding framework. Ethical approval was obtained from a UK university and all participating hospital ethics committees. Data saturation was achieved after interviewing ten nurses, ten pharmacists and nine physicians. Whilst it appeared that patient safety and organisational improvement goals and intentions were behavioural determinants which facilitated reporting, there were key determinants which deterred reporting. These included the beliefs of the consequences of reporting (lack of any feedback following reporting and impacting professional reputation, relationships and career progression), emotions (fear and worry) and issues related to the environmental context (time taken to report). These key behavioural determinants which negatively impact error reporting can facilitate the development of an intervention, centring on organisational safety and reporting culture, to enhance reporting effectiveness and efficiency.

Review of the current deficiencies in personnel beta dosimetry, with recommendations

International Nuclear Information System (INIS)

Sherbini, S.; Porter, S.W.

1983-06-01

The report describes the design and use of personnel dosimeters used by the nuclear power industry to monitor occupational radiation exposure. It then shows why the monitoring method is inaccurate when personnel are exposed to beta particles. Then the report describes alternatives that would lead to improved measurements. The report also critiques the dosimetry processor testing criteria developed by the Health Physics Society Standards Committee. Survey instruments are shown often to be inaccurate when used to measure beta dose rates

Occupational injury rates in personnel of emergency medical services

Directory of Open Access Journals (Sweden)

Robert Gałązkowski

2015-12-01

Full Text Available [i][/i][b]Introduction and objectives. [/b]The system of emergency medical services (EMS in Poland was established in 2006. The risk of occupational injuries to EMS personnel is very high, irrespective of the country where they operate, as they face many hazards in their everyday work. The aim of this study is to describe the type, incidence and consequences of occupational accidents among the personnel of the National Emergency Medical Services in Poland (NEMS – land and air ambulance crews in 2008–2012. [b]Material and methods:[/b] The study reviewed all occupational accidents among the EMS personnel reported to the National Labour Inspectorate in 2008–2012. [b]Results[/b]: In the period reported, the number of accidents decreased from 32 in 2008 to just 6 in 2012. Traffic accidents predominated and most of the victims were male paramedics under 30 years of age. The most common injuries included multiple organ injuries and injuries of the cervical spine, chest and trunk. [b]Conclusions:[/b] The growing professional experience of the EMS personnel has a beneficial effect on occupational injury rates as they tend to decrease with longer employment. Occupational accidents are definitely more common among ambulance crews than in the personnel of other organizational units of the National Emergency Medical Services.

Interpreting the change detection error matrix

NARCIS (Netherlands)

Oort, van P.A.J.

2007-01-01

Two different matrices are commonly reported in assessment of change detection accuracy: (1) single date error matrices and (2) binary change/no change error matrices. The third, less common form of reporting, is the transition error matrix. This paper discuses the relation between these matrices.

Occupational stress among police personnel in India

Directory of Open Access Journals (Sweden)

G Ragesh

2017-06-01

Full Text Available Background: Occupational stress and associated physical and mental health related issues are not addressed in Indian police personnel with adequate importance. Methods: Cross-sectional survey was conducted among police personnel (both male and female in Calicut urban police district, Kerala state, India. Police personnel from all designations (ranks, except from the all India services (Indian Police Service were included in the study. Data were collected using a specifically designed datasheet covering socio-demographic profile, physical and mental health related details which was prepared by researchers. Occupational stress was measured using Operational Police Stress Questionnaire (PSQ-OP and Organisational Police Stress Questionnaire (PSQ-ORG. Result: The study found that both operational and organisational stress was significant among the police officers. Organisational stress was experienced in moderate level by 68% and in high level by 14%. Operational stress scores were in the moderate range in 67% and in high range in 16.5%. The younger age group (21-35 years and lower level rank police personnel had higher stress. Stress was higher among female police personnel compared to males. While 23% of them had been diagnosed with physical illnesses, a significant four per cent of them with mental illness, and 29% of them reported substance abuse. Conclusion: The results point to the high level of stress among Indian police personnel and the need for urgent interventions from the government to address the occupational stress.

The Maintenance Personnel Performance Simulation (MAPPS) model: A human reliability analysis tool

International Nuclear Information System (INIS)

Knee, H.E.

1985-01-01

The Maintenance Personnel Performance Simulation (MAPPS) model is a computerized, stochastic, task-oriented human behavioral model developed to provide estimates of nuclear power plant (NPP) maintenance team performance measures. It is capable of addressing person-machine, person-environment, and person-person relationships, and accounts for interdependencies that exist between the subelements that make up the maintenance task of interest. The primary measures of performance estimated by MAPPS are: 1) the probability of successfully completing the task of interest and 2) the task duration time. MAPPS also estimates a host of other performance indices, including the probability of an undetected error, identification of the most- and least-likely error-prone subelements, and maintenance team stress profiles during task execution

Personnel preferences in personnel planning and scheduling

OpenAIRE

van der Veen, Egbert

2013-01-01

Summary The personnel of an organization often has two conflicting goals. Individual employees like to have a good work-life balance, by having personal preferences taken into account, whereas there is also the common goal to work efficiently. By applying techniques and methods from Operations Research, a subfield of applied mathematics, we show that operational efficiency can be achieved while taking personnel preferences into account. In the design of optimization methods, we explicitly con...

Civil Service Evaluation. The Evolving Role of the U.S. Office of Personnel Management. A Report concerning Significant Actions of the U.S. Office of Personnel Management

National Research Council Canada - National Science Library

Erdreich, Ben

1998-01-01

The Government's program to oversee Federal personnel systems has existed in some form since World War II when rapid expansion of the civil service necessitated the delegation of personnel authorities...

Report: EPA’s Information Systems and Data Are at Risk Due to Insufficient Training of Personnel With Significant Information Security Responsibilities

Science.gov (United States)

Report #14-P-0142, March 21, 2014. The EPA places its information systems and data at risk due to an organizational structure that has not specified required duties and responsibilities to ensure personnel are trained on key information security roles.

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

Science.gov (United States)

Ko, YuKyung; Yu, Soyoung

2017-09-01

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

Participant characteristics associated with errors in self-reported energy intake from the Women's Health Initiative food-frequency questionnaire.

Science.gov (United States)

Horner, Neilann K; Patterson, Ruth E; Neuhouser, Marian L; Lampe, Johanna W; Beresford, Shirley A; Prentice, Ross L

2002-10-01

Errors in self-reported dietary intake threaten inferences from studies relying on instruments such as food-frequency questionnaires (FFQs), food records, and food recalls. The objective was to quantify the magnitude, direction, and predictors of errors associated with energy intakes estimated from the Women's Health Initiative FFQ. Postmenopausal women (n = 102) provided data on sociodemographic and psychosocial characteristics that relate to errors in self-reported energy intake. Energy intake was objectively estimated as total energy expenditure, physical activity expenditure, and the thermic effect of food (10% addition to other components of total energy expenditure). Participants underreported energy intake on the FFQ by 20.8%; this error trended upward with younger age (P = 0.07) and social desirability (P = 0.09) but was not associated with body mass index (P = 0.95). The correlation coefficient between reported energy intake and total energy expenditure was 0.24; correlations were higher among women with less education, higher body mass index, and greater fat-free mass, social desirability, and dissatisfaction with perceived body size (all P diet and disease association studies.

Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

Energy Technology Data Exchange (ETDEWEB)

Callan, J.R.; Kelly, R.T.; Quinn, M.L. [Pacific Science and Engineering Group, San Diego, CA (United States)] [and others

1995-05-01

Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error.

Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

International Nuclear Information System (INIS)

Callan, J.R.; Kelly, R.T.; Quinn, M.L.

1995-05-01

Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error

Competency assessments for nuclear industry personnel

International Nuclear Information System (INIS)

2004-04-01

In 1996, the IAEA published Technical Reports Series No. 380, Nuclear Power Plant Personnel Training and its Evaluation: A Guidebook. This publication provides guidance for the development, implementation and evaluation of training programmes for all nuclear power plant personnel using the systematic approach to training (SAT) methodology. The SAT methodology has since been adopted and used for the development and implementation of training programmes for all types of nuclear facility and activities in the nuclear industry. The IAEA Technical Working Group on Training and Qualification of Nuclear Power Plant Personnel recommended that an additional publication be prepared to provide further guidance concerning competency assessments used for measuring the knowledge, skills and attitudes of personnel as the result of training. This publication has been prepared in response to that recommendation. A critical component of SAT (as part of the implementation phase) is the assessment of whether personnel have achieved the standards identified in the training objectives. The nuclear industry spends a significant amount of resources conducting competency assessments. Competency assessments are used for employee selection, trainee assessment, qualification, requalification and authorization (in some Member States the terminology may be 'certification' or 'licensing'), and job advancement and promotion. Ineffective testing methods and procedures, or inappropriate interpretation of test results, can have significant effects on both human performance and nuclear safety. Test development requires unique skills and, as with any skill, training and experience are needed to develop and improve them. Test item and examination development, use, interpretation of results and examination refinement, like all other aspects of SAT, should be part of an ongoing, systematic process. This publication is primarily intended for use by personnel responsible for developing and administering

Training of personnel in the field of radioactive materials transport

International Nuclear Information System (INIS)

Fasten, Ch.

1997-01-01

Training of personnel in the whole nuclear fuel cycle and also in the other fields of the use of radioactivity is one of the essentials with respect to compliance assurance. The transport of radioactive material is the only activity that takes place outside a facility: on roads, on railways, on the sea or in the air. A high level of safety is therefore an absolute requirement for all transport operations. To ensure this high level the training of the personnel involved in these activities plays an important role. Many studies show that most of the incidents in radioactive materials transport are caused by man-made errors: even so there have been no events with serious radiological consequences anywhere worldwide. There are many requirements in the various national and international regulations for the safe transport of radioactive material with regard to training. An overview is given of the special regulations, e.g. for road transport drivers, for safety advisers in the whole field of the transport of dangerous goods, for specially educated personnel in sea and air transports. In addition, the newest developments in the European Community in this field are discussed. An evaluation of the present regulations and proposals for further rules are also given. (Author)

Nuclear security. DOE actions to improve the personnel clearance program

International Nuclear Information System (INIS)

Fultz, Keith O.; Bannerman, Carl J.; Daniel, Beverly A.

1988-11-01

The status of the Department of Energy's (DOE) implementation of recommendations in our two reports on DOE's personnel security clearance program was determined. The recommendations were aimed at improving the timeliness, accuracy, and efficiency of personnel security clearance decisions. Specifically, the objective was to determine and report on steps DOE is taking to implement these recommendations. In summary, it was found that DOE has either initiated action or is studying ways to address all the recommendations, but none of the recommendations have been completely implemented. The effectiveness of the DOE actions will depend, in part, on the adequacy of its internal control system for overseeing and evaluating program operations. DOE's personnel security clearance program is intended to provide reasonable assurance that personnel with access to classified information and materials are trustworthy. The Department requests that the Office of Personnel Management or the Federal Bureau of Investigation collect personal data on each person who requires such access to do his or her job. Based on these background investigations, DOE officials authorize individuals whose personal histories indicate that they are trustworthy to have access to classified information, secured facilities, and controlled materials as needed to perform their jobs. DOE has five types of these authorizations or personnel security clearances and must update information on personnel holding each type at 5-year intervals to confirm their continuing reliability. The five types are based on the types of security interests to which the person needs access, e.g., persons needing nuclear weapons-related data must have a Q clearance, and persons with a top secret clearance can have access to national security data classified as top secret

How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention?

Science.gov (United States)

Breitkreuz, Karen R; Dougal, Renae L; Wright, Melanie C

2016-10-01

The objective of this project was to determine whether simulated exposure to error situations changes attitudes in a way that may have a positive impact on error prevention behaviors. Using a stratified quasi-randomized experiment design, we compared risk perception attitudes of a control group of nursing students who received standard error education (reviewed medication error content and watched movies about error experiences) to an experimental group of students who reviewed medication error content and participated in simulated error experiences. Dependent measures included perceived memorability of the educational experience, perceived frequency of errors, and perceived caution with respect to preventing errors. Experienced nursing students perceived the simulated error experiences to be more memorable than movies. Less experienced students perceived both simulated error experiences and movies to be highly memorable. After the intervention, compared with movie participants, simulation participants believed errors occurred more frequently. Both types of education increased the participants' intentions to be more cautious and reported caution remained higher than baseline for medication errors 6 months after the intervention. This study provides limited evidence of an advantage of simulation over watching movies describing actual errors with respect to manipulating attitudes related to error prevention. Both interventions resulted in long-term impacts on perceived caution in medication administration. Simulated error experiences made participants more aware of how easily errors can occur, and the movie education made participants more aware of the devastating consequences of errors.

[Errors in medicine. Causes, impact and improvement measures to improve patient safety].

Science.gov (United States)

Waeschle, R M; Bauer, M; Schmidt, C E

2015-09-01

The guarantee of quality of care and patient safety is of major importance in hospitals even though increased economic pressure and work intensification are ubiquitously present. Nevertheless, adverse events still occur in 3-4 % of hospital stays and of these 25-50 % are estimated to be avoidable. The identification of possible causes of error and the development of measures for the prevention of medical errors are essential for patient safety. The implementation and continuous development of a constructive culture of error tolerance are fundamental.The origins of errors can be differentiated into systemic latent and individual active causes and components of both categories are typically involved when an error occurs. Systemic causes are, for example out of date structural environments, lack of clinical standards and low personnel density. These causes arise far away from the patient, e.g. management decisions and can remain unrecognized for a long time. Individual causes involve, e.g. confirmation bias, error of fixation and prospective memory failure. These causes have a direct impact on patient care and can result in immediate injury to patients. Stress, unclear information, complex systems and a lack of professional experience can promote individual causes. Awareness of possible causes of error is a fundamental precondition to establishing appropriate countermeasures.Error prevention should include actions directly affecting the causes of error and includes checklists and standard operating procedures (SOP) to avoid fixation and prospective memory failure and team resource management to improve communication and the generation of collective mental models. Critical incident reporting systems (CIRS) provide the opportunity to learn from previous incidents without resulting in injury to patients. Information technology (IT) support systems, such as the computerized physician order entry system, assist in the prevention of medication errors by providing

A survey of mindset theories of intelligence and medical error self-reporting among pediatric housestaff and faculty.

Science.gov (United States)

Jegathesan, Mithila; Vitberg, Yaffa M; Pusic, Martin V

2016-02-11

Intelligence theory research has illustrated that people hold either "fixed" (intelligence is immutable) or "growth" (intelligence can be improved) mindsets and that these views may affect how people learn throughout their lifetime. Little is known about the mindsets of physicians, and how mindset may affect their lifetime learning and integration of feedback. Our objective was to determine if pediatric physicians are of the "fixed" or "growth" mindset and whether individual mindset affects perception of medical error reporting.  We sent an anonymous electronic survey to pediatric residents and attending pediatricians at a tertiary care pediatric hospital. Respondents completed the "Theories of Intelligence Inventory" which classifies individuals on a 6-point scale ranging from 1 (Fixed Mindset) to 6 (Growth Mindset). Subsequent questions collected data on respondents' recall of medical errors by self or others. We received 176/349 responses (50 %). Participants were equally distributed between mindsets with 84 (49 %) classified as "fixed" and 86 (51 %) as "growth". Residents, fellows and attendings did not differ in terms of mindset. Mindset did not correlate with the small number of reported medical errors. There is no dominant theory of intelligence (mindset) amongst pediatric physicians. The distribution is similar to that seen in the general population. Mindset did not correlate with error reports.

Translating Research Into Practice: Voluntary Reporting of Medication Errors in Critical Access Hospitals

Science.gov (United States)

Jones, Katherine J.; Cochran, Gary; Hicks, Rodney W.; Mueller, Keith J.

2004-01-01

Context:Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health…

Error and discrepancy in radiology: inevitable or avoidable?

Science.gov (United States)

Brady, Adrian P

2017-02-01

Errors and discrepancies in radiology practice are uncomfortably common, with an estimated day-to-day rate of 3-5% of studies reported, and much higher rates reported in many targeted studies. Nonetheless, the meaning of the terms "error" and "discrepancy" and the relationship to medical negligence are frequently misunderstood. This review outlines the incidence of such events, the ways they can be categorized to aid understanding, and potential contributing factors, both human- and system-based. Possible strategies to minimise error are considered, along with the means of dealing with perceived underperformance when it is identified. The inevitability of imperfection is explained, while the importance of striving to minimise such imperfection is emphasised. • Discrepancies between radiology reports and subsequent patient outcomes are not inevitably errors. • Radiologist reporting performance cannot be perfect, and some errors are inevitable. • Error or discrepancy in radiology reporting does not equate negligence. • Radiologist errors occur for many reasons, both human- and system-derived. • Strategies exist to minimise error causes and to learn from errors made.

