Continuous improvement methods in the nuclear industry

International Nuclear Information System (INIS)

Heising, Carolyn D.

1995-01-01

The purpose of this paper is to investigate management methods for improved safety in the nuclear power industry. Process improvement management, methods of business process reengineering, total quality management, and continued process improvement (KAIZEN) are explored. The anticipated advantages of extensive use of improved process oriented management methods in the nuclear industry are increased effectiveness and efficiency in virtually all tasks of plant operation and maintenance. Important spin off include increased plant safety and economy. (author). 6 refs., 1 fig

Continuing education for performance improvement: a creative approach.

Science.gov (United States)

Collins, Patti-Ann; Hardesty, Ilana; White, Julie L; Zisblatt, Lara

2012-10-01

In an effort to improve patient safety and health care outcomes, continuing medical education has begun to focus on performance improvement initiatives for physician practices. Boston University School of Medicine's (BUSM) Continuing Nursing Education Accredited Provider Unit has begun a creative project to award nursing contact hours for nurses' participation in performance improvement activities. This column highlights its initial efforts. Copyright 2012, SLACK Incorporated.

Sign up to Safety: developing a safety improvement plan.

Science.gov (United States)

Dight, Carol; Peters, Hayley

2015-04-01

The Sign up to Safety (SutS) programme was launched in June 2014 by health secretary Jeremy Hunt. It focuses on listening to patients, carers and staff, learning from what they say when things go wrong, and then taking action to improve patient safety. The programme aims to make the NHS the safest healthcare system in the world by creating a culture devoted to continuous learning and improvement (NHS England 2014). Musgrove Park Hospital, part of Taunton and Somerset NHS Foundation Trust, was one of 12 NHS organisations that signed up to the SutS programme, making public its commitment to the national pledges to be 'open and transparent' and to develop a safety improvement plan. This paper describes the development of the strategy.

Management of continual improvement for facilities and activities: A structured approach

International Nuclear Information System (INIS)

2006-04-01

In recent years there has been an upward trend in the safety and operational performance of nuclear installations. Safe, efficient operation is their goal. Continual improvement of the processes of organizations has led to enhanced safety performance and efficiency benefits such as cost reductions and improved cycle times. Many organizations have experienced significant cost improvement largely by or through better financial management and a common drive to reduce costs brought on by commercial pressures. Without the use of a structured methodology to identify and implement improvements, changes to an organization to reduce costs through cutting staff and activities could eventually fail to produce the desired changes and even have a negative effect on safety and overall performance. The following fundamental principles are considered essential to the effective introduction of structured continual improvement: - Long term commitment from senior management throughout the entire organization; - The implementation in the organization of a process management approach such as that advocated by IAEA Safety Standards, ISO 9001, Malcolm Baldridge National Quality Award and European Foundation for Quality Management Business Excellence model; - The alignment of the processes with the objectives of the organization through the organization's business plan; - The utilization by Management of the process information as an input to managing the organization; - The employment of the information derived from the process performance to identify and prioritize the processes that require improvement; - The active participation of all staff of the organization to using its processes in order to contribute to continual process improvement (CPI). This publication defines a structured approach for continual improvement and focuses on the way an organization can improve its processes. It is recognized that there are many different approaches and methods available in the marketplace to

Research reactor management. Safety improvement activities in HANARO

International Nuclear Information System (INIS)

Wu, Jong-Sup; Jung, Hoan-Sung; Hong, Sung Taek; Ahn, Guk-Hoon

2012-01-01

Safety activities in HANARO have been continuously conducted to enhance its safe operation. Great effort has been placed on a normalization and improvement of the safety attitude of the regular staff and other employees working at the reactor and other experimental facilities. This paper introduces the activities on safety improvement that were performed over the last few years. (author)

Safety Campaign Continues

CERN Multimedia

2002-01-01

If you see this poster, stop and read it! This is the third poster produced by TIS Division as part of its information campaign on health and safety in the workplace. It provides statistics on occupational accidents at CERN. You will see that, as in the rest of Europe, falls, slips and trips continue to be the main cause of accident. So, eyes open and take care! For more information : http://safety.cern.ch/

Framework for Continuous Assessment and Improvement of Occupational Health and Safety Issues in Construction Companies

OpenAIRE

Mahmoudi, Shahram; Ghasemi, Fakhradin; Mohammadfam, Iraj; Soleimani, Esmaeil

2014-01-01

Background: Construction industry is among the most hazardous industries, and needs a comprehensive and simple-to-administer tool to continuously assess and promote its health and safety performance. Methods: Through the study of various standard systems (mainly Health, Safety, and Environment Management System; Occupational Health and Safety Assessment Series 180001; and British Standard, occupational health and safety management systems-Guide 8800), seven main elements were determined fo...

Patient handover in orthopaedics, improving safety using Information Technology.

Science.gov (United States)

Pearkes, Tim

2015-01-01

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

PROPOSAL OF VOIVODESHIP ROAD SAFETY IMPROVEMENT PROGRAMME

Directory of Open Access Journals (Sweden)

Tomasz SZCZURASZEK

2016-07-01

Full Text Available The article presents a proposal of the ‘GAMBIT KUJAWSKO-POMORSKI’ Road Safety Improvement Programme. The main idea of the Programme is to establish and initiate systems that will be responsible for the most important areas of activity within road safety, including road safety control, supervision, and management systems in the whole Voivodeship. In total, the creation and start of nine such systems has been proposed, namely: the Road Safety Management, the Integrated Road Rescue Service, the Personnel Continuing Education, the Hazardous Road Behaviour Monitoring, the Social Education for Safe Behaviour on Road, the Teaching Personnel Improvement, the Area Development and Planning Process Improvement, the Road Infrastructure Design Quality Improvement, and the Road and Traffic Management Process Efficiency Improvement. The basic aim of each system has been discussed as well as the most important tasks implemented as its part. The Road Safety Improvement Programme for the Kujawsko-Pomorskie Voivodeship presented in this article is a part of the National Road Safety Programme 2013-2020. Moreover, it is not only an original programme in Poland, but also a universal project that may be adapted for other voivodeships as well.

The program of continuous improvements in factory in Juzbado

International Nuclear Information System (INIS)

Prieto, M.

2015-01-01

This articles describes the historical development of the continuous improvement program at Juzbado Factory, since its beginning to nowadays. The evolution throughout the ideas of Total Quality, ISO, EFQM, Six Sigma, and so on, leading to the present situation in which all these tools and methodologies live together is shown. all this has led to a philosophy and business culture focused on safety, quality and continuous improvement. (Author)

Continuous improvement: A win-win process

International Nuclear Information System (INIS)

Lawrence, T.M.; Wichert, A.

1992-01-01

The strategies used within PanCanadian Petroleum Limited's production division to successfully introduce the continuous improvement (CI) process are discussed. Continuous improvement is an operating philosophy and management style which allows all employees to participate in and improve the way an organization performs its day-to-day business. In the CI work environment the supervisor's traditional role changes from one of monitoring and controlling, to one of inspiring, motivating and leading people by communicating a clear vision. Employees at all levels in the work environment are organized into teams and armed with a good working knowledge of the problem-solving tools which allow them to pursue and implement improvement initiatives. The outcome of the process is an ongoing win-win situation for both PanCanadian and its people. Employees are gaining more trust, eliminating job irritants, and enjoying their work in a team environment. The company is benefiting through increased production, improved safety and reduced operating expenses, thanks to the many innovative ideas introduced by employees. 4 refs

Improving the safety of future nuclear fission power plants

International Nuclear Information System (INIS)

Frisch, W.; Gros, G.

2001-01-01

The main objectives and principles in nuclear fission reactor safety are presented, e.g. the defence in depth strategy and technical principles such as redundancy, diversity and physical separation. After a brief historical review of the continuous development of safety improvement, the most recent international discussion is presented. This includes mainly the international activities within IAEA and its International Nuclear Safety Advisory Group (INSAG). The safety improvement, presented in recommendations of IAEA and INSAG is expressed as an improvement of all elements and all levels of the defence in depth concept. Special emphasis is put on improvement of the highest level, which requires the implementation of means to mitigate consequences of accidents with severe core damage. The different future concepts are briefly characterised. Some examples from the French-German safety approach are taken to demonstrate how requirements for safety improvement by means of an enhancement of the defence in depth principle are developed

Leadership Actions to Improve Nuclear Safety Culture

International Nuclear Information System (INIS)

Clewett, L.K.

2016-01-01

The challenge many leaders face is how to effectively implement and then utilise the results of Safety Culture surveys. Bruce Power has recently successfully implemented changes to the Safety Culture survey process including how corrective actions were identified and implemented. The actions taken in response to the latest survey have proven effective with step change performance noted. Nuclear Safety is a core value for Bruce Power. Nuclear Safety at Bruce Power is based on the following four pillars: reactor safety, industrial safety, radiological safety and environmental safety. Processes and practices are in place to achieve a healthy Nuclear Safety Culture within Bruce Power such that nuclear safety is the overriding priority. This governance is based on industry leading practices which monitor, asses and take action to drive continual improvements in the Nuclear Safety Culture within Bruce Power.

The continuous improvement process and ergonomics in ultrasound department.

Science.gov (United States)

Coffin, Carolyn T

2013-01-01

Continuous improvement processes, such as Lean, Six Sigma and Quality Control Circles, have been implemented in the manufacturing industries in an effort to increase productivity, eliminate waste, and engage employees in problem solving. These processes can be adapted to the healthcare sector as medical facilities strive to improve the patient experience, increase financial returns, and improve worker safety and morale. In the ultrasound department, productivity can be improved and the quality of patient care can be ensured by standardizing exam protocols and decreasing work related musculoskeletal disorders among sonography professionals. This article summarizes the more commonly used continuous improvement processes and provides a description of how one method might be applied to the ultrasound department.

ELECTRICAL SAFETY IMPROVEMENT PROJECT A COMPLEX WIDE TEAMING INITIATIVE

Energy Technology Data Exchange (ETDEWEB)

GRAY BJ

2007-11-26

This paper describes the results of a year-long project, sponsored by the Energy Facility Contractors Group (EFCOG) and designed to improve overall electrical safety performance throughout Department of Energy (DOE)-owned sites and laboratories. As evidenced by focused metrics, the Project was successful primarily due to the joint commitment of contractor and DOE electrical safety experts, as well as significant support from DOE and contractor senior management. The effort was managed by an assigned project manager, using classical project-management principles that included execution of key deliverables and regular status reports to the Project sponsor. At the conclusion of the Project, the DOE not only realized measurable improvement in the safety of their workers, but also had access to valuable resources that will enable them to do the following: evaluate and improve electrical safety programs; analyze and trend electrical safety events; increase electrical safety awareness for both electrical and non-electrical workers; and participate in ongoing processes dedicated to continued improvement.

Designing continuous safety improvement within chemical industrial areas

NARCIS (Netherlands)

Reniers, G.L.L.; Ale, B. J.M.; Dullaert, W.; Soudan, K.

This article provides support in organizing and implementing novel concepts for enhancing safety on a cluster level of chemical plants. The paper elaborates the requirements for integrating Safety Management Systems of chemical plants situated within a so-called chemical cluster. Recommendations of

Can we improve patient safety?

Science.gov (United States)

Corbally, Martin Thomas

2014-01-01

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

A word from the DG: Improved safety at CERN

CERN Multimedia

2006-01-01

One of the important objectives of my term of office is improving safety at CERN. My consideration of safety issues over the last few months, in conjunction with the Safety Commission and the Heads of Department, has led me to define a new approach for the implementation of safety policy at CERN. It is not a question of changing the safety policy and the basic safety rules laid down in document 'Safety Policy at CERN' (SAPOCO 42) but, rather, of improving the way they are applied by clarifying the roles of everyone concerned. The existing safety policy and rules have yet to be fully implemented. Some people continue to think, for example, that safety implementation only concerns the Safety Commission (SC). In reality, as SAPOCO 42 clearly specifies, safety is the responsibility of each and every individual. This means that each person in charge of a task is also responsible for guaranteeing its safe completion by implementing all the necessary measures. To enhance the awareness of this responsibility and t...

Continuing the service of safety-related concrete structures in nuclear power plants

International Nuclear Information System (INIS)

Naus, D.J.; Oland, C.B.; Ellingwood, B.R.; Mori, Y.; Arndt, E.G.

1993-01-01

The Structural Aging (SAG) Program is addressing the aging management of safety-related concrete structures in nuclear power plants (NPPs) for the purpose of providing improved technical bases for their continued service. The program consists of three technical tasks: materials property data base, structural component assessment/repair technologies, and quantitative methodologies for continued service determinations. Recent accomplishments under each of these tasks are summarized

The Power of Collaboration for Improving Safety in Complex Systems

International Nuclear Information System (INIS)

Hart, C. A.

2016-01-01

Many potentially hazardous industries involve systems that consist of a complex array of subsystems that must work together effectively in order for the entire system to perform. Often the subsystems are coupled, such that changes in any one subsystem can affect other subsystems. “System Think” refers to an awareness of the impacts throughout a system of changes in any subsystem. The U.S. commercial aviation industry, in its continuing endeavor to improve safety, uses a collaborative approach to accomplish System Think— bringing all of the key parts of the industry together to work in a collaborative manner to identify and address potential safety concerns. The collaborative approach resulted in an 83% reduction in the fatal accident rate in only 10 years. It also demonstrated that, contrary to conventional wisdom that safety improvements usually hurt productivity, safety improvements that result from a collaborative approach can simultaneously improve productivity. Last but not least, it minimised one of the continuing challenges of making changes in complex systems, which is unintended consequences. The purpose of this presentation is to describe the collaborative approach and to discuss its transferability to other potentially hazardous industries that are seeking to manage their risks more efficiently and effectively. (author)

Continual improvement plan

Science.gov (United States)

1994-01-01

NASA's approach to continual improvement (CI) is a systems-oriented, agency-wide approach that builds on the past accomplishments of NASA Headquarters and its field installations and helps achieve NASA's vision, mission, and values. The NASA of the future will fully use the principles of continual improvement in every aspect of its operations. This NASA CI plan defines a systematic approach and a model for continual improvement throughout NASA, stressing systems integration and optimization. It demonstrates NASA's constancy of purpose for improvement - a consistent vision of NASA as a worldwide leader in top-quality science, technology, and management practices. The CI plan provides the rationale, structures, methods, and steps, and it defines NASA's short term (1-year) objectives for improvement. The CI plan presents the deployment strategies necessary for cascading the goals and objectives throughout the agency. It also provides guidance on implementing continual improvement with participation from top leadership and all levels of employees.

2003 Stewardship progress report : committed to continuous improvement

Energy Technology Data Exchange (ETDEWEB)

NONE

2003-12-01

The stewardship initiative is a mandatory requirement for members of the Canadian Association of Petroleum Producers (CAPP). It involves performance management and benchmarking, voluntary audits and verification, as well as training and improved communication inside and outside the industry. This fourth annual progress report describes the environment, health, safety and socio-economic stewardship initiative. This report presents an aggregate of industry performance. Stewardship of Excellence awards were presented in 2003, celebrating outstanding performance by members who demonstrated their commitment to responsible development and continuous improvement within a business framework. The awards were presented in three categories, namely environment, health and safety, and socio-economic. Northrock Resources was presented with the award in the environment category for its voluntary waste gas reduction. The health and safety recognition went to Burlington Resources Canada Ltd. for superior office ergonomics, while the award in the socio-economic category was presented to Suncor Energy Inc. for Aboriginal business development. A brief overview of the achievements of each of these three companies was presented. tabs., figs.

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

International Nuclear Information System (INIS)

Sumi, Y.

1987-01-01

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

[An approach to care indicators benchmarking. Learning to improve patient safety].

Science.gov (United States)

de Andrés Gimeno, B; Salazar de la Guerra, R M; Ferrer Arnedo, C; Revuelta Zamorano, M; Ayuso Murillo, D; González Soria, J

2014-01-01

Improvements in clinical safety can be achieved by promoting a safety culture, professional training, and learning through benchmarking. The aim of this study was to identify areas for improvement after analysing the safety indicators in two public Hospitals in North-West Madrid Region. Descriptive study performed during 2011 in Hospital Universitario Puerta de Hierro Majadahonda (HUPHM) and Hospital de Guadarrama (HG). The variables under study were 40 indicators on nursing care related to patient safety. Nineteen of them were defined in the SENECA project as care quality standards in order to improve patient safety in the hospitals. The data collected were clinical history, Madrid Health Service assessment reports, care procedures, and direct observation Within the 40 indicators: 22 of them were structured (procedures), HUPHM had 86%, and HG 95% 14 process indicators (training and protocols compliance) with similar results in both hospitals, apart from the care continuity reports and training in hand hygiene. The 4 results indicators (pressure ulcer, falls and pain) showed different results. The analysis of the indicators allowed the following actions to be taken: to identify improvements to be made in each hospital, to develop joint safety recommendations in nursing care protocols in prevention and treatment of chronic wound, to establish systematic pain assessments, and to prepare continuity care reports on all patients transferred from HUPHM to HG. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.

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

Science.gov (United States)

2010-10-01

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

Improving patient safety culture in Saudi Arabia (2012-2015): trending, improvement and benchmarking.

Science.gov (United States)

Alswat, Khalid; Abdalla, Rawia Ahmad Mustafa; Titi, Maher Abdelraheim; Bakash, Maram; Mehmood, Faiza; Zubairi, Beena; Jamal, Diana; El-Jardali, Fadi

2017-08-02

Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans. This paper also explored the association between patient safety culture predictors and patient safety grade, perception of patient safety, frequency of events reported and number of events reported. We utilized a customized version of the patient safety culture survey developed by the Agency for Healthcare Research and Quality. The Medical City is a tertiary care teaching facility composed of two sites (total capacity of 904 beds). Data was analyzed using SPSS 24 at a significance level of 0.05. A t-Test was used to compare results from the 2012 survey to that conducted in 2015. Two adopted Generalized Estimating Equations in addition to two linear models were used to assess the association between composites and patient safety culture outcomes. Results were also benchmarked against similar initiatives in Lebanon, Palestine and USA. Areas of strength in 2015 included Teamwork within units, and Organizational Learning-Continuous Improvement; areas requiring improvement included Non-Punitive Response to Error, and Staffing. Comparing results to the 2012 survey revealed improvement on some areas but non-punitive response to error and Staffing remained the lowest scoring composites in 2015. Regression highlighted significant association between managerial support, organizational learning and feedback and improved survey outcomes. Comparison to international benchmarks revealed that the hospital is performing at or

Does external evaluation of laboratories improve patient safety?

Science.gov (United States)

Noble, Michael A

2007-01-01

Laboratory accreditation and External Quality Assessment (also called proficiency testing) are mainstays of laboratory quality assessment and performance. Both practices are associated with examples of improved laboratory performance. The relationship between laboratory performance and improved patient safety is more difficult to assess because of the many variables that are involved with patient outcome. Despite this difficulty, the argument to continue external evaluation of laboratories is too compelling to consider the alternative.

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

Science.gov (United States)

Singh, Hardeep; Sittig, Dean F

2016-04-01

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

Improving operating room safety

Directory of Open Access Journals (Sweden)

Garrett Jill

2009-11-01

Full Text Available Abstract Despite the introduction of the Universal Protocol, patient safety in surgery remains a daily challenge in the operating room. This present study describes one community health system's efforts to improve operating room safety through human factors training and ultimately the development of a surgical checklist. Using a combination of formal training, local studies documenting operating room safety issues and peer to peer mentoring we were able to substantially change the culture of our operating room. Our efforts have prepared us for successfully implementing a standardized checklist to improve operating room safety throughout our entire system. Based on these findings we recommend a multimodal approach to improving operating room safety.

Organisational learning: A tool for continuous improvement of the organization

International Nuclear Information System (INIS)

Santos, J. L.; Esteban, M. J.

2013-01-01

We are used to hear a success company in today's world is not possible unless a continuous improvement is developed. How can we be successful in the nuclear plant? We have to achieve safety for workers, people and environment in the first step, and for the second step availability and reliability for systems and components to avoid failure of components that could reduce availability. The aim is to search for new measures to reach this way. One of the improvements implemented in the plants to improve continuously was mainly Operating Experience activities, which was based in event analysis in the plants, causes identification, and to implement corrective actions. For External Operating Experience the aim was to learn from others to avoid occurrence of events in our plants. This was the lessons learned from Three Mile Island event. This was the learning process implemented so far, to get a continuous improvement. So far, the developed capabilities for process improvement follow the Operating Experience process that could be considered classical and will be revitalized nowadays. (Author)

Characterization and improvement of the nuclear safety culture through self-assessment

International Nuclear Information System (INIS)

Levin, H.A.; McGehee, R.B.; Cottle, W.T.

1996-01-01

Organizational culture has a powerful influence on overall corporate performance. The ability to sustain superior results in ensuring the public's health and safety is predicated on an organization's deeply embedded values and behavioral norms and how these affect the ability to change and seek continuous improvement. The nuclear industry is developing increased recognition of the relationship of culture to nuclear safety performance as a critical element of corporate strategy. This paper describes a self-assessment methodology designed to characterize and improve the nuclear safety culture, including processes for addressing employee concerns. This methodology has been successfully applied on more than 30 occasions in the last several years, resulting in measurable improvements in safety performance and quality and employee motivation, productivity, and morale. Benefits and lessons learned are also presented

Improvements in operational safety performance of the Magnox power stations

Energy Technology Data Exchange (ETDEWEB)

Marchese, C.J. [BNFL Magnox Generation, Berkeley (United Kingdom)

2000-10-01

In the 43 years since commencement of operation of Calder Hall, the first Magnox power station, there remain eight Magnox stations and 20 reactors still in operation, owned by BNFL Magnox Generation. This paper describes how the operational safety performance of these stations has significantly improved over the last ten years. This has been achieved against a background of commercial competition introduced by privatization and despite the fact that the Magnox base design belongs to the past. Finally, the company's future plans for continued improvements in operational safety performance are discussed. (author)

[Improving patient safety through voluntary peer review].

Science.gov (United States)

Kluge, S; Bause, H

2015-01-01

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

Researchers' Roles in Patient Safety Improvement.

Science.gov (United States)

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

2016-03-01

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

Evaluation of a guided continuous quality improvement program in community pharmacies.

Science.gov (United States)

Chinthammit, Chanadda; Rupp, Michael T; Armstrong, Edward P; Modisett, Tara; Snead, Rebecca P; Warholak, Terri L

2017-01-01

The importance of creating and sustaining a strong culture of patient safety has been recognized as a critical component of safe medication use. This study aims to assess changes in attitudes toward patient safety culture and frequency of quality-related event (QRE) reporting after guided implementation of a continuous quality improvement (CQI) program in a panel of community pharmacies in the United States (U.S.). Twenty-one community pharmacies volunteered to participate in the project and were randomly assigned to intervention or control groups. Pharmacy staff in the intervention group received guided training to ensure full implementation of a CQI program while those in the control group partially implemented the program. Pharmacy staff in both groups completed retrospective pre-post safety culture questionnaires and reported medication errors and near misses that occurred in their practices. Rasch analysis was applied to assess questionnaire validity and reliability and to confirm if the ordinal level data approximated interval level measures. Paired t-tests and repeated measure analysis of covariance tests were subsequently used to compare observed changes in the attitudes of subjects and frequency of QREs reporting in intervention and control groups. Sixty-nine employees completed the questionnaire, a 43.9% response rate. Improvement in attitudes toward patient safety was statistically significant in the intervention group in six domains: staff, training, and skill ( p  = 0.017); patient counseling ( p  = 0.043); communication about mistakes ( p  continuous improvement ( p  < 0.001); and overall patient safety perceptions ( p  = 0.033). No significant differences were observed in QRE reporting rates between intervention and control groups. However, differences were observed in the types of QREs reported (e.g., incorrect safety cap) and the point in the prescription processing workflow where a QRE was detected (e.g., partner check station, and drug

Framework for continuous assessment and improvement of occupational health and safety issues in construction companies.

Science.gov (United States)

Mahmoudi, Shahram; Ghasemi, Fakhradin; Mohammadfam, Iraj; Soleimani, Esmaeil

2014-09-01

Construction industry is among the most hazardous industries, and needs a comprehensive and simple-to-administer tool to continuously assess and promote its health and safety performance. Through the study of various standard systems (mainly Health, Safety, and Environment Management System; Occupational Health and Safety Assessment Series 180001; and British Standard, occupational health and safety management systems-Guide 8800), seven main elements were determined for the desired framework, and then, by reviewing literature, factors affecting these main elements were determined. The relative importance of each element and its related factors was calculated at organizational and project levels. The provided framework was then implemented in three construction companies, and results were compared together. THE RESULTS OF THE STUDY SHOW THAT THE RELATIVE IMPORTANCE OF THE MAIN ELEMENTS AND THEIR RELATED FACTORS DIFFER BETWEEN ORGANIZATIONAL AND PROJECT LEVELS: leadership and commitment are the most important elements at the organization level, whereas risk assessment and management are most important at the project level. The present study demonstrated that the framework is easy to administer, and by interpreting the results, the main factors leading to the present condition of companies can be determined.

Nuclear Criticality Safety Organization guidance for the development of continuing technical training. Revision 1

International Nuclear Information System (INIS)

Carroll, K.J.; Taylor, R.G.; Worley, C.A.

1997-01-01

The Nuclear Criticality Safety Organization (NCSO) is committed to developing and maintaining a staff of highly qualified personnel to meet the current and anticipated needs in nuclear criticality safety at the Oak Ridge Y-12 Plant and throughout the DOE complex. Continuing technical training is training outside of the initial qualification program to address identified organization-wide needs. Typically, this training is used to improve organization performance in the conduct of business. This document provides guidelines for the development of the technical portions of the Continuing Training Program. It is not a step-by-step procedure, but a collection of considerations to be used during the development process

Continuous quality improvement using intelligent infusion pump data analysis.

Science.gov (United States)

Breland, Burnis D

2010-09-01

The use of continuous quality-improvement (CQI) processes in the implementation of intelligent infusion pumps in a community teaching hospital is described. After the decision was made to implement intelligent i.v. infusion pumps in a 413-bed, community teaching hospital, drug libraries for use in the safety software had to be created. Before drug libraries could be created, it was necessary to determine the epidemiology of medication use in various clinical care areas. Standardization of medication administration was performed through the CQI process, using practical knowledge of clinicians at the bedside and evidence-based drug safety parameters in the scientific literature. Post-implementation, CQI allowed refinement of clinically important safety limits while minimizing inappropriate, meaningless soft limit alerts on a few select agents. Assigning individual clinical care areas (CCAs) to individual patient care units facilitated customization of drug libraries and identification of specific CCA compliance concerns. Between June 2007 and June 2008, there were seven library updates. These involved drug additions and deletions, customization of individual CCAs, and alterations of limits. Overall compliance with safety software use rose over time, from 33% in November 2006 to over 98% in December 2009. Many potentially clinically significant dosing errors were intercepted by the safety software, prompting edits by end users. Only 4-6% of soft limit alerts resulted in edits. Compliance rates for use of infusion pump safety software varied among CCAs over time. Education, auditing, and refinement of drug libraries led to improved compliance in most CCAs.

Continuous Improvement and Collaborative Improvement: Similarities and Differences

DEFF Research Database (Denmark)

Middel, Rick; Boer, Harry; Fisscher, Olaf

2006-01-01

the similarities and differences between key components of continuous and collaborative improvement by assessing what is specific for continuous improvement, what for collaborative improvement, and where the two areas of application meet and overlap. The main conclusions are that there are many more similarities...... between continuous and collaborative improvement. The main differences relate to the role of hierarchy/market, trust, power and commitment to collaboration, all of which are related to differences between the settings in which continuous and collaborative improvement unfold....

Driving forces behind the Chinese public's demand for improved environmental safety.

Science.gov (United States)

Wen, Ting; Wang, Jigan; Ma, Zongwei; Bi, Jun

2017-12-15

Over the past decades, the public demand for improved environmental safety keeps increasing in China. This study aims to assess the driving forces behind the increasing public demand for improved environmental safety using a provincial and multi-year (1995, 2000, 2005, 2010, and 2014) panel data and the Stochastic Impacts by Regression on Population, Affluence, and Technology (STIRPAT) model. The potential driving forces investigated included population size, income levels, degrees of urbanization, and educational levels. Results show that population size and educational level are positively (Pdemand for improved environmental safety. No significant impact on demand was found due to the degree of urbanization. For the impact due to income level, an inverted U-shaped curve effect with the turning point of ~140,000 CNY GDP per capita is indicated. Since per capita GDP of 2015 in China was approximately 50,000 CNY and far from the turning point, the public demand for improved environmental safety will continue rising in the near future. To meet the increasing public demand for improved environmental safety, proactive and risk prevention based environmental management systems coupled with effective environmental risk communication should be established. Copyright © 2017 Elsevier B.V. All rights reserved.

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

Science.gov (United States)

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

2010-01-01

with naval aviation. Major interventions to bolster hospital safety climate continue to be required to improve patient safety.

Steam Pressure-Reducing Station Safety and Energy Efficiency Improvement Project

Energy Technology Data Exchange (ETDEWEB)

Lower, Mark D [ORNL; Christopher, Timothy W [ORNL; Oland, C Barry [ORNL

2011-06-01

The Facilities and Operations (F&O) Directorate is sponsoring a continuous process improvement (CPI) program. Its purpose is to stimulate, promote, and sustain a culture of improvement throughout all levels of the organization. The CPI program ensures that a scientific and repeatable process exists for improving the delivery of F&O products and services in support of Oak Ridge National Laboratory (ORNL) Management Systems. Strategic objectives of the CPI program include achieving excellence in laboratory operations in the areas of safety, health, and the environment. Identifying and promoting opportunities for achieving the following critical outcomes are important business goals of the CPI program: improved safety performance; process focused on consumer needs; modern and secure campus; flexibility to respond to changing laboratory needs; bench strength for the future; and elimination of legacy issues. The Steam Pressure-Reducing Station (SPRS) Safety and Energy Efficiency Improvement Project, which is under the CPI program, focuses on maintaining and upgrading SPRSs that are part of the ORNL steam distribution network. This steam pipe network transports steam produced at the ORNL steam plant to many buildings in the main campus site. The SPRS Safety and Energy Efficiency Improvement Project promotes excellence in laboratory operations by (1) improving personnel safety, (2) decreasing fuel consumption through improved steam system energy efficiency, and (3) achieving compliance with applicable worker health and safety requirements. The SPRS Safety and Energy Efficiency Improvement Project being performed by F&O is helping ORNL improve both energy efficiency and worker safety by modifying, maintaining, and repairing SPRSs. Since work began in 2006, numerous energy-wasting steam leaks have been eliminated, heat losses from uninsulated steam pipe surfaces have been reduced, and deficient pressure retaining components have been replaced. These improvements helped ORNL

Safety goals and safety culture opening plenary. 1. WANO's Role in Maintaining and Improving Safety Culture

International Nuclear Information System (INIS)

Tsutsumi, Ryosuke

2001-01-01

focus on reactor safety and reliability. WANO provides an excellent program for members to always improve their safety performance. Continuous improvement of safety performance is important to maintaining the safety culture. The basic improvement cycle includes identifying issues, setting objectives, designing solutions, implementing solutions, evaluating solutions, and tracking success. WANO members have a common aim: to improve the operational safety in their NPPs. Without exception, plant managers hope that the safety culture takes root deeply in the minds of plant staffs in their daily work and that all members of NPP staffs make every effort to carry out their jobs with the safety culture in mind. However, safety culture is very vulnerable. No matter how hard plant people work, once they think their plant is safe, the safety of the plant starts decaying at that instant. Let me remind you that safety culture is a daily thing and can never be completed. Humility is essential for the people at a plant because complacency immediately destroys the safety culture. Participation in WANO programs and communicating with various fellow plant staff all over the world can keep plant people alert and encourage unfailing efforts for safety. This is what WANO can be proud of

Improving Patient Safety: Improving Communication.

Science.gov (United States)

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

2017-12-01

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

IMPROVING PATIENT SAFETY:

DEFF Research Database (Denmark)

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

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

Improved obstetric safety through programmatic collaboration.

Science.gov (United States)

Goffman, Dena; Brodman, Michael; Friedman, Arnold J; Minkoff, Howard; Merkatz, Irwin R

2014-01-01

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p Risk Management of the American Hospital Association.

Radiation safety infrastructure in developing countries: a proactive approach for integrated and continuous improvement

International Nuclear Information System (INIS)

Mrabit, Khammar

2008-01-01

The International Atomic Energy Agency (the Agency) is authorized, by its statute, to establish or adopt safety standards for the protection of health and minimization of danger to life and property, and to provide for their application to its own operations as well as to operations under its control or supervision. The Agency has been assisting, since the mid 1960 's, its Member States through mainly its Technical Cooperation Programme (TCP) to improve their national radiation safety infrastructures. However up to the early nineties, assistance was specific and mostly ad hoc and did not systematically utilize an integrated and harmonized approach to achieving effective and sustainable national radiation safety infrastructures in Member States. An unprecedented and integrated international cooperative effort was launched by the Agency in 1994 to establish and/or upgrade the national radiation safety infrastructure in more than 90 countries within the framework of its TCP through the so-called Model project on upgrading radiation protection infrastructure. In this project proactive co-operation with Member States was used in striving towards achieving an effective and sustainable radiation safety infrastructure, compatible with the International basic safety standards for protection against ionizing radiation and for the safety of radiation sources (the BSS) and related standards. Extension to include compatibility with the guidance of the Code of Conduct on the Safety and Security of Radioactive Sources occurred towards the end of the Model Project in December 2004, and with the more recent ensuing follow up projects that started in 2005. The Model Project started with 5 countries in 1994 and finished with 91 countries in 2004. Up to the end of 2007 more than one hundred Member States had been participating in follow up projects covering six themes - namely: legislative and regulatory infrastructure; occupational radiation protection; radiation protection in

Review of Risk Reduction Methods using Probabilistic Safety Assessment Insights and Improved Technology

Energy Technology Data Exchange (ETDEWEB)

Lee, Eun-Chan; Choi, Byung-Pil [Korea Hydro and Nuclear Power Co., Daejeon (Korea, Republic of)

2016-10-15

As seen in the process of the periodic safety review of domestic nuclear power plants, the risk management objectives such as core damage frequency and large early release frequency are not easy to be met without continuous safety improvements and the integratoin of the improved technologies into the PSA evaluation methodologies. Because external event analyses have a protion of uncertainty factors in the current analysis methodologies, the technical efforts in various perspectives.

Proposals for an effective application of the continuous improvement at the ININ according to the IAEA 50-C/SG-Q new code

International Nuclear Information System (INIS)

Cardenas A, B.M.; Olivares O, L.A.

1997-01-01

This work contains the requirements of continuous improvement contained in the IAEA new code Q uality assurance for safety in nuclear power plants and other nuclear installations, code 50-C/SG-Q. Assuming that it was the base for to elaborate the review No. 5 of the Quality assurance plan at ININ, it was done an analysis to give proposals for the application of continuous improvement in effective way. The relevant points which must be taken in account at the continuous improvement process are: Direction responsibility, involucring of all personnel, process planning, education and training, elaboration of improvement projects, investigation of processes which can be improved, continuation of the improvement process and its evaluation. With the implantation of an effective continuous improvement system it will be obtained to get a better quality and a more efficient safety. (Author)

Continuous Improvement and Collaborative Improvement: Similarities and Differences

NARCIS (Netherlands)

Middel, H.G.A.; Boer, Harm; Fisscher, O.A.M.

