safety process improvement: Topics by WorldWideScience.org

Sample records for safety process improvement

Process safety improvement-Quality and target zero

Energy Technology Data Exchange (ETDEWEB)

Van Scyoc, Karl [Det Norske Veritas (U.S.A.) Inc., DNV Energy Solutions, 16340 Park Ten Place, Suite 100, Houston, TX 77084 (United States)], E-mail: karl.van.scyoc@dnv.com

2008-11-15

Process safety practitioners have adopted quality management principles in design of process safety management systems with positive effect, yet achieving safety objectives sometimes remain a distant target. Companies regularly apply tools and methods which have roots in quality and productivity improvement. The 'plan, do, check, act' improvement loop, statistical analysis of incidents (non-conformities), and performance trending popularized by Dr. Deming are now commonly used in the context of process safety. Significant advancements in HSE performance are reported after applying methods viewed as fundamental for quality management. In pursuit of continual process safety improvement, the paper examines various quality improvement methods, and explores how methods intended for product quality can be additionally applied to continual improvement of process safety. Methods such as Kaizen, Poke yoke, and TRIZ, while long established for quality improvement, are quite unfamiliar in the process safety arena. These methods are discussed for application in improving both process safety leadership and field work team performance. Practical ways to advance process safety, based on the methods, are given.
Process safety improvement-Quality and target zero

International Nuclear Information System (INIS)

Van Scyoc, Karl

2008-01-01

Process safety practitioners have adopted quality management principles in design of process safety management systems with positive effect, yet achieving safety objectives sometimes remain a distant target. Companies regularly apply tools and methods which have roots in quality and productivity improvement. The 'plan, do, check, act' improvement loop, statistical analysis of incidents (non-conformities), and performance trending popularized by Dr. Deming are now commonly used in the context of process safety. Significant advancements in HSE performance are reported after applying methods viewed as fundamental for quality management. In pursuit of continual process safety improvement, the paper examines various quality improvement methods, and explores how methods intended for product quality can be additionally applied to continual improvement of process safety. Methods such as Kaizen, Poke yoke, and TRIZ, while long established for quality improvement, are quite unfamiliar in the process safety arena. These methods are discussed for application in improving both process safety leadership and field work team performance. Practical ways to advance process safety, based on the methods, are given
Process safety improvement--quality and target zero.

Science.gov (United States)

Van Scyoc, Karl

2008-11-15

Process safety practitioners have adopted quality management principles in design of process safety management systems with positive effect, yet achieving safety objectives sometimes remain a distant target. Companies regularly apply tools and methods which have roots in quality and productivity improvement. The "plan, do, check, act" improvement loop, statistical analysis of incidents (non-conformities), and performance trending popularized by Dr. Deming are now commonly used in the context of process safety. Significant advancements in HSE performance are reported after applying methods viewed as fundamental for quality management. In pursuit of continual process safety improvement, the paper examines various quality improvement methods, and explores how methods intended for product quality can be additionally applied to continual improvement of process safety. Methods such as Kaizen, Poke yoke, and TRIZ, while long established for quality improvement, are quite unfamiliar in the process safety arena. These methods are discussed for application in improving both process safety leadership and field work team performance. Practical ways to advance process safety, based on the methods, are given.
Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

Science.gov (United States)

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

2014-10-01

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

Science.gov (United States)

Basili, Victor r.; Zelkowitz, Marvin V.; Layman, Lucas; Dangle, Kathleen; Diep, Madeline

2010-01-01

We report on a preliminary case study to examine software safety risk in the early design phase of the NASA Constellation spaceflight program. Our goal is to provide NASA quality assurance managers with information regarding the ongoing state of software safety across the program. We examined 154 hazard reports created during the preliminary design phase of three major flight hardware systems within the Constellation program. Our purpose was two-fold: 1) to quantify the relative importance of software with respect to system safety; and 2) to identify potential risks due to incorrect application of the safety process, deficiencies in the safety process, or the lack of a defined process. One early outcome of this work was to show that there are structural deficiencies in collecting valid safety data that make software safety different from hardware safety. In our conclusions we present some of these deficiencies.
Interface management: Effective communication to improve process safety

International Nuclear Information System (INIS)

Kelly, Brian; Berger, Scott

2006-01-01

Failure to successfully communicate maintenance activities, abnormal conditions, emergency response procedures, process hazards, and hundreds of other items of critical information can lead to disaster, regardless of the thoroughness of the process safety management system. Therefore, a well-functioning process safety program depends on maintaining successful communication interfaces between each involved employee or stakeholder and the many other employees or stakeholders that person must interact with. The authors discuss a process to identify the critical 'Interfaces' between the many participants in a process safety management system, and then to establish a protocol for each critical interface
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.
Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized?

Science.gov (United States)

Simons, Pascale A M; Houben, Ruud; Benders, Jos; Pijls-Johannesma, Madelon; Vandijck, Dominique; Marneffe, Wim; Backes, Huub; Groothuis, Siebren

2014-10-01

To realize safe radiotherapy treatment, processes must be stabilized. Standard operating procedures (SOP's) were expected to stabilize the treatment process and perceived task importance would increase sustainability in compliance. This paper presents the effects on compliance to safety related tasks of a process redesign based on lean principles. Compliance to patient safety tasks was measured by video recording of actual radiation treatment, before (T0), directly after (T1) and 1.5 years after (T2) a process redesign. Additionally, technologists were surveyed on perceived task importance and reported incidents were collected for three half-year periods between 2007 and 2009. Compliance to four out of eleven tasks increased at T1, of which improvements on three sustained (T2). Perceived importance of tasks strongly correlated (0.82) to compliance rates at T2. The two tasks, perceived as least important, presented low base-line compliance, improved (T1), but relapsed at T2. The reported near misses (patient-level not reached) on accelerators increased (P improvements sustained after 1.5 years, indicating increased stability. Perceived importance of tasks correlated positively to compliance and sustainability. Raising the perception of task importance is thus crucial to increase compliance. The redesign resulted in increased willingness to report incidents, creating opportunities for patient safety improvement in radiotherapy treatment. Copyright © 2014 Elsevier Ltd. All rights reserved.
Improved safety culture and labor-management relations attributed to changing at-risk behavior process at Union Pacific.

Science.gov (United States)

2009-09-01

Changing At-Risk Behavior (CAB) is a safety process that is being conducted at Union Pacifics San Antonio Service Unit (SASU) with the aim of improving road and yard safety. CAB is an example of a proactive safety risk-reduction method called Clea...
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)
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.
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
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.
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...
Integrating natural language processing expertise with patient safety event review committees to improve the analysis of medication events.

Science.gov (United States)

Fong, Allan; Harriott, Nicole; Walters, Donna M; Foley, Hanan; Morrissey, Richard; Ratwani, Raj R

2017-08-01

Many healthcare providers have implemented patient safety event reporting systems to better understand and improve patient safety. Reviewing and analyzing these reports is often time consuming and resource intensive because of both the quantity of reports and length of free-text descriptions in the reports. Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication related patient safety events. Different NLP algorithmic approaches were developed to identify four types of medication related patient safety events and the models were compared. Well performing NLP models were generated to categorize medication related events into pharmacy delivery delays, dispensing errors, Pyxis discrepancies, and prescriber errors with receiver operating characteristic areas under the curve of 0.96, 0.87, 0.96, and 0.81 respectively. We also found that modeling the brief without the resolution text generally improved model performance. These models were integrated into a dashboard visualization to support the patient safety committee review process. We demonstrate the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication related patient safety events. The NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis. Copyright © 2017 Elsevier B.V. All rights reserved.
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.
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
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.