Medication Errors in Hospitals: A Study of Factors Affecting Nursing Reporting in a Selected Center Affiliated with Shahid Beheshti University of Medical Sciences

Directory of Open Access Journals (Sweden)

HamidReza Mirzaee

2015-10-01

Full Text Available Background: Medication errors are mentioned as the most common important challenges threatening healthcare system in all countries worldwide. This study is conducted to investigate the most significant factors in refusal to report medication errors among nursing staff.Methods: The cross-sectional study was conducted on all nursing staff of a selected Education& Treatment Center in 2013. Data was collected through a teacher made questionnaire. The questionnaires’ face and content validity was confirmed by experts and for measuring its reliability test-retest was used. Data was analyzed by descriptive and analytic statistics. 16th  version of SPSS was also used for related statistics.Results: The most important factors in refusal to report medication errors respectively are: lack of reporting system in the hospital(3.3%, non-significance of reporting medication errors to hospital authorities and lack of appropriate feedback(3.1%, and lack of a clear definition for a medication error (3%. there was a significant relationship between the most important factors of refusal to report medication errors and work shift (p:0.002, age(p:0.003, gender(p:0.005, work experience(p<0.001 and employment type of nurses(p:0.002.Conclusion: Factors pertaining to management in hospitals as well as the fear of the consequences of reporting are two broad fields among the factors that make nurses not report their medication errors. In this regard, providing enough education to nurses, boosting the job security for nurses, management support and revising related processes and definitions are some factors that can help decreasing medication errors and increasing their report in case of occurrence.

Evaluation of the neutron dose received by personnel at the LLNL

International Nuclear Information System (INIS)

Hankins, D.E.

1982-01-01

This report was prepared to document the techniques being used to evaluate the neutron exposures received by personnel at the LLNL. Two types of evaluations are discussed covering the use of the routine personnel dosimeter and of the albedo neutron dosimeter. Included in the report are field survey results which were used to determine the calibration factors being applied to the dosimeter readings. Calibration procedures are discussed and recommendations are made on calibration and evaluation procedures

Analyzing temozolomide medication errors: potentially fatal.

Science.gov (United States)

Letarte, Nathalie; Gabay, Michael P; Bressler, Linda R; Long, Katie E; Stachnik, Joan M; Villano, J Lee

2014-10-01

The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.

Neutron personnel dosimetry

International Nuclear Information System (INIS)

Griffith, R.V.

1981-01-01

The current state-of-the-art in neutron personnel dosimetry is reviewed. Topics covered include dosimetry needs and alternatives, current dosimetry approaches, personnel monitoring devices, calibration strategies, and future developments

Pulmonary function test in traffic police personnel in Pondicherry.

Science.gov (United States)

Pal, Pravati; John, Robert A; Dutta, T K; Pal, G K

2010-01-01

Traffic policemen working in the busy traffic signal areas get exposed to the vehicular emissions for years together. The fumes, chemicals and particles present in the emission are reported to be damaging to the lung functions of these individuals. Since there were no data available on the PFT parameters of traffic police personnel of Pondicherry, this study was taken up to assess the effect of traffic air pollution on their pulmonary functions. PFT parameters were recorded in age- and BMI-matched 30 traffic police personnel (study group) and 30 general police personnel (control group) of male gender. As chronic smoking is known to be a critical factor in altering lung function, PFT parameters were compared between the smokers as well as nonsmokers of both the groups. In nonsmokers, there was significant decrease in VC (P traffic police personnel compared to the general police personnel. This may be due to exposure to vehicular pollution for several hours in a day for many years causing decreased functional capacity of the lungs and chronic smoking worsens the condition.

Rotational error in path integration: encoding and execution errors in angle reproduction.

Science.gov (United States)

Chrastil, Elizabeth R; Warren, William H

2017-06-01

Path integration is fundamental to human navigation. When a navigator leaves home on a complex outbound path, they are able to keep track of their approximate position and orientation and return to their starting location on a direct homebound path. However, there are several sources of error during path integration. Previous research has focused almost exclusively on encoding error-the error in registering the outbound path in memory. Here, we also consider execution error-the error in the response, such as turning and walking a homebound trajectory. In two experiments conducted in ambulatory virtual environments, we examined the contribution of execution error to the rotational component of path integration using angle reproduction tasks. In the reproduction tasks, participants rotated once and then rotated again to face the original direction, either reproducing the initial turn or turning through the supplementary angle. One outstanding difficulty in disentangling encoding and execution error during a typical angle reproduction task is that as the encoding angle increases, so does the required response angle. In Experiment 1, we dissociated these two variables by asking participants to report each encoding angle using two different responses: by turning to walk on a path parallel to the initial facing direction in the same (reproduction) or opposite (supplementary angle) direction. In Experiment 2, participants reported the encoding angle by turning both rightward and leftward onto a path parallel to the initial facing direction, over a larger range of angles. The results suggest that execution error, not encoding error, is the predominant source of error in angular path integration. These findings also imply that the path integrator uses an intrinsic (action-scaled) rather than an extrinsic (objective) metric.

Severe accident testing of a personnel airlock

International Nuclear Information System (INIS)

Clauss, D.B.; Parks, M.B.; Julien, J.T.; Peters, S.W.

1988-01-01

Sandia National Laboratories (Sandia) is investigating the leakage potential of mechanical penetrations as part of a research program on containment integrity under severe accident loads for the U.S. Nuclear Regulatory Commission (NRC). Barnes et al. (1984) and Shackelford et al. (1985) identified leakage from personnel airlocks as an important failure mode of containments subject to severe accident loads. However, these studies were based on relatively simple analysis methods. The complex structural interaction between the door, gasket, and bulkhead in personnel airlocks makes analytical evaluation of leakage difficult. In order to provide data to validate methods for evaluating the leakage potential, a full-size personnel airlock was subject to simulated severe accident loads consisting of pressure and temperature up to 300 psig and 800 degrees F. The test was conducted at Chicago Bridge and Iron under contract to Sandia. The authors provide a detailed report on the test program

Personnel radiation dosimetry laboratory accreditation programme for thermoluminescent dosimeters : a proposal

International Nuclear Information System (INIS)

Bhatt, B.C.; Srivastava, J.K.; Iyer, P.S.; Venkatraman, G.

1993-01-01

Accreditation for thermoluminescent dosimeters is the process of evaluating a programme intending to use TL personnel dosimeters to measure, report and record dose equivalents received by radiation workers. In order to test the technical competence for conducting personnel dosimetry service as well as to decentralize personnel monitoring service, it has been proposed by Radiological Physics Division (RPhD) to accredit some of the laboratories, in the country. The objectives of this accreditation programme are: (i) to give recognition to competent dosimetry processors, and (ii) to provide periodic evaluation of dosimetry processors, including review of internal quality assurance programme to improve the quality of personnel dosimetry processing. The scientific support for the accreditation programme will be provided by the scientific staff from Radiological Physics Division (RPhD) and Radiation Protection Services Division (RPSD). This paper describes operational and technical requirements for the Personnel Radiation Dosimetry Laboratory Accreditation Programme for Thermoluminescent Dosimeters for Personnel Dosimetry Processors. Besides, many technical documents dealing with the TL Personnel Dosimeter System have been prepared. (author). 5 refs., 2 figs

Control in personnel exposure at HIRUP facility during the period 2006-2010

International Nuclear Information System (INIS)

Ojha, Shashikala; Suman, Santosh Kumar; Murali, S.

2012-01-01

HIRUP facility is designed to handle MCi of 60 Co, fabrication of sealed source, is carried out in hot cell. The design safety features allow the handling of sealed sources and other gamma emitters under suitable containment systems. The NP Unit of the facility provides personnel monitoring programmes viz., TLD/DRD monitoring for the radiation workers. 60 Co and other gamma emitters pose mainly external hazard during the handling of sealed source in hot cell. TLD is processed to assess the external exposure of personnel. Air activity and gross bg contamination at the work place is periodically monitored and reported. The TLD users of HIRUP are periodically referred for internal monitoring - whole body counting and bio-assay to estimate internal exposure. There is no reported internal exposure so far. Personnel from IAD and BRIT facility are provided with personnel monitoring coverage by HP Unit; the TLD is issued with respective institution no. as - 0283, 4288. Each person gets identified by individual TLD number, renewed TLD issue on quarterly service period. Based on job requirement such as handling of high activity, additional Wrist TLDs are provided. The used TLD of IAD and BRIT are sent for processing. The dose report obtained, enlists personnel exposure details. HP Unit does the report making to the concerned agencies enlisting the operational status, total occupational exposure of the facility (person mSv), average exposure (mSv) and few other details. Details of exposure for 2006 - 2010 (non-zero exposure cases), indicate that for IAD collective exposure got reduced by 78.5 %, average exposure got reduced by 62.6 %; for BRIT collective exposure got reduced by 58.2 %, average exposure got reduced by 46.8 %, at HIRUP facility. There is a decreasing trend in personnel exposure over the period 2006-2010, is due to HP safety protocol, on job HP surveillance and related safety measures. The personnel exposure is controlled as per ALARA, decreasing trend in the

Protecting military personnel from high risk dietary supplements.

Science.gov (United States)

Deuster, Patricia A; Lieberman, Harris R

2016-01-01

It is legal tomarketmost naturally occurring substances as dietary supplements in the USA without manufacturers demonstrating they are safe or effective, and an endless variety of ingredients, from esoteric botanicals to unapproved pharmaceuticals, can be found in dietary supplements. Use of certain supplements can pose a risk, but since a robust reporting systemdoes not exist in the USA it is difficult to know which are problematic and the number of adverse events (AE) resulting from their use. Certain populations, includingmilitary personnel, aremore likely to use dietary supplements than the general population. Approximately 70% of military personnel take dietary supplements while about 50% of civilians do. Service members prefer supplements purported to enhance physical performance such as supposedly natural stimulants, protein and amino acids, and combination products. Since some of thesemay be problematic, Servicemembers are probably at higher risk of injury than the general population. Ten percent of military populations appear to be taking potentially risky supplements, and the US Department of Defense (DoD) has taken variousmeasures to protect uniformed personnel including education, policy changes, and restricting sales. Actions taken include launching Operation Supplement Safety (OPSS), introducing a High Risk Supplement list, educating health care professionals on reporting AE thatmight be associated with dietary supplements, recommending policy for reporting AE, and developing an online AE reporting system. OPSS is a DoD-wide effort to educate service members, leaders, health care providers, military families, and retirees on how to safely select supplements

A preliminary taxonomy of medical errors in family practice.

Science.gov (United States)

Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P

2002-09-01

To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

E-Prescribing Errors in Community Pharmacies: Exploring Consequences and Contributing Factors

Science.gov (United States)

Stone, Jamie A.; Chui, Michelle A.

2014-01-01

Objective To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. Methods Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. Results Pharmacy staff detected 75 e-prescription errors during the 45 hour observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. Conclusion Study findings suggest that a wide range of e-prescribing errors are encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies. PMID:24657055

Task types and error types involved in the human-related unplanned reactor trip events

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2008-01-01

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed

Task types and error types involved in the human-related unplanned reactor trip events

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Park, Jin Kyun [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2008-12-15

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed.

Attitudes of Mashhad Public Hospital's Nurses and Midwives toward the Causes and Rates of Medical Errors Reporting.

Science.gov (United States)

Mobarakabadi, Sedigheh Sedigh; Ebrahimipour, Hosein; Najar, Ali Vafaie; Janghorban, Roksana; Azarkish, Fatemeh

2017-03-01

Patient's safety is one of the main objective in healthcare services; however medical errors are a prevalent potential occurrence for the patients in treatment systems. Medical errors lead to an increase in mortality rate of the patients and challenges such as prolonging of the inpatient period in the hospitals and increased cost. Controlling the medical errors is very important, because these errors besides being costly, threaten the patient's safety. To evaluate the attitudes of nurses and midwives toward the causes and rates of medical errors reporting. It was a cross-sectional observational study. The study population was 140 midwives and nurses employed in Mashhad Public Hospitals. The data collection was done through Goldstone 2001 revised questionnaire. SPSS 11.5 software was used for data analysis. To analyze data, descriptive and inferential analytic statistics were used. Standard deviation and relative frequency distribution, descriptive statistics were used for calculation of the mean and the results were adjusted as tables and charts. Chi-square test was used for the inferential analysis of the data. Most of midwives and nurses (39.4%) were in age range of 25 to 34 years and the lowest percentage (2.2%) were in age range of 55-59 years. The highest average of medical errors was related to employees with three-four years of work experience, while the lowest average was related to those with one-two years of work experience. The highest average of medical errors was during the evening shift, while the lowest were during the night shift. Three main causes of medical errors were considered: illegibile physician prescription orders, similarity of names in different drugs and nurse fatigueness. The most important causes for medical errors from the viewpoints of nurses and midwives are illegible physician's order, drug name similarity with other drugs, nurse's fatigueness and damaged label or packaging of the drug, respectively. Head nurse feedback, peer

Threat and error management for anesthesiologists: a predictive risk taxonomy

Science.gov (United States)

Ruskin, Keith J.; Stiegler, Marjorie P.; Park, Kellie; Guffey, Patrick; Kurup, Viji; Chidester, Thomas

2015-01-01

Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. Recent findings Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. Summary TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation. PMID:24113268

A Six Sigma Trial For Reduction of Error Rates in Pathology Laboratory.

Science.gov (United States)

Tosuner, Zeynep; Gücin, Zühal; Kiran, Tuğçe; Büyükpinarbaşili, Nur; Turna, Seval; Taşkiran, Olcay; Arici, Dilek Sema

2016-01-01

A major target of quality assurance is the minimization of error rates in order to enhance patient safety. Six Sigma is a method targeting zero error (3.4 errors per million events) used in industry. The five main principles of Six Sigma are defining, measuring, analysis, improvement and control. Using this methodology, the causes of errors can be examined and process improvement strategies can be identified. The aim of our study was to evaluate the utility of Six Sigma methodology in error reduction in our pathology laboratory. The errors encountered between April 2014 and April 2015 were recorded by the pathology personnel. Error follow-up forms were examined by the quality control supervisor, administrative supervisor and the head of the department. Using Six Sigma methodology, the rate of errors was measured monthly and the distribution of errors at the preanalytic, analytic and postanalytical phases was analysed. Improvement strategies were reclaimed in the monthly intradepartmental meetings and the control of the units with high error rates was provided. Fifty-six (52.4%) of 107 recorded errors in total were at the pre-analytic phase. Forty-five errors (42%) were recorded as analytical and 6 errors (5.6%) as post-analytical. Two of the 45 errors were major irrevocable errors. The error rate was 6.8 per million in the first half of the year and 1.3 per million in the second half, decreasing by 79.77%. The Six Sigma trial in our pathology laboratory provided the reduction of the error rates mainly in the pre-analytic and analytic phases.

An Exploratory Analysis of the Navy Personnel Support Delivery Model

Science.gov (United States)

2017-09-01

and accurate information, and seamless customer relationship management (Department of the Navy, 2010). There will be field level support for when...of Management and Budget, Paperwork Reduction Project (0704-0188) Washington, DC 20503. 1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE September...through the Pay and Personnel Management Department (PERS-2). The current pay and personnel service delivery model is manpower heavy and relies on

Characteristics of medication errors with parenteral cytotoxic drugs

OpenAIRE

Fyhr, A; Akselsson, R

2012-01-01

Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the pati...

Generalizing human error rates: A taxonomic approach

International Nuclear Information System (INIS)

Buffardi, L.; Fleishman, E.; Allen, J.

1989-01-01

It is well established that human error plays a major role in malfunctioning of complex, technological systems and in accidents associated with their operation. Estimates of the rate of human error in the nuclear industry range from 20-65% of all system failures. In response to this, the Nuclear Regulatory Commission has developed a variety of techniques for estimating human error probabilities for nuclear power plant personnel. Most of these techniques require the specification of the range of human error probabilities for various tasks. Unfortunately, very little objective performance data on error probabilities exist for nuclear environments. Thus, when human reliability estimates are required, for example in computer simulation modeling of system reliability, only subjective estimates (usually based on experts' best guesses) can be provided. The objective of the current research is to provide guidelines for the selection of human error probabilities based on actual performance data taken in other complex environments and applying them to nuclear settings. A key feature of this research is the application of a comprehensive taxonomic approach to nuclear and non-nuclear tasks to evaluate their similarities and differences, thus providing a basis for generalizing human error estimates across tasks. In recent years significant developments have occurred in classifying and describing tasks. Initial goals of the current research are to: (1) identify alternative taxonomic schemes that can be applied to tasks, and (2) describe nuclear tasks in terms of these schemes. Three standardized taxonomic schemes (Ability Requirements Approach, Generalized Information-Processing Approach, Task Characteristics Approach) are identified, modified, and evaluated for their suitability in comparing nuclear and non-nuclear power plant tasks. An agenda for future research and its relevance to nuclear power plant safety is also discussed

Background and Theory Behind the Compensation, Accessions, and Personnel Management (CAPM) Model

National Research Council Canada - National Science Library

Ausink, John; Cave, Jonathan; Carrillo, Manuel

2003-01-01

.... This report descries the Compensation, Accession, and Personnel Management (CAPM) model, which was developed to be a relatively easy-to-use personal computer-based analytical tool that would enable decisionmakers to study the effects of changes in policy on retention behavior and future inventories of military personnel.

