Peran Polri Dalam Penanggulangan Kejahatan Hacking Terhadap Bank

OpenAIRE

Idha Endri Prastiono

2009-01-01

Cybercrime atau kejahatan dunia siber mempunyai banyak bentuk atau rupa, tetapi dari kesemua bentuk yang ada, hacking merupakan bentuk yang banyak mendapat sorotan karena selain kongres PBB X di Wina menetapkan hacking sebagai first crime, juga dilihat dari aspek teknis, hacking mempunyai kelebihan-kelebihan. Pertama, orang yang melakukan hacking sudah barang tentu dapat melakukan bentuk cybercrime yang lain karena dengan kemampuan masuk ke dalam sistem komputer dan kemudian mengacak-acak si...

Hacking for a cause

OpenAIRE

Still, Brian

2005-01-01

This paper explores the concept of hacktivism, which is hacking for a political or social cause on the Internet. Generally hackers, even those hacking government–sponsored sites, have been negatively stereotyped as malicious thrill seekers or, worse yet, cyberterrorists. But increasingly there are more politically motivated hackers distancing themselves from cyberterrorism by engaging in hacktivism that is intent more upon disruption than disobedience. Certain hacktivists, in fact, have creat...

Students "Hacking" School Computer Systems

Science.gov (United States)

Stover, Del

2005-01-01

This article deals with students hacking school computer systems. School districts are getting tough with students "hacking" into school computers to change grades, poke through files, or just pit their high-tech skills against district security. Dozens of students have been prosecuted recently under state laws on identity theft and unauthorized…

Do-it-yourself biology and electronic waste hacking: A politics of demonstration in precarious times.

Science.gov (United States)

Delgado, Ana; Callén, Blanca

2017-02-01

In recent years, there has been an explosion of do it yourself, maker and hacker spaces in Europe. Through makers and do-it-yourself initiatives, 'hacking' is moving into the everyday life of citizens. This article explores the collective and political nature of those hacks by reporting on empirical work on electronic waste and do-it-yourself biology hacking. Using Dewey's experimental approach to politics, we analyse hacks as 'inquiry' to see how they serve to articulate public and political action. We argue that do-it-yourself and makers' hacks are technical and political demonstrations. What do-it-yourself and makers' hacks ultimately demonstrate is that things can be done otherwise and that 'you' can also do it. In this sense, they have a potential viral effect. The final part of the article explores some potential shortcomings of such politics of demonstration.

Low Tech Hacking Street Smarts for Security Professionals

CERN Document Server

Wiles, Jack; Jabbusch, Jennifer; Rogers, Russ; Lowther, Sean

2011-01-01

Criminals using hacking techniques can cost corporations, governments, and individuals millions of dollars each year. While the media focuses on the grand-scale attacks that have been planned for months and executed by teams and countries, there are thousands more that aren't broadcast. Low Tech Hacking focuses on the everyday hacks that, while simple in nature, actually add up to the most significant losses. Attackers are using common techniques like social engineering, wireless hacking, and targeting and surveillance to gain access to valuable data. This book contains detailed descriptions

The extent and consequences of p-hacking in science.

Science.gov (United States)

Head, Megan L; Holman, Luke; Lanfear, Rob; Kahn, Andrew T; Jennions, Michael D

2015-03-01

A focus on novel, confirmatory, and statistically significant results leads to substantial bias in the scientific literature. One type of bias, known as "p-hacking," occurs when researchers collect or select data or statistical analyses until nonsignificant results become significant. Here, we use text-mining to demonstrate that p-hacking is widespread throughout science. We then illustrate how one can test for p-hacking when performing a meta-analysis and show that, while p-hacking is probably common, its effect seems to be weak relative to the real effect sizes being measured. This result suggests that p-hacking probably does not drastically alter scientific consensuses drawn from meta-analyses.

Do-it-yourself biology and electronic waste hacking: A politics of demonstration in precarious times

Science.gov (United States)

Delgado, Ana; Callén, Blanca

2016-01-01

In recent years, there has been an explosion of do it yourself, maker and hacker spaces in Europe. Through makers and do-it-yourself initiatives, ‘hacking’ is moving into the everyday life of citizens. This article explores the collective and political nature of those hacks by reporting on empirical work on electronic waste and do-it-yourself biology hacking. Using Dewey’s experimental approach to politics, we analyse hacks as ‘inquiry’ to see how they serve to articulate public and political action. We argue that do-it-yourself and makers’ hacks are technical and political demonstrations. What do-it-yourself and makers’ hacks ultimately demonstrate is that things can be done otherwise and that ‘you’ can also do it. In this sense, they have a potential viral effect. The final part of the article explores some potential shortcomings of such politics of demonstration. PMID:27233296

Hacking the next generation

CERN Document Server

Dhanjani, Nitesh; Hardin, Brett

2009-01-01

With the advent of rich Internet applications, the explosion of social media, and the increased use of powerful cloud computing infrastructures, a new generation of attackers has added cunning new techniques to its arsenal. For anyone involved in defending an application or a network of systems, Hacking: The Next Generation is one of the few books to identify a variety of emerging attack vectors. You'll not only find valuable information on new hacks that attempt to exploit technical flaws, you'll also learn how attackers take advantage of individuals via social networking sites, and abuse

Hacking Around.

Science.gov (United States)

Zirkel, Perry A.

1999-01-01

Discusses a complicated appellate-court case upholding a Milwaukee high-school junior's expulsion for advocating computer hacking in a student newspaper. The decision is noteworthy for signaling a growing technology-related litigation trend, conflating the advocacy/incitement issue, and showing courts' decreasing tolerance for perceived threats to…

Penegakan Hukum Kejahatan Hacking dalam Prespektif Kebijakan Hukum Pidana di Indonesia

OpenAIRE

-, Sugiaryo

2013-01-01

Hacking is a dark side of information and communication improvement bringing a very wide implication in all aspects of life, especially in close relation with enconomical crime. Hacking can be classified into two, they are usual crime-like hacking in which using information and communication technology as the supporting tools and also post internet-based hacking. In regards of such thing, then it is clearly must be considered on how does the method to enforce it. Hacking crime enforcement in ...

Cognitive Hacking and Digital Government: Digital Identity

Directory of Open Access Journals (Sweden)

Paul Thompson

2004-04-01

Full Text Available Recently the National Center for Digital Government held a workshop on "The Virtual Citizen: Identity, Autonomy, and Accountability: A Civic Scenario Exploration of the Role of Identity in On-Line. Discussions at the workshop focused on five scenarios for future authentication policies with respect to digital identity. The underlying technologies considered for authentication were: biometrics: cryptography, with a focus on digital signatures; secure processing/computation; and reputation systems. Most discussion at the workshop focused on issues related to authentication of users of digital government, but, as implied by the inclusion of a scenario related to ubiquitous identity theft, there was also discussion of problems related to misinformation, including cognitive hacking. Cognitive hacking refers to a computer or information system attack that relies on changing human users' perceptions and corresponding behaviors in order to succeed. This paper describes cognitive hacking, suggests countermeasures, and discusses the implications of cognitive hacking for identity in digital government. In particular, spoofing of government websites and insider misuse are considered.

BioHack*Kolding

DEFF Research Database (Denmark)

Wilde, Danielle

Short Abstract BioHack*Kolding explores the potential of do-it-together biology to support community building in a town that lacks strong science representation, assisting participants to reflect on the bio-potential of their personal, social and political ecologies and to translate their ideas...... into action. Long Abstract Organisations that support lay people to practice bioscience alongside experts are proliferating. They enable interested people to join the global discussion on Bio Engineering by supporting them to gain the necessary knowledge and skills to do it themselves. Such organisations play...... an important role in facilitating informed debate around the biological sciences. Yet they cannot reach everyone. BioHack*Kolding asks how community-focused biology initiatives can reach people in smaller towns that lack science representation, so that they too can join the debate and ensure that its...

Problems in using p-curve analysis and text-mining to detect rate of p-hacking and evidential value.

Science.gov (United States)

Bishop, Dorothy V M; Thompson, Paul A

2016-01-01

Background. The p-curve is a plot of the distribution of p-values reported in a set of scientific studies. Comparisons between ranges of p-values have been used to evaluate fields of research in terms of the extent to which studies have genuine evidential value, and the extent to which they suffer from bias in the selection of variables and analyses for publication, p-hacking. Methods. p-hacking can take various forms. Here we used R code to simulate the use of ghost variables, where an experimenter gathers data on several dependent variables but reports only those with statistically significant effects. We also examined a text-mined dataset used by Head et al. (2015) and assessed its suitability for investigating p-hacking. Results. We show that when there is ghost p-hacking, the shape of the p-curve depends on whether dependent variables are intercorrelated. For uncorrelated variables, simulated p-hacked data do not give the "p-hacking bump" just below .05 that is regarded as evidence of p-hacking, though there is a negative skew when simulated variables are inter-correlated. The way p-curves vary according to features of underlying data poses problems when automated text mining is used to detect p-values in heterogeneous sets of published papers. Conclusions. The absence of a bump in the p-curve is not indicative of lack of p-hacking. Furthermore, while studies with evidential value will usually generate a right-skewed p-curve, we cannot treat a right-skewed p-curve as an indicator of the extent of evidential value, unless we have a model specific to the type of p-values entered into the analysis. We conclude that it is not feasible to use the p-curve to estimate the extent of p-hacking and evidential value unless there is considerable control over the type of data entered into the analysis. In particular, p-hacking with ghost variables is likely to be missed.

Detecting Hacked Twitter Accounts based on Behavioural Change

NARCIS (Netherlands)

Nauta, Meike; Habib, Mena Badieh; van Keulen, Maurice

Social media accounts are valuable for hackers for spreading phishing links, malware and spam. Furthermore, some people deliberately hack an acquaintance to damage his or her image. This paper describes a classification for detecting hacked Twitter accounts. The model is mainly based on features

Hacking of Passwords in Windows Environment

OpenAIRE

C.K. GOEL; GAURAV ARYA

2012-01-01

Hacking is so simple! Not only the operating system‟s loop holes offers opportunities to hackers but also the applications like Skype and Google Chrome developed for the operating systems are quite attractive to hackers. In this paper I present the various ways in which the passwords like user account‟s passwords stored by the operating system or the passwords required by different applications are stored on the system and can be hacked by intended hackers. This paper presents in depth resear...

Medication incidents reported to an online incident reporting system.

LENUS (Irish Health Repository)

Alrwisan, Adel

2011-01-15

AIMS: Approximately 20% of deaths from adverse events are related to medication incidents, costing the NHS an additional £500 million annually. Less than 5% of adverse events are reported. This study aims to assess the reporting rate of medication incidents in NHS facilities in the north east of Scotland, and to describe the types and outcomes of reported incidents among different services. Furthermore, we wished to quantify the proportion of reported incidents according to the reporters\\' profession. METHODS: A retrospective description was made of medication incidents reported to an online reporting system (DATIX) over a 46-month-period (July 2005 to April 2009). Reports originated from acute and community hospitals, mental health, and primary care facilities. RESULTS: Over the study period there were 2,666 incidents reported with a mean monthly reporting rate of 78.2\\/month (SD±16.9). 6.1% of all incidents resulted in harm, with insulin being the most commonly implicated medication. Nearly three-quarters (74.2%, n=1,978) of total incidents originated from acute hospitals. Administration incidents were implicated in the majority of the reported medication incidents (59%), followed by prescribing (10.8%) and dispensing (9.9%), while the nondescript "other medication incidents" accounted for 20.3% of total incidents. The majority of reports were made by nursing and midwifery staff (80%), with medical and dental professionals reporting the lowest number of incidents (n=56, 2%). CONCLUSIONS: The majority of medication incidents in this study were reported by nursing and midwifery staff, and were due to administration incidents. There is a clear need to elucidate the reasons for the limited contribution of the medical and dental professionals to reporting medication incidents.

P-Hacking: A Wake-Up Call for the Scientific Community.

Science.gov (United States)

Raj, A Thirumal; Patil, Shankargouda; Sarode, Sachin; Salameh, Ziad

2017-10-25

P-hacking or data dredging involves manipulation of the research data in order to obtain a statistically significant result. The reasons behind P-hacking and the consequences of the same are discussed in the present manuscript.

Implementasi Algoritma Pengenalan Wajah Untuk Mendeteksi Visual Hacking

OpenAIRE

Alexander, Luisan William; Sentinuwo, Steven; sambul, alwin

2017-01-01

Visual Hacking merupakan sebuah isu keamanan dan privasi data yang perlu diperhatikan saat ini, dimana visual hacking berfokus pada pencurian informasi yang terpampang pada tampilan elektronik, seperti layar monitor komputer. Isu ini dapat terjadi ketika pengguna membiarkan informasi terpampang pada layar komputer sehingga dapat dilihat oleh siapa saja. Pada penelitian ini, dibuatlah sebuah aplikasi berbasis computer vision dengan tujuan mengimplementasikan algoritma pengenalan wajah eigenfac...

Attributing Hacks

OpenAIRE

Liu, Ziqi; Smola, Alexander J.; Soska, Kyle; Wang, Yu-Xiang; Zheng, Qinghua; Zhou, Jun

2016-01-01

In this paper we describe an algorithm for estimating the provenance of hacks on websites. That is, given properties of sites and the temporal occurrence of attacks, we are able to attribute individual attacks to joint causes and vulnerabilities, as well as estimating the evolution of these vulnerabilities over time. Specifically, we use hazard regression with a time-varying additive hazard function parameterized in a generalized linear form. The activation coefficients on each feature are co...

Techniques de hacking

CERN Document Server

Erickson, Jon

2008-01-01

Dans cet ouvrage, Jon Erickson présente les bases de la programmation en C du point de vue du hacker et dissèque plusieurs techniques de hacking, passées et actuelles, afin de comprendre comment et pourquoi elles fonctionnent. Même si vous ne savez pas programmer, ce livre vous donnera une vue complète de la programmation, de l'architecture des machines, des communications réseau et des techniques de hacking existantes. Associez ces connaissances à l'environnement Linux fourni et laissez libre cours à votre imagination. Avec ce livre vous apprendrez à : • programmer les ordinateurs en C, en assembleur et avec des scripts shell ; • inspecter les registres du processeur et la mémoire système avec un débogueur afin de comprendre précisément ce qui se passe ; Vous découvrirez comment les hackers parviennent à : • corrompre la mémoire d'un système, en utilisant les débordements de tampons et les chaînes de format, pour exécuter un code quelconque ; • surpasser les mesures de sécurit...

P-hacking in academic research : a critical review of the job strain model and of the association between night work and breast cancer in women

OpenAIRE

Ingre, Michael

2017-01-01

P-hacking can be described as a more or less deliberate, explorative approach to data analysis with a flexible/opportunistic search space and the reporting of primarily statistically significant findings. This leads to inflated type-1 error rates and to bias in reported estimates in the scientific literature. This thesis aims to describe how p-hacking can be manifested in academic research and to illustrate how bias due to p-hacking is expected to affect the veracity of published findings usi...

GROWTH HACKING PRACTICES IN A START-UP: A CASE STUDY ON THECON.RO

Directory of Open Access Journals (Sweden)

Marius GERU

2014-06-01

Full Text Available Despite the increasing awareness of content marketing tools in the academic community, the benefits of growth hacking were highlighted especially in blog posts and several e-books. This paper examines the particular features of growth hacking techniques, which differentiates it from traditional marketing. Specifically, a content analysis was conducted to identify the experts’ opinions regarding the effective use of growth hacking techniques, to detect the specific skills that a growth hacker must gain and to compare the tools related to this concept from both inbound and outbound marketing perspective. On the other hand, we outlined the need for development of start-ups, without spending huge amounts of money in marketing. Using a case study methodology, we examined the motivations of adopting growth hacking techniques by an Internet pure player - Thecon. Results show that the effective mix of growth hacking techniques applied by this company tends to forward more online content than its competitors.

GROWTH HACKING PRACTICES IN A START-UP: A CASE STUDY ON THECON.RO

OpenAIRE

Marius GERU; Ema RUSU; Alexandru CAPATINA

2014-01-01

Despite the increasing awareness of content marketing tools in the academic community, the benefits of growth hacking were highlighted especially in blog posts and several e-books. This paper examines the particular features of growth hacking techniques, which differentiates it from traditional marketing. Specifically, a content analysis was conducted to identify the experts’ opinions regarding the effective use of growth hacking techniques, to detect the specific skills that a growth hacker ...

Google Hacks

CERN Document Server

Dornfest, Rael; Calishain, Tara

2006-01-01

Everyone knows that Google lets you search billions of web pages. But few people realize that Google also gives you hundreds of cool ways to organize and play with information.Since we released the last edition of this bestselling book, Google has added many new features and services to its expanding universe: Google Earth, Google Talk, Google Maps, Google Blog Search, Video Search, Music Search, Google Base, Google Reader, and Google Desktop among them. We've found ways to get these new services to do even more.The expanded third edition of Google Hacks is a brand-new and infinitely more usef

Hacking and penetration testing with low power devices

CERN Document Server

Polstra, Philip

2014-01-01

Hacking and Penetration Testing with Low Power Devices shows you how to perform penetration tests using small, low-powered devices that are easily hidden and may be battery-powered. It shows how to use an army of devices, costing less than you might spend on a laptop, from distances of a mile or more. Hacking and Penetration Testing with Low Power Devices shows how to use devices running a version of The Deck, a full-featured penetration testing and forensics Linux distribution, and can run for days or weeks on batteries due to their low power consumption. Author Philip Polstra shows how to

The Need for Specific Penalties for Hacking in Criminal Law

Directory of Open Access Journals (Sweden)

Sangkyo Oh

2014-01-01

Full Text Available In spite of the fact that hacking is a widely used term, it is still not legally established. Moreover, the definition of the concept of hacking has been deployed in a wide variety of ways in national literature. This ambiguity has led to various side effects. Recently in the United States, reforms collectively known as Aaron's Law were proposed as intended amendments to the Computer Fraud and Abuse Act (CFAA. Most experts expect that this change will put the brakes on the CFAA as a severe punishment policy, and result in a drop in controversial court decisions. In this study, we analyze the definitions and the penalties for hacking for each country and compare them with the national law and then make suggestions through more specific legislation. We expect it will reduce legal controversy and prevent excessive punishment.

The need for specific penalties for hacking in criminal law.

Science.gov (United States)

Oh, Sangkyo; Lee, Kyungho

2014-01-01

In spite of the fact that hacking is a widely used term, it is still not legally established. Moreover, the definition of the concept of hacking has been deployed in a wide variety of ways in national literature. This ambiguity has led to various side effects. Recently in the United States, reforms collectively known as Aaron's Law were proposed as intended amendments to the Computer Fraud and Abuse Act (CFAA). Most experts expect that this change will put the brakes on the CFAA as a severe punishment policy, and result in a drop in controversial court decisions. In this study, we analyze the definitions and the penalties for hacking for each country and compare them with the national law and then make suggestions through more specific legislation. We expect it will reduce legal controversy and prevent excessive punishment.

p-Curve and p-Hacking in Observational Research.

Science.gov (United States)

Bruns, Stephan B; Ioannidis, John P A

2016-01-01

The p-curve, the distribution of statistically significant p-values of published studies, has been used to make inferences on the proportion of true effects and on the presence of p-hacking in the published literature. We analyze the p-curve for observational research in the presence of p-hacking. We show by means of simulations that even with minimal omitted-variable bias (e.g., unaccounted confounding) p-curves based on true effects and p-curves based on null-effects with p-hacking cannot be reliably distinguished. We also demonstrate this problem using as practical example the evaluation of the effect of malaria prevalence on economic growth between 1960 and 1996. These findings call recent studies into question that use the p-curve to infer that most published research findings are based on true effects in the medical literature and in a wide range of disciplines. p-values in observational research may need to be empirically calibrated to be interpretable with respect to the commonly used significance threshold of 0.05. Violations of randomization in experimental studies may also result in situations where the use of p-curves is similarly unreliable.

Hacking medical devices a review - biomed 2013.

Science.gov (United States)

Frenger, Paul

2013-01-01

Programmable, implantable and external biomedical devices (such as pacemakers, defibrillators, insulin pumps, pain management pumps, vagus nerve stimulators and others) may be vulnerable to unauthorized access, commonly referred to as “hacking”. This intrusion may lead to compromise of confidential patient data or loss of control of the device itself, which may be deadly. Risks to health from unauthorized access is in addition to hazards from faulty (“buggy”) software or circuitry. Historically, this aspect of medical device design has been underemphasized by both manufacturers and regulatory bodies until recently. However, an insulin pump was employed as a murder weapon in 2001 and successful hacking of an implantable defibrillator was demonstrated in 2008. To remedy these problems, professional groups have announced a variety of design standards and the governmental agencies of several countries have enacted device regulations. In turn, manufacturers have developed new software products and hardware circuits to assist biomedical engineering firms to improve their commercial offerings. In this paper the author discusses these issues, reviewing known problems and zero-day threats, with potential solutions. He outlines his approach to secure software and hardware challenges using the Forth language. A plausible scenario is described in which hacking of an implantable defibrillator by terrorists results in a severe national security threat to the United States.

Ethical Hacking in Information Security Curricula

Science.gov (United States)

Trabelsi, Zouheir; McCoey, Margaret

2016-01-01

Teaching offensive security (ethical hacking) is becoming a necessary component of information security curricula with a goal of developing better security professionals. The offensive security components extend curricula beyond system defense strategies. This paper identifies and discusses the learning outcomes achieved as a result of hands-on…

The Need for Specific Penalties for Hacking in Criminal Law

OpenAIRE

Oh, Sangkyo; Lee, Kyungho

2014-01-01

In spite of the fact that hacking is a widely used term, it is still not legally established. Moreover, the definition of the concept of hacking has been deployed in a wide variety of ways in national literature. This ambiguity has led to various side effects. Recently in the United States, reforms collectively known as Aaron's Law were proposed as intended amendments to the Computer Fraud and Abuse Act (CFAA). Most experts expect that this change will put the brakes on the CFAA as a severe p...

Hacking Europe from computer cultures to demoscenes

CERN Document Server

Alberts, Gerard

2014-01-01

This book traces the evolution of European hacker culture: chopping games in Warsaw, hacking software in Athens, chaos in Hamburg, producing demos in Turku and partying with computing in Zagreb and Amsterdam. Emphasizes the role of mischief, humor and play.

Professional penetration testing creating and operating a formal hacking lab

CERN Document Server

Wilhelm, Thomas

2009-01-01

PART I - Setting Up. Chapter 1: Introduction. Chapter 2: Ethics and Hacking. Chapter 3: Hacking as a Career. Chapter 4: Setting up Your Lab. Chapter 5: Creating and Using PenTest Targets in Your Lab. Chapter 6: Methodologies. Chapter 7: PenTest Metrics. Chapter 8: Management of a PenTest. PART II - Running a PenTest. Chapter 9: Information Gathering. Chapter 10: Vulnerability Identification. Chapter 11: Vulnerability Verification. Chapter 12: Compromising a System and Privilege Escalation. Chapter 13: Maintaining Access. Chapter 14: Covering Your Tracks. PART III - Wrapping Everything Up. Chap

Connected Learning in the Library as a Product of Hacking, Making, Social Diversity and Messiness

Science.gov (United States)

Bilandzic, Mark

2016-01-01

Learning is most effective when intrinsically motivated through personal interest, and situated in a supportive socio-cultural context. This paper reports on findings from a study that explored implications for design of interactive learning environments through 18 months of ethnographic observations of people's interactions at "Hack The…

The walking-induced transient hack concept is valid & relies on a transient early-exercise hypoxemia.

Directory of Open Access Journals (Sweden)

Antoine Bruneau

Full Text Available Decreased arterial oxygen pressure obtained at peak exercise is strong evidence of walking-induced hypoxemia, assuming that the lower pressure occurs just before exercise is stopped. Using empirical predefined models and transcutaneous oximetry, we have shown that some patients reporting exercise intolerance show a minimal value at the onset of walking and a post-exercise overshoot. These changes are referred to as transcutaneous "walking-induced transient hacks".In 245 patients, walking-induced transcutaneous oxygen pressure changes in the chest were analyzed using observer-independent clustering techniques. Clustering classes were compared to the profile types previously proposed with the cross-correlation technique. The classifications of patients according to both approaches were compared using kappa statistics. In 10 patients showing a hack on transcutaneous oximetry, we analyzed the results of direct iterative arterial sampling recorded during a new walking treadmill test.Clustering analysis resulted in 4 classes that closely fit the 4 most frequently proposed empirical models (cross-correlation coefficients: 0.93 to 0.97. The kappa between the two classifications was 0.865. In 10 patients showing transcutaneous hacks, the minimal direct arterial oxygen pressure value occurred at exercise onset, and these patients exhibited a recovery overshoot reaching a maximum at two minutes of recovery, confirming the walking-induced transient hypoxemia.In patients reporting exercise intolerance, transcutaneous oximetry could help to detect walking-induced transient hypoxemia, while peak-exercise arterial oximetry might be normal.

Hacking in the University: Contesting the Valorisation of Academic Labour

Directory of Open Access Journals (Sweden)

Joss Winn

2013-11-01

Full Text Available In this article I argue for a different way of understanding the emergence of hacker culture. In doing so, I outline an account of ‘the university’ as an institution that provided the material and subsequent intellectual conditions that early hackers were drawn to and in which they worked. I argue that hacking was originally a form of academic labour that emerged out of the intensification and valorisation of scientific research within the institutional context of the university. The reproduction of hacking as a form of academic labour took place over many decades as academics and their institutions shifted from an ideal of unproductive, communal science to a more productive, entrepreneurial approach to the production of knowledge.  A such, I view hacking as a peculiar, historically situated form of labour that arose out of the contradictions of the academy: vocation vs. profession; teaching vs. research; basic vs. applied research; research vs. development; private vs. public; war vs. peace; institutional autonomy vs. state dependence; scientific communalism vs. intellectual property.

Hacking Europe: From Computer Cultures to Demoscenes

NARCIS (Netherlands)

Alberts, G.; Oldenziel, R.

2014-01-01

Hacking Europe focuses on the playfulness that was at the heart of how European users appropriated microcomputers in the last quarter of the twentieth century. The essays argue that users--whether the design of the projected use of computers was detailed or still unfinished--assigned their own

A Systems Approach to Healthcare Innovation Using the MIT Hacking Medicine Model.

Science.gov (United States)

Gubin, Tatyana A; Iyer, Hari P; Liew, Shirlene N; Sarma, Aartik; Revelos, Alex; Ribas, João; Movassaghi, Babak; Chu, Zen M; Khalid, Ayesha N; Majmudar, Maulik D; Lee, Christopher Xiang

2017-07-26

MIT Hacking Medicine is a student, academic, and community-led organization that uses systems-oriented "healthcare hacking" to address challenges around innovation in healthcare. The group has organized more than 80 events around the world that attract participants with diverse backgrounds. These participants are trained to address clinical needs from the perspective of multiple stakeholders and emphasize utility and implementation viability of proposed solutions. We describe the MIT Hacking Medicine model as a potential method to integrate collaboration and training in rapid innovation techniques into academic medical centers. Built upon a systems approach to healthcare innovation, the time-compressed but expertly guided nature of the events could enable more widely accessible preliminary training in systems-level innovation methodology, as well as creating a structured opportunity for interdisciplinary congregation and collaboration. Copyright © 2017 Elsevier Inc. All rights reserved.

Computer Hacking as a Social Problem

OpenAIRE

Alleyne, Brian

2018-01-01

This chapter introduces the ideas and practices of digital technology enthusiasts who fall under the umbrella of “hackers. “We will discuss how their defining activity has been constructed as a social problem and how that construction has been challenged in different ways. The chapter concludes with several policy suggestions aimed at addressing the more problematic aspects of computer hacking.

Vulnerability Assessments in Ethical Hacking

OpenAIRE

Ashiqur Rahman ,; Md. SarwarAlam Rasel; Asaduzzaman Noman; Shakh Md. Alimuzjaman Alim

2016-01-01

Ethical hackers use the same methods and techniques to test and bypass a system's defenses as their less-principled counterparts, but rather than taking advantage of any vulnerabilities found, they document them and provide actionable advice on how to fix them so the organization can improve its overall security. The purpose of ethical hacking is to evaluate the security of a network or system's infrastructure. It entails finding and attempting to exploit any vulnerabilities to de...

Herramientas para hacking ético

OpenAIRE

Redondo Gil, Juan José

2015-01-01

The objective of this project is to describe and test the most important hacking tools available in the Kali Linux distribution. This distribution, based on UNIX, contains tools for network auditing, cracking passwords and traffic sniffing of various protocols (TCP, UDP, HTTP, SSH, ..). The hosts used to test the attacks will be based on UNIX, Windows and Android architecture. It is very important to previously study the architecture of the target (host, network) because the attacks are focus...

Growth Hacking a Global Community

OpenAIRE

Sarkkinen, Laura; Rauhala, Marita

2015-01-01

As technology is developing at a fast phase people are engaging in community activities more and more online, either by extending their offline social life or by creating themselves a whole new parallel life as a member of virtual community. Companies behind communities are rivaling for attention and need to come up with increasingly clever tactics to attract and engage new members. In this thesis the relatively new phenomenon of growth hacking, the use of unconventional methods in order ...

Quantum key distribution with hacking countermeasures and long term field trial.

Science.gov (United States)

Dixon, A R; Dynes, J F; Lucamarini, M; Fröhlich, B; Sharpe, A W; Plews, A; Tam, W; Yuan, Z L; Tanizawa, Y; Sato, H; Kawamura, S; Fujiwara, M; Sasaki, M; Shields, A J

2017-05-16

Quantum key distribution's (QKD's) central and unique claim is information theoretic security. However there is an increasing understanding that the security of a QKD system relies not only on theoretical security proofs, but also on how closely the physical system matches the theoretical models and prevents attacks due to discrepancies. These side channel or hacking attacks exploit physical devices which do not necessarily behave precisely as the theory expects. As such there is a need for QKD systems to be demonstrated to provide security both in the theoretical and physical implementation. We report here a QKD system designed with this goal in mind, providing a more resilient target against possible hacking attacks including Trojan horse, detector blinding, phase randomisation and photon number splitting attacks. The QKD system was installed into a 45 km link of a metropolitan telecom network for a 2.5 month period, during which time the system operated continuously and distributed 1.33 Tbits of secure key data with a stable secure key rate over 200 kbit/s. In addition security is demonstrated against coherent attacks that are more general than the collective class of attacks usually considered.

Genetic diversity of Pogonatherum paniceum (Lam.) Hack. in ...

African Journals Online (AJOL)

Amplified fragment length polymorphism (AFLP) markers were used to estimate the genetic diversity of Pogonatherum paniceum (Lam.) Hack. from Sichuan Province, Yunnan Province, Chongqing City and. Guangxi Zhuang autonomous Region in China. 10 primer combinations were carried out on 180 different individuals ...

Ian Hacking, Learner Categories and Human Taxonomies

Science.gov (United States)

Davis, Andrew

2008-01-01

I use Ian Hacking's views to explore ways of classifying people, exploiting his distinction between indifferent kinds and interactive kinds, and his accounts of how we "make up" people. The natural kind/essentialist approach to indifferent kinds is explored in some depth. I relate this to debates in psychiatry about the existence of mental…

Linux Server Hacks, 2 Tips & Tools for Connecting, Monitoring, and Troubleshooting

CERN Document Server

von Hagen, William

2009-01-01

This handy reference offers 100 completely new server management tips and techniques designed to improve your productivity and sharpen your administrative skills. Each hack represents a clever way to accomplish a specific task, saving you countless hours of searching for the right answer. And you don't have to be a system administrator with hundreds of boxen to get something useful from this book as many of the hacks apply equally well to a single system or a home network. Whether they help you recover lost data, collect information from distributed clients, or synchronize administrative envir

Statistics Hacks Tips & Tools for Measuring the World and Beating the Odds

CERN Document Server

Frey, Bruce

2008-01-01

Want to calculate the probability that an event will happen? Be able to spot fake data? Prove beyond doubt whether one thing causes another? Or learn to be a better gambler? You can do that and much more with 75 practical and fun hacks packed into Statistics Hacks. These cool tips, tricks, and mind-boggling solutions from the world of statistics, measurement, and research methods will not only amaze and entertain you, but will give you an advantage in several real-world situations-including business.

Explanation of the values of Hack's drainage basin, river length scaling exponent

Science.gov (United States)

Hunt, A. G.

2015-08-01

Percolation theory can be used to find water flow paths of least resistance. The application of percolation theory to drainage networks allows identification of the range of exponent values that describe the tortuosity of rivers in real river networks, which is then used to generate the observed scaling between drainage basin area and channel length, a relationship known as Hack's law. Such a theoretical basis for Hack's law allows interpretation of the range of exponent values based on an assessment of the heterogeneity of the substrate.

Genetic diversity of Pogonatherum paniceum (Lam.) Hack in ...

African Journals Online (AJOL)

Inter-simple sequence repeats markers were used to estimate the genetic diversity of Pogonatherum paniceum (Lam.) Hack. from Sichuan Province, Yunnan Province, Chongqing City and Guangxi Zhuang Autonomous Region in China. 100 primers were carried out on 22 wild populations, 14 could produce highly ...

One Coin has Two Sides: A Comparative Appraisal of New York Times and China Daily’s News Coverage of Alleged Internet Hacking

Directory of Open Access Journals (Sweden)

Wenyu Liu

2015-04-01

Full Text Available There is always some debate as to whether news reporting is objective and emotionless. Under the guidance of engagement system, a sub-system of Appraisal Theory, concerning the conveyance of ideology, the present study attempts to make a comparative study of different ideological attitudes by news coverage in New York Times and China Daily’s (English version on alleged internet hacking. The findings suggest that similar distributions of engagement resources in the news reports are adopted when engaged in an ideological attitude. Additionally, China Daily and New York Times hold different attitudes to Internet hacking. The attitude by China Daily changes before and after Snowden Event, while New York Times remains the same.

P.S. I love you...and other growth hacking strategies used by disruptive tech start-ups : A case study on the relevance and enactment of growth hacking by Sweden's tech start-ups

OpenAIRE

Bergendal, Taghrid Sara

2017-01-01

Disruption innovation theory has been the zeitgeist for building globally disruptive tech companies since 1997. One decade later, disruptive tech start-ups are moving away from traditional marketing strategies in favour of growth hacking. There is a seemingly growing consensus by online tech experts, tech entrepreneurs, advisors and investors, that suggests that growth hacking is becoming increasingly important practice for disruption based tech start-ups. Furthermore, Sweden is becoming the ...

iPhone Hacks Tips and Tools for Pushing the Smartest Phone to Its Limits

CERN Document Server

Jurick, David; Stolarz, Damien

2009-01-01

With iPhone Hacks, you can make your iPhone do all you'd expect of a smartphone -- and more. Learn tips and techniques to unleash little-known features, find and create innovative applications for both the iPhone and iPod touch, and unshackle these devices to run everything from network utilities to video game emulators. iPhone Hacks is exactly what you need to make the most of your iPhone.

An introduction to hacking and crimeware a pocket guide

CERN Document Server

Loewengart, Victoria

2012-01-01

An Introduction to Hacking & Crimeware is a comprehensive guide to the most recent and the more serious threats. Knowing about these threats will help you understand how to ensure that your computer systems are protected and that your business is safe, enabling you to focus on your core activities.

Reactor incident status 1981 annual report

International Nuclear Information System (INIS)

Kiser, S.H.

1982-01-01

Reactor Incident followup action is summarized through periodic status reports. This annual report summarizes action taken or anticipated for Reactor Incidents through December 1981. Incidents for which action has been completed, have been deleted from the report. Quarterly addende will update the report by tabulating incidents for each three month period through the coming year. The report consists of a part for the P, K, and C Reactors. Each reactor part is divided into three sections: Further Technical Analysis or Followup Needed; Funding and/or Implementation Needed; and No Further Technical Analysis Anticipated

Forty Years of Movie Hacking: Considering the Potential Implications of the Popular Media Representation of Computer Hackers from 1968 to 2008

OpenAIRE

Gordon, Damian

2010-01-01

Increasingly movies are being produced which feature plots that incorporate elements of computer security and hacking, and cumulatively these movies are creating a public perception as to the nature of computer security. This research examines movies that feature hackers (and hacking) to identify if any common themes emerge from these movies in their representation of these issues. To achieve this, first a corpus of hacking movies is created, and then using a qualitative data analysis techniq...

Attitudes and perceived barriers influencing incident reporting by nurses and their correlation with reported incidents: A systematic review.

Science.gov (United States)

Fung, Wing Mei; Koh, Serena Siew Lin; Chow, Yeow Leng

Clinical incident reporting is an integral feature of risk management system in the healthcare sector. By reporting clinical incidents, nurses allow for learning from errors, identification of error patterns and development of error preventive strategies. The need to understand attitudes to reporting, perceived barriers and incident reporting patterns by nurses are the core highlights of this review. INCLUSION CRITERIA: This review considered descriptive quantitative studies that examined nurses' attitudes or perceived barriers towards incident reporting.The participants in this review were nurses working in acute care settings or step-down care settings. Studies that included non-nursing healthcare personnel were excluded.This review considered studies which examined nurses' attitudes towards incident reporting, perceived barriers and incident reporting practices.The outcomes of interest were the attitudes that nurses have towards incident reporting, perceived barriers and the types of reported incidents in correlation with nurses' attitudes and barriers. A three-step search strategy was utilised in this review. An initial limited search of CINAHL and MEDLINE was undertaken. Search strategies were then developed using identified keywords and index terms. Lastly, the reference lists of all identified articles were examined. All searches were limited to studies published in English, between 1991 and 2010. The studies were independently assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal Checklist for Descriptive/ Case Series studies. The reviewers extracted data independently from included studies using the Joanna Briggs Institute Data Extraction Form for Descriptive/ Case Series studies. Due to the descriptive nature of the study designs, statistical pooling was not possible. Therefore, the findings of this systematic review are presented in a narrative summary. Fifty-five papers were identified from the searches based on their titles and

Little River revisited - thirty-five years after Hack and Goodlett

Science.gov (United States)

Osterkamp, W.R.; Hupp, C.R.; Schening, M.R.

1995-01-01

In possibly the first detailed study to relate geomorphology, vegetation, and hydrology at a watershed scale, Hack and Goodlett (1960) documented variation in the eastern forest with topographic positions of cove, side slope, and nose. The study also described effects on landforms and vegetation of a catastrophic flood that occurred in June, 1949. Field investigations, conducted nearly four decades later, review selected parts of the study by Hack and Goodlett (1960). Replicate data provide a basis to evaluate their interpretations, to document geomorphic change since the 1949 flood, and to identify vegetation change in uplands and bottomlands. Results suggest that change to hillslope landforms has been minor since 1949, but that changes have occurred, seemingly during flow events of 1952, 1955 and 1985. Change in areal extent of forest types was not detected. Change in the relative abundances of dominant species may have resulted from 20th century fire suppression. -from Authors

Brief communication: Possible explanation of the values of Hack's drainage basin, river length scaling exponent

Science.gov (United States)

Hunt, Allen G.

2016-04-01

Percolation theory can be used to find water flow paths of least resistance. Application of percolation theory to drainage networks allows identification of the range of exponent values that describe the tortuosity of rivers in real river networks, which is then used to generate the observed scaling between drainage basin area and channel length, a relationship known as Hack's law. Such a theoretical basis for Hack's law may allow interpretation of the range of exponent values based on an assessment of the heterogeneity of the substrate.

Can a biologist fix a smartphone?-Just hack it!

Science.gov (United States)

Kamoun, Sophien

2017-05-08

Biological systems integrate multiscale processes and networks and are, therefore, viewed as difficult to dissect. However, because of the clear-cut separation between the software code (the information encoded in the genome sequence) and hardware (organism), genome editors can operate as software engineers to hack biological systems without any particularly deep understanding of the complexity of the systems.

Variations in Tectonic Activities of the Central and Southwestern Foothills, Taiwan, Inferred from River Hack Profiles

Directory of Open Access Journals (Sweden)

Yen-Chieh Chen

2006-01-01

Full Text Available A longitudinal profile of a river under static equilibrium shows no degradation or aggradation and can be ideally described as a straight line on a semi-logarithmic graph. This type of profile is called a “Hack profile”. If a river runs across uprising active structure systems, its Hack profile becomes convex. Accumulated tectonic strain varies positively with the intensity of the upwarping in Hack-profile convexity. In this paper, we compare curvature changes in Hack profiles of a series of rivers running through faults in the central and southwestern Foothills of Taiwan. Longitudinal profiles of these rivers were derived from two versions of topographic maps (1904 and 1985 and recent DTM data (2000. Prior to comparisons, we calibrated the 1904 topographic map, named “Taiwan Bautu”, by “offsetting” horizontal coordinates north and westward approximately 440 m and then “linear transforming” the elevation values. The Tungtzchiau fault of the central Foothills has remained inactive since 1935. Here relatively high uplift activity near the Wu River is indicated by significantly convex Hack profiles. This strain accumulation can be attributed to a lack of small magnitude earthquakes along the fault over the past 70 years. In the southwestern Foothills, relatively high uplift activity of similar intensity to the central Foothills is indicted near the Neocho River. Significant profiles with concave segments below the ideal graded profiles, at the lower reaches of rivers where continuous small magnitude strain release events have occurred, can only be found along the Sandieh, Neocho and Bazhang rivers in the southwestern Foothills. All these findings indicate that fault systems in the central Foothills tend to be locked and these faults could yield large earthquakes similar to the Chi-Chi event.