2006-01-01

A substantial body of theoretical and practical knowledge has been developed on continuous improvement. However, there is still a considerable lack of empirically grounded contributions and theories on collaborative improvement, that is, continuous improvement in an inter-organizational setting. The

Five Years after the Fukushima Daiichi Accident: Nuclear Safety Improvements and Lessons Learnt

International Nuclear Information System (INIS)

Magwood, William D. IV; Niel, Jean-Christophe; Fuketa, Toyoshi; Sheron, Brian; Boyd, Michael; McGarry, Ann; Dussart-Desart, Roland; Reig, Javier; Hah, Yeonhee; Nieh, Ho; Vasquez-Maignan, Ximena; Salgado, Nancy; White, Andrew; Lazo, Edward; Creswell, Len; Leeds, Eric; Gannon-Picot, Cynthia; Griffiths, Janice

2016-01-01

Countries around the world continue to implement safety improvements and corrective actions based on lessons learnt from the 11 March 2011 accident at the Fukushima Daiichi nuclear power plant. This report provides a high-level summary and update on these activities, and outlines further lessons learnt and challenges identified for future consideration. It focuses on actions taken by NEA committees and NEA member countries, and as such is complementary to reports produced by other international organisations. It is in a spirit of openness and transparency that NEA member countries share this information to illustrate that appropriate actions are being taken to maintain and enhance the level of safety at their nuclear facilities. Nuclear power plants are safer today because of these actions. High-priority follow-on items identified by NEA committees are provided to assist countries in continuously benchmarking and improving their nuclear safety practices. (authors)

Nuclear safety in Slovak Republic. Status of safety improvements

International Nuclear Information System (INIS)

Toth, A.

1999-01-01

Status of the safety improvements at Bohunice V-1 units concerning WWER-440/V-230 design upgrading were as follows: supplementing of steam generator super-emergency feed water system; higher capacity of emergency core cooling system; supplementing of automatic links between primary and secondary circuit systems; higher level of secondary system automation. The goal of the modernization program for Bohunice V-1 units WWER-440/V-230 was to increase nuclear safety to the level of the proposals and IAEA recommendations and to reach probability goals of the reactor concerning active zone damage, leak of radioactive materials, failures of safety systems and damage shields. Upgrading program for Mochovce NPP - WWER-440/V-213 is concerned with improving the integrity of the reactor pressure vessel, steam generators 'leak before break' methods applied for the NPP, instrumentation and control of safety systems, diagnostic systems, replacement of in-core monitoring system, emergency analyses, pressurizers safety relief valves, hydrogen removal system, seismic evaluations, non-destructive testing, fire protection. Implementation of quality assurance has a special role in improvement of operational safety activities as well as safety management and safety culture, radiation protection, decommissioning and waste management and training. The Year 2000 problem is mentioned as well

An optimization model for improving highway safety

Directory of Open Access Journals (Sweden)

Promothes Saha

2016-12-01

Full Text Available This paper developed a traffic safety management system (TSMS for improving safety on county paved roads in Wyoming. TSMS is a strategic and systematic process to improve safety of roadway network. When funding is limited, it is important to identify the best combination of safety improvement projects to provide the most benefits to society in terms of crash reduction. The factors included in the proposed optimization model are annual safety budget, roadway inventory, roadway functional classification, historical crashes, safety improvement countermeasures, cost and crash reduction factors (CRFs associated with safety improvement countermeasures, and average daily traffics (ADTs. This paper demonstrated how the proposed model can identify the best combination of safety improvement projects to maximize the safety benefits in terms of reducing overall crash frequency. Although the proposed methodology was implemented on the county paved road network of Wyoming, it could be easily modified for potential implementation on the Wyoming state highway system. Other states can also benefit by implementing a similar program within their jurisdictions.

Improving Our Odds: Success through Continuous Risk Management

Science.gov (United States)

Greenhalgh, Phillip O.

2009-01-01

Launching a rocket, running a business, driving to work and even day-to-day living all involve some degree of risk. Risk is ever present yet not always recognized, adequately assessed and appropriately mitigated. Identification, assessment and mitigation of risk are elements of the risk management component of the "continuous improvement" way of life that has become a hallmark of successful and progressive enterprises. While the application of risk management techniques to provide continuous improvement may be detailed and extensive, the philosophy, ideals and tools can be beneficially applied to all situations. Experiences with the use of risk identification, assessment and mitigation techniques for complex systems and processes are described. System safety efforts and tools used to examine potential risks of the Ares I First Stage of NASA s new Constellation Crew Launch Vehicle (CLV) presently being designed are noted as examples. Recommendations from lessons learned are provided for the application of risk management during the development of new systems as well as for the improvement of existing systems. Lessons learned and suggestions given are also examined for applicability to simple systems, uncomplicated processes and routine personal daily tasks. This paper informs the reader of varied uses of risk management efforts and techniques to identify, assess and mitigate risk for improvement of products, success of business, protection of people and enhancement of personal life.

Improving the effectiveness of road safety campaigns : current and new practices.

NARCIS (Netherlands)

Hoekstra, A.T.G. & Wegman, F.C.M.

2015-01-01

The evaluation of campaigns aimed at improving road safety is still the exception rather than the rule. Because of this, ineffective campaigns and campaign techniques are allowed to continue to be utilised without question, while new methods of behaviour modification are often ignored. Therefore,

Improving the effectiveness of road safety campaigns : Current and new practices

NARCIS (Netherlands)

Hoekstra, T.; Wegman, F.C.M.

2011-01-01

The evaluation of campaigns aimed at improving road safety is still the exception rather than the rule. Because of this, ineffective campaigns and campaign techniques are allowed to continue to be utilised without question, while new methods of behaviour modification are often ignored. Therefore,

Advanced power reactors with improved safety characteristics

International Nuclear Information System (INIS)

Birkhofer, A.

1994-01-01

The primary objective of nuclear safety is the protection of individuals, society and environment against radiological hazards from accidental releases of radioactive materials contained in nuclear reactors. Hereto, these materials are enclosed by several successive barriers and the barriers protected against mishaps and accidents by a multi-level system of safety precautions. The evolution of reactor technology continuously improves this concept and its implementation. At a world-wide scale, several advanced reactor concepts are currently being considered, some of them already at a design stage. Essential safety objectives include both further strengthening the prevention of accidents and improving the containment of fission products should an accident occur. The proposed solutions differ considerably with regard to technical principles, plant size and time scales considered for industrial application. Two typical approaches can be distinguished: The first approach basically aims at an evolution of power reactors currently in use, taking into account the findings from safety research and from operation of current plants. This approach makes maximum use of proven technology and operating experience but may nevertheless include new safety features. The corresponding designs are often termed 'large evolutionary'. The second approach consists in more fundamental changes compared to present designs, often with strong emphasis on specific passive features protecting the fuel and fuel cladding barriers. Owing to the nature and capability of those passive features such 'innovative designs' are mostly smaller in power output. The paper describes the basic objectives of such developments and illustrates important technical concepts focusing on next generation plants, i.e. designs to be available for industrial application until the end of this decade. 1 tab. (author)

Monitoring System For Improving Radiation Safety Management

International Nuclear Information System (INIS)

Osovizky, A.; Paran, J.; Tal, N.; Ankry, N.; Ashkenazi, B.; Tirosh, D.; Marziano, R.; Chisin, R.

1999-01-01

Medi SMARTS (Medical Survey Mapping Automatic Radiation Tracing System), a gamma radiation monitoring system, was installed in a nuclear medicine department. In this paper the evaluation of the system's ability to improve radiation safety management is presented. The system is based on a state of the art software that continuously collects on line radiation measurements for display, analysis and logging. Radiation is measured by GM tubes; the signal is transferred to a data processing unit and then via an RS-485 communication line to a computer. The system automatically identifies the detector type and its calibration factor, thus providing compatibility, maintainability and versatility when changing detectors. Radiation levels are displayed on the nuclear medicine department map at six locations. The system has been operating continuously for more than one year, documenting abnormal events caused by routine operation or failure incidents. In cases where abnormal working conditions were encountered, an alarm message was sent automatically to the supervisor via his tele-pager. An interesting issue observed during the system evaluation, was the inability to distinguish between high radiation levels caused by proper routine operation and those caused by safety failure incidents. The solution included examination of two parameters, radiation levels as well as their duration period. A careful analysis of the historical data, applying the appropriated combined parameters determined for each location, verified that such a system can identify abnormal events, provide alarms to warn in case of incidents and improve standard operating procedures

Safety improvements of Temelin NPP

International Nuclear Information System (INIS)

Vita, J.

2000-01-01

A detailed overview is given of the efforts made to enhance the safety level of the plant considering recommendations of a number of assessment missions. A list is presented of 10 international missions of the IAEA at the Temelin plant, covering the period 1990 to 1998. For each mission the date and objective is given, the focus of the assessment is characterized, the international participation of experts is specified, and the main conclusions of the experts is reproduced. A commented list of 60 main design changes and safety improvements is also included, as they were implemented in the wake of various safety assessments. An overview of the Temelin safety improvement programme is attached, comprising brief descriptions of 30 planned improvement items together with the time schedules. (A.K.)

Continuous Personal Improvement.

Science.gov (United States)

Emiliani, M. L.

1998-01-01

Suggests that continuous improvement tools used in the workplace can be applied to self-improvement. Explains the use of such techniques as one-piece flow, kanban, visual controls, and total productive maintenance. Points out misapplications of these tools and describes the use of fishbone diagrams to diagnose problems. (SK)

Near-peers improve patient safety training in the preclinical curriculum.

Science.gov (United States)

Raty, Sally R; Teal, Cayla R; Nelson, Elizabeth A; Gill, Anne C

2017-01-01

Accrediting bodies require medical schools to teach patient safety and residents to develop teaching skills in patient safety. We created a patient safety course in the preclinical curriculum and used continuous quality improvement to make changes over time. To assess the impact of resident teaching on student perceptions of a Patient Safety course. Using the Institute for Healthcare Improvement patient safety curriculum as a frame, the course included the seven IHI modules, large group lectures and small group facilitated discussions. Applying a social action methodology, we evaluated the course for four years (Y1-Y4). In Y1, Y2, Y3 and Y4, we distributed a course evaluation to each student (n = 184, 189, 191, and 184, respectively) and the response rate was 96, 97, 95 and 100%, respectively. Overall course quality, clarity of course goals and value of small group discussions increased in Y2 after the introduction of residents as small group facilitators. The value of residents and the overall value of the course increased in Y3 after we provided residents with small group facilitation training. Preclinical students value the interaction with residents and may perceive the overall value of a course to be improved based on near-peer involvement. Residents gain valuable experience in small group facilitation and leadership.

Integrating Quality and Safety Competencies to Improve Outcomes: Application in Infusion Therapy Practice.

Science.gov (United States)

Sherwood, Gwen; Nickel, Barbara

Despite intense scrutiny and process improvement initiatives, patient harm continues to occur in health care with alarming frequency. The Quality and Safety Education for Nursing (QSEN) project provides a roadmap to transform nursing by integrating 6 competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. As front-line caregivers, nurses encounter inherent risks in their daily work. Infusion therapy is high risk with multiple potential risks for patient harm. This study examines individual and system application of the QSEN competencies and the Infusion Nurses Society's 2016 Infusion Therapy Standards of Practice in the improvement of patient outcomes.

Progress toward international agreement to improve reactor safety

International Nuclear Information System (INIS)

Lieberman, J.I.; Graham, B.

1993-01-01

Representatives of nearly one-half of the 114 member states of the International Atomic Energy Agency (IAEA), including the United States, have participated in the development of an international nuclear safety conventions proposed multilateral treaty to improve civil nuclear power reactor safety. A preliminary draft of the convention has been developed (referred to as the draft convention for this report), but discussions are continuing, and when the final convention text will be completed and presented to IAEA member states for signature is uncertain. This report responds to the former and current Chairman's request that we provide information on the development of the nuclear safety convention, including a discussion of (1) the draft convention's scope and objectives, (2) how the convention will be implemented and monitored, (3) the views of selected country representatives on what provisions should be included in the draft convention, and (4) the convention's potential benefits and limitations

Design safety improvements of Kozloduy NPP

International Nuclear Information System (INIS)

Hinovski, I.

1999-01-01

Design safety improvements of Kozloduy NPP, discussed in detail, are concerned with: primary circuit integrity; reactor pressure vessel integrity; primary coolant piping integrity; primary coolant overpressure protection; leak before break status; design basis accidents and transients; severe accident analysis; improvements of safety and support systems; containment/confinement leak tightness and strength; seismic safety improvements; WWER-1000 control rod insertion; upgrading and modernization of Units 5 and 6; Year 2000 problem

Improving safety culture through the health and safety organization: a case study.

Science.gov (United States)

Nielsen, Kent J

2014-02-01

International research indicates that internal health and safety organizations (HSO) and health and safety committees (HSC) do not have the intended impact on companies' safety performance. The aim of this case study at an industrial plant was to test whether the HSO can improve company safety culture by creating more and better safety-related interactions both within the HSO and between HSO members and the shop-floor. A quasi-experimental single case study design based on action research with both quantitative and qualitative measures was used. Based on baseline mapping of safety culture and the efficiency of the HSO three developmental processes were started aimed at the HSC, the whole HSO, and the safety representatives, respectively. Results at follow-up indicated a marked improvement in HSO performance, interaction patterns concerning safety, safety culture indicators, and a changed trend in injury rates. These improvements are interpreted as cultural change because an organizational double-loop learning process leading to modification of the basic assumptions could be identified. The study provides evidence that the HSO can improve company safety culture by focusing on safety-related interactions. © 2013. Published by Elsevier Ltd and National Safety Council.

Continuous quality improvement

NARCIS (Netherlands)

Rohlin, Madeleine; Schaub, Rob M.H.; Holbrook, Peter; Leibur, Edvitar; Lévy, Gérard; Roubalikova, Lenka; Nilner, Maria; Roger-Leroi, Valerie; Danner, Gunter; Iseri, Haluk; Feldman, Cecile

2002-01-01

Versch. in: Eur J Dent Educ; 6 (Suppl. 3): 67–77 Continuous quality improvement (CQI) can be envisaged as a circular process of goal-setting, followed by external and internal evaluations resulting in improvements that can serve as goals for a next cycle. The need for CQI is apparent, because of

Temperature and level measurements realized for Nuclear Safety Level Improvement of Slovak NPPs

International Nuclear Information System (INIS)

Badiar, S.; Slanina, M.; Stanc, S.; Golan, P.; Krupa, J.

2001-01-01

Process of continual safety improvement in the individual Slovak nuclear power plants has been in progress since the beginning of nineties with the objective to upgrade the safety level of units in operation up to the European standards. In the framework of these activities, safety instrumentation systems with 1E qualification for the control of WWER reactor coolant systems were built and added. Methods for implementation of safety instrumentation systems for monitoring temperature and level in reactor coolant systems in the particular plants in Slovakia are presented showing the objectives and methods of their implementation. (Authors)

Perspectives: The Continuous Improvement Trap

Science.gov (United States)

Arnold, David L.

2011-01-01

Accrediting agencies, legislators, pundits, and even higher educational professionals have become enamored with applying the language of continuous improvement to learning outcomes. The Southern Association of Colleges and Schools Commission on Colleges specifically uses the term "continuing improvement" in Core Standard 2.5, one of its…

Continuous quality improvement

International Nuclear Information System (INIS)

Bourne, P.B.

1985-01-01

This paper describes the various statistical tools used at the Hanford Engineering Development Laboratory to achieve continuous quality improvement in the development of Breeder Reactor Technology and in reactor operations. The role of the quality assurance professionals in this process, including quantifiable measurements using actual examples, is provided. The commitment to quality improvement through top management involvement is dramatically illustrated

Planned activities to improve safety

International Nuclear Information System (INIS)

1998-01-01

This document presents the fulfilling of the Brazilian obligations under the Convention on Nuclear Safety. The Chapter 6 of the document contains some details about the planed activities to safety improvements

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

Science.gov (United States)

Basuni, Enas M; Bayoumi, Magda M

2015-01-13

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

Safety improvements at Canadian nuclear power plants in the aftermath of Fukushima accident

International Nuclear Information System (INIS)

Rzentkowski, G.; Khouaja, H.

2014-01-01

This paper describes the safety review of operating nuclear power plants undertaken by the Canadian Nuclear Safety Commission in light of the March 11, 2011 accident at the Fukushima Daiichi Nuclear Power Plants (NPPs). The review confirmed that the Canadian NPPs are robust and have a strong design relying on multiple layers of defence to protect the public from credible external events. Nevertheless, in the spirit of continuous safety improvements, the review identified a number of recommendations to further strengthen reactor defence-in-depth in preventing and mitigating the consequences of beyond design basis accidents, enhance onsite and offsite emergency response, and improve the CNSC regulatory framework. Progress achieved to date, in implementing these measures, is described in this paper along with a summary of safety benefits for each level of the reactor defence-in-depth. (author)

Safety improvements at Canadian nuclear power plants in the aftermath of Fukushima accident

Energy Technology Data Exchange (ETDEWEB)

Rzentkowski, G.; Khouaja, H. [Canadian Nuclear Safety Commission, Ottawa, ON (Canada)

2014-07-01

This paper describes the safety review of operating nuclear power plants undertaken by the Canadian Nuclear Safety Commission in light of the March 11, 2011 accident at the Fukushima Daiichi Nuclear Power Plants (NPPs). The review confirmed that the Canadian NPPs are robust and have a strong design relying on multiple layers of defence to protect the public from credible external events. Nevertheless, in the spirit of continuous safety improvements, the review identified a number of recommendations to further strengthen reactor defence-in-depth in preventing and mitigating the consequences of beyond design basis accidents, enhance onsite and offsite emergency response, and improve the CNSC regulatory framework. Progress achieved to date, in implementing these measures, is described in this paper along with a summary of safety benefits for each level of the reactor defence-in-depth. (author)

Improving safety on rural local and tribal roads safety toolkit.

Science.gov (United States)

2014-08-01

Rural roadway safety is an important issue for communities throughout the country and presents a challenge for state, local, and Tribal agencies. The Improving Safety on Rural Local and Tribal Roads Safety Toolkit was created to help rural local ...

[Process management in the hospital pharmacy for the improvement of the patient safety].

Science.gov (United States)

Govindarajan, R; Perelló-Juncá, A; Parès-Marimòn, R M; Serrais-Benavente, J; Ferrandez-Martí, D; Sala-Robinat, R; Camacho-Calvente, A; Campabanal-Prats, C; Solà-Anderiu, I; Sanchez-Caparrós, S; Gonzalez-Estrada, J; Martinez-Olalla, P; Colomer-Palomo, J; Perez-Mañosas, R; Rodríguez-Gallego, D

2013-01-01

To define a process management model for a hospital pharmacy in order to measure, analyse and make continuous improvements in patient safety and healthcare quality. In order to implement process management, Igualada Hospital was divided into different processes, one of which was the Hospital Pharmacy. A multidisciplinary management team was given responsibility for each process. For each sub-process one person was identified to be responsible, and a working group was formed under his/her leadership. With the help of each working group, a risk analysis using failure modes and effects analysis (FMEA) was performed, and the corresponding improvement actions were implemented. Sub-process indicators were also identified, and different process management mechanisms were introduced. The first risk analysis with FMEA produced more than thirty preventive actions to improve patient safety. Later, the weekly analysis of errors, as well as the monthly analysis of key process indicators, permitted us to monitor process results and, as each sub-process manager participated in these meetings, also to assume accountability and responsibility, thus consolidating the culture of excellence. The introduction of different process management mechanisms, with the participation of people responsible for each sub-process, introduces a participative management tool for the continuous improvement of patient safety and healthcare quality. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.

Indicators of the management for the continuous improvement of the radiological safety in a radioactive facility; Indicadores de gestion para la mejora continua de la seguridad radiologica en una instalacion radiactiva

Energy Technology Data Exchange (ETDEWEB)

Amador B, Z. H. [Centro de Isotopos, Ave. Monumental y Carretera La Rada, Km 3, Guanabacoa, Apartado 3415, Ciudad de La Habana (Cuba)]. e-mail: zabalbona@centis.edu.cu

2006-07-01

The use of safety indicators is common in the nuclear industry. In this work the implementation of indicators for the efficiency analysis of the radiological safety management system of a radioactive installation is presented. Through the same ones the occupational exposure, the training Y authorization of the personnel, the control of practices Y radioactive inventory, the results of the radiological surveillance, the occurrence of radiological events, the aptitude of the monitoring equipment, the management of the radioactive waste, the public exposure, the audits Y the costs of safety are evaluated. Its study is included in the periodic training of the workers. Without this interrelation it is not possible to maintain the optimization of the safety neither to achieve a continuous improvement. (Author)

Baseline budgeting for continuous improvement.

Science.gov (United States)

Kilty, G L

1999-05-01

This article is designed to introduce the techniques used to convert traditionally maintained department budgets to baseline budgets. This entails identifying key activities, evaluating for value-added, and implementing continuous improvement opportunities. Baseline Budgeting for Continuous Improvement was created as a result of a newly named company president's request to implement zero-based budgeting. The president was frustrated with the mind-set of the organization, namely, "Next year's budget should be 10 to 15 percent more than this year's spending." Zero-based budgeting was not the answer, but combining the principles of activity-based costing and the Just-in-Time philosophy of eliminating waste and continuous improvement did provide a solution to the problem.

Airline Safety Improvement Through Experience with Near-Misses: A Cautionary Tale.

Science.gov (United States)

Madsen, Peter; Dillon, Robin L; Tinsley, Catherine H

2016-05-01

In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes. Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry. Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses-those where the possible dangers are salient. Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses. © 2015 Society for Risk Analysis.

Research on the improvement of nuclear safety

International Nuclear Information System (INIS)

Yoo, Keon Joong; Kim, Dong Soo; Kim, Hui Dong; Park, Chang Kyu

1993-06-01

To improve the nuclear safety, this project is divided into three areas which are the development of safety analysis technology, the development of severe accident analysis technology and the development of integrated safety assessment technology. 1. The development of safety analysis technology. The present research aims at the development of necessary technologies for nuclear safety analysis in Korea. Establishment of the safety analysis technologies enables to reduce the expenditure both by eliminating excessive conservatisms incorporated in nuclear reactor design and by increasing safety margins in operation. It also contributes to improving plant safety through realistic analyses of the Emergency Operating Procedures (EOP). 2. The development of severe accident analysis technology. By the computer codes (MELCOR and CONTAIN), the in-vessel and the ex-vessel severe accident phenomena are simulated. 3. The development of integrated safety assessment technology. In the development of integrated safety assessment techniques, the included research areas are the improvement of PSA computer codes, the basic study on the methodology for human reliability analysis (HRA) and common cause failure (CCF). For the development of the level 2 PSA computer code, the basic research for the interface between level 1 and 2 PSA, the methodology for the treatment of containment event tree are performed. Also the new technologies such as artificial intelligence, object-oriented programming techniques are used for the improvement of computer code and the assessment techniques

Mochovce NPP safety improvement and completion

International Nuclear Information System (INIS)

1997-01-01

6th Nuclear society information meeting dealt with the completion of the Mochovce NPP with regard to implementation of safety measures. It was aimed to next problems: I. 'Survey' presentation on the situation of the nuclear power industry in partner countries; II. Basic technical presentations; III. Presentations of operators of the other VVER 440/213 NPPs on their activities in the field of safety improvement in relation to IAEA recommendations; IV. Technical solutions of safety improvements ranked with IAEA degree 3 (Report SC 108 VVER); V: Technical solutions of selected Safety Measures ranked with IAEA degree 2 and 1 (Report SC 108 VVER)

Labor-Management Cooperation in Illinois: How a Joint Union Company Team Is Improving Facility Safety.

Science.gov (United States)

Mahan, Bruce; Maclin, Reggie; Ruttenberg, Ruth; Mundy, Keith; Frazee, Tom; Schwartzkopf, Randy; Morawetz, John

2018-01-01

This study of Afton Chemical Corporation's Sauget facility and its International Chemical Workers Union Council (ICWUC) Local 871C demonstrates how significant safety improvements can be made when committed leadership from both management and union work together, build trust, train the entire work force in U.S. Occupational Safety and Health Administration 10-hour classes, and communicate with their work force, both salaried and hourly. A key finding is that listening to the workers closest to production can lead to solutions, many of them more cost-efficient than top-down decision-making. Another is that making safety and health an authentic value is hard work, requiring time, money, and commitment. Third, union and management must both have leadership willing to take chances and learn to trust one another. Fourth, training must be for everyone and ongoing. Finally, health and safety improvements require dedicated funding. The result was resolution of more than one hundred safety concerns and an ongoing institutionalized process for continuing improvement.

Sustainable MSD prevention: management for continuous improvement between prevention and production. Ergonomic intervention in two assembly line companies.

Science.gov (United States)

Caroly, S; Coutarel, F; Landry, A; Mary-Cheray, I

2010-07-01

To increase output and meet customers' needs, companies have turned to the development of production management systems: Kaizen, one piece flow, Kanban, etc. The aim of such systems is to accelerate decisions, react to environmental issues and manage various productions. In the main, this type of management system has led to the continuous improvement of production performance. Consequently, such production management systems can have unexpected negative effects on operators' health and safety. Conversely, regulation and control systems focusing on work-related risks have obliged firms to implement health and safety management systems such as OHSAS 18001. The purpose of this type of system, also based on continuous improvement, is to reduce risks, facilitate work-related activities and identify solutions in terms of equipment and tools. However, the prevention actions introduced through health and safety systems often result in other unexpected and unwanted effects on production. This paper shows how companies can improve the way they are run by taking into account both types of management system. Copyright 2010 Elsevier Ltd. All rights reserved.

Current activities on safety improvement at Ukrainian NPPs

International Nuclear Information System (INIS)

Stovbun, V.V.

2000-01-01

This report describes general development status of the national programs on safety improvement of the Ukrainian NPPs, basic approaches adopted for planning and implementation of safety improvement works, and state of implementation of principal technical activities aimed at safety improvement of Ukrainian NPPs. (author)

Overcoming institutional challenges through continuous professionalism improvement: the University of Washington experience.

Science.gov (United States)

Fryer-Edwards, Kelly; Van Eaton, Erik; Goldstein, Erika A; Kimball, Harry R; Veith, Richard C; Pellegrini, Carlos A; Ramsey, Paul G

2007-11-01

The University of Washington (UW) School of Medicine is in the midst of an emerging ecology of professionalism. This initiative builds on prior work focusing on professionalism at the student level and moves toward the complete integration of a culture of professionalism within the UW medical community of including staff, faculty, residents, and students. The platform for initiating professionalism as institutional culture is the Committee on Continuous Professionalism Improvement, established in November 2006. This article reviews three approaches to organizational development used within and outside medicine and highlights features that are useful for enhancing an institutional culture of professionalism: organizational culture, safety culture, and appreciative inquiry. UW Medicine has defined professional development as a continuous process, built on concrete expectations, using mechanisms to facilitate learning from missteps and highlighting strengths. To this end, the school of medicine is working toward improvements in feedback, evaluation, and reward structures at all levels (student, resident, faculty, and staff) as well as creating opportunities for community dialogues on professionalism issues within the institution. Throughout all the Continuous Professionalism Improvement activities, a two-pronged approach to cultivating a culture of professionalism is taken: celebration of excellence and attention to accountability.

Continuous Improvement in Schools: Understanding the Practice

Science.gov (United States)

Anderson, Stephen; Kumari, Roshni

2009-01-01

This article investigates conceptually and practically what it means for schools to engage in the practice of continuous improvement. The analysis draws upon prior research and discussion to predict core elements of the practice of continuous improvement in schools. The predictions are then applied to a case study of continuous improvement efforts…

Continuous improvement: A win... win process

International Nuclear Information System (INIS)

Lawrence, T.; Wichert, A.

1993-01-01

Implementing a continuous improvement (CI) process within PanCanadian's oil and gas production operations might have been a simple assignment if one were not also trying to capture the hearts and imaginations of the people in a changing work environment. Meeting the challenge is resulting in big payoffs to both the organization and its people. The plan used within the Company's Production Division to successfully introduce the CI process is discussed. A brief insight is provided on the process philosophy, with emphasis placed on planning, training and coaching used to launch the process. Also reviewed at length are the impediments to change and the challenges faced when changing an organization's culture. In a CI work environment, the supervisor's traditional role changes from one of monitoring and controlling to one of inspiring, motivating and leading people by communicating a clear vision. Employees at all levels in the work environment are organized into teams and armed with a good working knowledge of the problem solving tools which allow them to pursue and implement improvement initiatives. The outcome of the process is an ongoing 'win-win' situation for both the Company and its people. Employees are gaining more trust, eliminating job irritants and enjoying their work more in a team environment. The Company is winning through increased production, improved safety and reduced operating expenses, thanks to many innovative ideas which the employees have implemented. 4 refs

Methods for safety culture improvement

International Nuclear Information System (INIS)

Sivintsev, Yu.V.

1998-01-01

New IAEA publication concerning the problems of safety assurance covering different aspects beginning from terminology applied and up to concrete examples of well and poor safety culture development at nuclear facilities is discussed. The safety culture is defined as such set of characteristics and specific activities of institutions and individual persons which states that safety problems of a nuclear facility are given the attention determined by their importance as being of highest priority. The statements of the new document have recommended, not mandatory character. It is emphasized that the process of safety culture improvement at nuclear facilities should be integral component of management procedure, not a bolt on extra

The program of continuous improvements in factory in Juzbado; El programa de mejora continua en la Fabrica de Juzbado

Energy Technology Data Exchange (ETDEWEB)

Prieto, M.

2015-07-01

This articles describes the historical development of the continuous improvement program at Juzbado Factory, since its beginning to nowadays. The evolution throughout the ideas of Total Quality, ISO, EFQM, Six Sigma, and so on, leading to the present situation in which all these tools and methodologies live together is shown. all this has led to a philosophy and business culture focused on safety, quality and continuous improvement. (Author)

Structural Aging Program to evaluate continued performance of safety-related concrete structures in nuclear power plants

International Nuclear Information System (INIS)

Naus, D.J.; Oland, C.B.; Ellingwood, B.R.

1994-01-01

This report discusses the Structural Aging (SAG) Program which is being conducted at the Oak Ridge National Laboratory (ORNL) for the United States Nuclear Regulatory commission (USNRC). The SAG Program is addressing the aging management of safety-related concrete structures in nuclear power plants for the purpose of providing improved technical bases for their continued service. The program is organized into three technical tasks: Materials Property Data Base, Structural Component Assessment/Repair Technologies, and Quantitative Methodology for continued Service Determinations. Objectives and a summary of recent accomplishments under each of these tasks are presented

International conference on the strengthening of nuclear safety in Eastern Europe. Keynote papers. Regulatory aspects of NPP safety, status of safety improvements, status of safety analysis report

International Nuclear Information System (INIS)

1999-06-01

The Objective of the Conference was to assess the past decade of nuclear safety efforts in countries operating WWER and RBMK nuclear reactors and to address remaining safety issues which require further work. A particular focus of the Conference was on international co-operation and assistance and where such efforts should be focused in the future. All Eastern European countries that operate RBMK or WWER reactors participated in the Conference, and presented papers on three key areas of nuclear safety: Regulatory Aspects of Nuclear Power Plant Safety; Status of Safety Improvements; and Status of Safety Analysis Reports. In addition, representatives from 18 additional countries that provide financial and/or technical assistance and co-operation in the area of WWER and RBMK safety offered the most extensive commentary. Key international (IAEA, World Association of Nuclear Operators, the Nuclear Energy Agency, the G-24 NUSAC, the European Commission, and the EBRD) organizations that provide nuclear safety assistance for WWER and RBMK reactors also made presentations. There is no question that considerable progress on nuclear safety has been made in Eastern Europe. Special mention should be made of successful efforts to strengthen the independence and technical competence of the nuclear regulatory authorities. Efforts should now concentrate on improving the depth and scope of the technical abilities of the regulatory authorities. More attention by governments is needed to ensure that the regulatory authorities have the financial resources and enforcement authority to fully execute their missions. In respect to the operators of the nuclear power plants, they have demonstrated clear progress in operational safety improvements. Significant additional efforts are required to maintain and enhance an effective safety culture. Design safety improvement programmes are in place in all countries. Implementation of these programmes has varied and is particularly affected by

Improving patient safety: lessons from rock climbing.

Science.gov (United States)

Robertson, Nic

2012-02-01

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

Safety improvement of Paks nuclear power plant

International Nuclear Information System (INIS)

Vamos, G.

1999-01-01

Safety upgrading completed in the early nineties at the Paks NPP include: replacement of steam generator safety valves and control valves; reliability improvement of the electrical supply system; modification of protection logic; enhancement of the fire protection; construction of full scope Training Simulator. Design safety upgrading measures achieved in recent years were concerned with: relocation of steam generator emergency feed-water supply; emergency gas removal from the primary coolant system; hydrogen management in the containment; protection against sumps; preventing of emergency core cooling system tanks from refilling. Increasing seismic resistance, containment assessment, refurbishment of reactor protection system, improving reliability of emergency electrical supply, analysis of internal hazards are now being implemented. Safety upgrading measures which are being prepared include: bleed and feed procedures; reactor over-pressurisation protection in cold state; treatment of steam generator primary to secondary leak accidents. Operational safety improvements are dealing with safety culture, training measures and facilities; symptom based emergency operating procedures; in-service inspection; fire protection. The significance of international cooperation is emphasised in view of achieving nuclear safety standards recognised in EU

Can we Improve Patient Safety?

Directory of Open Access Journals (Sweden)

Martin Thomas Corbally

2014-09-01

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

Safety culture improvement. An adaptive management framework

International Nuclear Information System (INIS)

Obadia, Isaac Jose

2005-01-01

After the Chernobyl nuclear accident in 1986, the International Atomic Energy Agency (IAEA) established the safety culture concept as a proactive mean to contribute to safety improvement, starting a worldwide safety culture enhancement program within nuclear organizations mainly focused on nuclear power plants. More recently, the safety culture concept has been extended to non-power applications such as nuclear research reactors and nuclear technological research and development organizations. In 1999, the Nuclear Engineering Institute (IEN), a research and technological development unit of the Brazilian Nuclear Energy Commission (CNEN), started a management change program aiming at improving its performance level of excellence. This change program has been developed assuming the occurrence of complex causal inter-relationships between the organizational culture and the implementation of the management process. A systematic and adaptive management framework comprised of a safety culture improvement practice integrated to a management process based on the Criteria for Excellence of the Brazilian Quality Award Model, has been developed and implemented at IEN. The case study has demonstrated that the developed framework makes possible an effective safety culture improvement and simultaneously facilitates an effective implementation of the management process, thus providing some governance to the change program. (author)

EC6 safety design improvements

Energy Technology Data Exchange (ETDEWEB)

Yu, S.; Lee, A.G.; Soulard, M. [Candu Energy Inc., Mississauga, ON (Canada)

2014-07-01

The Enhanced CANDU 6 (EC6) builds on the proven high performance design such as the Qinshan CANDU 6 reactor, and has made improvements to safety, operational performance, and has incorporated extensive operational feedback. Completion of all three phases of the pre-licensing design review by the Canadian Regulator - the Canadian Nuclear Safety Commission has provided a higher level of assurance that the EC6 reference design has taken modern regulatory requirements and expectations into account and further confirmed that there are no fundamental barriers to licensing the EC6 design in Canada. The EC6 design is based on the defence-in-depth principles in INSAG-10 and provides further safety features that address the lessons learned from Fukushima. With these safety features, the EC6 design has strengthened accident prevention as the first priority in the defence-in-depth strategy, as outlined in INSAG-10. As well, the EC6 design has incorporated further mitigation measures to provide additional protection of the public and the environment if the preventive measures fail. The EC6 design has an appropriate combination of inherent, passive safety characteristics, engineered features and administrative safety measures to effectively prevent and mitigate severe accident progressions. A strong contributor to the robustness and redundancy of CANDU design is the two-group separation philosophy. This ensures a high degree of independence between safety systems as well as physical separation and functional independence in how fundamental safety functions are provided. This paper will describe the following safety features based on the application of defence-in-depth and design approach to prevent beyond design basis events progressing to severe accidents and to mitigate the consequences if it occurs: Improved steam generator heat sink via a more reliable emergency heat removal system; Increased time before manual field actions are required via enhanced capacity of

An interprofessional approach to improving paediatric medication safety

Directory of Open Access Journals (Sweden)

Kennedy Neil

2010-02-01

Full Text Available Abstract Background Safe drug prescribing and administration are essential elements within undergraduate healthcare curricula, but medication errors, especially in paediatric practice, continue to compromise patient safety. In this area of clinical care, collective responsibility, team working and communication between health professionals have been identified as key elements in safe clinical practice. To date, there is limited research evidence as to how best to deliver teaching and learning of these competencies to practitioners of the future. Methods An interprofessional workshop to facilitate learning of knowledge, core competencies, communication and team working skills in paediatric drug prescribing and administration at undergraduate level was developed and evaluated. The practical, ward-based workshop was delivered to 4th year medical and 3rd year nursing students and evaluated using a pre and post workshop questionnaire with open-ended response questions. Results Following the workshop, students reported an increase in their knowledge and awareness of paediatric medication safety and the causes of medication errors (p Conclusion This study has helped bridge the knowledge-skills gap, demonstrating how an interprofessional approach to drug prescribing and administration has the potential to improve quality and safety within healthcare.