The content of lexical stimuli and self-reported physiological state modulate error-related negativity amplitude.

Science.gov (United States)

Benau, Erik M; Moelter, Stephen T

2016-09-01

The Error-Related Negativity (ERN) and Correct-Response Negativity (CRN) are brief event-related potential (ERP) components-elicited after the commission of a response-associated with motivation, emotion, and affect. The Error Positivity (Pe) typically appears after the ERN, and corresponds to awareness of having committed an error. Although motivation has long been established as an important factor in the expression and morphology of the ERN, physiological state has rarely been explored as a variable in these investigations. In the present study, we investigated whether self-reported physiological state (SRPS; wakefulness, hunger, or thirst) corresponds with ERN amplitude and type of lexical stimuli. Participants completed a SRPS questionnaire and then completed a speeded Lexical Decision Task with words and pseudowords that were either food-related or neutral. Though similar in frequency and length, food-related stimuli elicited increased accuracy, faster errors, and generated a larger ERN and smaller CRN than neutral words. Self-reported thirst correlated with improved accuracy and smaller ERN and CRN amplitudes. The Pe and Pc (correct positivity) were not impacted by physiological state or by stimulus content. The results indicate that physiological state and manipulations of lexical content may serve as important avenues for future research. Future studies that apply more sensitive measures of physiological and motivational state (e.g., biomarkers for satiety) or direct manipulations of satiety may be a useful technique for future research into response monitoring. Copyright © 2016 Elsevier Inc. All rights reserved.

Job stress, depression, work performance, and perceptions of supervisors in military personnel.

Science.gov (United States)

Pflanz, Steven E; Ogle, Alan D

2006-09-01

Recent studies have identified high levels of job stress in military personnel. This study examined the relationship among job stress, depression, work performance, types of stressors, and perceptions about supervisors in military personnel. Eight hundred nine military personnel answered a 43-item survey on work stress, physical and emotional health, work performance, perceptions about leadership, job stressors, and demographics. More than one- quarter (27.4%) of this military population reported suffering from significant job stress. Both the report of work stress and depression were significantly related to impaired work performance, more days of missed work, poorer physical health, and negative perceptions about the abilities of supervisors and commanders. Depression and job stress were significantly and positively related to each other. These results support accumulating data indicating that work stress is a significant occupational health hazard in the routine military work environment. Targeting and eliminating sources of job stress should be a priority for the U.S. military to preserve and protect the mental health of military personnel.

Barriers and facilitators to recovering from e-prescribing errors in community pharmacies.

Science.gov (United States)

Odukoya, Olufunmilola K; Stone, Jamie A; Chui, Michelle A

2015-01-01

To explore barriers and facilitators to recovery from e-prescribing errors in community pharmacies and to explore practical solutions for work system redesign to ensure successful recovery from errors. Cross-sectional qualitative design using direct observations, interviews, and focus groups. Five community pharmacies in Wisconsin. 13 pharmacists and 14 pharmacy technicians. Observational field notes and transcribed interviews and focus groups were subjected to thematic analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) work system and patient safety model. Barriers and facilitators to recovering from e-prescription errors in community pharmacies. Organizational factors, such as communication, training, teamwork, and staffing levels, play an important role in recovering from e-prescription errors. Other factors that could positively or negatively affect recovery of e-prescription errors include level of experience, knowledge of the pharmacy personnel, availability or usability of tools and technology, interruptions and time pressure when performing tasks, and noise in the physical environment. The SEIPS model sheds light on key factors that may influence recovery from e-prescribing errors in pharmacies, including the environment, teamwork, communication, technology, tasks, and other organizational variables. To be successful in recovering from e-prescribing errors, pharmacies must provide the appropriate working conditions that support recovery from errors.

Personnel Monitoring Department - DEMIN

International Nuclear Information System (INIS)

1989-01-01

The activities and purposes of the Personnel Monitoring Dept. of the Institute of Radioprotection and Dosimetry of the Brazilian CNEN are presented. A summary of the personnel monitoring service is given, such as dosemeters supply, laboratorial inspections, and so on. The programs of working, publishing, courses and personnel interchange are also presented. (J.A.M.M.)

IAEA world survey on nuclear power plant personnel training

International Nuclear Information System (INIS)

1999-01-01

Training of personnel is acknowledged to be essential for safe and reliable operation of nuclear power plants. The preparation of this TECDOC was recommended by the IAEA International Working group on Nuclear Power Plant Personnel Training and Qualification and represents a unique compilation of information including all aspects of NPP personnel training from 23 Member States and 129 training organizations. The basic aims of this survey are: to provide a worldwide overview of all aspects of NPP personnel training; to foster both national and international cooperation between organizations involved in nuclear training; to provide the means of exchange of experiences and practices in systematic approach to training (SAT). The survey provides information for each corresponding country on the: national system and organization of training; job positions for which SAT is used; training programmes for key operations, maintenance, instructor and other jobs; role of management and the regulatory body; training facilities; recommended training practices; availability of training personnel from organizations outside the country; and contact points. The three main parts of the publication are the summary, the analysis of training programmes for each job position and the analysis of training resources, and the country reports

Source Memory Errors Associated with Reports of Posttraumatic Flashbacks: A Proof of Concept Study

Science.gov (United States)

Brewin, Chris R.; Huntley, Zoe; Whalley, Matthew G.

2012-01-01

Flashbacks are involuntary, emotion-laden images experienced by individuals with posttraumatic stress disorder (PTSD). The qualities of flashbacks could under certain circumstances lead to source memory errors. Participants with PTSD wrote a trauma narrative and reported the experience of flashbacks. They were later presented with stimuli from…

Awareness of technology-induced errors and processes for identifying and preventing such errors.

Science.gov (United States)

Bellwood, Paule; Borycki, Elizabeth M; Kushniruk, Andre W

2015-01-01

There is a need to determine if organizations working with health information technology are aware of technology-induced errors and how they are addressing and preventing them. The purpose of this study was to: a) determine the degree of technology-induced error awareness in various Canadian healthcare organizations, and b) identify those processes and procedures that are currently in place to help address, manage, and prevent technology-induced errors. We identified a lack of technology-induced error awareness among participants. Participants identified there was a lack of well-defined procedures in place for reporting technology-induced errors, addressing them when they arise, and preventing them.

Personnel monitoring- overexposure investigations and follow-up in non-DAE institutions during 1994-2003

International Nuclear Information System (INIS)

Mahajan, J.M.; Massand, O.P.

2004-04-01

Personnel Monitoring Section, Bhabha Atomic Research Centre, Mumbai, is entrusted with the responsibility of providing a countrywide personnel monitoring to radiation workers using external radiation like X, beta, gamma and neutron. As per Radiation Protection Rules (RPR) of 1971 promulgated by the competent authority the personnel monitoring service is mandatory for all the workers working with radiation. The radiation exposures received by them should be within the limits prescribed by AERB. For effective control of doses to the radiation workers the reporting, investigation and follow-up of overexposure cases play an important part in the countrywide personnel monitoring programme. Various aspects of overexposure investigations and follow-up as well as the analysis of overexposure doses recorded or received by the radiation workers during 1994 to 2003 are presented in this report. (author)

An intervention to decrease patient identification band errors in a children's hospital.

Science.gov (United States)

Hain, Paul D; Joers, B; Rush, M; Slayton, J; Throop, P; Hoagg, S; Allen, L; Grantham, J; Deshpande, J K

2010-06-01

Patient misidentification continues to be a quality and safety issue. There is a paucity of US data describing interventions to reduce identification band error rates. Monroe Carell Jr Children's Hospital at Vanderbilt. Percentage of patients with defective identification bands. Web-based surveys were sent, asking hospital personnel to anonymously identify perceived barriers to reaching zero defects with identification bands. Corrective action plans were created and implemented with ideas from leadership, front-line staff and the online survey. Data from unannounced audits of patient identification bands were plotted on statistical process control charts and shared monthly with staff. All hospital personnel were expected to "stop the line" if there were any patient identification questions. The first audit showed a defect rate of 20.4%. The original mean defect rate was 6.5%. After interventions and education, the new mean defect rate was 2.6%. (a) The initial rate of patient identification band errors in the hospital was higher than expected. (b) The action resulting in most significant improvement was staff awareness of the problem, with clear expectations to immediately stop the line if a patient identification error was present. (c) Staff surveys are an excellent source of suggestions for combating patient identification issues. (d) Continued audit and data collection is necessary for sustainable staff focus and continued improvement. (e) Statistical process control charts are both an effective method to track results and an easily understood tool for sharing data with staff.

Medication administration errors in Eastern Saudi Arabia

International Nuclear Information System (INIS)

Mir Sadat-Ali

2010-01-01

To assess the prevalence and characteristics of medication errors (ME) in patients admitted to King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia. Medication errors are documented by the nurses and physicians standard reporting forms (Hospital Based Incident Report). The study was carried out in King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia and all the incident reports were collected during the period from January 2008 to December 2009. The incident reports were analyzed for age, gender, nationality, nursing unit, and time where ME was reported. The data were analyzed and the statistical significance differences between groups were determined by Student's t-test, and p-values of <0.05 using confidence interval of 95% were considered significant. There were 38 ME reported for the study period. The youngest patient was 5 days and the oldest 70 years. There were 31 Saudis, and 7 non-Saudi patients involved. The most common error was missed medication, which was seen in 15 (39.5%) patients. Over 15 (39.5%) of errors occurred in 2 units (pediatric medicine, and obstetrics and gynecology). Nineteen (50%) of the errors occurred during the 3-11 pm shift. Our study shows that the prevalence of ME in our institution is low, in comparison with the world literature. This could be due to under reporting of the errors, and we believe that ME reporting should be made less punitive so that ME can be studied and preventive measures implemented (Author).

Error management process for power stations

International Nuclear Information System (INIS)

Hirotsu, Yuko; Takeda, Daisuke; Fujimoto, Junzo; Nagasaka, Akihiko

2016-01-01

The purpose of this study is to establish 'error management process for power stations' for systematizing activities for human error prevention and for festering continuous improvement of these activities. The following are proposed by deriving concepts concerning error management process from existing knowledge and realizing them through application and evaluation of their effectiveness at a power station: an entire picture of error management process that facilitate four functions requisite for maraging human error prevention effectively (1. systematizing human error prevention tools, 2. identifying problems based on incident reports and taking corrective actions, 3. identifying good practices and potential problems for taking proactive measures, 4. prioritizeng human error prevention tools based on identified problems); detail steps for each activity (i.e. developing an annual plan for human error prevention, reporting and analyzing incidents and near misses) based on a model of human error causation; procedures and example of items for identifying gaps between current and desired levels of executions and outputs of each activity; stages for introducing and establishing the above proposed error management process into a power station. By giving shape to above proposals at a power station, systematization and continuous improvement of activities for human error prevention in line with the actual situation of the power station can be expected. (author)

Operational Stress and Correlates of Mental Health Among Joint Task Force Guantanamo Bay Military Personnel.

Science.gov (United States)

Webb-Murphy, Jennifer A; De La Rosa, Gabriel M; Schmitz, Kimberly J; Vishnyak, Elizabeth J; Raducha, Stephanie C; Roesch, Scott C; Johnston, Scott L

2015-12-01

Military personnel deployed to Joint Task Force Guantanamo Bay (JTF-GTMO) faced numerous occupational stressors. As part of a program evaluation, personnel working at JTF-GTMO completed several validated self-report measures. Personnel were at the beginning, middle, or end of their deployment phase. This study presents data regarding symptoms of posttraumatic stress disorder, alcohol abuse, depression, and resilience among 498 U.S. military personnel deployed to JTF-GTMO in 2009. We also investigated individual and organizational correlates of mental health among these personnel. Findings indicated that tenure at JTF-GTMO was positively related to adverse mental health outcomes. Regression models including these variables had R2 values ranging from .02 to .11. Occupation at JTF-GTMO also related to mental health such that guards reported poorer mental health than medical staff. Reluctance to seek out mental health care was also related to mental health outcomes. Those who reported being most reluctant to seek out care tended to report poorer mental health than those who were more willing to seek out care. Results suggested that the JTF-GTMO deployment was associated with significant psychological stress, and that both job-related and attitude-related variables were important to understanding mental health symptoms in this sample. Copyright © 2015 International Society for Traumatic Stress Studies.

Tendencies in human factor influence on initiating events occurrence in NPP Kozloduy

International Nuclear Information System (INIS)

Hristova, R.

2001-01-01

Overview of the methods and documents concerning human factor in nuclear safety and selection of the most appropriate methods and concept for human factor assessment in the reported events in Kozloduy NPP are presented. List of human error types and statistical data (the mean time between similar errors, the human rate λ, the number of occurrences ect.) is given. Some general results from the human error behavior investigation for all units of Kozloduy NPP related to the 4 personnel categories: Management personnel, Designers, Operating personnel, Maintenance personnel are also shown. At the end the following conclusion are made:18 % operating personnel errors (for comparison for the same category personnel in similar NPPs abroad this value is between 10 % and 30%); Human errors in Kozloduy NPP tend to increase after year 1990; only for the operating personnel a maximum near year 1997 was observed, after which the error values was decreased; at the beginning of year 2000 the reliability characteristics for all units have similar values; it is necessary to be taken into account the observed tendencies to take measurements for reducing of the most important error types for Kozloduy NPP personnel

Survey of international personnel radiation dosimetry programs

International Nuclear Information System (INIS)

Swaja, R.E.

1985-04-01

In September of 1983, a mail survey was conducted to determine the status of external personnel gamma and neutron radiation dosimetry programs at international agencies. A total of 130 agencies participated in this study including military, regulatory, university, hospital, laboratory, and utility facilities. Information concerning basic dosimeter types, calibration sources, calibration phantoms, corrections to dosimeter responses, evaluating agencies, dose equivalent reporting conventions, ranges of typical or expected dose equivalents, and degree of satisfaction with existing systems was obtained for the gamma and neutron personnel monitoring programs at responding agencies. Results of this survey indicate that to provide the best possible occupational radiation monitoring programs and to improve dosimetry accuracy in performance studies, facility dosimetrists, regulatory and standards agencies, and research laboratories must act within their areas of responsibility to become familiar with their radiation monitoring systems, establish common reporting guidelines and performance standards, and provide opportunities for dosimetry testing and evaluation. 14 references, 10 tables

Incident reporting: Its role in aviation safety and the acquisition of human error data

Science.gov (United States)

Reynard, W. D.

1983-01-01

The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

Suicidal or Self-Harming Ideation in Military Personnel Transitioning to Civilian Life

Science.gov (United States)

Mansfield, Alyssa J.; Bender, Randall H.; Hourani, Laurel L.; Larson, Gerald E.

2011-01-01

Suicides have markedly increased among military personnel in recent years. We used path analysis to examine factors associated with suicidal/self-harming ideation among male Navy and Marine Corps personnel transitioning to civilian life. Roughly 7% of men (Sailors = 5.3%, Marines = 9.0%) reported ideation during the previous 30 days. Results…

Preventing statistical errors in scientific journals.

NARCIS (Netherlands)

Nuijten, M.B.

2016-01-01

There is evidence for a high prevalence of statistical reporting errors in psychology and other scientific fields. These errors display a systematic preference for statistically significant results, distorting the scientific literature. There are several possible causes for this systematic error

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

Science.gov (United States)

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

2017-12-21

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

Evaluating a medical error taxonomy.

OpenAIRE

Brixey, Juliana; Johnson, Todd R.; Zhang, Jiajie

2002-01-01

Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a stand...