Understanding network hacks attack and defense with Python

CERN Document Server

Ballmann, Bastian

2015-01-01

This book explains how to see one's own network through the eyes of an attacker, to understand their techniques and effectively protect against them. Through Python code samples the reader learns to code tools on subjects such as password sniffing, ARP poisoning, DNS spoofing, SQL injection, Google harvesting and Wifi hacking. Furthermore the reader will be introduced to defense methods such as intrusion detection and prevention systems and log file analysis by diving into code.

Hazmat Yearly Incident Summary Reports

Data.gov (United States)

Department of Transportation — Series of Incident data and summary statistics reports produced which provide statistical information on incidents by type, year, geographical location, and others....

Reanalyzing Head et al. : Investigating the robustness of widespread p-hacking

NARCIS (Netherlands)

Hartgerink, C.H.J.

2017-01-01

Head et al. (2015) provided a large collection of p-values that, from their perspective, indicates widespread statistical significance seeking (i.e., p-hacking). This paper inspects this result for robustness. Theoretically, the p-value distribution should be a smooth, decreasing function, but the

Science Hack Day: an opportunity for public engagement, art/science mash-ups, and inspiration

Science.gov (United States)

Bellis, Matthew

2013-04-01

The idea of a Science Hack Day (http://sciencehackday.com/) is to put non-scientists (designers, web developers, artists, interested enthusiasts) in a room with scientists and some good ideas, and see what science-themed project they can create in a weekend (about 24 hours of real hacking). The motto of the organizers is ``Get Excited and Make Things with Science!'' I have participated in several of these events including the first one held in the United State in Palo Alto in 2010 and as a remote advisor to participants in Nairobi, Kenya. To these events I have brought particle physics data from both the BaBar and the CMS (Compact Muon Solenoid) experiments, data from the CoGeNT dark matter direct-detection experiment, and my expertise and enthusiasm. The experience has been transformative for me as both a scientist and a science advocate. This talk will recount my experiences with Science Hack Day events in general and detail some projects that have come out of these days, including the Particle Physics Wind Chime (http://www.mattbellis.com/windchime/) and the Standard Model of Cocktail Physics (http://www.physicsdavid.net/2012/11/standard-model-of-cocktail-physics/). Opportunities for other scientists to take part in similar events will be discussed.

A critical incident reporting system in anaesthesia.

Science.gov (United States)

Madzimbamuto, F D; Chiware, R

2001-01-01

To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Between May and October 2000, 62 completed critical incident forms were collected. The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome. Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The

Hacking Health: Bottom-up Innovation for Healthcare

Directory of Open Access Journals (Sweden)

Jeeshan Chowdhury

2012-07-01

Full Text Available Healthcare is not sustainable and still functions with outdated technology (e.g., pagers, paper records. Top-down approaches by governments and corporations have failed to deliver digital technologies to modernize healthcare. Disruptive innovation must come from the ground up by bridging the gap between front-line health experts and innovators in the latest web and mobile technology. Hacking Health is a hackathon that is focused on social innovation more than technical innovation. Our approach to improve healthcare is to pair technological innovators with healthcare experts to build realistic, human-centric solutions to front-line healthcare problems.

SU-E-P-07: Retrospective Analysis of Incident Reports at a Radiology Department: Feedback From Incident Reporting System

Energy Technology Data Exchange (ETDEWEB)

Kakinohana, Y; Toita, T; Heianna, J; Murayama, S [School of medicine, University of the Ryukyus, Nishihara-cho, Okinawa (Japan)

2015-06-15

Purpose: To provide an overview of reported incidents that occurred in a radiology department and to describe the most common causal source of incidents. Methods: Incident reports from the radiology department at the University of the Ryukyus Hospital between 2008 and 2013 were collected and analyzed retrospectively. The incident report form contains the following items, causal factors of the incident and desirable corrective actions to prevent recurrence of similar incidents. These items allow the institution to investigate/analyze root causes of the incidents and suggest measures to be taken to prevent further, similar incidents. The ‘causal factors of the incident’ item comprises multiple selections from among 24 selections and includes some synonymous selections. In this study, this item was re-categorized into four causal source types: (i) carelessness, (ii) lack of skill or knowledge, (iii) deficiencies in communication, and (iv) external factors. Results: There were a total of 7490 incident reports over the study period and 276 (3.7%) were identified as originating from the radiology department. The most frequent causal source type was carelessness (62%). The other three types showed similar frequencies (10–14%). The staff members involved in incidents indicate three predominant desirable corrective actions to prevent or decrease the recurrence of similar incidents. These are ‘improvement in communication’ (24%), ‘staff training/education’ (19%), and ‘daily medical procedures’ (22%), and the most frequent was ‘improvement in communication’. Even though the most frequent causal factor was related to carelessness, the most desirable corrective action indicated by the staff members was related to communication. Conclusion: Our finding suggests that the most immediate causes are strongly related to carelessness. However, the most likely underlying causes of incidents would be related to deficiencies in effective communication. At our

The relationship between addiction to internet and adolescence’s tendency toward opposite sex, sexual behaviors, alcohol, aggression, chatting and hacking

Directory of Open Access Journals (Sweden)

Mehri Mowlaie

2016-01-01

Full Text Available Background: Given the importance of adolescent period and impact of internet and virtual communication tools on high risk behaviors, this research was conducted to examine the relationship between addiction to internet and adolescent’s tendency toward opposite sex, sexual behaviors, alcohol, aggression, chatting and hacking. Methods: The population of this study included all (n=40597 junior and senior high school students (boys and girls in academic year 2014-2015 in Ardabil, Iran. 380 subjects were selected as the study sample by multistage cluster sampling. The instruments for data collection in this research were addiction to internet questionnaire, Iranian adolescent's risk-taking scale and the researcher-made tendency to chat and hacking questionnaire. The data were analyzed by SPSS-22 software using correlation coefficient and simultaneous regression analysis. Results: The results showed a significantly positive correlation between addiction to internet and sexual behavior, tendency toward opposite sex, aggression, chatting and hacking (P<0.001, but there was no significant relationship between addiction to internet and alcohol. Conclusion: The results of the present study showed that addiction to internet was able to significantly predict sexual behavior, tendency toward opposite sex, aggression, chatting and hacking.

NEA incident reporting system: Three years' experience

International Nuclear Information System (INIS)

Otsuka, Y.; Haeussermann, W.

1984-01-01

The paper presents an overview of the NEA Incident Reporting System (IRS) which was set up to collect, assess and disseminate on safety-related incidents in nuclear power plants. The IRS information exchange is significant in two senses. First, it enables regulatory authorities and utilities in participating countries to take appropriate action to prevent the reported mishaps occurring again elsewhere. Secondly, the continuous collection and systematic analysis of such information allows identification of areas of concern where safety research should be strengthened. There are two stages in the IRS information exchange. First, the national IRS Co-ordinator selects information on significant incidents, in accordance with a common reporting threshold, from the abnormal occurrences reported to the regulatory body, to be distributed through the NEA Secretariat. This screening is intended to exclude minor events, so that only significant information is sent to participating countries. Secondly, a group of experts periodically reviews the incidents reported during the preceding twelve months to identify major areas of concern. To assist this process, a computer-based data retrieval system is being developed for IRS incident reports. The paper gives some details of the IRS mechanism and discusses reporting criteria and the information included in a report. Areas of concern derived from reported incidents, an outline of the data retrieval system, and examples of feedback of lessons learned and possibilities for international co-operation are also discussed. (author)

49 CFR 225.11 - Reporting of accidents/incidents.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Reporting of accidents/incidents. 225.11 Section... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.11 Reporting of accidents/incidents. Each railroad subject to this part shall submit to FRA...

Second generation bioethanol production from Saccharum spontaneum L. ssp. aegyptiacum (Willd.) Hack.

Science.gov (United States)

Danilo Scordia; Salvatore L. Consentino; Thomas W. Jeffries

2010-01-01

Saccharum (Saccharum spontaneum L. ssp. aegyptiacum (Willd.) Hack.), is a rapidly growing, wide ranging high-yield perennial, suitable for second generation bioethanol production. This study evaluated oxalic acid as a pretreatment for bioconversion. Overall sugar yields, sugar degradation products, enzymatic glucan hydrolysis and ethanol production were studied as...

Hacking with Kali practical penetration testing techniques

CERN Document Server

Broad, James

2013-01-01

Hacking with Kali introduces you the most current distribution of the de facto standard tool for Linux pen testing. Starting with use of the Kali live CD and progressing through installation on hard drives, thumb drives and SD cards, author James Broad walks you through creating a custom version of the Kali live distribution. You'll learn how to configure networking components, storage devices and system services such as DHCP and web services. Once you're familiar with the basic components of the software, you'll learn how to use Kali through the phases of the penetration testing lifecycle

The ethical hack a framework for business value penetration testing

CERN Document Server

Tiller, James S

2004-01-01

INTRODUCTIONPerspectives of ValueSECURITY AND HACKINGInformation SecuritySecurity ArchitectureHacking ImpactsTHE FRAMEWORKBusiness Planning and OperationsReconnaissanceEnumerationVulnerability AnalysisExploitationFinal AnalysisDeliverableIntegration INFORMATION SECURITY PROGRAMScope of Information Security ProgramsThe Process of Information SecurityComponent Parts of Information Security ProgramsBUSINESS PLANNING AND OPERATIONSBusiness ObjectivesSecurity PolicyPrevious Test ResultsBusiness ChallengesThe Business of SecurityReasoningOverall ExpectationsHow Deep is Deep Enough?Timing is Everythi

Concepts, Diagnosis and the History of Medicine: Historicising Ian Hacking and Munchausen Syndrome.

Science.gov (United States)

Millard, Chris

2017-08-01

Concepts used by historians are as historical as the diagnoses or categories that are studied. The example of Munchausen syndrome (deceptive presentation of illness in order to adopt the 'sick role') is used to explore this. Like most psychiatric diagnoses, Munchausen syndrome is not thought applicable across time by social historians of medicine. It is historically specific, drawing upon twentieth-century anthropology and sociology to explain motivation through desire for the 'sick role'. Ian Hacking's concepts of 'making up people' and 'looping effects' are regularly utilised outside of the context in which they are formed. However, this context is precisely the same anthropological and sociological insight used to explain Munchausen syndrome. It remains correct to resist the projection of Munchausen syndrome into the past. However, it seems inconsistent to use Hacking's concepts to describe identity formation before the twentieth century as they are given meaning by an identical context.

Hacking's 'Between Goffman and Foucault': A Theoretical Frame for Criminology

OpenAIRE

Tomás Speziale

2017-01-01

This paper aims to analyse how Ian Hacking states the theoretical basis of his research on the classification of people. Although all his early philosophical education had been based in Foucault, it is also true that Erving Goffman’s perspective provided him with epistemological and methodological tools for understanding face-to-face relationships. Hence, all his works must be thought of as social science texts that combine the research on how the individuals are constitu...

p-hacking by post hoc selection with multiple opportunities: Detectability by skewness test?: Comment on Simonsohn, Nelson, and Simmons (2014).

Science.gov (United States)

Ulrich, Rolf; Miller, Jeff

2015-12-01

Simonsohn, Nelson, and Simmons (2014) have suggested a novel test to detect p-hacking in research, that is, when researchers report excessive rates of "significant effects" that are truly false positives. Although this test is very useful for identifying true effects in some cases, it fails to identify false positives in several situations when researchers conduct multiple statistical tests (e.g., reporting the most significant result). In these cases, p-curves are right-skewed, thereby mimicking the existence of real effects even if no effect is actually present. (c) 2015 APA, all rights reserved).

AlphaCo: A Teaching Case on Information Technology Audit and Security

Directory of Open Access Journals (Sweden)

Hüseyin Tanriverdi

2006-03-01

Full Text Available Recent regulations in the United States (U.S. such as the Sarbanes-Oxley Act of 2002 require top management of a public firm to provide reasonable assurance that they institute internal controls that minimize risks over the firm’s operations and financial reporting. External auditors are required to attest to the management’s assertions over the effectiveness of those internal controls. As firms rely more on information technology (IT in conducting business, they also become more vulnerable to IT related risks. IT is critical for initiating, recording, processing, summarizing and reporting accurate financial and non-financial data. Thus, understanding IT related risks and instituting internal control mechanisms that minimize them have become important and created an urgent need for professionals who are equipped with IT audit and security skills and knowledge. However, there is severe shortage of teaching cases that can be used in courses aimed at training such professionals. This teaching case begins to address this gap by fostering classroom discussions around IT audit and security issues. It revolves around a hacking incident that compromised online order processing systems of AlphaCo and led to some fraudulent activity. The hacking incident raises a series of questions about IT security vulnerabilities, internal control deficiencies, integrity of financial statements, and independent auditors’ assessment of fraud in the context of the Sarbanes-Oxley Act. The case places students in the roles of executives, IT managers, and auditors and encourages them to discuss several important questions: how and why did the hacking incident happen; what harm did it cause to the firm; how can the firm prevent such hacking incidents in the future; if they do happen, how can the firm detect hacking incidents and fraud sooner; how do auditors assess the impact of such incidents in the context of a financial statement audit; and whether the management

EMS helicopter incidents reported to the NASA Aviation Safety Reporting System

Science.gov (United States)

Connell, Linda J.; Reynard, William D.

1993-01-01

The objectives of this evaluation were to: Identify the types of safety-related incidents reported to the Aviation Safety Reporting System (ASRS) in Emergency Medical Service (EMS) helicopter operations; Describe the operational conditions surrounding these incidents, such as weather, airspace, flight phase, time of day; and Assess the contribution to these incidents of selected human factors considerations, such as communication, distraction, time pressure, workload, and flight/duty impact.

National Fire Incident Reporting System (NFIRS)

Data.gov (United States)

Department of Homeland Security — The National Fire Incident Reporting System (NFIRS) is a reporting standard that fire departments use to uniformly report on the full range of their activities, from...

‘Hacking multitude’ and Big Data: Some insights from the Turkish ‘digital coup’

Directory of Open Access Journals (Sweden)

Paolo Cardullo

2015-04-01

Full Text Available The paper presents my first findings and reflections on how ordinary people may opportunistically and unpredictably respond to Internet censorship and tracking. I try to capture this process with the concept of ‘hacking multitude'. Working on a case study of the Turkish government's block of the social media platform Twitter (March 2014, I argue that during systemic data choke-points, a multitude of users might acquire a certain degree of reflexivity over ubiquitous software of advanced techno-capitalism. Resisting naïve parallels between urban streets and virtual global streets, the article draws on Fuller's ‘media ecologies' to make sense of complex and dynamic interactions between processes and materialities, strategies of communication and mundane practices. Such a dense space is mostly invisible to network and traffic analysis, although it comes alive under the magnifying lens of digital ethnography. As the Turkish government tried to stop protesters on both the urban and the Twitter spheres, alternative material configurations and new hybrid formations and practices emerged. I try to bring this process alive following the traces – that is, a combination of digital data and materialities – of a social space between the protest for Twitter access, the ‘digital coup' and the interactions that this situation determined. In the final section, I briefly explore two research trajectories which can further develop my initial formulation of a ‘hacking multitude'. I argue that a generalisation of hacking/multitude is problematic for the political, cultural or economic processes more directly associated with Big Data.

Cloud amount/frequency, NITRATE and other data from PORT HACKING 50M, STORM BAY and other platforms from 1989-01-04 to 1990-12-05 (NODC Accession 9300100)

Data.gov (United States)

National Oceanic and Atmospheric Administration, Department of Commerce — The Ocean Serial data in this accession was collected as part of Global Ocean Data Archeaology and Rescue (GODAR) project from ships PORT HACKING 100M, PORT HACKING...

Development of Incident Report Database for Organizational Learning

Science.gov (United States)

Otsuka, Yuichi; Abe, Tomotaka; Noguchi, Hiroshi; Makinouchi, Akifumi

The necessity of an incident reporting system has recently been increasing for hospitals. Japan Council for Quality Health Care (JCQHC) started operating a national incident reporting system to which domestic hospitals would report their incidents. However, the reporting system obtained an additional problem for the hospitals. They managed their own systems which collected reports by papers. The purposes of the reporting systems was to analyze considerable causes involved in incidents to improve the quality of patient safety management. On the contrary, the national reporting system aimed at collecting a statistical tendency of normal incidents. Simultaneously operating the two systems would be too much workload for safety managers. The load may have the managers rest only a short time for summarizing occurrences, not enough for analyzing their causes. However, to the authors' knowledge, there has not been an integrating policy of the two forms to adapt them to practical situations in patient safety management. The scope of this paper is to establish the integrated form in order to use in analyzing the causes of incidents as well as reporting for the national system. We have developed new data base system using XML + XSLT and Java Servlet. The developed system is composed of three computers; DB server , DB client and Data sending server. To investigate usability of the developed system, we conducted a monitoring test by real workers in reporting workplaces. The result of subjective evaluations by examinees was so preferable for the developed system. The results of usability test and the achievement of increasing the number of reports after the introduction can demonstrate the enough effectiveness of the developed system for supporting the activity of patient safety management.

Safety culture and learning from incidents: the role of incident reporting and causal analyses

International Nuclear Information System (INIS)

Wilpert, B.

1994-01-01

Nuclear industry more than any other industrial branch has developed and used predictive risk analysis as a method of feedforward control of safety and reliability. Systematic evaluation of operating experience, statistical documentation of component failures, systematic documentation and analysis of incidents are important complementary elements of feedback control: we are dealing here with adjustment and learning from experience, in particular from past incidents. Using preliminary findings from ongoing research at the Research Center Systems Safety at the Berlin University of Technology the contribution discusses preconditions for an effective use of lessons to be learnt from closely matched incident reporting and in depth analyses of causal chains leading to incidents. Such conditions are especially standardized documentation, reporting and analyzing methods of incidents; structured information flows and feedback loops; abstaining from culpability search; mutual trust of employees and management; willingness of all concerned to continually evaluate and optimize the established learning system. Thus, incident related reporting and causal analyses contribute to safety culture, which is seen to emerge from tightly coupled organizational measures and respective change in attitudes and behaviour. (author) 2 figs., 7 refs

How to Report a Pesticide Incident Involving Exposures to People

Science.gov (United States)

Pesticides incidents must be reported by pesticide registrants. Others, such as members of the public and environmental professionals, would like to report pesticide incidents. This website will facilitate such incident reporting.

49 CFR 225.15 - Accidents/incidents not to be reported.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Accidents/incidents not to be reported. 225.15... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.15 Accidents/incidents not to be reported. A railroad need not report: (a) Casualties which...

Factors influencing incident reporting in surgical care.

Science.gov (United States)

Kreckler, S; Catchpole, K; McCulloch, P; Handa, A

2009-04-01

To evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events. Anonymous web-based questionnaire survey. General Surgical Department in a UK teaching hospital. Of 203 eligible staff, 55 (76.4%) doctors and 82 (62.6%) nurses participated. Knowledge and use of local reporting system; propensity to report incidents which vary by outcome (harm, no harm, harm prevented); propensity to report surgical complications; practical and psychological barriers to reporting. Nurses were significantly more likely to know of the local reporting system and to have recently completed a report than doctors. The level of harm (F(1.8,246) = 254.2, pvs 53%, z = 4.633, psystems.

Hacking point of sale payment application secrets, threats, and solutions

CERN Document Server

Gomzin, Slava

2014-01-01

Must-have guide for professionals responsible for securing credit and debit card transactions As recent breaches like Target and Neiman Marcus show, payment card information is involved in more security breaches than any other data type. In too many places, sensitive card data is simply not protected adequately. Hacking Point of Sale is a compelling book that tackles this enormous problem head-on. Exploring all aspects of the problem in detail - from how attacks are structured to the structure of magnetic strips to point-to-point encryption, and more - it's packed with practical recommendati

Hacking the quantum revolution: 1925-1975

Science.gov (United States)

Schweber, Silvan S.

2015-01-01

I argue that the quantum revolution should be seen as an Ian Hacking type of scientific revolution: a profound, longue durée, multidisciplinary process of transforming our understanding of physical nature, with deep-rooted social components from the start. The "revolution" exhibits a characteristic style of reasoning - the hierarchization of physical nature - and developed and uses a specific language - quantum field theory (QFT). It is by virtue of that language that the quantum theory has achieved some of its deepest insights into the description of the dynamics of the physical world. However, the meaning of what a quantum field theory is and what it describes has deeply altered, and one now speaks of "effective" quantum field theories. Interpreting all present day quantum field theories as but "effective" field theories sheds additional light on Phillip Anderson's assertion that "More is different". This important element is addressed in the last part of the paper.

Reporting Helicopter Emergency Medical Services in Major Incidents

DEFF Research Database (Denmark)

Fattah, Sabina; Johnsen, Anne Siri; Sollid, Stephen J M

2016-01-01

OBJECTIVE: Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences...... variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. CONCLUSION: Based on opinions from European...

En torno a la construcción social de la locura: Ian Hacking y la historia cultural de la psiquiatría

OpenAIRE

Huertas, Rafael

2011-01-01

El objetivo de este trabajo es analizar la contribución del filósofo de la ciencia Ian Hacking a la historia cultural de la psiquiatría. Partiendo de conceptos propuestos por el autor, como "enfermedad mental transitoria" o "inventar/construir gente", se reflexiona en torno a la construcción socio-cultural de la enfermedad mental. Se examinan y discuten los dos estudios de caso propuestos por Hacking: la fuga disociativa y la personalidad múltiple, identificando las fortalezas y debilidades d...

Between Freedom and Constraint: ROM Hacking of Pokémon Games

OpenAIRE

Barnabé, Fanny

2018-01-01

This paper aims to study a creative practice widespread in video game cultures: “ROM hacking”. By examining with the tools of rhetoric a defined corpus of ROM hacks derived from 『Pokémon』 games, the presentation will show that the formal construction of these derivative works demonstrates less a free or subversive transformation than a fairly strict respect for the original games’ conventions. By reproducing the structure of official 『Pokémon 』games, these fan productions become mirrors revea...

Optimised quantum hacking of superconducting nanowire single-photon detectors.

Science.gov (United States)

Tanner, Michael G; Makarov, Vadim; Hadfield, Robert H

2014-03-24

We explore bright-light control of superconducting nanowire single-photon detectors (SNSPDs) in the shunted configuration (a practical measure to avoid latching). In an experiment, we simulate an illumination pattern the SNSPD would receive in a typical quantum key distribution system under hacking attack. We show that it effectively blinds and controls the SNSPD. The transient blinding illumination lasts for a fraction of a microsecond and produces several deterministic fake clicks during this time. This attack does not lead to elevated timing jitter in the spoofed output pulse, and hence does not introduce significant errors. Five different SNSPD chip designs were tested. We consider possible countermeasures to this attack.

Optimised quantum hacking of superconducting nanowire single-photon detectors

Science.gov (United States)

Tanner, Michael G.; Makarov, Vadim; Hadfield, Robert H.

2014-03-01

We explore bright-light control of superconducting nanowire single-photon detectors (SNSPDs) in the shunted configuration (a practical measure to avoid latching). In an experiment, we simulate an illumination pattern the SNSPD would receive in a typical quantum key distribution system under hacking attack. We show that it effectively blinds and controls the SNSPD. The transient blinding illumination lasts for a fraction of a microsecond and produces several deterministic fake clicks during this time. This attack does not lead to elevated timing jitter in the spoofed output pulse, and hence does not introduce significant errors. Five different SNSPD chip designs were tested. We consider possible countermeasures to this attack.

Hazmat Yearly Incident Summary Reports - Data Mining Tool

Data.gov (United States)

Department of Transportation — Series of Incident data and summary statistics reports produced which provide statistical information on incidents by type, year, geographical location, and others....

Análisis filosófico de la construcción social de la escuela: claves críticas a partir de Ian Hacking

Directory of Open Access Journals (Sweden)

José PENALVA BUITRAGO

2009-01-01

Full Text Available RESUMEN: Este artículo ofrece un análisis filosófico de la idea de la construcción social de la escuela. Tomando como punto de partida algunas de las claves críticas que I. Hacking señala respecto del constructivismo, el autor ensaya una nueva ruta de análisis, no explorada por Hacking: el análisis del constructivismo social en los procesos educativos y en las instituciones educativas. Con ello se intenta poner de relieve cuestiones teóricas de fondo –principalmente de carácter ontológico– acerca de las cuales la comunidad pedagógica ha prestado escasa atención. El análisis se desarrolla en cuatro pasos: en primer lugar, se ofrecen las ideas de Hacking más relevantes al respecto; después, se expone una síntesis de la posición dominante acerca de la construcción social de la escuela. Seguidamente, se analizan los aspectos ontológicos implicados en tal idea, y, por último, se extraen las consecuencias educativas.ABSTRACT: This paper offers a philosophical analysis of the idea of the social construction of School. Taking as a standpoint some critical questions which I. Hacking proposed regarding constructivism, the author examines a new route, not explored by Hacking, i.e., the analysis of social constructivism in educational processes and educational institutions. In this way we expect to throw light on certain deep theoretical questions –of an ontological nature, mainly– to which the educational community has paid little attention. The analysis follows four steps: first, it describes Hacking’s most important ideas in this regard; second, it synthesises the dominant stance concerning the social construction of School. Third, it examines the ontological assumptions of this idea, and, finally, describes some educational consequences.SOMMAIRE: Cet article offre une analyse philosophique de la structure sociale des écoles. L’auteur, à partir de quelques idées critiques signalées par I. Hacking à propos du

Less noise, more hacking: how to deploy principles from MIT's hacking medicine to accelerate health care.

Science.gov (United States)

DePasse, Jacqueline W; Carroll, Ryan; Ippolito, Andrea; Yost, Allison; Santorino, Data; Chu, Zen; Olson, Kristian R

2014-07-01

Medical technology offers enormous potential for scalable medicine--to improve the quality and access in health care while simultaneously reducing cost. However, current medical device innovation within companies often only offers incremental advances on existing products, or originates from engineers with limited knowledge of the clinical complexities. We describe how the Hacking Medicine Initiative, based at Massachusetts Institute of Technology has developed an innovative "healthcare hackathon" approach, bringing diverse teams together to rapidly validate clinical needs and develop solutions. Hackathons are based on three core principles; emphasis on a problem-based approach, cross-pollination of disciplines, and "pivoting" on or rapidly iterating on ideas. Hackathons also offer enormous potential for innovation in global health by focusing on local needs and resources as well as addressing feasibility and cultural contextualization. Although relatively new, the success of this approach is clear, as evidenced by the development of successful startup companies, pioneering product design, and the incorporation of creative people from outside traditional life science backgrounds who are working with clinicians and other scientists to create transformative innovation in health care.

Inadvertent P-hacking among trials and systematic reviews of the effect of progestogens in pregnancy? A systematic review and meta-analysis.

Science.gov (United States)

Prior, M; Hibberd, R; Asemota, N; Thornton, J G

2017-06-01

Progestogens have been evaluated in numerous trials and meta-analyses, many of which concluded they were effective. However, two large trials PROMISE and OPPTIMUM have recently concluded that progesterone was ineffective. This raises the possibility that earlier studies and reviews had been biased by either selective publication or selective choice of outcomes, so called "P-hacking". To compare the findings all progestogen trials and systematic reviews with those of trials with pre-registered primary outcomes which avoided selective outcome reporting. Search of PubMed, the Cochrane Library and trial registries. Registration PROSPERO CRD42016035303. Systematic reviews of randomised trials comparing progestogen with placebo in pregnancy and the individual trials included in those reviews. The subset of trials reporting a pre-registered primary outcome were compared with the totality of trials and reviews. For reviews all outcomes were included. For individual trials all outcomes reported in the systematic reviews were included. For the comparison group we recorded the registered primary outcome from trials that were either registered before they started, or registered during the recruitment phase and also double blind. Nineteen of twenty-nine meta-analyses concluded that progestogens were effective. Twenty-two trials reported their pre-registered primary outcomes. There was no effect of progesterone on primary registered dichotomous outcome RR 1.00 (95% CI 0.94-1.07). Only one of the 22 showed a nominally statistically significant benefit. When evaluated in registered double-blind trials with analysis restricted to predefined primary outcomes, progestational agents in pregnancy are ineffective. Progestogens to prevent pregnancy loss, an example of P-hacking. © 2017 Royal College of Obstetricians and Gynaecologists.

A Descriptive Analysis of Incidents Reported by Community Aged Care Workers.

Science.gov (United States)

Tariq, Amina; Douglas, Heather E; Smith, Cheryl; Georgiou, Andrew; Osmond, Tracey; Armour, Pauline; Westbrook, Johanna I

2015-07-01

Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care. © The Author(s) 2014.

Safety and Health Standard 110: Incident/accident reporting and investigation

Energy Technology Data Exchange (ETDEWEB)

Sones, K. [West Kootenay Power, BC (Canada)

1999-10-01

Incident/accident reporting requirements in effect at West Kootenay Power are discussed. Details provided include definitions of low risk, high risk, and critical events, the incidents to be reported, the nature of the reports, the timelines, the investigation to be undertaken for each type of incident/accident, counselling services available to employees involved in serious incidents, and the procedures to be followed in accidents involving serious injury to non-employees. The emphasis is on the `critical five` high risk events and the procedures relating to them.

Upconversion-based receivers for quantum hacking-resistant quantum key distribution

Science.gov (United States)

Jain, Nitin; Kanter, Gregory S.

2016-07-01

We propose a novel upconversion (sum frequency generation)-based quantum-optical system design that can be employed as a receiver (Bob) in practical quantum key distribution systems. The pump governing the upconversion process is produced and utilized inside the physical receiver, making its access or control unrealistic for an external adversary (Eve). This pump facilitates several properties which permit Bob to define and control the modes that can participate in the quantum measurement. Furthermore, by manipulating and monitoring the characteristics of the pump pulses, Bob can detect a wide range of quantum hacking attacks launched by Eve.

Incidents/accidents classification and reporting in Statoil.

Science.gov (United States)

Berentsen, Rune; Holmboe, Rolf H

2004-07-26

Based on requirements in the new petroleum regulations from Norwegian Petroleum Directorate (NPD) and the realisation of a need to improve and rationalise the routines for reporting and follow up of incidents, Statoil Exploration & Production Norway (Statoil E&P Norway) has formulated a new strategy and process for handling of incidents/accidents. The following past experiences serve as basis for the changes made to incident reporting in Statoil E&P Norway; too much resources were spent on a comprehensive handling and analysis of a vast amount of incidents with less importance for the safety level, taking the focus away from the more severe and important issues at hand, the assessment of "Risk Factor", i.e. the combination of recurrence frequency and consequence, was difficult to use. The high degree of subjectivity involved in the determination of the "Risk Factor" (in particular the estimation of the recurrence frequency) resulted in poor data quality and lack of consistency in the data material. The new system for categorisation and handling of undesirable incidents was established in January 2002. The intention was to get a higher degree of focus on serious incidents (injuries, damages, loss and near misses), with a thorough handling and follow-up. This is reflected throughout the handling of the serious incidents, all the way from immediate notification of the incident, through investigation and follow-up of corrective and preventive actions. Simultaneously, it was also an objective to rationalise/simplify the handling of less serious incidents. These incidents are, however, subjected to analyses twice a year in order to utilize the learning opportunity that they also provide. A year after the introduction of this new system for categorisation and follow-up of undesirable incidents, Statoil's experiences are predominantly good; the intention to get a higher degree of focus on serious incidents (injuries, damages, loss and near misses), has been met, the data

Steal Your Life Using 5 Cents: Hacking Android Smartphones with NFC Tags

OpenAIRE

Bermejo, Carlos; Hui, Pan

2017-01-01

Nowadays privacy in the connected world is a big user's concern. The ubiquity of mobile devices permits billions of users browse the web at anytime, anywhere. Near Field Communication (NFC) appeared as a seamlessly and simply communication protocol between devices. Commercial services such as Android Pay, and Apple Pay offer contactless payment methods that are spreading in more and more scenarios. However, we take risks while using NFC on Android devices, we can be hacked, and our privacy ca...

The value of Growth Hacking. Business development manual for Emi-Rent Properties

OpenAIRE

Elezovic, Velimir

2017-01-01

This thesis was commissioned by Emi-Rent Properties, a real estate company based in Bel-grade, Serbia. The main objective of this thesis is to help determine the value of growth hack-er marketing for the case company’s newly commissioned marketing campaign. Secondary objective of this thesis is to present practical advice on the implementation of a successful marketing campaign with strong international aspects. The thesis will cover major marketing concepts and provide an alternative view by...

78 FR 14877 - Pipeline Safety: Incident and Accident Reports

Science.gov (United States)

2013-03-07

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

Sci-Fri AM: Quality, Safety, and Professional Issues 06: An Evaluation of Incident Reporting and Learning using the Canadian National System for Incident Reporting – Radiation Treatment

Energy Technology Data Exchange (ETDEWEB)

Montgomery, Logan; Kildea, John [McGill University Health Centre (Canada)

2016-08-15

We report on the development and clinical deployment of an in-house incident reporting and learning system that implements the taxonomy of the Canadian National System for Incident Reporting – Radiation Treatment (NSIR-RT). In producing our new system, we aimed to: Analyze actual incidents, as well as potentially dangerous latent conditions. Produce recommendations on the NSIR-RT taxonomy. Incorporate features to divide reporting responsibility among clinical staff and expedite incident categorization within the NSIR-RT framework. Share anonymized incident data with the national database. Our multistep incident reporting workflow is focused around an initial report and a detailed follow-up investigation. An investigator, chosen at the time of reporting, is tasked with performing the investigation. The investigation feature is connected to our electronic medical records database to allow automatic field population and quick reference of patient and treatment information. Additional features include a robust visualization suite, as well as the ability to flag incidents for discussion at monthly Risk Management meetings and task ameliorating actions to staff. Our system was deployed into clinical use in January 2016. Over the first three months of use, 45 valid incidents were reported; 31 of which were reported as actual incidents as opposed to near-misses or reportable circumstances. However, we suspect there is ambiguity within our centre in determining the appropriate event type, which may be arising from the taxonomy itself. Preliminary trending analysis aided in revealing workflow issues pertaining to storage of treatment accessories and treatment planning delays. Extensive analysis will be undertaken as more data are accrued.

Sci-Fri AM: Quality, Safety, and Professional Issues 06: An Evaluation of Incident Reporting and Learning using the Canadian National System for Incident Reporting – Radiation Treatment

International Nuclear Information System (INIS)

Montgomery, Logan; Kildea, John

2016-01-01

We report on the development and clinical deployment of an in-house incident reporting and learning system that implements the taxonomy of the Canadian National System for Incident Reporting – Radiation Treatment (NSIR-RT). In producing our new system, we aimed to: Analyze actual incidents, as well as potentially dangerous latent conditions. Produce recommendations on the NSIR-RT taxonomy. Incorporate features to divide reporting responsibility among clinical staff and expedite incident categorization within the NSIR-RT framework. Share anonymized incident data with the national database. Our multistep incident reporting workflow is focused around an initial report and a detailed follow-up investigation. An investigator, chosen at the time of reporting, is tasked with performing the investigation. The investigation feature is connected to our electronic medical records database to allow automatic field population and quick reference of patient and treatment information. Additional features include a robust visualization suite, as well as the ability to flag incidents for discussion at monthly Risk Management meetings and task ameliorating actions to staff. Our system was deployed into clinical use in January 2016. Over the first three months of use, 45 valid incidents were reported; 31 of which were reported as actual incidents as opposed to near-misses or reportable circumstances. However, we suspect there is ambiguity within our centre in determining the appropriate event type, which may be arising from the taxonomy itself. Preliminary trending analysis aided in revealing workflow issues pertaining to storage of treatment accessories and treatment planning delays. Extensive analysis will be undertaken as more data are accrued.

A consistent framework for Horton regression statistics that leads to a modified Hack's law

Science.gov (United States)

Furey, P.R.; Troutman, B.M.

2008-01-01

A statistical framework is introduced that resolves important problems with the interpretation and use of traditional Horton regression statistics. The framework is based on a univariate regression model that leads to an alternative expression for Horton ratio, connects Horton regression statistics to distributional simple scaling, and improves the accuracy in estimating Horton plot parameters. The model is used to examine data for drainage area A and mainstream length L from two groups of basins located in different physiographic settings. Results show that confidence intervals for the Horton plot regression statistics are quite wide. Nonetheless, an analysis of covariance shows that regression intercepts, but not regression slopes, can be used to distinguish between basin groups. The univariate model is generalized to include n > 1 dependent variables. For the case where the dependent variables represent ln A and ln L, the generalized model performs somewhat better at distinguishing between basin groups than two separate univariate models. The generalized model leads to a modification of Hack's law where L depends on both A and Strahler order ??. Data show that ?? plays a statistically significant role in the modified Hack's law expression. ?? 2008 Elsevier B.V.

30 CFR 250.187 - What are MMS' incident reporting requirements?

Science.gov (United States)

2010-07-01

... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What are MMS' incident reporting requirements... Reporting Requirements § 250.187 What are MMS' incident reporting requirements? (a) You must report all... other permit issued by MMS, and that are related to operations resulting from the exercise of your...

Mapping the Most Significant Computer Hacking Events to a Temporal Computer Attack Model

OpenAIRE

Heerden , Renier ,; Pieterse , Heloise; Irwin , Barry

2012-01-01

Part 4: Section 3: ICT for Peace and War; International audience; This paper presents eight of the most significant computer hacking events (also known as computer attacks). These events were selected because of their unique impact, methodology, or other properties. A temporal computer attack model is presented that can be used to model computer based attacks. This model consists of the following stages: Target Identification, Reconnaissance, Attack, and Post-Attack Reconnaissance stages. The...

Does 'hacking' surface type affect equine forelimb foot placement, movement symmetry or hoof impact deceleration during ridden walk and trot exercise?

Science.gov (United States)

Barstow, A; Bailey, J; Campbell, J; Harris, C; Weller, R; Pfau, T

2018-04-17

Both pleasure and competition horses regularly exercise on surfaces such as tarmac, gravel and turf during 'hacking'. Despite this, there is limited evidence relating to the effect of these surfaces upon foot-surface interaction. To investigate forelimb foot placement, hoof vibration and movement symmetry in pleasure horses on three commonly encountered hacking surfaces. Quantitative gait study in a convenience sample. Six horses regularly partaking in hacking exercise were ridden in walk and trot on all surfaces. Horses were equipped with one hoof-mounted, accelerometer and four body-mounted inertial measurement units (IMUs) to measure foot impact and movement symmetry. High-speed (400 FPS) video footage of foot-placement was acquired (dorsal, palmar, lateral views). Foot-impact and movement symmetry were analysed with a mixed effects model and Bowker symmetry tests for foot-placement analysis. Vibration power and frequency parameters increase as perceived surface firmness increases from grass, to gravel, to tarmac (P≤0.001). Vibration power parameters were consistently greater at trot compared with walk (P≤0.001), but the same was not true for vibration frequency (P≥0.2). Greatest movement asymmetry was recorded during grass surface trotting. No significant difference in foot-placement was detected between the three surfaces. This was a field study using three commonly encountered hacking surfaces. Surface properties change easily with water content and temperature fluctuations so care must be taken when considering other similar surfaces, especially at different times of the year. Six leisure horses were used so the results may not be representative of horses of all types. Vibration parameters generally increase as perceived surface firmness increases. Increasing speed alters vibration power but not frequency. Further investigations are required to determine the role that this may play in the development of musculoskeletal disease in horses. © 2018 EVJ

Hazmat 10 Year Incident Summary Reports - Data Mining Tool

Data.gov (United States)

Department of Transportation — Series of Incident data and summary statistics reports produced which provide statistical information on incidents by type, year, geographical location, and others....

Which factors affect reported headache incidences after lumbar myelography?

International Nuclear Information System (INIS)

Sand, T.

1989-01-01

Nineteen publications were reviewed and subjected to a combined statistical analysis (meta-analysis) regarding the influence of study design factors upon reported headache and total symptom incidences after lumbar iohexol myelography. A significant association was found between reported side effects on one hand and needle diameter, follow-up time and the method of questioning respectively on the other. The combination of long follow-up time and specific questioning and the combination between larger diameter (20G) needles and long follow-up time, both seemed to be strong predictors for reporting high side effect incidences. Nine studies were similarly analyzed regarding the influence of early ambulation and contrast type upon reported headache incidences. Early ambulation significantly increased headache after iohexol or iopamidol lumbar myelography as opposed to metrizamide myelography. (orig.)