The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement, Research, Training, and Practice.

Science.gov (United States)

Pronovost, Peter J; Holzmueller, Christine G; Molello, Nancy E; Paine, Lori; Winner, Laura; Marsteller, Jill A; Berenholtz, Sean M; Aboumatar, Hanan J; Demski, Renee; Armstrong, C Michael

2015-10-01

Academic medical centers (AMCs) could advance the science of health care delivery, improve patient safety and quality improvement, and enhance value, but many centers have fragmented efforts with little accountability. Johns Hopkins Medicine, the AMC under which the Johns Hopkins University School of Medicine and the Johns Hopkins Health System are organized, experienced similar challenges, with operational patient safety and quality leadership separate from safety and quality-related research efforts. To unite efforts and establish accountability, the Armstrong Institute for Patient Safety and Quality was created in 2011.The authors describe the development, purpose, governance, function, and challenges of the institute to help other AMCs replicate it and accelerate safety and quality improvement. The purpose is to partner with patients, their loved ones, and all interested parties to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste in health care. A governance structure was created, with care mapped into seven categories, to oversee the quality and safety of all patients treated at a Johns Hopkins Medicine entity. The governance has a Patient Safety and Quality Board Committee that sets strategic goals, and the institute communicates these goals throughout the health system and supports personnel in meeting these goals. The institute is organized into 13 functional councils reflecting their behaviors and purpose. The institute works daily to build the capacity of clinicians trained in safety and quality through established programs, advance improvement science, and implement and evaluate interventions to improve the quality of care and safety of patients.

Improving the international system for operating experience feedback. INSAG-23. A report by the International Nuclear Safety Group

International Nuclear Information System (INIS)

2008-01-01

The operational safety performance of nuclear facilities has, in general, improved notably over time throughout the world. This has been achieved, in part, through operating experience feedback (OEF) and the introduction of new technology. While the continued strong safety performance by operators is encouraging, safety significant events continue to recur in nuclear installations. This indicates that operators are not learning and applying the lessons that experience can teach us. This report focuses on systems that are operated by intergovernmental organizations with close contacts to national regulatory authorities. These systems provide an alternative network to the worldwide system employed by the operators of nuclear facilities known as the World Association of Nuclear Operators (WANO). The WANO system is restricted to its members, who have concluded that keeping the information exchanged confidential improves its usefulness. INSAG recognizes the merits of this approach, particularly in light of the primary responsibility of licensed operators for the safety of their facilities. Nevertheless, INSAG encourages WANO to share key safety lessons with national regulatory authorities and intergovernmental organization

Improved safety in ski jumping.

Science.gov (United States)

Wester, K

1988-01-01

Among approximately 2,600 licensed Norwegian ski jumpers, only three injuries that caused a permanent medical disability of at least 10% were incurred during the 5 year period from 1982 through 1986. When compared to the previous 5 year period (1977 to 1981), a dramatic improvement in safety is seen, as both number and severity of such injuries were markedly reduced. There are several probable reasons for this improved safety record: better preparation of the jumps, the return to using only one standard heel block, and the fact that coaches are being more responsible, especially with younger jumpers.

International conference on the strengthening of nuclear safety in Eastern Europe. Keynote papers. Regulatory aspects of NPP safety, status of safety improvements, status of safety analysis report

Energy Technology Data Exchange (ETDEWEB)

NONE

1999-06-01

The Objective of the Conference was to assess the past decade of nuclear safety efforts in countries operating WWER and RBMK nuclear reactors and to address remaining safety issues which require further work. A particular focus of the Conference was on international co-operation and assistance and where such efforts should be focused in the future. All Eastern European countries that operate RBMK or WWER reactors participated in the Conference, and presented papers on three key areas of nuclear safety: Regulatory Aspects of Nuclear Power Plant Safety; Status of Safety Improvements; and Status of Safety Analysis Reports. In addition, representatives from 18 additional countries that provide financial and/or technical assistance and co-operation in the area of WWER and RBMK safety offered the most extensive commentary. Key international (IAEA, World Association of Nuclear Operators, the Nuclear Energy Agency, the G-24 NUSAC, the European Commission, and the EBRD) organizations that provide nuclear safety assistance for WWER and RBMK reactors also made presentations. There is no question that considerable progress on nuclear safety has been made in Eastern Europe. Special mention should be made of successful efforts to strengthen the independence and technical competence of the nuclear regulatory authorities. Efforts should now concentrate on improving the depth and scope of the technical abilities of the regulatory authorities. More attention by governments is needed to ensure that the regulatory authorities have the financial resources and enforcement authority to fully execute their missions. In respect to the operators of the nuclear power plants, they have demonstrated clear progress in operational safety improvements. Significant additional efforts are required to maintain and enhance an effective safety culture. Design safety improvement programmes are in place in all countries. Implementation of these programmes has varied and is particularly affected by

Continuous Improvement in Education. Advancing Teaching--Improving Learning. White Paper

Science.gov (United States)

Park, Sandra; Hironaka, Stephanie; Carver, Penny; Nordstrum, Lee

2013-01-01

In recent years, "continuous improvement" has become a popular catchphrase in the field of education. However, while continuous improvement has become commonplace and well-documented in other industries, such as healthcare and manufacturing, little is known about how this work has manifested itself in education. This white paper attempts…

Health innovation for patient safety improvement.

Science.gov (United States)

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

2013-01-01

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

Health innovation for patient safety improvement

Directory of Open Access Journals (Sweden)

Renukha Sellappans

2013-01-01

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

ThedaCare's business performance system: sustaining continuous daily improvement through hospital management in a lean environment.

Science.gov (United States)

Barnas, Kim

2011-09-01

For 2003-2008, ThedaCare, a community health system in Wisconsin, achieved significant improvements in quality and the elimination of waste through the development of an improvement system, which included Value Stream analysis, rapid improvement events, and projects applied to specific processes. However, to meet its continuous daily improvement goals, particularly the goal of increasing productivity by 10% annually, ThedaCare needed to change the way its managers and leaders (in its hospital division) conduct and manage their daily work. Accordingly, it developed its Business Performance System (BPS) to achieve and sustain continuous daily improvement. BUILDING THE BPS: ThedaCare devised a multipart pilot project, consisting of "learning to see" and then, "problem solving." On completion of the 15-week alpha phase (6 units) in July 2009, the BPS was spread to the beta pilot (12 units; September 2009-January 2010) and then to cohort 3 (10 units; September 2010-January 2011). Each alpha unit improved performance on (1) the key driver metric of increasing productivity from 2008 to year-end 2009 (by 1%-11%) and (2) its respective safety/ quality drivers over the respective 2008 baselines. For 2010, improvements across the alpha, beta, and cohort 3 units were found for 11 of the 14 safety/quality drivers-85% of the 11 customer satisfaction drivers, 83% of 6 people engagement drivers; and 48% of 23 financial stewardship drivers. The tools developed for the BPS have enabled teams to see, prioritize, and pursue continuous daily improvement opportunities. Unit leaders now have a structured management reporting system to reduce variation in their management styles. Leaders all now follow leadership standard work, and their daily work is now consistently aligned with the hospital and system strategy.

A tool for safety evaluations of road improvements.

Science.gov (United States)

Peltola, Harri; Rajamäki, Riikka; Luoma, Juha

2013-11-01

Road safety impact assessments are requested in general, and the directive on road infrastructure safety management makes them compulsory for Member States of the European Union. However, there is no widely used, science-based safety evaluation tool available. We demonstrate a safety evaluation tool called TARVA. It uses EB safety predictions as the basis for selecting locations for implementing road-safety improvements and provides estimates of safety benefits of selected improvements. Comparing different road accident prediction methods, we demonstrate that the most accurate estimates are produced by EB models, followed by simple accident prediction models, the same average number of accidents for every entity and accident record only. Consequently, advanced model-based estimates should be used. Furthermore, we demonstrate regional comparisons that benefit substantially from such tools. Comparisons between districts have revealed significant differences. However, comparisons like these produce useful improvement ideas only after taking into account the differences in road characteristics between areas. Estimates on crash modification factors can be transferred from other countries but their benefit is greatly limited if the number of target accidents is not properly predicted. Our experience suggests that making predictions and evaluations using the same principle and tools will remarkably improve the quality and comparability of safety estimations. Copyright © 2013 Elsevier Ltd. All rights reserved.

IAEA Safety Standards on Management Systems and Safety Culture

International Nuclear Information System (INIS)

Persson, Kerstin Dahlgren

2007-01-01

The IAEA has developed a new set of Safety Standard for applying an integrated Management System for facilities and activities. The objective of the new Safety Standards is to define requirements and provide guidance for establishing, implementing, assessing and continually improving a Management System that integrates safety, health, environmental, security, quality and economic related elements to ensure that safety is properly taken into account in all the activities of an organization. With an integrated approach to management system it is also necessary to include the aspect of culture, where the organizational culture and safety culture is seen as crucial elements of the successful implementation of this management system and the attainment of all the goals and particularly the safety goals of the organization. The IAEA has developed a set of service aimed at assisting it's Member States in establishing. Implementing, assessing and continually improving an integrated management system. (author)

Total safety management: An approach to improving safety culture

International Nuclear Information System (INIS)

Blush, S.M.

1993-01-01

A little over 4 yr ago, Admiral James D. Watkins became Secretary of Energy. President Bush, who had appointed him, informed Watkins that his principal task would be to clean up the nuclear weapons complex and put the US Department of Energy (DOE) back in the business of producing tritium for the nation's nuclear deterrent. Watkins recognized that in order to achieve these objectives, he would have to substantially improve the DOE's safety culture. Safety culture is a relatively new term. The International Atomic Energy Agency (IAEA) used it in a 1986 report on the root causes of the Chernobyl nuclear accident. In 1990, the IAEA's International Nuclear Safety Advisory Group issued a document focusing directly on safety culture. It provides guidelines to the international nuclear community for measuring the effectiveness of safety culture in nuclear organizations. Safety culture has two principal aspects: an organizational framework conducive to safety and the necessary organizational and individual attitudes that promote safety. These obviously go hand in hand. An organization must create the right framework to foster the right attitudes, but individuals must have the right attitudes to create the organizational framework that will support a good safety culture. The difficulty in developing such a synergistic relationship suggests that achieving and sustaining a strong safety culture is not easy, particularly in an organization whose safety culture is in serious disrepair

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

Science.gov (United States)

Yassi, Annalee; Hancock, Tina

2005-01-01

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

Managerial implications for improving continuous production processes

DEFF Research Database (Denmark)

Capaci, Francesca; Vanhatalo, Erik; Bergquist, Bjarne

2017-01-01

. In this article we highlight SPC and DoE implementation challenges described in the literature for managers, researchers and practitioners interested in continuous production process improvement. The results may help managers support the implementation of these methods and make researchers and practitioners aware......Data analytics remains essential for process improvement and optimization. Statistical process control and design of experiments are among the most powerful process and product improvement methods available. However, continuous process environments challenge the application of these methods...... of methodological challenges in continuous process environments...

Continue service improvement at CERN computing centre

International Nuclear Information System (INIS)

Lopez, M Barroso; Everaerts, L; Meinhard, H; Baehler, P; Haimyr, N; Guijarro, J M

2014-01-01

Using the framework of ITIL best practises, the service managers within CERN-IT have engaged into a continuous improvement process, mainly focusing on service operation. This implies an explicit effort to understand and improve all service management aspects in order to increase efficiency and effectiveness. We will present the requirements, how they were addressed and share our experiences. We will describe how we measure, report and use the data to continually improve both the processes and the services being provided. The focus is not the tool or the process, but the results of the continuous improvement effort from a large team of IT experts providing services to thousands of users, supported by the tool and its local team. This is not an initiative to address user concerns in the way the services are managed but rather an on-going working habit of continually reviewing, analysing and improving the service management processes and the services themselves, having in mind the currently agreed service levels and whose results also improve the experience of the users about the current services.

Fukushima Ministerial Conference Urges Continued Work to Strengthen Nuclear Safety

International Nuclear Information System (INIS)

2012-01-01

Full text: Strengthening nuclear safety is a continuous process that leaves no room for complacency, the Co-Presidents of the Fukushima Ministerial Conference on Nuclear Safety said in a statement today. Koichiro Gemba, Japan's Minister of Foreign Affairs, and Fadillah bin Haji Yusof, Malaysia's Deputy Minister of Science, Technology and Innovation, released the Co-Presidents' Statement at the conclusion of the Conference's Ministerial Plenary, on day one of the three-day event. ''It was stressed that nuclear safety is a prerequisite for the peaceful uses of nuclear energy, that strengthening nuclear safety is a continuous process and that there should be no complacency in safety matters,'' the statement said. The statement recognized progress reported by Japan in the response to the Fukushima Daiichi accident, including the achievement of the present stable status of the nuclear power station and the significant decrease in radioactive releases at the accident site. It stressed the importance of continued transparency in sharing objective information on the progress of decommissioning the plant, remediation and waste management, and encouraged Japan to lead an international effort to obtain data from the damaged reactors. ''The lessons learned from these activities, through their dissemination and related cooperation with the international community, are expected to contribute to enhancing the safety and effectiveness of future decommissioning and remediation activities worldwide,'' it said. The statement emphasized the importance of strengthening the IAEA's central role in international efforts to enhance global nuclear safety, underlining the Agency's Safety Standards and the IAEA Action Plan on Nuclear Safety. It urged IAEA Member States to strengthen efforts to implement the Action Plan fully, including the use of international peer reviews and putting the recommendations of such reviews into practice. It stressed the ''utmost importance of establishing and

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

Science.gov (United States)

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

2013-10-01

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

Human Resource Management for Continuous Improvement

DEFF Research Database (Denmark)

Jørgensen, Frances; Laugen, Bjørge Timenes; Boer, Harry

2007-01-01

This paper investigates the relationship between HRM practices and Continuous Improvement (CI) activities in order to gain an understanding of how the HRM function may be utilized to improve CI implementation success, and consequently, company performance. The paper begins with a brief review...... of the HRM and CI literature and then presents statistical analyses of data collected from the Continuous Improvement Network Survey (2003), which demonstrate that HRM has a significant effect on CI behaviour and company performance, with the strongest relationship between HRM, CI and performance occurring...

Improving the safety and reliability of Monju

International Nuclear Information System (INIS)

Itou, Kazumoto; Maeda, Hiroshi; Moriyama, Masatoshi

1998-01-01

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

The awareness of employees in safety culture through the improved nuclear safety culture evaluation method

Energy Technology Data Exchange (ETDEWEB)

Kim, Young Ga; Sung, Chan Ho; Jung, Yeon Sub [KHNP Central Research Institute, Daejeon (Korea, Republic of)

2012-10-15

After the Chernobyl nuclear accident in 1986, nuclear safety culture terminology was at first introduced emphasizing the importance of employees' attitude and organizational safety. The concept of safety culture was spread by INSAG 4 published in 1991. From that time, IAEA had provided the service of ASCOT for the safety culture assessment. However, many people still are thinking that safety culture is abstract and is not clear. It is why the systematic and reliable assessment methodology was not developed. Assessing safety culture is to identify what is the basic assumption for any organization to accept unconsciously. Therefore, it is very difficult to reach a meaningful conclusion by a superficial investigation alone. KHNP had been doing the safety culture assessment which was based on ASCOT methodology every 2 years. And this result had contributed to improving safety culture. But this result could not represent the level of organization's safety culture due to the limitation of method. So, KHNP has improved the safety culture method by benchmarking the over sea assessment techniques in 2011. The effectiveness of this improved methodology was validated through a pilot assessment. In this paper, the level of employees' safety culture awareness was analyzed by the improved method and reviewed what is necessary for the completeness and objectivity of the nuclear safety culture assessment methodology.

The awareness of employees in safety culture through the improved nuclear safety culture evaluation method

International Nuclear Information System (INIS)

Kim, Young Ga; Sung, Chan Ho; Jung, Yeon Sub

2012-01-01

After the Chernobyl nuclear accident in 1986, nuclear safety culture terminology was at first introduced emphasizing the importance of employees' attitude and organizational safety. The concept of safety culture was spread by INSAG 4 published in 1991. From that time, IAEA had provided the service of ASCOT for the safety culture assessment. However, many people still are thinking that safety culture is abstract and is not clear. It is why the systematic and reliable assessment methodology was not developed. Assessing safety culture is to identify what is the basic assumption for any organization to accept unconsciously. Therefore, it is very difficult to reach a meaningful conclusion by a superficial investigation alone. KHNP had been doing the safety culture assessment which was based on ASCOT methodology every 2 years. And this result had contributed to improving safety culture. But this result could not represent the level of organization's safety culture due to the limitation of method. So, KHNP has improved the safety culture method by benchmarking the over sea assessment techniques in 2011. The effectiveness of this improved methodology was validated through a pilot assessment. In this paper, the level of employees' safety culture awareness was analyzed by the improved method and reviewed what is necessary for the completeness and objectivity of the nuclear safety culture assessment methodology

EUROSAFE Forum for nuclear safety. Towards Convergence of Technical Nuclear Safety Practices in Europe. Safety Improvements - Reasons, Strategies, Implementation

Energy Technology Data Exchange (ETDEWEB)

Erven, Ulrich (ed.) [Gesellschaft fuer Anlagen- und Reaktorsicherheit, GRS mbH, Schwertnergasse 1, 50667 Koeln (Germany); Cherie, Jean-Bernard (ed.) [Institut de Radioprotection et de Surete Nucleaire, IRSN, BP 17, 92262 Fontenay-aux-Roses Cedex (France); Boeck, Benoit De (ed.) [Association Vincotte Nuclear, AVN, Rue Walcourt 148, 1070 Bruxelles (Belgium)

2005-07-01

The EUROSAFE Forum for Nuclear Safety is part of the EUROSAFE approach, which consists of two further elements: the EUROSAFE Tribune and the EUROSAFE Web site. The general aim of EUROSAFE is to contribute to fostering the convergence of technical nuclear safety practices in a broad European context. This is done by providing technical safety and research organisations, safety authorities, power utilities, the rest of the industry and non-governmental organisations mainly from the European Union and East-European countries, and international organisations with a platform for the presentation of recent analyses and R and D in the field of nuclear safety. The goal is to share experiences, to exchange technical and scientific opinions, and to conduct debates on key issues in the fields of nuclear safety and radiation protection. The EUROSAFE Forum on 2005 focused on Safety Improvements, Reasons - Strategies - Implementation, from the point of view of the authorities, TSOs and industry. Latest work in nuclear installation safety and research, waste management, radiation safety as well as nuclear material and nuclear facilities security carried out by GRS, IRSN, AVN and their partners in the European Union, Switzerland and Eastern Europe are presented. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety and safety management, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge, and the need for greater transparency - these are all issues where the value of an international approach is gaining

EUROSAFE Forum for nuclear safety. Towards Convergence of Technical Nuclear Safety Practices in Europe. Safety Improvements - Reasons, Strategies, Implementation

Energy Technology Data Exchange (ETDEWEB)

Erven, Ulrich [Gesellschaft fuer Anlagen- und Reaktorsicherheit, GRS mbH, Schwertnergasse 1, 50667 Koeln (Germany); Cherie, Jean-Bernard [Institut de Radioprotection et de Surete Nucleaire, IRSN, BP 17, 92262 Fontenay-aux-Roses Cedex (France); Boeck, Benoit De [Association Vincotte Nuclear, AVN, Rue Walcourt 148, 1070 Bruxelles (Belgium)

2005-07-01

The EUROSAFE Forum for Nuclear Safety is part of the EUROSAFE approach, which consists of two further elements: the EUROSAFE Tribune and the EUROSAFE Web site. The general aim of EUROSAFE is to contribute to fostering the convergence of technical nuclear safety practices in a broad European context. This is done by providing technical safety and research organisations, safety authorities, power utilities, the rest of the industry and non-governmental organisations mainly from the European Union and East-European countries, and international organisations with a platform for the presentation of recent analyses and R and D in the field of nuclear safety. The goal is to share experiences, to exchange technical and scientific opinions, and to conduct debates on key issues in the fields of nuclear safety and radiation protection. The EUROSAFE Forum on 2005 focused on Safety Improvements, Reasons - Strategies - Implementation, from the point of view of the authorities, TSOs and industry. Latest work in nuclear installation safety and research, waste management, radiation safety as well as nuclear material and nuclear facilities security carried out by GRS, IRSN, AVN and their partners in the European Union, Switzerland and Eastern Europe are presented. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety and safety management, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge, and the need for greater transparency - these are all issues where the value of an international approach is gaining

CONTINUOUS IMPROVEMENT PRACTICE IN LARGE ENTERPRISES: STUDY RESULTS

Directory of Open Access Journals (Sweden)

Dorota Stadnicka

2015-03-01

Full Text Available Continuous improvement is indispensable for ensuring the company's development and its survival on the constantly changing global market. Continuous improvement is particularly important in the quality and production management systems. A company should deliver a product compliant with a client's requirements in a specified time and at an appropriate price. That is why, continuous improvement refers to different areas of an organization's functioning and it is an integral part of Lean Manufacturing. This article presents the results of the study conducted in production enterprises on a limited area. The aim of the study was the assessment of the implementation of continuous improvement in Lean Manufacturing, and, in particular, employees' involvement in the problem identification and in reporting improvements as well as the way of motivating employees to involve themselves. The authors also tried to identify the factors influencing the elements of a continuous improvement system.

Beyond safety accountability

CERN Document Server

Geller, E Scott

2001-01-01

Written in an easy-to-read conversational tone, Beyond Safety Accountability explains how to develop an organizational culture that encourages people to be accountable for their work practices and to embrace a higher sense of personal responsibility. The author begins by thoroughly explaining the difference between safety accountability and safety responsibility. He then examines the need of organizations to improve safety performance, discusses why such performance improvement can be achieved through a continuous safety process, as distinguished from a safety program, and provides the practic

Twenty years of improvements in LWR safety

International Nuclear Information System (INIS)

Franks, S. III; Mulkey, J.P.; Moonka, A.

1996-01-01

Substantial improvements have been made in the safety of light-water reactors in the US during the past two decades, making currently operating reactors safer than ever before. Safety improvements have resulted both from regulatory and operational changes and from new knowledge and technology. The US Nuclear Regulatory Commission, the US Department of Energy, and the American nuclear power industry have worked together and with the international community to enhance the safety of existing plants and to incorporate lessons learned from prior operation into designs for a new generation of advanced, inherently safer reactors

A BWR Safety and Operability Improvements

International Nuclear Information System (INIS)

Sawyer, Craig D.

1993-01-01

The A BWR is the culmination of 30 years of design, development and operating experience of BWRs around the world. It represents across the board improvements is safety, operation and maintenance practices (O and M), economics, radiation exposure and rad waste generation. More than ten years and $20m5 went into the design and development of its new features, and it is now under construction in Japan. This paper concentrates on the safety and operability improvements. In the safety area, more than a decade improvement in core damage frequency (CDFR) has been assessed by formal PIRA techniques, with CDFR less than 10 -6 /year. Severe accident mitigation has also been formally addressed in the design. Plant operations were simplified by incorporation of better materials, optimum use of redundancy in mechanical and electrical equipment so that on-line maintenance can be performed, by better arrangements which account for required maintenance practices, and by an advanced control room

R and D techniques and how to continuously improve them?

International Nuclear Information System (INIS)

Massaut, V.; Collard, G.

2005-01-01

Although decommissioning of nuclear installations has been carried out successfully in different countries, and decommissioning is sometimes considered as a mature industrial activity, Research and Development can still improve the operations, and is also needed to keep the current know how. The research and development can bring reduction of costs, limitation of radioactive waste generation, and improve the safety and radioprotection aspects. When one consider that less than 100 facilities are currently in decommissioning for more than 800 reactors (power plants and research reactors, almost half and half) worldwide, the present used technology can be considered as the prehistory of D and D. The paper will focus on the needs for improvements and developments, on the attached constraints and restriction, and will then look at the potential ways to continue R and D and technology improvement. Regarding the rather recent development of the D and D technology and the large remaining market for D and D of nuclear installations, there is still a large field of open development for techniques and technologies for the dismantling of nuclear installations worldwide. Although D and D of all kinds of nuclear installations have proven to be feasible, improvements are surely needed to reduce the costs and waste of D and D, therefore reducing the burden to the plant owners, and to improve the radioprotection of the operations. The same applies for the improvement of the overall operators safety during such operations. There are different ways to go in this direction and the groups to gather the necessary experience and technological data are existing, but the will has to be present to go forward, in a competitive environment. It is difficult to believe that such improvements in the technologies and the approach of decommissioning can rely only on commercial and private initiatives. Therefore, organized international R and D should be promoted wherever it is possible, enhancing

78 FR 48029 - Improving Chemical Facility Safety and Security

Science.gov (United States)

2013-08-07

... Improving Chemical Facility Safety and Security By the authority vested in me as President by the... at reducing the safety risks and security risks associated with hazardous chemicals. However... to further improve chemical facility safety and security in coordination with owners and operators...

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

Science.gov (United States)

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

2015-02-01

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

Technical specification improvement through safety margin considerations

International Nuclear Information System (INIS)

Howard, R.C.; Jansen, R.L.

1986-01-01

Westinghouse has developed an approach for utilizing safety analysis margin considerations to improve plant operability through technical specification revision. This approach relies on the identification and use of parameter interrelations and sensitivities to identify acceptable operating envelopes. This paper summarizes technical specification activities to date and presents the use of safety margin considerations as another viable method to obtain technical specification improvement

Confidence improvement of disosal safety bydevelopement of a safety case for high-level radioactive waste disposal

Energy Technology Data Exchange (ETDEWEB)

Baik, Min Hoon; Ko, Nak Youl; Jeong, Jong Tae; Kim, Kyung Su [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2016-12-15

Many countries have developed a safety case suitable to their own countries in order to improve the confidence of disposal safety in deep geological disposal of high-level radioactive waste as well as to develop a disposal program and obtain its license. This study introduces and summarizes the meaning, necessity, and development process of the safety case for radioactive waste disposal. The disposal safety is also discussed in various aspects of the safety case. In addition, the status of safety case development in the foreign countries is briefly introduced for Switzerland, Japan, the United States of America, Sweden, and Finland. The strategy for the safety case development that is being developed by KAERI is also briefly introduced. Based on the safety case, we analyze the efforts necessary to improve confidence in disposal safety for high-level radioactive waste. Considering domestic situations, we propose and discuss some implementing methods for the improvement of disposal safety, such as construction of a reliable information database, understanding of processes related to safety, reduction of uncertainties in safety assessment, communication with stakeholders, and ensuring justice and transparency. This study will contribute to the understanding of the safety case for deep geological disposal and to improving confidence in disposal safety through the development of the safety case in Korea for the disposal of high-level radioactive waste.

Safety culture improvements in a nuclear laboratory setting

International Nuclear Information System (INIS)

Smith, K.L.; McKenna, J.

2014-01-01

In 2008, AECL performed a comprehensive safety culture assessment using recognized, industry-proven methodologies. Main observations were grouped into several key areas including standards, procedures, error-free work, and leadership fundamentals. Shortly thereafter, in 2009 May, the National Research Universal (NRU) reactor was shut down following discovery of a small leak of heavy water. Extensive repairs were required to return the reactor to service and a root cause investigation was conducted to determine the organizational and programmatic causes that led to the event. Taken together, these presented management with insights into common areas of weaknesses in performance and behaviours. A Corrective Action Plan (CAP) to address both the findings of the root cause analysis and safety culture assessment was captured in a comprehensive improvement plan issued in 2010 March, entitled the Voyageur Program Phase II (Voyageur II). The CAP addresses six key areas: Improve equipment reliability; Drive desired behaviours; Improve problem identification and resolution; Improve use of industry Operating Experience (OPEX) and reduce isolationism; Improve standards of operation; and, Improve management oversight. AECL's safety culture has been monitored regularly using quarterly surveys. A detailed safety culture assessment was executed in 2012 September. Compared with previous results, improvements for AECL were noted in the following areas: Use of Operating Experience, specifically in work planning, pre job briefs and training; Procedure quality; Availability of safety equipment; Control of temporary changes; and, Improved operational standards. (author)

Safety culture improvements in a nuclear laboratory setting

Energy Technology Data Exchange (ETDEWEB)

Smith, K.L.; McKenna, J. [Atomic Energy of Canada Limited, Chalk River, ON (Canada)

2014-07-01

In 2008, AECL performed a comprehensive safety culture assessment using recognized, industry-proven methodologies. Main observations were grouped into several key areas including standards, procedures, error-free work, and leadership fundamentals. Shortly thereafter, in 2009 May, the National Research Universal (NRU) reactor was shut down following discovery of a small leak of heavy water. Extensive repairs were required to return the reactor to service and a root cause investigation was conducted to determine the organizational and programmatic causes that led to the event. Taken together, these presented management with insights into common areas of weaknesses in performance and behaviours. A Corrective Action Plan (CAP) to address both the findings of the root cause analysis and safety culture assessment was captured in a comprehensive improvement plan issued in 2010 March, entitled the Voyageur Program Phase II (Voyageur II). The CAP addresses six key areas: Improve equipment reliability; Drive desired behaviours; Improve problem identification and resolution; Improve use of industry Operating Experience (OPEX) and reduce isolationism; Improve standards of operation; and, Improve management oversight. AECL's safety culture has been monitored regularly using quarterly surveys. A detailed safety culture assessment was executed in 2012 September. Compared with previous results, improvements for AECL were noted in the following areas: Use of Operating Experience, specifically in work planning, pre job briefs and training; Procedure quality; Availability of safety equipment; Control of temporary changes; and, Improved operational standards. (author)

Systematic review and meta-analysis of behavioral interventions to improve child pedestrian safety.

Science.gov (United States)

Schwebel, David C; Barton, Benjamin K; Shen, Jiabin; Wells, Hayley L; Bogar, Ashley; Heath, Gretchen; McCullough, David

2014-09-01

Pedestrian injuries represent a pediatric public health challenge. This systematic review/meta-analysis evaluated behavioral interventions to teach children pedestrian safety. Multiple strategies derived eligible manuscripts (published before April 1, 2013, randomized design, evaluated behavioral child pedestrian safety interventions). Screening 1,951 abstracts yielded 125 full-text retrievals. 25 were retained for data extraction, and 6 were later omitted due to insufficient data. In all, 19 articles reporting 25 studies were included. Risk of bias and quality of evidence were assessed. Behavioral interventions generally improve children's pedestrian safety, both immediately after training and at follow-up several months later. Quality of the evidence was low to moderate. Available evidence suggested interventions targeting dash-out prevention, crossing at parked cars, and selecting safe routes across intersections were effective. Individualized/small-group training for children was the most effective training strategy based on available evidence. Behaviorally based interventions improve children's pedestrian safety. Efforts should continue to develop creative, cost-efficient, and effective interventions. © The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Research notes : are safety corridors really safe? Evaluation of the corridor safety improvement program.

Science.gov (United States)

1998-08-26

High accident frequencies on Oregons highway corridors are of concern to the Oregon Department of Transportation (ODOT). : ODOT adopted the Corridor Safety Improvement Program as part of an overall program of safety improvements using federal and ...

Radiotherapy professionals faced with the obligation of treatments safety improvement

International Nuclear Information System (INIS)

2011-01-01

The occurrence of a major accident in Epinal (2006), followed by one in Toulouse (2007), led the Ministry of Health to mobilize the whole actors in radiotherapy in order to define national measures intended to improve health care security. Compiled in the so-called 'road map', these measures were presented in November 2007, and implemented in the 2009-2013 cancer programme. The French Institute for Radiological Protection and Nuclear Safety (IRSN) undertook a study aiming at assessing the effects of the above-mentioned measures on organization and safety management of radiotherapy facilities, but also on treatment achievement procedures and health professionals. More specifically, IRSN sought to examine the ability of health professionals to take into account new safety demands and to adapt their practices accordingly. With these purposes objectives, a qualitative study using the methods of ergonomics and sociology of organizations was completed in 2009-2010. The results of the study presented in this report show an effective improvement of health care safety along with a variable integration of safety measures depending on radiotherapy facilities and units. In particular, integration depends on 1) the governance mode of the health care facility, more or less conducive to promoting safety, 2) the pre-existence of a safety culture and safety organization, and 3) the facility commitment to health care safety improvement actions. The study also reveals that the implementation of new safety demands and the changes they involve create new constraints, which put pressure on health professionals and may threaten the durability of the improvements made. In order to facilitate the appropriation and implementation by radiotherapy units of the measures meant to improve health care safety, IRSN identifies 6 lines of thought: - strengthen coordination between institutional actors in order to ensure the consistency of the requests addressed to the facilities and limit their

Gap Analysis Approach for Construction Safety Program Improvement

Directory of Open Access Journals (Sweden)

Thanet Aksorn

2007-06-01

Full Text Available To improve construction site safety, emphasis has been placed on the implementation of safety programs. In order to successfully gain from safety programs, factors that affect their improvement need to be studied. Sixteen critical success factors of safety programs were identified from safety literature, and these were validated by safety experts. This study was undertaken by surveying 70 respondents from medium- and large-scale construction projects. It explored the importance and the actual status of critical success factors (CSFs. Gap analysis was used to examine the differences between the importance of these CSFs and their actual status. This study found that the most critical problems characterized by the largest gaps were management support, appropriate supervision, sufficient resource allocation, teamwork, and effective enforcement. Raising these priority factors to satisfactory levels would lead to successful safety programs, thereby minimizing accidents.

Continued efforts to improve the robustness of the French Gen II PWRs with respect to the risk of severe accidents. Safety assessment and research activities

International Nuclear Information System (INIS)

Raimond, E.; Bonnet, J.M.; Generino, G.; Dubreuil, M.; Pichereau, F.; Van Dorsselaere, J.P.