Impact of Measurement Error on Synchrophasor Applications

Energy Technology Data Exchange (ETDEWEB)

Liu, Yilu [Univ. of Tennessee, Knoxville, TN (United States); Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Gracia, Jose R. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Ewing, Paul D. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Zhao, Jiecheng [Univ. of Tennessee, Knoxville, TN (United States); Tan, Jin [Univ. of Tennessee, Knoxville, TN (United States); Wu, Ling [Univ. of Tennessee, Knoxville, TN (United States); Zhan, Lingwei [Univ. of Tennessee, Knoxville, TN (United States)

2015-07-01

Phasor measurement units (PMUs), a type of synchrophasor, are powerful diagnostic tools that can help avert catastrophic failures in the power grid. Because of this, PMU measurement errors are particularly worrisome. This report examines the internal and external factors contributing to PMU phase angle and frequency measurement errors and gives a reasonable explanation for them. It also analyzes the impact of those measurement errors on several synchrophasor applications: event location detection, oscillation detection, islanding detection, and dynamic line rating. The primary finding is that dynamic line rating is more likely to be influenced by measurement error. Other findings include the possibility of reporting nonoscillatory activity as an oscillation as the result of error, failing to detect oscillations submerged by error, and the unlikely impact of error on event location and islanding detection.

A Global Perspective of Vaccination of Healthcare Personnel against Measles: Systematic Review

Science.gov (United States)

Fiebelkorn, Amy Parker; Seward, Jane F.; Orenstein, Walter

2015-01-01

Measles transmission has been well documented in healthcare facilities. Healthcare personnel who are unvaccinated and who lack other evidence of measles immunity put themselves and their patients at risk for measles. We conducted a systematic literature review of measles vaccination policies and their implementation in healthcare personnel, measles seroprevalence among healthcare personnel, measles transmission and disease burden in healthcare settings, and impact/costs incurred by healthcare facilities for healthcare-associated measles transmission. Five database searches yielded 135 relevant articles; 47 additional articles were found through cross-referencing. The risk of acquiring measles is estimated to be 2 to 19 times higher for susceptible healthcare personnel than for the general population. Fifty-three articles published worldwide during 1989–2013 reported measles transmission from patients to healthcare personnel; many of the healthcare personnel were unvaccinated or had unknown vaccination status. Eighteen articles published worldwide during 1982–2013 described examples of transmission from healthcare personnel to patients or to other healthcare personnel. Half of European countries have no measles vaccine policies for healthcare personnel. There is no global policy recommendation for the vaccination of healthcare personnel against measles. Even in countries such as the United States or Finland that have national policies, the recommendations are not uniformly implemented in healthcare facilities. Measles serosusceptibility in healthcare personnel varied widely across studies (median 6.5%, range 0%-46%) but was consistently higher among younger healthcare personnel. Deficiencies in documentation of two doses of measles vaccination or other evidence of immunity among healthcare personnel presents challenges in responding to measles exposures in healthcare settings. Evaluating and containing exposures and outbreaks in healthcare settings can be

Qualification of NPP operations personnel

International Nuclear Information System (INIS)

Wang Jiao.

1987-01-01

Competence of personnel is one of the important problems for safety operation of nuclear power plant. This paper gives a description of some aspects, such as the administration of NPP, posts, competence of personnel, training, assessing the competence and personnel management

TLD personnel dosimetry and its relationship with the radiodiagnostic training

International Nuclear Information System (INIS)

Gaona, E.; Franco E, J.G.; Gaona C, E.

2002-01-01

The personnel dosimetry and the training in radiological protection in radiodiagnostic in Mexico before 1997 were almost nonexistent except few services of public and private radiology, we can to say that the personnel dosimetry and the obligatory training was born in the year 1997, together with the present Mexican Official Standards in radiology. This study has the purpose to make an evaluation of the personnel dosimetry of 110 radiology services distributed in the Mexican Republic for the year 2001 and to estimate the annual and bimonthly mean doses, as well as its trust intervals and its relationships with the personnel training in radiological protection by means of a sampling that was realized in two stages (1997 and 2000) in the metropolitan area of Mexico City. The results show that the received doses by the medical and technical personnel in the participating radiology services are in the 0.03 mSv and 0.94 mSv interval and the mean is 0.25 mSv. The estimated annual personnel dose would be in the 0.18 mSv to 5.64 mSv interval, which are values very lower to the annual dose limit that is 50 mSv and its magnitude is similar to the effective annual dose by natural background radiation. In the first stage in training was found that there is not a significant difference in the response frequencies among the medical and technical personnel with a p < 0.05. The 52% of the occupational exposure personnel of radiology uses dosemeter, but only 17% of them know the dose reports. the 15.8% of personnel considers that dosemeter protects against radiation and only 16.5% knows the annual maximum permissible dose for stochastic effects. The second stage, the results shown that there is a significant difference in the response of frequencies among medical and technical personnel, the same results which are obtained for members and non members of a professional association with a p < 0.05. The 38% has personnel dosimetry, the 19% knows the principles of radiological

Errorful and errorless learning: The impact of cue-target constraint in learning from errors.

Science.gov (United States)

Bridger, Emma K; Mecklinger, Axel

2014-08-01

The benefits of testing on learning are well described, and attention has recently turned to what happens when errors are elicited during learning: Is testing nonetheless beneficial, or can errors hinder learning? Whilst recent findings have indicated that tests boost learning even if errors are made on every trial, other reports, emphasizing the benefits of errorless learning, have indicated that errors lead to poorer later memory performance. The possibility that this discrepancy is a function of the materials that must be learned-in particular, the relationship between the cues and targets-was addressed here. Cued recall after either a study-only errorless condition or an errorful learning condition was contrasted across cue-target associations, for which the extent to which the target was constrained by the cue was either high or low. Experiment 1 showed that whereas errorful learning led to greater recall for low-constraint stimuli, it led to a significant decrease in recall for high-constraint stimuli. This interaction is thought to reflect the extent to which retrieval is constrained by the cue-target association, as well as by the presence of preexisting semantic associations. The advantage of errorful retrieval for low-constraint stimuli was replicated in Experiment 2, and the interaction with stimulus type was replicated in Experiment 3, even when guesses were randomly designated as being either correct or incorrect. This pattern provides support for inferences derived from reports in which participants made errors on all learning trials, whilst highlighting the impact of material characteristics on the benefits and disadvantages that accrue from errorful learning in episodic memory.

76 FR 78658 - Webinar Overview of the National Vaccine Advisory Committee Healthcare Personnel Influenza...

Science.gov (United States)

2011-12-19

... Committee Healthcare Personnel Influenza Vaccination Subgroup's Draft Report and Draft Recommendations for Achieving the Healthy People 2020 Annual Coverage Goals for Influenza Vaccination in Healthcare Personnel... Influenza Vaccination Subgroup (HCPIVS), will host an informational webinar to introduce the committee's...

Personnel neutron dosimetry using TLD elements at PNC

International Nuclear Information System (INIS)

Ishiguro, Hideharu

1985-01-01

The evaluation method of neutron dose equivalent was studied on the basis of the albedo type neutron dosimetory to design the personnel dosimeter. The dosimeter was composed of three 6 Li 2 10 B 4 O 7 (Cu) TL elements and one 7 Li 2 11 B 4 O 7 (Cu) element. The equations for assessing thermal, epithermal and fast neutron dose equivalents were derived by 252 Cf, 241 Am-Be and PuO 2 neutron sources. The minimum detectable amount of 6 Li 2 10 B 4 O 7 (Cu) element to thermal neutron was 0.02 m rem. The neutron dose equivalent and the gamma one were evaluated separately within about 20 % error in the mixed radiation field. (author)

Representing cognitive activities and errors in HRA trees

International Nuclear Information System (INIS)

Gertman, D.I.

1992-01-01

This paper discusses development of a means by which to present cognitive information in human reliability assessment (HRA) event trees. The descriptions found in probabilistic risk assessments (PRAs) regarding the demands on, and the resulting performance of, nuclear power plant (NPP) crews often make use of the technique for human error rate prediction (THERP), which provides a mechanism, the HRA event tree, for presenting the analyst's conceptualization of the activities underlying performance and the errors associated with that performance. When using THERP, analysts have often omitted the more complex elements of human cognition from these trees. There has yet to be a concerted effort to take theory, principles, and data from cognitive psychology and wed it to the logic structure of the HRA event tree. This paper attempts to do so. The COGENT modeling scheme (cognitively based HRA event trees) adds two taxonomies to the HRA event tree proposed by Swain and Guttman. The first taxonomy, the one proposed by Norman and Reason, describes the type of error committed and implies something about the underlying cognition as well. The second of these, the Rasmussen taxonomy, provides description regarding the skill-based, rule-based, or knowledge-based behavior underlying the execution of tasks. It is not apparent and must be deduced from the pattern of errors exhibited by personnel

The aspect of personnel metal attitude in the production safety

International Nuclear Information System (INIS)

Joyosukarto, Priyanto M.

2002-01-01

The occurrence of an accident could always be traced to component/system failures and/or human error. The two factors are closely related to competency of the personnel's involved, in which mental attitude is a decisive factor. Furthermore mental attitude could be viewed as an element of Safety (S) Culture. Consequently, S. Culture could might created or at lea ts, be enhanced by the introduction of appropriate values, norms, as well as attitudes. The ABC and TBC of safety norm have been discussed briefly. Whereas mental attitude has been defined and discussed in detail and graded into six levels, namely: attending, responding, complying, accepting, preferring, and integrating. To assure highest level of safety, personnel must achieve integrating level of attitude, in the sense that he would merely do an action on the basis of safety values and/or norms prevailing in the system, not due to external pressure. Furthermore, considering the work as a physical and an emotional activity resulting in stress and strain on the body, Karate exercises have been promoted as an alternative for enhancing mental attitude by means of reducing personnel vulnerability to strain and stress. This method is accomplished by exploiting Roux's Low of conditioning effect and by implementation of an in-depth understanding on the spiritual aspect of Karate. It is concluded that in the field of production safety, there is a positive correlation between Karate, mental attitude, competence, performance, quality, and safety

DETECTING AND REPORTING THE FRAUDS AND ERRORS BY THE AUDITOR

OpenAIRE

Ovidiu Constantin Bunget; Alin Constantin Dumitrescu

2009-01-01

Responsibility for preventing and detecting fraud rest with management entities.Although the auditor is not and cannot be held responsible for preventing fraud and errors, in yourwork, he can have a positive role in preventing fraud and errors by deterring their occurrence. Theauditor should plan and perform the audit with an attitude of professional skepticism, recognizingthat condition or events may be found that indicate that fraud or error may exist.Based on the audit risk assessment, aud...

Workplace victimization risk and protective factors for suicidal behavior among active duty military personnel.

Science.gov (United States)

Hourani, Laurel L; Williams, Jason; Lattimore, Pamela K; Morgan, Jessica K; Hopkinson, Susan G; Jenkins, Linda; Cartwright, Joel

2018-04-22

Workplace victimization is a potential risk factor for suicidal behaviors (SB) among military personnel that has been largely overlooked. This paper examines both the impact of workplace victimization on reported SB and several potential protective factors associated with such suicidal behaviors in a large sample of active duty soldiers. A case-control study was conducted with 71 soldiers who reported SB in the past 12 months, each matched on sociodemographic characteristics to two others without reported suicidal behaviors. A multiple regression model was estimated to assess the effects of risk and protective factors while controlling for other variables. SB was associated with several aspects of victimization, mental health and substance abuse conditions, pain, impulsivity, stressors, negative life events, work-family conflict, active coping behaviors and positive military-related factors. Controlling for other variables, those with SB were more likely to have sought mental health or substance abuse services, to be depressed, anxious, impulsive, and less resilient than non-SB personnel. Study limitations included the use of retrospective self-report data, absence of some known SB predictors, and a population restricted to active duty Army personnel. SB among active duty personnel is associated with victimization since joining the military and is protected by resiliency. These findings suggest that in addition to the usual mental health factors, these additional predictors should be accounted for in SB intervention and prevention planning for active duty personnel. Copyright © 2018 Elsevier B.V. All rights reserved.

Pilot Error in Air Carrier Mishaps: Longitudinal Trends Among 558 Reports, 1983–2002

Science.gov (United States)

Baker, Susan P.; Qiang, Yandong; Rebok, George W.; Li, Guohua

2009-01-01

Background Many interventions have been implemented in recent decades to reduce pilot error in flight operations. This study aims to identify longitudinal trends in the prevalence and patterns of pilot error and other factors in U.S. air carrier mishaps. Method National Transportation Safety Board investigation reports were examined for 558 air carrier mishaps during 1983–2002. Pilot errors and circumstances of mishaps were described and categorized. Rates were calculated per 10 million flights. Results The overall mishap rate remained fairly stable, but the proportion of mishaps involving pilot error decreased from 42% in 1983–87 to 25% in 1998–2002, a 40% reduction. The rate of mishaps related to poor decisions declined from 6.2 to 1.8 per 10 million flights, a 71% reduction; much of this decrease was due to a 76% reduction in poor decisions related to weather. Mishandling wind or runway conditions declined by 78%. The rate of mishaps involving poor crew interaction declined by 68%. Mishaps during takeoff declined by 70%, from 5.3 to 1.6 per 10 million flights. The latter reduction was offset by an increase in mishaps while the aircraft was standing, from 2.5 to 6.0 per 10 million flights, and during pushback, which increased from 0 to 3.1 per 10 million flights. Conclusions Reductions in pilot errors involving decision making and crew coordination are important trends that may reflect improvements in training and technological advances that facilitate good decisions. Mishaps while aircraft are standing and during push-back have increased and deserve special attention. PMID:18225771

Development of neutron personnel monitoring system based on CR-39 solid state nuclear track detector

International Nuclear Information System (INIS)

Massand, O.P.; Kundu, H.K.; Marathe, P.K.; Supe, S.J.

1990-01-01

Personnel neutron monitoring aims at providing a method to evaluate the magnitude of the detrimental effects on the personnel exposed to neutrons. Neutron monitoring is done for a small though growing number of personnel working with neutrons in a wide range of situations. Over the years, many solid state nuclear track detectors (SSNTD) have been tried for neutron personnel monitoring. CR-39 SSNTD is a proton sensitive polymer and offers a lot of promise for neutron personnel monitoring due to its high sensitivity and lower energy threshold for neutron detection. This report presents the mechanism of track formation in this polymer, the development of this neutron personnel monitoring system in our laboratory, its various characteristics and its promise as a routine personnel neutron monitor. (author). 1 tab., 7 figs

Radiation monitoring data representation for duty personnel

Energy Technology Data Exchange (ETDEWEB)

Gavrilov, S.L.; Kiselev, V.P.; Krasnoperov, S.N.; Kudeshov, E.V.; Maslov, S.Y.; Semin, N.N.; Sirotinskiy, S.E.; Yakovlev, V.Y. [Nuclear Safety Institute of the Russian Academy of Sciences (NSI RAS), Moscow (Russian Federation)

2014-07-01

Currently, Web-GIS technologies are widely used to generate a reliable and intuitive web-based interface to monitor the current radiation situation in various regions of the Russian Federation. The developed 'Server Web-Monitoring' web-application is intended for duty personnel and can operate not only on desktop computers but also on mobile devices. The subsystem of duty personnel notification about any Off-Normal Situation (ONS) (such as: critical threshold exceedances or failures in operation of monitoring systems) is also considered in the paper. Three types of Automated Radiation Monitoring Systems (ARMS) are available for monitoring: - regional ARMS; - facility-level ARMS; - ARMS of nuclear power plant surveillance areas. Google Maps and Google Maps API toolbox are used as the cartographic basis. In the general-monitoring window only general information on each of the local systems is available. Next, the operator can move to monitoring of local ARMS he is interested in. The operator can either view a list of Radiation Situation Monitoring Posts (RSMP) showing the current data in the right frame or hide it and use the map only. Viewing the log of critical threshold exceedances for 24 hours and a report on all RSMPs of a given system over the last 7 days is also possible. The report contains maximum values of measurements for every day and for each RSMP. The developed web-application includes: - monitoring of the radiation situation and its changes on the general map of the Russian Federation and on maps of local ARMS; - displaying 7-day reports for all RSMPs of the selected ARMS; - displaying the log of critical threshold exceedances recorded over the past day. The notification subsystem informs duty personnel on all ONS, namely, on critical threshold exceedances in the incoming data and failures in operation of monitoring systems. The key features of the notification subsystem are: - round-the-clock functioning; - automatic notification in case of

Basis scheme of personnel training system

International Nuclear Information System (INIS)

Rerucha, F.; Odehnal, J.