Behavior based safety process - a pragmatic approach

International Nuclear Information System (INIS)

Sharma, R.K.; Malaikar, N.L.; Belokar, S.G.; Arora, Yashpal

2009-01-01

Materials handling, processing and storage of hazardous chemicals has grown exponentially. The chemical industries has reacted to the situation by introducing numerous safety systems such as IS18001, 'HAZOP', safety audits, risk assessment, training etc, which has reduced hazards and improved safety performance, but has not totally eliminated exposure to the hazards. These safety systems aim to bring change in attitude of the persons which is difficult to change or control. However, behaviour of plant personnel can be controlled or improved upon, which should be our aim. (author)
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.
Improving timeliness and efficiency in the referral process for safety net providers: application of the Lean Six Sigma methodology.

Science.gov (United States)

Deckard, Gloria J; Borkowski, Nancy; Diaz, Deisell; Sanchez, Carlos; Boisette, Serge A

2010-01-01

Designated primary care clinics largely serve low-income and uninsured patients who present a disproportionate number of chronic illnesses and face great difficulty in obtaining the medical care they need, particularly the access to specialty physicians. With limited capacity for providing specialty care, these primary care clinics generally refer patients to safety net hospitals' specialty ambulatory care clinics. A large public safety net health system successfully improved the effectiveness and efficiency of the specialty clinic referral process through application of Lean Six Sigma, an advanced process-improvement methodology and set of tools driven by statistics and engineering concepts.
Food safety management systems performance in African food processing companies: a review of deficiencies and possible improvement strategies.

Science.gov (United States)

Kussaga, Jamal B; Jacxsens, Liesbeth; Tiisekwa, Bendantunguka Pm; Luning, Pieternel A

2014-08-01

This study seeks to provide insight into current deficiencies in food safety management systems (FSMS) in African food-processing companies and to identify possible strategies for improvement so as to contribute to African countries' efforts to provide safe food to both local and international markets. This study found that most African food products had high microbiological and chemical contamination levels exceeding the set (legal) limits. Relative to industrialized countries, the study identified various deficiencies at government, sector/branch, retail and company levels which affect performance of FSMS in Africa. For instance, very few companies (except exporting and large companies) have implemented HACCP and ISO 22000:2005. Various measures were proposed to be taken at government (e.g. construction of risk-based legislative frameworks, strengthening of food safety authorities, recommend use of ISO 22000:2005, and consumers' food safety training), branch/sector (e.g. sector-specific guidelines and third-party certification), retail (develop stringent certification standards and impose product specifications) and company levels (improving hygiene, strict raw material control, production process efficacy, and enhancing monitoring systems, assurance activities and supportive administrative structures). By working on those four levels, FSMS of African food-processing companies could be better designed and tailored towards their production processes and specific needs to ensure food safety. © 2014 Society of Chemical Industry.
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.
Improved people detection in nuclear plants by video processing for safety purpose

Energy Technology Data Exchange (ETDEWEB)

Jorge, Carlos Alexandre F.; Mol, Antonio Carlos A.; Carvalho, Paulo Victor R., E-mail: calexandre@ien.gov.br, E-mail: mol@ien.gov.br, E-mail: paulov@ien.gov.br [Instituto de Engenharia Nuclear (IEN/CNEN-RJ), Rio de Janeiro, RJ (Brazil); Seixas, Jose M.; Silva, Eduardo Antonio B., E-mail: seixas@lps.ufrj.br, E-mail: eduardo@smt.ufrj.br [Coordenacao dos Programas de Pos-Graduacao em Engenharia (COPPE/UFRJ), RJ (Brazil). Programa de Engenharia Eletrica; Waintraub, Fabio, E-mail: fabiowaintraub@hotmail.com [Universidade Federal do Rio de Janeiro (UFRJ), RJ (Brazil). Escola Politecnica. Departamento de Engenharia Eletronica e de Computacao

2013-07-01

This work describes improvements in a surveillance system for safety purposes in nuclear plants. The objective is to track people online in video, in order to estimate the dose received by personnel, during working tasks executed in nuclear plants. The estimation will be based on their tracked positions and on dose rate mapping in a nuclear research reactor, Argonauta. Cameras have been installed within Argonauta room, supplying the data needed. Video processing methods were combined for detecting and tracking people in video. More specifically, segmentation, performed by background subtraction, was combined with a tracking method based on color distribution. The use of both methods improved the overall results. An alternative approach was also evaluated, by means of blind source signal separation. Results are commented, along with perspectives. (author)
Improved people detection in nuclear plants by video processing for safety purpose

International Nuclear Information System (INIS)

Jorge, Carlos Alexandre F.; Mol, Antonio Carlos A.; Carvalho, Paulo Victor R.; Seixas, Jose M.; Silva, Eduardo Antonio B.; Waintraub, Fabio

2013-01-01

This work describes improvements in a surveillance system for safety purposes in nuclear plants. The objective is to track people online in video, in order to estimate the dose received by personnel, during working tasks executed in nuclear plants. The estimation will be based on their tracked positions and on dose rate mapping in a nuclear research reactor, Argonauta. Cameras have been installed within Argonauta room, supplying the data needed. Video processing methods were combined for detecting and tracking people in video. More specifically, segmentation, performed by background subtraction, was combined with a tracking method based on color distribution. The use of both methods improved the overall results. An alternative approach was also evaluated, by means of blind source signal separation. Results are commented, along with perspectives. (author)
Nuclear safety. Improvement programme

International Nuclear Information System (INIS)

2000-01-01

In this brochure the improvement programme of nuclear safety of the Mochovce NPP is presented in detail. In 1996, a 'Mochovce NPP Nuclear Safety Improvement Programme' was developed in the frame of unit 1 and 2 completion project. The programme has been compiled as a continuous one, with the aim to reach the highest possible safety level at the time of commissioning and to establish good preconditions for permanent safety improvement in future. Such an approach is in compliance with the world's trends of safety improvement, life-time extension, modernisation and nuclear station power increase. The basic document for development of the 'Programme' is the one titled 'Safety Issues and their Ranking for WWER 440/213 NPP' developed by a group of IAEA experts. The following organisations were selected for solution of the safety measures: EUCOM (Consortium of FRAMATOME, France, and SIEMENS, Germany); SKODA Prague, a.s.; ENERGOPROJEKT Prague, a.s. (EGP); Russian organisations associated in ATOMENERGOEXPORT; VUJE Trnava, a.s
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 Considerations in the Chemical Process Industries

Science.gov (United States)

Englund, Stanley M.

There is an increased emphasis on chemical process safety as a result of highly publicized accidents. Public awareness of these accidents has provided a driving force for industry to improve its safety record. There has been an increasing amount of government regulation.
[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.
PNRA Process for Utilizing Experience Feedback for Enhancing Nuclear Safety

International Nuclear Information System (INIS)

Shah, Z.H.