"Hacking at Our Very Roots": Rearticulating White Racial Identity within the Context of Teacher Education

Science.gov (United States)

Aveling, Nado

2006-01-01

When teaching about race and racism and how we as "Whites" are implicated in the discursive practices that sustain racism, we are indeed "hacking at the very roots" of the ways in which students have conceptualized their identity in terms of being non-racialized and at the same time non-racist. In this paper I focus on the challenges and…

The evaluation of a web-based incident reporting system.

Science.gov (United States)

Kuo, Ya-Hui; Lee, Ting-Ting; Mills, Mary Etta; Lin, Kuan-Chia

2012-07-01

A Web-based reporting system is essential to report incident events anonymously and confidentially. The purpose of this study was to evaluate a Web-based reporting system in Taiwan. User satisfaction and impact of system use were evaluated through a survey answered by 249 nurses. Incident events reported in paper and electronic systems were collected for comparison purposes. Study variables included system user satisfaction, willingness to report, number of reports, severity of the events, and efficiency of the reporting process. Results revealed that senior nurses were less willing to report events, nurses on internal medicine units had higher satisfaction than others, and lowest satisfaction was related to the time it took to file a report. In addition, the Web-based reporting system was used more often than the paper system. The percentages of events reported were significantly higher in the Web-based system in laboratory, environment/device, and incidents occurring in other units, whereas the proportions of reports involving bedsores and dislocation of endotracheal tubes were decreased. Finally, moderate injury event reporting decreased, whereas minor or minimal injury event reporting increased. The study recommends that the data entry process be simplified and the network system be improved to increase user satisfaction and reporting rates.

Obtaining plant Miscanthus sacchariflorus (Maxim. Hack and Miscanthus sinensis Andersson in vitro culture by indirect morphogenesis

Directory of Open Access Journals (Sweden)

С. М. Гонтаренко

2017-03-01

Full Text Available Purpose. To obtain Miscanthus sacchariflorus (Maxim. Hack and Miscanthus sinensis Andersson in vitro culture by indirect morphogenesis. Methods. Biotechnological procedures, mathematical and statistical analyses. Results. Composition of nutrient medium was developed intended for induction of callusogenesis from Miscanthus seeds with a poor germination and viability of seedlings – Murashige and Skoog (MS medium was modified for the amount of macroelements (half-dose that was supplemented with amino acids (300 mg/l of glutamic acid, 50 mg/l of aspartic acid, 5 mg/l of tyrosine, 3 mg/l of arginine, 2 mg/l of hydroxyproline and plant growth regulators [2,5 mg/l of 2.4D (2.4-Dichlorophenoxyacetic acid, 0,6 mg/l of BAP (6-Benzyl-aminopurine and 0,3 mg/l of ABA (Abscisic acid]. Composition of nutrient medium was developed for regeneration of microplants from callus – agar MS medium was modified for the amount of macroelements (half-dose supplemented with vitamins: 10 mg/l of thiaminum, 1,0 mg/l of pyridoxine, 1,0 mg/l of nicotinic acid (by White, 1,0 mg/l of ascorbic acid, 250 mg/l of glutamic acid, 2,0 mg/l of BAP, 0,3 mg/l of NAA (Naphthaleneacetic acid. On this medium, 100% regeneration of M. sacchariflorus (Maxim. Hack and 50% regeneration of M. sinensis Andersson was obtained. Due to media modification aimed at initiating callusogenesis and microplants regeneration, reproduction factor of M. sinensis was increased 20 times at the average, M. sacchariflorus – 35–40 times. Conclusions. Plants of M. sacchariflorus (Maxim. Hack and M. sinensis Andersson were obtained in vitro culture by initiation of callusogenes and microplants regeneration from the Miscanthus seeds with poor germination and viability on nutrient media of certain composition.

Hacking web intelligence open source intelligence and web reconnaissance concepts and techniques

CERN Document Server

Chauhan, Sudhanshu

2015-01-01

Open source intelligence (OSINT) and web reconnaissance are rich topics for infosec professionals looking for the best ways to sift through the abundance of information widely available online. In many cases, the first stage of any security assessment-that is, reconnaissance-is not given enough attention by security professionals, hackers, and penetration testers. Often, the information openly present is as critical as the confidential data. Hacking Web Intelligence shows you how to dig into the Web and uncover the information many don't even know exists. The book takes a holistic approach

Governance responses to hacking in the banking sector of South Africa : an exploratory study

OpenAIRE

2013-01-01

D.Comm. (Auditing) Organisations today are critically dependent on IT to enable business operations and ensure competitiveness in a growing international marketplace. At the same time, IT also introduces significant risks, such as hacking. The board of directors is ultimately responsible for mitigating IT risk as a component of business risk. This task is included in its corporate governance responsibilities, which, in the South African context, is underpinned by the King Code of Corporate...

Critical Incident Reporting Systems: Perceived Competing Social ...

African Journals Online (AJOL)

The safe operation of complex socio-technical systems is dependent upon the reporting of safety critical incidents by operators within a system. Through the action of reporting, systems develop the capability as a learning organisation to improve human and organisational performance. The aim of the study is therefore to ...

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

DEFF Research Database (Denmark)

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

2010-01-01

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

Unintentional Insider Threats: A Review of Phishing and Malware Incidents by Economic Sector

Science.gov (United States)

2014-07-01

the conclusions in the Verizon Data Breach Report 2013 that 47% of malware was downloaded through e-mail at- tachments, 48% of hacking took place...the attackers pivoted onto other systems and databases and exfiltrated approximately 8.2 GB of data . BREACH : Accessing an employee account via a...Symantec. “Internet Security Threat Report 2014.” 2013 Trends 19 (April 2014). Symantec Cor- poration. [Verizon 2013] Verizon. 2013 Data Breach Investigations

Progress on white papers from the Demographic Hack Session at WiA IV

Science.gov (United States)

Norman, Dara J.; WiA IV Demographics Hack Session Attendees.

2018-06-01

At the Women in Astronomy IV meeting in June 2017, a number of white papers were started as part of the Demographic Hack session. Several of these white papers are intended for submission to the Decadal Survey on topics including, ‘Providing a Timely Review of Input Demographics to Advisory Committees’, and ‘Tying Research Funding to Progress in Inclusion’. In my talk, I will review the content of these white papers and the progress that has been made in writing them. Interested session attendees are encouraged ‘endorse’ the papers by becoming signatories.

Identifying Predictive Factors for Incident Reports in Patients Receiving Radiation Therapy

Energy Technology Data Exchange (ETDEWEB)

Elnahal, Shereef M., E-mail: selnaha1@jhmi.edu [Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Blackford, Amanda [Department of Oncology Biostatistics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Smith, Koren; Souranis, Annette N.; Briner, Valerie; McNutt, Todd R.; DeWeese, Theodore L.; Wright, Jean L.; Terezakis, Stephanie A. [Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (United States)

2016-04-01

Purpose: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. Methods and Materials: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause. A control group of patients without events was generated for comparison. Summary statistics, likelihood ratios, and mixed-effect logistic regression models were used for group comparisons. Results: The incident and control groups comprised 794 and 499 patients, respectively. Common root causes included documentation errors (26.5%), communication (22.5%), technical treatment planning (37.5%), and technical treatment delivery (13.5%). Incidents were more frequently reported in minors (age <18 years) than in adult patients (37.7% vs 0.4%, P<.001). Patients with head and neck (16% vs 8%, P<.001) and breast (20% vs 15%, P=.03) primaries more frequently had incidents, whereas brain (18% vs 24%, P=.008) primaries were less frequent. Larger tumors (17% vs 10% had T4 lesions, P=.02), and cases on protocol (9% vs 5%, P=.005) or with intensity modulated radiation therapy/image guided intensity modulated radiation therapy (52% vs 43%, P=.001) were more likely to have incidents. Conclusions: We found several treatment- and patient-specific variables associated with incidents. These factors should be considered by treatment teams at the time of peer review to identify patients at higher risk. Larger datasets are required to recommend changes in care process standards, to minimize safety risks.

Identifying Predictive Factors for Incident Reports in Patients Receiving Radiation Therapy

International Nuclear Information System (INIS)

Elnahal, Shereef M.; Blackford, Amanda; Smith, Koren; Souranis, Annette N.; Briner, Valerie; McNutt, Todd R.; DeWeese, Theodore L.; Wright, Jean L.; Terezakis, Stephanie A.

2016-01-01

Purpose: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. Methods and Materials: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause. A control group of patients without events was generated for comparison. Summary statistics, likelihood ratios, and mixed-effect logistic regression models were used for group comparisons. Results: The incident and control groups comprised 794 and 499 patients, respectively. Common root causes included documentation errors (26.5%), communication (22.5%), technical treatment planning (37.5%), and technical treatment delivery (13.5%). Incidents were more frequently reported in minors (age <18 years) than in adult patients (37.7% vs 0.4%, P<.001). Patients with head and neck (16% vs 8%, P<.001) and breast (20% vs 15%, P=.03) primaries more frequently had incidents, whereas brain (18% vs 24%, P=.008) primaries were less frequent. Larger tumors (17% vs 10% had T4 lesions, P=.02), and cases on protocol (9% vs 5%, P=.005) or with intensity modulated radiation therapy/image guided intensity modulated radiation therapy (52% vs 43%, P=.001) were more likely to have incidents. Conclusions: We found several treatment- and patient-specific variables associated with incidents. These factors should be considered by treatment teams at the time of peer review to identify patients at higher risk. Larger datasets are required to recommend changes in care process standards, to minimize safety risks.

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

Risk factors for radiotherapy incidents and impact of an online electronic reporting system

International Nuclear Information System (INIS)

Chang, David W.; Cheetham, Lynn; Marvelde, Luc te; Bressel, Mathias; Kron, Tomas; Gill, Suki; Tai, Keen Hun; Ball, David; Rose, William; Silva, Linas; Foroudi, Farshad

2014-01-01

Background and purpose: To ascertain the rate, type, significance, trends and the potential risk factors associated with radiotherapy incidents in a large academic department. Materials and methods: Data for all radiotherapy activities from July 2001 to January 2011 were reviewed from radiotherapy incident reporting forms. Patient and treatment data were obtained from the radiotherapy record and verification database (MOSAIQ) and the patient database (HOSPRO). Logistic regression analyses were performed to determine variables associated with radiotherapy incidents. Results: In that time, 65,376 courses of radiotherapy were delivered with a reported incident rate of 2.64 per 100 courses. The rate of incidents per course increased (1.96 per 100 courses to 3.52 per 100 courses, p < 0.001) whereas the proportion of reported incidents resulting in >5% deviation in dose (10.50 to 2.75%, p < 0.001) had decreased after the introduction of an online electronic reporting system. The following variables were associated with an increased rate of incidents: afternoon treatment time, paediatric patients, males, inpatients, palliative plans, head-and-neck, skin, sarcoma and haematological malignancies. In general, complex plans were associated with higher incidence rates. Conclusion: Radiotherapy incidents were infrequent and most did not result in significant dose deviation. A number of risk factors were identified and these could be used to highlight high-risk cases in the future. Introduction of an online electronic reporting system resulted in a significant increase in the number of incidents being reported

Comparison of macroscopic and microscopic (stereomicroscopy and scanning electron microscopy) features of bone lesions due to hatchet hacking trauma.

Science.gov (United States)

Nogueira, Luísa; Quatrehomme, Gérald; Bertrand, Marie-France; Rallon, Christophe; Ceinos, Romain; du Jardin, Philippe; Adalian, Pascal; Alunni, Véronique

2017-03-01

This experimental study examined the lesions produced by a hatchet on human bones (tibiae). A total of 30 lesions were produced and examined macroscopically (naked eye) and by stereomicroscopy. 13 of them were also analyzed using scanning electron microscopy. The general shape of the lesion, both edges, both walls, the kerf floor and the extremities were described. The length and maximum width of the lesions were also recorded. The microscopic analysis of the lesions led to the description of a sharp-blunt mechanism. Specific criteria were identified (lateral pushing back, fragmentation of the upraising, fossa dug laterally to the edge and vertical striae) enabling the forensic expert to conclude that a hacking instrument was used. These criteria are easily identifiable using scanning electron microscopy, but can also be observed with stereomicroscopy. Overall, lateral pushing back and vertical striae visible using stereomicroscopy and scanning electron microscopy signal the use of a hacking tool.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

Energy Technology Data Exchange (ETDEWEB)

Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Harris, Kendra M. [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Ford, Eric [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Department of Radiation Oncology, University of Washington, Seattle, Washington (United States); Michalski, Jeff [Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri (United States); DeWeese, Theodore [Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland (United States); Santanam, Lakshmi; Mutic, Sasa; Gay, Hiram [Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri (United States)

2013-03-15

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

International Nuclear Information System (INIS)

Terezakis, Stephanie A.; Harris, Kendra M.; Ford, Eric; Michalski, Jeff; DeWeese, Theodore; Santanam, Lakshmi; Mutic, Sasa; Gay, Hiram

2013-01-01

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement

Surface Movement Incidents Reported to the NASA Aviation Safety Reporting System

Science.gov (United States)

Connell, Linda J.; Hubener, Simone

1997-01-01

Increasing numbers of aircraft are operating on the surface of airports throughout the world. Airport operations are forecast to grow by more that 50%, by the year 2005. Airport surface movement traffic would therefore be expected to become increasingly congested. Safety of these surface operations will become a focus as airport capacity planning efforts proceed toward the future. Several past events highlight the prevailing risks experienced while moving aircraft during ground operations on runways, taxiways, and other areas at terminal, gates, and ramps. The 1994 St. Louis accident between a taxiing Cessna crossing an active runway and colliding with a landing MD-80 emphasizes the importance of a fail-safe system for airport operations. The following study explores reports of incidents occurring on an airport surface that did not escalate to an accident event. The Aviation Safety Reporting System has collected data on surface movement incidents since 1976. This study sampled the reporting data from June, 1993 through June, 1994. The coding of the data was accomplished in several categories. The categories include location of airport, phase of ground operation, weather /lighting conditions, ground conflicts, flight crew characteristics, human factor considerations, and airport environment. These comparisons and distributions of variables contributing to surface movement incidents can be invaluable to future airport planning, accident prevention efforts, and system-wide improvements.

Human factors analysis of incident/accident report

International Nuclear Information System (INIS)

Kuroda, Isao

1992-01-01

Human factors analysis of accident/incident has different kinds of difficulties in not only technical, but also psychosocial background. This report introduces some experiments of 'Variation diagram method' which is able to extend to operational and managemental factors. (author)

Documentation of in-hospital falls on incident reports: qualitative investigation of an imperfect process.

Science.gov (United States)

Haines, Terry P; Cornwell, Petrea; Fleming, Jennifer; Varghese, Paul; Gray, Len

2008-12-11

Incident reporting is the prevailing approach to gathering data on accidental falls in hospitals for both research and quality assurance purposes, though is of questionable quality as staff time pressures, perception of blame and other factors are thought to contribute to under-reporting. This research aimed to identify contextual factors influencing recording of in-hospital falls on incident reports. A qualitative multi-centre investigation using an open written response questionnaire was undertaken. Participants were asked to describe any factors that made them feel more or less likely to record a fall on an incident report. 212 hospital staff from 30 wards in 7 hospitals in Queensland, Australia provided a response. A framework approach was employed to identify and understand inter-relationships between emergent categories. Three main categories were developed. The first, determinants of reporting, describes a hierarchical structure of primary (principle of reporting), secondary (patient injury), and tertiary determinants that influenced the likelihood that an in-hospital fall would be recorded on an incident report. The tertiary determinants frequently had an inconsistent effect. The second and third main categories described environmental/cultural facilitators and barriers respectively which form a background upon which the determinants of reporting exists. A distinctive framework with clear differences to recording of other types of adverse events on incident reports was apparent. Providing information to hospital staff regarding the purpose of incident reporting and the usefulness of incident reporting for preventing future falls may improve incident reporting practices.

Deep learning quick reference useful hacks for training and optimizing deep neural networks with TensorFlow and Keras

CERN Document Server

Bernico, Michael

2018-01-01

This book is a practical guide to applying deep neural networks including MLPs, CNNs, LSTMs, and more in Keras and TensorFlow. Packed with useful hacks to solve real-world challenges along with the supported math and theory around each topic, this book will be a quick reference for training and optimize your deep neural networks.

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

Science.gov (United States)

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

2017-09-01

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

Documentation of in-hospital falls on incident reports: Qualitative investigation of an imperfect process

Directory of Open Access Journals (Sweden)

Fleming Jennifer

2008-12-01

Full Text Available Abstract Background Incident reporting is the prevailing approach to gathering data on accidental falls in hospitals for both research and quality assurance purposes, though is of questionable quality as staff time pressures, perception of blame and other factors are thought to contribute to under-reporting. Methods This research aimed to identify contextual factors influencing recording of in-hospital falls on incident reports. A qualitative multi-centre investigation using an open written response questionnaire was undertaken. Participants were asked to describe any factors that made them feel more or less likely to record a fall on an incident report. 212 hospital staff from 30 wards in 7 hospitals in Queensland, Australia provided a response. A framework approach was employed to identify and understand inter-relationships between emergent categories. Results Three main categories were developed. The first, determinants of reporting, describes a hierarchical structure of primary (principle of reporting, secondary (patient injury, and tertiary determinants that influenced the likelihood that an in-hospital fall would be recorded on an incident report. The tertiary determinants frequently had an inconsistent effect. The second and third main categories described environmental/cultural facilitators and barriers respectively which form a background upon which the determinants of reporting exists. Conclusion A distinctive framework with clear differences to recording of other types of adverse events on incident reports was apparent. Providing information to hospital staff regarding the purpose of incident reporting and the usefulness of incident reporting for preventing future falls may improve incident reporting practices.

Community pharmacy incident reporting: a new tool for community pharmacies in Canada.

Science.gov (United States)

Ho, Certina; Hung, Patricia; Lee, Gary; Kadija, Medina

2010-01-01

Incident reporting offers insight into a variety of intricate processes in healthcare. However, it has been found that medication incidents are under reported in the community pharmacy setting. The Community Pharmacy Incident Reporting (CPhIR) program was created by the Institute for Safe Medication Practices Canada specifically for incident reporting in the community pharmacy setting in Canada. The initial development of key elements for CPhIR included several focus-group teleconferences with pharmacists from Ontario and Nova Scotia. Throughout the development and release of the CPhIR pilot, feedback from pharmacists and pharmacy technicians was constantly incorporated into the reporting program. After several rounds of iterative feedback, testing and consultation with community pharmacy practitioners, a final version of the CPhIR program, together with self-directed training materials, is now ready to launch. The CPhIR program provides users with a one-stop platform to report and record medication incidents, export data for customized analysis and view comparisons of individual and aggregate data. These unique functions allow for a detailed analysis of underlying contributing factors in medication incidents. A communication piece for pharmacies to share their experiences is in the process of development. To ensure the success of the CPhIR program, a patient safety culture must be established. By gaining a deeper understanding of possible causes of medication incidents, community pharmacies can implement system-based strategies for quality improvement and to prevent potential errors from occurring again in the future. This article highlights key features of the CPhIR program that will assist community pharmacies to improve their drug distribution system and, ultimately, enhance patient safety.

Committee's report on ruthenium fall-out incident

International Nuclear Information System (INIS)

Borkowski, C.J.; Crawford, J.H.; Livingston, R.; Ritchie, R.H.; Rupp, A.F.; Taylor, E.H.

1983-07-01

Investigations of the fall-out incident of November 11 and 12, 1959, by responsible parties (Health Physics Division and Operations Division personnel) established beyond reasonable doubt that the incident had its origin in the expulsion of particles, heavily contaminated with ruthenium, which had been detached from the walls of the electric fan housing and ducts in the off-gas system associated with the brick stack. All available evidence indicates that the particles were loosened during maintenance work on the exhaust damper and the bearings of the electric fan and were carried up the stack in two bursts as particulate fall-out when this fan was put back into service. Radiographic and chemical analysis showed the activity to be almost entirely ruthenium (Ru 106 ) and its daughter rhodium (Rh 106 ) with very little, if any, strontium being present. This report summarizes the findings and sets forth the conclusions and recommendations of the Committee asked to investigate the incident

Survey of reportable incidents in nuclear power plants in Germany in the year 1992

International Nuclear Information System (INIS)

1993-01-01

In 1992, 223 reportable incidents in German nuclear power plant have been reported. There was no radioactivity release exceeding the maximum permissible limits, and there were no hazardous effects on the population or the environment. There was no incident belonging to category S of the official event scale, requiring urgent notification, while there were two incidents requiring immediate notification. All other incidents reported belonged to category N, the lowest on the scale, requiring normal notification. 216 incidents belonged to category 0 of the INES scale, and 7 to INES category 1 (disturbance). The tabulated survey of the report lists the various events and their position on the INES scale. The reportable events have been analysed thoroughly from various viewpoints, but no systematic pattern of weak points could be detected. (orig./HP) [de

The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008.

Science.gov (United States)

Rutherford, J S; Flin, R; Irwin, A

2015-07-01

The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance". A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative non-technical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.

Critical incidence reporting systems - an option in equine anaesthesia? Results from a panel meeting.

Science.gov (United States)

Hartnack, Sonja; Bettschart-Wolfensberger, Regula; Driessen, Bernd; Pang, Daniel; Wohlfender, Franziska

2013-11-01

To provide a brief introduction into Critical Incident Reporting Systems (CIRS) as used in human medicine, and to report the discussion from a recent panel meeting discussion with 23 equine anaesthetists in preparation for a new CEPEF-4 (Confidential Enquiry into Perioperative Equine Fatalities) study. Moderated group discussions, and review of literature. The first group discussion focused on the definition of 'preventable critical incidents' and/or 'near misses' in the context of equine anaesthesia. The second group discussion focused on categorizing critical incidents according to an established framework for analysing risk and safety in clinical medicine. While critical incidents do occur in equine anaesthesia, no critical incident reporting system including systematic collection and analysis of critical incidents is in place. Critical incident reporting systems could be used to improve safety in equine anaesthesia - in addition to other study types such as mortality studies. © 2013 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia.

Generating randomised virtualised scenarios for ethical hacking and computer security education: SecGen implementation and deployment

OpenAIRE

Schreuders, ZC; Ardern, L

2015-01-01

Computer security students benefit from having hands-on experience with hacking tools and with access to vulnerable systems that they can attack and defend. However, vulnerable VMs are static; once they have been exploited by a student there is no repeatable challenge as the vulnerable boxes never change. A new novel solution, SecGen, has been created and deployed. SecGen solves the issue by creating vulnerable machines with randomised vulnerabilities and services, with constraints that ensur...

Macroscopic and stereomicroscopic comparison of hacking trauma of bones before and after carbonization.

Science.gov (United States)

Alunni, Véronique; Nogueira, Luísa; Quatrehomme, Gérald

2018-03-01

This experimental study examined lesions produced by a hatchet on pig femurs before and after carbonization. A total of 30 lesions were produced and analyzed using stereomicroscopy and then reexamined after carbonization. Not only was the sharp-blunt mechanism of the hacking trauma (V-shape, regularity of one edge, irregularity of the other edge, upraising, lateral pushing back, fossae dug laterally to the edge) still recognizable after carbonization; in some instances, the carbonization actually enhanced the features observed. Carbonization also did not significantly alter the measurements of the lesions. Carbonization tends to alter the structure of the bone especially in areas weakened by the blunt trauma.

Outcomes From AAS Hack Day at the 227th AAS Meeting

Science.gov (United States)

Kohler, Susanna

2016-01-01

Editors Note:This is a final post from the 227th AAS Meeting in Kissimmee, FL. This special summary of AAS Hack Day, a meeting of AAS members to collaboratively work on various small projects, was written by Meredith Rawls (@Merrdiff) and was originally posted on astrobites.com.As the 227thAmerican Astronomical Society meeting drew to a close (see highlights from Day 1, Day 2, Day 3, and Day 4), a group of at least 50 attendees spent Day 4working on small projects fondly called hacks. Thanks to sponsorship from LSST and Northrup Grumman, the industrious hackers werewell-caffeinated and fed so we could devote time and energy toworking in groups on one-day projects.TheHack Day beganat 10am with pitches. Anybody with a project idea was welcome to briefly speak and try to convince others to work with them. Only someideas panned out, but the enthusiasm was palpable. Its not every day you get a full room of astronomers and affiliates eager to spend hours working on fun and useful projects to benefit the community.#hackAAS is getting underway! #aas227 pic.twitter.com/yX7jlOnSCK James R A Davenport (@jradavenport) January 8, 2016Here is a rundown of what we accomplished. Pretty impressive for a single day! Many thanks to fellow astrobiter Erika Nesvold (now at Carnegie DTM; @erikanesvold) whose hack was live-documenting all the other hacks. Her tweets as @astrobites appeared with the #hackaas hashtag, and her notes made this recap post infinitely easier to write.Interested in joining the fun? Sign up for Hack Day at the 2017 JanuaryAAS meeting (its free with meeting registration), and consider applying for the .Astronomy conference this summer.Towards Optimal Session Scheduling:Adrian Price-Whelan (Columbia), David Hogg (NYU), and Scott Idem (AAS) began writing a program to take all submitted abstracts to a conference like AAS and sort them using keywords to avoid scheduling similar talks in parallel sessions. Its impossible to make everyone happy, but minimizing conflicts

Physicians' and Nurses' Perceptions of and Attitudes Toward Incident Reporting in Palestinian Hospitals.

Science.gov (United States)

Rashed, Anan; Hamdan, Motasem

2015-06-22

Underreporting of incidents that happen in health care services undermines the ability of the systems to improve patient safety. This study assessed the attitudes of physicians and nurses toward incident reporting and the factors influencing reporting in Palestinian hospitals. It also examined clinicians' views about the preferred features of incident reporting system. Cross-sectional self-administered survey of 475 participants, 152 physicians and 323 nurses, from 11 public hospitals in the West Bank; response rate, 81.3%. There was a low level of event reporting among participants in the past year (40.3%). Adjusted for sex and age, physicians were 2.1 times more likely to report incidents than nurses (95% confidence interval, 1.32-3.417; P = 0.002). Perceived main barriers for reporting were grouped under lack of proper structure for reporting, prevalence of blame, and punitive environment. The clinicians indicated fear of administrative sanctions, social and legal liability, and of their competence being questioned (P > 0.05). Getting help for patients, learning from mistakes, and ethical obligation were equally indicated motivators for reporting (P > 0.05). Meanwhile, clinicians prefer formal reporting (77.8%) of all type of errors (65.5%), disclosure of reporters (52.7%), using reports to improve patient safety (80.3%), and willingness to report to immediate supervisors (57.6%). Clinicians acknowledge the importance of reporting incidents; however, prevalence of punitive culture and inadequate reporting systems are key barriers. Improving feedback about reported errors, simplifying procedures, providing clear guidelines on what and who should report, and avoiding blame are essential to enhance reporting. Moreover, health care organizations should consider the opinions of the clinicians in developing reporting systems.

Metal accumulation in the greentail prawn, Metapenaeus bennettae, in Sydney and Port Hacking estuaries, Australia.

Science.gov (United States)

Lewtas, K L M; Birch, G F; Foster-Thorpe, C

2014-01-01

Metal concentrations of the inshore greentail prawn, Metapenaeus bennettae, and surface sediments from locations within Sydney estuary and Port Hacking (Australia) were assessed for bioaccumulation and contamination. The current study aimed to assess metal concentrations in prawn tissue (tail muscle, exoskeleton, hepatopancreas and gills), relate whole body prawn tissue metal concentrations to sediment metal concentrations and animal size, as well as assess prawn consumption as a risk to human health. Metal concentrations were highest in sediment and prawns from contaminated locations (Iron Cove, Hen and Chicken Bay and Lane Cove) in Sydney estuary compared with the reference estuary (Port Hacking). Concentrations in sediments varied considerably between sites and between metals (As, Cd, Cr, Cu, Ni, Pb and Zn), and although concentrations exceeded Interim Sediment Quality Guideline-Low values, metals (As, Cd, Cr, Cu, Ni, Pb and Zn) were below Australian National Health and Medical Research Council human consumption guidelines in prawn tail muscle tissue. Metal concentrations in prawn tail muscle tissue were significantly different (p ≤ 0.05) amongst locations for Pb, Zn and Cd, and metal concentrations were generally highest in gills tissue, followed by the hepatopancreas, exoskeleton and tail muscle. The exoskeleton contained the highest Sr concentration; the hepatopancreas contained the highest As, Cu and Mo concentrations; and the gills contained the highest Al, Cr, Fe and Pb concentrations. Concentrations of Pb, As and Sr were significantly different (p ≤ 0.05) between size groups amongst locations.

Reporter Concerns in 300 Mode-Related Incident Reports from NASA's Aviation Safety Reporting System

Science.gov (United States)

McGreevy, Michael W.

1996-01-01

A model has been developed which represents prominent reporter concerns expressed in the narratives of 300 mode-related incident reports from NASA's Aviation Safety Reporting System (ASRS). The model objectively quantifies the structure of concerns which persist across situations and reporters. These concerns are described and illustrated using verbatim sentences from the original narratives. Report accession numbers are included with each sentence so that concerns can be traced back to the original reports. The results also include an inventory of mode names mentioned in the narratives, and a comparison of individual and joint concerns. The method is based on a proximity-weighted co-occurrence metric and object-oriented complexity reduction.

Pilot Critical Incident Reports as a Means to Identify Human Factors of Remotely Piloted Aircraft

Science.gov (United States)

Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

2016-01-01

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. Human factor issues included the impact of reduced sensory cues, traffic separation in the absence of an out-the-window view, control latencies, vigilance during monotonous and ultra-long endurance flights, control station design considerations, transfer of control between control stations, the management of lost link procedures, and decision-making during emergencies. Pilots participated willingly and enthusiastically in the study

The Incidence of Human Papillomavirus in Tanzanian Adolescent Girls Before Reported Sexual Debut.

Science.gov (United States)

Houlihan, Catherine F; Baisley, Kathy; Bravo, Ignacio G; Kapiga, Saidi; de Sanjosé, Silvia; Changalucha, John; Ross, David A; Hayes, Richard J; Watson-Jones, Deborah

2016-03-01

Acquisition of human papillomavirus (HPV) in women occurs predominantly through vaginal sex. However, HPV has been detected in girls reporting no previous sex. We aimed to determine incidence and risk factors for HPV acquisition in girls who report no previous sex in Tanzania, a country with high HPV prevalence and cervical cancer incidence. We followed 503 adolescent girls aged 15-16 years in Mwanza, Tanzania, with face-to-face interviews and self-administered vaginal swabs every 3 months for 18 months; 397 girls reported no sex before enrollment or during follow-up; of whom, 120 were randomly selected. Samples from enrollment, 6-, 12-, and 18-month visits were tested for 37 HPV genotypes. Incidence, clearance, point prevalence, and duration of any HPV and genotype-specific infections were calculated and associated factors were evaluated. Of 120 girls who reported no previous sex, 119 were included, contributing 438 samples. HPV was detected in 51 (11.6%) samples. The overall incidence of new HPV infections was 29.4/100 person-years (95% confidence interval: 15.9-54.2). The point prevalence of vaccine types HPV-6,-11,-16, and -18 was .9%, .9%, 2.0%, and 0%, respectively. Spending a night away from home and using the Internet were associated with incident HPV, and reporting having seen a pornographic movie was inversely associated with HPV incidence. Incident HPV infections were detected frequently in adolescent girls who reported no previous sex over 18 months. This is likely to reflect under-reporting of sex. A low-point prevalence of HPV genotypes in licensed vaccines was seen, indicating that vaccination of these girls might still be effective. Copyright © 2016 Society for Adolescent Health and Medicine. All rights reserved.

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

Science.gov (United States)

Yoo, Moon Sook; Kim, Kyoung Ja

2017-09-01

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

Cancer incidence in south-east Nigeria: a report from Nnewi Cancer ...

African Journals Online (AJOL)

Background: This study is the first population based cancer incidence report from a cancer registry in south-east Nigeria. Objective: To evaluate the incidence of some invasive cancers in southeast Nigeria. Methodology: We collected all new cases of invasive cancers between 1st January and 31st December, 2013.

Sobre la existencia de la ley de Hack en las cuencas hidrográficas de Colombia.

OpenAIRE

Mantilla Gutiérrez, Ricardo; Mesa Sánchez, Óscar José; Poveda Jaramillo, Germán

2000-01-01

En este trabajo se presenta una caracterización geomorfométrica de las cuencas hidrográficas de Colombia, en términos de un estudio detallado de la relación potencial encontrada por J. T. Hack [3], entre la longitud del cauce principal y el área de la cuenca, que busca determinar una explicación del exponente que se obtiene con datos muestrales para tal relación potencial. Nuestros resultados sugieren que en 1000 cuencas Colombianas, el exponente anómalo de Kack puede explicarse en término...

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

Science.gov (United States)

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

2017-05-30

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

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

A Profile of Criminal Incidents at School: Results from the 2003-05 National Crime Victimization Survey Crime Incident Report NCES 2010-318

Science.gov (United States)

Ruddy, Sally A.; Bauer, Lynn; Neiman, Samantha

2010-01-01

This report provides estimates of criminal incidents that occur at school. Incident-level data were obtained from the National Crime Victimization Survey (NCVS), the nation's primary source of information on criminal victimization and criminal incidents in the United States. The NCVS collects demographic information on respondents in the NCVS…

Spatial Distribution of Black Bear Incident Reports in Michigan.

Directory of Open Access Journals (Sweden)

Jamie E McFadden-Hiller

Full Text Available Interactions between humans and carnivores have existed for centuries due to competition for food and space. American black bears are increasing in abundance and populations are expanding geographically in many portions of its range, including areas that are also increasing in human density, often resulting in associated increases in human-bear conflict (hereafter, bear incidents. We used public reports of bear incidents in Michigan, USA, from 2003-2011 to assess the relative contributions of ecological and anthropogenic variables in explaining the spatial distribution of bear incidents and estimated the potential risk of bear incidents. We used weighted Normalized Difference Vegetation Index mean as an index of primary productivity, region (i.e., Upper Peninsula or Lower Peninsula, primary and secondary road densities, and percentage land cover type within 6.5-km2 circular buffers around bear incidents and random points. We developed 22 a priori models and used generalized linear models and Akaike's Information Criterion (AIC to rank models. The global model was the best compromise between model complexity and model fit (w = 0.99, with a ΔAIC 8.99 units from the second best performing model. We found that as deciduous forest cover increased, the probability of bear incident occurrence increased. Among the measured anthropogenic variables, cultivated crops and primary roads were the most important in our AIC-best model and were both positively related to the probability of bear incident occurrence. The spatial distribution of relative bear incident risk varied markedly throughout Michigan. Forest cover fragmented with agriculture and other anthropogenic activities presents an environment that likely facilitates bear incidents. Our map can help wildlife managers identify areas of bear incident occurrence, which in turn can be used to help develop strategies aimed at reducing incidents. Researchers and wildlife managers can use similar mapping

Spatial Distribution of Black Bear Incident Reports in Michigan.

Science.gov (United States)

McFadden-Hiller, Jamie E; Beyer, Dean E; Belant, Jerrold L

2016-01-01

Interactions between humans and carnivores have existed for centuries due to competition for food and space. American black bears are increasing in abundance and populations are expanding geographically in many portions of its range, including areas that are also increasing in human density, often resulting in associated increases in human-bear conflict (hereafter, bear incidents). We used public reports of bear incidents in Michigan, USA, from 2003-2011 to assess the relative contributions of ecological and anthropogenic variables in explaining the spatial distribution of bear incidents and estimated the potential risk of bear incidents. We used weighted Normalized Difference Vegetation Index mean as an index of primary productivity, region (i.e., Upper Peninsula or Lower Peninsula), primary and secondary road densities, and percentage land cover type within 6.5-km2 circular buffers around bear incidents and random points. We developed 22 a priori models and used generalized linear models and Akaike's Information Criterion (AIC) to rank models. The global model was the best compromise between model complexity and model fit (w = 0.99), with a ΔAIC 8.99 units from the second best performing model. We found that as deciduous forest cover increased, the probability of bear incident occurrence increased. Among the measured anthropogenic variables, cultivated crops and primary roads were the most important in our AIC-best model and were both positively related to the probability of bear incident occurrence. The spatial distribution of relative bear incident risk varied markedly throughout Michigan. Forest cover fragmented with agriculture and other anthropogenic activities presents an environment that likely facilitates bear incidents. Our map can help wildlife managers identify areas of bear incident occurrence, which in turn can be used to help develop strategies aimed at reducing incidents. Researchers and wildlife managers can use similar mapping techniques to

Incident and Trafficking Database: New Systems for Reporting and Accessing State Information

International Nuclear Information System (INIS)

Dimitrovski, D.; Kittley, S.

2015-01-01

The IAEA's Incident and Trafficking Database (ITDB) is the Agency's authoritative source for information on incidents in which nuclear and other radioactive material is out of national regulatory control. It was established in 1995 and, as of June 2014, 126 States participate in the ITDB programme. Currently, the database contains over 2500 confirmed incidents, out of which 21% involve nuclear material, 62% radioactive source and 17% radioactively contaminated material. In recent years, the system for States to report incidents to the ITDB has been evolving — moving from fax-based to secure email and most recently to secure on-line reporting. A Beta version of the on-line system was rolled out this June, offering a simple, yet secure, communication channel for member states to provide information. In addition the system serves as a central hub for information related to official communication of the IAEA with Member States so some communication that is traditionally shared by e-mail does not get lost when ITDB counterparts change. In addition the new reporting system incorporates optional features that allow multiple Member State users to collaboratively contribute toward an INF. States are also being given secure on-line access to a streamlined version of the ITDB. This improves States' capabilities to retrieve and analyze information for their own purposes. In addition, on-line access to ITDB statistical information on incidents is available to States through an ITDB Dashboard. The dashboard contains aggregate information on number and types of incidents, material involved, as well some other statistics related to the ITDB that is typically provided in the ITDB Quarterly reports. (author)

Systemizers Are Better Code-Breakers: Self-Reported Systemizing Predicts Code-Breaking Performance in Expert Hackers and Naïve Participants

Science.gov (United States)

Harvey, India; Bolgan, Samuela; Mosca, Daniel; McLean, Colin; Rusconi, Elena

2016-01-01

Studies on hacking have typically focused on motivational aspects and general personality traits of the individuals who engage in hacking; little systematic research has been conducted on predispositions that may be associated not only with the choice to pursue a hacking career but also with performance in either naïve or expert populations. Here, we test the hypotheses that two traits that are typically enhanced in autism spectrum disorders—attention to detail and systemizing—may be positively related to both the choice of pursuing a career in information security and skilled performance in a prototypical hacking task (i.e., crypto-analysis or code-breaking). A group of naïve participants and of ethical hackers completed the Autism Spectrum Quotient, including an attention to detail scale, and the Systemizing Quotient (Baron-Cohen et al., 2001, 2003). They were also tested with behavioral tasks involving code-breaking and a control task involving security X-ray image interpretation. Hackers reported significantly higher systemizing and attention to detail than non-hackers. We found a positive relation between self-reported systemizing (but not attention to detail) and code-breaking skills in both hackers and non-hackers, whereas attention to detail (but not systemizing) was related with performance in the X-ray screening task in both groups, as previously reported with naïve participants (Rusconi et al., 2015). We discuss the theoretical and translational implications of our findings. PMID:27242491

Systemizers are better code-breakers:Self-reported systemizing predicts code-breaking performance in expert hackers and naïve participants

Directory of Open Access Journals (Sweden)

India eHarvey

2016-05-01

Full Text Available Studies on hacking have typically focused on motivational aspects and general personality traits of the individuals who engage in hacking; little systematic research has been conducted on predispositions that may be associated not only with the choice to pursue a hacking career but also with performance in either naïve or expert populations. Here we test the hypotheses that two traits that are typically enhanced in autism spectrum disorders - attention to detail and systemizing - may be positively related to both the choice of pursuing a career in information security and skilled performance in a prototypical hacking task (i.e. crypto-analysis or code-breaking. A group of naïve participants and of ethical hackers completed the Autism Spectrum Quotient, including an attention to detail scale, and the Systemizing Quotient (Baron-Cohen et al., 2001; Baron-Cohen et al., 2003. They were also tested with behavioural tasks involving code-breaking and a control task involving security x-ray image interpretation. Hackers reported significantly higher systemizing and attention to detail than non-hackers. We found a positive relation between self-reported systemizing (but not attention to detail and code-breaking skills in both hackers and non-hackers, whereas attention to detail (but not systemizing was related with performance in the x-ray screening task in both groups, as previously reported with naïve participants (Rusconi et al., 2015. We discuss the theoretical and translational implications of our findings.

Systemizers Are Better Code-Breakers: Self-Reported Systemizing Predicts Code-Breaking Performance in Expert Hackers and Naïve Participants.