1998-01-01

Basic scheme of the training system for NPP personnel of CEZ-EDU personnel training system is described in detail. This includes: specific training both basic and periodic, and professional training meaning specialized and continuous training. The following schemes are shown: licence acquisition and authorisation for PWR-440 Control Room Personnel; upgrade training for job positions of Control Room personnel; maintaining and refresh training; module training for certificate acquisition of servicing shift and operating personnel

Department of the Army - The Fiscal Year 2008 Military Personnel, Army Appropriation and the Antideficiency Act

Science.gov (United States)

2010-06-22

of the Army, U.S. Army Audit Agency, Budgeting for the Military Personnel, Army Appropriation, Report No. A-2010-0028- FFM (Jan. 6, 2010); Department...of the Army, U.S. Army Audit Agency, Military Personnel, Army FY 05 Subsistence Charges, Report No. A-2008-0037- FFM (Feb. 12, 2008); Department of

Personnel protective equipment total-encapsulating suit decontamination study using shower systems

International Nuclear Information System (INIS)

Menkhaus, D.E.

1991-01-01

This report documents an experimental evaluation, conducted at the Idaho National Engineering Laboratory, of a shower-based decontamination station for personnel wearing a Level A, total- encapsulating, chemical-protective suit. The decontamination station is used by personnel when egressing a dry, dusty environment contaminated with transuranic radionuclides. This system has the potential to minimize the risk of spreading the contaminants to clean areas. Two types of shower systems were evaluated, a drench shower and a multi-nozzle shower. A total-encapsulating suit, worn by personnel. was contaminated with soil containing 239 Pu. Pre- shower and post-shower contamination samples were collected and visual observations were made to evaluate the ability of the shower system to remove the contaminated dust and to obtain baseline data useful in designing a shower-based personnel decontamination system. 12 figs., 7 tabs

Information Management System Development for the Investigation, Reporting, and Analysis of Human Error in Naval Aviation Maintenance

National Research Council Canada - National Science Library

Nelson, Douglas

2001-01-01

The purpose of this research is to evaluate and refine a safety information management system that will facilitate data collection, organization, query, analysis and reporting of maintenance errors...

Radiographer and radiologist perception error in reporting double contrast barium enemas: A pilot study

International Nuclear Information System (INIS)

Booth, Alison M.; Mannion, Richard A.J.

2005-01-01

Purpose: The practice of radiographers performing double contrast barium enemas (DCBE) is now widespread and in many centres the radiographer's opinion is, at least, contributing to a dual reporting system [Bewell J, Chapman AH. Radiographer performed barium enemas - results of a survey to assess progress. Radiography 1996;2:199-205; Leslie A, Virjee JP. Detection of colorectal carcinoma on double contrast barium enema when double reporting is routinely performed: an audit of current practice. Clin Radiol 2001;57:184-7; Culpan DG, Mitchell AJ, Hughes S, Nutman M, Chapman AH. Double contrast barium enema sensitivity: a comparison of studies by radiographers and radiologists. Clin Radiol 2002;57:604-7]. To ensure this change in practice does not lead to an increase in reporting errors, this study aimed to compare the perception abilities of radiographers with those of radiologists. Methods: Three gastro-intestinal (GI) radiographers and three consultant radiologists independently reported on a selection of 50 DCBE examinations, including the level of certainty in their comments for each examination. A blinded comparison of the results with an independent 'standard report' was recorded. Results: The results demonstrate there was no significant difference in perception error for any of the levels of certainty, for single reporting, for double reading by a radiographer/radiologist or by two radiologists. Conclusions: The study shows that radiographers can perceive abnormalities on DCBE at similar sensitivities and specificities as radiologists. While the participants in the study may be typical of a district general hospital, the nature of the study gives it limited external validity. As a pilot, the results demonstrate that, with slight modification, the methodology could be used for a larger study

Errors in chest x-ray interpretation

International Nuclear Information System (INIS)

Woznitza, N.; Piper, K.

2015-01-01

Full text: Reporting of adult chest x-rays by appropriately trained radiographers is frequently used in the United Kingdom as one method to maintain a patient focused radiology service in times of increasing workload. With models of advanced practice being developed in Australia, New Zealand and Canada, the spotlight is on the evidence base which underpins radiographer reporting. It is essential that any radiographer who extends their scope of practice to incorporate definitive clinical reporting perform at a level comparable to a consultant radiologist. In any analysis of performance it is important to quantify levels of sensitivity and specificity and to evaluate areas of error and variation. A critical review of the errors made by reporting radiographers in the interpretation of adult chest x-rays will be performed, examining performance in structured clinical examinations, clinical audit and a diagnostic accuracy study from research undertaken by the authors, and including studies which have compared the performance of reporting radiographers and consultant radiologists. overall performance will be examined and common errors discussed using a case based approach. Methods of error reduction, including multidisciplinary team meetings and ongoing learning will be considered

Industry to Education Technology Transfer Program. Composite Materials--Personnel Development. Final Report.

Science.gov (United States)

Tomezsko, Edward S. J.

A composite materials education program was established to train Boeing Helicopter Company employees in the special processing of new filament-reinforced polymer composite materials. During the personnel development phase of the joint Boeing-Penn State University project, an engineering instructor from Penn State completed a 5-month, full-time…

Time-dependent, low-dose reporting limit for dosimeters that are taken home at the end of the workday

International Nuclear Information System (INIS)

Sonder, E.

1994-01-01

In routine personnel dosimetry, it is usual to report doses only where th occupational dose (measured dose with background subtracted) is greater than previously determined reporting limit. The reporting limit, although se administratively, should be justified by an assessment of the errors inherent in th personnel and background dose measurements, and estimates of the probability that a zero exposure will yield a dosimeter response equal to the reporting limit. For background subtraction and reporting limits, it was realized that the source of low-dose uncertainty is very much dependent on whether dosimeters are held in racks at the work site or remain with the employee. The External dosimetry Program for the DOE facilities at Oak Ridge, Tennessee, is operated such that dosimeters are taken home by the employee at the end of each workday. This report is a summary measurements of background radiation in a variety of home locations, and calculations of the effect of the variation of this background on the uncertainty low-level occupational dose and on the reporting level. When dosimeters are stored at a given location (e.g., the facility gate), it theoretically possible to determine the background there to any desired accuracy; the errors in occupational dose are then those due to measurement noise and dosimeter calibration. However, when different dosimeters are stored in different homes, th difference in background between a particular location and the average for a locations appears as an added uncertainty in the occupational dose. Since this difference is not random, but fixed for a given location, the error due to this difference increases linearly with assignment time. From the background measurements, time-dependent values of the standard deviation of occupational do and critical levels are derived and used to define an expression for the reporting limit

45 CFR 61.6 - Reporting errors, omissions, revisions or whether an action is on appeal.

Science.gov (United States)

2010-10-01

... 45 Public Welfare 1 2010-10-01 2010-10-01 false Reporting errors, omissions, revisions or whether an action is on appeal. 61.6 Section 61.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION HEALTHCARE INTEGRITY AND PROTECTION DATA BANK FOR FINAL ADVERSE INFORMATION ON...

Experience in the use of systematic approach to training (SAT) for nuclear power plant personnel

International Nuclear Information System (INIS)

1998-12-01

One of the essential requirements for safe and reliable nuclear power plant operation and maintenance is the availability of competent personnel, and thus systematic approach to training (SAT) is recognized world-wide. Many countries have applied and implemented the use of SAT in their training systems as demonstrated by the results of the IAEA World Survey on Nuclear Power Plant Personnel Training. This report complements two IAEA publications, the Guidebook on Nuclear Power Plant Personnel and its Evaluation (Technical Reports Series No. 380) and the IAEA World Survey of Nuclear Power Plant Personnel Training (IAEA-TECDOC-1063). It provides a detailed overview and analysis of the experience gained worldwide on the introduction and application of SAT, including the reasons why SAT was introduced and lessons learned. The technical document will be of use for nuclear power plant managers and supervisors and all those responsible for training of personnel. The report was initiated by the International Working Group at a Technical Committee Meeting. Experiences gained from the application of SAT in the following Member States are included: Armenia, Bulgaria, Canada, China, Czech Republic, Finland, France, Germany, Hungary, India, Kazakhstan, Lithuania, Mexico, Romania, Russian Federation, Slovenia, Slovakia, Spain, Sweden, Ukraine, United Kingdom and United States of America

Experience in the use of systematic approach to training (SAT) for nuclear power plant personnel

Energy Technology Data Exchange (ETDEWEB)

NONE

1998-12-01

One of the essential requirements for safe and reliable nuclear power plant operation and maintenance is the availability of competent personnel, and thus systematic approach to training (SAT) is recognized world-wide. Many countries have applied and implemented the use of SAT in their training systems as demonstrated by the results of the IAEA World Survey on Nuclear Power Plant Personnel Training. This report complements two IAEA publications, the Guidebook on Nuclear Power Plant Personnel and its Evaluation (Technical Reports Series No. 380) and the IAEA World Survey of Nuclear Power Plant Personnel Training (IAEA-TECDOC-1063). It provides a detailed overview and analysis of the experience gained worldwide on the introduction and application of SAT, including the reasons why SAT was introduced and lessons learned. The technical document will be of use for nuclear power plant managers and supervisors and all those responsible for training of personnel. The report was initiated by the International Working Group at a Technical Committee Meeting. Experiences gained from the application of SAT in the following Member States are included: Armenia, Bulgaria, Canada, China, Czech Republic, Finland, France, Germany, Hungary, India, Kazakhstan, Lithuania, Mexico, Romania, Russian Federation, Slovenia, Slovakia, Spain, Sweden, Ukraine, United Kingdom and United States of America. Refs, figs, tabs

The District Nursing Clinical Error Reduction Programme.

Science.gov (United States)

McGraw, Caroline; Topping, Claire

2011-01-01

The District Nursing Clinical Error Reduction (DANCER) Programme was initiated in NHS Islington following an increase in the number of reported medication errors. The objectives were to reduce the actual degree of harm and the potential risk of harm associated with medication errors and to maintain the existing positive reporting culture, while robustly addressing performance issues. One hundred medication errors reported in 2007/08 were analysed using a framework that specifies the factors that predispose to adverse medication events in domiciliary care. Various contributory factors were identified and interventions were subsequently developed to address poor drug calculation and medication problem-solving skills and incorrectly transcribed medication administration record charts. Follow up data were obtained at 12 months and two years. The evaluation has shown that although medication errors do still occur, the programme has resulted in a marked shift towards a reduction in the associated actual degree of harm and the potential risk of harm.

Aged-care nurses in rural Tasmanian clinical settings more likely to think hypothetical medication error would be reported and disclosed compared to hospital and community nurses.

Science.gov (United States)

Carnes, Debra; Kilpatrick, Sue; Iedema, Rick

2015-12-01

This study aims to determine the likelihood that rural nurses perceive a hypothetical medication error would be reported in their workplace. This employs cross-sectional survey using hypothetical error scenario with varying levels of harm. Clinical settings in rural Tasmania. Participants were 116 eligible surveys received from registered and enrolled nurses. Frequency of responses indicating the likelihood that severe, moderate and near miss (no harm) scenario would 'always' be reported or disclosed. Eighty per cent of nurses viewed a severe error would 'always' be reported, 64.8% a moderate error and 45.7% a near-miss error. In regards to disclosure, 54.7% felt this was 'always' likely to occur for a severe error, 44.8% for a moderate error and 26.4% for a near miss. Across all levels of severity, aged-care nurses were more likely than nurses in other settings to view error to 'always' be reported (ranging from 72-96%, P = 0.010 to 0.042,) and disclosed (68-88%, P = 0.000). Those in a management role were more likely to view error to 'always' be disclosed compared to those in a clinical role (50-77.3%, P = 0.008-0.024). Further research in rural clinical settings is needed to improve the understanding of error management and disclosure. © 2015 The Authors. Australian Journal of Rural Health published by Wiley Publishing Asia Pty Ltd on behalf of National Rural Health Alliance.

Does the Current 20th Century Navy Personnel Management System Meet 21st Century Sailors’ Needs

Science.gov (United States)

2003-04-01

49 Personnel Management and Labor Economics Literature . . . . 56 Technical Reports of Defense Manpower Analysis...4. MANPOWER MODELING AND PERSONNEL CHARACTERISTICS 159 Labor Economics and Requirements Determination . . . . . . 159...assigned in courses. The second grouping concerns the key ideas of other authors on the subjects of personnel management and labor economics . Although the

Personnel Investigations and Clearance Tracking (OPI)

Data.gov (United States)

Office of Personnel Management — Security file-related information for the U.S. Office of Personnel Management (OPM)'s employee and contractor personnel. The data is OPM-specific, not government-wide.

Stress, mental health, and job performance among active duty military personnel: findings from the 2002 Department of Defense Health-Related Behaviors Survey.

Science.gov (United States)

Hourani, Laurel L; Williams, Thomas V; Kress, Amii M

2006-09-01

This study examined the extent to which high levels of occupational and family stress were associated with mental health problems and productivity loss among active duty military personnel. We analyzed data from the 2002 Department of Defense Survey of Health-Related Behaviors among Military Personnel, which provided extensive population-based information on 12,756 active duty personnel in all branches of the military worldwide. Military personnel reported higher levels of stress at work than in their family life. The personnel reporting the highest levels of occupational stress were those 25 or younger, those who were married with spouses not present, and women. Personnel with high levels of stress had significantly higher rates of mental health problems and productivity loss than those with less stress. We recommend that prevention and intervention efforts geared toward personnel reporting the highest levels of stress be given priority for resources in this population.

Common patterns in 558 diagnostic radiology errors.

Science.gov (United States)

Donald, Jennifer J; Barnard, Stuart A

2012-04-01

As a Quality Improvement initiative our department has held regular discrepancy meetings since 2003. We performed a retrospective analysis of the cases presented and identified the most common pattern of error. A total of 558 cases were referred for discussion over 92 months, and errors were classified as perceptual or interpretative. The most common patterns of error for each imaging modality were analysed, and the misses were scored by consensus as subtle or non-subtle. Of 558 diagnostic errors, 447 (80%) were perceptual and 111 (20%) were interpretative errors. Plain radiography and computed tomography (CT) scans were the most frequent imaging modalities accounting for 246 (44%) and 241 (43%) of the total number of errors, respectively. In the plain radiography group 120 (49%) of the errors occurred in chest X-ray reports with perceptual miss of a lung nodule occurring in 40% of this subgroup. In the axial and appendicular skeleton missed fractures occurred most frequently, and metastatic bone disease was overlooked in 12 of 50 plain X-rays of the pelvis or spine. The majority of errors within the CT group were in reports of body scans with the commonest perceptual errors identified including 16 missed significant bone lesions, 14 cases of thromboembolic disease and 14 gastrointestinal tumours. Of the 558 errors, 312 (56%) were considered subtle and 246 (44%) non-subtle. Diagnostic errors are not uncommon and are most frequently perceptual in nature. Identification of the most common patterns of error has the potential to improve the quality of reporting by improving the search behaviour of radiologists. © 2012 The Authors. Journal of Medical Imaging and Radiation Oncology © 2012 The Royal Australian and New Zealand College of Radiologists.

THEORETICAL BASIS FOR MANAGEMENT OF PERSONNEL RISKS

OpenAIRE

Haliashova, Katsiaryna

2017-01-01

Necessity of personnel risks management is based on research results. The authors' approaches to the determination of personnel risks and to their management have been explored. The author's definition of the concept of "personnel risks" is proposed. A classification of personnel risks is developed depending on the stage of origin and the tasks of the personnel policy, as well as the methods of management personnel risks in the organization. The article presents a methodical approach to perso...

Causes and prevention of violence toward emergency personnel by patients and their relatives in a province in Turkey.

Science.gov (United States)

Cebeci, Fatma; Sucu, Gülten; Karazeybek, Ebru

2009-03-23

STUDY OBJECTIVE: This research was conducted to determine the opinions of the emergency department's personnel about the causes and prevention of violence directed at them by patients and their relatives. METHODS: This research was conducted between 3 February and 15 June, 2006, in Antalya, a province in southern Turkey, with a total of 216 emergency department personnel who work in the emergency departments of three hospitals. A questionnaire developed by researchers was used to collect data for the purpose of determining what kind of violence is directed at emergency personnel by patients and their relatives and the personnel's socio-demographic characteristics and opinions. Pearson's chi and Fisher's exact test were used in the analysis of the data. RESULTS: Almost all (94.4%) of the participating emergency personnel had been exposed to verbal violence and 59.7% to physical violence. Only 24.5% of those exposed to violence reported the violence. The majority of the personnel (72.5%) thought that individuals' personality tendencies are the primary cause of violence. Their primary recommendation for preventing violence was to increase security measures. Statistically significant differences were found between emergency personnel's place of work and physical violence, between gender and physical violence, and between level of education and reporting violence. CONCLUSION: On the basis of the research results, it is recommended that emergency personnel be trained on the subject of violence, a documentation system be developed for recording and reporting violence, and corrections be made to prevent violence based on the personnel's opinions.