2016-01-01

One of the elements essential for any organization to become a learning organization is to learn from its own and others experience. The importance of utilizing experience feedback for enhancing operational safety is highlighted in nuclear industry again and again and this has resulted in establishment of several national and international forums. In addition, IAEA action plan on nuclear safety issued after Fukushima accident further highlighted the importance of experience sharing among nuclear community to enhance global nuclear safety regime. PNRA utilizes operating experience feedback gathered through different sources in order to improve its regulatory processes. During the review of licensing submissions, special emphasis is given to utilize the lessons learnt from experience feedback relating to nuclear industry within and outside the country. This emphasis has gradually resulted in various safety improvements in the facilities and processes. Accordingly, PNRA has developed a systematic process of evaluation of international operating experience feedback with the aim to create safety conscious approach. This process includes collecting information from different international forums such as IAEA, regulatory bodies of other countries and useful feedback of past accidents followed by its screening, evaluation and suggesting recommendations both for PNRA and its licensees. As a result of this process, several improvements concerning regulatory inspection plans of PNRA as well as in regulatory decision making and operational practices of licensees have been highlighted. This paper will present PNRA approach for utilizing experience feedback in its regulatory processes for enhancing / improving nuclear safety. (author)
Improved Process Used to Treat Aqueous Mixed Waste Results in Cost Savings and Improved Worker Safety

International Nuclear Information System (INIS)

Hodge, D.S.; Preuss, D.E.; Belcher, K.J.; Rock, C.M.; Bray, W.S.; Herman, J.P.

2006-01-01

testing costs by 50-75%. Reduced treatment time also reduces worker radiation exposure to As Low As Reasonably Achievable (ALARA) levels. Additionally, the treatment system components used previously were adapted to be used with the new AMWTS. This allowed for less dependence on personnel protective equipment (PPE) than the prior system by separating the waste handling/bulking steps of the process from the treatment steps. The AMWTS also improved worker safety by incorporating more automated engineering controls such as system logic controls; personnel safety and equipment protection interlocks, off normal condition indicators/alarms, and system emergency stop controls. In a time of ever-decreasing budgets, it makes sense to rethink the use of existing treatment systems. Utilizing, and possibly retooling, equipment and infrastructure may allow for reduced treatment costs and increase worker safety. (authors)
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.
Safety implications of standardized continuous quality improvement programs in community pharmacy.

Science.gov (United States)

Boyle, Todd A; Ho, Certina; Mackinnon, Neil J; Mahaffey, Thomas; Taylor, Jeffrey M

2013-06-01

Standardized continuous quality improvement (CQI) programs combine Web-based technologies and standardized improvement processes, tools, and expectations to enable quality-related events (QREs) occurring in individual pharmacies to be shared with pharmacies in other jurisdictions. Because standardized CQI programs are still new to community pharmacy, little is known about how they impact medication safety. This research identifies key aspects of medication safety that change as a result of implementing a standardized CQI program. Fifty-three community pharmacies in Nova Scotia, Canada, adopted the SafetyNET-Rx standardized CQI program in April 2010. The Institute for Safe Medication Practices (ISMP) Canada's Medication Safety Self-Assessment (MSSA) survey was administered to these pharmacies before and 1 year into their use of the SafetyNET-Rx program. The nonparametric Wilcoxon signed-rank test was used to explore where changes in patient safety occurred as a result of SafetyNETRx use. Significant improvements occurred with quality processes and risk management, staff competence, and education, and communication of drug orders and other information. Patient education, environmental factors, and the use of devices did not show statistically significant changes. As CQI programs are designed to share learning from QREs, it is reassuring to see that the largest improvements are related to quality processes, risk management, staff competence, and education.
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.
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
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
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.
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)

Food safety management systems performance in African food processing companies: a review of deficiencies and possible improvement strategies

NARCIS (Netherlands)

Kussaga, J.B.; Jacxsens, L.; Tiisekwa, B.P.M.; Luning, P.A.

2014-01-01

This study seeks to provide insight into current deficiencies in food safety management systems (FSMS) in African food-processing companies and to identify possible strategies for improvement so as to contribute to African countries’ efforts to provide safe food to both local and international
The practice of safety culture construction in radiation processing enterprise

International Nuclear Information System (INIS)

Kong Xiangshan; Zhang Yue; Yang Bin; Xu Tao; Liu Wei; Hao Jiangang

2014-01-01

Security is an integral part of the process of business operations. The radiation processing enterprises due to their own particularity, more need to focus on the operation of the safety factors, the construction of corporate safety culture is of great significance in guiding carry out the work of the Radiation Protection. Radiation processing enterprises should proceed from their own characteristics, the common attitude of security systems and security construction, and constantly improved to ensure the personal safety of radiation workers in the area of safety performance. (authors)
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)
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.
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.
Recognising safety critical events: can automatic video processing improve naturalistic data analyses?

Science.gov (United States)

Dozza, Marco; González, Nieves Pañeda

2013-11-01

New trends in research on traffic accidents include Naturalistic Driving Studies (NDS). NDS are based on large scale data collection of driver, vehicle, and environment information in real world. NDS data sets have proven to be extremely valuable for the analysis of safety critical events such as crashes and near crashes. However, finding safety critical events in NDS data is often difficult and time consuming. Safety critical events are currently identified using kinematic triggers, for instance searching for deceleration below a certain threshold signifying harsh braking. Due to the low sensitivity and specificity of this filtering procedure, manual review of video data is currently necessary to decide whether the events identified by the triggers are actually safety critical. Such reviewing procedure is based on subjective decisions, is expensive and time consuming, and often tedious for the analysts. Furthermore, since NDS data is exponentially growing over time, this reviewing procedure may not be viable anymore in the very near future. This study tested the hypothesis that automatic processing of driver video information could increase the correct classification of safety critical events from kinematic triggers in naturalistic driving data. Review of about 400 video sequences recorded from the events, collected by 100 Volvo cars in the euroFOT project, suggested that drivers' individual reaction may be the key to recognize safety critical events. In fact, whether an event is safety critical or not often depends on the individual driver. A few algorithms, able to automatically classify driver reaction from video data, have been compared. The results presented in this paper show that the state of the art subjective review procedures to identify safety critical events from NDS can benefit from automated objective video processing. In addition, this paper discusses the major challenges in making such video analysis viable for future NDS and new potential
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.)
Enhanced Time Out: An Improved Communication Process.