2012-01-01

In the context of post Fukushima accident, the paper presents the continuous efforts performed in France to upgrade progressively the French Gen II pressurised water reactors safety features in order to face the risks of any severe accident. It reminds some decisions taken after the TMI2 and the Chernobyl accidents and describes the situation in France before the Fukushima accident: -) progress done on severe accident consequences analysis thanks to recent research activities, -) improvement of Gen II PWRs safety features, in relation with the periodic safety review process, -) definition of higher safety levels requirement directly linked to the protection of population in the framework of Gen II PWRs long term operation. The last part of the paper comments carefully how the Fukushima accident will interfere on all these previous efforts to increase the Gen II PWRs robustness. The Fukushima accident clearly highlights a need of additional efforts to identify possible cliff edge effect in case of beyond design events (especially external events). The definition of additional accident management procedures and means to secure a reactor (or a site) whatever the conditions will be a major consequence for the French NPPs. In a second step, some complements on the existing defense-in-depth approach are now expected: additional requirements to define line of defense against adverse consequences of beyond design situations. The need for specific additional research activities after the Fukushima accident seems to be limited to some specific issues (for example spent fuel pool behaviour in case of long term loss of cooling). This paper is followed by the slides of the presentation

Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

Science.gov (United States)

Sanchez-Izquierdo-Riera, Jose Angel; Molano-Alvarez, Esteban; Saez-de la Fuente, Ignacio; Maynar-Moliner, Javier; Marín-Mateos, Helena; Chacón-Alves, Silvia

2016-01-01

The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.

Improving nuclear safety of VVER-440 units

International Nuclear Information System (INIS)

Nochev, T.; Sabinov, S.

2001-01-01

In this paper authors deals with improvement of nuclear safety of WWER-440 units in Kozloduy NPP. Main directions for improving nuclear safety of WWER-440 units were: - to expand number of the design accident; - to increase reliability of equipment important for the safety; - to decrease the probability of initiating events; - improvements the integrity of the primary circuit (application LBB concept, qualification of the pressure safety valves to avoid pressurized thermal shock); - improvement of the fire protection; - improvement of the operation including upgrading and improvement of operational documents, implementation of new system for training the operators and etc.; - reassessment of the seismic response of the plant. Main actions were made at NPP Kozloduy to increase nuclear safety of VVER-440 units. 1. Modernization of Emergency High Pressure Safety Injection System. The modernization includes dividing of independent channels with reservation of active elements. Pumps were exchanged with more effective and reliable ones. HPSIS was increased reliability in general through decrease number of active elements and exchanged with passive. 2. For the purpose of avoiding fast cooling at the primary circuit and obtaining thermal shock of reactor vessel, Main Safety Insulation Valves are installed at NPP Kozloduy. 3. Modernization of Emergency power supplies AC. Oil breakers VMP-10 are exchanged with gas FS-4. 4. Generator breakers are installed to decrease probability of loss power supply and blackout. They provide reliable power supply to the system important for the safety in case of failure on generator. 5. I and C system has been qualified and optimized. 6. Reassessments of Limiting Conditions of Operation and new scram signals have been introduced. 7. An operators-oriented Informational System has been developed. It includes ensuring and updating of equipment data, new informational support of operator and etc. 8. A new auxiliary independent system for

Building a Foundation of Continuous Improvement in a Rapidly Changing Environment: The Dartmouth-Hitchcock Value Institute Experience.

Science.gov (United States)

McGrath, Susan P; Blike, George T

2015-10-01

A performance improvement competency development program, known as the Value Institute (VI), was established at Dartmouth-Hitchcock (D-H; Lebanon, New Hampshire) in 2011 to develop a performance improvement-focused workforce and systems capable of meeting the challenges of creating a sustainable health system. A tiered competency development program that provides patient safety, health care quality, and improvement science education, and an execution support infrastructure that enables access to performance improvement tools for all employees, comprise the core of the VI. At 20 months after the launch of the first VI classes, more than 10% of all employees were trained to the Yellow Belt level, and approximately 1.5% of all employees became advanced practitioners (Green Belts or Black Belts). Improvement projects have focused on both clinical and business process optimization, as well as regulatory and accreditation compliance and patient safety. Project savings during the two years of operation have exceeded the investment of resources to establish this long-term performance improvement capability by 2.5 times. The D-H VI model promotes multidisciplinary team-based learning, incremental skill development, and access to a common continuous improvement vocabulary and method for all employees-all key to building the teams and momentum needed for successful execution of improvement work and to maintain outcomes. Initial outcomes, represented by organizational spread, project execution status, participants' feedback scores, and return on investment estimates, suggest that robust team-based learning combined with coaching provides sufficient depth and breadth of learning and effective opportunities to gain practical experience in continuous improvement.

Teacher Research as Continuous Process Improvement

Science.gov (United States)

Ellis, Charles; Castle, Kathryn

2010-01-01

Purpose: Teacher research (inquiry) has been characterized as practice improvement, professional development and action research, among numerous names and descriptions. The purpose of this paper is to support the case that teacher research is also a form of quality improvement known as continuous process improvement (CPI).…

Continuous Improvement Implementation in the Nottingham University Hospitals NHS Trust: A Case Study of a Continuous Improvement Programme & Project

OpenAIRE

Velzen, Jeena

2012-01-01

This paper aims at identifying the extent to which the Nottingham University Hospitals NHS Trust has fulfilled literature requirements for successful continuous improvement as exemplified by its Better for You programme and chemotherapy service improvement project. Both the theory and ideals of the continuous improvement programme, along with the actualization of these philosophies and methodologies in the context of the particular project,were compared against a framework for the enabling...

PROPOSAL OF VOIVODESHIP ROAD SAFETY IMPROVEMENT PROGRAMME

OpenAIRE

Tomasz SZCZURASZEK; Jan KEMPA

2016-01-01

The article presents a proposal of the ‘GAMBIT KUJAWSKO-POMORSKI’ Road Safety Improvement Programme. The main idea of the Programme is to establish and initiate systems that will be responsible for the most important areas of activity within road safety, including road safety control, supervision, and management systems in the whole Voivodeship. In total, the creation and start of nine such systems has been proposed, namely: the Road Safety Management, the Integrated Road Rescue Service, the ...

Developing a Continuous Improvement System

Science.gov (United States)

2016-09-16

disagree that continuous improvement is critical to an organization’s suc-cess, since conducting business using a status quo philosophy will not work...for implementing one of these processes include: better operational efficiency, increased customer satisfaction, improved employee morale ...when a problem in reliability or maintenance may become the greatest opportunity. As described in the January-February 2011 issue of Defense AT&L

Memorandum on the use of information technology to improve medication safety.

Science.gov (United States)

Ammenwerth, E; Aly, A-F; Bürkle, T; Christ, P; Dormann, H; Friesdorf, W; Haas, C; Haefeli, W E; Jeske, M; Kaltschmidt, J; Menges, K; Möller, H; Neubert, A; Rascher, W; Reichert, H; Schuler, J; Schreier, G; Schulz, S; Seidling, H M; Stühlinger, W; Criegee-Rieck, M

2014-01-01

Information technology in health care has a clear potential to improve the quality and efficiency of health care, especially in the area of medication processes. On the other hand, existing studies show possible adverse effects on patient safety when IT for medication-related processes is developed, introduced or used inappropriately. To summarize definitions and observations on IT usage in pharmacotherapy and to derive recommendations and future research priorities for decision makers and domain experts. This memorandum was developed in a consensus-based iterative process that included workshops and e-mail discussions among 21 experts coordinated by the Drug Information Systems Working Group of the German Society for Medical Informatics, Biometry and Epidemiology (GMDS). The recommendations address, among other things, a stepwise and comprehensive strategy for IT usage in medication processes, the integration of contextual information for alert generation, the involvement of patients, the semantic integration of information resources, usability and adaptability of IT solutions, and the need for their continuous evaluation. Information technology can help to improve medication safety. However, challenges remain regarding access to information, quality of information, and measurable benefits.

Improving Employees' Safety Awareness in Healthcare Organizations Using the DMAIC Quality Improvement Approach.

Science.gov (United States)

Momani, Amer; Hirzallah, Muʼath; Mumani, Ahmad

Occupational injuries and illnesses in healthcare can cause great human suffering, incur high cost, and have an adverse impact on the quality of patient care. One of the most effective solutions for addressing health and safety issues and improving decisions at the point of care rests in raising employees' safety awareness to recognize, avoid, or respond to potential problems before they arise. In this article, the DMAIC Six Sigma model (Define, Measure, Analyze, Improve, Control) is used as a systematic program to measure, improve, and sustain employees' safety awareness in healthcare organizations. We report on a case study using the model, which was implemented and validated at a local hospital. First, the occupational health and safety knowledge that each job requires was identified. Next, the degree of competence of jobholders to meet these requirements was assessed. Based on the assessment, different awareness-raising efforts were proposed and implemented. The results showed significant improvement in the overall safety awareness compliance assessed: from 74.2% to 84.4% (p < .001) after the intervention. The proposed model ensures that the organization's awareness-raising efforts serve its actual needs and produce optimized and sustained results that eventually lead to safer healthcare service.

Expanding Continuous Quality Improvement Capacity in the Medical Intensive Care Unit: Prehealth Volunteers as a Solution.

Science.gov (United States)

Priest, Kelsey C; Lobingier, Hannah; McCully, Nancy; Lombard, Jackie; Hansen, Mark; Uchiyama, Makoto; Hagg, Daniel S

2016-01-01

Health care delivery systems are challenged to support the increasing demands for improving patient safety, satisfaction, and outcomes. Limited resources and staffing are common barriers for making significant and sustained improvements. At Oregon Health & Science University, the medical intensive care unit (MICU) leadership team faced internal capacity limitations for conducting continuous quality improvement, specifically for the implementation and evaluation of the mobility portion of an evidence-based care bundle. The MICU team successfully addressed this capacity challenge using the person power of prehealth volunteers. In the first year of the project, 52 trained volunteers executed an evidence-based mobility intervention for 305 critically ill patients, conducting more than 200 000 exercise repetitions. The volunteers contributed to real-time evaluation of the project, with the collection of approximately 26 950 process measure data points. Prehealth volunteers are an untapped resource for effectively expanding internal continuous quality improvement capacity in the MICU and beyond.

Practice Change From Intermittent Medication Boluses to Bolusing From a Continuous Infusion in Pediatric Critical Care: A Quality Improvement Project.

Science.gov (United States)

Hochstetler, Jessica L; Thompson, A Jill; Ball, Natalie M; Evans, Melissa C; Frame, Shaun C; Haney, A Lauren; Little, Amelia K; O'Donnell, Jaime L; Rickett, Bryna M; Mack, Elizabeth H

2018-04-12

To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost. This is a pre- and postimplementation quality improvement study. An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital. Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion. Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs. Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p 0.05). Annualized cost avoidance was $124,160. Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.

Improving the safety of LWR power plants. Final report

International Nuclear Information System (INIS)

1980-04-01

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

Health IT for Patient Safety and Improving the Safety of Health IT.

Science.gov (United States)

Magrabi, Farah; Ong, Mei-Sing; Coiera, Enrico

2016-01-01

Alongside their benefits health IT applications can pose new risks to patient safety. Problems with IT have been linked to many different types of clinical errors including prescribing and administration of medications; as well as wrong-patient, wrong-site errors, and delays in procedures. There is also growing concern about the risks of data breach and cyber-security. IT-related clinical errors have their origins in processes undertaken to design, build, implement and use software systems in a broader sociotechnical context. Safety can be improved with greater standardization of clinical software and by improving the quality of processes at different points in the technology life cycle, spanning design, build, implementation and use in clinical settings. Oversight processes can be set up at a regional or national level to ensure that clinical software systems meet specific standards. Certification and regulation are two mechanisms to improve oversight. In the absence of clear standards, guidelines are useful to promote safe design and implementation practices. Processes to identify and mitigate hazards can be formalised via a safety management system. Minimizing new patient safety risks is critical to realizing the benefits of IT.

SAFETY IMPROVES DRAMATICALLY IN FLUOR HANFORD SOIL AND GROUNDWATER REMEDIATION PROJECT

International Nuclear Information System (INIS)

GERBER MS

2007-01-01

This paper describes dramatic improvements in the safety record of the Soil and Groundwater Remediation Project (SGRP) at the Hanford Site in southeast Washington state over the past four years. During a period of enormous growth in project work and scope, contractor Fluor Hanford reduced injuries, accidents, and other safety-related incidents and enhanced a safety culture that earned the SGRP Star Status in the Department of Energy's (DOE's) Voluntary Protection Program (VPP) in 2007. This paper outlines the complex and multi-faceted work of Fluor Hanford's SGRP and details the steps taken by the project's Field Operations and Safety organizations to improve safety. Holding field safety meetings and walkdowns, broadening safety inspections, organizing employee safety councils, intensively flowing down safety requirements to subcontractors, and adopting other methods to achieve remarkable improvement in safety are discussed. The roles of management, labor and subcontractors are detailed. Finally, SGRP's safety improvements are discussed within the context of overall safety enhancements made by Fluor Hanford in the company's 11 years of managing nuclear waste cleanup at the Hanford Site

THE FLUORBOARD A STATISTICALLY BASED DASHBOARD METHOD FOR IMPROVING SAFETY

International Nuclear Information System (INIS)

PREVETTE, S.S.

2005-01-01

The FluorBoard is a statistically based dashboard method for improving safety. Fluor Hanford has achieved significant safety improvements--including more than a 80% reduction in OSHA cases per 200,000 hours, during its work at the US Department of Energy's Hanford Site in Washington state. The massive project on the former nuclear materials production site is considered one of the largest environmental cleanup projects in the world. Fluor Hanford's safety improvements were achieved by a committed partnering of workers, managers, and statistical methodology. Safety achievements at the site have been due to a systematic approach to safety. This includes excellent cooperation between the field workers, the safety professionals, and management through OSHA Voluntary Protection Program principles. Fluor corporate values are centered around safety, and safety excellence is important for every manager in every project. In addition, Fluor Hanford has utilized a rigorous approach to using its safety statistics, based upon Dr. Shewhart's control charts, and Dr. Deming's management and quality methods

Improvement of the Patient Safety Culture in the Primary Health Care Corporation - Qatar.

Science.gov (United States)

El Zoghbi, Mohamad; Farooq, Saad; Abulaban, Ali; Taha, Heba; Ajanaz, Sajna; Aljasmi, Jawaher; Ahmad, Shakil; Said, Hana

2018-04-17

Primary Health Care Corporation (PHCC) is the public primary health care provider in Qatar. Having a patient safety culture (PSC) is the keystone to enabling a continuous process to improve the quality of services and to reduce errors. The objective of this study was to assess the impact of accreditation, quality improvement trainings, and patient safety (PS) trainings on the improvement of the PSC at the PHCC in Qatar. The Medical Office Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality was used in 2012 and 2015 to assess the culture of PS and health care quality in the 21 health centers. The results of the two surveys were compared using the χ test. A P value of less than 0.05 was considered significant. Out of 2689 staff working in the 21 health centers, 1810 (67.3%) completed the survey in 2012, and 2616 (70.0%) of 3735 completed the survey in 2015. The comparison between 2012 and 2015 survey's results showed a statistically significant improvement for all the 10 dimensions (P < 0.05). Although a statistically significant difference was observed between 2012 and 2015 results for work pressure and pace, three of the four questions of the work pressure and pace dimension presented nonsignificant differences. The survey was a good tool to raise awareness on PS and quality issues at PHCC. There is evidence that the implementation of accreditation program, the quality improvement trainings, and PS trainings helped the organization improve its PS culture.

Continuous improvement in teams : The (mis)fit between improvement and operational activities of improvement teams

NARCIS (Netherlands)

Ros, D.J.

1999-01-01

Since the 1970s and 1980s, increasing attention has been paid to the Japanese ways of organising production. One of the subjects often discussed is the importance of continuous incremental improvements. Nowadays, for many organisations, continuous improvement has become an important topic; many

KHNP Safety Culture Framework based on Global Standard, and Lessons learned from Safety Culture Evaluation

International Nuclear Information System (INIS)

Kim, Younggab; Hur, Nam Young; Jeong, Hyeon Jong

2015-01-01

In order to eliminate the vague fears of the people about the nuclear power and operate continuously NPPs, a strong safety culture of NPPs should be demonstrated. Strong safety culture awareness of workers can overcome social distrust about NPPs. KHNP has been a variety efforts to improve and establish safety culture of NPPs. Safety culture framework applying global standards was set up and safety culture assessment has been carried out periodically to enhance safety culture of workers. In addition, KHNP developed various safety culture contents and they are being used in NPPs by workers. As a result of these efforts, safety culture awareness of workers is changed positively and the safety environment of NPPs is expected to be improved. KHNP makes an effort to solve areas for improvement derived from safety culture assessment. However, there are some areas to take a long time in completing the work. Therefore, these actions are necessary to be carried out consistently and continuously. KHNP also developed recently safety culture enhancement system based on web. All information related to safety culture in KHNP will be shared through this web system and this system will be used to safety culture assessment. In addition to, KHNP plans to develop safety culture indicators for monitoring the symptoms of safety culture weakening

KHNP Safety Culture Framework based on Global Standard, and Lessons learned from Safety Culture Evaluation

Energy Technology Data Exchange (ETDEWEB)

Kim, Younggab; Hur, Nam Young; Jeong, Hyeon Jong [KHNP Central Research Institute, Daejeon (Korea, Republic of)

2015-05-15

In order to eliminate the vague fears of the people about the nuclear power and operate continuously NPPs, a strong safety culture of NPPs should be demonstrated. Strong safety culture awareness of workers can overcome social distrust about NPPs. KHNP has been a variety efforts to improve and establish safety culture of NPPs. Safety culture framework applying global standards was set up and safety culture assessment has been carried out periodically to enhance safety culture of workers. In addition, KHNP developed various safety culture contents and they are being used in NPPs by workers. As a result of these efforts, safety culture awareness of workers is changed positively and the safety environment of NPPs is expected to be improved. KHNP makes an effort to solve areas for improvement derived from safety culture assessment. However, there are some areas to take a long time in completing the work. Therefore, these actions are necessary to be carried out consistently and continuously. KHNP also developed recently safety culture enhancement system based on web. All information related to safety culture in KHNP will be shared through this web system and this system will be used to safety culture assessment. In addition to, KHNP plans to develop safety culture indicators for monitoring the symptoms of safety culture weakening.

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

Science.gov (United States)

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

2016-05-01

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

Human Resource Management for Continuous Improvement

DEFF Research Database (Denmark)

Jørgensen, Frances; Boer, Harry; Laugen, Bjørge

2006-01-01

The objective of this paper is to investigate the relationship between HRM practices and Continuous Improvement (CI) activities in order to gain an understanding of how the HRM function may be utilized to improve CI implementation success, and consequently, organizational performance. The paper i...

NPP Temelin. Status of safety improvements

International Nuclear Information System (INIS)

1999-01-01

The WWER-1000 Temelin NPP under construction has been subjected as other NPPs of the same type to numerous project reviews resulting in quite a number of recommendations for design changes. Results of the IAEA mission to review the resolution of WWER-1000 safety issues at Temelin NPP are cited in this paper. The main conclusions emphasize that a combination of eastern and western technology and practices led to safety improvements in comparison with the international practices. Plant managers are clearly committed to implementation of operational programs which are consistent with effective western operational safety practices. Considerable effort remains to bring planned programs to successful implementation, in particular in meeting the need to foster strong safety culture among all personnel

Using Principles of Quality and Safety Education for Nurses in School Nurse Continuing Education

Science.gov (United States)

Rosenblum, Ruth K.; Sprague-McRae, Julie

2014-01-01

School nurses require ongoing continuing education in a number of areas. The Quality and Safety Education for Nurses (QSEN) framework can be utilized in considering school nurses' roles and developing continuing education. Focusing on neurology continuing education, the QSEN framework is illustrated with the example of concussion management…

Recipe Modification Improves Food Safety Practices during Cooking of Poultry.

Science.gov (United States)

Maughan, Curtis; Godwin, Sandria; Chambers, Delores; Chambers, Edgar

2016-08-01

Many consumers do not practice proper food safety behaviors when preparing food in the home. Several approaches have been taken to improve food safety behaviors among consumers, but there still is a deficit in actual practice of these behaviors. The objective of this study was to assess whether the introduction of food safety instructions in recipes for chicken breasts and ground turkey patties would improve consumers' food safety behaviors during preparation. In total, 155 consumers in two locations (Manhattan, KS, and Nashville, TN) were asked to prepare a baked chicken breast and a ground turkey patty following recipes that either did or did not contain food safety instructions. They were observed to track hand washing and thermometer use. Participants who received recipes with food safety instructions (n = 73) demonstrated significantly improved food safety preparation behaviors compared with those who did not have food safety instructions in the recipe (n = 82). In addition, the majority of consumers stated that they thought the recipes with instructions were easy to use and that they would be likely to use similar recipes at home. This study demonstrates that recipes could be a good source of food safety information for consumers and that they have the potential to improve behaviors to reduce foodborne illness.

SAFETY IMPROVES DRAMATICALLY IN FLUOR HANFORD SOIL AND GROUNDWATER REMEDIATION PROJECT

Energy Technology Data Exchange (ETDEWEB)

GERBER MS

2007-12-05

This paper describes dramatic improvements in the safety record of the Soil and Groundwater Remediation Project (SGRP) at the Hanford Site in southeast Washington state over the past four years. During a period of enormous growth in project work and scope, contractor Fluor Hanford reduced injuries, accidents, and other safety-related incidents and enhanced a safety culture that earned the SGRP Star Status in the Department of Energy's (DOE's) Voluntary Protection Program (VPP) in 2007. This paper outlines the complex and multi-faceted work of Fluor Hanford's SGRP and details the steps taken by the project's Field Operations and Safety organizations to improve safety. Holding field safety meetings and walkdowns, broadening safety inspections, organizing employee safety councils, intensively flowing down safety requirements to subcontractors, and adopting other methods to achieve remarkable improvement in safety are discussed. The roles of management, labor and subcontractors are detailed. Finally, SGRP's safety improvements are discussed within the context of overall safety enhancements made by Fluor Hanford in the company's 11 years of managing nuclear waste cleanup at the Hanford Site.

Developing a strong safety culture - a safety management challenge

International Nuclear Information System (INIS)

Low, M.; Gipson, G. P.; Williams, M.

1995-01-01

The approach is presented adapted by Nuclear Electric to build a strong safety culture through the development of its safety management system. Two features regarded as critical to a strong safety culture are: provision of effective communications to promote an awareness and ownership of safety among craft, and commitment to continuous improvement with a genuine willingness to learn from own experiences and those from others. (N.T.) 5 refs., 4 figs., 1 tab

Criticality safety validation of MCNP5 using continuous energy libraries

International Nuclear Information System (INIS)

Salome, Jean A.D.; Pereira, Claubia; Assuncao, Jonathan B.A.; Veloso, Maria Auxiliadora F.; Costa, Antonella L.; Silva, Clarysson A.M. da

2013-01-01

The study of subcritical systems is very important in the design, installation and operation of various devices, mainly nuclear reactors and power plants. The information generated by these systems guide the decisions to be taken in the executive project, the economic viability and the safety measures to be employed in a nuclear facility. Simulating some experiments from the International Handbook of Evaluated Criticality Safety Benchmark Experiments, the code MCNP5 was validated to nuclear criticality analysis. Its continuous libraries were used. The average values and standard deviation (SD) were evaluated. The results obtained with the code are very similar to the values obtained by the benchmark experiments. (author)

SCALE Graphical Developments for Improved Criticality Safety Analyses

International Nuclear Information System (INIS)

Barnett, D.L.; Bowman, S.M.; Horwedel, J.E.; Petrie, L.M.

1999-01-01

New computer graphic developments at Oak Ridge National Ridge National Laboratory (ORNL) are being used to provide visualization of criticality safety models and calculational results as well as tools for criticality safety analysis input preparation. The purpose of this paper is to present the status of current development efforts to continue to enhance the SCALE (Standardized Computer Analyses for Licensing Evaluations) computer software system. Applications for criticality safety analysis in the areas of 3-D model visualization, input preparation and execution via a graphical user interface (GUI), and two-dimensional (2-D) plotting of results are discussed

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

Science.gov (United States)

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

2015-08-01

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

Enhancement of nuclear safety culture

International Nuclear Information System (INIS)

Anderson, Stanley J.

1996-01-01

Throughout the 40-year history of the commercial nuclear power industry, improvements have continually been made in the design of nuclear power plants and the equipment in them. In one sense, we have reached an enviable point -- in most plants, equipment failures have become relatively rare. Yet events continue to occur. Regardless of how much the plants are improved, that equipment is operated by people -- highly motivated, well-trained people -- but people nonetheless. And people occasionally make mistakes. By setting the right climate and by setting high standards, good plant management can reduce the number of mistakes made ? and also reduce their potential consequences. Another way to say this is that the proper safety culture must be established and continually improved upon in our nuclear plants. Safety culture is defined by the International Atomic Energy Agency as 'that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.' In short, we must make safety our top priority

Evolution of Technology for Continuous Renal Replacement Therapy: Forty Years of Improvement.

Science.gov (United States)

Ronco, Claudio

2018-01-01

Continuous arteriovenous hemofiltration (CAVH) was proposed in 1977 as an alternative treatment for acute renal failure in patients in whom peritoneal dialysis or hemodialysis was clinically or technically precluded. In the mid-1980s, this technique was extended to infants and children. CAVH presented important advantages in the areas of hemodynamic stability, control of circulating volume, and nutritional support. However, there were serious shortcomings such as the need for arterial cannulation and limited solute clearance. These problems were solved by the introduction of continuous arteriovenous hemodiafiltration and continuous arteriovenous hemodialysis, where uremic control could be achieved by increasing countercurrent dialysate flow rates to 1.5 or 2 L/h as necessary, or by venovenous techniques utilizing a double-lumen central venous catheter for vascular access. Thus, continuous venovenous hemofiltration replaced CAVH because of its improved performance and safety. From the initial adoptive technology, specific machines have been designed to permit safe and reliable performance of the therapy. These new machines have progressively undergone a series of technological steps that have resulted in the evolution of highly sophisticated equipment utilized today. A significant number of advances have taken place since the time continuous renal replacement therapy was initiated. In particular, there have been successful experiments with high-volume hemofiltration and high-permeability hemofiltration. The additional and combined use of sorbent has also been tested successfully. Progress has been made in the technology as well as the understanding of the pathophysiology of acute kidney injury. Today, new biomaterials and new devices are available and new frontiers are on the horizon. Although improvements have been made, a lot remains to be done. Critical care nephrology is expected to further evolve in the near future, especially in the area of information and

To improve the safety of treatments in radiotherapy by developing a safety culture

International Nuclear Information System (INIS)

2008-01-01

Following the radiotherapy accidents between 2004 and 2006, the I.R.S.N. deemed necessary to lead a study on the safety of treatments in radiotherapy and on the use and the adaptation to the medical domain of safety analysis approach developed for the nuclear installations. Of this study, six mains lines of investigation appear: Endow the radiotherapy services with real referential of safety, reinforce the robustness of the organization of radiotherapy services, improve the safety of the equipment and software at the design and operating stages, improve the management of the expertise and reinforce the operating feed back on incidents and accidents. The main learning from this study is the benefit that could be gained by fitting the safety analysis concepts and methods to the specificities of radiotherapy considering the organization of it collective work, the cooperation between actors stemming from different jobs as well as the interactions between actors and technical systems in the process of the treatments, when they are put into service and during their periodic checks. (author)

[Team Care for Patient Safety, TeamSTEPPS to Improve Nontechnical Skills and Teamwork--Actions to Become an HRO].

Science.gov (United States)

Kaito, Ken

2015-07-01

It is important to develop safer medical systems and follow manuals of medical procedures for patient safety. However, these approaches do not always result in satisfactory results because of many human factors. It is known that defects of nontechnical skills are more important than those of technical skills regarding medical accidents and incidents. So, it is necessary to improve personal nontechnical skills and compensate for each other's defects based on a team approach. For such purposes, we have implemented TeamSTEPPS to enhance performance and patient safety in our hospital. TeamSTEPPS (team strategies and tools to enhance performance and patient safety) is a useful method to improve the nontechnical skills of each member and the team. In TeamSTEPPS, leadership to share mental models among the team, continuous monitoring and awareness for team activities, mutual support for workload and knowledge, and approaches to complete communication are summarized to enhance teamwork and patient safety. Other than improving nontechnical skills and teamwork, TeamSTEPPS is also very important as a High Reliability Organization (HRO). TeamSTEPPS is worth implementing in every hospital to decrease medical errors and improve patient outcomes and satisfaction.

Operational safety and reactor life improvements of Kyoto University Reactor

International Nuclear Information System (INIS)

Utsuro, M.; Fujita, Y.; Nishihara, H.

1990-01-01

Recent important experience in improving the operational safety and life of a reactor are described. The Kyoto University Reactor (KUR) is a 25-year-old 5 MW light water reactor provided with two thermal columns of graphite and heavy water as well as other kinds of experimental facilities. In the graphite thermal column, noticeable amounts of neutron irradiation effects had accumulated in the graphite blocks near the core. Before the possible release of the stored energy, all the graphite blocks in the column were successfully replaced with new blocks using the opportunity provided by the installation of a liquid deuterium cold neutron source in the column. At the same time, special seal mechanisms were provided for essential improvements to the problem of radioactive argon production in the column. In the heavy-water thermal column we have accomplished the successful repair of a slow leak of heavy water through a thin instrumentation tube failure. The repair work included the removal and reconstructions of the lead and graphite shielding layers and welding of the instrumentation tube under radiation fields. Several mechanical components in the reactor cooling system were also exchanged for new components with improved designs and materials. On-line data logging of almost all instrumentation signals is continuously performed with a high speed data analysis system to diagnose operational conditions of the reactor. Furthermore, through detailed investigations on critical components, operational safety during further extended reactor life will be supported by well scheduled maintenance programs

Experience of safety and performance improvement for fuel handling equipment

International Nuclear Information System (INIS)

Gyoon Chang, Sang; Hee Lee, Dae

2014-01-01

The purpose of this study is to provide experience of safety and performance improvement of fuel handling equipment for nuclear power plants in Korea. The fuel handling equipment, which is used as an important part of critical processes during the refueling outage, has been improved to enhance safety and to optimize fuel handling procedures. Results of data measured during the fuel reloading are incorporated into design changes. The safety and performance improvement for fuel handling equipment could be achieved by simply modifying the components and improving the interlock system. The experience provided in this study can be useful lessons for further improvement of the fuel handling equipment. (authors)

Improvement of Managers’ Safety Knowledge through Scientifically Reasonable Interviews

Directory of Open Access Journals (Sweden)

Paas Õnnela

2015-11-01

Full Text Available The safety management system has been analysed in 16 Estonian enterprises using the MISHA method (Method for Industrial Safety and Health Activity Assessment. The factor analysis (principal component analysis and varimax with Kaiser analysis has been implemented for the interpretation of the results on safety performance at the enterprises implementing OHSAS 18001 and the ones that do not implement OHSAS 18001. The division of the safety areas into four parts for a better understanding of the safety level and its improvement possibilities has been proven through the statistical analysis. The connections between the questions aimed to clarify the safety level and performance at the enterprises have been set based on the statistics. New learning package “training through the questionnaires” has been worked out in the current paper for the top and middle-level managers to improve their safety knowledge, where the MISHA questionnaire has been taken as the basis.

Operational safety improvement in OPR 1000

International Nuclear Information System (INIS)

Jung, Y.-E.

2005-01-01

Nuclear power operating experience management might be an important factor for the operational safety improvement. KHNP's nuclear information management system, called KONIS receives, distributes and manages all nuclear information from domestic and foreign, especially operating experience. Ulchin 3 and 4, the first units of OPR 1000 series operates several organizations regarding management of operating experience e.g. specialist group program, various task forces, equipment specialist system for operator, etc. Peer review is another contribution for nuclear safety. (author)

Organizational factors influencing improvements in safety

International Nuclear Information System (INIS)

Marcus, A.; Nichols, M.L.; Olson, J.; Osborn, R.; Thurber, J.

1992-01-01

Research reported here seeks to identify the key organizational factors that influence safety-related performance indicators in nuclear power plants over time. It builds upon organizational factors identified in NUREG/CR-5437, and begins to develop a theory of safety-related performance and performance improvement based on economic and behavioral theories of the firm. Central to the theory are concepts of past performance, problem recognition, resource availability, resource allocation, and business strategies that focus attention. Variables which reflect those concepts are combined in statistical models and tested for their ability to explain scrams, safety system actuations, significant events, safety system failures, radiation exposure, and critical hours. Results show the performance indicators differ with respect to the sets of variables which serve as the best predictors of future performance, and past performance is the most consistent predictor of future performance

Applying principles from safety science to improve child protection.

Science.gov (United States)

Cull, Michael J; Rzepnicki, Tina L; O'Day, Kathryn; Epstein, Richard A

2013-01-01

Child Protective Services Agencies (CPSAs) share many characteristics with other organizations operating in high-risk, high-profile industries. Over the past 50 years, industries as diverse as aviation, nuclear power, and healthcare have applied principles from safety science to improve practice. The current paper describes the rationale, characteristics, and challenges of applying concepts from the safety culture literature to CPSAs. Preliminary efforts to apply key principles aimed at improving child safety and well-being in two states are also presented.

Safety research in the field of energy production. Plan for continued Nordic projects

Energy Technology Data Exchange (ETDEWEB)

Ahlstroem, P E [Statens Vattenfallsverk, Stockholm (Sweden); Berg, J [Institutt for Atomenergi, Kjeller (Norway); Eckered, T [Statens Kaernkraftinspektion, Stockholm (Sweden)

1980-01-01

NGS, an ad hoc group of the Nordic Co-ordination Committee for Atomic Energy, has prepared this survey of proposed cooperative projects as a continuation of previous projects. New areas to be given priority are:- reactor safety, environmental effects in energy production and human reliability. Continued projects are:- quality assurance, radioactive waste and radioecology. (JIW)

A Typology of Continuous Improvement Implementation Processes

DEFF Research Database (Denmark)

Rijnders, Sander; Boer, Harry

2004-01-01

This article presents a typology of continuous improvement (CI) implementation processes. The typology is based on an empirical study of 26 companies engaged in the implementation of CI. The data underpinning the typology was collected through retrospective interviews guided by a semi-structured ......This article presents a typology of continuous improvement (CI) implementation processes. The typology is based on an empirical study of 26 companies engaged in the implementation of CI. The data underpinning the typology was collected through retrospective interviews guided by a semi...

Improving patient safety in radiology: a work in progress

International Nuclear Information System (INIS)

Sze, Raymond W.

2008-01-01

The purpose of this paper is to share the experiences, including successes and failures, as well as the ongoing process of developing and implementing a safety program in a large pediatric radiology department. Building a multidisciplinary pediatric radiology safety team requires successful recruitment of team members, selection of a team leader, and proper and ongoing training and tools, and protected time. Challenges, including thorough examples, are presented on improving pediatric radiology safety intradepartmentally, interdepartmentally, and institutionally. Finally, some major challenges to improving safety in pediatric radiology, and healthcare in general, are presented along with strategies to overcome these challenges. Our safety program is a work in progress; this article is a personal account and the reader is asked for tolerance of its occasional subjective tone and contents. (orig.)

The role of individual diligence in improving safety.