Revision of IMO Model Course 3.17 Maritime English. Focus on Maritime English to Auxiliary Personnel

Directory of Open Access Journals (Sweden)

L. Martes

2015-09-01

Full Text Available Under the Manila 2010 amendments to the STCW , all crew members on board cruise vessels, mainly those assisting passengers during emergency situations and not only, “should be able to communicate safety-related issues in English or in the language spoken by the passengers and other personnel on board.” Having in view that navigational and safety communications from ship to shore and vice versa, ship to ship, and on board ships must be precise, simple and unambiguous, so as to avoid confusion and error, besides the need to standardize the language used, there is a growing demand of developing communication skills in English, especially for personnel working on cruise vessels, but also on RORO vessels, yachts and small passenger vessels. This is the reason why we have designed, developed and are already delivering the “Maritime English for Auxiliary Personnel" course in Specialized Maritime English to auxiliary personnel working on board cruise vessels to develop their ability to communicate with passengers, mainly during an emergency. The course covers the specific language used to describe the parts of ships, organisation on board ships, all essential safety-related matters and work-specific topics. It also reflects the situations in which auxiliary personnel need to communicate, with each other, with other crew members and with shore side authorities. The final goal of this course is to improve fluency in spoken English in real life situations which, of course, can be both routine and non-routine.

Error tracking in a clinical biochemistry laboratory

DEFF Research Database (Denmark)

Szecsi, Pal Bela; Ødum, Lars

2009-01-01

BACKGROUND: We report our results for the systematic recording of all errors in a standard clinical laboratory over a 1-year period. METHODS: Recording was performed using a commercial database program. All individuals in the laboratory were allowed to report errors. The testing processes were cl...

Personnel radiation dosimetry

International Nuclear Information System (INIS)

1987-01-01

The book contains the 21 technical papers presented at the Technical Committee Meeting to Elaborate Procedures and Data for the Intercomparison of Personnel Dosimeters organizaed by the IAEA on 22-26 April 1985. A separate abstract was prepared for each of these papers. A list of areas in which additional research and development work is needed and recommendations for an IAEA-sponsored intercomparison program on personnel dosimetry is also included

Noise exposure and cognitive performance: A study on personnel on board Royal Norwegian Navy vessels.

Science.gov (United States)

Irgens-Hansen, Kaja; Gundersen, Hilde; Sunde, Erlend; Baste, Valborg; Harris, Anette; Bråtveit, Magne; Moen, Bente E

2015-01-01

Prior research shows that work on board vessels of the Royal Norwegian Navy (RNoN) is associated with noise exposure levels above recommended standards. Further, noise exposure has been found to impair cognitive performance in environmental, occupational, and experimental settings, although prior research in naval and maritime settings is sparse. The aim of this study was to evaluate cognitive performance after exposure to noise among personnel working on board vessels in the RNoN. Altogether 87 Navy personnel (80 men, 7 women; 31 ± 9 years) from 24 RNoN vessels were included. Noise exposure was recorded by personal noise dosimeters at a minimum of 4 h prior to testing, and categorized into 4 groups for the analysis: 85.2 dB(A). The participants performed a visual attention test based on the Posner cue-target paradigm. Multivariable general linear model (GLM) analyses were performed to analyze whether noise exposure was associated with response time (RT) when adjusting for the covariates age, alertness, workload, noise exposure in test location, sleep the night before testing, use of hearing protection device (HPD), and percentage of errors. When adjusting for covariates, RT was significantly increased among personnel exposed to >85.2 dB(A) and 77.1-85.2 dB(A) compared to personnel exposed to <72.6 dB(A).

Noise exposure and cognitive performance: A study on personnel on board Royal Norwegian Navy vessels

Directory of Open Access Journals (Sweden)

Kaja Irgens-Hansen

2015-01-01

Full Text Available Prior research shows that work on board vessels of the Royal Norwegian Navy (RNoN is associated with noise exposure levels above recommended standards. Further, noise exposure has been found to impair cognitive performance in environmental, occupational, and experimental settings, although prior research in naval and maritime settings is sparse. The aim of this study was to evaluate cognitive performance after exposure to noise among personnel working on board vessels in the RNoN. Altogether 87 Navy personnel (80 men, 7 women; 31 ± 9 years from 24 RNoN vessels were included. Noise exposure was recorded by personal noise dosimeters at a minimum of 4 h prior to testing, and categorized into 4 groups for the analysis: 85.2 dB(A. The participants performed a visual attention test based on the Posner cue-target paradigm. Multivariable general linear model (GLM analyses were performed to analyze whether noise exposure was associated with response time (RT when adjusting for the covariates age, alertness, workload, noise exposure in test location, sleep the night before testing, use of hearing protection device (HPD, and percentage of errors. When adjusting for covariates, RT was significantly increased among personnel exposed to >85.2 dB(A and 77.1-85.2 dB(A compared to personnel exposed to <72.6 dB(A.

Nurses' systems thinking competency, medical error reporting, and the occurrence of adverse events: a cross-sectional study.

Science.gov (United States)

Hwang, Jee-In; Park, Hyeoun-Ae

2017-12-01

Healthcare professionals' systems thinking is emphasized for patient safety. To report nurses' systems thinking competency, and its relationship with medical error reporting and the occurrence of adverse events. A cross-sectional survey using a previously validated Systems Thinking Scale (STS), was conducted. Nurses from two teaching hospitals were invited to participate in the survey. There were 407 (60.3%) completed surveys. The mean STS score was 54.5 (SD 7.3) out of 80. Nurses with higher STS scores were more likely to report medical errors (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.02-1.08) and were less likely to be involved in the occurrence of adverse events (OR = 0.96; 95% CI = 0.93-0.98). Nurses showed moderate systems thinking competency. Systems thinking was a significant factor associated with patient safety. Impact Statement: The findings of this study highlight the importance of enhancing nurses' systems thinking capacity to promote patient safety.

Some problems of NPP personnel training

International Nuclear Information System (INIS)

Vajshnis, P.P.; Kumkov, L.P.; Omel'chuk, V.V.

1984-01-01

Shortcomings of NPP personnel training are discussed. Development of full-scale training systems is necessary for qualitative training operative personnel. Primary problems that should be necessarily solved for ensuring effective training NPP personnel are considered

Technology-Induced Errors and Adverse Event Reporting in an Organizational Learning Perspective.

Science.gov (United States)

Vinther, Line Dausel; Jensen, Christian Møller; Hjelmager, Ditte Meulengracht; Lyhne, Nicoline; Nøhr, Christian

2017-01-01

This paper addresses the possibilities of evaluating technology-induced errors, through the utilization of experiences of the Danish adverse event reporting system. The learning loop in the adverse event reporting system is identified and analyzed, to examine which elements can be utilized to evaluate technologies. The empirical data was collected through interviews and a workshop with members of the nursing staff at a nursing home in Aalborg, Denmark. It was found that, the establishment of sustainable feedback learning loops depends on shared visions in the organization and how creating shared visions requires involvement and participation. Secondly, care workers must possess fundamental knowledge about the technologies available to them. Thirdly comprehensive classification of adverse events should be established to allow for a systematic and goal directed feed-back process.

The next organizational challenge: finding and addressing diagnostic error.

Science.gov (United States)

Graber, Mark L; Trowbridge, Robert; Myers, Jennifer S; Umscheid, Craig A; Strull, William; Kanter, Michael H

2014-03-01

Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to identify cases of diagnostic error. WHY HEALTH CARE ORGANIZATIONS NEED TO GET INVOLVED: HCOs are preoccupied with many quality- and safety-related operational and clinical issues, including performance measures. The case for paying attention to diagnostic errors, however, is based on the following four points: (1) diagnostic errors are common and harmful, (2) high-quality health care requires high-quality diagnosis, (3) diagnostic errors are costly, and (4) HCOs are well positioned to lead the way in reducing diagnostic error. FINDING DIAGNOSTIC ERRORS: Current approaches to identifying diagnostic errors, such as occurrence screens, incident reports, autopsy, and peer review, were not designed to detect diagnostic issues (or problems of omission in general) and/or rely on voluntary reporting. The realization that the existing tools are inadequate has spurred efforts to identify novel tools that could be used to discover diagnostic errors or breakdowns in the diagnostic process that are associated with errors. New approaches--Maine Medical Center's case-finding of diagnostic errors by facilitating direct reports from physicians and Kaiser Permanente's electronic health record--based reports that detect process breakdowns in the followup of abnormal findings--are described in case studies. By raising awareness and implementing targeted programs that address diagnostic error, HCOs may begin to play an important role in addressing the problem of diagnostic error.

Ethnic Minority Personnel Careers: Hindrances and Hopes

OpenAIRE

Ross, Catharine

2004-01-01

Personnel departments often have particular responsibility for equal opportunities within their organizations. This paper explores equal opportunities within personnel departments themselves, in relation to the careers of ethnic minority personnel practitioners. Through primary research, it identifies a range of criteria which can affect personnel careers, of which ethnic origin is often one. However, although being categorized as of ethnic minority origin often hinders personnel careers, the...

Model Agreements for the granting of Associate Member Status Implementation arrangements concerning eligibility for personnel appointments and industrial participation for Associate Member States Progress report by the Management

CERN Document Server

2011-01-01

Model Agreements for the granting of Associate Member Status Implementation arrangements concerning eligibility for personnel appointments and industrial participation for Associate Member States Progress report by the Management

Learning mechanisms to limit medication administration errors.

Science.gov (United States)

Drach-Zahavy, Anat; Pud, Dorit

2010-04-01

This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors. Since the influential report ;To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning. Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year's reported medication administration errors were assessed using administrative data. The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors. Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.

Special training of shift personnel

International Nuclear Information System (INIS)

Martin, H.D.

1981-01-01

The first step of on-the-job training is practical observation phase in an operating Nuclear Plant, where the participants are assigned to shift work. The simulator training for operating personnel, for key personnel and, to some extent, also for maintenance personnel and specialists give the practical feeling for Nuclear Power Plant behaviour during normal and abnormal conditions. During the commissioning phase of the own Nuclear Power Plant, which is the most important practical training, the participants are integrated into the commissioning staff and assisted during their process of practical learning by special instructors. The preparation for the licensing exams is vitally important for shift personnel and special courses are provided after the first non-nuclear trial operation of the plant. Personnel training also includes performance of programmes and material for retraining, training of instructors and assistance in building up special training programmes and material as well as training centers. (orig./RW)

Integrated Personnel and Pay System-Army Increment 2 (IPPS-A Inc 2)

Science.gov (United States)

2016-03-01

system maintenance, and minimizing pay discrepancies . IPPS-A Inc 2 will account for status changes between Active, Reserve, and National Guard components...2016 Major Automated Information System Annual Report Integrated Personnel and Pay System-Army Increment 2 (IPPS-A Inc 2) Defense Acquisition...703-325-3747 DSN Phone: 865-2915 DSN Fax: 221-3747 Date Assigned: May 2, 2014 Program Information Program Name Integrated Personnel and Pay System

Unmasking the health problems faced by the police personnel

Directory of Open Access Journals (Sweden)

G.Jahnavi

2012-11-01

Full Text Available Aim: To assess the health problems of the police personnel under Vijayawada police commisionerate 2. To make the health check ups regular and 3. To make the physical fitness programme mandatory for them.Study design: cross sectional study Methodology: Health check up was done for 617 police personnel from 12.11.09 to 4.12.09. In the morning hours, a group of junior doctors, paramedical staff and technicians visited the police dispensary to do the general check up, take blood samples and ECG. The following afternoon a group of specialists visited to check the same patients along with their reports to make the final diagnosis. Results: Out of 617 police personnel 259 (42% were overweight/obese, lack of physical activity was found in 397 (64% of them, alcohol consumption was present in 148 (24% and smoking in 136 (22% of the police personnel. Diabetes was diagnosed in 229 (37% and hypertension in 203 (33%. Anemia was detected in 154 (25%, visual abnormalities in 59 (10%, lipid abnormalities in 185 (30%, liver function test abnormalities in 31 (5%, ECG abnormalities in 25 (4%, renal function abnormalities in 6 (1%. Conclusion: A Physical fitness Schedule along with Stress alleviation techniques to be made mandatory for the police personnel to keep them physically and mentally fit, to perform critical job functions, to alleviate stress, and to improve their quality of life. Routine health checkups should be done to detect lurking dangers.

76 FR 81359 - National Security Personnel System

Science.gov (United States)

2011-12-28

... Security Personnel System AGENCY: Department of Defense; Office of Personnel Management. ACTION: Final rule... concerning the National Security Personnel System (NSPS). Section 1113 of the National Defense Authorization... National Security Personnel System (NSPS) in regulations jointly prescribed by DOD and OPM (Office of...

10 CFR 26.125 - Licensee testing facility personnel.

Science.gov (United States)

2010-01-01

... 10 Energy 1 2010-01-01 2010-01-01 false Licensee testing facility personnel. 26.125 Section 26.125 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Licensee Testing Facilities § 26.125... reports, if any; results of tests that establish employee competency for the position he or she holds...

Personnel Policy and Profit

DEFF Research Database (Denmark)

Bingley, Paul; Westergård-Nielsen, Niels Chr.

2004-01-01

personnel structure variation. It is found that personnel policy is strongly related to economic performance. At the margin, more hires are associated with lower profit, and more separations with higher profit. For the average firm, one new job, all else equal, is associated with ?2680 (2000 prices) lower...

The Causes of Medical Error from the Perspective of Nurses

Directory of Open Access Journals (Sweden)

Oguz Isik

2012-08-01

Full Text Available This study was conducted as a descriptive study in order to determine the medical errors in hospital services and preventive measures that could be taken to reduce these errors, from the perspective of nurses. The population of the study is composed of nurses working in 2 public hospitals in center of the province of Sakarya. We haven’t selected sample and it was aimed to reach as many nurses as possible in the study. A total of 441 questionnaires were send and 324 were returned. A questionnaire as a means of data collection was prepared and used by the authors. Structural Equation Modeling, confirmatory factor analysis, descriptive statistical methods, the significance control test between compared means and ANOVA test were used in statistical analysis. Physicians, nurses, work environment and lack of communication are stated as possible causes of medical error. According to nurses, the major causes of medical errors, in order of their frequency, were inadequate number of health personnel, excessive work stress, high number of patients per nurse, the weariness due to the behavior and attitudes of superiors and the pressure to care so many patients in a very short period of time, and long time of study. Compensation of medical error is very difficult in health care. A great amount of health care is provided in hospitals and medical errors in hospital services must be prevented. In order to prevent these errors which directly affect human life, it is thought that adequate number of staff should be employed in hospitals and the attitude of superiors towards the employees should be motivating. [TAF Prev Med Bull 2012; 11(4.000: 421-430

Technological Advancements and Error Rates in Radiation Therapy Delivery

Energy Technology Data Exchange (ETDEWEB)

Margalit, Danielle N., E-mail: dmargalit@partners.org [Harvard Radiation Oncology Program, Boston, MA (United States); Harvard Cancer Consortium and Brigham and Women' s Hospital/Dana Farber Cancer Institute, Boston, MA (United States); Chen, Yu-Hui; Catalano, Paul J.; Heckman, Kenneth; Vivenzio, Todd; Nissen, Kristopher; Wolfsberger, Luciant D.; Cormack, Robert A.; Mauch, Peter; Ng, Andrea K. [Harvard Cancer Consortium and Brigham and Women' s Hospital/Dana Farber Cancer Institute, Boston, MA (United States)

2011-11-15

Purpose: Technological advances in radiation therapy (RT) delivery have the potential to reduce errors via increased automation and built-in quality assurance (QA) safeguards, yet may also introduce new types of errors. Intensity-modulated RT (IMRT) is an increasingly used technology that is more technically complex than three-dimensional (3D)-conformal RT and conventional RT. We determined the rate of reported errors in RT delivery among IMRT and 3D/conventional RT treatments and characterized the errors associated with the respective techniques to improve existing QA processes. Methods and Materials: All errors in external beam RT delivery were prospectively recorded via a nonpunitive error-reporting system at Brigham and Women's Hospital/Dana Farber Cancer Institute. Errors are defined as any unplanned deviation from the intended RT treatment and are reviewed during monthly departmental quality improvement meetings. We analyzed all reported errors since the routine use of IMRT in our department, from January 2004 to July 2009. Fisher's exact test was used to determine the association between treatment technique (IMRT vs. 3D/conventional) and specific error types. Effect estimates were computed using logistic regression. Results: There were 155 errors in RT delivery among 241,546 fractions (0.06%), and none were clinically significant. IMRT was commonly associated with errors in machine parameters (nine of 19 errors) and data entry and interpretation (six of 19 errors). IMRT was associated with a lower rate of reported errors compared with 3D/conventional RT (0.03% vs. 0.07%, p = 0.001) and specifically fewer accessory errors (odds ratio, 0.11; 95% confidence interval, 0.01-0.78) and setup errors (odds ratio, 0.24; 95% confidence interval, 0.08-0.79). Conclusions: The rate of errors in RT delivery is low. The types of errors differ significantly between IMRT and 3D/conventional RT, suggesting that QA processes must be uniquely adapted for each technique

Technological Advancements and Error Rates in Radiation Therapy Delivery

International Nuclear Information System (INIS)

Margalit, Danielle N.; Chen, Yu-Hui; Catalano, Paul J.; Heckman, Kenneth; Vivenzio, Todd; Nissen, Kristopher; Wolfsberger, Luciant D.; Cormack, Robert A.; Mauch, Peter; Ng, Andrea K.