Science.gov (United States)

Nelson, Patricia E

2017-06-01

An enhanced time out is an improved communication process initiated to prevent such surgical errors as wrong-site, wrong-procedure, or wrong-patient surgery. The enhanced time out at my facility mandates participation from all members of the surgical team and requires designated members to respond to specified time out elements on the surgical safety checklist. The enhanced time out incorporated at my facility expands upon the safety measures from the World Health Organization's surgical safety checklist and ensures that all personnel involved in a surgical intervention perform a final check of relevant information. Initiating the enhanced time out at my facility was intended to improve communication and teamwork among surgical team members and provide a highly reliable safety process to prevent wrong-site, wrong-procedure, and wrong-patient surgery. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
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...
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)
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)
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
Radiation technology in finishing process improves health, safety and environment (HSE) in the furniture manufacturing industry

International Nuclear Information System (INIS)

Ahmad Shakri Mat Seman

1999-01-01

In furniture manufacturing, processes like cross cutting, molding, planning, shaping, turning, assembling and finishing are involved. The most significant types of negative impact of these processes are such as dust emission, noise, hazardous work, health risk, emission of organic solvent, toxic chemicals emission and chemical waste. In the finishing process, a number of negative effects that will cause health, safety and environmental (HSE) performance. This article highlights the environmental problems in the furniture finishing processes and how the radiation technology can reduce these negative impacts. The drawbacks that hamper the manufacturers from adopting this technology are also discussed. The objective of the paper is to create the awareness among the industrialist and consumers on the HSE hazardous in furniture finishing and steps can be taken to improve
CESAR cost-efficient methods and processes for safety-relevant embedded systems

CERN Document Server

Wahl, Thomas

2013-01-01

The book summarizes the findings and contributions of the European ARTEMIS project, CESAR, for improving and enabling interoperability of methods, tools, and processes to meet the demands in embedded systems development across four domains - avionics, automotive, automation, and rail. The contributions give insight to an improved engineering and safety process life-cycle for the development of safety critical systems. They present new concept of engineering tools integration platform to improve the development of safety critical embedded systems and illustrate capacity of this framework for end-user instantiation to specific domain needs and processes. They also advance state-of-the-art in component-based development as well as component and system validation and verification, with tool support. And finally they describe industry relevant evaluated processes and methods especially designed for the embedded systems sector as well as easy adoptable common interoperability principles for software tool integratio...
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.
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...
Radiotherapy professionals faced with the obligation of treatments safety improvement

International Nuclear Information System (INIS)

2011-01-01

redundancy; - better take into account the need to adapt safety demands to the features of the various types of radiotherapy units; - promote mutualization of safety practices between radiotherapy units in order to optimize the associated workload; - improve knowledge of safety demand impacts on actual conditions of treatment achievement in order to control negative effects; - improve knowledge about decision-making processes implemented by health care facilities in order to match safety improvement objectives and resources; - expend reflection on the role and means of scientific comities and hospital federations in order to improve their contribution to the dynamics of treatment safety improvement. (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
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

Improving Safety, Quality and Efficiency through the Management of Emerging Processes: The TenarisDalmine Experience

Science.gov (United States)

Bonometti, Patrizia

2012-01-01

Purpose: The aim of this contribution is to describe a new complexity-science-based approach for improving safety, quality and efficiency and the way it was implemented by TenarisDalmine. Design/methodology/approach: This methodology is called "a safety-building community". It consists of a safety-behaviour social self-construction…
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...
Incident Reporting to Improve Patient Safety: The Effects of Process Variance on Pediatric Patient Safety in the Emergency Department.

Science.gov (United States)

OʼConnell, Karen J; Shaw, Kathy N; Ruddy, Richard M; Mahajan, Prashant V; Lichenstein, Richard; Olsen, Cody S; Funai, Tomohiko; Blumberg, Stephen; Chamberlain, James M

2018-04-01

Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care. We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics. The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008. Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels. Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to
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
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.)
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)
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
Combination of minimal processing and irradiation to improve the microbiological safety of lettuce (Lactuca sativa, L.)

International Nuclear Information System (INIS)

Goularte, L.; Martins, C.G.; Morales-Aizpurua, I.C.; Destro, M.T.; Franco, B.D.G.M.; Vizeu, D.M.; Hutzler, B.W.; Landgraf, M.

2004-01-01

The feasibility of gamma radiation in combination with minimal processing (MP) to reduce the number of Salmonella spp. and Escherichia coli O157:H7 in iceberg lettuce (Lactuca sativa, L.) (shredded) was studied in order to increase the safety of the product. The reduction of the microbial population during the processing, the D 10 -values for Salmonella spp. and E. coli O157:H7 inoculated on shredded iceberg lettuce as well as the sensory evaluation of the irradiated product were evaluated. The immersion in chlorine (200 ppm) reduced coliform and aerobic mesophilic microorganisms by 0.9 and 2.7 log, respectively. D-values varied from 0.16 to 0.23 kGy for Salmonella spp. and from 0.11 to 0.12 kGy for E. coli O157:H7. Minimally processed iceberg lettuce exposed to 0.9 kGy does not show any change in sensory attributes. However, the texture of the vegetable was affected during the exposition to 1.1 kGy. The exposition of MP iceberg lettuce to 0.7 kGy reduced the population of Salmonella spp. by 4.0 log and E. coli by 6.8 log without impairing the sensory attributes. The combination of minimal process and gamma radiation to improve the safety of iceberg lettuce is feasible if good hygiene practices begins at farm stage
Combination of minimal processing and irradiation to improve the microbiological safety of lettuce (Lactuca sativa, L.)

Energy Technology Data Exchange (ETDEWEB)

Goularte, L.; Martins, C.G.; Morales-Aizpurua, I.C.; Destro, M.T.; Franco, B.D.G.M.; Vizeu, D.M.; Hutzler, B.W.; Landgraf, M. E-mail: landgraf@usp.br

2004-10-01

The feasibility of gamma radiation in combination with minimal processing (MP) to reduce the number of Salmonella spp. and Escherichia coli O157:H7 in iceberg lettuce (Lactuca sativa, L.) (shredded) was studied in order to increase the safety of the product. The reduction of the microbial population during the processing, the D{sub 10}-values for Salmonella spp. and E. coli O157:H7 inoculated on shredded iceberg lettuce as well as the sensory evaluation of the irradiated product were evaluated. The immersion in chlorine (200 ppm) reduced coliform and aerobic mesophilic microorganisms by 0.9 and 2.7 log, respectively. D-values varied from 0.16 to 0.23 kGy for Salmonella spp. and from 0.11 to 0.12 kGy for E. coli O157:H7. Minimally processed iceberg lettuce exposed to 0.9 kGy does not show any change in sensory attributes. However, the texture of the vegetable was affected during the exposition to 1.1 kGy. The exposition of MP iceberg lettuce to 0.7 kGy reduced the population of Salmonella spp. by 4.0 log and E. coli by 6.8 log without impairing the sensory attributes. The combination of minimal process and gamma radiation to improve the safety of iceberg lettuce is feasible if good hygiene practices begins at farm stage.
Combination of minimal processing and irradiation to improve the microbiological safety of lettuce ( Lactuca sativa, L.)

Science.gov (United States)

Goularte, L.; Martins, C. G.; Morales-Aizpurúa, I. C.; Destro, M. T.; Franco, B. D. G. M.; Vizeu, D. M.; Hutzler, B. W.; Landgraf, M.