Science.gov (United States)

Harvey, India; Bolgan, Samuela; Mosca, Daniel; McLean, Colin; Rusconi, Elena

2016-01-01

Studies on hacking have typically focused on motivational aspects and general personality traits of the individuals who engage in hacking; little systematic research has been conducted on predispositions that may be associated not only with the choice to pursue a hacking career but also with performance in either naïve or expert populations. Here, we test the hypotheses that two traits that are typically enhanced in autism spectrum disorders-attention to detail and systemizing-may be positively related to both the choice of pursuing a career in information security and skilled performance in a prototypical hacking task (i.e., crypto-analysis or code-breaking). A group of naïve participants and of ethical hackers completed the Autism Spectrum Quotient, including an attention to detail scale, and the Systemizing Quotient (Baron-Cohen et al., 2001, 2003). They were also tested with behavioral tasks involving code-breaking and a control task involving security X-ray image interpretation. Hackers reported significantly higher systemizing and attention to detail than non-hackers. We found a positive relation between self-reported systemizing (but not attention to detail) and code-breaking skills in both hackers and non-hackers, whereas attention to detail (but not systemizing) was related with performance in the X-ray screening task in both groups, as previously reported with naïve participants (Rusconi et al., 2015). We discuss the theoretical and translational implications of our findings.

Medication Incidents Related to Automated Dose Dispensing in Community Pharmacies and Hospitals - A Reporting System Study

Science.gov (United States)

Cheung, Ka-Chun; van den Bemt, Patricia M. L. A.; Bouvy, Marcel L.; Wensing, Michel; De Smet, Peter A. G. M.

2014-01-01

Introduction Automated dose dispensing (ADD) is being introduced in several countries and the use of this technology is expected to increase as a growing number of elderly people need to manage their medication at home. ADD aims to improve medication safety and treatment adherence, but it may introduce new safety issues. This descriptive study provides insight into the nature and consequences of medication incidents related to ADD, as reported by healthcare professionals in community pharmacies and hospitals. Methods The medication incidents that were submitted to the Dutch Central Medication incidents Registration (CMR) reporting system were selected and characterized independently by two researchers. Main Outcome Measures Person discovering the incident, phase of the medication process in which the incident occurred, immediate cause of the incident, nature of incident from the healthcare provider's perspective, nature of incident from the patient's perspective, and consequent harm to the patient caused by the incident. Results From January 2012 to February 2013 the CMR received 15,113 incidents: 3,685 (24.4%) incidents from community pharmacies and 11,428 (75.6%) incidents from hospitals. Eventually 1 of 50 reported incidents (268/15,113 = 1.8%) were related to ADD; in community pharmacies more incidents (227/3,685 = 6.2%) were related to ADD than in hospitals (41/11,428 = 0.4%). The immediate cause of an incident was often a change in the patient's medicine regimen or relocation. Most reported incidents occurred in two phases: entering the prescription into the pharmacy information system and filling the ADD bag. Conclusion A proportion of incidents was related to ADD and is reported regularly, especially by community pharmacies. In two phases, entering the prescription into the pharmacy information system and filling the ADD bag, most incidents occurred. A change in the patient's medicine regimen or relocation was the immediate causes of an incident

Better P-curves: Making P-curve analysis more robust to errors, fraud, and ambitious P-hacking, a Reply to Ulrich and Miller (2015).

Science.gov (United States)

Simonsohn, Uri; Simmons, Joseph P; Nelson, Leif D

2015-12-01

When studies examine true effects, they generate right-skewed p-curves, distributions of statistically significant results with more low (.01 s) than high (.04 s) p values. What else can cause a right-skewed p-curve? First, we consider the possibility that researchers report only the smallest significant p value (as conjectured by Ulrich & Miller, 2015), concluding that it is a very uncommon problem. We then consider more common problems, including (a) p-curvers selecting the wrong p values, (b) fake data, (c) honest errors, and (d) ambitiously p-hacked (beyond p < .05) results. We evaluate the impact of these common problems on the validity of p-curve analysis, and provide practical solutions that substantially increase its robustness. (c) 2015 APA, all rights reserved).

Safety Incident Management Team Report for NIMLT Case 50796

LENUS (Irish Health Repository)

2017-01-17

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

E-Community: Mobile application for reporting incidents of public services of a city

OpenAIRE

Jaime Suárez; Elvia Aispuro; Mónica Carreño; Andrés Sandoval; Italia Estrada; Jesús Hernández; Javier Aguilar; Yoshio Valles; Emma Ibarra

2013-01-01

This paper reports the mobile application call E-Community, an application of a social nature with the objective that the civilian population in the city of La Paz, Baja California Sur, Mexico, have an alternative to report incidents that deal with services public. Generally, citizens reported by telephone different types of incidents such as traffic accidents, water leaks, lighting shabby, fire, garbage collection, however sometimes the phone is not attended for various reasons so regularly ...

National critical incident reporting systems relevant to anaesthesia: a European survey.

Science.gov (United States)

Reed, S; Arnal, D; Frank, O; Gomez-Arnau, J I; Hansen, J; Lester, O; Mikkelsen, K L; Rhaiem, T; Rosenberg, P H; St Pierre, M; Schleppers, A; Staender, S; Smith, A F

2014-03-01

Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia. We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure. Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed. We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.

Mind Invasion: Situated Affectivity and the Corporate Life Hack.

Science.gov (United States)

Slaby, Jan

2016-01-01

In view of the philosophical problems that vex the debate on situated affectivity, it can seem wise to focus on simple cases. Accordingly, theorists often single out scenarios in which an individual employs a device in order to enhance their emotional experience, or to achieve new kinds of experience altogether, such as playing an instrument, going to the movies, or sporting a fancy handbag. I argue that this narrow focus on cases that fit a "user/resource model" tends to channel attention away from more complex and also more problematic instances of situated affectivity. Among these are scenarios in which a social domain draws individuals into certain modes of affective interaction, often by way of attunement and habituation to affective styles and interaction patterns that are normative in the domain in question. This can lead to a phenomenon that is not so much "mind extension" than "mind invasion": affectivity is dynamically framed and modulated from without, often contrary to the prior orientations of the individuals in question. As an example, I discuss affective patterns prevalent in today's corporate workplace. I claim that workplace affect sometimes contributes to what is effectively a "hack" of employees' subjectivity.

Analysis of human factors in incidents reported by Swiss nuclear power plants to the inspectorate

International Nuclear Information System (INIS)

Alder, H.P.; Hausmann, W.

1997-01-01

197 reported incidents in Swiss Nuclear Power Plants were analyzed by a team of the Swiss Federal Nuclear Safety Inspectorate (HSK) using the OECD/NEA Incident Reporting System. The following conclusions could be drawn from this exercise. While the observed cause reported by the plant was ''technical failure'' in about 90% of the incidents, the HSK-Team identified for more than 60% of the incidents ''human factors'' as the root cause. When analyzing this root cause further it was shown that only a smaller contribution came from the side of the operators and the more important shares were caused by plant maintenance, vendors/constructors and plant management with procedural and organizational deficiencies. These findings demonstrate that root cause analysis of incidents by the IRS-Code is a most useful tool to analyze incidents and to find weak points in plant performance. (author). 5 tabs

Hacking on decoy-state quantum key distribution system with partial phase randomization

Science.gov (United States)

Sun, Shi-Hai; Jiang, Mu-Sheng; Ma, Xiang-Chun; Li, Chun-Yan; Liang, Lin-Mei

2014-04-01

Quantum key distribution (QKD) provides means for unconditional secure key transmission between two distant parties. However, in practical implementations, it suffers from quantum hacking due to device imperfections. Here we propose a hybrid measurement attack, with only linear optics, homodyne detection, and single photon detection, to the widely used vacuum + weak decoy state QKD system when the phase of source is partially randomized. Our analysis shows that, in some parameter regimes, the proposed attack would result in an entanglement breaking channel but still be able to trick the legitimate users to believe they have transmitted secure keys. That is, the eavesdropper is able to steal all the key information without discovered by the users. Thus, our proposal reveals that partial phase randomization is not sufficient to guarantee the security of phase-encoding QKD systems with weak coherent states.

Hacking on decoy-state quantum key distribution system with partial phase randomization.

Science.gov (United States)

Sun, Shi-Hai; Jiang, Mu-Sheng; Ma, Xiang-Chun; Li, Chun-Yan; Liang, Lin-Mei

2014-04-23

Quantum key distribution (QKD) provides means for unconditional secure key transmission between two distant parties. However, in practical implementations, it suffers from quantum hacking due to device imperfections. Here we propose a hybrid measurement attack, with only linear optics, homodyne detection, and single photon detection, to the widely used vacuum + weak decoy state QKD system when the phase of source is partially randomized. Our analysis shows that, in some parameter regimes, the proposed attack would result in an entanglement breaking channel but still be able to trick the legitimate users to believe they have transmitted secure keys. That is, the eavesdropper is able to steal all the key information without discovered by the users. Thus, our proposal reveals that partial phase randomization is not sufficient to guarantee the security of phase-encoding QKD systems with weak coherent states.

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

Science.gov (United States)

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

2015-01-01

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

Statistical analysis of incidents reported in the Greek Petrochemical Industry for the period 1997-2003

International Nuclear Information System (INIS)

Konstandinidou, Myrto; Nivolianitou, Zoe; Markatos, Nikolaos; Kiranoudis, Chris

2006-01-01

This paper makes an analysis of all reported accidents and incidents in the Greek Petrochemical Industry for the period spanning from 1997 to 2003. The work performed is related to the analysis of important parameters of the incidents, their inclusion in a database adequately designed for the purposes of this analysis and an importance assessment of this reporting scheme. Indeed, various stakeholders have highlighted the importance of a reporting system for industrial accidents and incidents. The European Union has established for this purpose the Major Accident Reporting System (MARS) for the reporting of major accidents in the Member States. However, major accidents are not the only measure that can characterize the safety status of an establishment; neither are the former the only events from which important lessons can be learned. Near misses, industrial incidents without major consequences, as well as occupational accidents could equally supply with important findings the interested analyst, while statistical analysis of these incidents could give significant insight in the understanding and the prevention of similar incidents or major accidents in the future. This analysis could be more significant, if each industrial sector was separately analyzed, as the authors do for the petrochemical sector in the present article

Modification of Hack Saw Blade Support 'REMOR 400' from the Length of 650 mm to 450 mm

International Nuclear Information System (INIS)

Sagino, Abdul-Hafid

2005-01-01

REMOR 400 type is the hack saw machine for cutting large work piece. The capacity of cutting is 310 mm diameter. The length of the blade is 650 mm (26 inches). For cutting small work piece (≤ 150 mm), the use of this blade is not efficient because the blade is relatively expensive. To solve this problem, the modification of the blade support is performed so that REMOR 400 machine can use the blade of 450 mm which is cheaper and easier to find in the market. (author)

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

DEFF Research Database (Denmark)

Maaløe, R; la Cour, M; Hansen, A

2006-01-01

The purpose of the present study was to measure the incidence and type of incidents that occurred in relation to anaesthesia and surgery during a 1-year period in six Danish hospitals. Furthermore, we wanted to identify risk factors for incidents, as well as risk factors for incidents being deeme...... critical....

SU-E-T-524: Web-Based Radiation Oncology Incident Reporting and Learning System (ROIRLS)

Energy Technology Data Exchange (ETDEWEB)

Kapoor, R; Palta, J; Hagan, M [Virginia Commonwealth University, Richmond, VA (United States); National Radiation Oncology Program (10P4H), Richmond, VA (United States); Grover, S; Malik, G [TSG Innovations Inc., Richmond, VA (United States)

2014-06-01

Purpose: Describe a Web-based Radiation Oncology Incident Reporting and Learning system that has the potential to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: The VA National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and near miss data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. Software used for this program is deployed on the VAs intranet as a Website. All data entry forms (adverse event or near miss reports, work product reports) utilize standard causal, RT process step taxonomies and data dictionaries defined in AAPM and ASTRO reports on error reporting (AAPM Work Group Report on Prevention of Errors and ASTROs safety is no accident report). All reported incidents are investigated by the radiation oncology domain experts. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The operational workflow is similar to that of the Aviation Safety Reporting System. This system is also synergistic with ROSIS and SAFRON. Results: The ROIRLS facilitates the collection of data that help in tracking adverse events and near misses and develop new interventions to prevent such incidents. The ROIRLS electronic infrastructure is fully integrated with each registered facility profile data thus minimizing key strokes and multiple entries by the event reporters. Conclusions: OIRLS is expected to improve the quality and safety of a broad spectrum of radiation therapy patients treated in the VA and fulfills our goal of Effecting Quality While Treating Safely The Radiation Oncology Incident Reporting and Learning System software used for this program has been developed, conceptualized and maintained by TSG Innovations

SU-E-T-524: Web-Based Radiation Oncology Incident Reporting and Learning System (ROIRLS)

International Nuclear Information System (INIS)

Kapoor, R; Palta, J; Hagan, M; Grover, S; Malik, G

2014-01-01

Purpose: Describe a Web-based Radiation Oncology Incident Reporting and Learning system that has the potential to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: The VA National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and near miss data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. Software used for this program is deployed on the VAs intranet as a Website. All data entry forms (adverse event or near miss reports, work product reports) utilize standard causal, RT process step taxonomies and data dictionaries defined in AAPM and ASTRO reports on error reporting (AAPM Work Group Report on Prevention of Errors and ASTROs safety is no accident report). All reported incidents are investigated by the radiation oncology domain experts. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The operational workflow is similar to that of the Aviation Safety Reporting System. This system is also synergistic with ROSIS and SAFRON. Results: The ROIRLS facilitates the collection of data that help in tracking adverse events and near misses and develop new interventions to prevent such incidents. The ROIRLS electronic infrastructure is fully integrated with each registered facility profile data thus minimizing key strokes and multiple entries by the event reporters. Conclusions: OIRLS is expected to improve the quality and safety of a broad spectrum of radiation therapy patients treated in the VA and fulfills our goal of Effecting Quality While Treating Safely The Radiation Oncology Incident Reporting and Learning System software used for this program has been developed, conceptualized and maintained by TSG Innovations

SU-F-T-223: Radiotherapy Incident Reporting and Analysis System (RIRAS):Early Experience

International Nuclear Information System (INIS)

Kapoor, R; Palta, J; Hagan, M; Burkett, D; Leidholdt, E

2016-01-01

Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reporting facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly

SU-F-T-223: Radiotherapy Incident Reporting and Analysis System (RIRAS):Early Experience

Energy Technology Data Exchange (ETDEWEB)

Kapoor, R; Palta, J; Hagan, M [National Radiation Oncology Program (10P4H), Dept. of Veterans Affairs, Richmond, VA (United States); Burkett, D; Leidholdt, E [National Health Physics Program (10P4X), Dept. of Veterans Affairs, Little Rock, AR (United States)

2016-06-15

Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reporting facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly

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

Science.gov (United States)

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

2009-02-01

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

Australian Hackers and Ethics

OpenAIRE

M.J. Warren; W. Hutchinson

2003-01-01

The aim of the paper is to look at the way hackers act and ways in which society can protect itself. The paper will show the current views and attitudes of hackers in an Australian context. The paper will also include a case study to show how a hacking incident can develop and how technology can be used to protect against hacking.

Properties of incident reporting systems in relation to statistical trend and pattern analysis

International Nuclear Information System (INIS)

Kalfsbeek, H.W.; Arsenis, S.P.

1990-01-01

This paper describes the properties deemed desirable for an incident reporting system in order to render it useful for extracting valid statistical trend and pattern information. The perspective under which a data collection system is seen in this paper is the following: data are essentially gathered on a set of variables describing an event or incident (the items featuring on a reporting format) in order to learn about (multiple) dependencies (called interactions) between these variables. Hence, the necessary features of the data source are highlighted and potential problem sources limiting the validity of the results to be obtained are identified. In this frame, important issues are the reporting completeness, related to the reporting criteria and reporting frequency, and of course the reporting contents and quality. The choice of the report items (the variables) and their categorization (code dictionary) may influence (bias) the insights gained from trend and pattern analyses, as may the presence or absence of a structure for correlating the reported issues within an incident. The issues addressed in this paper are brought in relation to some real world reporting systems on safety related events in Nuclear Power Plants, so that their possibilities and limitations with regard to statistical trend and pattern analysis become manifest

Efficacy of ‘hack and squirt’ application of imazapyr, triclopyr, and glyphosate to control the invasive tree species Chinese tallowtree

Science.gov (United States)

Charles A. Gresham

2010-01-01

In May 2005, 12 plots approximately 21 by 27 m each were established on the exterior bank of a dredge spoil area in Georgetown, SC. The tree cover was primarily Chinese tallowtree, but there were also live oak trees in each plot. Also in May 2005, Chinese tallowtree s (d.b.h. > 2.4 cm) in three randomly selected plots received a ‘hack and squirt’ application of...

The relationship between addiction to internet and adolescence’s tendency toward opposite sex, sexual behaviors, alcohol, aggression, chatting and hacking

OpenAIRE

Mehri Mowlaie; Setareh Jani

2016-01-01

Background: Given the importance of adolescent period and impact of internet and virtual communication tools on high risk behaviors, this research was conducted to examine the relationship between addiction to internet and adolescent’s tendency toward opposite sex, sexual behaviors, alcohol, aggression, chatting and hacking. Methods: The population of this study included all (n=40597) junior and senior high school students (boys and girls) in academic year 2014-2015 in Ardabil, Iran. 38...

Perceptions of Police Legitimacy and Citizen Decisions to Report Hate Crime Incidents in Australia

Directory of Open Access Journals (Sweden)

Susann Wiedlitzka

2018-06-01

Full Text Available This article examines the importance of perceptions of police legitimacy in the decision to report hate crime incidents in Australia. It addresses an identified gap in the literature by analysing the 2011-2012 National Security and Preparedness Survey (NSPS results to not only explore differences between hate crime and non-hate crime reporting but also how individual characteristics and perceptions of legitimacy influence decisions about reporting crime to police. Using the NSPS survey data, we created three Generalised Linear Latent and Mixed Models (Gllamm, which explore the influence of individual characteristics and potential barriers on the decision to report crime/hate crime incidents to police. Our results suggest that hate crimes are less likely to be reported to police in comparison to non-hate crime incidents, and that more positive perceptions of police legitimacy and police cooperation are associated with the victim’s decision to report hate crime victimisation.

Analysis of human factor aspects in connection with available incident reports obligatorily reported by German nuclear power plants

International Nuclear Information System (INIS)

Wilpert, B.; Freitag, M.; Miller, R.

1993-01-01

Goal of the present study is the analysis of human factor aspects in connection with available incident reports obligatorily reported by German nuclear power plants. Based on psychological theories and empirical studies this study develops a classification scheme which permits the identification of foci of erroneous human actions. This classification scheme is applied to a selection of human factor relevant incidents by calculating frequencies of the occurrence of human error categories. The results allow insights into human factor related problem areas. (orig.) [de

Incidence et Caracteristiques des Signalements d'Enfants Maltraites: Comparaison Interculturelle (Incidence and Characteristics of Reported Child Abuse: Intercultural Comparisons).

Science.gov (United States)

Tourigny, Marc; Bouchard, Camil

1994-01-01

Analysis of 953 reports of child abuse in Montreal (Quebec) found the incidence slightly higher among Haitians than French-Canadians. Among Haitians, reporting tended to originate with police or school personnel, and cases consisted mainly of physical abuse. Results suggest that child-rearing practices of Haitian families are in conflict with…

75 FR 75911 - Adjustment of Monetary Threshold for Reporting Rail Equipment Accidents/Incidents for Calendar...

Science.gov (United States)

2010-12-07

..., Notice No. 3] RIN 2130-ZA04 Adjustment of Monetary Threshold for Reporting Rail Equipment Accidents... (DOT). ACTION: Final rule. SUMMARY: This rule increases the rail equipment accident/incident reporting threshold from $9,200 to $9,400 for certain railroad accidents/incidents involving property damage that...

Australian Hackers and Ethics

Directory of Open Access Journals (Sweden)

M.J. Warren

2003-05-01

Full Text Available The aim of the paper is to look at the way hackers act and ways in which society can protect itself. The paper will show the current views and attitudes of hackers in an Australian context. The paper will also include a case study to show how a hacking incident can develop and how technology can be used to protect against hacking.

A self-report critical incident assessment tool for army night vision goggle helicopter operations.

Science.gov (United States)

Renshaw, Peter F; Wiggins, Mark W

2007-04-01

The present study sought to examine the utility of a self-report tool that was designed as a partial substitute for a face-to-face cognitive interview for critical incidents involving night vision goggles (NVGs). The use of NVGs remains problematic within the military environment, as these devices have been identified as a factor in a significant proportion of aircraft accidents and incidents. The self-report tool was structured to identify some of the cognitive features of human performance that were associated with critical incidents involving NVGs. The tool incorporated a number of different levels of analysis, ranging from specific behavioral responses to broader cognitive constructs. Reports were received from 30 active pilots within the Australian Army using the NVG Critical Incident Assessment Tool (NVGCIAT). The results revealed a correspondence between specific types of NVG-related errors and elements of the Human Factors Analysis and Classification System (HFACS). In addition, uncertainty emerged as a significant factor associated with the critical incidents that were recalled by operators. These results were broadly consistent with previous research and provide some support for the utility of subjective assessment tools as a means of extracting critical incident-related data when face-to-face cognitive interviews are not possible. In some circumstances, the NVGCIAT might be regarded as a substitute cognitive interview protocol with some level of diagnosticity.

Hacking the Cell: Network Intrusion and Exploitation by Adenovirus E1A.

Science.gov (United States)

King, Cason R; Zhang, Ali; Tessier, Tanner M; Gameiro, Steven F; Mymryk, Joe S

2018-05-01

As obligate intracellular parasites, viruses are dependent on their infected hosts for survival. Consequently, viruses are under enormous selective pressure to utilize available cellular components and processes to their own advantage. As most, if not all, cellular activities are regulated at some level via protein interactions, host protein interaction networks are particularly vulnerable to viral exploitation. Indeed, viral proteins frequently target highly connected "hub" proteins to "hack" the cellular network, defining the molecular basis for viral control over the host. This widespread and successful strategy of network intrusion and exploitation has evolved convergently among numerous genetically distinct viruses as a result of the endless evolutionary arms race between pathogens and hosts. Here we examine the means by which a particularly well-connected viral hub protein, human adenovirus E1A, compromises and exploits the vulnerabilities of eukaryotic protein interaction networks. Importantly, these interactions identify critical regulatory hubs in the human proteome and help define the molecular basis of their function. Copyright © 2018 King et al.

Educators' Reports on Incidence of Harassment and Advocacy toward LGBTQ Students

Science.gov (United States)

Dragowski, Eliza A.; McCabe, Paul C.; Rubinson, Florence

2016-01-01

This study is based on a national survey investigation of 968 educators, who reported the incidence of LGBTQ harassment in schools, and their advocacy efforts on behalf of this population. LGBTQ-related knowledge, attitudes, norms, and perceived ability to advocate were also assessed. Ninety percent of educators reported observing LGBTQ harassment…

Survey of reportable incidents in nuclear power plants of the Federal Republic of Germany in the year 1991

International Nuclear Information System (INIS)

1992-01-01

In 1991, there were 249 reportable nuclear power plant incidents in Germany (old and new federal Laender). The report comprehensively lists all these incidents. There was no release of radioactivity exceeding the maximum permissible limits, and there were no effects on man or the environment. There were no incidents of reporting category S (Urgent notification), and ten belonging to category E (immediate notification). The six incidents reported in the first half of 1991 from nuclear power plants in the new federal Laender all belonged to category AE 3, which is the lowest. (orig./DG) [de

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

Science.gov (United States)

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

2016-02-01

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

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

Science.gov (United States)

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

2017-06-12

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

In situ simulation: Taking reported critical incidents and adverse events back to the clinic

DEFF Research Database (Denmark)

Juul, Jonas; Paltved, Charlotte; Krogh, Kristian

2014-01-01

for content analysis4 and thematic analysis5. Medical experts and simulation faculty will design scenarios for in situ simulation training based on the analysis. Short-term observations using time logs will be performed along with interviews with key informants at the departments. Video data will be collected...... improve patient safety if coupled with training and organisational support2. Insight into the nature of reported critical incidents and adverse events can be used in writing in situ simulation scenarios and thus lead to interventions that enhance patient safety. The patient safety literature emphasises...... well-developed non-technical skills in preventing medical errors3. Furthermore, critical incidents and adverse events reporting systems comprise a knowledgebase to gain in-depth insights into patient safety issues. This study explores the use of critical incidents and adverse events reports to inform...

Integrating student feedback during "Dental Curriculum Hack-A-thon".

Science.gov (United States)

Saffari, Shawheen S; Frederick Lambert, R; Dang, Lucy; Pagni, Sarah; Dragan, Irina F

2018-05-02

The future of dental education is at crossroads. This study used the parameter of the 2016 Dental Curriculum Hack-a-Thon to assess intra- and inter-institutional agreement between student and faculty views regarding dental curriculums to determine if there is an impact in student perceptions towards dental education from before and after the event. This exploratory, cross-sectional study involved two surveys, with Survey 1 being distributed among four faculty-student pairs of the four participating dental schools answering 14 questions. Survey 2 assessed the views of 20 participating dental students through 26 questions in a pre- and post- event survey design. Descriptive statistics were used to explore differences in perceptions towards dental education across both instrument surveys. The results revealed valuable student insights regarding intra- and inter-institutional agreement relevant for the change in dental curriculum that needs to occur. Survey 2 revealed that mandatory attendance in didactic courses, electronic based examination preferences, and the preference of preclinical courses being held in the first and second years of a four-year dental curriculum were of particular importance to student participants. The results of this study indicate that exposure and participation in subjects pertaining to dental education can be influential on student preferences and opinions on how dental education should be delivered in a four-year curriculum.

Survey to identify depth of penetration of critical incident reporting systems in Austrian healthcare facilities.

Science.gov (United States)

Sendlhofer, Gerald; Eder, Harald; Leitgeb, Karina; Gorges, Roland; Jakse, Heidelinde; Raiger, Marianne; Türk, Silvia; Petschnig, Walter; Pregartner, Gudrun; Kamolz, Lars-Peter; Brunner, Gernot

2018-01-01

Incident reporting systems or so-called critical incident reporting systems (CIRS) were first recommended for use in health care more than 15 years ago. The uses of these CIRS are highly variable among countries, ranging from being used to report critical incidents, falls, or sentinel events resulting in death. In Austria, CIRS have only been introduced to the health care sector relatively recently. The goal of this work, therefore, was to determine whether and specifically how CIRS are used in Austria. A working group from the Austrian Society for Quality and Safety in Healthcare (ASQS) developed a survey on the topic of CIRS to collect information on penetration of CIRS in general and on how CIRS reports are used to increase patient safety. Three hundred seventy-one health care professionals from 274 health care facilities were contacted via e-mail. Seventy-eight respondents (21.0%) completed the online survey, thereof 66 from hospitals and 12 from other facilities (outpatient clinics, nursing homes). In all, 64.1% of the respondents indicated that CIRS were used in the entire health care facility; 20.6% had not yet introduced CIRS and 15.4% used CIRS only in particular areas. Most often, critical incidents without any harm to patients were reported (76.9%); however, some health care facilities also use their CIRS to report patient falls (16.7%), needle stick injuries (17.9%), technical problems (51.3%), or critical incidents involving health care professionals. CIRS are not yet extensively or homogeneously used in Austria. Inconsistencies exist with respect to which events are reported as well as how they are followed up and reported to health care professionals. Further recommendations for general use are needed to support the dissemination in Austrian health care environments.

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.

SU-E-T-511: Inter-Rater Variability in Classification of Incidents in a New Incident Reporting System

International Nuclear Information System (INIS)

Pappas, D; Reis, S; Ali, A; Kapur, A

2015-01-01

Purpose To determine how consistent the results of different raters are when reviewing the same cases within the Radiation Oncology Incident Learning System (ROILS). Methods Three second-year medical physics graduate students filled out incident reports in spreadsheets set up to mimic ROILS. All students studied the same 33 cases and independently entered their assessments, for a total of 99 reviewed cases. The narratives for these cases were obtained from a published International Commission on Radiological Protection (ICRP) report which included shorter narratives selected from the Radiation Oncology Safety Information System (ROSIS) database. Each category of questions was reviewed to see how consistent the results were by utilizing free-marginal multirater kappa analysis. The percentage of cases where all raters shared full agreement or full disagreement was recorded to show which questions were answered consistently by multiple raters for a given case. The consistency among the raters was analyzed between ICRP and ROSIS cases to see if either group led to more reliable results. Results The categories where all raters agreed 100 percent in their choices were the event type (93.94 percent of cases 0.946 kappa) and the likelihood of the event being harmful to the patient (42.42 percent of cases 0.409 kappa). The categories where all raters disagreed 100 percent in their choices were the dosimetric severity scale (39.39 percent of cases 0.139 kappa) and the potential future toxicity (48.48 percent of cases 0.205 kappa). ROSIS had more cases where all raters disagreed than ICRP (23.06 percent of cases compared to 15.58 percent, respectively). Conclusion Despite reviewing the same cases, the results among the three raters was widespread. ROSIS narratives were shorter than ICRP, which suggests that longer narratives lead to more consistent results. This study shows that the incident reporting system can be optimized to yield more consistent results

SU-E-T-511: Inter-Rater Variability in Classification of Incidents in a New Incident Reporting System

Energy Technology Data Exchange (ETDEWEB)

Pappas, D; Reis, S; Ali, A [Hofstra University, Hempstead, NY (United States); Kapur, A [Long Island Jewish Medical Center, New Hyde Park, NY (United States)

2015-06-15

Purpose To determine how consistent the results of different raters are when reviewing the same cases within the Radiation Oncology Incident Learning System (ROILS). Methods Three second-year medical physics graduate students filled out incident reports in spreadsheets set up to mimic ROILS. All students studied the same 33 cases and independently entered their assessments, for a total of 99 reviewed cases. The narratives for these cases were obtained from a published International Commission on Radiological Protection (ICRP) report which included shorter narratives selected from the Radiation Oncology Safety Information System (ROSIS) database. Each category of questions was reviewed to see how consistent the results were by utilizing free-marginal multirater kappa analysis. The percentage of cases where all raters shared full agreement or full disagreement was recorded to show which questions were answered consistently by multiple raters for a given case. The consistency among the raters was analyzed between ICRP and ROSIS cases to see if either group led to more reliable results. Results The categories where all raters agreed 100 percent in their choices were the event type (93.94 percent of cases 0.946 kappa) and the likelihood of the event being harmful to the patient (42.42 percent of cases 0.409 kappa). The categories where all raters disagreed 100 percent in their choices were the dosimetric severity scale (39.39 percent of cases 0.139 kappa) and the potential future toxicity (48.48 percent of cases 0.205 kappa). ROSIS had more cases where all raters disagreed than ICRP (23.06 percent of cases compared to 15.58 percent, respectively). Conclusion Despite reviewing the same cases, the results among the three raters was widespread. ROSIS narratives were shorter than ICRP, which suggests that longer narratives lead to more consistent results. This study shows that the incident reporting system can be optimized to yield more consistent results.

Self-Reported Minimalist Running Injury Incidence and Severity: A Pilot Study.

Science.gov (United States)

Ostermann, Katrina; Ridpath, Lance; Hanna, Jandy B

2016-08-01

Minimalist running entails using shoes with a flexible thin sole and is popular in the United States. Existing literature disagrees over whether minimalist running shoes (MRS) improve perceived severity of injuries associated with running in traditional running shoes (TRS). Additionally, the perceived injury patterns associated with MRS are relatively unknown. To examine whether injury incidence and severity (ie, degree of pain) by body region change after switching to MRS, and to determine if transition times affect injury incidences or severity with MRS. Runners who were either current or previous users of MRS were recruited to complete an Internet-based survey regarding self-reported injury before switching to MRS and whether self-reported pain from that injury decreased after switching. Questions regarding whether new injuries developed in respondents after switching to MRS were also included. Analyses were calculated using t tests, Wilcoxon signed rank tests, and Fischer exact tests. Forty-seven runners completed the survey, and 16 respondents reported injuries before switching to MRS. Among these respondents, pain resulting from injuries of the feet (P=.03) and knees (P=.01) decreased. Eighteen respondents (38.3%) indicated they sustained new injuries after switching to MRS, but the severity of these did not differ significantly from no injury. Neither time allowed for transition to MRS nor use or disuse of a stretching routine during this period was correlated with an increase in the incidence or severity of injuries. After switching to MRS, respondents perceived an improvement in foot and knee injuries. Additionally, respondents using MRS reported an injury rate of 38.3%, compared with the approximately 64% that the literature reports among TRS users. Future studies should be expanded to determine the full extent of the differences in injury patterns between MRS and TRS.

Characterizing Cyberbullying among College Students: Hacking, Dirty Laundry, and Mocking

Directory of Open Access Journals (Sweden)

Rajitha Kota

2014-10-01

Full Text Available Bullying behaviors occur across the lifespan and have increasingly migrated to online platforms where they are known as cyberbullying. The purpose of this study was to explore the phenomenon of cyberbullying among college students. Participants were recruited for focus groups through purposeful sampling, including recruitment from groups traditionally at risk for bullying. Focus groups discussed views and perceptions of cyberbullying on campuses. Groups were led by a trained facilitator and were audio recorded and manually transcribed. The constant comparative approach was used to identify themes and representative quotations. The 42 participants had an average age of 19.2 (SD = 1.2, 55% were female, 83% were Caucasian. Three themes emerged from the data: (1 lack of agreement on a definition of cyberbullying, but consensus on three representative scenarios: hacking, dirty laundry and mocking; (2 concerns with translating definitions of traditional bullying to cyberbullying; (3 opinions that cyberbullying may manifest differently in college compared to younger adolescents, including increased potential for long-term effects. College students were not in agreement about a theoretical definition, but they could agree upon specific representative instances of cyberbullying.  Future studies could consider using common case examples or vignettes of cyberbullying, or creation of developmentally representative definitions by age group.

Using Pareto Analysis with Trend Analysis: Statistical Techniques to Investigate Incident Reports within a Housing System

Science.gov (United States)

Luna, Andrew L.

1998-01-01

The purpose of this study was to determine trends and difficulties concerning student incident reports within the residence halls as they relate to the incident reporting system from the Department of Housing and Residential Life at a Southeastern Doctoral I Granting Institution. This study used the frequency distributions of each classified…

77 FR 69925 - Assessment of Hazardous Materials Incident Data Collection, Analysis, Reporting, and Use

Science.gov (United States)

2012-11-21

...), 126 Stat. 835, July 6, 2012) requires the Department to conduct an assessment to improve the... adequacy of and suggestions for improvement to: 1. Information requested on the accident and incident... technology; and 5. The database used by PHMSA for recording and reporting such accidents and incidents...

Criteria for classification and reporting of fire incidences in nuclear power plants of India

International Nuclear Information System (INIS)

Kapoor, R.K.

1998-01-01

Is is important that all fires in and around fire effective neighbourhood of Nuclear Power Plant (NPP) should be promptly reported (Reportable fires) and investigated. However, the depth of investigation and the range of authorities to whom the individual fire incidence need to be reported depends upon the severity of fire. In case of conventional non-chemical industries, the severity of fire depends mainly on the extent of loss caused by fire on property and the burn injury to persons. In case of NPP, two additional losses viz, release of radioactivity to working/public environment and the risk to safety related systems of NPP due to fire assume greater importance. This paper describes the criteria used in NPPs of India for classification of reportable fire incidences into four categories, viz. Insignificant, small, medium and large fires. It also gives the level of investigation depending upon the severity of fire. The fire classification scheme is explained in this paper with the help of worked out examples and two incidences of fire in Indian NPPs. (author)

Contributory factors in surgical incidents as delineated by a confidential reporting system.

Science.gov (United States)

Mushtaq, F; O'Driscoll, C; Smith, Fct; Wilkins, D; Kapur, N; Lawton, R

2018-05-01

Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) - with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures - those closest in time and space to the adverse event - pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.

SU-F-T-462: Lessons Learned From a Machine Incident Reporting System

International Nuclear Information System (INIS)

Sutlief, S; Hoisak, J

2016-01-01

Purpose: Linear accelerators must operate with minimal downtime. Machine incident logs are a crucial tool to meet this requirement. They providing a history of service and demonstrate whether a fix is working. This study investigates the information content of a large department linear accelerator incident log. Methods: Our department uses an electronic reporting system to provide immediate information to both key department staff and the field service department. This study examines reports for five linac logs during 2015. The report attributes for analysis include frequency, level of documentation, who solved the problem, and type of fix used. Results: Of the reports, 36% were documented as resolved. In another 25% the resolution allowed treatment to proceed although the reported problem recurred within days. In 5% only intermediate troubleshooting was documented. The remainder lacked documentation. In 60% of the reports, radiation therapists resolved the problem, often by clearing the appropriate faults or reinitializing a software or hardware service. 22% were resolved by physics and 10% by field service engineers. The remaining 8% were resolved by IT, Facilities, or resolved spontaneously. Typical fixes, in order of scope, included clearing the fault and moving on, closing and re-opening the patient session or software, cycling power to a sub-unit, recalibrating a device (e.g., optical surface imaging), and calling in Field Service (usually resolving the problem through maintenance or component replacement). Conclusion: The reports with undocumented resolution represent a missed opportunity for learning. Frequency of who resolves a problem scales with the proximity of the person’s role (therapist, physicist, or service engineer), which is inversely related to the permanence of the resolution. Review of lessons learned from machine incident logs can form the basis for guidance to radiation therapists and medical physicists to minimize equipment downtime and

SU-F-T-462: Lessons Learned From a Machine Incident Reporting System

Energy Technology Data Exchange (ETDEWEB)

Sutlief, S; Hoisak, J [University of California, San Diego, La Jolla, CA (United States)

2016-06-15

Purpose: Linear accelerators must operate with minimal downtime. Machine incident logs are a crucial tool to meet this requirement. They providing a history of service and demonstrate whether a fix is working. This study investigates the information content of a large department linear accelerator incident log. Methods: Our department uses an electronic reporting system to provide immediate information to both key department staff and the field service department. This study examines reports for five linac logs during 2015. The report attributes for analysis include frequency, level of documentation, who solved the problem, and type of fix used. Results: Of the reports, 36% were documented as resolved. In another 25% the resolution allowed treatment to proceed although the reported problem recurred within days. In 5% only intermediate troubleshooting was documented. The remainder lacked documentation. In 60% of the reports, radiation therapists resolved the problem, often by clearing the appropriate faults or reinitializing a software or hardware service. 22% were resolved by physics and 10% by field service engineers. The remaining 8% were resolved by IT, Facilities, or resolved spontaneously. Typical fixes, in order of scope, included clearing the fault and moving on, closing and re-opening the patient session or software, cycling power to a sub-unit, recalibrating a device (e.g., optical surface imaging), and calling in Field Service (usually resolving the problem through maintenance or component replacement). Conclusion: The reports with undocumented resolution represent a missed opportunity for learning. Frequency of who resolves a problem scales with the proximity of the person’s role (therapist, physicist, or service engineer), which is inversely related to the permanence of the resolution. Review of lessons learned from machine incident logs can form the basis for guidance to radiation therapists and medical physicists to minimize equipment downtime and

Book Review: Professional Penetration Testing: Creating and Learning in a Hacking Lab 2E

Directory of Open Access Journals (Sweden)

Joshua Bartolomie

2013-09-01

Full Text Available Wilhelm, T. (2013. Professional Penetration Testing: Creating and Learning in a Hacking Lab 2E. Waltham, MA: Syngress, 464 pages, ISBN-10: 1597499935; ISBN-13: 978-1597499934, US$79.99Reviewed by Joshua Bartolomie, CISSP, CEECS, CFCE, DFCP, CRISC, CSMOrganizations often strive for proactive information security programs in an effort to limit occurrence and impact of security breaches. However, traditional security programs run the risk of being unable to provide adequate insight and proactive awareness into real attack vectors that may exist within their organizations. With attack methods and efforts becoming increasingly aggressive, and effective, organizations must take equally assertive measures to protect their critical information and assets. Penetration testing is one of those tools that is often misunderstood, overlooked, and undervalued. A true adversary would not hesitate to exploit every potential to gain entry or cause a disruption to their target.(see PDF for full review

Analysis of general aviation single-pilot IFR incident data obtained from the NASA Aviation Safety Reporting System

Science.gov (United States)

Bergeron, H. P.

1983-01-01

An analysis of incident data obtained from the NASA Aviation Safety Reporting System (ASRS) has been made to determine the problem areas in general aviation single-pilot IFR (SPIFR) operations. The Aviation Safety Reporting System data base is a compilation of voluntary reports of incidents from any person who has observed or been involved in an occurrence which was believed to have posed a threat to flight safety. This paper examines only those reported incidents specifically related to general aviation single-pilot IFR operations. The frequency of occurrence of factors related to the incidents was the criterion used to define significant problem areas and, hence, to suggest where research is needed. The data was cataloged into one of five major problem areas: (1) controller judgment and response problems, (2) pilot judgment and response problems, (3) air traffic control (ATC) intrafacility and interfacility conflicts, (4) ATC and pilot communication problems, and (5) IFR-VFR conflicts. In addition, several points common to all or most of the problems were observed and reported. These included human error, communications, procedures and rules, and work load.