2011-01-01

Purpose: Technological advances in radiation therapy (RT) delivery have the potential to reduce errors via increased automation and built-in quality assurance (QA) safeguards, yet may also introduce new types of errors. Intensity-modulated RT (IMRT) is an increasingly used technology that is more technically complex than three-dimensional (3D)–conformal RT and conventional RT. We determined the rate of reported errors in RT delivery among IMRT and 3D/conventional RT treatments and characterized the errors associated with the respective techniques to improve existing QA processes. Methods and Materials: All errors in external beam RT delivery were prospectively recorded via a nonpunitive error-reporting system at Brigham and Women’s Hospital/Dana Farber Cancer Institute. Errors are defined as any unplanned deviation from the intended RT treatment and are reviewed during monthly departmental quality improvement meetings. We analyzed all reported errors since the routine use of IMRT in our department, from January 2004 to July 2009. Fisher’s exact test was used to determine the association between treatment technique (IMRT vs. 3D/conventional) and specific error types. Effect estimates were computed using logistic regression. Results: There were 155 errors in RT delivery among 241,546 fractions (0.06%), and none were clinically significant. IMRT was commonly associated with errors in machine parameters (nine of 19 errors) and data entry and interpretation (six of 19 errors). IMRT was associated with a lower rate of reported errors compared with 3D/conventional RT (0.03% vs. 0.07%, p = 0.001) and specifically fewer accessory errors (odds ratio, 0.11; 95% confidence interval, 0.01–0.78) and setup errors (odds ratio, 0.24; 95% confidence interval, 0.08–0.79). Conclusions: The rate of errors in RT delivery is low. The types of errors differ significantly between IMRT and 3D/conventional RT, suggesting that QA processes must be uniquely adapted for each technique

Personnel training and certification

International Nuclear Information System (INIS)

Whittemore, W.L.

1976-01-01

In order to make the full benefits of neutron radiography available in the nondestructive test (NDT) field, it has been necessary to formalize its application. A group under the Penetrating Radiation Committee of the American Society for Nondestructive Testing (ASNT) was organized to prepare a recommended practice for neutron radiography. The recommended practices require the establishment of an appropriate certification program. The requirements on the employer to establish and maintain a qualification and certification program are outlined. To conduct a program of nondestructive testing using neutron radiography requires the usual three levels of qualified and certified personnel. The program is administered by a Level III person. Routine exposure, reviews, and reporting of test results are the responsibilities of Level I and Level II personnal. The amount of training and nature of the required practical examination are also specified. The recommended practices document assures users that NDT work in the field of neutron radiography is performed by qualified personnel. Although no training courses are available to provide experience in the depth required by the recommended practices document, SNT-TC-1A, short courses are provided at a number of locations to familarize user's representatives with the interpretation of neutron radiographs and capabilities and limitations of the technique

49 CFR 193.2711 - Personnel health.

Science.gov (United States)

2010-10-01

... 49 Transportation 3 2010-10-01 2010-10-01 false Personnel health. 193.2711 Section 193.2711 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY...: FEDERAL SAFETY STANDARDS Personnel Qualifications and Training § 193.2711 Personnel health. Each operator...

Error-related brain activity and error awareness in an error classification paradigm.

Science.gov (United States)

Di Gregorio, Francesco; Steinhauser, Marco; Maier, Martin E

2016-10-01

Error-related brain activity has been linked to error detection enabling adaptive behavioral adjustments. However, it is still unclear which role error awareness plays in this process. Here, we show that the error-related negativity (Ne/ERN), an event-related potential reflecting early error monitoring, is dissociable from the degree of error awareness. Participants responded to a target while ignoring two different incongruent distractors. After responding, they indicated whether they had committed an error, and if so, whether they had responded to one or to the other distractor. This error classification paradigm allowed distinguishing partially aware errors, (i.e., errors that were noticed but misclassified) and fully aware errors (i.e., errors that were correctly classified). The Ne/ERN was larger for partially aware errors than for fully aware errors. Whereas this speaks against the idea that the Ne/ERN foreshadows the degree of error awareness, it confirms the prediction of a computational model, which relates the Ne/ERN to post-response conflict. This model predicts that stronger distractor processing - a prerequisite of error classification in our paradigm - leads to lower post-response conflict and thus a smaller Ne/ERN. This implies that the relationship between Ne/ERN and error awareness depends on how error awareness is related to response conflict in a specific task. Our results further indicate that the Ne/ERN but not the degree of error awareness determines adaptive performance adjustments. Taken together, we conclude that the Ne/ERN is dissociable from error awareness and foreshadows adaptive performance adjustments. Our results suggest that the relationship between the Ne/ERN and error awareness is correlative and mediated by response conflict. Copyright © 2016 Elsevier Inc. All rights reserved.

The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.

Science.gov (United States)

Vogus, Timothy J; Sutcliffe, Kathleen M

2011-01-01

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

Error and its meaning in forensic science.

Science.gov (United States)

Christensen, Angi M; Crowder, Christian M; Ousley, Stephen D; Houck, Max M

2014-01-01

The discussion of "error" has gained momentum in forensic science in the wake of the Daubert guidelines and has intensified with the National Academy of Sciences' Report. Error has many different meanings, and too often, forensic practitioners themselves as well as the courts misunderstand scientific error and statistical error rates, often confusing them with practitioner error (or mistakes). Here, we present an overview of these concepts as they pertain to forensic science applications, discussing the difference between practitioner error (including mistakes), instrument error, statistical error, and method error. We urge forensic practitioners to ensure that potential sources of error and method limitations are understood and clearly communicated and advocate that the legal community be informed regarding the differences between interobserver errors, uncertainty, variation, and mistakes. © 2013 American Academy of Forensic Sciences.

Pedal Application Errors

Science.gov (United States)

2012-03-01

This project examined the prevalence of pedal application errors and the driver, vehicle, roadway and/or environmental characteristics associated with pedal misapplication crashes based on a literature review, analysis of news media reports, a panel ...

Going beyond "highly-qualified personnel" to "value-added personnel"

Science.gov (United States)

Nantel, Marc; Fox, Bradley; Gelsthorpe, Leanne; Hamilton, Roxy; Marshall, Robert; Williamson, Guida

2005-10-01

Employers clamour for more "Highly-Qualified Personnel" (HQP) to hire, and photonics is no exception. The challenge facing all new graduates lies in what actually constitutes a Highly-Qualified Person. Yesterday, an HQP was often understood to be a graduate with a Bachelor's, Master's or Ph.D. degree. Today, industry is demanding that an HQP be either a university or college graduate with strong academic standing AND a sound business and communications skill set. In this paper, we introduce the concept of "Value-Added Personnel" (VAP), which marries both scientific and "soft-skills" aspects, and we present a new program in Ontario to produce VAPs.

Identification and Evaluation of Human Errors in the Medication Process Using the Extended CREAM Technique

Directory of Open Access Journals (Sweden)

Iraj Mohammadfam

2017-10-01

Full Text Available Background Medication process is a powerful instrument for curing patients. Obeying the commands of this process has an important role in the treatment and provision of care to patients. Medication error, as a complicated process, can occur in any stage of this process, and to avoid it, appropriate decision-making, cognition, and performance of the hospital staff are needed. Objectives The present study aimed at identifying and evaluating the nature and reasons of human errors in the medication process in a hospital using the extended CREAM method. Methods This was a qualitative and cross-sectional study conducted in a hospital in Hamadan. In this study, first, the medication process was selected as a critical issue based on the opinions of experts, specialists, and experienced individuals in the nursing and medical departments. Then, the process was analyzed into relative steps and substeps using the method of HTA and was evaluated using extended CREAM technique considering the probability of human errors. Results Based on the findings achieved through the basic CREAM method, the highest CFPt was in the step of medicine administration to patients (0.056. Moreover, the results revealed that the highest CFPt was in the substeps of calculating the dose of medicine and determining the method of prescription and identifying the patient (0.0796 and 0.0785, respectively. Also, the least CFPt was related to transcribing the prescribed medicine from file to worksheet of medicine (0.0106. Conclusions Considering the critical consequences of human errors in the medication process, holding pharmacological retraining classes, using the principles of executing pharmaceutical orders, increasing medical personnel, reducing working overtime, organizing work shifts, and using error reporting systems are of paramount importance.

Storage of radioactive material - accidents - precipitation - personnel monitoring

International Nuclear Information System (INIS)

Matijasic, A.; Gacinovic, O.

1961-12-01

This volume covers the reports on four routine tasks concerned with safe handling of radioactive material and influence of nuclear facilities on the environment. The tasks performed were as follows: Storage of solid and liquid radioactive material; actions in case of accidents; radiation monitoring of the fallout, water and ground; personnel dosimetry

10 CFR 36.55 - Personnel monitoring.

Science.gov (United States)

2010-01-01

... 10 Energy 1 2010-01-01 2010-01-01 false Personnel monitoring. 36.55 Section 36.55 Energy NUCLEAR REGULATORY COMMISSION LICENSES AND RADIATION SAFETY REQUIREMENTS FOR IRRADIATORS Operation of Irradiators § 36.55 Personnel monitoring. (a) Irradiator operators shall wear a personnel dosimeter that is...

Individual protection of NPP personnel

International Nuclear Information System (INIS)

Koshcheev, V.S.; Gol'dshtejn, D.S.; Chetverikova, Z.S.

1983-01-01

Specific features of NPP personnel individual protection are considered, mainly with respect to maintenance and repair works on various type reactors. The major concern is given to the selection and application reglamentations of the individual protection system (IPS), employment of sanitary locks, the organization of individual protection under the conditions of a heating microclimate. The ways are specified to the development and introduction of the most effective IPS and improvement of the entire NPP personnel individual protection system with respect to providing the necessary protection effect for maintaining high working capability of the personnel and minimizing the IPS impact on human organism functional systems. The accumulated experience in the personnel individual protection can be applied during construction and operation of NPP's in CMEA member-countries [ru

Personnel monitoring in geologic fields

International Nuclear Information System (INIS)

Romanova, I.N.; Seredin, Yu.V.

1981-01-01

State of radiation safety for the personnel of geologic crews carrying out neutron logging of wells using Po-Be sources has been evaluated. Given are results of development of methods for the evaluation of individual radiation loads for personnel when working with Po-Be neutron sources useful for the application in practice by a geologic logging crew as well as a quantitative evaluation of profissional radiation loads during this kind of work. The following methods are recommended for personnel monitoring: 1) calculation of whole-body irradiation doses and hands from averaged values of radiation dose rate; 2) calculational tabulated determination of irradiation doses during recharging of shanks of well instruments. Personnel monitoring by means of instrumental methods is not necessary in the considered case [ru

An assessment of the risk significance of human errors in selected PSAs and operating events

International Nuclear Information System (INIS)

Palla, R.L. Jr.; El-Bassioni, A.

1991-01-01

Sensitivity studies based on Probabilistic Safety Assessments (PSAs) for a pressurized water reactor and a boiling water reactor are described. In each case human errors modeled in the PSAs were categorized according to such factors as error type, location, timing, and plant personnel involved. Sensitivity studies were then conducted by varying the error rates in each category and evaluating the corresponding change in total core damage frequency and accident sequence frequency. Insights obtained are discussed and reasons for differences in risk sensitivity between plants are explored. A separate investigation into the role of human error in risk-important operating events is also described. This investigation involved the analysis of data from the USNRC Accident Sequence Precursor program to determine the effect of operator-initiated events on accident precursor trends, and to determine whether improved training can be correlated to current trends. The findings of this study are also presented. 5 refs., 15 figs., 1 tab

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

Science.gov (United States)

Rajih, Emad; Tholomier, Côme; Cormier, Beatrice; Samouëlian, Vanessa; Warkus, Thomas; Liberman, Moishe; Widmer, Hugues; Lattouf, Jean-Baptiste; Alenizi, Abdullah M; Meskawi, Malek; Valdivieso, Roger; Hueber, Pierre-Alain; Karakewicz, Pierre I; El-Hakim, Assaad; Zorn, Kevin C

2017-05-01

The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Implementation of the Education of the Handicapped Act [Public Law 94-142], 1989. Eleventh Annual Report to Congress. Information on the Supply and Demand for Personnel: Excerpts. Reporting Data on the 1986-87 School Year. Information on Personnel Supply and Demand.

Science.gov (United States)

National Clearinghouse for Professions in Special Education, Reston, VA.

This paper concerns the supply and demand for special education personnel for the 1986-87 school year. Obtaining valid, reliable, and comparable data on all the elements that generated personnel need was not possible. Single indicators were most commonly used to obtain data for planning by states, school districts, universities, and the Federal…

Medical Errors in Cyprus: The 2005 Eurobarometer Survey

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Andreas Pavlakis

2012-01-01

Full Text Available Background: Medical errors have been highlighted in recent years by different agencies, scientific bodies and research teams alike. We sought to explore the issue of medical errors in Cyprus using data from the Eurobarometer survey.Methods: Data from the special Eurobarometer survey conducted in 2005 across all European Union countries (EU-25 and the acceding countries were obtained from the corresponding EU office. Statisticalanalyses including logistic regression models were performed using SPSS.Results: A total of 502 individuals participated in the Cyprus survey. About 90% reported that they had often or sometimes heard about medical errors, while 22% reported that a family member or they had suffered a serious medical error in a local hospital. In addition, 9.4% reported a serious problem from a prescribed medicine. We also found statistically significant differences across different ages and gender and in rural versus urban residents. Finally, using multivariable-adjusted logistic regression models, wefound that residents in rural areas were more likely to have suffered a serious medical error in a local hospital or from a prescribed medicine.Conclusion: Our study shows that the vast majority of residents in Cyprus in parallel with the other Europeans worry about medical errors and a significant percentage report having suffered a serious medical error at a local hospital or from a prescribed medicine. The results of our study could help the medical community in Cyprus and the society at large to enhance its vigilance with respect to medical errors in order to improve medical care.

A theory of human error

Science.gov (United States)

Mcruer, D. T.; Clement, W. F.; Allen, R. W.

1981-01-01

Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Personnel preferences in personnel planning and scheduling

NARCIS (Netherlands)

van der Veen, Egbert

2013-01-01

Summary The personnel of an organization often has two conflicting goals. Individual employees like to have a good work-life balance, by having personal preferences taken into account, whereas there is also the common goal to work efficiently. By applying techniques and methods from Operations

Cytogenic Investigations in Flight Personnel

International Nuclear Information System (INIS)

Wolf, G.; Obe, G.; Bergau, L.

1999-01-01

During long-distance flights at high altitudes flight personnel are exposed to cosmic radiation. In order to determine whether there are biological effects of such low dose radiation exposure in aircrew, chromosomal aberrations were investigated in 59 female cabin attendants and a matched control group of 31 members of station personnel. The mean number of dicentric chromosomes amounts to 1.3 (95% CI 1.0-1.6) per 1,000 cells in cabin attendants and 1.4 (95% CI 1.0-1.9) per 1,000 cells in controls. In an additional control group of 56 female clerks from Berlin the mean frequency of dicentric chromosomes was 1.3 (95% CI 1.0-1.6). Neither in dicentric frequency and distribution nor in other aberrations was a significant difference between the groups of flight and station personnel found. The high frequency of multi-aberrant cells was remarkable in flight personnel as well as in station personnel. The reason for this phenomenon is unknown and needs further investigation. (author)

A Chance to Get Ahead: Proficiency Examinations for Clerical Laboratory Personnel. Final Report.

Science.gov (United States)

Linehan, Jean D.