2004-09-01

The feasibility of gamma radiation in combination with minimal processing (MP) to reduce the number of Salmonella spp. and Escherichia coli O157:H7 in iceberg lettuce ( Lactuca sativa, L.) (shredded) was studied in order to increase the safety of the product. The reduction of the microbial population during the processing, the D10-values for Salmonella spp. and E. coli O157:H7 inoculated on shredded iceberg lettuce as well as the sensory evaluation of the irradiated product were evaluated. The immersion in chlorine (200 ppm) reduced coliform and aerobic mesophilic microorganisms by 0.9 and 2.7 log, respectively. D-values varied from 0.16 to 0.23 kGy for Salmonella spp. and from 0.11 to 0.12 kGy for E. coli O157:H7. Minimally processed iceberg lettuce exposed to 0.9 kGy does not show any change in sensory attributes. However, the texture of the vegetable was affected during the exposition to 1.1 kGy. The exposition of MP iceberg lettuce to 0.7 kGy reduced the population of Salmonella spp. by 4.0 log and E. coli by 6.8 log without impairing the sensory attributes. The combination of minimal process and gamma radiation to improve the safety of iceberg lettuce is feasible if good hygiene practices begins at farm stage.
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.
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.
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
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.
Improving versus maintaining nuclear safety

International Nuclear Information System (INIS)

2002-01-01

The concept of improving nuclear safety versus maintaining it has been discussed at a number of nuclear regulators meetings in recent years. National reports have indicated that there are philosophical differences between NEA member countries about whether their regulatory approaches require licensees to continuously improve nuclear safety or to continuously maintain it. It has been concluded that, while the actual level of safety achieved in all member countries is probably much the same, this is difficult to prove in a quantitative way. In practice, all regulatory approaches require improvements to be made to correct deficiencies and when otherwise warranted. Based on contributions from members of the NEA Committee on Nuclear Regulatory Activities (CNRA), this publication provides an overview of current nuclear regulatory philosophies and approaches, as well as insights into a selection of public perception issues. This publication's intended audience is primarily nuclear safety regulators, but government authorities, nuclear power plant operators and the general public may also be interested. (author)
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.
Safety implications of computerized process control in nuclear power plants

International Nuclear Information System (INIS)

1991-02-01

Modern nuclear power plants are making increasing use of computerized process control because of the number of potential benefits that accrue. This practice not only applies to new plants but also to those in operation. Here, the replacement of both conventional process control systems and outdated computerized systems is seen to be of benefit. Whilst this contribution is obviously of great importance to the viability of nuclear electricity generation, it must be recognized that there are major safety concerns in taking this route. However, there is the potential for enhancing the safety of nuclear power plants if the full power of microcomputers and the associated electronics is applied correctly through well designed, engineered, installed and maintained systems. It is essential that areas where safety can be improved be identified and that the pitfalls are clearly marked so that they can be avoided. The deliberations of this Technical Committee Meeting are a step on the road to this goal of improved safety through computerized process control. This report also contains the papers presented at the technical committee meeting by participants. A separate abstract was prepared for each of these 15 presentations. Refs, figs and tabs
Organisational learning and continuous improvement of health and safety in certified manufacturers

DEFF Research Database (Denmark)

Granerud, Lise; Rocha, Robson Sø

2011-01-01

and raise goals within health and safety on a continuous basis. The article examines how certified occupational and health management systems influence this process to evaluate how far they hinder or support learning. It presents a model with which it is possible to identify and analyse improvement......Certified management systems have increasingly been applied by firms in recent decades and now cover the management of health and safety, principally through the OHSAS 18001 standard. In order to become certified, firms must not only observe the relevant legislation, but also improve performance...... processes. The model is applied to five cases from a qualitative study of Danish manufacturers with certified health and safety management systems. The cases illustrate the wide variation in health and safety management among certified firms. Certification is found to support lower levels of continuous...
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
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 ...

Evolution of International Space Station Program Safety Review Processes and Tools

Science.gov (United States)

Ratterman, Christian D.; Green, Collin; Guibert, Matt R.; McCracken, Kristle I.; Sang, Anthony C.; Sharpe, Matthew D.; Tollinger, Irene V.

2013-01-01

The International Space Station Program at NASA is constantly seeking to improve the processes and systems that support safe space operations. To that end, the ISS Program decided to upgrade their Safety and Hazard data systems with 3 goals: make safety and hazard data more accessible; better support the interconnection of different types of safety data; and increase the efficiency (and compliance) of safety-related processes. These goals are accomplished by moving data into a web-based structured data system that includes strong process support and supports integration with other information systems. Along with the data systems, ISS is evolving its submission requirements and safety process requirements to support the improved model. In contrast to existing operations (where paper processes and electronic file repositories are used for safety data management) the web-based solution provides the program with dramatically faster access to records, the ability to search for and reference specific data within records, reduced workload for hazard updates and approval, and process support including digital signatures and controlled record workflow. In addition, integration with other key data systems provides assistance with assessments of flight readiness, more efficient review and approval of operational controls and better tracking of international safety certifications. This approach will also provide new opportunities to streamline the sharing of data with ISS international partners while maintaining compliance with applicable laws and respecting restrictions on proprietary data. One goal of this paper is to outline the approach taken by the ISS Progrm to determine requirements for the new system and to devise a practical and efficient implementation strategy. From conception through implementation, ISS and NASA partners utilized a user-centered software development approach focused on user research and iterative design methods. The user-centered approach used on
Unlocking the “black box” of practice improvement strategies to implement surgical safety checklists: a process evaluation

Directory of Open Access Journals (Sweden)

Gillespie BM

2017-04-01

Full Text Available Brigid M Gillespie,1–3 Kyra Hamilton,4 Dianne Ball,5 Joanne Lavin,6 Therese Gardiner,6 Teresa K Withers,7 Andrea P Marshall1–3 1School of Nursing & Midwifery, Griffith University, Gold Coast, 2Gold Coast University Hospital and Health Service, Southport, 3Nursing & Midwifery Education & Research Unit (NMERU, National Centre of Research Excellence in Nursing, Menzies Health Institute of Queensland, Griffith University, Gold Coast, 4School of Applied Psychology, Griffith University, Mt Gravatt, 5Communio Pty Ltd, Sydney, 6Nursing & Midwifery Education & Research Unit, 7Surgical and Procedural Services, Gold Coast University Hospital and Health Service, Southport, Australia Background: Compliance with surgical safety checklists (SSCs has been associated with improvements in clinical processes such as antibiotic use, correct site marking, and overall safety processes. Yet, proper execution has been difficult to achieve.Objectives: The objective of this study was to undertake a process evaluation of four knowledge translation (KT strategies used to implement the Pass the Baton (PTB intervention which was designed to improve utilization of the SSC. Methods: As part of the process evaluation, a logic model was generated to explain which KT strategies worked well (or less well in the operating rooms of a tertiary referral hospital in Queensland, Australia. The KT strategies implemented included change champions/opinion leaders, education, audit and feedback, and reminders. In evaluating the implementation of these strategies, this study considered context, intervention and underpinning assumptions, implementation, and mechanism of impact. Observational and interview data were collected to assess implementation of the KT strategies relative to fidelity, feasibility, and acceptability. Results: Findings from 35 structured observations and 15 interviews with 96 intervention participants suggest that all of the KT strategies were consistently
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
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)
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)
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.
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
Does applying technology throughout the medication use process improve patient safety with antineoplastics?