Investigación en Progreso: Método de Inclusión de Hacking Ético en el Proceso de Testing de Software

Directory of Open Access Journals (Sweden)

Ariel Giannone

2017-01-01

Full Text Available Debido al crecimiento exponencial de Internet y a que las organizaciones poseen cada vez mas información, se hace imprescindible bloquear y eliminar todas las intrusiones posibles. Gracias al hacking ético es posible detectar y corregir algunas de las vulnerabilidades antes que el sistema salga a la luz. Con el fin de mejorar este proceso se intentan incluir estas técnicas y métodos en el proceso tradicional de testing de software dentro de las organizaciones.

Investigación en Progreso: Método de Inclusión de Hacking Ético en el Proceso de Testing de Software

OpenAIRE

Ariel Giannone

2017-01-01

Debido al crecimiento exponencial de Internet y a que las organizaciones poseen cada vez mas información, se hace imprescindible bloquear y eliminar todas las intrusiones posibles. Gracias al hacking ético es posible detectar y corregir algunas de las vulnerabilidades antes que el sistema salga a la luz. Con el fin de mejorar este proceso se intentan incluir estas técnicas y métodos en el proceso tradicional de testing de software dentro de las organizaciones.

Medical students' perceptions of a novel institutional incident reporting system : A thematic analysis.

Science.gov (United States)

Gordon, Morris; Parakh, Dillan

2017-10-01

Errors in healthcare are a major patient safety issue, with incident reporting a key solution. The incident reporting system has been integrated within a new medical curriculum, encouraging medical students to take part in this key safety process. The aim of this study was to describe the system and assess how students perceived the reporting system with regards to its role in enhancing safety. Employing a thematic analysis, this study used interviews with medical students at the end of the first year. Thematic indices were developed according to the information emerging from the data. Through open, axial and then selective stages of coding, an understanding of how the system was perceived was established. Analysis of the interview specified five core themes: (1) Aims of the incident reporting system; (2) internalized cognition of the system; (3) the impact of the reporting system; (4) threshold for reporting; (5) feedback on the systems operation. Selective analysis revealed three overriding findings: lack of error awareness and error wisdom as underpinned by key theoretical constructs, student support of the principle of safety, and perceptions of a blame culture. Students did not interpret reporting as a manner to support institutional learning and safety, rather many perceived it as a tool for a blame culture. The impact reporting had on students was unexpected and may give insight into how other undergraduates and early graduates interpret such a system. Future studies should aim to produce interventions that can support a reporting culture.

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country.

Science.gov (United States)

Abbasi, Shemila; Khan, Fauzia Anis; Khan, Sobia

2018-01-01

The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

Development and test of a classification scheme for human factors in incident reports

International Nuclear Information System (INIS)

Miller, R.; Freitag, M.; Wilpert, B.

1997-01-01

The Research Center System Safety of the Berlin University of Technology conducted a research project on the analysis of Human Factors (HF) aspects in incident reported by German Nuclear Power Plants. Based on psychological theories and empirical studies a classification scheme was developed which permits the identification of human involvement in incidents. The classification scheme was applied in an epidemiological study to a selection of more than 600 HF - relevant incidents. The results allow insights into HF related problem areas. An additional study proved that the application of the classification scheme produces results which are reliable and independent from raters. (author). 13 refs, 1 fig

Improvement in the incident reporting and investigation procedures using process excellence (DMAI2C) methodology

International Nuclear Information System (INIS)

Miles, Elizabeth N.

2006-01-01

In 1996, Health and Safety introduced an incident investigation process called Learning to Look ( C) to Johnson and Johnson. This process provides a systematic way of analyzing work-related injuries and illness, uncovers root cause that leads to system defects, and points to viable solutions. The process analyzed involves three steps: investigation and reporting of the incident, determination of root cause, and development and implementation of a corrective action plan. The process requires the investigators to provide an initial communication for work-related serious injuries and illness as well as lost workday cases to Corporate Headquarters within 72h of the incident with a full investigative report to follow within 10 days. A full investigation requires a written report, a cause-result logic diagram (CRLD), a corrective action plan (CAP) and a report of incident costs (SafeCost) all due to be filed electronically. It is incumbent on the principal investigator and his or her investigative teams to assemble the various parts of the investigation and to follow up with the relevant parties to ensure corrective actions are implemented, and a full report submitted to Corporate executives. Initial review of the system revealed that the process was not working as designed. A number of reports were late, not signed by the business leaders, and in some instances, all cause were not identified. Process excellence was the process used to study the issue. The team used six sigma DMAI 2 C methodologies to identify and implement system improvements. The project examined the breakdown of the critical aspects of the reporting and investigation process that lead to system errors. This report will discuss the study findings, recommended improvements, and methods used to monitor the new improved process

[Preliminary results of an anonymous internet-based reporting system for critical incidents in ambulatory primary care].

Science.gov (United States)

Brun, A

2005-03-01

To learn from errors is not always easy, especially if they happened to others! This paper describes the organization and management of a critical incident reporting system for primary care physicians in Switzerland and reports about the difficulties and experiences during the first 18 months since the start of the program. It seems to be particularly difficult to enhance the attentiveness of physicians for apparently harmless daily critical incidents and to motivate them to report it even in an anonymous reporting system. As incentives for more intensive participation there are the hope for comments on reported cases by other participants and the expectation that reported errors will be avoided by the readers.

Radioactive Materials Packaging (RAMPAC) Radioactive Materials Incident Report (RMIR). RAMTEMP users manual

International Nuclear Information System (INIS)

Tyron-Hopko, A.K.; Driscoll, K.L.

1985-10-01

The purpose of this document is to familiarize the potential user with RadioActive Materials PACkaging (RAMPAC), Radioactive Materials Incident Report (RMIR), and RAMTEMP databases. RAMTEMP is a minor image of RAMPAC. This reference document will enable the user to access and obtain reports from databases while in an interactive mode. This manual will be revised as necessary to reflect enhancements made to the system

Incident reporting culture: scale development with validation and reliability and assessment of hospital nurses in Taiwan.

Science.gov (United States)

Chiang, Hui-Ying; Hsiao, Ya-Chu; Lin, Shu-Yuan; Lee, Huan-Fang

2011-08-01

To examine the psychometric validity and reliability of the incident reporting culture questionnaire (IRCQ; in Chinese) following an exploration of the reporting culture perceived by hospital nurses in Taiwan. Scale development with psychometric examination and a cross-sectional study. Ten teaching hospitals. A total of 1064 nurses participated with an average response rate of 83% between November 2008 and June 2009. The factorial construct, criterion-related validity, homogeneity and stability of the IRCQ were evaluated. The nurses' perceptions of the IRCQ were also explored. The four-factor structure of the 20-item IRCQ had satisfactory construct validity (explained variance: 49.37%), criterion-related validity (r = 0.42; P = 0.001), reliability (Cronbach's alpha: 0.83) and stability (3-week-interval correlation: r = 0.80; P = 0.001). These factors included 'application of learning from errors', 'readiness to provide feedback on incident reports', 'collegial atmospheres of unpleasantness and punishment' (CA) and 'incident management: confidential and system driven'. The nurses perceived a moderate overall reporting culture (mean positive response = 49.25%; range: 67.2-24.94%). They weakly agreed on the CA factor of five items (mean positive response = 24.94%; range: 33.0-17.2%). This study provides empirical evidence for the psychometric properties of the IRCQ and the reporting culture which nurses perceive in Taiwan. To Taiwanese nurses, the reporting culture within their work environments especially as it relates to coworker relations, inter-professional collaboration and non-punitive atmosphere is their major concern. Healthcare administrators should consider nurses' perceptions related to incident reporting when managing underreporting issues.

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

Science.gov (United States)

Sahlström, Merja; Partanen, Pirjo; Turunen, Hannele

2018-04-16

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

Lessons for pediatric anesthesia from audit and incident reporting.

Science.gov (United States)

Bell, Graham

2011-07-01

This review will attempt to put the various systems that allow clinicians to assess errors, omissions, or avoidable incidents into context and where possible, look for areas that deserve more or less attention and resource specifically for those of us who practice pediatric anesthesia. Different approaches will be contrasted with respect to their outputs in terms of positive impact on the practice of anesthesia. These approaches include audits by governmental organizations, national representative bodies, specialist societies, commissioned boards of inquiry, medicolegal sources, and police force investigations. Implementation strategies are considered alongside the reports as the reports cannot be considered end points themselves. Specific areas where pediatric anesthetics has failed to address recurring risk through any currently available tools will be highlighted. © 2011 Blackwell Publishing Ltd.

SU-E-T-469: Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

International Nuclear Information System (INIS)

Kapoor, R; Palta, J; Hagan, M; Malik, G

2015-01-01

Purpose: This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process. Results: Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of �

SU-E-T-469: Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

Energy Technology Data Exchange (ETDEWEB)

Kapoor, R; Palta, J; Hagan, M [Veteran Health Administration, Richmond, Virginia (United States); Virginia Commonwealth University, Richmond, VA (United States); Malik, G [TSG Innovations Inc. (United States)

2015-06-15

Purpose: This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process. Results: Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of �

Pharmacovigilance in oncology: pattern of spontaneous notifications, incidence of adverse drug reactions and under-reporting

Directory of Open Access Journals (Sweden)

Marília Berlofa Visacri

2014-04-01

Full Text Available The high toxicity and narrow therapeutic window of antineoplastic agents makes pharmacovigilance studies essential in oncology. The objectives of the current study were to analyze the pattern of spontaneous notifications of adverse drug reactions (ADRs in oncology patients and to analyze the incidence of ADRs reported by outpatients on antineoplastic treatment in a tertiary care teaching hospital. To compose the pattern of ADR, the notification forms of reactions in oncology patients in 2010 were reviewed, and the reactions were classified based on the drug involved, mechanism, causality, and severity. To evaluate the incidence of reactions, a questionnaire at the time of chemotherapy was included, and the severity was classified based on the Common Terminology Criteria. The profiles of the 10 responses reported to the Pharmacovigilance Sector were type B, severe, possible, and they were primarily related to platinum compounds and taxanes. When the incidence of reactions was analyzed, it was observed that nausea, alopecia, fatigue, diarrhea, and taste disturbance were the most frequently reported reactions by oncology patients, and the grade 3 and 4 reactions were not reported. Based on this analysis, it is proposed that health professionals should be trained regarding notifications and clinical pharmacists should increasingly be brought on board to reduce under-reporting of ADRs.

Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review.

Science.gov (United States)

Polisena, Julie; Gagliardi, Anna; Urbach, David; Clifford, Tammy; Fiander, Michelle

2015-03-29

Medical devices have improved the treatment of many medical conditions. Despite their benefit, the use of devices can lead to unintended incidents, potentially resulting in unnecessary harm, injury or complications to the patient, a complaint, loss or damage. Devices are used in hospitals on a routine basis. Research to date, however, has been primarily limited to describing incidents rates, so the optimal design of a hospital-based surveillance system remains unclear. Our research objectives were twofold: i) to explore factors that influence device-related incident recognition, reporting and resolution and ii) to investigate interventions or strategies to improve the recognition, reporting and resolution of medical device-related incidents. We searched the bibliographic databases: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and PsycINFO database. Grey literature (literature that is not commercially available) was searched for studies on factors that influence incident recognition, reporting and resolution published and interventions or strategies for their improvement from 2003 to 2014. Although we focused on medical devices, other health technologies were eligible for inclusion. Thirty studies were included in our systematic review, but most studies were concentrated on other health technologies. The study findings indicate that fear of punishment, uncertainty of what should be reported and how incident reports will be used and time constraints to incident reporting are common barriers to incident recognition and reporting. Relevant studies on the resolution of medical errors were not found. Strategies to improve error reporting include the use of an electronic error reporting system, increased training and feedback to frontline clinicians about the reported error. The available evidence on factors influencing medical device-related incident recognition, reporting and resolution by healthcare professionals can inform data collection and

Radiological incidents in radiotherapy

International Nuclear Information System (INIS)

Hobzova, L.; Novotny, J.

2008-01-01

In many countries a reporting system of radiological incidents to national regulatory body exists and providers of radiotherapy treatment are obliged to report all major and/or in some countries all incidents occurring in institution. State Office for Nuclear Safety (SONS) is providing a systematic guidance for radiotherapy departments from 1997 by requiring inclusion of radiation safety problems into Quality assurance manual, which is the basic document for obtaining a license of SONS for handling with sources of ionizing radiation. For that purpose SONS also issued the recommendation 'Introduction of QA system for important sources in radiotherapy-radiological incidents' in which the radiological incidents are defined and the basic guidance for their classification (category A, B, C, D), investigation and reporting are given. At regular periods the SONS in co-operation with radiotherapy centers is making a survey of all radiological incidents occurring in institutions and it is presenting obtained information in synoptic communication (2003 Motolske dny, 2005 Novy Jicin). This presentation is another summary report of radiological incidents that occurred in our radiotherapy institutions during last 3 years. Emphasis is given not only to survey and statistics, but also to analysis of reasons of the radiological incidents and to their detection and prevention. Analyses of incidents in radiotherapy have led to a much broader understanding of incident causation. Information about the error should be shared as early as possible during or after investigation by all radiotherapy centers. Learning from incidents, errors and near misses should be a part of improvement of the QA system in institutions. Generally, it is recommended that all radiotherapy facilities should participate in the reporting, analyzing and learning system to facilitate the dissemination of knowledge throughout the whole country to prevent errors in radiotherapy.(authors)

Department of Veterans Affairs - Monthly Report to Congress of Data Incidents (April 2014)

Data.gov (United States)

Department of Veterans Affairs — This is a monthly report that the VA Office of Information Technology provides to congress about data incidents that took place during the month (April 2014). The...

Hacking for astronomy: can 3D printers and open-hardware enable low-cost sub-/millimeter instrumentation?

Science.gov (United States)

Ferkinhoff, Carl

2014-07-01

There have been several exciting developments in the technologies commonly used n in the hardware hacking community. Advances in low cost additive-manufacturing processes (i.e. 3D-printers) and the development of openhardware projects, which have produced inexpensive and easily programmable micro-controllers and micro-computers (i.e. Arduino and Raspberry Pi) have opened a new door for individuals seeking to make their own devices. Here we describe the potential for these technologies to reduce costs in construction and development of submillimeter/millimeter astronomical instrumentation. Specifically we have begun a program to measure the optical properties of the custom plastics used in 3D-printers as well as the printer accuracy and resolution to assess the feasibility of directly printing sub- /millimeter transmissive optics. We will also discuss low cost designs for cryogenic temperature measurement and control utilizing Arduino and Raspberry Pi.

APLICAÇÃO DO ÍNDICE DE HACK (SL A UM TRECHO DO RIO ZÊZERE, PORTUGAL

Directory of Open Access Journals (Sweden)

Daniel Vieira Souza

2011-11-01

Full Text Available Os perfis longitudinais de rios são sensíveis a movimentações tectônicas causando alterações no nível de base. Devido a isto, verifica-se incisão fluvial a montante de compartimentos abatidos e agradação a jusante de compartimentos levantados. Os canais fl uviais são dinâmicos e se modificam através da incisão e da agradação periódicas, o estudo destes processos reveste-se de grande importância na compreensão das alterações do relevo. A formação de vales encaixados com perfis típicos em V, ou o aparecimento de trechos de agradação pode ter origem em causas tectônicas, ou outras. Hack (1973 propôs um índice (stream-gradient index para detectar estas alterações em cursos fluviais, decorrentes de mudanças no substrato geológico, aporte de carga, ou tectonismo. O stream-gradient index, ou simplesmente índice SL, relação declive (slope vs. comprimento do curso (length. O presente trabalho objetiva identificar rupturas de declive, num trecho do rio Zêzere, afluente do rio Tejo. O rio Zêzere corre num vale encaixado no interior da Cordilheira Central Portuguesa. Para identificar as roturas de declive utilizou-se o perfil longitudinal, índice de Hack, SL (slope VS. Lenght. Como resultado foi possível detectar locais onde sofreram abatimentos tectônicos, principalmente entre Pedrógão e Bogas de Baixo, foi possível também observar a influência de processos de erosão diferencial e de soleiras Quartzíticas de Farjão a Sarzedas na regularização dos processos tectônicos a montante daqueles níveis de base locais.

What Caused the Breach? An Examination of Use of Information Technology and Health Data Breaches

Science.gov (United States)

Wikina, Suanu Bliss

2014-01-01

Data breaches arising from theft, loss, unauthorized access/disclosure, improper disclosure, or hacking incidents involving personal health information continue to increase every year. As of September 2013, reported breaches affecting individuals reached close to 27 million since 2009, when compilation of records on breaches began. These breaches, which involved 674 covered entities and 153 business associates, involved computer systems and networks, desktop computers, laptops, paper, e-mail, electronic health records, and removable/portable devices (CDs, USBs, x-ray films, backup tapes, etc.). Even with the increased use of health information technology by health institutions and allied businesses, theft and loss (not hacking) constitute the major types of data breaches encountered. Removable/portable devices, desktop computers, and laptops were the top sources or locations of the breached information, while the top six states—Virginia, Illinois, California, Florida, New York, and Tennessee—in terms of the number of reported breaches accounted for nearly 75 percent of the total individual breaches, 33 percent of breaches in covered entities, and about 30 percent of the total breaches involving business associates. PMID:25593574

What caused the breach? An examination of use of information technology and health data breaches.

Science.gov (United States)

Wikina, Suanu Bliss

2014-01-01

Data breaches arising from theft, loss, unauthorized access/disclosure, improper disclosure, or hacking incidents involving personal health information continue to increase every year. As of September 2013, reported breaches affecting individuals reached close to 27 million since 2009, when compilation of records on breaches began. These breaches, which involved 674 covered entities and 153 business associates, involved computer systems and networks, desktop computers, laptops, paper, e-mail, electronic health records, and removable/portable devices (CDs, USBs, x-ray films, backup tapes, etc.). Even with the increased use of health information technology by health institutions and allied businesses, theft and loss (not hacking) constitute the major types of data breaches encountered. Removable/portable devices, desktop computers, and laptops were the top sources or locations of the breached information, while the top six states-Virginia, Illinois, California, Florida, New York, and Tennessee-in terms of the number of reported breaches accounted for nearly 75 percent of the total individual breaches, 33 percent of breaches in covered entities, and about 30 percent of the total breaches involving business associates.

Systemizers Are Better Code-Breakers: Self-Reported Systemizing Predicts Code-Breaking Performance in Expert Hackers and Na?ve Participants

OpenAIRE

Harvey, India; Bolgan, Samuela; Mosca, Daniel; McLean, Colin; Rusconi, Elena

2016-01-01

Studies on hacking have typically focused on motivational aspects and general personality traits of the individuals who engage in hacking; little systematic research has been conducted on predispositions that may be associated not only with the choice to pursue a hacking career but also with performance in either naïve or expert populations. Here, we test the hypotheses that two traits that are typically enhanced in autism spectrum disorders—attention to detail and systemizing—may be positive...

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

Science.gov (United States)

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

2017-01-01

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

40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

Science.gov (United States)

2010-07-01

... 40 Protection of Environment 32 2010-07-01 2010-07-01 false Published reports and material... Published reports and material contained in the public incident investigation dockets. (a) Demands for published investigation reports should be directed to the Office of Congressional and Public Affairs, U.S...

Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data.

Science.gov (United States)

Ferroli, Paolo; Caldiroli, Dario; Acerbi, Francesco; Scholtze, Maurizio; Piro, Alfonso; Schiariti, Marco; Orena, Eleonora F; Castiglione, Melina; Broggi, Morgan; Perin, Alessandro; DiMeco, Francesco

2012-11-01

Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within

Morpho-anatomical structure of the leaves of Festuca trachyphylla (Hack. Krajina in the ecological aspect

Directory of Open Access Journals (Sweden)

Agnieszka Dąbrowska

2012-03-01

Full Text Available Festuca trachyphylla(Hack. Krajina is a morphologically variable species common in warm and dry habitats in various communities: xerothermic grasslands, dry meadows, sand dunes, scrub and well-lighted forest. The aim of this study was to determine the limits of morphological and anatomical trait variability of F. rachyphylla leaves. The study was conducted in 24 sub-populations (N-432 individuals in the Lublin Upland, southeastern Poland. Plants in two localities were investigated: in calcium carbonate-rich xerothermic grasslands and on sand dunes. Variability of the F. trachyphylla leaf blades was demonstrated to be dependent on thehabitat type. The following morphological and anatomical traits: the length of the leaf, width of the cauline leaf, number of ribs in theleaf, length of the cauline leaf, length of hair in the leaf, colour of the leaf, hairiness of the upper part leaf, cross-section of the leaf, and distribution of the sclerenchymatous tissue in the leaf blade exhibited high variability.

77 FR 53779 - Reports by Air Carriers on Incidents Involving Animals During Air Transport

Science.gov (United States)

2012-09-04

... Involving Animals During Air Transport AGENCY: Office of the Secretary (OST), Department of Transportation... period of an NPRM on the reporting of incidents involving animals during air transport that was published... animal during air transport. The NPRM proposed to: (1) Expand the reporting requirement to U.S. carriers...

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.

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

Science.gov (United States)

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

2018-06-01

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

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

Science.gov (United States)

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

2017-12-27

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

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

Science.gov (United States)

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

2016-06-01

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

78 FR 38803 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

Science.gov (United States)

2013-06-27

... Reports for Gas Pipeline Operators AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... (OMB) Control No. 2137-0522, titled ``Incident and Annual Reports for Gas Pipeline Operators.'' PHMSA...

Reproductive hacking. A male seminal protein acts through intact reproductive pathways in female Drosophila.

Science.gov (United States)

Rubinstein, C Dustin; Wolfner, Mariana F

2014-01-01

Seminal proteins are critical for reproductive success in all animals that have been studied. Although seminal proteins have been identified in many taxa, and female reproductive responses to receipt of these proteins have been documented in several, little is understood about the mechanisms by which seminal proteins affect female reproductive physiology. To explore this topic, we investigated how a Drosophila seminal protein, ovulin, increases ovulation rate in mated females. Ovulation is a relatively simple physiological process, with known female regulators: previous studies have shown that ovulation rate is promoted by the neuromodulator octopamine (OA) in D. melanogaster and other insects. We found that ovulin stimulates ovulation by increasing OA signaling in the female. This finding supports a model in which a male seminal protein acts through "hacking" a well-conserved, regulatory system females use to adjust reproductive output, rather than acting downstream of female mechanisms of control or in parallel pathways altogether. We also discuss similarities between 2 forms of intersexual control of behavior through chemical communication: seminal proteins and pheromones.

Poster - 27: Incident Learning Practices in Ontario

Energy Technology Data Exchange (ETDEWEB)

Angers, Crystal; Medlam, Gaylene; Liszewski, Brian; Simniceanu, Carina [The Ottawa Hospital Cancer Centre, Mississauga Halton/Central West Regional Cancer Center, Odette Cancer Centre, Cancer Care Ontario (Canada)

2016-08-15

Purpose: The Radiation Incident and Safety Committee (RISC), established and supported by Cancer Care Ontario (CCO), is responsible for advising the Provincial Head of the Radiation Treatment program on matters relating to provincial reporting of radiation incidents with the goal of improved risk mitigation. Methods: The committee is made up of Radiation Incident Leads (RILs) with representation from each of the 14 radiation medicine programs in the province. RISC routinely meets to review recent critical incidents and to discuss provincial reporting processes and future directions of the committee. Regular face to face meetings have provided an excellent venue for sharing incident learning practices. A summary of the incident learning practices across Ontario has been compiled. Results: Almost all programs in Ontario employ an incident learning committee to review incidents and identify corrective actions or process improvements. Tools used for incident reporting include: paper based reporting, a number of different commercial products and software solutions developed in-house. A wide range of classification schema (data taxonomies) are employed, although most have been influenced by national guidance documents. The majority of clinics perform root cause analyses but utilized methodologies vary significantly. Conclusions: Most programs in Ontario employ a committee approach to incident learning. However, the reporting tools and taxonomies in use vary greatly which represents a significant challenge to provincial reporting. RISC is preparing to adopt the National System for Incident Reporting – Radiation Therapy (NSIR-RT) which will standardize incident reporting and facilitate data analyses aimed at identifying targeted improvement initiatives.

Poster - 27: Incident Learning Practices in Ontario

International Nuclear Information System (INIS)

Angers, Crystal; Medlam, Gaylene; Liszewski, Brian; Simniceanu, Carina

2016-01-01

Purpose: The Radiation Incident and Safety Committee (RISC), established and supported by Cancer Care Ontario (CCO), is responsible for advising the Provincial Head of the Radiation Treatment program on matters relating to provincial reporting of radiation incidents with the goal of improved risk mitigation. Methods: The committee is made up of Radiation Incident Leads (RILs) with representation from each of the 14 radiation medicine programs in the province. RISC routinely meets to review recent critical incidents and to discuss provincial reporting processes and future directions of the committee. Regular face to face meetings have provided an excellent venue for sharing incident learning practices. A summary of the incident learning practices across Ontario has been compiled. Results: Almost all programs in Ontario employ an incident learning committee to review incidents and identify corrective actions or process improvements. Tools used for incident reporting include: paper based reporting, a number of different commercial products and software solutions developed in-house. A wide range of classification schema (data taxonomies) are employed, although most have been influenced by national guidance documents. The majority of clinics perform root cause analyses but utilized methodologies vary significantly. Conclusions: Most programs in Ontario employ a committee approach to incident learning. However, the reporting tools and taxonomies in use vary greatly which represents a significant challenge to provincial reporting. RISC is preparing to adopt the National System for Incident Reporting – Radiation Therapy (NSIR-RT) which will standardize incident reporting and facilitate data analyses aimed at identifying targeted improvement initiatives.

6. Analisis Implementasi Cyber Security Di Uni Eropa: Studi Kasus Carbon Credits Hacking Dalam European Union Emission Trading Scheme (EU ETS) Tahun 2010-2013

OpenAIRE

Aisya, Naila Sukma; Putranti, Ika Riswanti; Wahyudi, Fendy Eko

2017-01-01

Since the last two decades in the 20th century, the European Union (EU) has presented itself as a leader in climate change issues. The leadership manifested in the formation of the European Union Emission Trading Scheme (EU ETS) as an effort to fulfill the commitments of the Kyoto Protocol to reduce emissions in the region. But the existence of the EU ETS has been challenged by the emergence of carbon credits hacking case in some national registration systems in the EU ETS. This study discuss...

Wheelchair incidents

NARCIS (Netherlands)

Drongelen AW van; Roszek B; Hilbers-Modderman ESM; Kallewaard M; Wassenaar C; LGM

2002-01-01

This RIVM study was performed to gain insight into wheelchair-related incidents with powered and manual wheelchairs reported to the USA FDA, the British MDA and the Dutch Center for Quality and Usability Research of Technical Aids (KBOH). The data in the databases do not indicate that incidents with

Bangladesh Bank Heist

OpenAIRE

Md Ahsan Habib

2017-01-01

Cyber crime is a threat to our E- commerce . A hacker group named "Lazarus" hacked $951 million from Bangladesh Bank's account. This is the short case study of this incident with professional ethical view.

14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

Science.gov (United States)

2010-01-01

... involving animals during air transport. 234.13 Section 234.13 Aeronautics and Space OFFICE OF THE SECRETARY... REPORTS § 234.13 Reports by air carriers on incidents involving animals during air transport. (a) Any air... during air transport provided by the air carrier. (b) The report shall be made in the form and manner set...

Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study.

Science.gov (United States)

Seclen, Segundo Nicolas; Rosas, Moises Ernesto; Arias, Arturo Jaime; Medina, Cecilia Alexandra

2017-01-01

A recent report from a non-nationally representative, geographically diverse sample in four separate communities in Peru suggests an unusually high diabetes incidence. We aimed to estimate the national diabetes incidence rate using PERUDIAB, a probabilistic, national urban population-based longitudinal study. 662 subjects without diabetes, selected by multistage, cluster, random sampling of households, representing the 24 administrative and the 3 (coast, highlands and jungle) natural regions across the country, from both sexes, aged 25+ years at baseline, enrolled in 2010-2012, were followed for 3.8 years. New diabetes cases were defined as fasting blood glucose ≥126 mg/dL or on medical diabetes treatment. There were 49 cases of diabetes in 2408 person-years follow-up. The weighted cumulative incidence of diabetes was 7.2% while the weighted incidence rate was estimated at 19.5 (95% CI 13.9 to 28.3) new cases per 1000 person-years. Older age, obesity and technical or higher education were statistically associated with the incidence of diabetes. Our results confirm that the incidence of diabetes in Peru is among the highest reported globally. The fast economic growth in the last 20 years, high overweight and obesity rates may have triggered this phenomenon.

77 FR 36008 - Agency Information Collection Activities; Proposed Collection: Cargo Theft Incident Report...

Science.gov (United States)

2012-06-15

... Collection Activities; Proposed Collection: Cargo Theft Incident Report, Revision of a Currently Approved... collection: Revision of a currently approved collection. (2) The title of the form/collection: Cargo Theft... enforcement agencies. Brief Abstract: This collection is needed to collect information on cargo theft...

Brief Report: Incidence of and Risk Factors for Autistic Disorder in Neonatal Intensive Care Unit Survivors.

Science.gov (United States)

Matsuishi, Toyojiro; Yamashita, Yushiro; Ohtani, Yasuyo; Ornitz, Edward; Kuriya, Norikazu; Murakami, Yoshihiko; Fukuda, Seiichi; Hashimoto, Takeo; Yamashita, Fumio

1999-01-01

Analysis of the incidence of autistic disorder (AD) among 5,271 children in a neonatal intensive care unit in Japan found that 18 children were later diagnosed with AD, an incidence more than twice as high as previously reported. Children with AD had a significantly higher history of the meconium aspiration syndrome than the controls. (Author/DB)

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

Science.gov (United States)

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.

The Incidence of Needlestick Injuries During Perineorrhaphy and Attitudes Toward Occurrence Reports Among Medical Students

Directory of Open Access Journals (Sweden)

Nalinee Panichyawat

2016-07-01

Full Text Available Background: Medical students are at risk of needlestick injuries (NSIs while performing obstetrical procedures especially perineorrhaphy, because of their less experience. This study aims to determine the incidence and causes of NSIs during perineorrhaphy and medical students’ attitudes toward occurrence reports. Methods: A cross-sectional study was conducted. After completion of Obstetrics & Gynaecology rotation, the data from final year medical students were collected using a self-administered questionnaire. Results: Of 390 medical students, 290 (74.4% returned questionnaires with complete data. The annual NSIs incidence during perineorrhaphy was 26.9%. The most common site of injury was the index finger of the non- dominant hand (66.2%. Common causes of NSIs were time pressure (52.1% and lack of surgical skills (50.7%. Nearly half of students (41% did not report their occurrence, and 81.3% of injured students believed that NSIs were harmless. Conclusion: The incidence of NSIs during perineorrhaphy and the non-reporting occurrence were quite high among medical students. Structural clinical supervision by medical staffs, HBV vaccination for all medical students, and instruction on standard pre-exposure precaution should be applied. We advocate a strategy plan for increasing students’ awareness and having a simple occurrence reporting system for NSIs, with clear guidelines on post-exposure protocols in all medical schools and teaching hospitals.

Critical incidents and mortality reporting in pediatric anesthesia: the Australian experience.

Science.gov (United States)

Ragg, Philip

2011-07-01

Since 1960, the collection and analysis of mortality data for anesthesia in Australia has been of significant benefit to practising anesthetists. These figures include pediatric deaths which fortunately have been rare and often inevitable because of severe underlying disease and patient risk factors. The reporting of critical incidents and serious morbidity, on the other hand, has been far less impressive. Only one state in Australia, Victoria, currently has a committee that collects morbidity data and, as this reporting is voluntary, is likely to under-represent the true numbers of critical events. There is no specific pediatric morbidity database in Australia so much of this discussion will be regarding overall anesthesia critical event reporting which includes pediatrics as a subset. © 2011 Blackwell Publishing Ltd.

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

Directory of Open Access Journals (Sweden)

Armitage Gerry

2011-05-01

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

Change in Reported Lyme Disease Incidence in the Northeast and Upper Midwest, 1991-2014

Data.gov (United States)

U.S. Environmental Protection Agency — This indicator shows how reported Lyme disease incidence has changed by state since 1991, based on the number of new cases per 100,000 people. The total change has...

Sensationalization of reports of the Kashiwazaki-Kariwa nuclear power plant incident. A search for top stories in Japanese newspapers

International Nuclear Information System (INIS)

Nakajima, Tatsuo

2009-01-01

The purpose of this study is to clarify whether reports of nuclear accidents, particularly the damage done by the 2007 Niigata-ken Chuetsu-Oki earthquake to the Kashiwazaki-Kariwa nuclear power plant in Niigata, Japan, tend to be exaggerated by national media. News related to the Kashiwazaki incident was compared with that for nine other high-profile accidents in Japan, including the 1999 JCO critical accident and the 2005 JR-West Fukuchiyama Line derailment. Articles were extracted from four national newspapers in Japan, focusing on the 30 issues immediately following each accident. The numbers of articles and top stories related to the relevant accidents appearing on the front pages of the newspapers were counted. Based on these numbers, the Kashiwazaki incident was reported at a level similar to the JCO accident and Fukuchiyama line derailment in some newspapers, although these two accidents were more serious than the Kashiwazaki incident. This suggests that at least some newspapers in Japan sensationalized reports of the Kashiwazaki incident. (author)

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

Incidence and pattern of 12 years of reported transfusion adverse events in Zimbabwe: A retrospective analysis

NARCIS (Netherlands)

Mafirakureva, Nyashadzaishe; Khoza, Star; Mvere, David A.; Chitiyo, McLeod E.; Postma, Maarten J.; Van Hulst, Marinus

2014-01-01

Background. Haemovigilance hinges on a systematically structured reporting system, which unfortunately does not always exist in resource-limited settings. We determined the incidence and pattern of transfusion-related adverse events reported to the National Blood Service Zimbabwe. Materials and

Characteristics of bias-based harassment incidents reported by a national sample of U.S. adolescents.

Science.gov (United States)

Jones, Lisa M; Mitchell, Kimberly J; Turner, Heather A; Ybarra, Michele L

2018-06-01

Using a national sample of youth from the U.S., this paper examines incidents of bias-based harassment by peers that include language about victims' perceived sexual orientation, race/ethnicity, religion, weight or height, or intelligence. Telephone interviews were conducted with youth who were 10-20 years old (n = 791). One in six youth (17%) reported at least one experience with bias-based harassment in the past year. Bias language was a part of over half (52%) of all harassment incidents experienced by youth. Perpetrators of bias-based harassment were similar demographically to perpetrators of non-biased harassment. However, bias-based incidents were more likely to involve multiple perpetrators, longer timeframes and multiple harassment episodes. Even controlling for these related characteristics, the use of bias language in incidents of peer harassment resulted in significantly greater odds that youth felt sad as a result of the victimization, skipped school, avoided school activities, and lost friends, compared to non-biased harassment incidents. Copyright © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Cyber Incidents Involving Control Systems

Energy Technology Data Exchange (ETDEWEB)

Robert J. Turk

2005-10-01

The Analysis Function of the US-CERT Control Systems Security Center (CSSC) at the Idaho National Laboratory (INL) has prepared this report to document cyber security incidents for use by the CSSC. The description and analysis of incidents reported herein support three CSSC tasks: establishing a business case; increasing security awareness and private and corporate participation related to enhanced cyber security of control systems; and providing informational material to support model development and prioritize activities for CSSC. The stated mission of CSSC is to reduce vulnerability of critical infrastructure to cyber attack on control systems. As stated in the Incident Management Tool Requirements (August 2005) ''Vulnerability reduction is promoted by risk analysis that tracks actual risk, emphasizes high risk, determines risk reduction as a function of countermeasures, tracks increase of risk due to external influence, and measures success of the vulnerability reduction program''. Process control and Supervisory Control and Data Acquisition (SCADA) systems, with their reliance on proprietary networks and hardware, have long been considered immune to the network attacks that have wreaked so much havoc on corporate information systems. New research indicates this confidence is misplaced--the move to open standards such as Ethernet, Transmission Control Protocol/Internet Protocol, and Web technologies is allowing hackers to take advantage of the control industry's unawareness. Much of the available information about cyber incidents represents a characterization as opposed to an analysis of events. The lack of good analyses reflects an overall weakness in reporting requirements as well as the fact that to date there have been very few serious cyber attacks on control systems. Most companies prefer not to share cyber attack incident data because of potential financial repercussions. Uniform reporting requirements will do much to make this

Department of Defense Information Network (DODIN): A Study of Current Cyber Threats and Best Practices for Network Security

Science.gov (United States)

2016-06-10

DODIN) is being threatened by state actors, non-state actors, and continuous hacking and cyber-attacks. These threats against the network come in a...variety of forms; physical attacks from radio jamming, logical cyber threats from hacking , or a combination of both physical and logical attacks. Each...year the number of hacking attacks is increasing. Corporations like Symantec publish annual reports on cyber threats and provide tips for best

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

Directory of Open Access Journals (Sweden)

van der Wal Gerrit

2011-02-01

Full Text Available Abstract Background Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review. Methods We conducted a retrospective study using a database from a record review study of 5375 patient records in 14 hospitals in the Netherlands. Trained nurses and physicians using a method based on the protocol of The Harvard Medical Practice Study previously reviewed the records. Four reporting systems were linked with the database of reviewed records: 1 informal and 2 formal complaints by patients/relatives, 3 medico-legal claims by patients/relatives and 4 incident reports by healthcare professionals. For each adverse event identified in patient records the equivalent was sought in these reporting systems by comparing dates and descriptions of the events. The study focussed on the number of adverse event matches, overlap of adverse events detected by different sources, preventability and severity of consequences of reported and non-reported events and sensitivity and specificity of reports. Results In the sample of 5375 patient records, 498 adverse events were identified. Only 18 of the 498 (3.6% adverse events identified by record review were found in one or more of the four reporting systems. There was some overlap: one adverse event had an equivalent in both a complaint and incident report and in three cases a patient/relative used two or three systems to complain about an adverse event. Healthcare professionals

In-depth analysis of the causal factors of incidents reported in the Greek petrochemical industry

Energy Technology Data Exchange (ETDEWEB)

Konstandinidou, Myrto [Institute of Nuclear Technology-Radiation Protection, National Center for Scientific Research ' Demokritos' , Aghia Paraskevi 15310 (Greece); Nivolianitou, Zoe, E-mail: zoe@ipta.demokritos.gr [Institute of Nuclear Technology-Radiation Protection, National Center for Scientific Research ' Demokritos' , Aghia Paraskevi 15310 (Greece); Kefalogianni, Eirini; Caroni, Chrys [School of Applied Mathematical and Physical Sciences, National Technical University of Athens, 9 Iroon Polytexneiou Str., Zografou Campus, 157 80 Athens (Greece)

2011-11-15

This paper presents a statistical analysis of all reported incidents in the Greek petrochemical industry from 1997 to 2003. A comprehensive database has been developed to include industrial accidents (fires, explosions and substance releases), occupational accidents, incidents without significant consequences and near misses. The study concentrates on identifying and analyzing the causal factors related to different consequences of incidents, in particular, injury, absence from work and material damage. Methods of analysis include logistic regression with one of these consequences as dependent variable. The causal factors that are considered cover four major categories related to organizational issues, equipment malfunctions, human errors (of commission or omission) and external causes. Further analyses aim to confirm the value of recording near misses by comparing their causal factors with those of more serious incidents. The statistical analysis highlights the connection between the human factor and the underlying causes of accidents or incidents. - Highlights: > The research work is original, based on field data collected directly from the petrochemical industry. > It deals with the in-depth statistical analysis of accident data on human-organizational causes. > It researches underlying causes of accidents and the parameters affecting them. > The causal factors that are considered cover four big taxonomies. > Near misses are worth recording for comparing their causal factors with more serious incidents.

Cumulative incidence of postoperative severe pain at Hospital Universitario San Jose, Popayan. Preliminar report

Directory of Open Access Journals (Sweden)

Ingrid Muñoz

2013-12-01

Full Text Available Introduction: Postoperative pain remains as a problem. National studies report incidences of 31% for moderate and 22% for severe pain. Inadequate analgesia is related to dissatisfaction and adverse outcomes. The aim of this study was to describe the incidence and characteristics of the postoperative pain in the post-anesthesia care unit (PACU at Hospital Universitario San José of Popayán (HUSJ in patients undergoing general anesthesia during the first postoperative hour. Methods: Cohort study. We recruited patients attending PACU and undergoing procedures using general anesthesia, between 18 and 70 years. Using a standardized collection form medical history, demographic data, medical history, anesthetic management, intraoperative analgesia and postoperative pain assessment by verbal and numerical pain scale (1-10 were recorded. Postoperative outcome data were also collected in the PACU. Results: The incidence of severe postoperative pain at 10 minutes was 12.3% 95%CI [7.1-18.2] (19 patients. Within 30 minutes of assessment 4.5% 95%CI [1.3-8.4] (7 patients and 1.9% 60 minutes 95%CI [0-4.5] (3 patients. 48.7% required rescue analgesic at PACU. Incidence of postoperative nausea and vomiting (PONV was significantly different in patients requiring rescue analgesic. Conclusion: The incidence of severe postoperative pain in the first postoperative hour at HUSJ is close to 12% and it decreases as time goes by. Patients requiring rescue analgesic have a higher incidence of postoperative complications such as PONV.