Four Proficiency Examinations for Clinical Laboratory Personnel were developed in Clinical Chemistry, Microbiology, Hematology, and Blood Banking. Purpose of project was to enable competent military laboratory technicians who lack credentials to demonstrate their job-related skills and knowledge for civilian positions, and also to help civilians…

Electronic Official Personnel Folder System

Data.gov (United States)

US Agency for International Development — The eOPF is a digital recreation of paper personnel folder that stores electronic personnel data spanning an individual's Federal career. eOPF allows employees to...

Training of nonlicensed personnel

International Nuclear Information System (INIS)

Hetrick, D.E.

1975-01-01

The safety and efficiency with which a station operates is a function of the competence and proficiency of all personnel. This includes the nonlicensed personnel who make up the bulk of the station staff. Thus the training of these members of the station complement is an important function in overall station performance. Standards, regulations, regulatory guides, and codes provide guidance to the training requirements for such personnel. Training needs and objectives must be established, a plan prepared and then all incorporated into a training program. A well planned and operated training program will stimulate effective communications between the different groups within the station and between the station and off site support groups

Monitoring and reporting of preanalytical errors in laboratory medicine: the UK situation.

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Cornes, Michael P; Atherton, Jennifer; Pourmahram, Ghazaleh; Borthwick, Hazel; Kyle, Betty; West, Jamie; Costelloe, Seán J

2016-03-01

Most errors in the clinical laboratory occur in the preanalytical phase. This study aimed to comprehensively describe the prevalence and nature of preanalytical quality monitoring practices in UK clinical laboratories. A survey was sent on behalf of the Association for Clinical Biochemistry and Laboratory Medicine Preanalytical Working Group (ACB-WG-PA) to all heads of department of clinical laboratories in the UK. The survey captured data on the analytical platform and Laboratory Information Management System in use; which preanalytical errors were recorded and how they were classified and gauged interest in an external quality assurance scheme for preanalytical errors. Of the 157 laboratories asked to participate, responses were received from 104 (66.2%). Laboratory error rates were recorded per number of specimens, rather than per number of requests in 51% of respondents. Aside from serum indices for haemolysis, icterus and lipaemia, which were measured in 80% of laboratories, the most common errors recorded were booking-in errors (70.1%) and sample mislabelling (56.9%) in laboratories who record preanalytical errors. Of the laboratories surveyed, 95.9% expressed an interest in guidance on recording preanalytical error and 91.8% expressed interest in an external quality assurance scheme. This survey observes a wide variation in the definition, repertoire and collection methods for preanalytical errors in the UK. Data indicate there is a lot of interest in improving preanalytical data collection. The ACB-WG-PA aims to produce guidance and support for laboratories to standardize preanalytical data collection and to help establish and validate an external quality assurance scheme for interlaboratory comparison. © The Author(s) 2015.

Hospital medication errors in a pharmacovigilance system in Colombia

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Jorge Enrique Machado-Alba

2015-11-01

Full Text Available Objective: this study analyzes the medication errors reported to a pharmacovigilance system by 26 hospitals for patients in the healthcare system of Colombia. Methods: this retrospective study analyzed the medication errors reported to a systematized database between 1 January 2008 and 12 September 2013. The medication is dispensed by the company Audifarma S.A. to hospitals and clinics around Colombia. Data were classified according to the taxonomy of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP. The data analysis was performed using SPSS 22.0 for Windows, considering p-values < 0.05 significant. Results: there were 9 062 medication errors in 45 hospital pharmacies. Real errors accounted for 51.9% (n = 4 707, of which 12.0% (n = 567 reached the patient (Categories C to I and caused harm (Categories E to I to 17 subjects (0.36%. The main process involved in errors that occurred (categories B to I was prescription (n = 1 758, 37.3%, followed by dispensation (n = 1 737, 36.9%, transcription (n = 970, 20.6% and administration (n = 242, 5.1%. The errors in the administration process were 45.2 times more likely to reach the patient (CI 95%: 20.2–100.9. Conclusions: medication error reporting systems and prevention strategies should be widespread in hospital settings, prioritizing efforts to address the administration process.

Control in personnel exposure of RCD/FCD facility RLG during the period 2005 - 2008

International Nuclear Information System (INIS)

Murali, S.; Thanamani, S.; Sapkal, J.A.; Bairwa, Satya Manoj

2010-01-01

Full text: Radio Chemistry Wing, RLG, houses Radio Chemistry Division and Fuel Chemistry Division and certain common utility services. The personnel in the facility carry out radiochemical operations involving isotopes of Pu and other actinides. The HP Unit, Radio Chemistry Wing provides essential safety coverage to the personnel of the facility. The lab personnel of RCD/FCD facility at RLG carry out active operations, such operations held in suitable containment systems, under the HP supervision by RHC Unit advising safe work practices. The lab personnel are provided with monitoring programmes viz. TLD, Bio-assay and Lung counting periodically. Presently the dose limit for occupational exposure is 20 mSv per annum with 100 mSv for 5 consecutive calendar years. The present paper on TLD dose report enlists the details of the personnel exposure year wise and highlights the control in personnel exposure due to the safe procedures followed. The decreasing trend in the average personnel exposure over the period 2005 - 2008 validates the practice of adherence to safety procedures, though the amount of activity handled in the facility has increased by a few folds

The Effect of In-Game Errors on Learning Outcomes. CRESST Report 835

Science.gov (United States)

Kerr, Deirdre; Chung, Gregory K. W. K.

2013-01-01

Student mathematical errors are rarely random and often occur because students are applying procedures that they believe to be accurate. Traditional approaches often view such errors as indicators of students' failure to understand the construct in question, but some theorists view errors as opportunities for students to expand their mental model…

Health Care Personnel Perception of the Privacy of Electronic Health Records.

Science.gov (United States)

Saito, Kenji; Shofer, Frances S; Saberi, Poune; Green-McKenzie, Judith

2017-06-01

: Health care facilities are increasingly converting paper medical records to electronic health records. This study investigates the perception of privacy health care personnel have of electronic health records. A pilot tested, anonymous survey was administered to a convenience sample of health care personnel. Standard summary statistics and Chi-square analysis were used to assess differences in perception. Of the 93% (96/103) who responded, 65% were female and 43% white. The mean age was 44.3 years. Most (94%) felt that Medical Record privacy was important and one-third reported they would not seek care at their workplace if Electronic Health Records were used. Efforts to assure and communicate the integrity of electronic health records are essential toward reducing deterrents for health care personnel to access geographically convenient and timely health care.

Self contained compressed air breathing apparatus to facilitate personnel decontamination

International Nuclear Information System (INIS)

McDonald, C.W.

1963-11-01

This report describes the modification of a Self Contained Compressed Air Breathing Apparatus to provide extended respiratory protection to grossly contaminated personnel during a decontamination period which may exceed the duration of the Breathing Apparatus air supply. (author)

Self contained compressed air breathing apparatus to facilitate personnel decontamination

Energy Technology Data Exchange (ETDEWEB)

McDonald, C W [Radiological and Safety Division, Atomic Energy Establishment, Winfrith, Dorchester, Dorset (United Kingdom)

1963-11-15

This report describes the modification of a Self Contained Compressed Air Breathing Apparatus to provide extended respiratory protection to grossly contaminated personnel during a decontamination period which may exceed the duration of the Breathing Apparatus air supply. (author)

Personnel scheduling using an integer programming model- an application at Avanti Blue-Nile Hotels.

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Kassa, Biniyam Asmare; Tizazu, Anteneh Eshetu

2013-01-01

In this paper, we report perhaps a first of its kind application of management science in the Ethiopian hotel industry. Avanti Blue Nile Hotels, a newly established five star hotel in Bahir Dar, is the company for which we developed an integer programming model that determines an optimal weekly shift schedule for the Hotel's engineering department personnel while satisfying several constraints including weekly rest requirements per employee, rest requirements between working shifts per employee, required number of personnel per shift, and other constraints. The model is implemented on an excel solver routine. The model enables the company's personnel department management to develop a fair personnel schedule as needed and to effectively utilize personnel resources while satisfying several technical, legal and economic requirements. These encouraging achievements make us optimistic about the gains other Ethiopian organizations can amass by introducing management science approaches in their management planning and decision making systems.

An error taxonomy system for analysis of haemodialysis incidents.

Science.gov (United States)

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

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

5 CFR 304.107 - Reports.

Science.gov (United States)

2010-01-01

... 5 Administrative Personnel 1 2010-01-01 2010-01-01 false Reports. 304.107 Section 304.107 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT CIVIL SERVICE REGULATIONS EXPERT AND CONSULTANT APPOINTMENTS § 304.107 Reports. As required by 5 U.S.C. 3109(e), each agency shall report to the Office of...

Learning from errors in radiology to improve patient safety.

Science.gov (United States)

Saeed, Shaista Afzal; Masroor, Imrana; Shafqat, Gulnaz

2013-10-01

To determine the views and practices of trainees and consultant radiologists about error reporting. Cross-sectional survey. Radiology trainees and consultant radiologists in four tertiary care hospitals in Karachi approached in the second quarter of 2011. Participants were enquired as to their grade, sub-specialty interest, whether they kept a record/log of their errors (defined as a mistake that has management implications for the patient), number of errors they made in the last 12 months and the predominant type of error. They were also asked about the details of their department error meetings. All duly completed questionnaires were included in the study while the ones with incomplete information were excluded. A total of 100 radiologists participated in the survey. Of them, 34 were consultants and 66 were trainees. They had a wide range of sub-specialty interest like CT, Ultrasound, etc. Out of the 100 responders, 49 kept a personal record/log of their errors. In response to the recall of approximate errors they made in the last 12 months, 73 (73%) of participants recorded a varied response with 1 - 5 errors mentioned by majority i.e. 47 (64.5%). Most of the radiologists (97%) claimed receiving information about their errors through multiple sources like morbidity/mortality meetings, patients' follow-up, through colleagues and consultants. Perceptual error 66 (66%) were the predominant error type reported. Regular occurrence of error meetings and attending three or more error meetings in the last 12 months was reported by 35% participants. Majority among these described the atmosphere of these error meetings as informative and comfortable (n = 22, 62.8%). It is of utmost importance to develop a culture of learning from mistakes by conducting error meetings and improving the process of recording and addressing errors to enhance patient safety.

Work environment, overtime and sleep among offshore personnel.

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Parkes, Katharine R

2017-02-01

Personnel working on North Sea oil/gas installations are exposed to remote and potentially hazardous environments, and to extended work schedules (typically, 14×12h shifts). Moreover, overtime (additional to the standard 84-h week) is not uncommon among offshore personnel. Evidence from onshore research suggests that long work hours and adverse environmental characteristics are associated with sleep impairments, and consequently with health and safety risks, including accidents and injuries. However, little is known about the extent to which long hours and a demanding work environment combine synergistically in relation to sleep. The present study sought to address this issue, using survey data collected from offshore day-shift personnel (N=551). The multivariate analysis examined the additive and interactive effects of overtime and measures of the psychosocial/physical work environment (job demands, job control, supervisor support, and physical stressors) as predictors of sleep outcomes during offshore work weeks. Control variables, including age and sleep during leave weeks, were also included in the analysis model. Sleep duration and quality were significantly impaired among those who worked overtime (54% of the participants) relative to those who worked only 12-h shifts. A linear relationship was found between long overtime hours and short sleep duration; personnel who worked >33h/week overtime reported job demands, and positively related to supervisor support, only among personnel who worked overtime. Poor sleep quality was predicted by the additive effects of overtime, low support and an adverse physical environment. These findings highlight the need to further examine the potential health and safety consequences of impaired sleep associated with high overtime rates offshore, and to identify the extent to which adverse effects of overtime can be mitigated by favourable physical and psychosocial work environment characteristics. Copyright © 2015 Elsevier Ltd

Human Error Probability Assessment During Maintenance Activities of Marine Systems

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Rabiul Islam

2018-03-01

Full Text Available Background: Maintenance operations on-board ships are highly demanding. Maintenance operations are intensive activities requiring high man–machine interactions in challenging and evolving conditions. The evolving conditions are weather conditions, workplace temperature, ship motion, noise and vibration, and workload and stress. For example, extreme weather condition affects seafarers' performance, increasing the chances of error, and, consequently, can cause injuries or fatalities to personnel. An effective human error probability model is required to better manage maintenance on-board ships. The developed model would assist in developing and maintaining effective risk management protocols. Thus, the objective of this study is to develop a human error probability model considering various internal and external factors affecting seafarers' performance. Methods: The human error probability model is developed using probability theory applied to Bayesian network. The model is tested using the data received through the developed questionnaire survey of >200 experienced seafarers with >5 years of experience. The model developed in this study is used to find out the reliability of human performance on particular maintenance activities. Results: The developed methodology is tested on the maintenance of marine engine's cooling water pump for engine department and anchor windlass for deck department. In the considered case studies, human error probabilities are estimated in various scenarios and the results are compared between the scenarios and the different seafarer categories. The results of the case studies for both departments are also compared. Conclusion: The developed model is effective in assessing human error probabilities. These probabilities would get dynamically updated as and when new information is available on changes in either internal (i.e., training, experience, and fatigue or external (i.e., environmental and operational conditions

Prevalence of Pre-Analytical Errors in Clinical Chemistry Diagnostic Labs in Sulaimani City of Iraqi Kurdistan.

Science.gov (United States)

Najat, Dereen

2017-01-01

Laboratory testing is roughly divided into three phases: a pre-analytical phase, an analytical phase and a post-analytical phase. Most analytical errors have been attributed to the analytical phase. However, recent studies have shown that up to 70% of analytical errors reflect the pre-analytical phase. The pre-analytical phase comprises all processes from the time a laboratory request is made by a physician until the specimen is analyzed at the lab. Generally, the pre-analytical phase includes patient preparation, specimen transportation, specimen collection and storage. In the present study, we report the first comprehensive assessment of the frequency and types of pre-analytical errors at the Sulaimani diagnostic labs in Iraqi Kurdistan. Over 2 months, 5500 venous blood samples were observed in 10 public diagnostic labs of Sulaimani City. The percentages of rejected samples and types of sample inappropriateness were evaluated. The percentage of each of the following pre-analytical errors were recorded: delay in sample transportation, clotted samples, expired reagents, hemolyzed samples, samples not on ice, incorrect sample identification, insufficient sample, tube broken in centrifuge, request procedure errors, sample mix-ups, communication conflicts, misinterpreted orders, lipemic samples, contaminated samples and missed physician's request orders. The difference between the relative frequencies of errors observed in the hospitals considered was tested using a proportional Z test. In particular, the survey aimed to discover whether analytical errors were recorded and examine the types of platforms used in the selected diagnostic labs. The analysis showed a high prevalence of improper sample handling during the pre-analytical phase. In appropriate samples, the percentage error was as high as 39%. The major reasons for rejection were hemolyzed samples (9%), incorrect sample identification (8%) and clotted samples (6%). Most quality control schemes at Sulaimani

Prevalence of Pre-Analytical Errors in Clinical Chemistry Diagnostic Labs in Sulaimani City of Iraqi Kurdistan.

Directory of Open Access Journals (Sweden)

Dereen Najat

Full Text Available Laboratory testing is roughly divided into three phases: a pre-analytical phase, an analytical phase and a post-analytical phase. Most analytical errors have been attributed to the analytical phase. However, recent studies have shown that up to 70% of analytical errors reflect the pre-analytical phase. The pre-analytical phase comprises all processes from the time a laboratory request is made by a physician until the specimen is analyzed at the lab. Generally, the pre-analytical phase includes patient preparation, specimen transportation, specimen collection and storage. In the present study, we report the first comprehensive assessment of the frequency and types of pre-analytical errors at the Sulaimani diagnostic labs in Iraqi Kurdistan.Over 2 months, 5500 venous blood samples were observed in 10 public diagnostic labs of Sulaimani City. The percentages of rejected samples and types of sample inappropriateness were evaluated. The percentage of each of the following pre-analytical errors were recorded: delay in sample transportation, clotted samples, expired reagents, hemolyzed samples, samples not on ice, incorrect sample identification, insufficient sample, tube broken in centrifuge, request procedure errors, sample mix-ups, communication conflicts, misinterpreted orders, lipemic samples, contaminated samples and missed physician's request orders. The difference between the relative frequencies of errors observed in the hospitals considered was tested using a proportional Z test. In particular, the survey aimed to discover whether analytical errors were recorded and examine the types of platforms used in the selected diagnostic labs.The analysis showed a high prevalence of improper sample handling during the pre-analytical phase. In appropriate samples, the percentage error was as high as 39%. The major reasons for rejection were hemolyzed samples (9%, incorrect sample identification (8% and clotted samples (6%. Most quality control schemes