Science.gov (United States)

Bubalo, Joseph; Warden, Bruce A; Wiegel, Joshua J; Nishida, Tess; Handel, Evelyn; Svoboda, Leanne M; Nguyen, Lam; Edillo, P Neil

2014-12-01

Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors. This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care. The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the
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)
A 'Toolbox' Equivalent Process for Safety Analysis Software

International Nuclear Information System (INIS)

O'Kula, K.R.; Eng, Tony

2004-01-01

Defense Nuclear Facilities Safety Board (DNFSB) Recommendation 2002-1 (Quality Assurance for Safety-Related Software) identified a number of quality assurance issues on the use of software in Department of Energy (DOE) facilities for analyzing hazards, and designing and operating controls that prevent or mitigate potential accidents. The development and maintenance of a collection, or 'toolbox', of multiple-site use, standard solution, Software Quality Assurance (SQA)-compliant safety software is one of the major improvements identified in the associated DOE Implementation Plan (IP). The DOE safety analysis toolbox will contain a set of appropriately quality-assured, configuration-controlled, safety analysis codes, recognized for DOE-broad, safety basis applications. Currently, six widely applied safety analysis computer codes have been designated for toolbox consideration. While the toolbox concept considerably reduces SQA burdens among DOE users of these codes, many users of unique, single-purpose, or single-site software may still have sufficient technical justification to continue use of their computer code of choice, but are thwarted by the multiple-site condition on toolbox candidate software. The process discussed here provides a roadmap for an equivalency argument, i.e., establishing satisfactory SQA credentials for single-site software that can be deemed ''toolbox-equivalent''. The process is based on the model established to meet IP Commitment 4.2.1.2: Establish SQA criteria for the safety analysis ''toolbox'' codes. Implementing criteria that establish the set of prescriptive SQA requirements are based on implementation plan/procedures from the Savannah River Site, also incorporating aspects of those from the Waste Isolation Pilot Plant (SNL component) and the Yucca Mountain Project. The major requirements are met with evidence of a software quality assurance plan, software requirements and design documentation, user's instructions, test report, a
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
40 CFR 68.65 - Process safety information.

Science.gov (United States)

2010-07-01

... (CONTINUED) CHEMICAL ACCIDENT PREVENTION PROVISIONS Program 3 Prevention Program § 68.65 Process safety... 40 Protection of Environment 15 2010-07-01 2010-07-01 false Process safety information. 68.65... compilation of written process safety information before conducting any process hazard analysis required by...
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
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
Keys to effective third-party process safety audits

International Nuclear Information System (INIS)

Birkmire, John C.; Lay, James R.; McMahon, Mona C.

2007-01-01

The Occupational Safety and Health Administration's (OSHA's) Process Safety Management (PSM) regulation was promulgated in 1992. The U.S. Environmental Protection Agency's (EPA's) corresponding Risk Management Program (RMP) rule followed in 1996. Both programs include requirements for triennial compliance audits. Effective compliance audits are critical in identifying program weaknesses and ensuring the safety of facility personnel and the surrounding public. Large companies with corporate and facility health, safety, and environmental groups typically have the resources and experience to conduct audits internally, either through a corporate audit team or the sharing of personnel between multiple facilities. Small to medium sized businesses frequently do not have the expertise or the resources to perform compliance audits, and rely on third-party consultants to provide these services. This paper will discuss the observations of the authors in performing audits and working with PSM/RMP programs across a number of market sectors (e.g. chemical, petrochemical, pharmaceutical, food and beverage, water treatment), including effective practices, hurdles to successful implementation and execution of programs, and typical program shortcomings. The paper will also discuss steps to improve the audit process and increase effectiveness whether performed by a third party or internally
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.
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
[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.

The association between event learning and continuous quality improvement programs and culture of patient safety.

Science.gov (United States)

Mazur, Lukasz; Chera, Bhishamjit; Mosaly, Prithima; Taylor, Kinley; Tracton, Gregg; Johnson, Kendra; Comitz, Elizabeth; Adams, Robert; Pooya, Pegah; Ivy, Julie; Rockwell, John; Marks, Lawrence B

2015-01-01

To present our approach and results from our quality and safety program and to report their possible impact on our culture of patient safety. We created an event learning system (termed a "good catch" program) and encouraged staff to report any quality or safety concerns in real time. Events were analyzed to assess the utility of safety barriers. A formal continuous quality improvement program was created to address these reported events and make improvements. Data on perceptions of the culture of patient safety were collected using the Agency for Health Care Research and Quality survey administered before, during, and after the initiatives. Of 560 good catches reported, 367 could be ascribed to a specific step on our process map. The calculated utility of safety barriers was highest for those embedded into the pretreatment quality assurance checks performed by physicists and dosimetrists (utility score 0.53; 93 of 174) and routine checks done by therapists on the initial day of therapy. Therapists and physicists reported the highest number of good catches (24% each). Sixty-four percent of events were caused by performance issues (eg, not following standardized processes, including suboptimal communications). Of 31 initiated formal improvement events, 26 were successfully implemented and sustained, 4 were discontinued, and 1 was not implemented. Most of the continuous quality improvement program was conducted by nurses (14) and therapists (7). Percentages of positive responses in the patient safety culture survey appear to have increased on all dimensions (p continuous quality improvement programs can be successfully implemented and that there are contemporaneous improvements in the culture of safety. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
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.
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.
Improving food safety within the dairy chain: an application of conjoint analysis

NARCIS (Netherlands)

Valeeva, N.I.; Meuwissen, M.P.M.; Oude Lansink, A.G.J.M.; Huirne, R.B.M.

2005-01-01

This study determined the relative importance of attributes of food safety improvement in the production chain of fluid pasteurized milk. The chain was divided into 4 blocks: "feed" (compound feed production and its transport), "farm" (dairy farm), "dairy processing" (transport and processing of raw
The effect of Health, Safety and Environment Management System (HSE-MS on the improvement of safety performance indices in Urea and Ammonia Kermanshah Petrochemical Company

Directory of Open Access Journals (Sweden)

M. S. Poursoleiman

2015-09-01

.Conclusion: The implementation of Health, Safety and the Environment Management System caused a reduction in accidents and its consequences and most of the safety performance indices in the entire process cycle of Kermanshah Petrochemical Company. Overall, safety condition has been improved considerably.
Safety guides development process in Spain

International Nuclear Information System (INIS)

Butragueno, J.L.; Perello, M.

1979-01-01

Safety guides have become a major factor in the licensing process of nuclear power plants and related nuclear facilities of the fuel cycle. As far as the experience corroborates better and better engineering methodologies and procedures, the results of these are settled down in form of standards, guides, and similar issues. This paper presents the actual Spanish experience in nuclear standards and safety guides development. The process to develop a standard or safety guide is shown. Up to date list of issued and on development nuclear safety guides is included and comments on the future role of nuclear standards in the licensing process are made. (author)
Using standardized insulin orders to improve patient safety in a tertiary care centre.