Nuclear power plant operating experiences from the IAEA/NEA Incident Reporting System 1999-2002

International Nuclear Information System (INIS)

2003-01-01

Incident reporting has become an increasingly important aspect of the operation and regulation of all public health and safety-related industries. Diverse industries such as aeronautics, chemicals, pharmaceuticals and explosives all depend on operating experience feedback to provide lessons learned about safety. The Incident Reporting System (IRS) is an essential element of the system for feeding back international operating experience for nuclear power plants. IRS reports contain information on events of Safety significance with important lessons learned. These experiences assist in reducing or eliminating recurrence of events at other plants. The IRS is jointly operated and managed by the Nuclear Energy Agency (NEA), a semi-autonomous body within the Organisation for Economic Co-operation and Development (OECD), and the International Atomic Energy Agency (IAEA). It is important that sufficient national resources be allocated to enable timely and high quality reporting of events important to safety, and to share these events in the IRS database. The first report, which covered the period July 1996 - June 1999, was widely acclaimed and encouraged both agencies to prepare this second report in order to highlight important lessons learned from around 300 events reported to the IRS for the period July 1999 - December 2002. Several areas were selected in this report to show the range of important topics available in the IRS. These include different types of failure in a variety of plant systems, as well as human performance considerations. This report is primarily aimed at senior officials in industry and government who have decision-making roles in the nuclear power industry

Application examples of the reports of the NEA Incident Reporting System of the OECD and evolution of the system

International Nuclear Information System (INIS)

Libmann, J.

1989-06-01

Some reports of the work group no. 1 of the Nuclear Installations Security Committee of NEA, are summarized. An example of the report coding system concerning human factors, is given. The aim of the study is to improve the report contents as well as the coding system. In this case, a fast data selection is possible, and allows an efficient analysis of a particular situation. Moreover, the corrective procedures of the nuclear installation conception or operation can be easily modified, by the national organisations. Due to the improvements in quality, the opinion of the member countries on the incident reporting systems efficiency was enhanced [fr

Report: Improvements Needed in CSB’s Identity and Access Management and Incident Response Security Functions

Science.gov (United States)

Report #18-P-0030, October 30, 2017. Weaknesses in the Identity and Access Management and Incident Response metric domains leave the CSB vulnerable to attacks occurring and not being detected in a timely manner.

A preliminary analysis of incident investigation reports of an integrated steel plant: some reflection.

Science.gov (United States)

Verma, A; Maiti, J; Gaikwad, V N

2018-06-01

Large integrated steel plants employ an effective safety management system and gather a significant amount of safety-related data. This research intends to explore and visualize the rich database to find out the key factors responsible for the occurrences of incidents. The study was carried out on the data in the form of investigation reports collected from a steel plant in India. The data were processed and analysed using some of the quality management tools like Pareto chart, control chart, Ishikawa diagram, etc. Analyses showed that causes of incidents differ depending on the activities performed in a department. For example, fire/explosion and process-related incidents are more common in the departments associated with coke-making and blast furnace. Similar kind of factors were obtained, and recommendations were provided for their mitigation. Finally, the limitations of the study were discussed, and the scope of the research works was identified.

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

Directory of Open Access Journals (Sweden)

Tariq Amina

2012-11-01

Full Text Available Abstract Background Medication incident reporting (MIR is a key safety critical care process in residential aged care facilities (RACFs. Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a design MIR artefacts that facilitate identification of the root causes of medication incidents, b integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

Science.gov (United States)

2012-01-01

Background Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes. PMID:23122411

In-depth analysis of the causal factors of incidents reported in the Greek petrochemical industry

International Nuclear Information System (INIS)

Konstandinidou, Myrto; Nivolianitou, Zoe; Kefalogianni, Eirini; Caroni, Chrys

2011-01-01

This paper presents a statistical analysis of all reported incidents in the Greek petrochemical industry from 1997 to 2003. A comprehensive database has been developed to include industrial accidents (fires, explosions and substance releases), occupational accidents, incidents without significant consequences and near misses. The study concentrates on identifying and analyzing the causal factors related to different consequences of incidents, in particular, injury, absence from work and material damage. Methods of analysis include logistic regression with one of these consequences as dependent variable. The causal factors that are considered cover four major categories related to organizational issues, equipment malfunctions, human errors (of commission or omission) and external causes. Further analyses aim to confirm the value of recording near misses by comparing their causal factors with those of more serious incidents. The statistical analysis highlights the connection between the human factor and the underlying causes of accidents or incidents. - Highlights: → The research work is original, based on field data collected directly from the petrochemical industry. → It deals with the in-depth statistical analysis of accident data on human-organizational causes. → It researches underlying causes of accidents and the parameters affecting them. → The causal factors that are considered cover four big taxonomies. → Near misses are worth recording for comparing their causal factors with more serious incidents.

Regeneração de espécies arbóreas sob a influência de Merostachys multiramea Hack. (Poaceae em uma floresta subtropical Regeneration of tree species influenced by Merostachys multiramea Hack. (Poaceae in a subtropical forest

Directory of Open Access Journals (Sweden)

Suzana Cyrino dos Santos

2012-03-01

Full Text Available A ocorrência de bambúseas é comum em muitas fisionomias florestais, sendo que a elevada abundância destas espécies pode interagir com a regeneração de espécies arbóreas. Foi avaliada a regeneração de espécies arbóreas e de Merostachys multiramea Hack. em uma área de transição entre Floresta Ombrófila Mista e Floresta Estacional no Sul do Brasil e comparada a estrutura de regeneração da área entre dois e quatro anos após floração, frutificação e morte de M. multiramea. Foram alocadas 25 unidades amostrais de 100 m² dispostas de forma aleatória, onde foram amostrados todos os colmos vivos de M. multiramea e indivíduos regenerantes de espécies arbóreas > 30 cm de altura e com perímetro à altura do peito The occurrence of bamboo species is common in several forest physiognomies, and the high abundance of these species may affect the regeneration of other ones. We evaluated both tree species and Merostachys multiramea Hack. recruitment in a transition area between mixed Araucaria rain forest and seasonal semideciduous forests in southern Brazil. We compared the regeneration structure of the areas evaluated two and four years after flowering, fruiting and death of M. multiramea. We randomly distributed 25 100 m² sampling units, and surveyed all living culms of M. multiramea and tree saplings. We sampled 4,372 living bamboos and 2,918 tree saplings, belonging to 32 plant families and 75 species. Most species were classified as zoochorous and canopy light-demanding. On the other hand, plant abundance revealed a greater contribution of autochorous, understory and shade-tolerant trees. M. multiramea density was higher over the four years after the reproductive event (p<0.05, with taller culms (p<0.01, but with the same mean number of culms (p=0.46. A NPMANOVA revealed significant differences in composition and abundance between surveys, with higher similarity among samplings two years after the reproductive event of M

Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study

OpenAIRE

Seclen, Segundo Nicolas; Rosas, Moises Ernesto; Arias, Arturo Jaime; Medina, Cecilia Alexandra

2017-01-01

Objective A recent report from a non-nationally representative, geographically diverse sample in four separate communities in Peru suggests an unusually high diabetes incidence. We aimed to estimate the national diabetes incidence rate using PERUDIAB, a probabilistic, national urban population-based longitudinal study. Research design and methods 662 subjects without diabetes, selected by multistage, cluster, random sampling of households, representing the 24 administrative and the 3 (coast, ...

Are the rules for the right to self-defense outdated to address current conflicts like attacks from non-state actors and cyber-attacks?

Directory of Open Access Journals (Sweden)

Gonzalo J. Arias

2017-06-01

Full Text Available The latest US-led coalition’s attacks against ISIS in Syria raised the question whether states can use defensive force against non-state actors. Two critical incidents had previously triggered the discussion on the importance and consequences of cyber-attacks as a new form armed attacks. The first one occurred in Estonia in 2007, when the country experienced extensive computer hacking attacks that lasted several weeks. The second incident happened in 2008, during the Georgia–Russia conflict over South Ossetia, when Georgia experienced cyber-attacks similar to those suffered by Estonia in the previous year. Furthermore, on June 21, 2016, the central banks of Indonesia and South Korea were hit by cyber-attacks on their public websites since activist hacking group Anonymous pledged last month to target banks across the world. The previous incidents have created, once again, public questioning if the rules on the use of force and the right of self-defense established in the United Nations Charter are sufficient and efficient to address these new forms of attacks.

Perioperative anaesthetic adverse events in Thailand (PAAd THAI) study: Incident report of perioperative convulsion.

Science.gov (United States)

Eiamcharoenwit, Jatuporn; Akavipat, Phuping; Ariyanuchitkul, Thidarat; Wirachpisit, Nichawan; Pulnitiporn, Aksorn; Pongraweewan, Orawan

2018-01-01

The aim of this study was to identify the characteristics of perioperative convulsion and to suggest possible correcting strategies. The multi-centre study was conducted prospectively in 22 hospitals across Thailand in 2015. The occurrences of perioperative adverse events were collected. The data was collated by site manager and forwarded to the data management unit. All perioperative convulsion incidences were enrolled and analysed. The consensus was documented for the relevant factors and the corrective strategies. Descriptive statistics were used. From 2,000 incident reports, perioperative convulsions were found in 16 patients. Six episodes (37.5%) were related to anaesthesia, 31.3% to patients, 18.8% to surgery, and 12.5% to systemic processes. The contributing factor was an inexperienced anaesthesia performer (25%), while the corrective strategy was improvements to supervision (43.8%). Incidents of perioperative convulsion were found to be higher than during the last decade. The initiation and maintenance of safe anaesthesia should be continued.

How often are patients harmed when they visit the computed tomography suite? A multi-year experience, in incident reporting, in a large academic medical center

International Nuclear Information System (INIS)

Mansouri, Mohammad; Aran, Shima; Shaqdan, Khalid W.; Abujudeh, Hani H.

2016-01-01

Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. (orig.)

Sécurité informatique ethical hacking : apprendre l'attaque pour mieux se défendre

CERN Document Server

ACISSI

2009-01-01

Ce livre sur la sécurité informatique (et le ethical hacking) s'adresse à tout utilisateur d'ordinateur sensibilisé au concept de la sécurité informatique. Il a pour objectif d'initier le lecteur aux techniques des attaquants pour lui apprendre comment se défendre. ACISSI (Audit, Conseil, Installation et Sécurisation des Systèmes d'Information) est une association à but non lucratif qui forme et conseille, depuis plusieurs années, sur les enjeux de la sécurité informatique. Les auteurs de ce livre sont bien sûr membres actifs de l'association, chacun détenteur d'une spécialité, et forment une équipe de personnes de conviction qui se donnent pour mission de rendre la sécurité informatique accessible à tous : ""apprendre l'attaque pour mieux se défendre"" est leur adage. Hackers blancs dans l'âme, ils ouvrent au lecteur les portes de la connaissance underground. Aperçu de la table des matières : Introduction et Définitions - La méthodologie d'une attaque - Le Social Engineering - Les ...

The Diffuse Involvement of Bilateral Breasts in the Incidence of Burkitt's Lymphoma: A Case Report

International Nuclear Information System (INIS)

Lee, Myung Su; Lee, Sa Rah; Yang, Woo Ick; Kim, Eun Kyung; Jung, Hae Kyoung

2009-01-01

The incidence of Burkitt's lymphoma involving both breasts is rare. We report such a case that was diagnosed by a core biopsy of a hypoechoic lesion visualized from the ultrasonographic results of a patient that was clinically suspected of mastitis

A Bayesian approach for estimating under-reported dengue incidence with a focus on non-linear associations between climate and dengue in Dhaka, Bangladesh.

Science.gov (United States)

Sharmin, Sifat; Glass, Kathryn; Viennet, Elvina; Harley, David

2018-04-01

Determining the relation between climate and dengue incidence is challenging due to under-reporting of disease and consequent biased incidence estimates. Non-linear associations between climate and incidence compound this. Here, we introduce a modelling framework to estimate dengue incidence from passive surveillance data while incorporating non-linear climate effects. We estimated the true number of cases per month using a Bayesian generalised linear model, developed in stages to adjust for under-reporting. A semi-parametric thin-plate spline approach was used to quantify non-linear climate effects. The approach was applied to data collected from the national dengue surveillance system of Bangladesh. The model estimated that only 2.8% (95% credible interval 2.7-2.8) of all cases in the capital Dhaka were reported through passive case reporting. The optimal mean monthly temperature for dengue transmission is 29℃ and average monthly rainfall above 15 mm decreases transmission. Our approach provides an estimate of true incidence and an understanding of the effects of temperature and rainfall on dengue transmission in Dhaka, Bangladesh.

Operating Experience from Events Reported to the IAEA Incident Reporting System for Research Reactors

International Nuclear Information System (INIS)

2015-03-01

Operating experience feedback is an effective mechanism in providing lessons learned from events and the associated corrective actions to prevent them, helping to improve safety at nuclear installations. The Incident Reporting System for Research Reactors (IRSRR), which is operated by the IAEA, is an important tool for international exchange of operating experience feedback for research reactors. The IRSRR reports contain information on events of safety significance with their root causes and lessons learned which help in reducing the occurrence of similar events at research reactors. To improve the effectiveness of the system, it is essential that national organizations demonstrate an appropriate interest for the timely reporting of events important to safety and share the information in the IRSRR database. At their biennial technical meetings, the IRSRR national coordinators recommended collecting the operating experience from the events reported to the IRSRR and disseminating it in an IAEA publication. This publication highlights the root causes, safety significance, lessons learned, corrective actions and the causal factors for the events reported to the IRSRR up to September 2014. The publication also contains relevant summary information on research reactor events from sources other than the IRSRR, operating experience feedback from the International Reporting System for Operating Experience considered relevant to research reactors, and a description of the elements of an operating experience programme as established by the IAEA safety standards. This publication will be of use to research reactor operating organizations, regulators and designers, and any other organizations or individuals involved in the safety of research reactors

Psychological Trauma in the Workplace: Variation of Incident Severity among Industry Settings and between Recurring vs Isolated Incidents.

Science.gov (United States)

DeFraia, G S

2015-07-01

Psychologically traumatic workplace events (known as critical incidents) occur within various work environments, with workgroups in certain industries vulnerable to multiple incidents. With the increasing prevalence of incidents in the USA, incident response is a growing practice area within occupational medicine, industrial psychology, occupational social work and other occupational health professions. To analyze a measure of incident severity based on level of disruption to the workplace and explore whether incident severity varied among different industry settings or between workgroups experiencing multiple vs single traumatic incidents. Administrative data mining was employed to examine practice data from a workplace trauma response unit in the USA. Bivariate analyses were conducted to test whether scores from an instrument measuring incident severity level varied among industry settings or between workgroups impacted by multiple vs isolated events. Incident severity level differed among various industry settings. Banks, retail stores and fast food restaurants accounted for the most severe incidents, while industrial and manufacturing sites reported less severe incidents. Workgroups experiencing multiple incidents reported more severe incidents than workgroups experiencing a single incident. Occupational health practitioners should be alert to industry differences in several areas: pre-incident resiliency training, the content of business recovery plans, assessing worker characteristics, strategies to assist continuous operations and assisting workgroups impacted by multiple or severe incidents.

Childhood Cancer Incidence in India Betweem 2012 and 2014: Report of a Population-based Cancer Registry.

Science.gov (United States)

Das, Suman; Paul, Dilip Kumar; Anshu, Kumar; Bhakta, Subhajit

2017-12-15

To provide an overview of childhood cancer incidence in India between 2012-2014. Secondary data analysis on age-adjusted rates of cancer incidence for children (0-14 years) were collected from the report of the National Cancer Registry Programme in the year 2016. Age-adjusted rates of childhood cancer incidence ranged from 18.5 per million in the state of Nagaland to 235.3 per million in Delhi for boys. The rates were 11.4 per million in East Khasi Hill district and 152.3 per million in Delhi for girls. Leukemia was the most predominant cancer for both boys and girls. Lymphoma was the second most common cancer in boys, and brain tumors in girls. Childhood cancer incidence is increasing in India compared to population-based cancer registry survey of 2009-2011. Cancers are mostly affecting 0-4 years age group, and there is a rising trend of Non-Hodgkin's lymphoma.

Piloting violence and incident reporting measures on one acute mental health inpatient unit.

Science.gov (United States)

Woods, Phil; Ashley, Carolyn; Kayto, Denise; Heusdens, Carol

2008-05-01

During May, 2006, on one acute mental health inpatient unit, nursing staff evaluated each patient three times a day (i.e., once each nursing shift) using the Broset Violence Checklist (BVC). Associated data were collected using the Staff Observation and Aggression Scale-Revised (SOAS-R) if an adverse incident occurred. At the end of the data collection period, the nursing staff were asked to complete a short questionnaire anonymously to evaluate how useful they had found the instruments. N = 93 patients were admitted to the unit during the month of study. Seven incidents were reported using the SOAS-R. A slight trend was noted for higher BVC score in aggressive patients. A potential high occurrence of underreporting on incidents was observed. There was limited feedback data from nursing staff at the end of the study, but the responses received were encouraging for continued use of the instruments in practice. The pilot study fulfilled its purpose in two ways. First, it allowed staff on the unit to experience using structured instruments to support their practice. Second, it allowed an opportunity to raise awareness of potential underreporting and tolerance of aggression on the unit.

Creating European guidelines for Chiropractic Incident Reporting and Learning Systems (CIRLS: relevance and structure

Directory of Open Access Journals (Sweden)

Wangler Martin

2011-04-01

Full Text Available Abstract Background In 2009, the heads of the Executive Council of the European Chiropractors' Union (ECU and the European Academy of Chiropractic (EAC involved in the European Committee for Standardization (CEN process for the chiropractic profession, set out to establish European guidelines for the reporting of adverse reactions to chiropractic treatment. There were a number of reasons for this: first, to improve the overall quality of patient care by aiming to reduce the application of potentially harmful interventions and to facilitate the treatment of patients within the context of achieving maximum benefit with a minimum risk of harm; second, to inform the training objectives for the Graduate Education and Continuing Professional Development programmes of all 19 ECU member nations, regarding knowledge and skills to be acquired for maximising patient safety; and third, to develop a guideline on patient safety incident reporting as it is likely to be part of future CEN standards for ECU member nations. Objective To introduce patient safety incident reporting within the context of chiropractic practice in Europe and to help individual countries and their national professional associations to develop or improve reporting and learning systems. Discussion Providing health care of any kind, including the provision of chiropractic treatment, can be a complex and, at times, a risky activity. Safety in healthcare cannot be guaranteed, it can only be improved. One of the most important aspects of any learning and reporting system lies in the appropriate use of the data and information it gathers. Reporting should not just be seen as a vehicle for obtaining information on patient safety issues, but also be utilised as a tool to facilitate learning, advance quality improvement and to ultimately minimise the rate of the occurrence of errors linked to patient care. Conclusions Before a reporting and learning system can be established it has to be clear

12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

Science.gov (United States)

2010-01-01

... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Reports of change in control of bank management... change in control of bank management incident to a merger. (a) A State member bank has inquired whether Pub. L. 88-593 (78 Stat. 940) requires reports of change in control of bank management in situations...

Pesticide exposure and self-reported incident depression among wives in the Agricultural Health Study.

Science.gov (United States)

Beard, John D; Hoppin, Jane A; Richards, Marie; Alavanja, Michael C R; Blair, Aaron; Sandler, Dale P; Kamel, Freya

2013-10-01

Depression in women is a public health problem. Studies have reported positive associations between pesticides and depression, but few studies were prospective or presented results for women separately. We evaluated associations between pesticide exposure and incident depression among farmers' wives in the Agricultural Health Study, a prospective cohort study in Iowa and North Carolina. We used data on 16,893 wives who did not report physician-diagnosed depression at enrollment (1993-1997) and who completed a follow-up telephone interview (2005-2010). Among these wives, 1054 reported physician diagnoses of depression at follow-up. We collected information on potential confounders and on ever use of any pesticide, 11 functional and chemical classes of pesticides, and 50 specific pesticides by wives and their husbands via self-administered questionnaires at enrollment. We used inverse probability weighting to adjust for potential confounders and to account for possible selection bias induced by the death or loss of 10,639 wives during follow-up. We used log-binomial regression models to estimate risk ratios and 95% confidence intervals. After weighting for age at enrollment, state of residence, education level, diabetes diagnosis, and drop out, wives' incident depression was positively associated with diagnosed pesticide poisoning, but was not associated with ever using any pesticide. Use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives' depression. Among wives who never used pesticides, husbands' ever use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives' incident depression. Our study adds further evidence that high level pesticide exposure, such as pesticide poisoning, is associated with increased risk of depression and sets a lower bound on the level of exposure related to depression, thereby providing reassurance that the moderate levels

49 CFR 225.19 - Primary groups of accidents/incidents.

Science.gov (United States)

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Primary groups of accidents/incidents. 225.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.19 Primary groups of accidents/incidents. (a) For reporting purposes reportable railroad...

Association Between Old Firm Football Matches and Reported Domestic (Violence Incidents in Strathclyde, Scotland

Directory of Open Access Journals (Sweden)

Damien J. Williams

2013-09-01

Full Text Available Media reports have suggested that the number of reports of domestic violence may increase when Scotland’s two largest, Glasgow-based football (soccer clubs, Rangers and Celtic (traditionally referred to as the “Old Firm” play one another. This study considers the number of domestic (violence incidents reported to Strathclyde Police between 2008 and 2011 in the 24 hours following these matches, and compares it with the number reported during two appropriate comparator periods. There is a statistically significant increase in the number of reports following Old Firm matches compared with the comparator periods. This preliminary analysis confirms previous speculation concerning the association between Old Firm matches and reports of domestic violence, and highlights the need to better understand the factors leading to such violence to inform preventive interventions.

The comparative incidence of reported concussions presenting for follow-up management in South African Rugby Union.

Science.gov (United States)

Shuttleworth-Edwards, Ann B; Noakes, Timothy D; Radloff, Sarah E; Whitefield, Victoria J; Clark, Susan B; Roberts, Craig O; Essack, Fathima B; Zoccola, Diana; Boulind, Melissa J; Case, Stephanie E; Smith, Ian P; Mitchell, Julia L G

2008-09-01

The objective of this study was to compare the seasonal concussion incidence for school, university, club and provincial level Rugby Union players in South Africa. The study presents a retrospective statistical analysis of the number of reported concussions documented annually for groups of Rugby Union players as a proportion of those who received preseason neurocognitive assessment. Between 2002 and 2006, concussion management programs using computerized neuropsychological assessment were implemented for clinical and research purposes by psychologists in selected South African institutions involved in Rugby Union from school through to the professional level. The incidence figures were based on 175 concussive episodes reported for 165 athletes who were referred for neurocognitive assessment from a population of 1366 athletes who received preseason baseline testing. Concussion management routines varied according to the protocols adopted by the different psychologists and rugby organizations. It was expected that the incidence of concussion would vary significantly due to level of play and different management protocols. There was wide disparity in the manner in which concussion follow-up was managed by the various organizations. Within broadly comparable cohorts, tighter control was associated with a relatively higher concussion incidence for athletes per rugby playing season, with average institutional figures ranging from 4% to 14% at school level and 3% to 23% at adult level. This analysis suggests that concussion goes unrecognized and therefore incorrectly managed in a number of instances. Recommendations for optimal identification of concussed athletes for follow-up management are presented.

Reported incidences and factors associated with percutaneous ...

African Journals Online (AJOL)

Microsoft Office User

precautions, training and reduction of long working hours are necessary in order to reduce infections from .... -4-. Incidences of percutaneous injuries and mucocutaneous blood exposure ... than 40 hours per week (14.9 %) (p= 0.001).

Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident Prevention

NARCIS (Netherlands)

Drupsteen, L.; Groeneweg, J.; Zwetsloot, G.I.J.M.

2013-01-01

Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process.

Psychological Trauma in the Workplace: Variation of Incident Severity among Industry Settings and between Recurring vs Isolated Incidents

Directory of Open Access Journals (Sweden)

GS DeFraia

2015-07-01

Full Text Available Background: Psychologically traumatic workplace events (known as critical incidents occur within various work environments, with workgroups in certain industries vulnerable to multiple incidents. With the increasing prevalence of incidents in the USA, incident response is a growing practice area within occupational medicine, industrial psychology, occupational social work and other occupational health professions. Objective: To analyze a measure of incident severity based on level of disruption to the workplace and explore whether incident severity varied among different industry settings or between workgroups experiencing multiple vs single traumatic incidents. Methods: Administrative data mining was employed to examine practice data from a workplace trauma response unit in the USA. Bivariate analyses were conducted to test whether scores from an instrument measuring incident severity level varied among industry settings or between workgroups impacted by multiple vs isolated events. Results: Incident severity level differed among various industry settings. Banks, retail stores and fast food restaurants accounted for the most severe incidents, while industrial and manufacturing sites reported less severe incidents. Workgroups experiencing multiple incidents reported more severe incidents than workgroups experiencing a single incident. Conclusion: Occupational health practitioners should be alert to industry differences in several areas: pre-incident resiliency training, the content of business recovery plans, assessing worker characteristics, strategies to assist continuous operations and assisting workgroups impacted by multiple or severe incidents.

The United States Department of Energy (DOE) Computerized Accident/Incident Reporting System (CAIRS)

International Nuclear Information System (INIS)

Briscoe, G.J.

1993-01-01

The Department of Energy's (DOE) Computerized Accident/Incident Reporting System (CAIRS) is a comprehensive data base containing more than 50,000 investigation reports of injury/illness, property damage and vehicle accident cases representing safety data from 1975 to the present for more than 150 DOE contractor organizations. A special feature is that the text of each accident report is translated using a controlled dictionary and rigid sentence structure called Factor Relationship and Sequence of Events (FRASE) that enhances the ability to retrieve specific types of information and to perform detailed analyses. DOE summary and individual contractor reports are prepared quarterly and annually. In addition, ''Safety Performance Profile'' reports for individual organizations are prepared to provide advance information to appraisal teams, and special topical reports are prepared for areas of concern such as an increase in the number of security injuries or environmental releases. The data base is open to all DOE and Contractor registered users with no access restrictions other than that required by the Privacy Act

Enhancing Police Responses to Domestic Violence Incidents: Reports From Client Advocates in New South Wales.

Science.gov (United States)

Goodman-Delahunty, Jane; Crehan, Anna Corbo

2016-07-01

In an online survey about experiences with the police complaint system, 239 client advocates described a recent incident in which a client with grounds to lodge a complaint declined to do so. Almost one third of those incidents involved domestic violence. Thematic analysis of case descriptions revealed that many police did not take domestic violence reports seriously. A typology of problematic police conduct was developed. Many officers failed to observe current procedures and appeared to lack knowledge of relevant laws. Citizens feared retaliatory victimization by police and/or perceived that complaining was futile. Implications of these findings are reviewed in light of procedural justice theory. © The Author(s) 2015.

Reporting Crime Victimizations to the Police and the Incidence of Future Victimizations: A Longitudinal Study.

Science.gov (United States)

Ranapurwala, Shabbar I; Berg, Mark T; Casteel, Carri

2016-01-01

Law enforcement depends on cooperation from the public and crime victims to protect citizens and maintain public safety; however, many crimes are not reported to police because of fear of repercussions or because the crime is considered trivial. It is unclear how police reporting affects the incidence of future victimization. To evaluate the association between reporting victimization to police and incident future victimization. We conducted a retrospective cohort study using National Crime Victimization Survey 2008-2012 data. Participants were 12+ years old household members who may or may not be victimized, were followed biannually for 3 years, and who completed at least one follow-up survey after their first reported victimization between 2008 and 2012. Crude and adjusted generalized linear mixed regression for survey data with Poisson link were used to compare rates of future victimization. Out of 18,657 eligible participants, 41% participants reported to their initial victimization to police and had a future victimization rate of 42.8/100 person-years (PY) (95% CI: 40.7, 44.8). The future victimization rate of those who did not report to the police (59%) was 55.0/100 PY (95% CI: 53.0, 57.0). The adjusted rate ratio comparing police reporting to not reporting was 0.78 (95%CI: 0.72, 0.84) for all future victimizations, 0.80 (95% CI: 0.72, 0.90) for interpersonal violence, 0.73 (95% CI: 0.68, 0.78) for thefts, and 0.95 (95% CI: 0.84, 1.07) for burglaries. Reporting victimization to police is associated with fewer future victimization, underscoring the importance of police reporting in crime prevention. This association may be attributed to police action and victim services provisions resulting from reporting.

[Report of Cancer Incidence and Mortality in China, 2014].

Science.gov (United States)

Chen, W Q; Li, H; Sun, K X; Zheng, R S; Zhang, S W; Zeng, H M; Zou, X N; Gu, X Y; He, J

2018-01-23

Objective: The registration data of local cancer registries in 2014 were collected by National Central Cancer Registry (NCCR)in 2017 to estimate the cancer incidence and mortality in China. Methods: The data submitted from 449 registries were checked and evaluated, and the data of 339 registries out of them were qualified and selected for the final analysis. Cancer incidence and mortality were stratified by area, gender, age group and cancer type, and combined with the population data of 2014 to estimate cancer incidence and mortality in China. The age composition of standard population of Chinese census in 2000 and Segi's population were used for age-standardized incidence and mortality in China and worldwide, respectively. Results: Total covered population of 339 cancer registries (129 in urban and 210 in rural) in 2014 were 288 243 347 (144 061 915 in urban and 144 181 432 in rural areas). The mortality verified cases (MV%) were 68.01%. Among them, 2.19% cases were identified through death certifications only (DCO%), and the mortality to incidence ratio was 0.61. There were about 3, 804, 000 new cases diagnosed as malignant cancer and 2, 296, 000 cases dead in 2014 in the whole country. The incidence rate was 278.07/100, 000 (males 301.67/100, 000, females 253.29/100, 000) in China, age-standardized incidence rates by Chinese standard population (ASIRC) and by world standard population were 190.63/100, 000 and 186.53/100, 000, respectively, and the cumulative incidence rate (0-74 age years old) was 21.58%. The cancer incidence and ASIRC in urban areas were 302.13/100, 000 and 196.58/100, 000, respectively, whereas in rural areas, those were 248.94/100, 000 and 182.64/100, 000, respectively. The cancer mortality in China was 167.89/100, 000 (207.24/100, 000 in males and 126.54/100, 000 in females), age-standardized mortality rates by Chinese standard population (ASMRC) and by world standard population were 106.98/100, 000 and 106.09/100, 000, respectively. And

Post-partum oestrusgedrag bij zeugen gaat niet gepaard met ovulatie

NARCIS (Netherlands)

Souren, N.Y.P.; Langendijk, P.; Soede, N.M.

2005-01-01

Sows occasionally show oestrous behaviour within 5 days of farrowing: this is termed post-partum oestrus (PPO). This study investigated the incidence and possible causes of PPO on nine Dutch farms. Lactation records (n = 1374) were used, hack fat thickness was measured (n=25), and ovarian condition

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

OpenAIRE

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

2016-01-01

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

Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the Atmospheric Environment Safety Technology Project

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

This study analyzed aircraft incidents in the NASA Aviation Safety Reporting System (ASRS) that apply to two of the three technical challenges (TCs) in NASA's Aviation Safety Program's Atmospheric Environment Safety Technology Project. The aircraft incidents are related to airframe icing and atmospheric hazards TCs. The study reviewed incidents that listed their primary problem as weather or environment-nonweather between 1994 and 2011 for aircraft defined by Federal Aviation Regulations (FAR) Parts 121, 135, and 91. The study investigated the phases of flight, a variety of anomalies, flight conditions, and incidents by FAR part, along with other categories. The first part of the analysis focused on airframe-icing-related incidents and found 275 incidents out of 3526 weather-related incidents over the 18-yr period. The second portion of the study focused on atmospheric hazards and found 4647 incidents over the same time period. Atmospheric hazards-related incidents included a range of conditions from clear air turbulence and wake vortex, to controlled flight toward terrain, ground encounters, and incursions.

Change in Reported Lyme Disease Incidence in the Northeast and Upper Midwest, 1991-2014

Science.gov (United States)

This indicator shows how reported Lyme disease incidence has changed by state since 1991, based on the number of new cases per 100,000 people. The total change has been estimated from the average annual rate of change in each state. This map is limited to the 14 states where Lyme disease is most common, where annual rates are consistently above 10 cases per 100,000. Connecticut, New York, and Rhode Island had too much year-to-year variation in reporting practices to allow trend calculation. For more information: www.epa.gov/climatechange/science/indicators

Changing incidence of diverticular disease of the colon in Korea : a serial radiologic study (report III)

Energy Technology Data Exchange (ETDEWEB)

Kwoen, Young Teck; Han, Sung Il; Chung, Soo Kyo; Bahk, Yong Whee [Catholic University Medical College, Seoul (Korea, Republic of)

1988-10-15

Diverticular disease of the colon (DDC), the most common affliction in developed countries, increases in incidence. It is an acquired disease where overactivity of smooth muscle of the colon causes mucosa and sub mucosa to herniate through the muscle layer of the bowel. Starting from 1964, we have periodically carried out radiologic survey to acertain the tendency of DDC to gradually increase in the Koreans. Initially Kim reported the incidence to be 0.2% in 1964 but the incidence in 1979 increased to 2.5% as reported by Chung et al. As the third survey on the series of the study on DDC, we have recently reviewed 1,859 consecutive new cases of double contrast barium enemas performed at the department of radiology, Kangnam St. Mary's Hospital, Catholic University Medical College during the 5 year's period from Feb. 1983 to May 1987. The results were as follows. 1. The present study revealed an incidence 6.0% of DDC, 7.2% in male and 5.0% in female. 2. The distribution of diverticular was 37.0% in cecum, 39.0% in ascending colon, 13.6% in transverse colon, 6.2% in descending colon, 3.7% in sigmoid colon. 3. The mean number of diverticular was 5. 4. The average age of patients with DDC was 50.5 years. From the present study, it has emerged that the diverticular disease of the colon in the Koreans is definitely on gradual increase with a significant change in the site of predominant involvement from the right to the left colon.

Changing incidence of diverticular disease of the colon in Korea : a serial radiologic study (report III)

International Nuclear Information System (INIS)

Kwoen, Young Teck; Han, Sung Il; Chung, Soo Kyo; Bahk, Yong Whee

1988-01-01

Diverticular disease of the colon (DDC), the most common affliction in developed countries, increases in incidence. It is an acquired disease where overactivity of smooth muscle of the colon causes mucosa and sub mucosa to herniate through the muscle layer of the bowel. Starting from 1964, we have periodically carried out radiologic survey to acertain the tendency of DDC to gradually increase in the Koreans. Initially Kim reported the incidence to be 0.2% in 1964 but the incidence in 1979 increased to 2.5% as reported by Chung et al. As the third survey on the series of the study on DDC, we have recently reviewed 1,859 consecutive new cases of double contrast barium enemas performed at the department of radiology, Kangnam St. Mary's Hospital, Catholic University Medical College during the 5 year's period from Feb. 1983 to May 1987. The results were as follows. 1. The present study revealed an incidence 6.0% of DDC, 7.2% in male and 5.0% in female. 2. The distribution of diverticular was 37.0% in cecum, 39.0% in ascending colon, 13.6% in transverse colon, 6.2% in descending colon, 3.7% in sigmoid colon. 3. The mean number of diverticular was 5. 4. The average age of patients with DDC was 50.5 years. From the present study, it has emerged that the diverticular disease of the colon in the Koreans is definitely on gradual increase with a significant change in the site of predominant involvement from the right to the left colon.

Nuclear power plant operating experiences from the IAEA / Nea incident reporting system 2002-2005

International Nuclear Information System (INIS)

2006-01-01

The Incident Reporting System (IRS) is an essential element of the international operating experience feedback system for nuclear power plants. The IRS is jointly operated and managed by the Nuclear Energy Agency (NEA), a semi-autonomous body within the Organisation for Economic Co-operation and Development (OECD), and the International Atomic Energy Agency (IAEA), a specialized agency within the United Nations System. (author)

Security incidents on the Internet, 1989--1995

Energy Technology Data Exchange (ETDEWEB)

Howard, J.D.

1995-12-31

This paper presents an analysis of trends in Internet security based on an investigation of 4,299 Internet security-related incidents reported to the CERT{reg_sign} Coordination Center (CERT{reg_sign}/CC) from 1989 through 1995. Prior to this research, knowledge of actual Internet security incidents was limited and primarily anecdotal. This research: (1) developed a taxonomy to classify Internet attacks and incidents, (2) organized, classified, and analyzed CERT{reg_sign}/CC incident records, (3) summarized the relative frequency of the use of tools and vulnerabilities, success in achieving access, and results of attacks, (4) estimated total Internet incident activity, (5) developed recommendations for Internet users and suppliers, and (6) developed recommendations for future research. With the exception of denial-of-service attacks, security incidents were found to be increasing at a rate less than Internet growth. Estimates showed that most, if not all, severe incidents were reported to the CERT{reg_sign}/CC, and that more than one out of three above average incidents (in terms of duration and number of sites) were reported. Estimates also indicated that a typical Internet site was involved in, at most, around one incident (of any kind) per year, and a typical Internet host in, at most, around one incident in 45 years. The probability of unauthorized privileged access was around an order of magnitude less likely. As a result, simple and reasonable security precautions should be sufficient for most Internet users.

Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the System-Wide Safety and Assurance Technologies Project

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2015-01-01

The Aviation Safety Program (AvSP) System-Wide Safety and Assurance Technologies (SSAT) Project asked the AvSP Systems and Portfolio Analysis Team to identify SSAT-related trends. SSAT had four technical challenges: advance safety assurance to enable deployment of NextGen systems; automated discovery of precursors to aviation safety incidents; increasing safety of human-automation interaction by incorporating human performance, and prognostic algorithm design for safety assurance. This report reviews incident data from the NASA Aviation Safety Reporting System (ASRS) for system-component-failure- or-malfunction- (SCFM-) related and human-factor-related incidents for commercial or cargo air carriers (Part 121), commuter airlines (Part 135), and general aviation (Part 91). The data was analyzed by Federal Aviation Regulations (FAR) part, phase of flight, SCFM category, human factor category, and a variety of anomalies and results. There were 38 894 SCFM-related incidents and 83 478 human-factorrelated incidents analyzed between January 1993 and April 2011.

Review of incidents to be reported under the Radiation Protection Ordinance for the years 1987 and 1988

International Nuclear Information System (INIS)

1989-01-01

The total of 80 incidents were caused by human failure, intentional disruption, theft, fire, violation of rules, transport losses, accidents, equipment deficiencies. 15 ionization smoke detectors were reported lost or stolen. (HP) [de

Report of the Task Force on the Incident of 19th September 2008 at the LHC

CERN Document Server

Bajko, M; Catalan-Lasheras, N; Claudet, S; Cruikshank, P; Dahlerup-Petersen, K; Denz, R; Fessia, P; Garion, C; Jimenez, JM; Kirby, G; Lebrun, Ph; Le Naour, S; Mess, K-H; Modena, M; Montabonnet, V; Nunes, R; Parma, V; Perin, A; de Rijk, G; Rijllart, A; Rossi, L; Schmidt, R; Siemko, A; Strubin, P; Tavian, L; Thiesen, H; Tock, J; Todesco, E; Veness, R; Verweij, A; Walckiers, L; Van Weelderen, R; Wolf, R; Fehér, S; Flora, R; Koratzinos, M; Limon, P; Strait, J

2009-01-01

This report summarizes the findings and recommendations of the AT department Task Force established to investigate the 19th September 2008 incident which occurred in sector 3-4 of the LHC. It includes a number of annexes where specific analyses are detailed.

Incidence of bruxism in TMD population.

Science.gov (United States)

Chandwani, Briesh; Ceneviz, Caroline; Mehta, Noshir; Scrivani, Steven

2011-01-01

The objective of the study presented here was to examine the incidence of bruxism in patients suffering from temporomandibular disorders. Two cohorts of patients suffering from temporomandibular disorders were evaluated. One group, composed of 163 patients, was asked specifically about the occurrence of bruxism, while the other group, composed of 200 patients, was not specifically asked about bruxism (self-reporting). The incidence of bruxism was only 20.5% for the group that only self-reported bruxism, while the incidence was 65% when asked specifically about bruxism. It is critical to ask specifically about bruxism. Patients are more likely to report bruxism when asked specifically about it. It is important to incorporate this as part of a TMD evaluation.

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center.

Directory of Open Access Journals (Sweden)

Jih-Shuin Jerng

Full Text Available There have been concerns about the workplace interpersonal conflict (WIC among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs.We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship and the three properties (disagreement, interference, and negative emotion, and analyzed relevant data.Of the 147 incidents with WIC, the most common related processes were patient transfer (20%, laboratory tests (17%, surgery (16% and medical imaging (16%. All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9% also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57% were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%, and the majority (67% of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064. The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1% than not on it (17.0%. The distributions of worker job types were similar between those with and without negative emotion (p = 0.125.The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center.