Science.gov (United States)

Corbett, Angus; Travaglia, Jo; Braithwaite, Jeffrey

2011-01-01

This paper aims to be a theoretical examination of the role of individuals in sponsoring and facilitating effective, systemic change in organisations. Using reports of a number of high-profile initiatives to improve patient safety, it seeks to analyse the role of individual health care professionals in developing and facilitating new systems of care that improve safety and quality. The paper uses recent work in sociology that is concerned with the phenomenon of "sociological citizenship". The authors test whether successful initiators of change in health care can be described as sociological citizens. This notion of sociological citizens is applied to a number of highly successful initiatives to improve safety and quality to extrapolate the factors associated with individual clinician leadership, which may have affected the success of such endeavours. In each of the examples analysed the initiators of change can be characterised as sociological citizens. In reviewing the roles of these charismatic individuals it is evident that they see the relational interdependence between the individuals and organisations and that they use this information to achieve both professional and organisational objectives. The paper uses a case study method to investigate the usefulness of the role of sociological citizenship in interventions that aim to improve patient safety. The paper reviews the key concepts and uses of the concept of sociological citizenship to produce a framework against which the case studies were assessed. The authors suggest that a goal of policy for improving patient safety should be directed to the problem of how hospitals and health care organisations can create the conditions for encouraging the individual diligence and care that is needed to support reliable, safe health care practices. Improving the safety and quality of health care is an important public health initiative. It has also proven to be difficult to achieve sustained reductions in the harm

Continuous Improvement and its Barriers in Electrical and Electronic Industry

Directory of Open Access Journals (Sweden)

Ahmad Md Fauzi

2017-01-01

Full Text Available Continuous improvement is one of the core strategies for manufacturing excellent and it is considered vital in today’s business environment. Continuous improvement is an important factor in TQM implementation. However, manufacturers in Electrical and Electronic Industry is facing variety of challenges such as, time constraint, quality issue, headcount issue, human issue and competition in domestic as well as the global market. This paper presents total quality management practices in Electrical and Electronic (EE Industry. These manufacturers have to keep improving in key activities and processes to cope the challenges. Therefore, EE industry realize the importance of continuous improvement in helping the industries by setting clear goals and priorities for the area of improvement. The aims of this study are to determine the main factor in implementing continuous improvement practices, identify tools of continuous improvement that have been used and their obstacle in implementing continuous improvement practices. 200 questionnaires had been distributed to the employees in Electrical and Electronic Industry located at Bayan Lepas, Penang, Malaysia. A total of 41 questionnaires were answered which represented about 20.5% response rates. Survey result shows that teamwork and training and learning are respectively the importance factor and the most practices factor in Electrical and Electronic Industry. Most of the Electrical and Electronic Industry emphasis is on using Lean Manufacturing as the tool of continuous improvement practices. Besides that, Electrical and Electronic Industry faced the problems of lack of budget and lack of worker commitment.

Multidisciplinary analysis of invasive meningococcal disease as a framework for continuous quality and safety improvement in regional Australia.

Science.gov (United States)

Taylor, Kathryn A; Durrheim, David N; Merritt, Tony; Massey, Peter; Ferguson, John; Ryan, Nick; Hullick, Carolyn

2018-01-01

System factors in a regional Australian health district contributed to avoidable care deviations from invasive meningococcal disease (IMD) management guidelines. Traditional root cause analysis (RCA) is not well-suited to IMD, focusing on individual cases rather than system improvements. As IMD requires complex care across healthcare silos, it presents an opportunity to explore and address system-based patient safety issues. Baseline assessment of IMD cases (2005-2006) identified inadequate triage, lack of senior clinician review, inconsistent vital sign recording and laboratory delays as common issues, resulting in antibiotic administration delays and inappropriate or premature discharge. Clinical governance, in partnership with clinical and public health services, established a multidisciplinary Meningococcal Reference Group (MRG) to routinely review management of all IMD cases. The MRG comprised representatives from primary care, acute care, public health, laboratory medicine and clinical governance. Baseline data were compared with two subsequent evaluation points (2011-2012 and 2013-2015). Phase I involved multidisciplinary process mapping and development of a standardised audit tool from national IMD management guidelines. Phase II involved formalisation of group processes and advocacy for operational change. Phase III focused on dissemination of findings to clinicians and managers. Greatest care improvements were observed in the final evaluation. Median antibiotic delay decreased from 72 to 42 min and proportion of cases triaged appropriately improved from 38% to 75% between 2013 and 2015. Increasing fatal outcomes were attributed to the emergence of more virulent meningococcal serotypes. The MRG was a key mechanism for identifying system gaps, advocating for change and enhancing communication and coordination across services. Employing IMD case review as a focus for district-level process reflection presents an innovative patient safety approach

Safety improvement and results of commissioning of Mochovce NPP WWER 440/213

International Nuclear Information System (INIS)

Lipar, M.

1998-01-01

Mochovce NPP is the last one of this kind and compared to its predecessors, it is characterized by several modifications which contribute to the improvement of the safety level. In addition based on Nuclear Regulatory Authority requirements and based on documents: - IAEA - Safety Issues and their ranking for NPP WWER 440/213, - IAEA - Safety Improvement of Mochovce NPP Project Review Mission, - Riskaudit - Evaluation of the Mochovce NPP Safety Improvements. Additional safety measures have been implemented before commissioning. The consortium EUCOM (FRAMATOME - SIEMENS), SKODA Praha, ENERGOPROJEKT Praha, Russian organizations and VUJE Trnava Nuclear Power Plants research institute were selected for design and implementation of the safety measures. The papers summarized, safety requirements, safety measures implemented, results of commissioning and results of safety analysis report evaluation. (author)

Continuous improvement and the mini-company concept

NARCIS (Netherlands)

de Leede, Jan; Looise, Jan C.

1999-01-01

The key issue of continuous improvement (CI) seems to be the problem of combining extensive employee involvement with market orientation and continuation of CI. In this article we review some existing organisational designs for CI on these three essential characteristics of CI. As an alternative to

Improving staff perception of a safety climate with crew resource management training.

Science.gov (United States)

Kuy, SreyRam; Romero, Ramon A L

2017-06-01

Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate. Published by Elsevier Inc.

Use of a Surgical Safety Checklist to Improve Team Communication.

Science.gov (United States)

Cabral, Richard A; Eggenberger, Terry; Keller, Kathryn; Gallison, Barry S; Newman, David

2016-09-01

To improve surgical team communication, a team at Broward Health Imperial Point Hospital, Ft Lauderdale, Florida, implemented a program for process improvement using a locally adapted World Health Organization Surgical Safety Checklist. This program included a standardized, comprehensive time out and a briefing/debriefing process. Postimplementation responses to the Safety Attitudes Questionnaire revealed a significant increase in the surgical team's perception of communication compared with that reported on the pretest (6% improvement resulting in t79 = -1.72, P improved surgical teamwork behaviors and an enhanced culture of safety in the OR. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Safety assessment of Olkiluoto NPP units 1 and 2. Decision of the Radiation and Nuclear Safety Authority regarding the periodic safety review of the Olkiluoto NPP

International Nuclear Information System (INIS)

2010-02-01

In this safety assessment the Radiation and Nuclear Safety Authority (STUK) has evaluated the safety of the Olkiluoto Nuclear Power Plant units 1 and 2 in connection with the periodic safety review. This safety assessment provides a summary of the reviews, inspections and continuous oversight carried out by STUK. The issues addressed in the assessment and the related evaluation criteria are set forth in the nuclear energy and radiation safety legislation and the regulations issued thereunder. The provisions of the Nuclear Energy Act concerning the safe use of nuclear energy, security and emergency preparedness arrangements, and waste management are specified in more detail in the Government Decrees and Regulatory Guides issued by STUK. Based on the assessment, STUK consideres that the Olkiluoto Nuclear Power Plant units 1 and 2 meet the set safety requirements for operational nuclear power plants, the emergency preparedness arrangements are sufficient and the necessary control to prevent the proliferation of nuclear weapons has been appropriately arranged. The physical protection of the Olkiluoto nuclear power plant is not yet completely in compliance with the requirements of Government Decree 734/2008, which came into force in December 2008. Further requirements concerning this issue based also on the principle of continuous improvement were included in the decision relating to the periodic safety review. The safety of the Olkiluoto nuclear power plant was assessed in compliance with the Government Decree on the Safety of Nuclear Power Plants (733/2008), which came into force in 2008. The decree notes that existing nuclear power plants need not meet all the requirements set out for new plants. Most of the design bases pertaining to the Olkiluoto 1 and 2 nuclear power plant units were set in the 1970s. Substantial modernisations have been carried out at the Olkiluoto 1 and 2 nuclear power plant units since their commissioning to improve safety. This is in line with

Occupational Analysis: A Continuous Improvement Approach

National Research Council Canada - National Science Library

Duffy, Tom

1998-01-01

.... In doing so, the Air Force has implemented "Quality Air Force (QAF)" (AF Handbook 90-502). QAF is a leadership commitment that inspires trust, teamwork, and continuous improvement everywhere in the Air Force...

Using game theory to improve safety within chemical industrial parks

CERN Document Server

Reniers, Genserik

2013-01-01

Though the game-theoretic approach has been vastly studied and utilized in relation to economics of industrial organizations, it has hardly been used to tackle safety management in multi-plant chemical industrial settings. Using Game Theory for Improving Safety within Chemical Industrial Parks presents an in-depth discussion of game-theoretic modelling which may be applied to improve cross-company prevention and -safety management in a chemical industrial park.   By systematically analyzing game-theoretic models and approaches in relation to managing safety in chemical industrial parks, Using Game Theory for Improving Safety within Chemical Industrial Parks explores the ways game theory can predict the outcome of complex strategic investment decision making processes involving several adjacent chemical plants. A number of game-theoretic decision models are discussed to provide strategic tools for decision-making situations.   Offering clear and straightforward explanations of methodologies, Using Game Theor...

How to improve safety of laparoscopic cholecystectomy

Directory of Open Access Journals (Sweden)

ZHANG Yong

2013-06-01

Full Text Available Laparoscopic cholecystectomy (LC has become the "gold standard" of treatment for benign gallbladder disease. This paper summarizes various surgical safety measures used in recent years, and suggests an emphasis on perioperative imaging examination, preoperative prevention of risk factors, training of surgical skills, and introduction of fast-track surgery concept, so as to avoid the incidence of complications and improve the safety of LC.

Improving patient safety through quality assurance.

Science.gov (United States)

Raab, Stephen S

2006-05-01

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

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

International Nuclear Information System (INIS)

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

2018-01-01

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

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

Energy Technology Data Exchange (ETDEWEB)

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

2018-01-15

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

Alternative off-site power supply improves nuclear power plant safety

International Nuclear Information System (INIS)

Gjorgiev, Blaže; Volkanovski, Andrija; Kančev, Duško; Čepin, Marko

2014-01-01

Highlights: • Additional power supply for mitigation of the station blackout event in NPP is used. • A hydro power plant is considered as an off-site alternative power supply. • An upgrade of the probabilistic safety assessment from its traditional use is made. • The obtained results show improvement of nuclear power plant safety. - Abstract: A reliable power system is important for safe operation of the nuclear power plants. The station blackout event is of great importance for nuclear power plant safety. This event is caused by the loss of all alternating current power supply to the safety and non-safety buses of the nuclear power plant. In this study an independent electrical connection between a pumped-storage hydro power plant and a nuclear power plant is assumed as a standpoint for safety and reliability analysis. The pumped-storage hydro power plant is considered as an alternative power supply. The connection with conventional accumulation type of hydro power plant is analysed in addition. The objective of this paper is to investigate the improvement of nuclear power plant safety resulting from the consideration of the alternative power supplies. The safety of the nuclear power plant is analysed through the core damage frequency, a risk measure assess by the probabilistic safety assessment. The presented method upgrades the probabilistic safety assessment from its common traditional use in sense that it considers non-plant sited systems. The obtained results show significant decrease of the core damage frequency, indicating improvement of nuclear safety if hydro power plant is introduced as an alternative off-site power source

Improving health care quality and safety: the role of collective learning.

Science.gov (United States)

Singer, Sara J; Benzer, Justin K; Hamdan, Sami U

2015-01-01

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

Science.gov (United States)

Harding, Andrew D

2012-01-01

The use of infusion pumps that incorporate "smart" technology (smart pumps) can reduce the risks associated with receiving IV therapies. Smart pump technology incorporates safeguards such as a list of high-alert medications, soft and hard dosage limits, and a drug library that can be tailored to specific patient care areas. Its use can help to improve patient safety and to avoid potentially catastrophic harm associated with medication errors. But when one independent community hospital in Massachusetts switched from older mechanical pumps to smart pumps, it neglected to assign an "owner" to oversee the implementation process. One result was that nurses were using the smart pump library for only 37% of all infusions.To increase pump library usage percentage-thereby reducing the risks associated with infusion and improving patient safety-the hospital undertook a continuous quality improvement project over a four-month period in 2009. With the involvement of direct care nurses, and using quantitative data available from the smart pump software, the nursing quality and pharmacy quality teams identified ways to improve pump and pump library use. A secondary goal was to calculate the hospital's return on investment for the purchase of the smart pumps. Several interventions were developed and, on the first of each month, implemented. By the end of the project, pump library usage had nearly doubled; and the hospital had completely recouped its initial investment.

Lab Safety and Bioterrorism Readiness Curricula Using Active Learning and Hands-on Strategies as Continuing Education for Medical Technologists

Directory of Open Access Journals (Sweden)

Steven Fiester

2010-04-01

Full Text Available Frequent reports of laboratory- (and hospital- acquired infection suggest a deficiency in safety training or lack of compliance. To assess the need for continuing education (CE addressing this problem, an original education needs assessment survey was designed and administered to medical technologists (med-techs in Northeast Ohio. Survey results were used to design a learner-centered training curriculum (for example, Lab Safety and Bioterrorism Readiness trainings that engaged med-techs in active learning, integrative peer-to-peer teaching, and hands-on exercises in order to improve microbiology safety knowledge and associated laboratory techniques. The Lab Safety training was delivered six times and the Bioterrorism Readiness training was delivered five times. Pre/posttesting revealed significant gains in knowledge and techniques specific to laboratory safety, security, risk assessment, and bioterrorism readiness amongst the majority of med-techs completing the CE trainings. The majority of participants felt that the hands-on exercises met their needs and that their personal laboratory practices would change as a result of the training course, as measured by attitudinal surveys. We conclude that active learning techniques and peer education significantly enhance microbiology learning amongst participating med-techs.

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

Science.gov (United States)

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

2018-04-16

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

Modelling of safety barriers including human and organisational factors to improve process safety

DEFF Research Database (Denmark)

Markert, Frank; Duijm, Nijs Jan; Thommesen, Jacob

2013-01-01

It is believed that traditional safety management needs to be improved on the aspect of preparedness for coping with expected and unexpected deviations, avoiding an overly optimistic reliance on safety systems. Remembering recent major accidents, such as the Deep Water Horizon, the Texas City....... A valuable approach is the inclusion of human and organisational factors into the simulation of the reliability of the technical system using event trees and fault trees and the concept of safety barriers. This has been demonstrated e.g. in the former European research project ARAMIS (Accidental Risk...

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

International Nuclear Information System (INIS)

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

1999-01-01

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

Organisational learning: A tool for continuous improvement of the organization; Aprendizaje Organizativo: una herramienta para la mejora continua de la organizacion

Energy Technology Data Exchange (ETDEWEB)

Santos, J. L.; Esteban, M. J.

2013-09-01

We are used to hear a success company in today's world is not possible unless a continuous improvement is developed. How can we be successful in the nuclear plant? We have to achieve safety for workers, people and environment in the first step, and for the second step availability and reliability for systems and components to avoid failure of components that could reduce availability. The aim is to search for new measures to reach this way. One of the improvements implemented in the plants to improve continuously was mainly Operating Experience activities, which was based in event analysis in the plants, causes identification, and to implement corrective actions. For External Operating Experience the aim was to learn from others to avoid occurrence of events in our plants. This was the lessons learned from Three Mile Island event. This was the learning process implemented so far, to get a continuous improvement. So far, the developed capabilities for process improvement follow the Operating Experience process that could be considered classical and will be revitalized nowadays. (Author)

Patient Education May Improve Perioperative Safety.

NARCIS (Netherlands)

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

2016-01-01

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

Continuous improvement in the Netherlands: A survey-based study into the current practices of continuous improvement

NARCIS (Netherlands)

Middel, H.G.A.; op de Weegh, S.; Gieskes, J.F.B.; Schuring, R.W.

2004-01-01

Continuous Improvement is a well-known and consolidated concept in literature and practice and is considered vital in today¿s business environment. In 2003 a survey, as part of the international CINet survey, has been performed in the Netherlands in order to gain insight into the current practices

Implementing Protocols to Improve Patient Safety in the Medical Imaging Department.

Science.gov (United States)

Carrizales, Gwen; Clark, Kevin R

2015-01-01

Patient safety is a focal point in healthcare because of recent changes issued by CMS. Hospital reimbursement rates have fallen, and these reimbursement rates are governed by CMS mandates regarding patient safety procedures. Reimbursement changes are reflected in the National Patient Safety Goals (NPSGs) administered annually by The Joint Commission. Medical imaging departments have multiple areas of patient safety concerns including effective handoff communication, proper patient identification, and safe medication/contrast administration. This literature review examines those areas of patient safety within the medical imaging department and reveals the need for continued protocol and policy changes to keep patients safe.

Nuclear Safety Charter

International Nuclear Information System (INIS)

2008-01-01

The AREVA 'Values Charter' reaffirmed the priority that must be given to the requirement for a very high level of safety, which applies in particular to the nuclear field. The purpose of this Nuclear Safety Charter is to set forth the group's commitments in the field of nuclear safety and radiation protection so as to ensure that this requirement is met throughout the life cycle of the facilities. It should enable each of us, in carrying out our duties, to commit to this requirement personally, for the company, and for all stakeholders. These commitments are anchored in organizational and action principles and in complete transparency. They build on a safety culture shared by all personnel and maintained by periodic refresher training. They are implemented through Safety, Health, and Environmental management systems. The purpose of these commitments, beyond strict compliance with the laws and regulations in force in countries in which we operate as a group, is to foster a continuous improvement initiative aimed at continually enhancing our overall performance as a group. Content: 1 - Organization: responsibility of the group's executive management and subsidiaries, prime responsibility of the operator, a system of clearly defined responsibilities that draws on skilled support and on independent control of operating personnel, the general inspectorate: a shared expertise and an independent control of the operating organization, an organization that can be adapted for emergency management. 2 - Action principles: nuclear safety applies to every stage in the plant life cycle, lessons learned are analyzed and capitalized through the continuous improvement initiative, analyzing risks in advance is the basis of Areva's safety culture, employees are empowered to improve nuclear Safety, the group is committed to a voluntary radiation protection initiative And a sustained effort in reducing waste and effluent from facility Operations, employees and subcontractors are treated

[Human factors and crisis resource management: improving patient safety].

Science.gov (United States)

Rall, M; Oberfrank, S

2013-10-01

A continuing high number of patients suffer harm from medical treatment. In 60-70% of the cases the sources of harm can be attributed to the field of human factors (HFs) and teamwork; nevertheless, those topics are still neither part of medical education nor of basic and advanced training even though it has been known for many years and it has meanwhile also been demonstrated for surgical specialties that training in human factors and teamwork considerably reduces surgical mortality.Besides the medical field, the concept of crisis resource management (CRM) has already proven its worth in many other industries by improving teamwork and reducing errors in the domain of human factors. One of the best ways to learn about CRM and HFs is realistic simulation team training with well-trained instructors in CRM and HF. The educational concept of the HOTT (hand over team training) courses for trauma room training offered by the DGU integrates these elements based on the current state of science. It is time to establish such training for all medical teams in emergency medicine and operative care. Accompanying safety measures, such as the development of a positive culture of safety in every department and the use of effective critical incident reporting systems (CIRs) should be pursued.

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

Science.gov (United States)

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

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

Structural Aging Program approach to providing an improved basis for aging management of safety-related concrete structures

International Nuclear Information System (INIS)

Naus, D.J.; Oland, C.B.; Ellingwood, B.

1993-01-01

The Structural Aging (SAG) Program is being conducted at the Oak Ridge National Laboratory (ORNL) for the United States Nuclear Regulatory Commission (USNRC). The SAG Program is addressing the aging management of safety-related concrete structures in nuclear power plants for the purpose of providing improved technical bases for their continued service. The program is organized into four tasks: Program Management, Materials Property Data Base, Structural Component Assessment/Repair Technologies, and Quantitative Methodology for Continued Service Determinations. Objectives and a summary of recent accomplishments under each of these tasks are presented

Quantifying the effectiveness of ITS in improving safety of VRUs

NARCIS (Netherlands)

Silla, A.; Rämä, P.; Leden, L.; Noort, M. van; Kruijff, J. de; Bell, D.; Morris, A.; Hancox, G.; Scholliers, J.

2017-01-01

This paper presents the results of a safety impact assessment, providing quantitative estimates of the safety impacts of ten intelligent transport systems (ITS) which were designed to improve safety, mobility and comfort of vulnerable road users (VRUs). The evaluation method originally developed to

Daily Management System of the Henry Ford Production System: QTIPS to Focus Continuous Improvements at the Level of the Work.

Science.gov (United States)

Zarbo, Richard J; Varney, Ruan C; Copeland, Jacqueline R; D'Angelo, Rita; Sharma, Gaurav

2015-07-01

To support our Lean culture of continuous improvement, we implemented a daily management system designed so critical metrics of operational success were the focus of local teams to drive improvements. We innovated a standardized visual daily management board composed of metric categories of Quality, Time, Inventory, Productivity, and Safety (QTIPS); frequency trending; root cause analysis; corrective/preventive actions; and resulting process improvements. In 1 year (June 2013 to July 2014), eight laboratory sections at Henry Ford Hospital employed 64 unique daily metrics. Most assessed long-term (>6 months), monitored process stability, while short-term metrics (1-6 months) were retired after successful targeted problem resolution. Daily monitoring resulted in 42 process improvements. Daily management is the key business accountability subsystem that enabled our culture of continuous improvement to function more efficiently at the managerial level in a visible manner by reviewing and acting based on data and root cause analysis. Copyright© by the American Society for Clinical Pathology.

Continuous improvement in pursuit of quality (presidential address to the Midland Institute Branch of the Institute of Mining Engineers)

Energy Technology Data Exchange (ETDEWEB)

Siddall, R G [British Coal Corporation (United Kingdom). South Yorkshire Group

1993-03-01

The author considers that quality must be a central element in the future strategy of the UK coal mining industry. This quality approach should be all embracing and extend beyond physical performance to include safety, effective use of capital, customer satisfaction, environmental pressures and overall image. The address discusses, the current position in British Coal; strategic planning; the need for continuous improvement; and productivity and production problems.

PNRA: Practically Improving Safety Culture within the Regulatory Body

International Nuclear Information System (INIS)

Bhatti, S.A.N.; Habib, M.A.

2016-01-01

were carried out in order to prepare the organization for the cultural assessment activity. After completion of safety culture self assessment at PNRA, the communication strategy was defined to share outcome of this assessment in the organization with the focus on developing dialogue and shared understanding. The safety culture improvement activities were designed to maintain and enhance strong areas of safety culture at PNRA and to address those areas that need attention in order to enhance safety consciousness. This paper presents PNRA’s experience of using IAEA emerging methodology for safety culture self assessment, challenges faced during the process and lessons learnt for further improvement in order to implement it more effectively in future. The paper also highlights strategy utilised for conveying outcomes of SCSA in the organization at different levels along with safety culture improvement activities. (author)

Nuclear safety improvement activities related to WWER-440 units in Bulgaria

International Nuclear Information System (INIS)

Gantchev, T.

1998-01-01

The systematic evaluation of the deficiencies of the original design of the WWER reactors brought to the development of a Short Term Programme for Safety Upgrading and Modernisation of Kozloduy WWER-440 units. The implementation of this Programme was completed in 1997. The strive for continuos improvement of Kozloduy Nuclear Power Plant (NPP) safety level, the new requirements of the Bulgarian Nuclear Safety Authority and the public concern initiated the development of new Complex Programme for Safety Improvement (PRG'97), now in a process of implementation. (author)

Design of launch systems using continuous improvement process

Science.gov (United States)

Brown, Richard W.

1995-01-01

The purpose of this paper is to identify a systematic process for improving ground operations for future launch systems. This approach is based on the Total Quality Management (TQM) continuous improvement process. While the continuous improvement process is normally identified with making incremental changes to an existing system, it can be used on new systems if they use past experience as a knowledge base. In the case of the Reusable Launch Vehicle (RLV), the Space Shuttle operations provide many lessons. The TQM methodology used for this paper will be borrowed from the United States Air Force 'Quality Air Force' Program. There is a general overview of the continuous improvement process, with concentration on the formulation phase. During this phase critical analyses are conducted to determine the strategy and goals for the remaining development process. These analyses include analyzing the mission from the customers point of view, developing an operations concept for the future, assessing current capabilities and determining the gap to be closed between current capabilities and future needs and requirements. A brief analyses of the RLV, relative to the Space Shuttle, will be used to illustrate the concept. Using the continuous improvement design concept has many advantages. These include a customer oriented process which will develop a more marketable product and a better integration of operations and systems during the design phase. But, the use of TQM techniques will require changes, including more discipline in the design process and more emphasis on data gathering for operational systems. The benefits will far outweigh the additional effort.

Performance standards of road safety management

Directory of Open Access Journals (Sweden)

Čabarkapa Milenko R.

2016-01-01

Full Text Available Road safety management controlling means the process of finding out the information whether the road safety is improving in a measure to achieve the objectives. The process of control consists of three basic elements: definition of performances and standards, measurement of current performances and comparison with the set standards, and improvement of current performances, if they deviate from the set standards. The performance standards of road safety management system are focused on a performances measurement, in terms of their design and characteristics, in order to support the performances improvement of road safety system and thus, ultimately, improve the road safety. Defining the performance standards of road safety management system, except that determines the design of the system for performances measurement, directly sets requirements whose fulfillment will produce a road safety improvement. The road safety management system, based on the performance standards of road safety, with a focus on results, will produce the continuous improvement of road safety, achieving the long-term 'vision zero', the philosophy of road safety, that human life and health take priority over mobility and other traffic objectives of the road traffic.

Continuous improvement of pump seals

International Nuclear Information System (INIS)

Wong, W.; Eyvindson, A.; Rhodes, D.B.

2003-01-01

Pump seal reliability continues to be an area needing improvement and ongoing vigilance. Methods have been developed for identifying and assessing factors relating to seal performance, selecting the most relevant ones for a specific station, and then focusing on the most significant aspects and how to improve. Discussion invariably addresses maintenance practices, seal design, monitoring capabilities, operating conditions, transients, and pump and motor design. Success in reliability improvement requires ongoing dialogue among the station operators, pump manufacturers and seal designers. AECL CAN-seals lead the nuclear industry in reliability and seal life. They effectively save operators millions of dollars in outage time and person-rem. This paper describes some of the significant developments in AECL's ongoing program in seal R and D, as well as recent new installations following the most demanding seal qualification programs to date. (author)

Operating experience: safety perspective

International Nuclear Information System (INIS)

Piplani, Vivek; Krishnamurthy, P.R.; Kumar, Neeraj; Upadhyay, Devendra

2015-01-01

Operating Experience (OE) provides valuable information for improving NPP safety. This may include events, precursors, deviations, deficiencies, problems, new insights to safety, good practices, lessons and corrective actions. As per INSAG-10, an OE program caters as a fundamental means for enhancing the defence-in-depth at NPPs and hence should be viewed as ‘Continuous Safety Performance Improvement Tool’. The ‘Convention on Nuclear Safety’ also recognizes the OE as a tool of high importance for enhancing the NPP safety and its Article 19 mandates each contracting party to establish an effective OE program at operating NPPs. The lessons drawn from major accidents at Three Mile Island, Chernobyl and Fukushima Daiichi NPPs had prompted nuclear stalwarts to change their safety perspective towards NPPs and to frame sound policies on issues like safety culture, severe accident prevention and mitigation. An effective OE program, besides correcting current/potential problems, help in proactively improving the NPP design, operating and maintenance procedures, practices, training, etc., and thus plays vital role in ensuring safe and efficient operation of NPPs. Further it enhances knowledge with regard to equipment operating characteristics, system performance trends and provides data for quantitative and qualitative safety analysis. Besides all above, an OE program inculcates a learning culture in the organisation and thus helps in continuously enhancing the expertise, technical competency and knowledge base of its staff. Nuclear and Radiation Facilities in India are regulated by Atomic Energy Regulatory Board (AERB). Operating Plants Safety Division (OPSD) of AERB is involved in managing operating experience activities. This paper provides insights about the operating experience program of OPSD, AERB (including its on-line data base namely OPSD STAR) and its utilisation in improving the regulations and safety at Indian NPPs/projects. (author)

A Scholarly Pathway in Quality Improvement and Patient Safety.

Science.gov (United States)

Ferguson, Catherine C; Lamb, Geoffrey

2015-10-01

There are several challenges to teaching quality improvement (QI) and patient safety material to medical students, as successful programs should combine didactic and experiential teaching methods, integrate the material into the preclinical and clinical years, and tailor the material to the schools' existing curriculum. The authors describe the development, implementation, and assessment of the Quality Improvement and Patient Safety (QuIPS) Scholarly Pathway-a faculty-mentored, three-year experience for students interested in gaining exposure to QI and patient safety concepts at the Medical College of Wisconsin (MCW). The QuIPS pathway capitalized on the existing structure of scholarly pathways for MCW medical students, allowing QI and patient safety to be incorporated into the existing curriculum using didactic and experiential instruction and spanning preclinical and clinical education. Student reaction to the QuIPS pathway has been favorable. Preliminary data demonstrate that student knowledge as measured by the Quality Improvement Knowledge Assessment Tool significantly increased after the first year of implementation. A novel curriculum such as the QuIPS pathway provides an important opportunity to develop and test new assessment tools for curricula in systems-based practice and practice-based learning and improvement. The authors also hope that by bringing together local QI and patient safety experts and stakeholders during the curricular development process, they have laid the groundwork for the creation of a more pervasive curriculum that will reach all MCW students in the future. The model may be generalizable to other U.S. medical schools with scholarly pathways as well.

Improving patient safety in radiation oncology

International Nuclear Information System (INIS)

Hendee, William R.; Herman, Michael G.

2011-01-01

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

A Continuous Improvement Capital Funding Model.

Science.gov (United States)

Adams, Matt

2001-01-01

Describes a capital funding model that helps assess facility renewal needs in a way that minimizes resources while maximizing results. The article explains the sub-components of a continuous improvement capital funding model, including budgeting processes for finish renewal, building performance renewal, and critical outcome. (GR)

RBMK nuclear reactors: Proposals for instrumentation and control improvements to enhanced safety and availability. IEC technical report of type 3. Working material

International Nuclear Information System (INIS)

1995-01-01

The present material presents a CD+V draft report ''RBMK nuclear reactors: Proposals for instrumentation and control improvements to enhance safety and availability'' prepared by the Joint IEC/IAEA team during 1993-1995. Experience has demonstrated the need to improve the safety instrumentation of the RBMK type reactors using well proven modern technology. The working group identified the upgrades and changes of the highest priority based on the evaluation of the RBMK systems and the events where the instrumentation was found to be inadequate for safe operation. The subjects discussed in this document were not selected on a systematic basis but were selected by the IEC and IAEA experts as considered to be appropriate to the activities of the IEC and for which technical experience was available. The items identified therefore do not reflect any ranking of the safety issues or any priority or impact on safety of any of the measures were they to be implemented. Many important safety issued and areas where physical measures are required to improve safety have been omitted and indeed not even acknowledged in this document. The recommendations presented in the document differ from those normally produced by the IEC in the form of standards as they are of a transitory nature and some have already been overtaken by the continuing process of improvements to plant safety. Figs and tabs

Transportation Safety Excellence in Operations Through Improved Transportation Safety Document

International Nuclear Information System (INIS)

Dr. Michael A. Lehto; MAL

2007-01-01

A recent accomplishment of the Idaho National Laboratory (INL) Materials and Fuels Complex (MFC) Nuclear Safety analysis group was to obtain DOE-ID approval for the inter-facility transfer of greater-than-Hazard-Category-3 quantity radioactive/fissionable waste in Department of Transportation (DOT) Type A drums at MFC. This accomplishment supported excellence in operations through safety analysis by better integrating nuclear safety requirements with waste requirements in the Transportation Safety Document (TSD); reducing container and transport costs; and making facility operations more efficient. The MFC TSD governs and controls the inter-facility transfer of greater-than-Hazard-Category-3 radioactive and/or fissionable materials in non-DOT approved containers. Previously, the TSD did not include the capability to transfer payloads of greater-than-Hazard-Category-3 radioactive and/or fissionable materials using DOT Type A drums. Previous practice was to package the waste materials to less-than-Hazard-Category-3 quantities when loading DOT Type A drums for transfer out of facilities to reduce facility waste accumulations. This practice allowed operations to proceed, but resulted in drums being loaded to less than the Waste Isolation Pilot Plant (WIPP) waste acceptance criteria (WAC) waste limits, which was not cost effective or operations friendly. An improved and revised safety analysis was used to gain DOE-ID approval for adding this container configuration to the MFC TSD safety basis. In the process of obtaining approval of the revised safety basis, safety analysis practices were used effectively to directly support excellence in operations. Several factors contributed to the success of MFC's effort to obtain approval for the use of DOT Type A drums, including two practices that could help in future safety basis changes at other facilities. (1) The process of incorporating the DOT Type A drums into the TSD at MFC helped to better integrate nuclear safety

Speech Recognition Interfaces Improve Flight Safety

Science.gov (United States)

2013-01-01

"Alpha, Golf, November, Echo, Zulu." "Sierra, Alpha, Golf, Echo, Sierra." "Lima, Hotel, Yankee." It looks like some strange word game, but the combinations of words above actually communicate the first three points of a flight plan from Albany, New York to Florence, South Carolina. Spoken by air traffic controllers and pilots, the aviation industry s standard International Civil Aviation Organization phonetic alphabet uses words to represent letters. The first letter of each word in the series is combined to spell waypoints, or reference points, used in flight navigation. The first waypoint above is AGNEZ (alpha for A, golf for G, etc.). The second is SAGES, and the third is LHY. For pilots of general aviation aircraft, the traditional method of entering the letters of each waypoint into a GPS device is a time-consuming process. For each of the 16 waypoints required for the complete flight plan from Albany to Florence, the pilot uses a knob to scroll through each letter of the alphabet. It takes approximately 5 minutes of the pilot s focused attention to complete this particular plan. Entering such a long flight plan into a GPS can pose a safety hazard because it can take the pilot s attention from other critical tasks like scanning gauges or avoiding other aircraft. For more than five decades, NASA has supported research and development in aviation safety, including through its Vehicle Systems Safety Technology (VSST) program, which works to advance safer and more capable flight decks (cockpits) in aircraft. Randy Bailey, a lead aerospace engineer in the VSST program at Langley Research Center, says the technology in cockpits is directly related to flight safety. For example, "GPS navigation systems are wonderful as far as improving a pilot s ability to navigate, but if you can find ways to reduce the draw of the pilot s attention into the cockpit while using the GPS, it could potentially improve safety," he says.

Nuclear Safety Review for 2014

International Nuclear Information System (INIS)

2014-07-01

The Nuclear Safety Review 2014 focuses on the dominant nuclear safety trends, issues and challenges in 2013. The Executive Overview provides general nuclear safety information along with a summary of the major issues covered in this report: strengthening safety in nuclear installations; improving radiation, transport and waste safety; enhancing emergency preparedness and response (EPR); improving regulatory infrastructure and effectiveness; and strengthening civil liability for nuclear damage. The Appendix provides details on the activities of the Commission on Safety Standards, and activities relevant to the Agency’s safety standards. The global nuclear community has made steady and continuous progress in strengthening nuclear safety in 2013, as promoted by the IAEA Action Plan on Nuclear Safety (hereinafter referred to as “the Action Plan”) and reported in Progress in the Implementation of the IAEA Action Plan on Nuclear Safety (document GOV/INF/2013/8-GC(57)/INF/5), and the Supplementary Information to that report and Progress in the Implementation of the IAEA Action Plan on Nuclear Safety (document GOV/INF/2014/2). • Significant progress continues to be made in several key areas, such as assessments of safety vulnerabilities of nuclear power plants (NPPs), strengthening of the Agency’s peer review services, improvements in EPR capabilities, strengthening and maintaining capacity building, and protecting people and the environment from ionizing radiation. The progress that has been made in these and other areas has contributed to the enhancement of the global nuclear safety framework. • Significant progress has also been made in reviewing the Agency’s safety standards, which continue to be widely applied by regulators, operators and the nuclear industry in general, with increased attention and focus on vitally important areas such as design and operation of NPPs, protection of NPPs against severe accidents, and EPR. • The Agency continued to

More safety by improving the safety culture

International Nuclear Information System (INIS)

Laaksonen, J.