Science.gov (United States)

Doyle, Mary-Anne; Brez, Sharon; Sicoli, Silvana; De Sousa, Filomena; Keely, Erin; Malcom, Janine C

2014-04-01

To standardize insulin prescribing practices for inpatients, improve management of hypoglycemia, reduce reliance on sliding scales, increase use of basal-bolus insulin and improve patient safety. Patients with diabetes were admitted to 2 pilot inpatient units followed by corporate spread to all insulin-treated patients on noncritical care units in a Canadian tertiary care multicampus teaching hospital. Standardized preprinted insulin and hypoglycemia management orders, decision support tools and multidisciplinary education strategies were developed, tested and implemented by way of the Model for Improvement and The Ottawa Model for Research Process. Clinical and balance measures were evaluated through statistical process control. Patient safety was improved through a reduction in hypoglycemia and decreased dependence on correctional scales. Utilization of the preprinted orders approached the target of 70% at the end of the test period and was sustained at 89% corporately 3 years post-implementation. The implementation of a standardized, preprinted insulin order set facilitates best practices for insulin therapy, improves patient safety and is highly supported by treating practitioners. The utilization of formal quality-improvement methodology promoted efficiency, enhanced sustainability, increased support among clinicians and senior administrators, and was effective in instituting sustained practice change in a complex care centre. Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.
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.
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.
Usage of information safety requirements in improving tube bending process

Science.gov (United States)

Livshitz, I. I.; Kunakov, E.; Lontsikh, P. A.

2018-05-01

This article is devoted to an improvement of the technological process's analysis with the information security requirements implementation. The aim of this research is the competition increase analysis in aircraft industry enterprises due to the information technology implementation by the example of the tube bending technological process. The article analyzes tube bending kinds and current technique. In addition, a potential risks analysis in a tube bending technological process is carried out in terms of information security.
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
[Sustainable process improvement with application of 'lean philosophy'].

Science.gov (United States)

Rouppe van der Voort, Marc B V; van Merode, G G Frits; Veraart, Henricus G N

2013-01-01

Process improvement is increasingly being implemented, particularly with the aid of 'lean philosophy'. This management philosophy aims to improve quality by reducing 'wastage'. Local improvements can produce negative effects elsewhere due to interdependence of processes. An 'integrated system approach' is required to prevent this. Some hospitals claim that this has been successful. Research into process improvement with the application of lean philosophy has reported many positive effects, defined as improved safety, quality and efficiency. Due to methodological shortcomings and lack of rigorous evaluations it is, however, not yet possible to determine the impact of this approach. It is, however, obvious that the investigated applications are fragmentary, with a dominant focus on the instrumental aspect of the philosophy and a lack of integration in a total system, and with insufficient attention to human aspects. Process improvement is required to achieve better and more goal-oriented healthcare. To achieve this, hospitals must develop integrated system approaches that combine methods for process design with continuous improvement of processes and with personnel management. It is crucial that doctors take the initiative to guide and improve processes in an integral manner.
Krsko periodic safety review project prioritization process

International Nuclear Information System (INIS)

Basic, I.; Vrbanic, I.; Spiler, J.; Lambright, J.

2004-01-01

Definition of a Krsko Periodic Safety Review (PSR) project is a comprehensive safety review of a plant after last ten years of operation. The objective is a verification by means of a comprehensive review using current methods that Krsko NPP remains safety when judged against current safety objectives and practices and that adequate arrangements are in place to maintain plant safety. This objective encompasses the three main criteria or goals: confirmation that the plant is as safe as originally intended, determination if there are any structures, systems or components that could limit the life of the plant in the foreseeable future, and comparison the plant against modern safety standards and to identify where improvements would be beneficial at justifiable cost. Krsko PSR project is structured in the three phases: Phase 1: Preparation of Detailed 10-years PSR Program, Phase 2: Performing of 10-years PSR Program and preparing of associated documents (2001-2003), and Phase 3: Implementation of the prioritized compensatory measures and modifications (development of associated EEAR, DMP, etc.) after agreement with the SNSA on the design, procedures and time-scales (2004-2008). This paper presents the NEK PSR results of work performed under Phase 2 focused on the ranking of safety issues and prioritization of corrective measures needed for establishing an efficient action plan. Safety issues were identified in Phase 2 during the following review processes: Periodic Safety Review (PSR) task; Krsko NPP Regulatory Compliance Program (RCP) review; Westinghouse Owner Group (WOG) catalog items screening/review; SNSA recommendations (including IAEA RAMP mission suggestions/recommendations).(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.
Improving occupational safety and health by integration into product development

DEFF Research Database (Denmark)

Broberg, Ole

1996-01-01

A cross-sectional case study was performed in a large company producing electro-mechanical products for industrial application. The objectives were: (i) to study the product development process and the role of key actors', (ii) to identify current practice on integrating occupational safety and h...... and studies of documents. A questionnaire regarding product development tasks and occupational safety and health were distributed to 30 design and production engineers. A total of 27 completed the questionnaire corresponding to a response rate of 90 per cent.......A cross-sectional case study was performed in a large company producing electro-mechanical products for industrial application. The objectives were: (i) to study the product development process and the role of key actors', (ii) to identify current practice on integrating occupational safety...... and health into the development process, especially the efforts and attitudes of design and production engineers', and (iii) to identify key actors'reflections on how to improve this integration. The study was based on qualitative as well as quantitative methods including interviews, questionnaires...
Keys to effective third-party process safety audits

Energy Technology Data Exchange (ETDEWEB)

Birkmire, John C. [Tourgee and Associates Inc., 11459 Cronhill Drive, Suite A, Owings Mills, MD 21117 (United States)]. E-mail: jbirkmire@taiengineering.com; Lay, James R. [5644 High Tor Hill, Columbia, MD 21045 (United States)]. E-mail: jim.lay21045@gmail.com; McMahon, Mona C. [General Physics Corporation, 6095 Marshalee Drive, Suite 300, Elkridge, MD 21075 (United States)]. E-mail: mmcmahon@gpworldwide.com

2007-04-11

The Occupational Safety and Health Administration's (OSHA's) Process Safety Management (PSM) regulation was promulgated in 1992. The U.S. Environmental Protection Agency's (EPA's) corresponding Risk Management Program (RMP) rule followed in 1996. Both programs include requirements for triennial compliance audits. Effective compliance audits are critical in identifying program weaknesses and ensuring the safety of facility personnel and the surrounding public. Large companies with corporate and facility health, safety, and environmental groups typically have the resources and experience to conduct audits internally, either through a corporate audit team or the sharing of personnel between multiple facilities. Small to medium sized businesses frequently do not have the expertise or the resources to perform compliance audits, and rely on third-party consultants to provide these services. This paper will discuss the observations of the authors in performing audits and working with PSM/RMP programs across a number of market sectors (e.g. chemical, petrochemical, pharmaceutical, food and beverage, water treatment), including effective practices, hurdles to successful implementation and execution of programs, and typical program shortcomings. The paper will also discuss steps to improve the audit process and increase effectiveness whether performed by a third party or internally.
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)
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.
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 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.
Process management - critical safety issues with focus on risk management

International Nuclear Information System (INIS)

Sanne, Johan M.