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Jerng, Jih-Shuin; Huang, Szu-Fen; Liang, Huey-Wen; Chen, Li-Chin; Lin, Chia-Kuei; Huang, Hsiao-Fang; Hsieh, Ming-Yuan; Sun, Jui-Sheng

2017-01-01

There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs. We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data. Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125). The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.

Incident reporting to BfArM - regulatory framework, results and challenges.

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Seidel, Robin; Stößlein, Ekkehard; Lauer, Wolfgang

2016-04-01

Medical devices are manifold and one of the most innovative fields of technology. As technologies advance, former limits cease to exist and complex devices become reality. Medical devices represent a very dynamic field with high economic relevance. The manufacturer of a medical device is obliged to minimize product-related risks as well as to demonstrate compliance with the so-called "essential requirements" regarding safety and performance before placing the device on the market. Any critical incident in relation to the application of a medical device has to be reported to the competent authority for risk assessment, which in Germany is either the Federal Institute for Drugs and Medical Devices (BfArM) or the Paul Ehrlich Institute (PEI) depending on the type of device. In this article, the German regulatory framework for medical devices and the resulting tasks for BfArM are described as well as the topics of its recently installed research and development group on prospective risk identification and application safety for medical devices. Results of failure mode and root cause analyses of incident data are presented as well as further data on cases with the result "root-cause analysis not possible". Finally an outlook is given on future challenges regarding risk assessment for medical devices.

Masking in reports of "most serious" events: bias in estimators of sports injury incidence in Canadian children

Directory of Open Access Journals (Sweden)

A. Gupta

2016-08-01

Full Text Available Introduction: Surveys that collect information on injuries often focus on the single "most serious" event to help limit recall error and reduce survey length. However, this can mask less serious injuries and result in biased incidence estimates for specific injury subcategories. Methods: Data from the 2002 Health Behaviour in School-aged Children (HBSC survey and from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP were used to compare estimates of sports injury incidence in Canadian children. Results: HBSC data indicate that 6.7% of children report sustaining a sports injury that required an emergency department (ED visit. However, details were only collected on a child's "most serious" injury, so children who had multiple injuries requiring an ED visit may have had sports injuries that went unreported. The rate of 6.7% can be seen to be an underestimate by as much as 4.3%. Corresponding CHIRPP surveillance data indicate an incidence of 9.9%. Potential masking bias is also highlighted in our analysis of injuries attended by other health care providers. Conclusion: The "one most serious injury" line of questioning induces potentially substantial masking bias in the estimation of sports injury incidence, which limits researchers' ability to quantify the burden of sports injury. Longer survey recall periods naturally lead to greater masking. The design of future surveys should take these issues into account. In order to accurately inform policy decisions and the direction of future research, researchers must be aware of these limitations.

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

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

2017-02-01

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

Self-Reported Sleep Duration, Napping, and Incident Heart Failure: Prospective Associations in the British Regional Heart Study.

Science.gov (United States)

Wannamethee, S Goya; Papacosta, Olia; Lennon, Lucy; Whincup, Peter H

2016-09-01

To examine the associations between self-reported nighttime sleep duration and daytime sleep and incident heart failure (HF) in men with and without preexisting cardiovascular disease (CVD). Population-based prospective study. General practices in 24 British towns. Men aged 60-79 without prevalent HF followed for 9 years (N = 3,723). Information on incident HF cases was obtained from primary care records. Assessment of sleep was based on self-reported sleep duration at night and daytime napping. Self-reported short nighttime sleep duration and daytime sleep of longer than 1 hour were associated with preexisting CVD, breathlessness, depression, poor health, physical inactivity, and manual social class. In all men, self-reported daytime sleep of longer than 1 hour duration was associated with significantly greater risk of HF after adjustment for potential confounders (adjusted hazard ratio (aHR) = 1.69, 95% CI = 1.06-2.71) than in those who reported no daytime napping. Self-reported nighttime sleep duration was not associated with HF risk except in men with preexisting CVD (napping of longer than 1 hour is associated with greater risk of HF in older men. Self-reported short sleep (<6 hours) in men with CVD is associated with particularly high risk of developing HF. © 2016 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

Hip fracture incidence is decreasing in the high incidence area of Oslo, Norway.

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Støen, R O; Nordsletten, L; Meyer, H E; Frihagen, J F; Falch, J A; Lofthus, C M

2012-10-01

This study reports a significant decrease in age-adjusted incidence rates of hip fracture for women in Oslo, Norway, even compared with data from 1978/1979. Use of bisphosphonate may explain up to one third of the decline in the incidence. The aims of the present study were to report the current incidence of hip fractures in Oslo and to estimate the influence of bisphosphonates on the current incidence. Using the electronic diagnosis registers and lists from the operating theaters of the hospitals of Oslo, all patients with ICD-10 codes S72.0 and S72.1 (hip fracture) in 2007 were identified. Medical records of all identified patients were reviewed to verify the diagnosis. Age- and gender-specific annual incidence rates were calculated using the population of Oslo on January 1, 2007 as the population at risk. Data on the use of bisphosphonates were obtained from official registers. A total number of 1,005 hip fractures, 712 (71%) in women, were included. The age-adjusted fracture rates per 10,000 for the age group >50 years were 82.0 for women and 39.1 for men in 2007, compared with 110.8 and 41.4 in 1996/1997, 116.5 and 42.9 in 1988/1989, and 97.5 and 34.5 in 1978/1979, respectively. It was estimated that the use of bisphosphonates may explain up to 13% of the decline in incidence in women aged 60-69 years and up to 34% in women aged 70-79 years. The incidence of hip fractures in women in Oslo has decreased significantly during the last decade and is now at a lower level than in 1978/1979. This reduction was not evident in men. The incidence of hip fractures in Oslo is, however, still the highest in the world.

Learning from radiation incidents: the new OTHEA website

International Nuclear Information System (INIS)

Shaw, P V; Ely, S Y; Croueail, P; Bataille, C

2010-01-01

OTHEA is the name of a new website (www.othea.net), created by the Health Protection Agency (UK) and the Centre d'etude sur l'evaluation de la protection dans le domaine nucleaire (CEPN, France), and supported by several other stakeholders including national societies and associations. The website is bi-lingual (French and English) and the purpose is to share the lessons learnt from radiological incidents that have occurred in the industrial, medical, research and teaching, and other non-nuclear sectors. OTHEA contains a collection of incident reports, categorised according to the sector and the type of application, and a search facility. The reports can be freely downloaded and printed, for example for use in radiation protection training activities. To encourage dissemination, the incident reports have been made anonymous, i.e. any information that could identify a particular individual, organisation or site has been removed. Each report contains a brief summary of the incident, the radiological consequences, and the lessons learnt. The aim is not to capture every single incident, but to provide a range of reports selected according to the value of the lessons learnt. For OTHEA to be a long-term success, it needs to be sustained with new reports. Therefore users are encouraged to submit incident reports that can be considered for inclusion in OTHEA. This note summarises the background to OTHEA, and provides a description of the operating features and content at its launch in summer 2010. (note)

Reported incidence and precipitating factors of work-related stress and mental ill-health in the United Kingdom (1996-2001).

Science.gov (United States)

Cherry, Nicola M; Chen, Yiqun; McDonald, J Corbett

2006-09-01

Work-related mental ill-health appears to be increasing. Population-based data on incidence are scarce but in the United Kingdom occupational physicians and psychiatrists report these conditions to voluntary surveillance schemes. To estimate the incidence of work-related stress and mental illness reported 1996-2001 by occupational physicians and 1999-2001 by psychiatrists. Estimated annual average incidence rates were calculated by sex, occupation and industry against appropriate populations at risk. An in-house coding scheme was used to classify and analyse data on precipitating events. An estimated annual average of 3,624 new cases were reported by psychiatrists, and 2,718 by occupational physicians; the rates were higher for men in reports based on the former and for women on the latter. Most diagnoses were of anxiety/depression or work-related stress, with post-traumatic stress accounting for approximately 10% of cases reported by psychiatrists. High rates of ill-health were seen among professional and associated workers and in those in personal and protective services. Factors (such as work overload) intrinsic to the job and issues with interpersonal relations were the most common causes overall. The steep increase in new cases of work-related mental ill-health reported by occupational physicians since 1996 may reflect a greater willingness by workers to seek help but may also signify an increasing dissonance between workers' expectations and the work environment. Greater expertise is needed to improve the workplace by adjustment of job demands, improvement of working relations, increasing workers' capacities and management of organizational change.

The child sexual abuse epidemic in addis ababa: some reflections on reported incidents, psychosocial consequences and implications.

Science.gov (United States)

Jemal, Jibril

2012-03-01

Though child sexual abuse is a universal phenomenon, only reported cases of the incidence are common source of information to get insight on how to understand the problem. Besides, investigating complaints presented by victims themselves would be a stepping stone for designing prevention and rehabilitation programs. The objective of this study was to identify the nature of sexual incidence and experience victims face. The research was conducted by collecting reported child sexual abuse cases from Child Protection Units of Addis Ababa Police Commission and three selected non-governmental organizations working for the welfare of sexually abused children in Addis Ababa. 64 selected samples of victim children were included from the three organizations. They completed a semi-structured questionnaire and data were analyzed. Of the total reported crime cases committed against children (between July 2005 and December 2006), 23% of them were child sexual victimization. On average, 21 children were reported to be sexually abused each month where majority of the sexual abuse incidence were committed against female children in their own home by someone they closely know. The psychological trauma and physical complaints presented by victims include symptoms of anxiety and depression. It was found out that child sexual abuse cases presented to the legal office was not properly managed. Female children appear to be more prone to sexual abuse than their male counterparts. By virtue of their nature, many children are at risk of sexual victimization by people they truest. Based on the findings, several implications are made, which includes the importance of nation-wide study to formulate a comprehensive policy guideline for protection and criminalization of child sexual abuse in Ethiopia.

The Use of Categorized Time-Trend Reporting of Radiation Oncology Incidents: A Proactive Analytical Approach to Improving Quality and Safety Over Time

International Nuclear Information System (INIS)

Arnold, Anthony; Delaney, Geoff P.; Cassapi, Lynette; Barton, Michael

2010-01-01

Purpose: Radiotherapy is a common treatment for cancer patients. Although incidence of error is low, errors can be severe or affect significant numbers of patients. In addition, errors will often not manifest until long periods after treatment. This study describes the development of an incident reporting tool that allows categorical analysis and time trend reporting, covering first 3 years of use. Methods and Materials: A radiotherapy-specific incident analysis system was established. Staff members were encouraged to report actual errors and near-miss events detected at prescription, simulation, planning, or treatment phases of radiotherapy delivery. Trend reporting was reviewed monthly. Results: Reports were analyzed for the first 3 years of operation (May 2004-2007). A total of 688 reports was received during the study period. The actual error rate was 0.2% per treatment episode. During the study period, the actual error rates reduced significantly from 1% per year to 0.3% per year (p < 0.001), as did the total event report rates (p < 0.0001). There were 3.5 times as many near misses reported compared with actual errors. Conclusions: This system has allowed real-time analysis of events within a radiation oncology department to a reduced error rate through focus on learning and prevention from the near-miss reports. Plans are underway to develop this reporting tool for Australia and New Zealand.

Customer focused incident monitoring in anaesthesia.

Science.gov (United States)

Khan, F A; Khimani, S

2007-06-01

The database of incident forms relating to anaesthesia services in an institutional risk management programme were reviewed for 2003-2005, the aim being to identify any recurring patterns. Incidents were prospectively categorised as relating to attitude/behaviour, communication breakdown, delay in service, or were related to care, cost, environment, equipment, security, administrative process, quality of service or miscellaneous. The total number of anaesthesia-related incidents reported during the period was 287, which related to 0.44% of the total number of anaesthetics administered during the time period. In all, 170 incidents were reported by the department, 96 by internal customers and 21 by external customers. Only 30% of the complaints came from the operating room. Thirty-four per cent of all incidents related to communication, behaviour and delay in service. A requirement to teach communication skills and stress handling formally in anaesthesia training programmes, and at the time of induction of staff into the department, has been identified.

Radioactive material (RAM) accident/incident data analysis program

International Nuclear Information System (INIS)

Emerson, E.L.; McClure, J.D.

1985-03-01

This report describes the development of the Radioactive Material Transportation Accident/Incident Data Base (RAM-AIDB), which contains information on the occurrences of transportation accidents and incidents, for radioactive materials (RAM) that are involved in the process of transportation, loading and unloading operation, or temporary storage. These transportation operations are in support of the nuclear fuel cycle for electrical energy generation. This study analyzes in some detail basic accident/incident statistical data, RAM packaging accident response data, and the health effects associated with RAM transport accidents/incidents. This report presents a summary of US RAM transport accident/incident experience for the period 1971 through December 1981. In addition, a sample annual summary of accident/incident experience is presented for the calendar year 1981

Hacking and securing the AR.Drone 2.0 quadcopter: investigations for improving the security of a toy

Science.gov (United States)

Pleban, Johann-Sebastian; Band, Ricardo; Creutzburg, Reiner

2014-02-01

In this article we describe the security problems of the Parrot AR.Drone 2.0 quadcopter. Due to the fact that it is promoted as a toy with low acquisition costs, it may end up being used by many individuals which makes it a target for harmful attacks. In addition, the videostream of the drone could be of interest for a potential attacker due to its ability of revealing confidential information. Therefore, we will perform a security threat analysis on this particular drone. We will set the focus mainly on obvious security vulnerabilities like the unencrypted Wi-Fi connection or the user management of the GNU/Linux operating system which runs on the drone. We will show how the drone can be hacked in order to hijack the AR.Drone 2.0. Our aim is to sensitize the end-user of AR.Drones by describing the security vulnerabilities and to show how the AR.Drone 2.0 could be secured from unauthorized access. We will provide instructions to secure the drones Wi-Fi connection and its operation with the official Smartphone App and third party PC software.

Comparative Incidence of Conformational, Neurodegenerative Disorders.

Directory of Open Access Journals (Sweden)

Jesús de Pedro-Cuesta

Full Text Available The purpose of this study was to identify incidence and survival patterns in conformational neurodegenerative disorders (CNDDs.We identified 2563 reports on the incidence of eight conditions representing sporadic, acquired and genetic, protein-associated, i.e., conformational, NDD groups and age-related macular degeneration (AMD. We selected 245 papers for full-text examination and application of quality criteria. Additionally, data-collection was completed with detailed information from British, Swedish, and Spanish registries on Creutzfeldt-Jakob disease (CJD forms, amyotrophic lateral sclerosis (ALS, and sporadic rapidly progressing neurodegenerative dementia (sRPNDd. For each condition, age-specific incidence curves, age-adjusted figures, and reported or calculated median survival were plotted and examined.Based on 51 valid reported and seven new incidence data sets, nine out of eleven conditions shared specific features. Age-adjusted incidence per million person-years increased from ≤1.5 for sRPNDd, different CJD forms and Huntington's disease (HD, to 1589 and 2589 for AMD and Alzheimer's disease (AD respectively. Age-specific profiles varied from (a symmetrical, inverted V-shaped curves for low incidences to (b those increasing with age for late-life sporadic CNDDs and for sRPNDd, with (c a suggested, intermediate, non-symmetrical inverted V-shape for fronto-temporal dementia and Parkinson's disease. Frequently, peak age-specific incidences from 20-24 to ≥90 years increased with age at onset and survival. Distinct patterns were seen: for HD, with a low incidence, levelling off at middle age, and long median survival, 20 years; and for sRPNDd which displayed the lowest incidence, increasing with age, and a short median disease duration.These results call for a unified population view of NDDs, with an age-at-onset-related pattern for acquired and sporadic CNDDs. The pattern linking age at onset to incidence magnitude and survival might

Comparative Incidence of Conformational, Neurodegenerative Disorders

Science.gov (United States)

de Pedro-Cuesta, Jesús; Rábano, Alberto; Martínez-Martín, Pablo; Ruiz-Tovar, María; Alcalde-Cabero, Enrique; Almazán-Isla, Javier; Avellanal, Fuencisla; Calero, Miguel

2015-01-01

Background The purpose of this study was to identify incidence and survival patterns in conformational neurodegenerative disorders (CNDDs). Methods We identified 2563 reports on the incidence of eight conditions representing sporadic, acquired and genetic, protein-associated, i.e., conformational, NDD groups and age-related macular degeneration (AMD). We selected 245 papers for full-text examination and application of quality criteria. Additionally, data-collection was completed with detailed information from British, Swedish, and Spanish registries on Creutzfeldt-Jakob disease (CJD) forms, amyotrophic lateral sclerosis (ALS), and sporadic rapidly progressing neurodegenerative dementia (sRPNDd). For each condition, age-specific incidence curves, age-adjusted figures, and reported or calculated median survival were plotted and examined. Findings Based on 51 valid reported and seven new incidence data sets, nine out of eleven conditions shared specific features. Age-adjusted incidence per million person-years increased from ≤1.5 for sRPNDd, different CJD forms and Huntington's disease (HD), to 1589 and 2589 for AMD and Alzheimer's disease (AD) respectively. Age-specific profiles varied from (a) symmetrical, inverted V-shaped curves for low incidences to (b) those increasing with age for late-life sporadic CNDDs and for sRPNDd, with (c) a suggested, intermediate, non-symmetrical inverted V-shape for fronto-temporal dementia and Parkinson's disease. Frequently, peak age-specific incidences from 20–24 to ≥90 years increased with age at onset and survival. Distinct patterns were seen: for HD, with a low incidence, levelling off at middle age, and long median survival, 20 years; and for sRPNDd which displayed the lowest incidence, increasing with age, and a short median disease duration. Interpretation These results call for a unified population view of NDDs, with an age-at-onset-related pattern for acquired and sporadic CNDDs. The pattern linking age at onset to

76 FR 30855 - Accident/Incident Reporting Requirements

Science.gov (United States)

2011-05-27

... sidewalk/walkway D5--In airport; D6- In airplane; D7--In hotel room; E1--On parking lot; E2--In building... Control C--Auto Train Stop D--Automatic Block Signals System E--Broken Rail Monitoring F--Direct Traffic... of the accident/incident. This document updates and moves footnote number four to make it clear that...

Investigation of reactor incident reports with regard to human malfunctions as far as these had an effect on the incident history

International Nuclear Information System (INIS)

Hoffmann, E.

1984-01-01

The study has the aim to examine by means of a human failure analysis the operation of a nuclear power plant with regard to its weak points, in order to deduce by this starting-points for operational improvements. Contrary to most studies published on this subject and which are often based on free-hand hypotheses and plausibility studies here, the experience gained in the operation is systematically examined with regard to human malfunction and their deeper causes, i.e. on the experience which was founded on some 1,000 collected reports on incidents. (orig./GL) [de

The management of radiation treatment error through incident learning

International Nuclear Information System (INIS)

Clark, Brenda G.; Brown, Robert J.; Ploquin, Jodi L.; Kind, Anneke L.; Grimard, Laval

2010-01-01

Purpose: To assess efficacy of an incident learning system in the management of error in radiation treatment. Materials and methods: We report an incident learning system implementation customized for radiation therapy where any 'unwanted or unexpected change from normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment' is reported, investigated and learned from. This system thus captures near-miss (potential) and actual events. Incidents are categorized according to severity, type and origin. Results: Our analysis spans a period of 3 years with an average accrual of 11.6 incidents per week. We found a significant reduction in actual incidents of 28% and 47% in the second and third year when compared to the first year (p < 0.001), which we attribute to the many interventions prompted by the analysis of incidents reported. We also saw a similar significant reduction in incidents generated at the treatment unit correlating with the introduction of direct treatment parameter transfer and electronic imaging (p < 0.001). Conclusions: Implementation of an incident learning system has helped us to establish a just environment where all staff members report deviations from normal system behaviour and thus generate evidence to initiate safety improvements.

Transportation accidents/incidents involving radioactive materials (1971--1991)

International Nuclear Information System (INIS)

Cashwell, C.E.; McClure, J.D.

1992-01-01

The Radioactive Materials Incident Report (RMIR) database contains information on transportation-related accidents and incidents involving radioactive materials that have occurred in the United States. The RMIR was developed at Sandia National Laboratories (SNL) to support its research and development program efforts for the US Department of Energy (DOE). This paper will address the following topics: background information on the regulations and process for reporting a hazardous materials transportation incident, overview data of radioactive materials transportation accidents and incidents, and additional information and summary data on how packagings have performed in accident conditions

Transportation accidents/incidents involving radioactive materials (1971-1991)

International Nuclear Information System (INIS)

Cashwell, C.E.; McClure, J.D.

1993-01-01

In 1981, Sandia National Laboratories developed the Radioactive Materials Incident Report (RMIR) database to support its research and development activities for the U.S. Department of Energy (DOE). The RMIR database contains information on transportation accidents/incidents with radioactive materials that have occurred since 1971. The RMIR classifies a transportation accident/incident in one of six ways: as a transportation accident, a handling accident, a reported incident, missing or stolen, cask weeping, or other. This paper will define these terms and provide detailed examples of each. (J.P.N.)

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

Science.gov (United States)

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

2017-11-03

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

Taxonometric Applications in Radiotherapy Incident Analysis

International Nuclear Information System (INIS)

Dunscombe, Peter B.; Ekaette, Edidiong U.; Lee, Robert C.; Cooke, David L.

2008-01-01

Recent publications in both the scientific and the popular press have highlighted the risks to which patients expose themselves when entering a healthcare system. Patient safety issues are forcing us to, not only acknowledge that incidents do occur, but also actively develop the means for assessing and managing the risks of such incidents. To do this, we ideally need to know the probability of an incident's occurrence, the consequences or severity for the patient should it occur, and the basic causes of the incident. A structured approach to the description of failure modes is helpful in terms of communication, avoidance of ambiguity, and, ultimately, decision making for resource allocation. In this report, several classification schemes or taxonomies for use in risk assessment and management are discussed. In particular, a recently developed approach that reflects the activity domains through which the patient passes and that can be used as a basis for quantifying incident severity is described. The estimation of incident severity, which is based on the concept of the equivalent uniform dose, is presented in some detail. We conclude with a brief discussion on the use of a defined basic-causes table and how adding such a table to the reports of incidents can facilitate the allocation of resources

Using hacked point and shoot cameras for time-lapse snow cover monitoring in an Alpine valley

Science.gov (United States)

Weijs, S. V.; Diebold, M.; Mutzner, R.; Golay, J. R.; Parlange, M. B.

2012-04-01

In Alpine environments, monitoring snow cover is essential get insight in the hydrological processes and water balance. Although measurement techniques based on LIDAR are available, their cost is often a restricting factor. In this research, an experiment was done using a distributed array of cheap consumer cameras to get insight in the spatio-temporal evolution of snowpack. Two experiments are planned. The first involves the measurement of eolic snow transport around a hill, to validate a snow saltation model. The second monitors the snowmelt during the melting season, which can then be combined with data from a wireless network of meteorological stations and discharge measurements at the outlet of the catchment. The poster describes the hardware and software setup, based on an external timer circuit and CHDK, the Canon Hack Development Kit. This latter is a flexible and developing software package, released under a GPL license. It was developed by hackers that reverse engineered the firmware of the camera and added extra functionality such as raw image output, more full control of the camera, external trigger and motion detection, and scripting. These features make it a great tool for geosciences. Possible other applications involve aerial stereo photography, monitoring vegetation response. We are interested in sharing experiences and brainstorming about new applications. Bring your camera!

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

NARCIS (Netherlands)

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

2009-01-01

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

Accidental nuclear excursion Recuplex operation 234-5 facility. Final report: Date of incident: April 7, 1962

Energy Technology Data Exchange (ETDEWEB)

1962-08-01

On Saturday morning, April 7, 1962, at about 1059 Armed Forces time, an accidental nuclear excursion occurred in the plutonium waste recovery facility (Recuplex) of the 234-5 Building. This excursion did not result in any mechanical damage or spread of contamination. Three employees of the General Electric Company received overexposures to gamma and neutron radiation. None were fatally exposed; in each case the overexposure was recognized promptly, and following medical observation and testing the men were released to return to work. In compliance with AEC Manual Chapter 0703, an AEC-HAPO committee composed of two AEC employees and five General Electric employees was appointed by the Manger, HOO, with the concurrence of the General Manager, HAPO, to conduct an investigation of the incident. The committee`s purpose was to determine the cause, nature, and extent of the incident, and recommend action to be taken by others to minimize or preclude future incidents of this magnitude. A study of operating practices and operating conditions that appeared to exist prior to, during, and subsequent to the accident was made by the committee. The committee believes that this report provides sufficient information to answer questions which may arise as a result of the criticality incident except those relating to its cause.

Critical steps in learning from incidents: using learning potential in the process from reporting an incident to accident prevention.

Science.gov (United States)

Drupsteen, Linda; Groeneweg, Jop; Zwetsloot, Gerard I J M

2013-01-01

Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.

Comparing electronic news media reports of potential bioterrorism-related incidents involving unknown white powder to reports received by the United States Centers for Disease Control and Prevention and the Federal Bureau of Investigation: U.S.A., 2009-2011.

Science.gov (United States)

Fajardo, Geroncio C; Posid, Joseph; Papagiotas, Stephen; Lowe, Luis

2015-01-01

There have been periodic electronic news media reports of potential bioterrorism-related incidents involving unknown substances (often referred to as "white powder") since the 2001 intentional dissemination of Bacillus anthracis through the U.S. Postal System. This study reviewed the number of unknown "white powder" incidents reported online by the electronic news media and compared them with unknown "white powder" incidents reported to the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Federal Bureau of Investigation (FBI) during a 2-year period from June 1, 2009 and May 31, 2011. Results identified 297 electronic news media reports, 538 CDC reports, and 384 FBI reports of unknown "white powder." This study showed different unknown "white powder" incidents captured by each of the three sources. However, the authors could not determine the public health implications of this discordance. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

International Cyber Incident Repository System: Information Sharing on a Global Scale

Energy Technology Data Exchange (ETDEWEB)

Joyce, Amanda L.; Evans, PhD, Nathaniel; Tanzman, Edward A.; Israeli, Daniel

2017-02-02

According to the 2016 Internet Security Threat Report, the largest number of cyber attacks were recorded last year (2015), reaching a total of 430 million incidents throughout the world. As the number of cyber incidents increases, the need for information and intelligence sharing increases, as well. This fairly large increase in cyber incidents is driving the need for an international cyber incident data reporting system. The goal of the cyber incident reporting system is to make available shared and collected information about cyber events among participating international parties. In its 2014 report, Insurance Industry Working Session Readout Report-Insurance for CyberRelated Critical Infrastructure Loss: Key Issues, on the outcomes of a working session on cyber insurance, the U.S. Department of Homeland Security observed that “many participants cited the need for a secure method through which organizations could pool and share cyber incident information” and noted that one underwriter emphasized the importance of internationally harmonized data taxonomies. This cyber incident data reporting system could benefit all nations that take part in reporting incidents to provide a more common operating picture. In addition, this reporting system could allow for trending and anticipated attacks and could potentially benefit participating members by enabling them to get in front of potential attacks. The purpose of this paper is to identify options for consideration for such a system in fostering cooperative cyber defense.

Real-time incident detection using social media data.

Science.gov (United States)

2016-05-09

The effectiveness of traditional incident detection is often limited by sparse sensor coverage, and reporting incidents to emergency response systems : is labor-intensive. This research project mines tweet texts to extract incident information on bot...

The role of the NEA incident reporting system in trend and pattern studies

International Nuclear Information System (INIS)

Ishack, G.; Iwabuchi, H.

1990-01-01

When the Incident Reporting System of the OECD Nuclear Energy Agency (NEA-IRS) was first instituted in 1980, Members recognized the fact that since the data thus collected only pertains to significant safety-related incidents, the system cannot be used for in-depth statistical analyses. Rather, the NEA-IRS is best suited, in addition to single event assessments, to studies that provide indications related to system, component or human performance; these indications could also initiate trend analyses on more complete data bases. Examples are the generic studies on the Loss of Containment Functions (completed last year) and the Loss of Residual Heat Removal (due for completion this year), and the studies related to the human factor. Another type of use of the IRS data was started last year by the NEA Principal Working Group 1 on Operating Experience and Human Factors (PWG 1) in response to the encouragement of the OECD/NEA Committee on the Safety of Nuclear Installations (CSNI), to make the best use of Operating Experience, notably of information disseminated through the NEA-IRS. These applications consisted of scanning the IRS data base for events that could be of interest to specialized domains such as radiation protection, fracture mechanics and fire protection. In the paragraphs which follow, some highlights of the results of these scans are presented (reference is made at the end of this paper to the reports detailing the results of these applications)

Estimating the incidence reporting rates of new influenza pandemics at an early stage using travel data from the source country.

Science.gov (United States)

Chong, K C; Fong, H F; Zee, C Y

2014-05-01

During the surveillance of influenza pandemics, underreported data are a public health challenge that complicates the understanding of pandemic threats and can undermine mitigation efforts. We propose a method to estimate incidence reporting rates at early stages of new influenza pandemics using 2009 pandemic H1N1 as an example. Routine surveillance data and statistics of travellers arriving from Mexico were used. Our method incorporates changes in reporting rates such as linearly increasing trends due to the enhanced surveillance. From our results, the reporting rate was estimated at 0·46% during early stages of the pandemic in Mexico. We estimated cumulative incidence in the Mexican population to be 0·7% compared to 0·003% reported by officials in Mexico at the end of April. This method could be useful in estimation of actual cases during new influenza pandemics for policy makers to better determine appropriate control measures.

What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group.

Science.gov (United States)

Caba Barrientos, F; Rodríguez Morillo, A; Galisteo Domínguez, R; Del Nozal Nalda, M; Almeida González, C V; Echevarría Moreno, M

2018-05-01

Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS). Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed. Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken. The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Growth Hacking, Dünyayı İşgal Eden Büyüklere Karşı Bir Kurtuluş Savaşı Olabilir mi?

OpenAIRE

FETTAHLIOĞLU, H. Seçil; AKDEMİR, Mehmet Alper

2016-01-01

Bilgi ekonomisinin etkisinin hissedildiği günümüz ortamında, internetin pazarlama üzerindeki rolü hızla artmaktadır. Dijital pazarlama, içerik pazarlaması, online pazarlama gibi bir çok başlık altında toplanabilecek olan; bilgi teknolojileri vasıtasıyla pazarlama faaliyetlerini ifade eden kavramlar “Growth Hacking (Büyüme Korsanlığı)” ile birlikte anılmaktadır. Büyüme korsanlığı, genellikle online girişimlerin, hızlı bir şekilde dijital pazarlama ve yazılım araçları vasıtasıyla büyütülmesi iç...

Password cracking

OpenAIRE

Χριστοφάκης, Μιχαήλ Κ.

2014-01-01

Information security is the next big thing in computers society because of the rapidly growing security incidents and the outcomes of those. Hacking and cracking existed even from the start of the eighties decade when there was the first step of the interconnection through the internet between humans. From then and ever after there was a big explosion of such incidents mostly because of the worldwide web which was introduced in the early nineties. Following the huge steps forward of computers...

USFA NFIRS 2013 Fire Incident & Cause Data

Data.gov (United States)

Department of Homeland Security — The 2013 Fire Causes & Incident data was provided by the U.S. Fire Administration’s (USFA) National Fire Data Center’s (NFDC’s) National Fire Incident Reporting...

40 CFR 68.81 - Incident investigation.

Science.gov (United States)

2010-07-01

... 40 Protection of Environment 15 2010-07-01 2010-07-01 false Incident investigation. 68.81 Section 68.81 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be...

Precursor incident program at EDF

International Nuclear Information System (INIS)

Fourest, B.; Maliverney, B.; Rozenholc, M.; Piovesan, C.

1998-01-01

The precursor program was started by EDF in 1994, after an investigation of the US NRC's Accident Sequence Precursor Program. Since then, reported operational events identified as Safety Outstanding Events have been analyzed whenever possible using probabilistic methods based on PSAs. Analysis provides an estimate of the remaining protection against core damage at the time the incident occurred. Measuring the incidents' severity enables to detect incidents important regarding safety. Moreover, the most efficient feedback actions can be derived from the main accident sequences identified through the analysis. Therefore, incident probabilistic analysis provides a way to assess priorities in terms of treatment and resource allocation, and so, to implement countermeasures preventing further occurrence and development of the most significant incidents. As some incidents cannot be analyzed using this method, probabilistic analysis can only be one among the methods used to assess the nuclear power plants' safety level. Nevertheless, it provides an interesting complement to classical methods of deterministic studies. (author)

Safety-related incidents at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Lehtinen, P.

1986-03-01

This report contains detailed descriptions of operating incidents and other safety-related matters at the Finnish nuclear power plants regarded as significant by the regulatory authority, the Finnish Centre for Radiation and Nuclear Safety. In this connection, an account is given of the practical actions caused by the incidents, and their significance to reactor safety is evaluated. The main features of the incidents are also described in the general Quartely Reports, Operation of Finnish Nuclear Power Plants, which are supplemented by this report intended for experts. (author)

Safety-related incidents at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Lehtinen, P.

1985-01-01

This report contains detailed descriptions of operating incidents and other safety-related matters at the Finnish nuclear power plants regarded as significant by the regulatory authority, the Finnish Centre for Radiation and Nuclear Safety. In this connection, an account is given of the practical actions caused by the incidents, and their significance to reactor safety is evaluated. The main features of the incidents are also described in the general Quartely Reports, Operation of Finnish Nuclear Power Plants, which are supplemented by this report intended for experts. (author)

Status Update on the NCRP Scientific Committee SC 5-1 Report: Decision Making for Late-Phase Recovery from Nuclear or Radiological Incidents - 13450

International Nuclear Information System (INIS)

Chen, S.Y.

2013-01-01

In August 2008, the U.S. Department of Homeland Security (DHS) issued its final Protective Action Guide (PAG) for radiological dispersal device (RDD) and improvised nuclear device (IND) incidents. This document specifies protective actions for public health during the early and intermediate phases and cleanup guidance for the late phase of RDD or IND incidents, and it discusses approaches to implementing the necessary actions. However, while the PAG provides specific guidance for the early and intermediate phases, it prescribes no equivalent guidance for the late-phase cleanup actions. Instead, the PAG offers a general description of a complex process using a site-specific optimization approach. This approach does not predetermine cleanup levels but approaches the problem from the factors that would bear on the final agreed-on cleanup levels. Based on this approach, the decision-making process involves multifaceted considerations including public health, the environment, and the economy, as well as socio-political factors. In an effort to fully define the process and approach to be used in optimizing late-phase recovery and site restoration following an RDD or IND incident, DHS has tasked the NCRP with preparing a comprehensive report addressing all aspects of the optimization process. Preparation of the NCRP report is a three-year (2010-2013) project assigned to a scientific committee, the Scientific Committee (SC) 5-1; the report was initially titled, Approach to Optimizing Decision Making for Late- Phase Recovery from Nuclear or Radiological Terrorism Incidents. Members of SC 5-1 represent a broad range of expertise, including homeland security, health physics, risk and decision analysis, economics, environmental remediation and radioactive waste management, and communication. In the wake of the Fukushima nuclear accident of 2011, and guided by a recent process led by the White House through a Principal Level Exercise (PLE), the optimization approach has since

Status Update on the NCRP Scientific Committee SC 5-1 Report: Decision Making for Late-Phase Recovery from Nuclear or Radiological Incidents - 13450

Energy Technology Data Exchange (ETDEWEB)

Chen, S.Y. [Environmental Science Division, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439 (United States)

2013-07-01

In August 2008, the U.S. Department of Homeland Security (DHS) issued its final Protective Action Guide (PAG) for radiological dispersal device (RDD) and improvised nuclear device (IND) incidents. This document specifies protective actions for public health during the early and intermediate phases and cleanup guidance for the late phase of RDD or IND incidents, and it discusses approaches to implementing the necessary actions. However, while the PAG provides specific guidance for the early and intermediate phases, it prescribes no equivalent guidance for the late-phase cleanup actions. Instead, the PAG offers a general description of a complex process using a site-specific optimization approach. This approach does not predetermine cleanup levels but approaches the problem from the factors that would bear on the final agreed-on cleanup levels. Based on this approach, the decision-making process involves multifaceted considerations including public health, the environment, and the economy, as well as socio-political factors. In an effort to fully define the process and approach to be used in optimizing late-phase recovery and site restoration following an RDD or IND incident, DHS has tasked the NCRP with preparing a comprehensive report addressing all aspects of the optimization process. Preparation of the NCRP report is a three-year (2010-2013) project assigned to a scientific committee, the Scientific Committee (SC) 5-1; the report was initially titled, Approach to Optimizing Decision Making for Late- Phase Recovery from Nuclear or Radiological Terrorism Incidents. Members of SC 5-1 represent a broad range of expertise, including homeland security, health physics, risk and decision analysis, economics, environmental remediation and radioactive waste management, and communication. In the wake of the Fukushima nuclear accident of 2011, and guided by a recent process led by the White House through a Principal Level Exercise (PLE), the optimization approach has since

Incidence of hyperthyroidism in Sweden.

Science.gov (United States)

Abraham-Nordling, Mirna; Byström, Kristina; Törring, Ove; Lantz, Mikael; Berg, Gertrud; Calissendorff, Jan; Nyström, Helena Filipsson; Jansson, Svante; Jörneskog, Gun; Karlsson, F Anders; Nyström, Ernst; Ohrling, Hans; Orn, Thomas; Hallengren, Bengt; Wallin, Göran

2011-12-01

The incidence of hyperthyroidism has been reported in various countries to be 23-93/100,000 inhabitants per year. This extended study has evaluated the incidence for ~40% of the Swedish population of 9 million inhabitants. Sweden is considered to be iodine sufficient country. All patients including children, who were newly diagnosed with overt hyperthyroidism in the years 2003-2005, were prospectively registered in a multicenter study. The inclusion criteria are as follows: clinical symptoms and/or signs of hyperthyroidism with plasma TSH concentration below 0.2 mIE/l and increased plasma levels of free/total triiodothyronine and/or free/total thyroxine. Patients with relapse of hyperthyroidism or thyroiditis were not included. The diagnosis of Graves' disease (GD), toxic multinodular goiter (TMNG) and solitary toxic adenoma (STA), smoking, initial treatment, occurrence of thyroid-associated eye symptoms/signs, and demographic data were registered. A total of 2916 patients were diagnosed with de novo hyperthyroidism showing the total incidence of 27.6/100,000 inhabitants per year. The incidence of GD was 21.0/100,000 and toxic nodular goiter (TNG=STA+TMNG) occurred in 692 patients, corresponding to an annual incidence of 6.5/100,000. The incidence was higher in women compared with men (4.2:1). Seventy-five percent of the patients were diagnosed with GD, in whom thyroid-associated eye symptoms/signs occurred during diagnosis in every fifth patient. Geographical differences were observed. The incidence of hyperthyroidism in Sweden is in a lower range compared with international reports. Seventy-five percent of patients with hyperthyroidism had GD and 20% of them had thyroid-associated eye symptoms/signs during diagnosis. The observed geographical differences require further studies.

Decreasing incidence rates of bacteremia

DEFF Research Database (Denmark)

Nielsen, Stig Lønberg; Pedersen, C; Jensen, T G

2014-01-01

BACKGROUND: Numerous studies have shown that the incidence rate of bacteremia has been increasing over time. However, few studies have distinguished between community-acquired, healthcare-associated and nosocomial bacteremia. METHODS: We conducted a population-based study among adults with first......-time bacteremia in Funen County, Denmark, during 2000-2008 (N = 7786). We reported mean and annual incidence rates (per 100,000 person-years), overall and by place of acquisition. Trends were estimated using a Poisson regression model. RESULTS: The overall incidence rate was 215.7, including 99.0 for community......-acquired, 50.0 for healthcare-associated and 66.7 for nosocomial bacteremia. During 2000-2008, the overall incidence rate decreased by 23.3% from 254.1 to 198.8 (3.3% annually, p incidence rate of community-acquired bacteremia decreased by 25.6% from 119.0 to 93.8 (3.7% annually, p

Rodenticide incidents of exposure and adverse effects on non-raptor birds

Science.gov (United States)

Vyas, Nimish B.

2017-01-01

Interest in the adverse effects of rodenticides on birds has focused primarily on raptors. However, non-raptor birds are also poisoned (rodenticide exposure resulting in adverse effects including mortality) by rodenticides through consumption of the rodenticide bait and contaminated prey. A literature search for rodenticide incidents (evidence of exposure to a rodenticide, adverse effects, or exposure to placebo baits) involving non-raptor birds returned 641 records spanning the years 1931 to 2016. The incidents included 17 orders, 58 families, and 190 non-raptor bird species. Nineteen anticoagulant and non-anticoagulant rodenticide active ingredients were associated with the incidents. The number of incidents and species detected were compared by surveillance method. An incident was considered to have been reported through passive surveillance if it was voluntarily reported to the authorities whereas the report of an incident found through field work that was conducted with the objective of documenting adverse effects on birds was determined to be from active surveillance. More incidents were reported from passive surveillance than with active surveillance but a significantly greater number of species were detected in proportion to the number of incidents found through active surveillance than with passive surveillance (z = 7.61, p raptor bird poisonings from rodenticides may increase incident reportings and can strengthen the predictions of harm characterized by risk assessments.