1993-01-01

In its meeting in 1986, after Chernobyl accident, the INSAG group concluded, that the most important reason for the accident was lack of safety culture. Later the group realized that the safety culture, if it is well enough, can be used as a powerful tool to assess and develop practices affecting safety in any country. A comprehensive view on the various aspects of safety culture was presented in the INSAG-4 report published in 1991. Finland was among the first nations include the concept of safety culture in its regulations. This article describes the roles of government and the regulatory body in creating a national safety culture. How safety culture is seen in the operation of a nuclear power plant is also discussed. (orig.)

Study of the Continuous Improvement Trend for Health, Safety and Environmental Indicators, after Establishment of Integrated Management System (IMS) in a Pharmaceutical Industry in Iran.

Science.gov (United States)

Mariouryad, Pegah; Golbabaei, Farideh; Nasiri, Parvin; Mohammadfam, Iraj; Marioryad, Hossein

2015-10-01

Nowadays, organizations try to improve their services and consequently adopt management systems and standards which have become key parts in various industries. One of these management systems which have been noticed in the recent years is Integrated Management System that is the combination of quality, health, safety and environment management systems. This study was conducted with the aim of evaluating the improvement trend after establishment of integrated management system for health, safety and environment indicators, in a pharmaceutical industry in Iran. First, during several inspections in different parts of the industry, indicators that should have been noted were listed and then these indicators were organized in 3 domains of health, safety and environment in the form of a questionnaire that followed Likert method of scaling. Also, the weight of each index was resulted from averaging out of 30 managers and the viewpoints of the related experts in the field. Moreover, by checking the documents and evidence of different years (5 contemplation years of this study), the score of each indicator was determined by multiplying the weight and score of the indices and were finally analysed. Over 5 years, scores of health scope indicators, increased from 161.99 to 202.23. Score in the first year after applying the integrated management system establishment was 172.37 in safety part and in the final year increased to 197.57. The changes of environmental scope rates, from the beginning of the program up to the last year increased from 49.24 to 64.27. Integrated management systems help organizations to improve programs to achieve their objectives. Although in this study all trends of health, safety and environmental indicator changes were positive, but at the same time showed to be slow. So, one can suggest that the result of an annual evaluation should be applied in planning future activities for the years ahead.

Proposal for the improvement of IRD safety culture based on risk analysis

International Nuclear Information System (INIS)

Aguiar, L.A.; Ferreira, P.R.R.; Silveira, C.S.

2017-01-01

The Safety Culture (SC) is a concept about the relationship of individuals and organizations towards the safety in a specific activity. Any organization that carries out activities with risks has a SC, even at minimum levels. People perceive different types of radiation risks in very different ways, therefore, to identify and to analysis of the possible radiation risks resulting from normal operation or accident conditions is an important issue in order to improve the SC in organization. The main is to present guidelines for the improvement of the safety culture in the Institute of Radiation Protection and Dosimetry - IRD through on risk-based approach. The methodology proposed here is: A) select a division of the IRD for case study; B) assess the level of the 10 culture safety basic elements of the IRD division selected; C) conduct a survey of the hazards and risks associated with the various activities developed by the division; D) reassess the level of the 10 basic elements of CS; And E) analyze the results and correlate the impact of risk knowledge on safety culture improvement. The expected result is improvement the safety and of safety culture by understanding of radiation risks and hazards relating to work and to the working environment; and thus enforce a collective commitment to safety by teams and individuals and raise the safety culture to higher levels. (author)

Proposal for the improvement of IRD safety culture based on risk analysis

Energy Technology Data Exchange (ETDEWEB)

Aguiar, L.A.; Ferreira, P.R.R. [Instituto de Radioproteção e Dosimetria (DIRAD/IRD/CNEN-RJ), Rio de Janeiro, RJ (Brazil); Silveira, C.S., E-mail: laguiar@ird.gov.br [Comissão Nacional de Energia Nuclear (DRS/CGMI/CNEN), Rio de Janeiro, RJ (Brazil)

2017-07-01

The Safety Culture (SC) is a concept about the relationship of individuals and organizations towards the safety in a specific activity. Any organization that carries out activities with risks has a SC, even at minimum levels. People perceive different types of radiation risks in very different ways, therefore, to identify and to analysis of the possible radiation risks resulting from normal operation or accident conditions is an important issue in order to improve the SC in organization. The main is to present guidelines for the improvement of the safety culture in the Institute of Radiation Protection and Dosimetry - IRD through on risk-based approach. The methodology proposed here is: A) select a division of the IRD for case study; B) assess the level of the 10 culture safety basic elements of the IRD division selected; C) conduct a survey of the hazards and risks associated with the various activities developed by the division; D) reassess the level of the 10 basic elements of CS; And E) analyze the results and correlate the impact of risk knowledge on safety culture improvement. The expected result is improvement the safety and of safety culture by understanding of radiation risks and hazards relating to work and to the working environment; and thus enforce a collective commitment to safety by teams and individuals and raise the safety culture to higher levels. (author)

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

Can Schools Meet the Promise of Continuous Improvement?

Science.gov (United States)

Elgart, Mark A.

2018-01-01

Continuous improvement is "an embedded behavior within the culture of a school that constantly focuses on the conditions, processes, and practices that will improve teaching and learning." The phrase has been part of the lexicon of school improvement for decades, but real progress is rare. Based on its observations of about 5,000…

Promoting safety culture in radiation industry through radiation audit

International Nuclear Information System (INIS)

Noriah, M.A.

2007-01-01

This paper illustrates the Malaysian experience in implementing and promoting effective radiation safety program. Current management practice demands that an organization inculcate culture of safety in preventing radiation hazard. The aforementioned objectives of radiation protection can only be met when it is implemented and evaluated continuously. Commitment from the workforce to treat safety as a priority and the ability to turn a requirement into a practical language is also important to implement radiation safety policy efficiently. Maintaining and improving safety culture is a continuous process. There is a need to establish a program to measure, review and audit health and safety performance against predetermined standards. This program is known as radiation safety audit and is able to reveal where and when action is needed to make improvements to the systems of controls. A structured and proper radiation self-auditing system is seen as the sole requirement to meet the current and future needs in sustainability of radiation safety. As a result safety culture, which has been a vital element on safety in many industries can be improved and promote changes, leading to good safety performance and excellence. (author)

Safety for all: bringing together patient and employee safety.

Science.gov (United States)

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

2013-01-01

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

Improving health care quality and safety: the role of collective learning

Directory of Open Access Journals (Sweden)

Singer SJ

2015-11-01

Full Text Available Sara J Singer,1–4 Justin K Benzer,4–6 Sami U Hamdan4,6 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; 2Department of Medicine, Harvard Medical School, Boston, MA, USA; 3Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA; 4Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA; 5VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; 6Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA Abstract: Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation, internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological

Patient Safety Based Knowledge Management SECI to Improve Nusrsing Students Competency

Directory of Open Access Journals (Sweden)

Joanggi Wiriatarina Harianto

2015-10-01

Full Text Available Introduction: Patient safety is an important component of health services quality,and  basic principles of patient care. Nursing students also have a great potential to make an action that could endanger the patient, because hospital is one of student practice area. The purpose of this study was to improve the nursing students competency in patient safety by using knowledge management SECI approached. Method: The study used exploratory survey, and quasy experiment. The samples were some of nursing students of STIKes Muhammadiyah Samarinda who were on internship programme that selected using simple random sampling technique, in total of 54 students. This research’s variables were the knowledge management SECI based-patient safety and nursing student’s competency. The data were collected by using questionnaires and observation. The data were analyze by using Partial Least Square (PLS. Result: The result showed that there were significant influence the implementation of a model patient safety based knowledge management seci on increased competence nursing students. Discussion: Improved student competency in patient safety using SECI knowledge management was carried out in four phases, that is Socialization, Externalization, Combination, and Internalization. The result was a new knowledge related to patient safety that able to improve the student’s competency.. Keywords: Patient safety, Knowledge management, SECI, competency

International conference on topical issues in nuclear installation safety: Continuous improvement of nuclear safety in a changing world. Book of contributed papers

Energy Technology Data Exchange (ETDEWEB)

NONE

2004-07-01

Papers presented at this conference where devoted to the following NPP safety related topical issues: Changing environments - coping with diversity and globalisation; Operating experience - managing changes effectively; Regulatory management systems - adapting to changes in the environment; Long term operations - maintaining safety margins while extending plant lifetime.

Improving Reference Service: The Case for Using a Continuous Quality Improvement Method.

Science.gov (United States)

Aluri, Rao

1993-01-01

Discusses the evaluation of library reference service; examines problems with past evaluations, including the lack of long-term planning and a systems perspective; and suggests a method for continuously monitoring and improving reference service using quality improvement tools such as checklists, cause and effect diagrams, Pareto charts, and…

Agile kaizen managing continuous improvement far beyond retrospectives

CERN Document Server

Medinilla, Ángel

2014-01-01

Agile teams have been struggling with the concept of continuous improvement since the first Agile frameworks were developed, and still very little has been written about the practice of continuous improvement in Agile environments. Although team retrospectives have been prescribed and some practices have been introduced in order to implement and facilitate them, the truth is that most Agile teams are conducting dull retrospectives that end with a list of things that have been done wrong, just to repeat the same list two weeks later at the next meeting.Instead of listing hundreds of Japanese-la

Continuous improvement comparison between Danish and Mexican companies

DEFF Research Database (Denmark)

Christiansen, Thomas Bøhm

2004-01-01

This article investigates continuous improvement tools that are used in two countries on two continents. For that purpose two surveys were conducted in the metropolitan area of Mexico City and in Denmark using the same scales and having about the same sample size. The continuous improvement tools...... comprise such concepts as TQM, Kaizen, Six Sigma and Lean Manufacturing. The paper shows the results of the analysis and a comparison of how and to what degree such tools are used in different places, which allow us to address similarities and dissimilarities of the application. The results are discussed...

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

Science.gov (United States)

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

2009-01-01

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

Leadership and Management for Safety. General Safety Requirements

International Nuclear Information System (INIS)

2016-01-01

This Safety Requirements publication establishes requirements that support Principle 3 of the Fundamental Safety Principles in relation to establishing, sustaining and continuously improving leadership and management for safety and an integrated management system. It emphasizes that leadership for safety, management for safety, an effective management system and a systemic approach (i.e. an approach in which interactions between technical, human and organizational factors are duly considered) are all essential to the specification and application of adequate safety measures and to the fostering of a strong safety culture. Leadership and an effective management system will integrate safety, health, environmental, security, quality, human-and-organizational factor, societal and economic elements. The management system will ensure the fostering of a strong safety culture, regular assessment of performance and the application of lessons from experience. The publication is intended for use by regulatory bodies, operating organizations (registrants and licensees) and other organizations concerned with facilities and activities that give rise to radiation risks

New IAEA guidance on safety culture

International Nuclear Information System (INIS)

Haage, Monica; )

2012-01-01

Monica Haage described a project for Kozloduy Nuclear Power Plant in Bulgaria which was also funded by the Norwegian government. This project included the development of guidance documents and training on self-assessment and continuous improvement of safety culture. A draft IAEA safety culture survey was also developed as part of this project in collaboration with St Mary's University, Canada. This project was conducted in parallel with an IAEA project to develop new safety reports on safety culture self-assessment and continuous improvement. A safety report on safety culture during the pre-operational phases of NPPs has also been drafted. The IAEA approach to safety culture assessment was outlined and core principles of the approach were discussed. These include the use of several assessment methods (survey, interview, observation, focus groups, document review), and two distinct levels of analysis. The first is a descriptive analysis of the observed cultural characteristics from each assessment method and overarching themes. This is followed by a 'normative' analysis comparing what has been observed with the desirable characteristics of a strong, positive, safety culture, as defined by the IAEA safety culture framework. The application of this approach during recent Operational Safety Assessment Review Team (OSART) missions was described along with key learning points

Safety assessment in development and operation of modular continuous-flow processes

NARCIS (Netherlands)

Kockmann, N.; Thenée, P.; Fleischer-Trebes, C.; Laudadio, G.; Noël, T.

2017-01-01

Improved safety is one of the main drivers for microreactor application in chemical process development and small-scale production. Typical examples of hazardous chemistry are presented indicating potential risks also in miniaturized equipment. Energy balance and kinetic parameters describe the heat

Nurse managers' experiences in continuous quality improvement in resource-poor healthcare settings.

Science.gov (United States)

Kakyo, Tracy Alexis; Xiao, Lily Dongxia

2017-06-01

Ensuring safe and quality care for patients in hospitals is an important part of a nurse manager's role. Continuous quality improvement has been identified as one approach that leads to the delivery of quality care services to patients and is widely used by nurse managers to improve patient care. Nurse managers' experiences in initiating continuous quality improvement activities in resource-poor healthcare settings remain largely unknown. Research evidence is highly demanded in these settings to address disease burden and evidence-based practice. This interpretive qualitative study was conducted to gain an understanding of nurse managers' Continuous Quality Improvement experiences in rural hospitals in Uganda. Nurse managers in rural healthcare settings used their role to prioritize quality improvement activities, monitor the Continuous Quality Improvement process, and utilize in-service education to support continuous quality improvement. The nurse managers in our sample encountered a number of barriers during the implementation of Continuous Quality Improvement, including: limited patient participation, lack of materials, and limited human resources. Efforts to address the challenges faced through good governance and leadership development require more attention. © 2017 John Wiley & Sons Australia, Ltd.

Effect of generic issues program on improving safety

International Nuclear Information System (INIS)

Fard, M. R.; Kauffman, J. V.

2010-01-01

The U.S. Nuclear Regulatory Commission (NRC) identifies (by its assessment of plant operation) certain issues involving public health and safety, the common defense and security, or the environment that could affect multiple entities under NRC jurisdiction. The Generic Issues Program (GIP) addresses the resolution of these Generic Issues (GIs). The resolution of these issues may involve new or revised rules, new or revised guidance, or revised interpretation of rules or guidance that affect nuclear power plant licensees, nuclear material certificate holders, or holders of other regulatory approvals. U.S. NRC provides information related to the past and ongoing GIP activities to the general public by the use of three main resources, namely NUREG-0933, 'Resolution of Generic Safety Issues, ' Generic Issues Management Control System (GIMCS), and GIP public web page. GIP information resources provide information such as historical information on resolved GIs, current status of the open GIs, policy documents, program procedures, GIP annual and quarterly reports and the process to contact GIP and propose a GI This paper provides an overview of the GIP and several examples of safety improvements resulting from the resolution of GIs. In addition, the paper provides a brief discussion of a few recent GIs to illustrate how the program functions to improve safety. (authors)

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

Science.gov (United States)

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

2014-10-01

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

Sustaining motivation for continuous improvement

DEFF Research Database (Denmark)

Jørgensen, Frances; Kofoed, Lise Busk

2007-01-01

The objective of this article is to explore possibilities for improving motivation for participation in Continuous Improvement (CI). Due to a number of issues, for example, challenges with measuring outcomes of CI activities on performance, the inherent slower, incremental rather than big bang...... activities is an important issue for managers. The paper begins with a short description of CI, with an emphasis on barriers to successful implementation cited in the literature. Thereafter, a number of widely-acknowledged-albeit perhaps somewhat dated-theories of motivation are explored in relation...... to the elements of CI in practice. Based on their own experiences with CI implementation in numerous action-research based studies, the authors propose a scenario for motivating CI participation through emphasis on factors common to the presented motivational theories. The paper ends with insights into future...

Assistance of Foreign Countries and International Organizations to Support Safety Improvements at Ignalina NPP

International Nuclear Information System (INIS)

Shevaldin, V.

1997-01-01

International cooperation and assistance for the improving safety of Ignalina NPP is described. Sweden was among the first countries which supported safety improvements at Ignalina NPP. The first project in the cooperation was BARSELINA, Probabilistic Safety Analysis of Ignalina NPP. The cooperation is still bringing significant support to the plant, including improvements in the fire protection, communications system, physical protection, and many other areas. Another one very important source of assistance was Nuclear Safety Account, administered by the EBRD. In 1993 experts of the plant, together with representatives of VATESI and SKI (Sweden) have worked out a short-term safety improvement program SIP-1, which was financed by the EBRD . Eighteen safety related projects were selected, expensive and reliable equipment was procured and installed

AEL Continuous School Improvement Questionnaire. User Manual and Technical Report.

Science.gov (United States)

Meehan, Merrill L.; Cowley, Kimberly S.; Craig, James R.; Balow, Nancy; Childers, Robert D.

The Continuous School Improvement Questionnaire (CSIQ) developed by the AEL helps a school staff gauge its performance on six dimensions related to continuous school improvement. Each member of the staff responds to the CSIQ individually. Although results might be used at the district or regional level, the most widely intended unit for applying…

Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Esmail, Aneez; Wensing, Michel

2015-01-01

ABSTRACT Background: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts. Objective: This paper provides a broad overview with practical guidance on how to improve patient safety. Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident. Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care. Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis. PMID:26339837

Improvement programme of safety performance indicators (SPIs) in Korea

International Nuclear Information System (INIS)

Lee, S.Y.

2001-01-01

KINS has developed and used Safety Performance Indicators (SPIs), which are count based and composed of 10 indicators in 8 areas, to monitor the trend of performance of NPPs in Korea since 1997. However, the limited usage of SPIs and the increasing worldwide interest on SPIs became the motivation of the SPI improvement programme in Korea. Korea is planning to establish plant performance evaluation programme through analysis of SPI and result of inspection. The SPI improvement programme is a part of the plant performance evaluation programme and includes study on performance evaluation areas, indicator categories, selection and development of indicators, redefinition of indicators and introduction of graphical display system. The selected performance evaluation areas are general performance, reactor safety and radiation safety. Each area will have categories as sub-areas and a total of six categories are selected. One or two indicators for each category are determined or will be developed to make a set of Safety Performance Indicators. Also, a graphic display system will be introduced to extend the usage of SPIs. (author)

Continuous Improvement in Schools and Districts: Policy Considerations

Science.gov (United States)

Best, Jane; Dunlap, Allison

2014-01-01

Discussions about improving public education often focus on outcomes without considering how schools and districts can accomplish those outcomes. Research shows that using a continuous improvement process has proven successful in healthcare, manufacturing, and technology, and may hold potential for use in education as well. This brief defines and…

Safety-I, Safety-II and Resilience Engineering.

Science.gov (United States)

Patterson, Mary; Deutsch, Ellen S

2015-12-01

In the quest to continually improve the health care delivered to patients, it is important to understand "what went wrong," also known as Safety-I, when there are undesired outcomes, but it is also important to understand, and optimize "what went right," also known as Safety-II. The difference between Safety-I and Safety-II are philosophical as well as pragmatic. Improving health care delivery involves understanding that health care delivery is a complex adaptive system; components of that system impact, and are impacted by, the actions of other components of the system. Challenges to optimal care include regular, irregular and unexampled threats. This article addresses the dangers of brittleness and miscalibration, as well as the value of adaptive capacity and margin. These qualities can, respectively, detract from or contribute to the emergence of organizational resilience. Resilience is characterized by the ability to monitor, react, anticipate, and learn. Finally, this article celebrates the importance of humans, who make use of system capabilities and proactively mitigate the effects of system limitations to contribute to successful outcomes. Copyright © 2015 Mosby, Inc. All rights reserved.

Leadership and Safety Management: Regulatory Initiatives for Enhancing Nuclear Safety in the Republic of Korea

International Nuclear Information System (INIS)

Yun, C.H.; Park, Y.W.; Choi, K.S.

2010-01-01

Since the construction of the first nuclear power plant (NPP) in the Republic of Korea in 1978, a high level of nuclear safety has continued to be maintained. This has been the important basis on which the continuous construction of NPPs has been possible in the country. To date, regulatory initiatives, leaderships and strategies adopting well harmonized regulatory systems and practices of advanced countries have contributed to improving the effectiveness and efficiency of safety regulation and further enhancing nuclear safety. The outcomes have resulted in a high level of safety and performance of Korean NPPs, attributing largely to the safety promotion policy. Recently, with the support of the Korean Ministry of Education, Science and Technology (MEST), the Korea Institute of Nuclear Safety (KINS) established the International Nuclear Safety School and created a Nuclear Safety Master's Degree Programme. Further, it developed multilateral and bilateral cooperation with other agencies to promote global nuclear safety, with the aim of providing knowledge and training to new entrant countries in establishing the safety infrastructure necessary for ensuring an acceptable level of nuclear safety. (author)

Observations of human factors as a continuous improvement tool

International Nuclear Information System (INIS)

Almeida, P.

2015-01-01

Principles for Excellence in Human Performance should promote behaviors throughout an organization that support safety and reliable operation of the plant. Such behaviors must be clearly defined, communicated and reinforced by managers, on a continuous basis. To identify if workers behaviors are in compliance with those expected is paramount to have an observations program in place, which in one hand identifies deviations from expectations to correct them, and on the other promotes the desired behaviors through positive reinforcement. (Author)

VVER Reactor Safety in Eastern Europe and Former Soviet Union

Science.gov (United States)

Papadopoulou, Demetra

2012-02-01

VVER Soviet-designed reactors that operate in Eastern Europe and former Soviet republics have heightened international concern for years due to major safety deficiencies. The governments of countries with VVER reactors have invested millions of dollars toward improving the safety of their nuclear power plants. Most of these reactors will continue to operate for the foreseeable future since they provide urgently-needed electrical power. Given this situation, this paper assesses the radiological consequences of a major nuclear accident in Eastern Europe. The paper also chronicles the efforts launched by the international nuclear community to improve the safety of the reactors and notes the progress made so far through extensive collaborative efforts in Armenia, Bulgaria, the Czech Republic, Hungary, Kazakhstan, Lithuania, Russia, Slovakia, and Ukraine to reduce the risks of nuclear accidents. Western scientific and technical staff collaborated with these countries to improve the safety of their reactor operations by strengthening the ability of the regulator to perform its oversight function, installing safety equipment and technologies, investing time in safety training, and working diligently to establish an enduring safety culture. Still, continued safety improvement efforts are necessary to ensure safe operating practices and achieve timely phase-out of older plants.

IMHEX fuel cell repeat component manufacturing continuous improvement accomplishments

Energy Technology Data Exchange (ETDEWEB)

Jakaitis, L.A.; Petraglia, V.J.; Bryson, E.S. [M-C Power Corp., Burr Ridge, IL (United States)] [and others

1996-12-31

M-C Power is taking a power generation technology that has been proven in the laboratory and is making it a commercially competitive product. There are many areas in which this technology required scale up and refinement to reach the market entry goals for the IMHEX{reg_sign} molten carbonate fuel cell power plant. One of the primary areas that needed to be addressed was the manufacturing of the fuel cell stack. Up to this point, the fuel cell stack and associated components were virtually hand made for each system to be tested. M-C Power has now continuously manufactured the repeat components for three 250 kW stacks. M-C Power`s manufacturing strategy integrated both evolutionary and revolutionary improvements into its comprehensive commercialization effort. M-C Power`s objectives were to analyze and continuously improve stack component manufacturing and assembly techniques consistent with established specifications and commercial scale production requirements. Evolutionary improvements are those which naturally occur as the production rates are increased and experience is gained. Examples of evolutionary (learning curve) improvements included reducing scrap rates and decreasing raw material costs by buying in large quantities. Revolutionary improvements result in significant design and process changes to meet cost and performance requirements of the market entry system. Revolutionary changes often involve identifying new methods and developing designs to accommodate the new process. Based upon our accomplishments, M-C Power was able to reduce the cost of continuously manufactured fuel cell repeat components from the first to third 250 kW stack by 63%. This paper documents the continuous improvement accomplishments realized by M-C Power during IMHEX{reg_sign} fuel cell repeat component manufacturing.

Improved safety at CERN

CERN Multimedia

2006-01-01

As announced in Weekly Bulletin No. 43/2006, a new approach to the implementation of Safety at CERN has been decided, which required taking some managerial decisions. The guidelines of the new approach are described in the document 'New approach to Safety implementation at CERN', which also summarizes the main managerial decisions I have taken to strengthen compliance with the CERN Safety policy and Rules. To this end I have also reviewed the mandates of the Safety Commission and the Safety Policy Committee (SAPOCO). Some details of the document 'Safety Policy at CERN' (also known as SAPOCO42) have been modified accordingly; its essential principles, unchanged, remain the basis for the safety policy of the Organisation. I would also like to inform you that I have appointed Dr M. Bona as the new Head of the Safety Commission until 31.12.2008, and that I will proceed soon to the appointment of the members of the new Safety Policy Committee. All members of the personnel are deemed to have taken note of the d...

Towards assuring the continued performance of safety-related concrete structures in nuclear power plants

International Nuclear Information System (INIS)

Naus, D.J.; Oland, C.B.; Ellingwood, B.; Mori, Y.; Arndt, E.G.

1993-01-01

The Structural Aging (SAG) Program is addressing the aging management of safety-related concrete structures in nuclear power plants for the purpose of providing improved technical bases for their continued service. Pertinent concrete structures are described in terms of their importance, design considerations, and materials of construction. Degradation factors which can potentially impact the ability of these structures to meet their functional and performance requirements are identified. A review of the performance history of the concrete components in nuclear power plants is provided. Accomplishments of the SLAG Program are summarized, i.e., development of the structural materials information center, development of a structural aging assessment methodology, evaluation of models for predicting the remaining life of in-service concrete, review of in-service inspection methods, and development of a methodology for reliability-based condition assessment and life prediction of concrete structures. On-going activities are also described

Integrating Quality Improvement and Continuing Professional Development at an Academic Medical Center: A Partnership Between Practice Plan, Hospital, and Medical School.

Science.gov (United States)

Gold, Barbara; England, Dawn; Riley, William; Jacobs-Halsey, Ginny; Webb, Corinne; Daniels, Bobbi

2016-01-01

While quality improvement (QI) initiatives can be a highly effective means for improving health care delivery in academic medical centers (AMCs), many health care professionals are not formally trained in basic QI methodology, engaging clinicians in QI activities can be challenging, and there is often a lack of integration and coordination among QI functions (eg, Departments of Quality and Safety, Continuing Professional Development). In our AMC, we undertook a collaborative approach to achieve better vertical and horizontal integration of our QI education efforts. This article provides a case example describing our organizational context, what was done, and with what effect and makes our example and lessons learned available to others. We developed a new educational QI program that was jointly planned and implemented by a group comprising major QI stakeholders. This project was intended to create horizontal organizational linkages between continuing professional development, clinicians, the hospital, and QI department and produce QI activities that aligned with the strategic objectives of senior management. The group developed and implemented a curriculum based on Lean methodology and concepts from the Institute for Health Care Improvement Model for Improvement. Two cohorts (27 teams) completed the training and planned and implemented QI projects. All projects were aligned with organizational quality, safety, and patient experience goals. The majority of projects met their aim statements. This case description provides an example of successful horizontal integration of an AMCs' QI functions to disseminate knowledge and implement meaningful QI aligned with strategic objectives (vertical integration).

Continuous Improvement in Action: Educators' Evidence Use for School Improvement

Science.gov (United States)

Cannata, Marisa; Redding, Christopher; Rubin, Mollie

2016-01-01

The focus of the article is the process educators use to interpret data to turn it into usable knowledge (Honig & Coburn, 2008) while engaging in a continuous improvement process. The authors examine the types of evidence educators draw upon, its perceived relevance, and the social context in which the evidence is examined. Evidence includes…

Safety culture. Keys for sustaining progress

International Nuclear Information System (INIS)

Barraclough, I.; Carnino, A.

1998-01-01

Principles of nuclear safety are now well known and being put into practice around the world, leading to a degree of international harmonization in safety standards. Continued improvement in levels of safety requires the development of a comprehensive 'safety culture' at all levels of an organization, with visible and consistent leadership from senior management. This article reviews the main elements required for establishing and sustaining a good safety culture at nuclear installations that involves staff at all levels

Improving safety through quality management system: SINAGAMA experience

International Nuclear Information System (INIS)

Muhammad Lebai Juri

2000-01-01

This paper discussed critically the policies and measures adopted during preoperational and operational stages to improve safety of workers, public, the environment as well as the products treated at SINAGAMA. (author)

Improving occupational safety in Kuzbass mines

Energy Technology Data Exchange (ETDEWEB)

Evseev, V S

1986-08-01

Some achievements of VostNII are listed in improving occupational safety in Kuzbass mines. Methane is a major problem: 90.6% of mines is in category III or supercategory; over 21% has an absolute methane emission of 30 m/sup 3//min or more. Another problem is spontaneous fires, which cost 2 million t of coal per year. One method of preventing these is injection of antipyrogens (urea and diammonium phosphate); another is the creation of gel (water glass, ammonium chloride and water) barriers in goaf areas. High pressure water jets are also used. Various methods of improving ventilation systems to match increased coal output are proposed, including drilling large diameter ventilation boreholes from the surface. In Leninskugol' mines the useful air is only 55.8% of the total delivered. More attention should be given to degassing (currently producing 130 million m/sup 3//y of methane). Dust levels are increasing due to the advent of narrow web cutter loaders (100% of coal cutter loaders in Kuzbass mines in 1984). Water injection and spraying are partially effective at dust suppression. Some electrical safety devices developed by VostNII are described.

Improving efficiency and safety in external beam radiation therapy treatment delivery using a Kaizen approach.

Science.gov (United States)

Kapur, Ajay; Adair, Nilda; O'Brien, Mildred; Naparstek, Nikoleta; Cangelosi, Thomas; Zuvic, Petrina; Joseph, Sherin; Meier, Jason; Bloom, Beatrice; Potters, Louis

Modern external beam radiation therapy treatment delivery processes potentially increase the number of tasks to be performed by therapists and thus opportunities for errors, yet the need to treat a large number of patients daily requires a balanced allocation of time per treatment slot. The goal of this work was to streamline the underlying workflow in such time-interval constrained processes to enhance both execution efficiency and active safety surveillance using a Kaizen approach. A Kaizen project was initiated by mapping the workflow within each treatment slot for 3 Varian TrueBeam linear accelerators. More than 90 steps were identified, and average execution times for each were measured. The time-consuming steps were stratified into a 2 × 2 matrix arranged by potential workflow improvement versus the level of corrective effort required. A work plan was created to launch initiatives with high potential for workflow improvement but modest effort to implement. Time spent on safety surveillance and average durations of treatment slots were used to assess corresponding workflow improvements. Three initiatives were implemented to mitigate unnecessary therapist motion, overprocessing of data, and wait time for data transfer defects, respectively. A fourth initiative was implemented to make the division of labor by treating therapists as well as peer review more explicit. The average duration of treatment slots reduced by 6.7% in the 9 months following implementation of the initiatives (P = .001). A reduction of 21% in duration of treatment slots was observed on 1 of the machines (P Kaizen approach has the potential to improve operational efficiency and safety with quick turnaround in radiation therapy practice by addressing non-value-adding steps characteristic of individual department workflows. Higher effort opportunities are identified to guide continual downstream quality improvements. Copyright © 2017 American Society for Radiation Oncology. Published by

A model for continuous improvement at a South African minerals benefication plant

Directory of Open Access Journals (Sweden)

Ras, Eugene Ras

2015-05-01

Full Text Available South Africa has a variety of mineral resources, and several minerals beneficiation plants are currently in operation. These plants must be operated effectively to ensure that the end-users of its products remain internationally competitive. To achieve this objective, plants need a sustainable continuous improvement programme. Several frameworks for continuous improvement are used, with variable success rates, in beneficiation plants around the world. However, none of these models specifically addresses continuous improvement from a minerals-processing point of view. The objective of this research study was to determine which factors are important for a continuous improvement model at a minerals beneficiation plant, and to propose a new model using lean manufacturing, six sigma, and the theory of constraints. A survey indicated that managers in the industry prefer a model that combines various continuous improvement models.

How to Improve Patient Safety Culture in Croatian Hospitals?

Science.gov (United States)

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

2016-09-01

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

Proposals for an effective application of the continuous improvement at the ININ according to the IAEA 50-C/SG-Q new code; Propuestas para una aplicacion efectiva del proceso de mejora continua en el ININ, de acuerdo al nuevo codigo 50-C/SG-Q del OIEA

Energy Technology Data Exchange (ETDEWEB)

Cardenas A, B.M.; Olivares O, L.A. [Instituto Nacional de Investigaciones Nucleares, A.P. 18-1027, 11801 Mexico D.F. (Mexico)

1997-07-01

This work contains the requirements of continuous improvement contained in the IAEA new code {sup Q}uality assurance for safety in nuclear power plants and other nuclear installations, code 50-C/SG-Q. Assuming that it was the base for to elaborate the review No. 5 of the Quality assurance plan at ININ, it was done an analysis to give proposals for the application of continuous improvement in effective way. The relevant points which must be taken in account at the continuous improvement process are: Direction responsibility, involucring of all personnel, process planning, education and training, elaboration of improvement projects, investigation of processes which can be improved, continuation of the improvement process and its evaluation. With the implantation of an effective continuous improvement system it will be obtained to get a better quality and a more efficient safety. (Author)

Ways of improving safety for future PWRs in France

International Nuclear Information System (INIS)

Gros, G.; Jalouneix, J.; Manesse, D.; Mattei, J.M.

1994-06-01

Results of thinkings and studies, conducted within the Institute for Nuclear Safety and Protection (IPSN) on various fields of nuclear power plant safety, on the definition of safety objectives and principles for future PWRs. The aim of the studies is to identify ways of improving the design of future plants in France and Germany, with the main following objectives: significant reduction of the global probability of core damage, significant reduction of radioactive releases, mainly for severe accident conditions, and reduction of individual and collective doses received by workers. (R.P.) 3 refs., 1 tab

Improved safety of the system 80+TM standard plants design through increased diversity and redundancy of safety systems

International Nuclear Information System (INIS)

Matzie, Regis A.; Carpentino, Frederick L.; Robertson, James E.

1996-01-01

Safely systems in the System 80+ TM Standard Plant are designed with more redundancy, diversity and simplicity than earlier nuclear power plant designs. These gains were accomplished by an evolutionary process that preserved the desirable and proven features in currently operating nuclear plants, while improving reliability and defense-in-depth. The System 80+ safety systems are the primary contributors to a core damage frequency that is more than 100 times lower than 1980's vintage U. S. designs, including the predecessor System 80 R standard nuclear steam supply system (NSSS) design. The System 80+ design includes significant improvements to the safety injection system, emergency feedwater system, shutdown cooling system, containment spray system, reactor coolant gas vent system, and to their vital support systems. These improvements enhance performance for traditional design basis events and significantly reduce the probability of a severe accident. The System 80+ design also incorporates safety systems to mitigate a severe accident. The added systems include the rapid depressurization system, the in-containment refueling water storage tank, the cavity flooding system. These systems fully address the U. S. Nuclear Regulatory Commission's (US NRC) severe accident policy. The System 80+ safety systems are integrated with the System 80+ Nuclear Island (NI) design. The NI general arrangement provides quadrant separation of the safety systems for protection from fire and flooding, and large equipment pull spaces and lay down areas for maintenance. This paper will describe the System 80+ safety systems advanced design features, the improved accident prevention and mitigation capabilities, and startup, operating and maintenance benefits

Nature-based strategies for improving urban health and safety

Science.gov (United States)

Michelle C. Kondo; Eugenia C. South; Charles C. Branas

2015-01-01

Place-based programs are being noticed as key opportunities to prevent disease and promote public health and safety for populations at-large. As one key type of place-based intervention, nature-based and green space strategies can play an especially large role in improving health and safety for dwellers in urban environments such as US legacy cities that lack nature...

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

Science.gov (United States)

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

2012-01-01

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

A new approach to preparing safety cases for existing nuclear plant (COSR)

International Nuclear Information System (INIS)

Rice, S.A.; Buchan, A.B.

2000-01-01

BNFL is committed to achieving world class safety performance, through a process of continuously reviewing and improving its safety practices. In the mid 1990s, as part of this process, the company began to develop a new type of safety case, for existing non-reactor nuclear plants, called the continued operation safety report (COSR). Following a significant amount of development work from experts within BNFL and important contributions from its regulators, the first approved COSR was recently completed and submitted to the Nuclear Installations Inspectorate. The COSR aims to provide a visibly integrated safety and engineering case for the adequacy of continued operation of a nuclear facility. It achieves this by identifying the main plant structures, systems and components that have a safety function and provides the appropriate supporting engineering substantiation. The COSR aims to explore plant safety and identify worthwhile improvements. The document also aims to be reader-friendly by focusing on the main safety issues. It is therefore a slim safety summary which provides operators, safety specialists and regulators with an overview and introduction into the broader, more detailed safety case. This paper provides an overview of the COSR and its production process, describing the safety case improvements that have been made by comparing it to its predecessor, the fully developed safety case. The paper also illustrates the benefits of the COSR by providing current examples of its application on existing BNFL plant. Finally, the paper describes ongoing development work aimed at further improving the COSR and its production process. (author)

77 FR 17119 - Pipeline Safety: Cast Iron Pipe (Supplementary Advisory Bulletin)

Science.gov (United States)

2012-03-23

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... national attention and highlight the need for continued safety improvements to aging gas pipeline systems... 26, 1992) covering the continued use of cast iron pipe in natural gas distribution pipeline systems...

Paths to continuous improvement of a CRM strategy

Directory of Open Access Journals (Sweden)

Lluís G. Renart

2008-07-01

Full Text Available The concept of relationship marketing has led to a paradigm change in marketing. Over the last few decades, numerous studies have analyzed the impact of customer relationship management (CRM programs on customer satisfaction and loyalty. Quite a few CRM programs have been found to have little or no impact. Having already published several articles and cases on the subject, in this paper we set out to answer the following question: assuming a company already has a reasonably successful CRM strategy in place, how can it continuously adapt and improve that strategy? Our recommendation is that such companies implement a continuous improvement process at four different but complementary levels: first, review and reinforce the company’s mission, culture and values; second, reconsider and, if necessary, redesign the CRM strategy; third, manage the various relationship-building activities more effectively; and lastly, review and, if necessary, improve the quality of material and human resources, program execution and process governance. A systematic review of these four levels or “paths” of improvement should help generate and maintain high quality relationships over time.

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

NARCIS (Netherlands)

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

2003-01-01

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

A Health Care Project Management Office's Strategies for Continual Change and Continuous Improvement.

Science.gov (United States)

Lavoie-Tremblay, Mélanie; Aubry, Monique; Richer, Marie-Claire; Cyr, Guylaine

Health care organizations need project and change management support in order to achieve successful transformations. A project management office (PMO) helps support the organizations through their transformations along with increasing their capabilities in project and change management. The aim of the present study was to extend understanding of the continuous improvement mechanisms used by PMOs and to describe PMO's strategies for continual change and continuous improvement in the context of major transformation in health care. This study is a descriptive case study design with interviews conducted from October to December 2015 with PMO's members (3 managers and 1 director) and 3 clients working with the PMO after a major redevelopment project ended (transition to the new facility). Participants suggested a number of elements including carefully selecting the members of the PMO, having a clear mandate for the PMO, having a method and a discipline at the same time as allowing openness and flexibility, clearly prioritizing projects, optimizing collaboration, planning for everything the PMO will need, not overlooking organizational culture, and retaining the existing support model. This study presents a number of factors ensuring the sustainability of changes.

USSR orders computers to improve nuclear safety

International Nuclear Information System (INIS)

Anon.

1990-01-01

Control Data Corp (CDC) has received an order valued at $32-million from the Soviet Union for six Cyber 962 mainframe computer systems to be used to increase the safety of civilian nuclear powerplants. The firm is now waiting for approval of the contract by the US government and Western Allies. The computers, ordered by the Soviet Research and Development Institute of Power Engineering (RDIPE), will analyze safety factors in the operation of nuclear reactors over a wide range of conditions. The Soviet Union's civilian nuclear program is one of the largest in the world, with over 50 plants in operation. Types of safety analyses the computers perform include: neutron-physics calculations, radiation-protection studies, stress analysis, reliability analysis of equipment and systems, ecological-impact calculations, transient analysis, and support activities for emergency response. They also include a simulator with realistic mathematical models of Soviet nuclear powerplants to improve operator training

Improving multiple sclerosis management and collecting safety information in the real world: the MSDS3D software approach.

Science.gov (United States)

Haase, Rocco; Wunderlich, Maria; Dillenseger, Anja; Kern, Raimar; Akgün, Katja; Ziemssen, Tjalf

2018-04-01

For safety evaluation, randomized controlled trials (RCTs) are not fully able to identify rare adverse events. The richest source of safety data lies in the post-marketing phase. Real-world evidence (RWE) and observational studies are becoming increasingly popular because they reflect usefulness of drugs in real life and have the ability to discover uncommon or rare adverse drug reactions. Areas covered: Adding the documentation of psychological symptoms and other medical disciplines, the necessity for a complex documentation becomes apparent. The collection of high-quality data sets in clinical practice requires the use of special documentation software as the quality of data in RWE studies can be an issue in contrast to the data obtained from RCTs. The MSDS3D software combines documentation of patient data with patient management of patients with multiple sclerosis. Following a continuous development over several treatment-specific modules, we improved and expanded the realization of safety management in MSDS3D with regard to the characteristics of different treatments and populations. Expert opinion: eHealth-enhanced post-authorisation safety study may complete the fundamental quest of RWE for individually improved treatment decisions and balanced therapeutic risk assessment. MSDS3D is carefully designed to contribute to every single objective in this process.

Safety Culture Improvement Activities of YGN 3 and 4

International Nuclear Information System (INIS)

Cho, Il Hoon

2006-01-01

In nuclear power industry all over the world, we can never overemphasize the importance of nuclear safety. After the Chernobyl accident occurred in 1986, Korean nuclear energy industry had made every effort to enhance nuclear safety culture further. And, as a result of the efforts, Korean government declared the five principles for the nuclear energy safety regulation, which were included in the Nuclear Energy Safety Policy Statement published in 1994. In 2001, through the announcement of Nuclear Safety Charter for the peaceful use of nuclear energy, the Ministry of Science and Technology proclaimed at home and abroad that the protection of citizens and environment by securing nuclear safety should be the highest priority in nuclear energy industry. Occupying almost 40% share of domestic electricity generation, Korea Hydro and Nuclear Power Co. decided 'Safety Top Priority Management' as president's management policy, and clearly presented the safety goal to the personnel. By this, the management can effectively place stress on securing safety, which is our highest priority and the only way to win public confidence toward nuclear energy industry. This is prepared to shortly introduce the activities for improving safety culture in Yonggwang Nuclear Power unit 3 and 4 (YGN 3 and 4)

Empirical Analysis of Construction Safety Climate - A Study

OpenAIRE

S.V.S.RAJA PRASAD; K.P.REGHUNATH

2010-01-01

Safety in the construction industry has always been a major issue. Though much improvement in construction safety has been achieved, the industry still continues to lag behind most other industries with regard to safety. The safety climate of any organization consists of employee’s attitudes towards and perceptions of, health and safety behavior. Construction workers attitudes towards safety are influenced by their perceptions of risk, management, safety rulesand procedures. A measure of safe...

Improving Aviation Safety in Indonesia: How Many More Accidents?

Directory of Open Access Journals (Sweden)

Ridha Aditya Nugraha

2016-12-01

Full Text Available Numerous and consecutive aircraft accidents combined with a consistent failure to meet international safety standards in Indonesia, namely from the International Civil Aviation Organization and the European Aviation Safety Agency have proven a nightmare for the country’s aviation safety reputation. There is an urgent need for bureaucracy reform, harmonization of legislation, and especially ensuring legal enforcement, to bring Indonesian aviation safety back to world standards. The Indonesian Aviation Law of 2009 was enacted to reform the situation in Indonesia. The law has become the ground for drafting legal framework under decrees of the Minister of Transportation, which have allowed the government to perform follow-up actions such as establishing a single air navigation service provider and guaranteeing the independency of the Indonesian National Transportation Safety Committee. A comparison with Thailand is made to enrich the perspective. Finally, foreign aviation entities have a role to assist states, in this case Indonesia, in improving its aviation safety, considering the global nature of air travel.

Implementing a customer focused continual business improvement program to improve the maintenance process

International Nuclear Information System (INIS)

Kharshafdjian, G.; Fisher, C.; Beres, T.; Brooks, S.; Forbes, S.; Krause, M.; McAuley, K.; Wendorf, M.

2006-01-01

Global market pressures and increasing competition demands that successful companies establish a continual business improvement program as part of implementing its business strategy. Such programs must be driven by the definition of quality from the customer's perspective. This customer quality focus often requires a change in all aspects of the business including products, services, processes and culture. This paper will describe how Atomic Energy of Canada Limited implemented a Continual Business Improvement Program in their Nuclear Laboratories Business Unit. In particular, to review how the techniques were applied to improve the maintenance process and the status of the project. Customer (internal users of the processes at CRL) feedback has shown repeatedly there is dissatisfaction of the maintenance process. Customers complain about jobs not getting done to schedule or being deferred. A project has been launched with the following goals: to improve the maintenance process customer satisfaction and increase trades wrench time by 30 minutes / trade / day. DMAIC (Define-Measure-Analyze-Improve-Control) methodology was applied to find out the Root Cause(s) of the problem, provide solutions, and implement improvements. The expected Operational Benefits include: Executing work efficiently to quality standards and business performance of the site, improve maintenance efficiencies, reduce cycle time for maintenance process and improve process yield, and improve customer and employee satisfaction. (author)

Implementing a customer focused continual business improvement program to improve the maintenance process

Energy Technology Data Exchange (ETDEWEB)

Kharshafdjian, G.; Fisher, C.; Beres, T.; Brooks, S.; Forbes, S.; Krause, M.; McAuley, K.; Wendorf, M. [Atomic Energy of Canada Limited, Chalk River, Ontario (Canada)

2006-07-01

Global market pressures and increasing competition demands that successful companies establish a continual business improvement program as part of implementing its business strategy. Such programs must be driven by the definition of quality from the customer's perspective. This customer quality focus often requires a change in all aspects of the business including products, services, processes and culture. This paper will describe how Atomic Energy of Canada Limited implemented a Continual Business Improvement Program in their Nuclear Laboratories Business Unit. In particular, to review how the techniques were applied to improve the maintenance process and the status of the project. Customer (internal users of the processes at CRL) feedback has shown repeatedly there is dissatisfaction of the maintenance process. Customers complain about jobs not getting done to schedule or being deferred. A project has been launched with the following goals: to improve the maintenance process customer satisfaction and increase trades wrench time by 30 minutes / trade / day. DMAIC (Define-Measure-Analyze-Improve-Control) methodology was applied to find out the Root Cause(s) of the problem, provide solutions, and implement improvements. The expected Operational Benefits include: Executing work efficiently to quality standards and business performance of the site, improve maintenance efficiencies, reduce cycle time for maintenance process and improve process yield, and improve customer and employee satisfaction. (author)

An integrated approach for improving occupational health and safety management: the voluntary protection program in Taiwan.

Science.gov (United States)

Su, Teh-Sheng; Tsai, Way-Yi; Yu, Yi-Chun

2005-05-01

A voluntary compliance program for occupational health and safety management, Voluntary Protection Programs (VPP), was implemented with a strategy of cooperation and encouragement in Taiwan. Due to limitations on increasing the human forces of inspection, a regulatory-based guideline addressing the essence of Occupational Health and Safety Management Systems (OHSMS) was promulgated, which combined the resources of third parties and insurance providers to accredit a self-improving worksite with the benefits of waived general inspection and a merit contributing to insurance premium payment reduction. A designated institute accepts enterprise's applications, performs document review and organizes the onsite inspection. A final review committee of Council of Labor Affairs (CLA) confers a two-year certificate on an approved site. After ten years, the efforts have shown a dramatic reduction of occupational injuries and illness in the total number of 724 worksites granted certification. VPP worksites, in comparison with all industries, had 49% lower frequency rate in the past three years. The severity rate reduction was 80% in the same period. The characteristics of Taiwan VPP program and international occupational safety and health management programs are provided. A Plan-Do-Check-Act management cycle was employed for pursuing continual improvements to the culture fostered. The use of a quantitative measurement for assessing the performance of enterprises' occupational safety and health management showed the efficiency of the rating. The results demonstrate that an employer voluntary protection program is a promising strategy for a developing country.

Software Maintenance Management Evaluation and Continuous Improvement

CERN Document Server

April, Alain

2008-01-01

This book explores the domain of software maintenance management and provides road maps for improving software maintenance organizations. It describes full maintenance maturity models organized by levels 1, 2, and 3, which allow for benchmarking and continuous improvement paths. Goals for each key practice area are also provided, and the model presented is fully aligned with the architecture and framework of software development maturity models of CMMI and ISO 15504. It is complete with case studies, figures, tables, and graphs.

Design safety improvements of Kozloduy NPP to meet the modern safety requirements towards the old generation PWR

International Nuclear Information System (INIS)

Hinovski, M.P.; Sabinov, S.

2001-01-01

Activities related to safety improvement of Kozloduy NPP units, started at the end of 1970s included seismic resistance upgrading, fire safety improvement, reliable heat final absorber etc. During the last 10 years the approach was systematized and improved. Units 1 to 4 are of great interest; therefore here we will discuss these units only. As a result of studies and analyses performed at the end of the 1980s and the beginning of the 1990s, problems related to the safety were identified and complex of technical measures was developed and planned. A considerable part of these measures has already been implemented, and the rest will be performed during the next years. Activities were performed by stages, and at the moment the last stage is under way. It shall be finished by the year 2003. The number of the measures is quite large to describe them here in full scope -- during the first stage of the safety program (1991-1993) were developed and analyzed more than 4200 documents and more than 160 measures were executed. During the second and third stages more than 300 important improvements were realized. In the frame of the program, financed by EBRD, 10 new systems with great importance were implemented and 8 systems were significantly modified. The main measures are described below. (author)

A performance improvement plan to increase nurse adherence to use of medication safety software.

Science.gov (United States)

Gavriloff, Carrie

2012-08-01

Nurses can protect patients receiving intravenous (IV) medication by using medication safety software to program "smart" pumps to administer IV medications. After a patient safety event identified inconsistent use of medication safety software by nurses, a performance improvement team implemented the Deming Cycle performance improvement methodology. The combined use of improved direct care nurse communication, programming strategies, staff education, medication safety champions, adherence monitoring, and technology acquisition resulted in a statistically significant (p < .001) increase in nurse adherence to using medication safety software from 28% to above 85%, exceeding national benchmark adherence rates (Cohen, Cooke, Husch & Woodley, 2007; Carefusion, 2011). Copyright © 2012 Elsevier Inc. All rights reserved.

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

Science.gov (United States)

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

2015-09-01

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

Application of VR and HF technologies for improving industrial safety

NARCIS (Netherlands)

Loupos, K.; Christopoulos, D.; Vezzadini, L.; Hoekstra, W.; Salem, W.; Chung, P.W.H.

2007-01-01

Safety in industrial environments can nowadays be regarded as an issue of major importance. Large amounts of money are spent by industries on this matter in order to improve safety in all levels, by reducing risks of causing damages to equipment, human injuries or even fatalities. Virtual Reality

Improving Patient Safety Culture in Primary Care: A Systematic Review

NARCIS (Netherlands)

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

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

Federal Aviation Administration weather program to improve aviation safety

Science.gov (United States)

Wedan, R. W.

1983-01-01

The implementation of the National Airspace System (NAS) will improve safety services to aviation. These services include collision avoidance, improved landing systems and better weather data acquisition and dissemination. The program to improve the quality of weather information includes the following: Radar Remote Weather Display System; Flight Service Automation System; Automatic Weather Observation System; Center Weather Processor, and Next Generation Weather Radar Development.

The Role of the Master in Improving Safety Culture Onboard Ships

Directory of Open Access Journals (Sweden)

T. Bielic

2017-03-01

Full Text Available As a complex socio-technical system marine transportation is open to risks. Due to the efforts of international organisations, flag and port administrations, classification societies and ship-owners the safety record has steadily improved. However, marine accidents resulting from inadequate safety culture still occur. In this paper examples of recent accidents related to different dimensions of safety culture are provided. The role of the master in achieving an enhanced safety is emphasised.

Keeping the "continuous" in continuous quality improvement: exploring perceived outcomes of CQI program use in community pharmacy.

Science.gov (United States)

Boyle, Todd A; Bishop, Andrea C; Duggan, Kellie; Reid, Carolyn; Mahaffey, Thomas; MacKinnon, Neil J; Mahaffey, Amelia

2014-01-01

Given the significant potential of continuous quality improvement (CQI) programs in enhancing overall levels of patient safety, community pharmacies in North America are under increasing pressure to have a formal and documented CQI program in place. However, while such initiatives may seem great on paper, in practice the outcomes of such programs to community pharmacy practice remain unclear. To explore the perceived outcomes identified by community pharmacies that adopted and actively used a standardized (i.e., common across pharmacies) CQI program for at least 1 year and to develop a framework for how such outcomes were achieved. A multi-site study of SafetyNET-Rx, a standardized and technologically sophisticated (e.g., online reporting of medication errors to a national database) CQI program, involving community pharmacies in Nova Scotia, Canada, was performed. During the summer and fall of 2011, 22 interviews were conducted with the CQI facilitators in 12 Nova Scotia community pharmacies; equally split between independent/banners and corporate chains. Of the CQI facilitators, 14 were pharmacists, while the remaining eight were pharmacy technicians. Thematic analysis following the procedures presented by Braun and Clarke was adopted to identify and explore the major outcomes. Results of the thematic analysis highlighted a number of perceived outcomes from the use of a standardized CQI program in community pharmacies, specifically: (1) perceived reduction in the number of medication errors that were occurring in the pharmacy, (2) increased awareness/confidence of individual actions related to dispensing, (3) increased understanding of the dispensing and related processes/workflow, (4) increased openness to talking about medication errors among pharmacy staff, and (5) quality and safety becoming more entrenched in the workflow (e.g., staff is more aware of their roles and responsibilities in patient safety and confident that the dispensing processes are safe and

CORPORATE CULTURE AS A TOOL TO IMPROVE SAFETY CULTURE

Directory of Open Access Journals (Sweden)

Erika SUJOVÁ

2013-07-01

Full Text Available The aim of the article is to explain interconnectivity between corporate culture and safety culture, which aim to utilize motivation to prevent work accidents and other unwanted events in an enterprise. The article deals with ways how to improve approaches to Occupational Health & Safety, OH&S, at work place through proper direction of corporate culture. It introduces internal and external determinants of corporate culture, which have a significant effect. The article introduces common features of corporate culture and safety culture as an element of the OH&S management system with emphasis on system effectiveness. The final portion of the article presents the hierarchy of needs model, which may serve as a basis motivating employees to follow safety and health rules at work place.

Kozloduy nuclear power plant. Units 1-4. Status of safety improvements. Rev. 2

International Nuclear Information System (INIS)

1999-01-01

This paper presents the results of the safety improvements activities carried out by the Kozloduy Nuclear Power Plant (KNPP) within the period 1990-1998. The steam supply system of this units is based of the reactor WWER-440/ B-230, which is a PWR of russian design developed according to the safety standards in force in USSR in late sixties. Up to now 10 reactor units of this type are in operation in four NPPs. Despite of efforts of the different plants to implement safety improvements measures during first 10-15 years of operation of this type of reactor its major safety problems were not eliminated and were a subject of international concern. The systematic evaluation of the deficiencies of the original design of this type of reactors have been initiated by IAEA in the beginning of 1990 and brought to developing a comprehensive list of safety problems which required urgent implementation of safety measures in all plants. To solve this problems in 1991 KNPP initiated implementation of so called 'short term' safety improvement program, developed with the help of WANO under agreement with Bulgarian Nuclear Safety Authority (BNSA) and consortium RISKAUDIT. The program was based on a stage approach and was foreseen to be implemented by tree stages in very tight time schedule in order to achieve significant and rapid improvements of the level of safety in operation of the units. The Short term program was implemented between from 1991 to 1997 owing to strong safety commitment of NEC and KNPP staff as well as broad international cooperation and financial support. Important part of resources were supplied under PHARE program of CEC, EBRD grant agreement and EDF support. In parallel a special assessment process started in 1995 in order to evaluate the level of safety, achieved by Short Term Program, according to current safety standards and to define the measures, which should be implemented by the Utility to complete the process of improving the safety in future

Leadership and Management for Safety. General Safety Requirements (Arabic Edition)

International Nuclear Information System (INIS)

2016-01-01

This Safety Requirements publication establishes requirements that support Principle 3 of the Fundamental Safety Principles in relation to establishing, sustaining and continuously improving leadership and management for safety and an integrated management system. It emphasizes that leadership for safety, management for safety, an effective management system and a systemic approach (i.e. an approach in which interactions between technical, human and organizational factors are duly considered) are all essential to the specification and application of adequate safety measures and to the fostering of a strong safety culture. Leadership and an effective management system will integrate safety, health, environmental, security, quality, human-and-organizational factors, societal and economic elements. The management system will ensure the fostering of a strong safety culture, regular assessment of performance and the application of lessons from experience. The publication is intended for use by regulatory bodies, operating organizations and other organizations concerned with facilities and activities that give rise to radiation risks.

Leadership and Management for Safety. General Safety Requirements (Chinese Edition)

International Nuclear Information System (INIS)

2016-01-01

This Safety Requirements publication establishes requirements that support Principle 3 of the Fundamental Safety Principles in relation to establishing, sustaining and continuously improving leadership and management for safety and an integrated management system. It emphasizes that leadership for safety, management for safety, an effective management system and a systemic approach (i.e. an approach in which interactions between technical, human and organizational factors are duly considered) are all essential to the specification and application of adequate safety measures and to the fostering of a strong safety culture. Leadership and an effective management system will integrate safety, health, environmental, security, quality, human-and-organizational factors, societal and economic elements. The management system will ensure the fostering of a strong safety culture, regular assessment of performance and the application of lessons from experience. The publication is intended for use by regulatory bodies, operating organizations and other organizations concerned with facilities and activities that give rise to radiation risks.

Leadership and Management for Safety. General Safety Requirements (French Edition)

International Nuclear Information System (INIS)

2016-01-01

This Safety Requirements publication establishes requirements that support Principle 3 of the Fundamental Safety Principles in relation to establishing, sustaining and continuously improving leadership and management for safety and an integrated management system. It emphasizes that leadership for safety, management for safety, an effective management system and a systemic approach (i.e. an approach in which interactions between technical, human and organizational factors are duly considered) are all essential to the specification and application of adequate safety measures and to the fostering of a strong safety culture. Leadership and an effective management system will integrate safety, health, environmental, security, quality, human-and-organizational factors, societal and economic elements. The management system will ensure the fostering of a strong safety culture, regular assessment of performance and the application of lessons from experience. The publication is intended for use by regulatory bodies, operating organizations and other organizations concerned with facilities and activities that give rise to radiation risks.

Leadership and Management for Safety. General Safety Requirements (Spanish Edition)

International Nuclear Information System (INIS)

2017-01-01

his Safety Requirements publication establishes requirements that support Principle 3 of the Fundamental Safety Principles in relation to establishing, sustaining and continuously improving leadership and management for safety and an integrated management system. It emphasizes that leadership for safety, management for safety, an effective management system and a systemic approach (i.e. an approach in which interactions between technical, human and organizational factors are duly considered) are all essential to the specification and application of adequate safety measures and to the fostering of a strong safety culture. Leadership and an effective management system will integrate safety, health, environmental, security, quality, human-and-organizational factors, societal and economic elements. The management system will ensure the fostering of a strong safety culture, regular assessment of performance and the application of lessons from experience. The publication is intended for use by regulatory bodies, operating organizations and other organizations concerned with facilities and activities that give rise to radiation risks.

BRICS: opportunities to improve road safety.

Science.gov (United States)

Hyder, Adnan A; Vecino-Ortiz, Andres I

2014-06-01

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--are currently undergoing a deep epidemiological transition that is mainly driven by rapid economic growth and technological change. The changes being observed in the distribution of the burden of diseases and injuries--such as recent increases in the incidence of road traffic injuries--are matters of concern. BRICS may need stronger institutional capacity to address such changes in a timely way. In this paper, we present data on road traffic injuries in BRICS and illustrate the enormous challenge that these countries currently face in reducing the incidence of such injuries. There is an urgent need to improve road safety indicators in every country constituting BRICS. It is imperative for BRICS to invest in system-wide road safety interventions and reduce the mortality and morbidity from road traffic injuries.

Improving ICU risk management and patient safety.

Science.gov (United States)

Kielty, Lucy Ann

2017-06-12

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

Nuclear Safety Review for the Year 2004

International Nuclear Information System (INIS)

2005-08-01

In the nuclear area, challenges continue to emerge from the globalization of issues related to safety, technology, business, information, communication and security. Scientific advances and operational experience in nuclear, radiation, waste and transport technology are providing new opportunities to continuously improve safety and security by utilizing synergies between safety and security. The prime responsibility for nuclear, radiation, waste and transport safety rests with users and national governments. The Agency continues to support a Global Nuclear Safety Regime based on strong national safety infrastructures and widespread subscription to international legal instruments to maintain high levels of safety worldwide. Central to the Agency's role are the establishment of international safety standards and the provision for applying these standards, as well as the promotion of sharing information through managing the knowledge base. Nuclear power plant operational safety performance remains high throughout the world. Challenges facing the nuclear power industry include avoiding complacency, maintaining the necessary infrastructure, nuclear power plant ageing and long-term operation, as well as new reactor designs and construction. The research reactor community has a long history of safe operation. However nearly two-thirds of the world's operating research reactors are now over 30 years old and face safety and security challenges. In 2004, the Board of Governors approved the Code of Conduct on the Safety of Research Reactors to help address these challenges. In 2004, there was international consensus on radionuclide activity concentrations in materials below which regulatory controls need not apply. Key occupational radiation protection performance indicators continued to improve in 2004. Challenges include new medical practices where workers can receive high exposures, industrial radiography and worker exposure to naturally occurring radioactive material. New

Continuous Improvement and its Barriers in Electrical and Electronic Industry

OpenAIRE

Ahmad Md Fauzi; Yan Toh Li; Wei Chan Shiau; Aizat Ahmad Ahmad Nur; Raja Mohd Rasi Raja Zuraidah; Abdul Rahman Nor Aida; Muhd Nor Nik Hisyamudin; Hassan Mohd Fahrul; Hashim Fatan Adibah

2017-01-01

Continuous improvement is one of the core strategies for manufacturing excellent and it is considered vital in today’s business environment. Continuous improvement is an important factor in TQM implementation. However, manufacturers in Electrical and Electronic Industry is facing variety of challenges such as, time constraint, quality issue, headcount issue, human issue and competition in domestic as well as the global market. This paper presents total quality management practices in Electric...

Improving the safety and quality of nursing care through standardized operating procedures in Bosnia and Herzegovina.

Science.gov (United States)

Ausserhofer, Dietmar; Rakic, Severin; Novo, Ahmed; Dropic, Emira; Fisekovic, Eldin; Sredic, Ana; Van Malderen, Greet

2016-06-01

We explored how selected 'positive deviant' healthcare facilities in Bosnia and Herzegovina approach the continuous development, adaptation, implementation, monitoring and evaluation of nursing-related standard operating procedures. Standardized nursing care is internationally recognized as a critical element of safe, high-quality health care; yet very little research has examined one of its key instruments: nursing-related standard operating procedures. Despite variability in Bosnia and Herzegovina's healthcare and nursing care quality, we assumed that some healthcare facilities would have developed effective strategies to elevate nursing quality and safety through the use of standard operating procedures. Guided by the 'positive deviance' approach, we used a multiple-case study design to examine a criterion sample of four facilities (two primary healthcare centres and two hospitals), collecting data via focus groups and individual interviews. In each studied facility, certification/accreditation processes were crucial to the initiation of continuous development, adaptation, implementation, monitoring and evaluation of nursing-related SOPs. In one hospital and one primary healthcare centre, nurses working in advanced roles (i.e. quality coordinators) were responsible for developing and implementing nursing-related standard operating procedures. Across the four studied institutions, we identified a consistent approach to standard operating procedures-related processes. The certification/accreditation process is enabling necessary changes in institutions' organizational cultures, empowering nurses to take on advanced roles in improving the safety and quality of nursing care. Standardizing nursing procedures is key to improve the safety and quality of nursing care. Nursing and Health Policy are needed in Bosnia and Herzegovina to establish a functioning institutional framework, including regulatory bodies, educational systems for developing nurses' capacities or the

Continuous-energy version of KENO V.a for criticality safety applications

International Nuclear Information System (INIS)

Dunn, Michael E.; Greene, N. Maurice; Petrie, Lester M.

2003-01-01

KENO V.a is a multigroup Monte Carlo code that solves the Boltzmann transport equation and is used extensively in the criticality safety community to calculate the effective multiplication factor of systems with fissionable material. In this work, a continuous-energy or pointwise version of KENO V.a has been developed by first designing a new continuous-energy cross-section format and then by developing the appropriate Monte Carlo transport procedures to sample the new cross-section format. In order to generate pointwise cross sections for a test library, a series of cross-section processing modules were developed and used to process 50 ENDF/B-6 Release 7 nuclides for the test library. Once the cross-section processing procedures were in place, a continuous-energy version of KENO V.a was developed and tested by calculating 21 critical benchmark experiments. The point KENO-calculated results for the 21 benchmarks are in agreement with calculated results obtained with the multigroup version of KENO V.a using the 238-group ENDF/B-5 and 199-group ENDF/B-6 Release 3 libraries. Based on the calculated results with the prototypic cross-section library, a continuous-energy version of the KENO V.a code has been successfully developed and demonstrated for modeling systems with fissionable material. (author)

Risk communication activities toward nuclear safety in Tokai: your safety is our safety

International Nuclear Information System (INIS)

Tsuchiya, T.

2007-01-01

As several decades have passed since the construction of nuclear power plants began, residents have become gradually less interested in nuclear safety. The Tokai criticality accident in 1909, however, had roused residents in Tokai-Mura to realize that they live with nuclear technology risks. To prepare a field of risk communication, the Tokai-Mura C 3 project began as a pilot research project supported by NISA. Alter the project ended, we are continuing risk. communication activities as a non-profit organisation. The most important activity of C 3 project is the citizen's inspection programme for nuclear related facilities. This programme was decided by participants who voluntarily applied to the project. The concept of the citizen's inspection programme is 'not the usual facility tours'. Participants are involved from the planning stage and continue to communicate with workers of the inspected nuclear facility. Since 2003, we have conducted six programmes for five nuclear related organisations. Participants evaluated that radiation protection measures were near good but there were some problems concerning the worker's safety and safety culture, and proposed a mixture of advice based on personal experience. Some advice was accepted and it did improve the facility's safety measures. Other suggestions were not agreed upon by nuclear organisations. The reason lies in the difference of concept between the nuclear expert's 'safety' and the citizen's 'safety'. Residents do not worry about radiation only, but also about the facility's safety as a whole including the worker's safety. They say, 'If the workers are not safe, you also are unable to protect us'. Although the disagreement remained, the participants and the nuclear industry learned much about each other. Participating citizens received a substantial amount of knowledge about the nuclear industry and its safety measures, and feel the credibility and openness of the nuclear industry. On the other hand, the nuclear

Improving nuclear safety at international research reactors: The Integrated Research Reactor Safety Enhancement Program (IRRSEP)

International Nuclear Information System (INIS)

Huizenga, David; Newton, Douglas; Connery, Joyce

2002-01-01

Nuclear energy continues to play a major role in the world's energy economy. Research and test reactors are an important component of a nation's nuclear power infrastructure as they provide training, experiments and operating experience vital to developing and sustaining the industry. Indeed, nations with aspirations for nuclear power development usually begin their programs with a research reactor program. Research reactors also are vital to international science and technology development. It is important to keep them safe from both accident and sabotage, not only because of our obligation to prevent human and environmental consequence but also to prevent corresponding damage to science and industry. For example, an incident at a research reactor could cause a political and public backlash that would do irreparable harm to national nuclear programs. Following the accidents at Three Mile Island and Chernobyl, considerable efforts and resources were committed to improving the safety posture of the world's nuclear power plants. Unsafe operation of research reactors will have an amplifying effect throughout a country or region's entire nuclear programs due to political, economic and nuclear infrastructure consequences. (author)

Continuous Improvement in State Funded Preschool Programs

Science.gov (United States)

Jackson, Sarah L.

2012-01-01

State funded preschool programs were constantly faced with the need to change in order to address internal and external demands. As programs engaged in efforts towards change, minimal research was available on how to support continuous improvement efforts within the context unique to state funded preschool programs. Guidance available had…

Food safety and total quality management

NARCIS (Netherlands)

Barendsz, A.W.

1998-01-01

Food safety is a growing global concern not only because of its continuing importance for public health but also because of its impact on international trade. The application of total quality management (TQM) provides the best possible care by continuously improving products and services to meet or

Nuclear Safety Review 2013

Energy Technology Data Exchange (ETDEWEB)

NONE

2013-07-15

The Nuclear Safety Review 2013 focuses on the dominant nuclear safety trends, issues and challenges in 2012. The Executive Overview provides crosscutting and worldwide nuclear safety information along with a summary of the major sections covered in this report. Sections A-E of this report cover improving radiation, transport and waste safety; strengthening safety in nuclear installations; improving regulatory infrastructure and effectiveness; enhancing emergency preparedness and response (EPR); and civil liability for nuclear damage. The Appendix provides details on the activities of the Commission on Safety Standards (CSS), and activities relevant to the IAEA Safety Standards. The world nuclear community has made noteworthy progress in strengthening nuclear safety in 2012, as promoted by the IAEA Action Plan on Nuclear Safety (hereinafter referred to as ''the Action Plan''). For example, an overwhelming majority of Member States with operating nuclear power plants (NPPs) have undertaken and essentially completed comprehensive safety reassessments ('stress tests') with the aim of evaluating the design and safety aspects of plant robustness to protect against extreme events, including: defence in depth, safety margins, cliff edge effects, multiple failures, and the prolonged loss of support systems. As a result, many have introduced additional safety measures including mitigation of station blackout. Moreover, the IAEA's peer review services and safety standards have been reviewed and strengthened where needed. Capacity building programmes have been built or improved, and EPR programmes have also been reviewed and improved. Furthermore, in 2012, the IAEA continued to share lessons learned from the Fukushima Daiichi accident with the nuclear community including through three international experts' meetings (IEMs) on reactor and spent fuel safety, communication in the event of a nuclear or radiological emergency, and protection against extreme earthquakes and tsunamis.