A Meta-Analysis of the Incidence of Patient-Reported Dysphagia After Anterior Cervical Decompression and Fusion with the Zero-Profile Implant System.

Science.gov (United States)

Yang, Yi; Ma, Litai; Liu, Hao; Xu, MangMang

2016-04-01

Dysphagia is a well-known complication following anterior cervical surgery. It has been reported that the Zero-profile Implant System can decrease the incidence of dysphagia following surgery, however, dysphagia after anterior cervical decompression and fusion (ACDF) with the Zero-profile Implant System remains controversial. Previous studies only focus on small sample sizes. The objective of this study was to determine the incidence of dysphagia after ACDF with the Zero-profile Implant System. Studies were collected from PubMed, EMBASE, the Cochrane library and the China Knowledge Resource Integrated Database using the keywords "Zero-profile OR Zero-p) AND (dysphagia OR [swallowing dysfunction]". The software STATA (Version 13.0) was used for statistical analysis. Statistical heterogeneity across the various trials, a test of publication bias and sensitivity analysis was performed. 30 studies with a total of 1062 patients were included in this meta-analysis. The occurrence of post-operative transient dysphagia ranged from 0 to 76 % whilst the pooled incidence was 15.6 % (95 % CI, 12.6, 18.5 %). 23 studies reported no persistent dysphagia whilst seven studies reported persistent dysphagia ranging from 1 to 7 %). In summary, the present study observed a low incidence of both transient and persistent dysphagia after ACDF using the Zero-profile Implant System. Most of the dysphagia was mild and gradually decreased during the following months. Moderate or severe dysphagia was uncommon. Future randomized controlled multi-center studies and those focusing on the mechanisms of dysphagia and methods to reduce its incidence are required.

Contaminated Mexican steel incident

International Nuclear Information System (INIS)

1985-01-01

This report documents the circumstances contributing to the inadvertent melting of cobalt 60 (Co-60) contaminated scrap metal in two Mexican steel foundries and the subsequent distribution of contaminated steel products into the United States. The report addresses mainly those actions taken by US Federal and state agencies to protect the US population from radiation risks associated with the incident. Mexico had much more serious radiation exposure and contamination problems to manage. The United States Government maintained a standing offer to provide technical and medical assistance to the Mexican Government. The report covers the tracing of the source to its origin, response actions to recover radioactive steel in the United States, and return of the contaminated materials to Mexico. The incident resulted in significant radiation exposures within Mexico, but no known significant exposure within the United States. Response to the incident required the combined efforts of the Nuclear Regulatory Commission (NRC), Department of Energy, Department of Transportation, Department of State, and US Customs Service (Department of Treasury) personnel at the Federal level and representatives of all 50 State Radiation Control Programs and, in some instances, local and county government personnel. The response also required a diplomatic interface with the Mexican Government and cooperation of numerous commercial establishments and members of the general public. The report describes the factual information associated with the event and may serve as information for subsequent recommendations and actions by the NRC. 8 figures

Review of methodologies for analysis of safety incidents at NPPs. Final report of a co-ordinated research project 1998-2001

International Nuclear Information System (INIS)

2002-03-01

The safe operation of nuclear power plants around the world and the prevention of incidents in these installations remain key concerns for the nuclear community. In this connection, the feedback of operating experience plays a major role: every nuclear power plant or nuclear utility needs to have a system in place for collecting information on unusual events, whether these are incidents or merely deviations from normal operation. Reporting to the regulatory body of important events and lessons learned is normally carried out through the national reporting schemes based on regulatory reporting requirements. The most important lessons learned are further shared internationally, through, for example, the Joint IAEA/NEA Incident Reporting System (IRS) or the event information exchange of the World Association of Nuclear Operators (WANO). In order to properly assess the event, an adequate event investigation methodology has to be applied, which leads to the identification of correct root causes. Once these root causes have been ascertained, appropriate corrective actions can be established and corresponding lessons can be drawn. The overall goal of root cause analysis is the prevention of events or their recurrence and thus the overall improvement in plant safety. In 1998, the IAEA established a co-ordinated research project with the objective of exploring root cause methodologies and techniques currently in use in Member States, evaluating their strengths and limitations and developing criteria for appropriate event investigation methodologies. This report is the outcome of four years of co-ordinated research which involved 15 national and international research organizations

Trunk muscle activation in the back and hack squat at the same relative loads.

Science.gov (United States)

Clark, David R; Lambert, Michael I; Hunter, Angus M

2017-07-12

The hack squat (HS) is likely to produce a greater 1 repetition maximum (1RM) compared to the back squat (BS). This can be attributed to the support of the trunk during the HS compared to no support during BS. This support however, may compromise trunk muscle activation (TMA), therefore producing different training adaptations. Accordingly, the purpose of this study was to compare 1RM in BS and HS and TMA at 4 relative loads, 65, 75, 85 and 95% of maximal system mass. Ten males completed 3 test sessions:1) BS and HS 1RM, 2) HS & BS neuromuscular test familiarization, and, 3) Neuromuscular test for 3 reps at 4 loads for BS and HS. BS TMA was significantly greater (p<0.05) than HS for all muscles and phases except rectus abdominus in concentric phase. TMA increased (p<0.05) with load in all muscles for both exercises and phases apart from lumbar sacral erector spinae in HS eccentric phase. Mean HS 1RM and submaximal loads were significantly (p<0.0001) higher than the equivalent BS loads. Duration of the eccentric phase was higher (p<0.01) in HS than BS but not different in concentric phase. Duration increased significantly (p<0.01) with load in both exercises and both phases. Despite higher absolute tests loads in HS, TMA was higher in BS. TMA is sensitive to load in both exercises. BS is more effective than HS in activating the muscles of the trunk and therefore arguably more effective in developing trunk strength and stability for dynamic athletic performance.

Self-Reported Periodontitis and Incident Type 2 Diabetes among Male Workers from a 5-Year Follow-Up to MY Health Up Study.

Directory of Open Access Journals (Sweden)

Atsushi Miyawaki

Full Text Available The purpose of this study was to examine whether periodontitis is associated with incident type 2 diabetes in a Japanese male worker cohort.The study participants were Japanese men, aged 36-55 years, without diabetes. Data were extracted from the MY Health Up study, consisting of self-administered questionnaire surveys at baseline and following annual health examinations for an insurance company in Japan. The oral health status of the participants was classified by two self-reported indicators: (1 gingival hemorrhage and (2 tooth loosening. Type 2 diabetes incidence was determined by self-reporting or blood test data. Modified Poisson regression approach was used to estimate the relative risks and the 95% confidence intervals of incident diabetes with periodontitis. Covariates included age, body mass index, family history of diabetes, hypertension, current smoking habits, alcohol use, dyslipidemia, and exercise habits.Of the 2895 candidates identified at baseline in 2004, 2469 men were eligible for follow-up analysis, 133 of whom were diagnosed with diabetes during the 5-year follow-up period. Tooth loosening was associated with incident diabetes [adjusted relative risk = 1.73, 95% confidence interval = 1.14-2.64] after adjusting for other confounding factors. Gingival hemorrhage displayed a similar trend but was not significantly associated with incident diabetes [adjusted relative risk = 1.32, 95% confidence interval = 0.95-1.85].Tooth loosening is an independent predictor of incident type 2 diabetes in Japanese men.

Cyber security in nuclear industry – Analytic study from the terror incident in nuclear power plants (NPPs)

International Nuclear Information System (INIS)

Cho, Hyo Sung; Woo, Tae Ho

2017-01-01

Highlights: • The cyber terrorism in NPPs of South Korea shows the study motivations. • Analyses of the cyber terrorism in NPPs are investigated. • Designed solutions for the cyber terrorism in NPPs are discussed. • South Korean case is considered as the cyber terrorism in NPPs. - Abstract: The cyber terrorism for nuclear power plants (NPPs) is investigated for the analytic study following the South Korean case on December 2014. There are several possible cyber terror attacks in which the twelve cases are studied for the nuclear terror cases including the computer hacking and data stealing. The defense-in-depth concept is compared for cyber terrorism, which was imported from the physical terror analysis. The conventional three conditions of the physical protection system (PPS) are modified as prevention, detection, and response. The six cases are introduced for the solutions of the facility against the possible cyber terrorism in NPPs. The computer hacking methods and related solutions are analyzed for the applications in the nuclear industry. The nuclear security in the NPPs could be an extremely serious condition and the remedies are very important in the safe plant operations. In addition, the quantitative modeling study is performed.

Self-reported whole-grain intake and plasma alkylresorcinol concentrations in combination in relation to the incidence of colorectal cancer

DEFF Research Database (Denmark)

Knudsen, Markus Dines; Kyrø, Cecilie; Olsen, Anja

2014-01-01

-grain consumption (HELGA, 1992-1998). Incidence rate ratios and 95% confidence intervals were calculated using conditional logistic regression. Plasma alkylresorcinol concentrations alone and Howe's score with ranks were inversely associated with the incidence of distal colon cancer when the highest quartile...... (colon, proximal, distal or rectum cancer) when using an FFQ as the measure/exposure variable for whole-grain intake. The results suggest that assessing whole-grain intake using a combination of FFQs and biomarkers slightly increases the precision in estimating the risk of colon or rectal cancer......Self-reported food frequency questionnaires (FFQs) have occasionally been used to investigate the association between whole-grain intake and the incidence of colorectal cancer, but the results from those studies have been inconsistent. We investigated this association using intakes of whole grains...

Homicide-suicide in Ghana: perpetrators, victims, and incidence characteristics.

Science.gov (United States)

Adinkrah, Mensah

2014-03-01

Homicide-suicide in the industrialized West has been studied for many years. Yet, only limited scholarly research currently exists on the subject in Africa and other non-Western societies. The aim of the present descriptive study was to investigate homicide-suicides in contemporary Ghana. A content analysis of homicide-suicide reports in a major Ghanaian daily newspaper during 1990 to 2009 was conducted. The results overwhelmingly support findings in the literature, suggesting that homicide-suicides are extremely rare events in Ghana. The overwhelming majority of reported homicide-suicides were committed by males, with females substantially more likely to be the homicide victims. The offenders and victims were generally of low socioeconomic status. Most homicide-suicides involved victims and offenders who were intimately acquainted as family members. The majority of cases involved men who killed their wives on suspicion of infidelity; the next largest category involved men who murdered wives who threatened divorce or separation. The principal homicide and suicide methods were shooting with firearms, hacking with machetes, and stabbing with knives. The findings of the study are discussed in relation to Ghana's patriarchal family system and ideology and present socioeconomic issues in the country. This study recommends further research on this subject in Ghana and other African countries. This is necessary to further an understanding of homicide-suicide as a phenomenon, as well as a necessary prelude to the development and implementation of effective preventive programs.

The role of patient simulation and incident reporting in the development and evaluation of medical devices and the training of their users

DEFF Research Database (Denmark)

Dieckmann, P; Rall, M; Østergaard, Doris

2009-01-01

incident report. Simulation can serve as a laboratory to analyse such cases and to create relevant and effective training scenarios based on such analyses. We will describe a methodological framework for analysing simulation scenarios in a way that allows discovering and discussing mismatches between...... conceptual models of the device design and mental models users hold about the device and its use. We further describe how incident reporting systems can be used as one source of data to conduct the necessary needs analyses - both for training and further needs for closer analysis of specific devices or some...

The incidence and aetiology of acute pancreatitis across Europe.

Science.gov (United States)

Roberts, Stephen E; Morrison-Rees, Sian; John, Ann; Williams, John G; Brown, Tim H; Samuel, David G

Acute pancreatitis is increasingly one of the most important acute gastrointestinal conditions throughout much of the world, although incidence and aetiology varies across countries and regions. This study investigated regional and national patterns in the incidence and aetiology of acute pancreatitis, demographic patterns in incidence and trends over time in incidence across Europe. A structured review of acute pancreatitis incidence and aetiology from studies of hospitalised patient case series, cohort studies or other population based studies from 1989 to 2015 and a review of trends in incidence from 1970 to 2015 across all 51 European states. The incidence of acute pancreatitis was reported from 17 countries across Europe and ranged from 4.6 to 100 per 100 000 population. Incidence was usually highest in eastern or northern Europe, although reported rates often varied according to case ascertainment criteria. Of 20 studies that reported on trends in incidence, all but three show percentage increases over time (overall median increase = 3.4% per annum; range = -0.4%-73%). The highest ratios of gallstone to alcohol aetiologies were identified in southern Europe (Greece, Turkey, Italy and Croatia) with lowest ratios mainly in eastern Europe (Latvia, Finland, Romania, Hungary, Russia and Lithuania). The incidence of acute pancreatitis varies across Europe. Gallstone is the dominant aetiology in southern Europe and alcohol in eastern Europe with intermediate ratios in northern and western Europe. Acute pancreatitis continues to increase throughout most of Europe. Copyright © 2017. Published by Elsevier B.V.

IAEA/NEA incident reporting system (IRS). Reporting guidelines. Feedback from safety related operating experience for nuclear power plants

International Nuclear Information System (INIS)

1998-01-01

The Incident Reporting System (IRS) is an international system jointly operated by the International Atomic Energy Agency (IAEA) and the Nuclear Energy Agency of the Organisation for Economic Cooperation and Development (OECD/NEA). The fundamental objective of the IRS is to contribute to improving the safety of commercial nuclear power plants (NPPs) which are operated worldwide. This objective can be achieved by providing timely and detailed information on both technical and human factors related to events of safety significance which occur at these plants. The purpose of these guidelines, which supersede the previous IAEA Safety Series No. 93 (Part II) and the NEA IRS guidelines, is to describe the system and to give users the necessary background and guidance to enable them to produce IRS reports meeting a high standard of quality while retaining the high efficiency of the system expected by all Member States operating nuclear power plants. These guidelines have been jointly developed and approved by the NEA/IAEA

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

Science.gov (United States)

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

2014-01-01

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

Invasive cancer incidence - Puerto Rico, 2007-2011.

Science.gov (United States)

O'Neil, Mary Elizabeth; Henley, S Jane; Singh, Simple D; Wilson, Reda J; Ortiz-Ortiz, Karen J; Ríos, Naydi Pérez; Torres Cintrón, Carlos R; Luna, Guillermo Tortolero; Zavala Zegarra, Diego E; Ryerson, A Blythe

2015-04-17

Cancer is a leading cause of morbidity and death in Puerto Rico. To set a baseline for identifying new trends and patterns of cancer incidence, Puerto Rico Central Cancer Registry staff and CDC analyzed data from Puerto Rico included in U.S. Cancer Statistics (USCS) for 2007-2011, the most recent data available. This is the first report of invasive cancer incidence rates for 2007-2011 among Puerto Rican residents by sex, age, cancer site, and municipality. Cancer incidence rates in Puerto Rico were compared with those in the U.S. population for 2011. A total of 68,312 invasive cancers were diagnosed and reported in Puerto Rico during 2007-2011. The average annual incidence rate was 330 cases per 100,000 persons. The cancer sites with the highest cancer incidence rates included prostate (152), female breast (84), and colon and rectum (43). Cancer incidence rates varied by municipality, particularly for prostate, lung and bronchus, and colon and rectum cancers. In 2011, cancer incidence rates in Puerto Rico were lower for all cancer sites and lung and bronchus, but higher for prostate and thyroid cancers, compared with rates within the U.S. Identifying these variations can aid evaluation of factors associated with high incidence, such as cancer screening practices, and development of targeted cancer prevention and control efforts. Public health professionals can monitor cancer incidence trends and use these findings to evaluate the impact of prevention efforts, such as legislation prohibiting tobacco use in the workplace and public places and the Puerto Rico Cessation Quitline in decreasing lung and other tobacco-related cancers.

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)

Radiological incidents in industrial gamma radiography in the Philippines, 1979-1993

International Nuclear Information System (INIS)

Borras, A.M.

1994-01-01

Among the many practices of radiation sources, the practice of industrial gamma radiography in the country has the most number of reported radiological incidents. During the past fourteen (14) years, from 1979-1993, twenty (20) incidents that have occurred were reported to the Institute. This paper presents the nature and extent of the 20 reported incidents as well as the results of the analysis of why these incidents happened. The results of the analysis showed that the causes of these incidents are mainly human error and equipment failure. Hence, the factors that can minimize or prevent the chance of occurrence and/or recurrence of incidents and in minimizing the hazard in case of radiological incidents are: a) proper training and re-training of personnel; b) proper and regular inspection and maintenance of equipment; c) adequate radiation survey; and d) proper storage and inventory of the radiography sealed sources. (author). 3 refs.; 5 figs.; 1 tab

Police Incident Blotter (Archive)

Data.gov (United States)

Allegheny County / City of Pittsburgh / Western PA Regional Data Center — The Police Blotter Archive contains crime incident data after it has been validated and processed to meet Uniform Crime Reporting (UCR) standards, published on a...

Classification of medication incidents associated with information technology.

Science.gov (United States)

Cheung, Ka-Chun; van der Veen, Willem; Bouvy, Marcel L; Wensing, Michel; van den Bemt, Patricia M L A; de Smet, Peter A G M

2014-02-01

Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals. The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary. The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process. From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital. A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

A five-year history of hazardous materials incidents in Chester County, PA

International Nuclear Information System (INIS)

Shorten, C.V.; McNamara, J.

1993-01-01

The Emergency Planning and Community Right-to-Know Act (EPCRA) of 1986 established Local Emergency Planning Committees (LEPCs) to oversee emergency response planning at the community level. In Pennsylvania, each county was assigned its own LEPC, and Chester County held its first LEPC meeting on October 15, 1987. From the data of that meeting through September 1992, 300 hazardous materials incidents have been reported. The majority of these incidents were met with fire department response, but several warranted response by hazardous materials teams. This report presents an analysis of the database of reported hazardous materials incidents in Chester County, including chemical identification, amount released, type of response, location, and trends. Over 235 of the reported spills were either gasoline, diesel fuel, home heating oil, or kerosene, often in five to 50 gallon amounts from transportation accidents. A number of extremely hazardous substance (EHS) incidents were reported, however, including sulfuric acid, chlorine, ammonia, phosphorus, formaldehyde, bromine, methyl mercaptan, and hydrofluoric acid. The most commonly released EHS's were ammonia and chlorine. The number of hazardous materials incidents reported in Chester County increased from only 14 in 1988 to 95 in 1991, with 67 in 1992 through September. This dramatic increase is attributable to both increased reporting and an increased number of incidents. This database clearly indicates both the success of EPCRA reporting system and the magnitude of hazardous materials incidents in this part of Pennsylvania

Dissociative Tendencies and Traffic Incidents

Directory of Open Access Journals (Sweden)

Valle, Virginia

2012-01-01

Full Text Available This paper analyses the relationship between dissociative experiences and road traffic incidents (crashes and traffic tickets in drivers (n=295 from Mar del Plata (Argentina city. A self-report questionnaire was applied to assess traffic crash involvement and sociodemographic variables. Dissociative tendencies were assessed by a modified version of the DES scale. To examine differences in DES scores tests of the difference of means were applied. Drivers who reported to be previously involved in traffic incidents obtained higher puntuations in the dissociative experiences scale than drivers who did not report such events. This result is observed for the total scale and for the three sub-scales (absorption, amnesia and depersonalization. However, differences appeared mainly for minor damage collisions. Further studies are needed to evaluate the role of dissociative tendencies as a risk factor in road traffic safety.

[Rules and regulations applying to incidents in radiotherapy].

Science.gov (United States)

Lohr, F; Baus, W; Vorwerk, H; Schlömp, B; André, L; Georg, D; Hodapp, N

2012-07-01

Radiotherapy is an essential and reliable element of the treatment armamentarium in oncology. Numerous rules, regulations, and protocols minimize the associated risks. It can, however, never be excluded that errors in the treatment delivery chain result in inadequate tumor doses or unnecessary damage to organs at risk. A legal framework governs the management of such incidents. The most important European and North American regulations are reported. Various directives issued by the European Union are differently implemented nationally. This applies particularly to the characterization of incidents that must be reported to authorities. Reporting thresholds, audit systems, and the extent of the integration of voluntary reporting systems vary. Radiotherapy incidents are dealt with differently on an international level. Changes are to be expected based on the European Basic Safety Standards Directive that is currently being prepared and will have to be implemented nationally in due course.

Rules and regulations applying to incidents in radiotheraphy

International Nuclear Information System (INIS)

Lohr, F.; Andre, L.; Georg, D.; Hodapp, N.

2012-01-01

Aims and purpose: Radiotherapy is an essential and reliable element of the treatment armamentarium in oncology. Numerous rules, regulations, and protocols minimize the associated risks. It can, however, never be excluded that errors in the treatment delivery chain result in inadequate tumor doses or unnecessary damage to organs at risk. A legal framework governs the management of such incidents. The most important European and North American regulations are reported. Results: Various directives issued by the European Union are differently implemented nationally. This applies particularly to the characterization of incidents that must be reported to authorities. Reporting thresholds, audit systems, and the extent of the integration of voluntary reporting systems vary. Conclusion: Radiotherapy incidents are dealt with differently on an international level. Changes are to be expected based on the European Basic Safety Standards Directive that is currently being prepared and will have to be implemented nationally in due course. (orig.)

Analysis of Aviation Safety Reporting System Incident Data Associated With the Technical Challenges of the Vehicle Systems Safety Technology Project

Science.gov (United States)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

This analysis was conducted to support the Vehicle Systems Safety Technology (VSST) Project of the Aviation Safety Program (AVsP) milestone VSST4.2.1.01, "Identification of VSST-Related Trends." In particular, this is a review of incident data from the NASA Aviation Safety Reporting System (ASRS). The following three VSST-related technical challenges (TCs) were the focus of the incidents searched in the ASRS database: (1) Vechicle health assurance, (2) Effective crew-system interactions and decisions in all conditions; and (3) Aircraft loss of control prevention, mitigation, and recovery.

Gastric sarcoidosis in children: A case report and review of the ...

African Journals Online (AJOL)

Sherif A. Sadek

2013-03-07

Mar 7, 2013 ... Corticosteroid therapy was started and the symptoms aba- ted almost .... of a dry hacking cough, with or without dyspnea. Bilateral hi- ... Visual symptoms such as eye pain, blurry vision, photophobia, ... Oral prednisolone. 324.

Appendix : airborne incidents : an econometric analysis of severity

Science.gov (United States)

2014-12-19

This is the Appendix for Airborne Incidents: An Econometric Analysis of Severity Report. : Airborne loss of separation incidents occur when an aircraft breaches the defined separation limit (vertical and/or horizontal) with another aircraft or terrai...

29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

Science.gov (United States)

2010-07-01

... to OSHA. 1904.39 Section 1904.39 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY... fatalities and multiple hospitalization incidents to OSHA. (a) Basic requirement. Within eight (8) hours... Administration (OSHA), U.S. Department of Labor, that is nearest to the site of the incident. You may also use...

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

Science.gov (United States)

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

2015-01-01

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

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.

Laser exposure incidents: pilot ocular health and aviation safety issues.

Science.gov (United States)

Nakagawara, Van B; Wood, Kathryn J; Montgomery, Ron W

2008-09-01

A database of aviation reports involving laser illumination of flight crewmembers has been established and maintained at the Civil Aerospace Medical Institute. A review of recent laser illumination reports was initiated to investigate the significance of these events. Reports that involved laser exposures of civilian aircraft in the United States were analyzed for the 13-month period (January 1, 2004, through January 31, 2005). There were 90 reported instances of laser illumination during the study period. A total of 53 reports involved laser exposure of commercial aircraft. Lasers illuminated the cockpit in 41 (46%) of the incidents. Of those, 13 (32%) incidents resulted in a visual impairment or distraction to a pilot, including 1 incident that reportedly resulted in an ocular injury. Nearly 96% of these reports occurred in the last 3 months of the study period. There were no aviation accidents in which laser light illumination was found to be a contributing factor. Operational problems have resulted from laser illumination incidents in the national airspace system. Eye care practitioners, to provide effective consultations to their pilot patients, should be familiar with the problems that can occur with laser exposure.

Critical incident monitoring in anaesthesia.

Science.gov (United States)

Choy, Y C

2006-12-01

Critical incident monitoring in anaesthesia is an important tool for quality improvement and maintenance of high safety standards in anaesthetic services. It is now widely accepted as a useful quality improvement technique for reducing morbidity and mortality in anaesthesia and has become part of the many quality assurance programmes of many general hospitals under the Ministry of Health. Despite wide-spread reservations about its value, critical incident monitoring is a classical qualitative research technique which is particularly useful where problems are complex, contextual and influenced by the interaction of physical, psychological and social factors. Thus, it is well suited to be used in probing the complex factors behind human error and system failure. Human error has significant contributions to morbidities and mortalities in anaesthesia. Understanding the relationships between, errors, incidents and accidents is important for prevention and risk management to reduce harm to patients. Cardiac arrests in the operating theatre (OT) and prolonged stay in recovery, constituted the bulk of reported incidents. Cardiac arrests in OT resulted in significant mortality and involved mostly de-compensated patients and those with unstable cardiovascular functions, presenting for emergency operations. Prolonged-stay in the recovery extended period of observation for ill patients. Prolonged stay in recovery was justifiable in some cases, as these patients needed a longer period of post-operative observation until they were stable enough to return to the ward. The advantages of the relatively low cost, and the ability to provide a comprehensive body of detailed qualitative information, which can be used to develop strategies to prevent and manage existing problems and to plan further initiatives for patient safety makes critical incident monitoring a valuable tool in ensuring patient safety. The contribution of critical incident reporting to the issue of patient safety is

Radiological Cs-137 accidents/incidents in Estonia

International Nuclear Information System (INIS)

Sinisso, Mark

1997-01-01

Two radiological accidents/incidents in Estonia are reported. The first -21 October 1994, three brothers entered the Tammiku repository and stole a radioactive Cs-137 source and received dangerous doses of radiation. The other incident (early 1995) involved an abandoned source - a discarded metal cylinder containing Cs-137. Chronologies and factual data are considered for both events. Concise descriptions of the incidents, a medical overview of the fate of injured people and lessons learned are presented

Radiological Cs-137 accidents/incidents in Estonia

Energy Technology Data Exchange (ETDEWEB)

Sinisso, Mark [Ministry of Foreign Affairs, Tallin (Estonia)

1997-12-31

Two radiological accidents/incidents in Estonia are reported. The first -21 October 1994, three brothers entered the Tammiku repository and stole a radioactive Cs-137 source and received dangerous doses of radiation. The other incident (early 1995) involved an abandoned source - a discarded metal cylinder containing Cs-137. Chronologies and factual data are considered for both events. Concise descriptions of the incidents, a medical overview of the fate of injured people and lessons learned are presented

Incidence of self-reported brain injury and the relationship with substance abuse: findings from a longitudinal community survey

Directory of Open Access Journals (Sweden)

Butterworth Peter

2010-03-01

Full Text Available Abstract Background Traumatic or serious brain injury (BI has persistent and well documented adverse outcomes, yet 'mild' or 'moderate' BI, which often does not result in hospital treatment, accounts for half the total days of disability attributed to BI. There are currently few data available from community samples on the incidence and correlates of these injuries. Therefore, the study aimed to assess the 1 incidence of self-reported mild (not requiring hospital admission and moderate (admitted to hospital brain injury (BI, 2 causes of injury 3 physical health scores and 4 relationship between BI and problematic alcohol or marijuana use. Methods An Australian community sequential-cohort study (cohorts aged 20-24, 40-44 and 60-64 years at wave one used a survey methodology to assess BI and substance use at baseline and four years later. Results Of the 7485 wave one participants, 89.7% were re-interviewed at wave two. There were 56 mild (230.8/100000 person-years and 44 moderate BI (180.5/100000 person-years reported between waves one and two. Males and those in the 20-24 year cohort had increased risk of BI. Sports injury was the most frequent cause of BI (40/100 with traffic accidents being a greater proportion of moderate (27% than mild (7% BI. Neither alcohol nor marijuana problems at wave one were predictors of BI. BI was not a predictor of developing substance use problems by wave two. Conclusions BI were prevalent in this community sample, though the incidence declined with age. Factors associated with BI in community samples differ from those reported in clinical samples (e.g. typically traumatic brain injury with traffic accidents the predominate cause. Further, detailed evaluation of the health consequences of these injuries is warranted.

Survey of incidents in West German nuclear power plants in the last quarter of the year 1988

International Nuclear Information System (INIS)

1989-01-01

There were 79 incidents reported. Six incidents belong to reporting category E (immediate notification), the remaining 73 incidents belong to reporting category N (normal notification). The survey covers all incidents reported to GRS until the 15th of February 1989 and also includes incidents that happened before the last quarter of 1988 but were recorded later. There was no release of radioactivity involved in the incidents, and there are no effects on man or the environment reported. (orig./HP) [de

The CSB Incident Screening Database: description, summary statistics and uses.

Science.gov (United States)

Gomez, Manuel R; Casper, Susan; Smith, E Allen

2008-11-15

This paper briefly describes the Chemical Incident Screening Database currently used by the CSB to identify and evaluate chemical incidents for possible investigations, and summarizes descriptive statistics from this database that can potentially help to estimate the number, character, and consequences of chemical incidents in the US. The report compares some of the information in the CSB database to roughly similar information available from databases operated by EPA and the Agency for Toxic Substances and Disease Registry (ATSDR), and explores the possible implications of these comparisons with regard to the dimension of the chemical incident problem. Finally, the report explores in a preliminary way whether a system modeled after the existing CSB screening database could be developed to serve as a national surveillance tool for chemical incidents.

Introduction of a prehospital critical incident monitoring system--pilot project results.

Science.gov (United States)

Stella, Julian; Davis, Anna; Jennings, Paul; Bartley, Bruce

2008-01-01

Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited. Implementation of an incident monitoring process in a prehospital setting. This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations. Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for

Agency procedures for the NRC incident response plan. Final report

International Nuclear Information System (INIS)

1983-02-01

The NRC Incident Response Plan, NUREG-0728/MC 0502 describes the functions of the NRC during an incident and the kinds of actions that comprise an NRC response. The NRC response plan will be activated in accordance with threshold criteria described in the plan for incidents occurring at nuclear reactors and fuel facilities involving materials licensees; during transportation of licensed material, and for threats against facilities or licensed material. In contrast to the general overview provided by the Plan, the purpose of these agency procedures is to delineate the manner in which each planned response function is performed; the criteria for making those response decisions which can be preplanned; and the information and other resources needed during a response. An inexperienced but qualified person should be able to perform functions assigned by the Plan and make necessary decisions, given the specified information, by becoming familiar with these procedures. This rule of thumb has been used to determine the amount of detail in which the agency procedures are described. These procedures form a foundation for the training of response personnel both in their normal working environment and during planned emergency exercises. These procedures also form a ready reference or reminder checklist for technical team members and managers during a response

Incident Reporting in Mashhad Hospitals

Directory of Open Access Journals (Sweden)

Davoodi R

2013-10-01

Full Text Available Objectives: In this study, our aim was to evaluate and classify the voluntary error reports in the hospitals of Mashhad University of Medical Sciences. Patients have the right to receive health care in accordance to the best standards. Health care carries a risk of harm for patient safety, and with respect to today’s stressful systems with a large number of patients, it would be inevitable. The meaning of risk management is to predict adverse events and reduce their occurrence.Materials and Methods: A voluntary medical error reporting form was designed and approved by the clinical governance team of Mashhad Medical University. They were then distributed inside hospitals in the way in which everyone (health providers and patients could access them easily. The forms were collected and classified monthly in all wards. Classification was performed on the base of type, outcome and reporter. Data gathering took place from spring to autumn 2012. The data was analyzed by the SPSS software. Results: 2500 errors were extracted from 1000 voluntary error reporting forms of the 12 hospitals of Mashhad Medical University. The most frequent error type was treatment errors (36% related to drug administration, standard procedures and surgical events. Conclusions: Error reporting as a basic activity has an important role in discovering pitfalls of the health care system. To promote the reporting culture, its non punitive base must become clear for all professors and staff members, because this kind of reporting could lead to fewer medical errors and higher staff awareness about probable errors.

Communicating the Improvements Developed from Critical Incident Reports is an Essential Part of CIRS.

Science.gov (United States)

Hubertus, J; Piehlmeier, W; Heinrich, M

2016-09-01

The Critical Incident Reporting System (CIRS) is a tool for employees to report anonymously of near misses. Its efficiency and improvement of safety is proved by many studies. Our department introduced CIRS in 2009 and it is used frequently. As the number of reports decreased over time we asked for factors responsible for the reduced use. All employees had access to CIRS and have been trained in several courses of instruction. Accomplished results and consequences were published in biannual newsletters. In 2014 we initiated an anonymous employee attitude survey to ask for their experience and satisfaction with CIRS. 88 near misses were reported since 2009. 44 (50%) reports were classified as RS1, 34 (38.6%) as RS2, and 10 (11.4%) as RS3. No RS4 reports were notified. Most reports concerned problems with administration of medication (n=26; 29.5%) and problems with technical devices (n=18; 20.5%). 75 (83%) of our employees participated in the survey. 64 (86.5%) discerned that CIRS is anonymous. 31 (41.9%) reported already a near miss. Of note, two-third didn't realize an improvement following their report. On the other hand, only half of the pollees stated to read the newsletter. Even if efficiency and advantages of CIRS are proved and undeniable, sufficient and perpetual feedback of results and improvements developed by the CIRS team and regular trainings of the employees are mandatory for the success of CIRS. © Georg Thieme Verlag KG Stuttgart · New York.

Using the critical incident survey to assess hospital service quality.

Science.gov (United States)

Longo, B; Connor, G; Barnhart, T

1993-01-01

This survey was designed to determine "standards of excellence" in hospital services as defined by (a) former patients, (b) physicians, (c) hospital employees, and (d) corporate insurance subscribers. One hundred forty-seven (147) patients, 188 employees, and 20 corporate subscribers were interviewed by telephone, and 52 physicians were interviewed in their offices. The interview consisted of a single question: "Can you think of a time when, as a patient/employee/employer/physician, you had a particularly satisfying or dissatisfying experience with a local hospital?" Reported incidents were reviewed, and 239 "critical incidents" were identified. These incidents were classified into 12 descriptive categories relating to the underlying factors in the incident reports. Six focus groups were later held with participants segregated by the population pool they represented. These groups were asked to develop definitions of "excellence" in hospital service quality and standards for service which would "exceed expectations." The focus groups created 122 standards of excellence, which were classified into 43 categories. Overall, the largest percentages of corporate, physician, and employee critical incidents were classified as "Administrative Policy" issues. Patients most often reported "Nurturing" incidents as critical to their perceptions of hospital service quality.

Investigation and evaluation of cracking incidents in piping in pressurized water reactors. Technical report

International Nuclear Information System (INIS)

1980-09-01

This report summarizes an investigation of known cracking incidents in pressurized water reactor plants. Several instances of cracking in feedwater piping in 1979, together with reported cases of stress corrosion cracking at Three Mile Island Unit 1, led to the establishment of the third Pipe Crack Study Group. Major differences between the scope of the third PCSG and the previous two are: (1) the emphasis given to systems safety implications of cracking, and (2) the consideration given all cracking mechanisms known to affect PWR piping, including the failure of small lines in secondary safety systems. The present PCSG reviewed existing information on cracking of PWR pipe systems, either contained in written records of collected from meetings in the United States, and made recommendations in response to the PCSG charter questions and to othe major items that may be considered to either reduce the potential for cracking or to improve licensing bases

A global model of malaria climate sensitivity: comparing malaria response to historic climate data based on simulation and officially reported malaria incidence

Directory of Open Access Journals (Sweden)

Edlund Stefan

2012-09-01

Full Text Available Abstract Background The role of the Anopheles vector in malaria transmission and the effect of climate on Anopheles populations are well established. Models of the impact of climate change on the global malaria burden now have access to high-resolution climate data, but malaria surveillance data tends to be less precise, making model calibration problematic. Measurement of malaria response to fluctuations in climate variables offers a way to address these difficulties. Given the demonstrated sensitivity of malaria transmission to vector capacity, this work tests response functions to fluctuations in land surface temperature and precipitation. Methods This study of regional sensitivity of malaria incidence to year-to-year climate variations used an extended Macdonald Ross compartmental disease model (to compute malaria incidence built on top of a global Anopheles vector capacity model (based on 10 years of satellite climate data. The predicted incidence was compared with estimates from the World Health Organization and the Malaria Atlas. The models and denominator data used are freely available through the Eclipse Foundation’s Spatiotemporal Epidemiological Modeller (STEM. Results Although the absolute scale factor relating reported malaria to absolute incidence is uncertain, there is a positive correlation between predicted and reported year-to-year variation in malaria burden with an averaged root mean square (RMS error of 25% comparing normalized incidence across 86 countries. Based on this, the proposed measure of sensitivity of malaria to variations in climate variables indicates locations where malaria is most likely to increase or decrease in response to specific climate factors. Bootstrapping measures the increased uncertainty in predicting malaria sensitivity when reporting is restricted to national level and an annual basis. Results indicate a potential 20x improvement in accuracy if data were available at the level ISO 3166–2

Perceived job insecurity as a risk factor for incident coronary heart disease

DEFF Research Database (Denmark)

Virtanen, Marianna; Nyberg, Solja T; Batty, George David

2013-01-01

To determine the association between self reported job insecurity and incident coronary heart disease.......To determine the association between self reported job insecurity and incident coronary heart disease....

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

Science.gov (United States)

Pham, Julius Cuong; Williams, Tamara L; Sparnon, Erin M; Cillie, Tam K; Scharen, Hilda F; Marella, William M

2016-05-01

In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

Science.gov (United States)

Pham, Julius Cuong; Williams, Tamara L; Sparnon, Erin M; Cillie, Tam K; Scharen, Hilda F; Marella, William M

2016-01-01

BACKGROUND: In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. METHODS: We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. RESULTS: A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. CONCLUSIONS: Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of

Radiological incident preparedness for community hospitals: a demonstration project.

Science.gov (United States)

Jafari, Mary Ellen

2010-08-01

In November 2007, the Wisconsin Division of Public Health Hospital Disaster Preparedness Program State Expert Panel on Radiation Emergencies issued a report titled The Management of Patients in a Radiological Incident. Gundersen Lutheran Health System was selected to conduct a demonstration project to implement the recommendations in that report. A comprehensive radiological incident response plan was developed and implemented in the hospital's Trauma and Emergency Center, including the purchase and installation of radiation detection and identification equipment, staff education and training, a tabletop exercise, and three mock incident test exercises. The project demonstrated that the State Expert Panel report provides a flexible template that can be implemented at community hospitals using existing staff for an approximate cost of $25,000.

Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine.

Science.gov (United States)

Martín Delgado, M C; Merino de Cos, P; Sirgo Rodríguez, G; Álvarez Rodríguez, J; Gutiérrez Cía, I; Obón Azuara, B; Alonso Ovies, Á

2015-01-01

To explore contributing factors (CF) associated to related critical patients safety incidents. SYREC study pos hoc analysis. A total of 79 Intensive Care Departments were involved. The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Tuberculosis incidence in prisons: a systematic review.

Science.gov (United States)

Baussano, Iacopo; Williams, Brian G; Nunn, Paul; Beggiato, Marta; Fedeli, Ugo; Scano, Fabio

2010-12-21

Transmission of tuberculosis (TB) in prisons has been reported worldwide to be much higher than that reported for the corresponding general population. A systematic review has been performed to assess the risk of incident latent tuberculosis infection (LTBI) and TB disease in prisons, as compared to the incidence in the corresponding local general population, and to estimate the fraction of TB in the general population attributable (PAF%) to transmission within prisons. Primary peer-reviewed studies have been searched to assess the incidence of LTBI and/or TB within prisons published until June 2010; both inmates and prison staff were considered. Studies, which were independently screened by two reviewers, were eligible for inclusion if they reported the incidence of LTBI and TB disease in prisons. Available data were collected from 23 studies out of 582 potentially relevant unique citations. Five studies from the US and one from Brazil were available to assess the incidence of LTBI in prisons, while 19 studies were available to assess the incidence of TB. The median estimated annual incidence rate ratio (IRR) for LTBI and TB were 26.4 (interquartile range [IQR]: 13.0-61.8) and 23.0 (IQR: 11.7-36.1), respectively. The median estimated fraction (PAF%) of tuberculosis in the general population attributable to the exposure in prisons for TB was 8.5% (IQR: 1.9%-17.9%) and 6.3% (IQR: 2.7%-17.2%) in high- and middle/low-income countries, respectively. The very high IRR and the substantial population attributable fraction show that much better TB control in prisons could potentially protect prisoners and staff from within-prison spread of TB and would significantly reduce the national burden of TB. Future studies should measure the impact of the conditions in prisons on TB transmission and assess the population attributable risk of prison-to-community spread. Please see later in the article for the Editors' Summary.