Nuclear Safety Review 2013

International Nuclear Information System (INIS)

2013-07-01

The Nuclear Safety Review 2013 focuses on the dominant nuclear safety trends, issues and challenges in 2012. The Executive Overview provides crosscutting and worldwide nuclear safety information along with a summary of the major sections covered in this report. Sections A-E of this report cover improving radiation, transport and waste safety; strengthening safety in nuclear installations; improving regulatory infrastructure and effectiveness; enhancing emergency preparedness and response (EPR); and civil liability for nuclear damage. The Appendix provides details on the activities of the Commission on Safety Standards (CSS), and activities relevant to the IAEA Safety Standards. The world nuclear community has made noteworthy progress in strengthening nuclear safety in 2012, as promoted by the IAEA Action Plan on Nuclear Safety (hereinafter referred to as ''the Action Plan''). For example, an overwhelming majority of Member States with operating nuclear power plants (NPPs) have undertaken and essentially completed comprehensive safety reassessments ('stress tests') with the aim of evaluating the design and safety aspects of plant robustness to protect against extreme events, including: defence in depth, safety margins, cliff edge effects, multiple failures, and the prolonged loss of support systems. As a result, many have introduced additional safety measures including mitigation of station blackout. Moreover, the IAEA's peer review services and safety standards have been reviewed and strengthened where needed. Capacity building programmes have been built or improved, and EPR programmes have also been reviewed and improved. Furthermore, in 2012, the IAEA continued to share lessons learned from the Fukushima Daiichi accident with the nuclear community including through three international experts' meetings (IEMs) on reactor and spent fuel safety, communication in the event of a nuclear or radiological emergency, and protection against extreme earthquakes and tsunamis

Quick and continuous improvement through kaizen blitz.

Science.gov (United States)

McNichols, T; Hassinger, R; Bapst, G W

1999-05-01

It is our objective to provide you with a step-by-step approach to conducting a kaizen blitz within two days and describe how to achieve dramatic performance improvement with employee buy-in through this process. Kaizen blitz has been used dozens of times by the authors, and in some instances the same area has been blitzed as many as four times, with significant improvements each and every time. Employees have even taken it on themselves to conduct informal blitzes as a continuing improvement effort after a formal blitz has been conducted in their area. Blitzes can succeed in a variety of environments. The morning after the employees of one company attended this presentation, they self initiated a mini-blitz and discovered opportunities for improvement that they enthusiastically presented to management.

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

Science.gov (United States)

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

2017-10-01

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

Five Topics Health Care Simulation Can Address to Improve Patient Safety

DEFF Research Database (Denmark)

Sollid, Stephen J M; Dieckman, Peter; Aase, Karina

2017-01-01

OBJECTIVES: There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore...... initiated to define priorities in health care simulation that contribute the most to improve patient safety.  METHODS: An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2......-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies...

Continuous Improvement in Nursing Education through Total Quality Management (TQM

Directory of Open Access Journals (Sweden)

Tang Wai Mun

2013-11-01

Full Text Available Total Quality Management (TQM has generally been validated as a crucial revolution in the management field. Many academicians believe that the concept of TQM is applicable to academics and provides guiding principles towards improving education. Therefore, an increasing number of educational institutions such as schools, colleges and universities have started to embrace TQM philosophies to their curricula.Within the context of TQM, this paper would explore the concept of continuous improvement by using the Deming philosophy. Subsequently, this paper would elaborate on the application of TQM to bring about continuous improvement in the current education system.

Reactor safety systems

International Nuclear Information System (INIS)

Kafka, P.

1975-01-01

The spectrum of possible accidents may become characterized by the 'maximum credible accident', which will/will not happen. Similary, the performance of safety systems in a multitude of situations is sometimes simplified to 'the emergency system will/will not work' or even 'reactors are/ are not safe'. In assessing safety, one must avoid this fallacy of reducing a complicated situation to the simple black-and-white picture of yes/no. Similarly, there is a natural tendency continually to improve the safety of a system to assure that it is 'safe enough'. Any system can be made safer and there is usually some additional cost. It is important to balance the increased safety against the increased costs. (orig.) [de

Line-robust statistics for continuous gravitational waves: safety in the case of unequal detector sensitivities

International Nuclear Information System (INIS)

Keitel, David; Prix, Reinhard

2015-01-01

The multi-detector F-statistic is close to optimal for detecting continuous gravitational waves (CWs) in Gaussian noise. However, it is susceptible to false alarms from instrumental artefacts, for example quasi-monochromatic disturbances (‘lines’), which resemble a CW signal more than Gaussian noise. In a recent paper (Keitel et al 2014 Phys. Rev. D 89 064023), a Bayesian model selection approach was used to derive line-robust detection statistics for CW signals, generalizing both the F-statistic and the F-statistic consistency veto technique and yielding improved performance in line-affected data. Here we investigate a generalization of the assumptions made in that paper: if a CW analysis uses data from two or more detectors with very different sensitivities, the line-robust statistics could be less effective. We investigate the boundaries within which they are still safe to use, in comparison with the F-statistic. Tests using synthetic draws show that the optimally-tuned version of the original line-robust statistic remains safe in most cases of practical interest. We also explore a simple idea on further improving the detection power and safety of these statistics, which we, however, find to be of limited practical use. (paper)

Optimization of safety equipment outages improves safety

International Nuclear Information System (INIS)

Cepin, Marko

2002-01-01

Testing and maintenance activities of safety equipment in nuclear power plants are an important potential for risk and cost reduction. An optimization method is presented based on the simulated annealing algorithm. The method determines the optimal schedule of safety equipment outages due to testing and maintenance based on minimization of selected risk measure. The mean value of the selected time dependent risk measure represents the objective function of the optimization. The time dependent function of the selected risk measure is obtained from probabilistic safety assessment, i.e. the fault tree analysis at the system level and the fault tree/event tree analysis at the plant level, both extended with inclusion of time requirements. Results of several examples showed that it is possible to reduce risk by application of the proposed method. Because of large uncertainties in the probabilistic safety assessment, the most important result of the method may not be a selection of the most suitable schedule of safety equipment outages among those, which results in similarly low risk. But, it may be a prevention of such schedules of safety equipment outages, which result in high risk. Such finding increases the importance of evaluation speed versus the requirement of getting always the global optimum no matter if it is only slightly better that certain local one

Discussion on establishment and improvement of the nuclear safety culture system

International Nuclear Information System (INIS)

Lu Weiqiang; Na Fuli

2010-01-01

By discussion of the problems in the manufacture process of nuclear power equipment enterprisers, puts forwards the tentative idea of establishment the nuclear safety culture system, meanwhile, gives some suggestions in order to improving the nuclear safety culture system. (authors)

Organizational factors influencing improvements in safety

International Nuclear Information System (INIS)

Marcus, A.; Nichols, M.L.; Olson, J.; Osborn, R.; Thurber, J.

1991-01-01

Results of conceptual and empirical research conducted by this research team, and published in NUREG-CR 5437, suggested that processes of organizational problem solving and learning provide a promising area for understanding improvement in safety-related performance in nuclear power plants. In this paper the authors describe the way in which they have built upon that work and gone much further in empirically examining a range of potentially important organizational factors related to safety. The paper describes (1) overall trends in plant performance over time on the Nuclear Regulatory Commission performance indicators, (2) the major elements in the conceptual framework guiding the current work, which seeks among other things to explain those trends, (3) the specific variables used as measures of the central concepts, (4) the results to date of the quantitative empirical work and qualitative work in progress, and (5) conclusions from the research

Processing and storage of blood components: strategies to improve patient safety

Directory of Open Access Journals (Sweden)

Pietersz RNI

2015-08-01

Full Text Available Ruby NI Pietersz, Pieter F van der Meer Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands Abstract: This review focuses on safety improvements of blood processing of various blood components and their respective storage. A solid quality system to ensure safe and effective blood components that are traceable from a donor to the patient is the foundation of a safe blood supply. To stimulate and guide this process, National Health Authorities should develop guidelines for blood transfusion, including establishment of a quality system. Blood component therapy enabled treatment of patients with blood constituents that were missing, only thus preventing reactions to unnecessarily transfused elements. Leukoreduction prevents many adverse reactions and also improves the quality of the blood components during storage. The safety of red cells and platelets is improved by replacement of plasma with preservative solutions, which results in the reduction of isoantibodies and plasma proteins. Automation of blood collection, separation of whole blood into components, and consecutive processing steps, such as preparation of platelet concentrate from multiple donations, improves the consistent composition of blood components. Physicians can better prescribe the number of transfusions and therewith reduce donor exposure and/or the risk of pathogen transmission. Pathogen reduction in cellular blood components is the latest development in improving the safety of blood transfusions for patients. Keywords: blood components, red cell concentrates, platelet concentrates, plasma, transfusion, safety 

Continuous quality improvement program for hip and knee replacement.

Science.gov (United States)

Marshall, Deborah A; Christiansen, Tanya; Smith, Christopher; Squire Howden, Jane; Werle, Jason; Faris, Peter; Frank, Cy

2015-01-01

Improving quality of care and maximizing efficiency are priorities in hip and knee replacement, where surgical demand and costs increase as the population ages. The authors describe the integrated structure and processes from the Continuous Quality Improvement (CQI) Program for Hip and Knee Replacement Surgical Care and summarize lessons learned from implementation. The Triple Aim framework and 6 dimensions of quality care are overarching constructs of the CQI program. A validated, evidence-based clinical pathway that measures quality across the continuum of care was adopted. Working collaboratively, multidisciplinary experts embedded the CQI program into everyday practices in clinics across Alberta. Currently, 83% of surgeons participate in the CQI program, representing 95% of the total volume of hip and knee surgeries. Biannual reports provide feedback to improve care processes, infrastructure planning, and patient outcomes. CQI programs evaluating health care services inform choices to optimize care and improve efficiencies through continuous knowledge translation. © The Author(s) 2014.

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.

Science.gov (United States)

Tscholl, David W; Weiss, Mona; Kolbe, Michaela; Staender, Sven; Seifert, Burkhardt; Landert, Daniel; Grande, Bastian; Spahn, Donat R; Noethiger, Christoph B

2015-10-01

An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked). A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork. One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P safety: 91% vs 84% (P improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.

Safety culture development in nuclear electric plc

International Nuclear Information System (INIS)

Gibson, G.P.; Low, M.B.J.

1995-01-01

Nuclear Electric plc (NE) has always given the highest priority to safety. However, past emphasis has been directed towards ensuring safety thorough engineering design and hazard control procedures. Whilst the company did achieve high safety standards, particularly with respect to accidents, it was recognized that further improvements could be obtained. Analysis of the safety performance across a wide range of industries showed that the key to improving safety performance lay in developing a strong safety culture within the company. Over the last five years, NE has made great strides to improve its safety culture. This has resulted in a considerable improvement in its measured safety performance indicators, such as the number of incidents at international nuclear event scale (INES) rating 1, the number of lost time accidents and the collective radiation dose. However, despite this success, the company is committed to further improvement and a means by which this process becomes self-sustaining. In this way the company will achieve its prime goal, to ''ensure the safety of people, plant and the environment''. The paper provides an overview of the development of safety culture in NE since its formation in November 1989. It describes the research and international developments that have influenced the company's understanding of safety culture, the key initiatives that the company has undertaken to enhance its safety culture and the future initiatives being considered to ensure continual improvement. (author). 5 refs, 2 figs, 2 tabs

Improvement of Safety Assessment Methodologies for Near Surface Disposal Facilities

International Nuclear Information System (INIS)

Batandjieva, B.; Torres-Vidal, C.

2002-01-01

The International Atomic Energy Agency (IAEA) Coordinated research program ''Improvement of Safety Assessment Methodologies for Near Surface Disposal Facilities'' (ISAM) has developed improved safety assessment methodology for near surface disposal facilities. The program has been underway for three years and has included around 75 active participants from 40 countries. It has also provided examples for application to three safety cases--vault, Radon type and borehole radioactive waste disposal facilities. The program has served as an excellent forum for exchange of information and good practices on safety assessment approaches and methodologies used worldwide. It also provided an opportunity for reaching broad consensus on the safety assessment methodologies to be applied to near surface low and intermediate level waste repositories. The methodology has found widespread acceptance and the need for its application on real waste disposal facilities has been clearly identified. The ISAM was finalized by the end of 2000, working material documents are available and an IAEA report will be published in 2002 summarizing the work performed during the three years of the program. The outcome of the ISAM program provides a sound basis for moving forward to a new IAEA program, which will focus on practical application of the safety assessment methodologies to different purposes, such as licensing radioactive waste repositories, development of design concepts, upgrading existing facilities, reassessment of operating repositories, etc. The new program will also provide an opportunity for development of guidance on application of the methodology that will be of assistance to both safety assessors and regulators

Learning from error: leading a culture of safety.

Science.gov (United States)

Gibson, Russell; Armstrong, Alexander; Till, Alex; McKimm, Judy

2017-07-02

A recent shift towards more collective leadership in the NHS can help to achieve a culture of safety, particularly through encouraging frontline staff to participate and take responsibility for improving safety through learning from error and near misses. Leaders must ensure that they provide psychological safety, organizational fairness and learning systems for staff to feel confident in raising concerns, that they have the autonomy and skills to lead continual improvement, and that they have responsibility for spreading this learning within and across organizations.

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

Science.gov (United States)

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

2016-11-01

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

Improving Patient Safety in Anesthesia: A Success Story?

International Nuclear Information System (INIS)

Botney, Richard

2008-01-01

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

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

Visual Acuity Improvement in Continuous vs Divided Occlusion in Anisometropic Amblyopia.

Science.gov (United States)

Irfani, Irawati; Feriyanto, Feri; Oktarima, Primawita; Kartasasmita, Arief

2018-01-01

To compare visual acuity improvement between continuous and split part-time occlusion for the treatment of moderate and severe anisometropic amblyopia. Randomised clinical trials in 6 - 13 y.o children with moderate and severe anisometropic amblyopia. Each patient was consecutively selected with continuous or split part-time occlusion. Best corrected visual acuity's improvement was followed up to six weeks and statistical data were analyzed using chi square and unpaired t-test. Best corrected visual acuity's improvement was comparable between continuous and split part-time occlusion (0.20±0.27 vs 0.21±0.25; p = 0.79). Split part-time occlusion may be considered as an alternative treatment for moderate and severe anisometropic amblyopia treatment.

Continuous improvement in manufacturing and inspection of fuel

International Nuclear Information System (INIS)

Domingon, A.; Ruiz, R.

2015-01-01

The manufacturing and inspection process of fuel assemblies in ENUSA is characterized by its robustness acquired over the last thirty years of experience in manufacturing. The reliability of these processes is based on a qualified processes and continuous improvement in the design and upgrading of equipment and optimization of software and manufacturing processes. Additionally, management and quality control systems have been improved in both software and measuring business objectives. this article emphasizes the improvements made over the past five years in management, production and inspection of fuel assemblies. (Author)

Multi-approach model for improving agrochemical safety among rice farmers in Pathumthani, Thailand

Directory of Open Access Journals (Sweden)

Siriwong W

2012-07-01

Full Text Available Buppha Raksanam,1,2 Surasak Taneepanichskul,2 Wattasit Siriwong,2 Mark Robson3,41Sirindhorn College of Public Health, Trang, 2College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand; 3School of Environmental and Biological Sciences, Rutgers University, 4School of Public Health, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ, USAAbstract: The large-scale use of agrochemicals has raised environmental and human health concerns. A comprehensive intervention strategy for improving agrochemical safety among rice farmers in Thailand is lacking. The objective of this study is to develop a model in order to improve farmers’ health and prevent them from being exposed to agrochemical hazards, in addition to evaluating the effectiveness of the intervention in terms of agrochemical safety. This study was conducted between October 2009 and January 2011. It measures changes in the mean scores of agrochemical knowledge, health beliefs, agrochemical use behaviors, and in-home pesticide safety. Knowledge of agrochemical use constitutes a basic knowledge of agrochemicals and agrochemical safety behaviors. Health beliefs constitute perceived susceptibility, severity, benefits, and barriers to using agrochemicals. Agrochemical use behaviors include self-care practices in terms of personal health at specific times including before spraying, while spraying, during storage, transportation, waste management, and health risk management. Fifty rice farmers from Khlong Seven Community (study group and 51 rice farmers from Bueng Ka Sam community (control group were randomly recruited with support from community leaders. The participants were involved in a combination of home visits (ie, pesticide safety assessments at home and community participatory activities regarding agrochemical safety. This study reveals that health risk behaviors regarding agrochemical exposure in the study area are mainly caused by lack of attention to

Improving Patient Safety With the Military Electronic Health Record

National Research Council Canada - National Science Library

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

2005-01-01

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

Nuclear Safety Charter; Charte Surete Nucleaire

Energy Technology Data Exchange (ETDEWEB)

NONE

2008-07-01

The AREVA 'Values Charter' reaffirmed the priority that must be given to the requirement for a very high level of safety, which applies in particular to the nuclear field. The purpose of this Nuclear Safety Charter is to set forth the group's commitments in the field of nuclear safety and radiation protection so as to ensure that this requirement is met throughout the life cycle of the facilities. It should enable each of us, in carrying out our duties, to commit to this requirement personally, for the company, and for all stakeholders. These commitments are anchored in organizational and action principles and in complete transparency. They build on a safety culture shared by all personnel and maintained by periodic refresher training. They are implemented through Safety, Health, and Environmental management systems. The purpose of these commitments, beyond strict compliance with the laws and regulations in force in countries in which we operate as a group, is to foster a continuous improvement initiative aimed at continually enhancing our overall performance as a group. Content: 1 - Organization: responsibility of the group's executive management and subsidiaries, prime responsibility of the operator, a system of clearly defined responsibilities that draws on skilled support and on independent control of operating personnel, the general inspectorate: a shared expertise and an independent control of the operating organization, an organization that can be adapted for emergency management. 2 - Action principles: nuclear safety applies to every stage in the plant life cycle, lessons learned are analyzed and capitalized through the continuous improvement initiative, analyzing risks in advance is the basis of Areva's safety culture, employees are empowered to improve nuclear Safety, the group is committed to a voluntary radiation protection initiative And a sustained effort in reducing waste and effluent from facility Operations, employees and

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

Science.gov (United States)

Groves, Patricia S; Bunch, Jacinda L

2018-05-18

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

Closing the Loop on a Continuous Program Improvement Process

Science.gov (United States)

Booth, Vickie; Booth, Larry

2010-01-01

The WebBSIT, a Bachelor of Science in Information Technology, is a fully online degree offered through a consortium of five University System of Georgia institutions. This paper begins by summarizing the change management system developed for continuous program improvement. Analysis of data should drive improvement, closing the loop. The balance…

Creating a Cycle of Continuous Improvement through Instructional Rounds

Science.gov (United States)

Meyer-Looze, Catherine L.

2015-01-01

Instructional Rounds is a continuous improvement strategy that focuses on the technical core of educational systems as well as educators collaborating side-by-side. Concentrating on collective learning, this process only makes sense within an overall strategy of improvement. This case study examined the Instructional Rounds process in a northern…

Patient safety culture among nurses.

Science.gov (United States)

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

2015-03-01

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

Safety Culture Activities of HANARO in 2007

Energy Technology Data Exchange (ETDEWEB)

Wu, Jong Sup [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2008-05-15

One of the important aims of a management system for nuclear facilities is to foster a strong safety culture. The safety culture activities in HANARO have been continuously conducted to enhance its safe operation. The following activities and events on a safety culture were performed last year; - Seminars and lectures on safety for the 'Nuclear Safety Check Day' every month - Development of safety culture indicators - Development of operational SPIs (Safety Performance Indicators) - Preparation of an e-Learning program for safety education. In this paper, the safety culture activities in HANARO of KAERI are described, and the efforts necessary for a safety improvement are presented.

Improving critical thinking and clinical reasoning with a continuing education course.

Science.gov (United States)

Cruz, Dina Monteiro; Pimenta, Cibele Mattos; Lunney, Margaret

2009-03-01

Continuing education courses related to critical thinking and clinical reasoning are needed to improve the accuracy of diagnosis. This study evaluated a 4-day, 16-hour continuing education course conducted in Brazil.Thirty-nine nurses completed a pretest and a posttest consisting of two written case studies designed to measure the accuracy of nurses' diagnoses. There were significant differences in accuracy from pretest to posttest for case 1 (p = .008) and case 2 (p = .042) and overall (p = .001). Continuing education courses should be implemented to improve the accuracy of nurses' diagnoses.

Opportunities for Using Building Information Modeling to Improve Worker Safety Performance

Directory of Open Access Journals (Sweden)

Kasim Alomari

2017-02-01

Full Text Available Building information modelling (BIM enables the creation of a digital representation of a designed facility combined with additional information about the project attributes, performance criteria, and construction process. Users of BIM tools point to the ability to visualize the final design along with the construction process as a beneficial feature of using BIM. Knowing the construction process in relationship to a facility’s design benefits both safety professionals when planning worker safety measures for a project and designers when creating a project’s design. Success in using BIM to enhance safety partly depends on the familiarity of project personnel with BIM tools and the extent to which the tools can be used to identify and eliminate safety hazards. In a separate, ongoing study, the authors investigated the connection between BIM and safety to document the opportunities, barriers, and impacts. Utilizing an on-line survey of project engineers who work for construction firms together with a comprehensive literature review, the study found those who use BIM feel that it aids in communication of project information and project delivery, both of which have been found to have positive impacts on construction site safety. Further, utilizing the survey results, the authors apply the binary logistic regression econometric framework to better understand the factors that lead to safety professionals believing that BIM increases safety in the work place. In addition, according to the survey results, a large percentage of the engineers who use BIM feel that ultimately it helps to eliminate safety hazards and improve worker safety. The study findings suggest that improvements in safety performance across the construction industry may be due in part to increased use of BIM in the construction industry.

NPP Krsko core calculations to improve operational safety

International Nuclear Information System (INIS)

Ivekovic, I.; Grgic, D.; Nemec, T.

2007-01-01

Calculation tools and methodology used to perform independent calculations of cumulative influence of different changes related to fuel and core operation of NPP Krsko were described. Some examples of steady state and transient results are used to illustrate potential improvements to understanding and reviewing plant safety. (author)

Thermal-hydraulics technological strategy roadmap for LWR safety improvement and development

International Nuclear Information System (INIS)

Nakamura, Hideo; Arai, Kenji; Oikawa, Hirohide

2015-01-01

New version of the Thermal-Hydraulics Safety Evaluation Fundamental Technology Enhancement Strategy Roadmap (TH-RM) was developed by the Atomic Energy Society of Japan (AESJ) for LWR safety improvement and development. The 1st version of TH-RM was prepared in 2009 under collaboration of utilities, vendors, universities, research institutes and technical support organizations (TSO) for regulatory body. The revision was made by three sub-working groups (SWGs) by considering the lessons learned from the Fukushima Daiichi Accident. The 'safety assessment' SWG pursued development of computer codes for safety assessment. The 'fundamental technology' SWG pursued safety improvement and risk reduction via accident management (AM) measures by referring the technical map for severe accident (SA) established by the 'severe accident' SWG. Phenomena and components for counter-measures and/or proper prediction are identified by going through SA progression in both reactor and spent-fuel pool of PWR and BWR. Twelve important technology development subjects were identified, which include melt coolability enhancement to maintain integrity of containment vessel. Fact Sheet was developed to describe each of identified and selected R and D subjects. External hazards are also considered how to cope with from thermal-hydraulic safety point of view. This paper summarizes the revised TH-RM with several examples and future perspectives. (author)

Constructing a Bayesian network model for improving safety behavior of employees at workplaces.

Science.gov (United States)

Mohammadfam, Iraj; Ghasemi, Fakhradin; Kalatpour, Omid; Moghimbeigi, Abbas

2017-01-01

Unsafe behavior increases the risk of accident at workplaces and needs to be managed properly. The aim of the present study was to provide a model for managing and improving safety behavior of employees using the Bayesian networks approach. The study was conducted in several power plant construction projects in Iran. The data were collected using a questionnaire composed of nine factors, including management commitment, supporting environment, safety management system, employees' participation, safety knowledge, safety attitude, motivation, resource allocation, and work pressure. In order for measuring the score of each factor assigned by a responder, a measurement model was constructed for each of them. The Bayesian network was constructed using experts' opinions and Dempster-Shafer theory. Using belief updating, the best intervention strategies for improving safety behavior also were selected. The result of the present study demonstrated that the majority of employees do not tend to consider safety rules, regulation, procedures and norms in their behavior at the workplace. Safety attitude, safety knowledge, and supporting environment were the best predictor of safety behavior. Moreover, it was determined that instantaneous improvement of supporting environment and employee participation is the best strategy to reach a high proportion of safety behavior at the workplace. The lack of a comprehensive model that can be used for explaining safety behavior was one of the most problematic issues of the study. Furthermore, it can be concluded that belief updating is a unique feature of Bayesian networks that is very useful in comparing various intervention strategies and selecting the best one form them. Copyright © 2016 Elsevier Ltd. All rights reserved.

Safety reassessment and life extension

International Nuclear Information System (INIS)

Gouffon, A.

1992-12-01

The safety reassessment policy implemented in France is a means of ensuring that no important point has been overlooked in the continuous safety reassessment process constituted by the integration of operating feedback. It also provides an opportunity for reappraisal of the basic design of a plant and examination of discrepancies between the safety options prevailing when it was built and those currently adopted. After a ten-year operating period, safety reassessment should enable identification of aging effects on structures and equipment, leading to improvement of component servicing and surveillance programs and provision for replacements which could be necessary

Strategy for continuous improvement in IC manufacturability, yield, and reliability

Science.gov (United States)

Dreier, Dean J.; Berry, Mark; Schani, Phil; Phillips, Michael; Steinberg, Joe; DePinto, Gary

1993-01-01

Continual improvements in yield, reliability and manufacturability measure a fab and ultimately result in Total Customer Satisfaction. A new organizational and technical methodology for continuous defect reduction has been established in a formal feedback loop, which relies on yield and reliability, failed bit map analysis, analytical tools, inline monitoring, cross functional teams and a defect engineering group. The strategy requires the fastest detection, identification and implementation of possible corrective actions. Feedback cycle time is minimized at all points to improve yield and reliability and reduce costs, essential for competitiveness in the memory business. Payoff was a 9.4X reduction in defectivity and a 6.2X improvement in reliability of 256 K fast SRAMs over 20 months.

Safety and safety analysis. From CP1 to Fukushima

International Nuclear Information System (INIS)

Yadigaroglu, George

2012-01-01

The safety of nuclear installations has been a serious concern starting from the days of infancy of this technology. When Fermi and co-workers built the first nuclear reactor in 1941, the Chicago Pile-1 or CP1 at the University of Chicago, some basic safety principles still in use today were already part of this very simple experiment. During the fast-growth period in the 1960ies, a number of NPP systems were conceived, tested and some of them built, mainly in the US and in the Soviet Union, but also in the UK, in France and in Canada, before just a handful of nuclear systems dominated: the LWRs conquered some 3 quarters of the world market and their dominance continues till today. The fission process has been amazingly well ''designed'' by nature: a remarkably simple to produce, self-sustained reaction that can be easily controlled, modulated and adjusted by a variety of available materials. Fission leads to large release of energy that can be easily collected and transformed into useful work. The process has only a major drawback, the inexorable production and accumulation in the core of the radioactive fission products that also produce decay heat. Criticality considerations put apart, the major goal of reactor safety is the confinement and cooling of these fission products. Although safety has been a major concern from the very first nuclear developments, feedback and actions following incidents and accidents have contributed to continuous enhancements. In particular, the three major nuclear accidents, TMI, Chernobyl and Fukushima had or will hopefully have in the future major impacts on safety improvements. Lessons learned from TMI have greatly enhanced the safety of LWRs, while Chernobyl triggered a number of radio-ecology studies and improved the readiness for radiological crisis management. It is hoped that Fukushima will be the trigger for much stronger international oversight and harmonization of safety practices, something that has already been launched

Safety and safety analysis. From CP1 to Fukushima

Energy Technology Data Exchange (ETDEWEB)

Yadigaroglu, George [ASCOMP GmbH, Zurich (Switzerland)

2012-02-15

The safety of nuclear installations has been a serious concern starting from the days of infancy of this technology. When Fermi and co-workers built the first nuclear reactor in 1941, the Chicago Pile-1 or CP1 at the University of Chicago, some basic safety principles still in use today were already part of this very simple experiment. During the fast-growth period in the 1960ies, a number of NPP systems were conceived, tested and some of them built, mainly in the US and in the Soviet Union, but also in the UK, in France and in Canada, before just a handful of nuclear systems dominated: the LWRs conquered some 3 quarters of the world market and their dominance continues till today. The fission process has been amazingly well ''designed'' by nature: a remarkably simple to produce, self-sustained reaction that can be easily controlled, modulated and adjusted by a variety of available materials. Fission leads to large release of energy that can be easily collected and transformed into useful work. The process has only a major drawback, the inexorable production and accumulation in the core of the radioactive fission products that also produce decay heat. Criticality considerations put apart, the major goal of reactor safety is the confinement and cooling of these fission products. Although safety has been a major concern from the very first nuclear developments, feedback and actions following incidents and accidents have contributed to continuous enhancements. In particular, the three major nuclear accidents, TMI, Chernobyl and Fukushima had or will hopefully have in the future major impacts on safety improvements. Lessons learned from TMI have greatly enhanced the safety of LWRs, while Chernobyl triggered a number of radio-ecology studies and improved the readiness for radiological crisis management. It is hoped that Fukushima will be the trigger for much stronger international oversight and harmonization of safety practices, something that has

Improvement of safety by analysis of costs and benefits of the system

OpenAIRE

T. Karkoszka; M. Andraczke

2011-01-01

Purpose: of the paper has been the assessment of the dependence between improvement of the implemented occupational health and safety management system and both minimization of costs connected with occupational health and safety assurance and optimization of real work conditions.Design/methodology/approach: used for the analysis has included definition of the occupational health and safety system with regard to the rules and tool allowing for occupational safety assurance in the organisationa...

Applying PPM to ERP Maintenance and Continuous Improvement Initiatives

DEFF Research Database (Denmark)

El-Tal, Nada Maria; Fonnesbæk, Majbrit; Kræmmergaard, Pernille

2006-01-01

to gain business benefits from the systems. However the ERP literature on how to do this is limited. The purpose of this article is to explore how Project Portfolio Management (PPM) from the Research and Development (R&D) literature can be applied to an ERP second wave context, when companies...... are to prioritize and select maintenance and continuous improvement initiatives. This is done by reviewing the existing literature in the fields of PPM from R&D literature and then by reviewing the existing literature about maintenance and improvement initiatives in the ERP literature, after which the two...... are compared and discussed using three case-studies. The paper contributes with a discussion on how PPM from R&D can be applied to maintenance and continuous improvement initiatives in the second wave of ERP. The paper ends with arguing that emphasis needs to be given to this field, since a conscious...

Continuous improvement of the BNFL transport integrated management system

International Nuclear Information System (INIS)

Hale, J.A.

1998-01-01

The integrated Management System of BNFL Transport and Pacific Nuclear Transport Limited (PNTL) is subject to continuous improvement by the application of established improvement techniques adopted by BNFL. The technique currently being used is the application of a Total Quality Management (TQM) philosophy, involving the identification of key processes, benchmarking against existing measures, initiating various improvement projects and applying process changes within the Company. The measurement technique being used is based upon the European Foundation for Quality Management Model (EFQM). A major initiative was started in 1996 to include the requirements of the Environmental Management Systems standard ISO 14001 within the existing integrated management system. This resulted in additional activities added to the system, modification to some existing activities and additional training for personnel. The system was audited by a third party certification organisation, Lloyds Register Quality Assurance (LRQA), during 1997. This paper describes the arrangements to review and update the integrated management system of BNFL Transport and PNTL to include the requirements of the environmental standard ISO 14001 and it also discusses the continuous improvement process adopted by BNFL Transport. (authors)

Improving the safety of fresh fruit and vegetables

NARCIS (Netherlands)

Jongen, W.M.F.

2005-01-01

Fresh fruit and vegetables have been identified as a significant source of pathogens and chemical contaminants. As a result, there has been a wealth of research on identifying and controlling hazards at all stages in the supply chain. Improving the safety of fresh fruit and vegetables reviews this

Improving the safety of Ukrainian NPP to reach an internationally accepted level

International Nuclear Information System (INIS)

Bozhko, S.; Helske, J.; Janke, R.; Mayoral, C.

2013-01-01

This paper summarizes the safety status and the modernization progress of Ukrainian NPPs towards an internationally accepted level of safety. After a brief discussion of the concept of what is called an 'international accepted level' for new and operating NPPs, the status of Russian type WWER and in particular the Ukrainian NPPs is presented. Then, the performed investigations of the gaps between international accepted level and the original status of Ukrainian NPPs are presented. The safety objectives of the modernization programs, some examples of defence in depth improvements, and an overall view of the modernization programs of Ukrainian NPPs are produced. Then, few important safety improvements implemented at the oldest Ukrainian WWER-1000 South Ukraine-1 are given in more detail. Finally, a conclusion presents the current status on the way to fulfill the national safety targets and to reach an internationally accepted level for all the Ukrainian NPPs. The paper is followed by the slides of the presentation. (authors)

Patient Safety Culture and the Ability to Improve: A Proof of Concept Study on Hand Hygiene.

Science.gov (United States)

Caris, Martine G; Kamphuis, Pim G A; Dekker, Mireille; de Bruijne, Martine C; van Agtmael, Michiel A; Vandenbroucke-Grauls, Christina M J E

2017-11-01

OBJECTIVE To investigate whether the safety culture of a hospital unit is associated with the ability to improve. DESIGN Qualitative investigation of safety culture on hospital units following a before-and-after trial on hand hygiene. SETTING VU University Medical Center, a tertiary-care hospital in the Netherlands. METHODS With support from hospital management, we implemented a hospital-wide program to improve compliance. Over 2 years, compliance was measured through direct observation, twice before, and 4 times after interventions. We analyzed changes in compliance from baseline, and selected units to evaluate safety culture using a positive deviance approach: the hospital unit with the highest hand hygiene compliance and 2 units that showed significant improvement (21% and 16%, respectively) were selected as high performing. Another 2 units showed no improvement and were selected as low performing. A blinded, independent observer conducted interviews with unit management, physicians, and nurses, based on the Hospital Survey on Patient Safety Culture. Safety culture was categorized as pathological (lowest level), reactive, bureaucratic, proactive, or generative (highest level). RESULTS Overall, 3 units showed a proactive or generative safety culture and 2 units had bureaucratic or pathological safety cultures. When comparing compliance and interview results, high-performing units showed high levels of safety culture, while low-performing units showed low levels of safety culture. CONCLUSIONS Safety culture is associated with the ability to improve hand hygiene. Interventions may not be effective when applied in units with low levels of safety culture. Although additional research is needed to corroborate our findings, the safety culture on a unit can benefit from enhancement strategies such as team-building exercises. Strengthening the safety culture before implementing interventions could aid improvement and prevent nonproductive interventions. Infect Control

The soul of the machine: continual improvement in ISO 14001

NARCIS (Netherlands)

Brouwer, M.A.C.; van Koppen, C.S.A.

2008-01-01

Continual improvement is a key component of ISO 14001, but in contrast to most other specifications in the standard, it is difficult to assess. Based on interviews with 19 certified companies in the chemical, food, and environmental services sectors, this article explores the dynamics of continual

The soul of the machine: continual improvement in ISO 14001.

NARCIS (Netherlands)

Brouwer, M.A.C.; Koppen, van C.S.A.

2008-01-01

Continual improvement is a key component of ISO 14001, but in contrast to most other specifications in the standard, it is difficult to assess. Based on interviews with 19 certified companies in the chemical, food, and environmental services sectors, this article explores the dynamics of continual