2005-12-01

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

Over the past several years, operators of the world's nuclear plants have compiled an increasingly impressive record of operational performance. Among the many factors that have led to this improvement are the unprecedented cooperation and information exchange among the world's nuclear operators. This paper presents the World Association of Nuclear Operators (WANO) operating experience program and WANO peer review program as examples of the kinds of interaction that are occurring around the globe to maintain and improve the nuclear safety culture. In addition, some unique features of WANO are discussed. WANO has established four programs to help its members communicate effectively with each other. These include the exchange of operating experiences, voluntary peer reviews, professional and technical development, and technical support and exchange. The operating experience program alerts members to events that have occurred at other NPPs and enables members to take appropriate actions to prevent event recurrence. When an event occurs at a plant, management at that plant analyses the event and completes an event report, which is then sent to the WANO regional center to which the plant belongs. After a regional center review and necessary iteration, the report is posted onto the WANO Web site to make it available to all WANO members. By the end of 2000, more than 1500 event reports had been posted. The WANO Peer Review Program is a unique opportunity for members to learn and share the best worldwide insights into safe and reliable nuclear operations. The peer review program has become one of WANO's most important activities containing all essential elements of WANO's mission. A WANO peer review team consists of 15 to 16 people with NPP experience; most team members are from countries outside the one that they are visiting. These teams of peers from plants around the world visit host plants upon request to identify strengths and areas for improvement, with a strong
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
Safety assessment as basis for the decision making process

International Nuclear Information System (INIS)

Ilie, P.; Didita, L.; Danchiv, A.

2005-01-01

This paper deals with the safety assessment for a new near surface repository, particularly for the early stage of repository development using ISAM (Improvement of Safety Assessment Methodologies for Near Surface Disposal Facilities) safety assessment methodology. In this stage of the repository life cycle the main purpose of the safety assessment is to demonstrate that the plant is capable to be constructed and operated safely. The paper is based on development of the ASAM (Application of the Safety Assessment Methodologies for Near-Surface Disposal Facilities) Decision Support Subgroup of the Common Aspects Working Group. The implications of decision making for the application of the ISAM methodology on post-closure safety assessment are analysed. Some important elements of the decision-making process with impact on key components of the ISAM process are described. Following the development of Decision Support Subgroup of the ASAM Common Aspects Working Group the proposed change of ISAM methodology is analysed. This approach puts all activities in a decision context where the first iteration of the safety assessment is based on the existing state of knowledge and the initial engineering design. Confidence in the process is accomplished through the direct inclusion of all decision makers and stakeholders in the formulation of decisions, the definition of the state of knowledge, and decision making activities. The decision process is developed in context of undertaking assessments with little site-specific information, this situation is specifically for new planned repository. Limited site-specific information can result in a high degree of uncertainty, therefore it is important first of all to identify the sources of uncertainty arising from the limited nature of the site-specific information and then to apply appropriate approaches to manage the uncertainties and to determine whether the uncertainties are important to the overall safety of the disposal facility
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
Chemical process safety at fuel cycle facilities

International Nuclear Information System (INIS)

Ayres, D.A.

1997-08-01

This NUREG provides broad guidance on chemical safety issues relevant to fuel cycle facilities. It describes an approach acceptable to the NRC staff, with examples that are not exhaustive, for addressing chemical process safety in the safe storage, handling, and processing of licensed nuclear material. It expounds to license holders and applicants a general philosophy of the role of chemical process safety with respect to NRC-licensed materials; sets forth the basic information needed to properly evaluate chemical process safety; and describes plausible methods of identifying and evaluating chemical hazards and assessing the adequacy of the chemical safety of the proposed equipment and facilities. Examples of equipment and methods commonly used to prevent and/or mitigate the consequences of chemical incidents are discussed in this document
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
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.
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
A multidisciplinary three-phase approach to improve the clinical utility of patient safety indicators.

Science.gov (United States)

Najjar, Peter; Kachalia, Allen; Sutherland, Tori; Beloff, Jennifer; David-Kasdan, Jo Ann; Bates, David W; Urman, Richard D

2015-01-01

The AHRQ Patient Safety Indicators (PSIs) are used for calculation of risk-adjusted postoperative rates for adverse events. The payers and quality consortiums are increasingly requiring public reporting of hospital performance on these metrics. We discuss processes designed to improve the accuracy and clinical utility of PSI reporting in practice. The study was conducted at a 793-bed tertiary care academic medical center where PSI processes have been aggressively implemented to track patient safety events at discharge. A three-phased approach to improving administrative data quality was implemented. The initiative consisted of clinical review of all PSIs, documentation improvement, and provider outreach including active querying for patient safety events. This multidisciplinary effort to develop a streamlined process for PSI calculation reduced the reporting of miscoded PSIs and increased the clinical utility of PSI monitoring. Over 4 quarters, 4 of 41 (10%) PSI-11 and 9 of 138 (7%) PSI-15 errors were identified on review of clinical documentation and appropriate adjustments were made. A multidisciplinary, phased approach leveraging existing billing infrastructure for robust metric coding, ongoing clinical review, and frontline provider outreach is a novel and effective way to reduce the reporting of false-positive outcomes and improve the clinical utility of PSIs.
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
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)

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 ...
Implementing process safety management in gas processing operations

International Nuclear Information System (INIS)

Rodman, D.L.

1992-01-01

The Occupational Safety and Health Administration (OSHA) standard entitled Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents was finalized February 24, 1992. The purpose of the standard is to prevent or minimize consequences of catastrophic releases of toxic, flammable, or explosive chemicals. OSHA believes that its rule will accomplish this goal by requiring a comprehensive management program that integrates technologies, procedures, and management practices. Gas Processors Association (GPA) member companies are significantly impacted by this major standard, the requirements of which are extensive and complex. The purpose of this paper is to review the requirements of the standard and to discuss the elements to consider in developing and implementing a viable long term Process Safety Management Program
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.
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 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
Variable Speed Limits: Strategies to Improve Safety and Traffic Parameters for a Bottleneck

Directory of Open Access Journals (Sweden)

M. Z. Hasanpour

2017-04-01

Full Text Available The primary purpose of the speed limit system is to enforce reasonable and safe speed. To reduce secondary problems such as accidents and queuing, Variable Speed Limits (VSL has been suggested. In this paper VSL is used to better safety and traffic parameters. Traffic parameters including speed, queue length and stopping time have been pondering. For VLS, an optimization decision tree algorithm with the function of microscopic simulation was used. The results in case of sub saturated, saturated and supersaturated at a bottleneck are examined and compared with the Allaby logic tree. The results show that the proposed decision tree shows an improved performance in terms of safety and comfort along the highway. The VSL pilot project is part of the Road Safety Improvement Program included in Iran’s road safety action plan that is in the research process in the BHRC Research Institute, Road and Housing & Urban Development Research that is planned for next 10-year Transportation safety view Plan.
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)
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
Using game technologies to improve the safety of construction plant operations.

Science.gov (United States)

Guo, Hongling; Li, Heng; Chan, Greg; Skitmore, Martin

2012-09-01

Many accidents occur world-wide in the use of construction plant and equipment, and safety training is considered by many to be one of the best approaches to their prevention. However, current safety training methods/tools are unable to provide trainees with the hands-on practice needed. Game technology-based safety training platforms have the potential to overcome this problem in a virtual environment. One such platform is described in this paper - its characteristics are analysed and its possible contribution to safety training identified. This is developed and tested by means of a case study involving three major pieces of construction plant, which successfully demonstrates that the platform can improve the process and performance of the safety training involved in their operation. This research not only presents a new and useful solution to the safety training of construction operations, but illustrates the potential use of advanced technologies in solving construction industry problems in general. Copyright © 2011 Elsevier Ltd. All rights reserved.
Applying Toyota production system techniques for medication delivery: improving hospital safety and efficiency.

Science.gov (United States)

Newell, Terry L; Steinmetz-Malato, Laura L; Van Dyke, Deborah L

2011-01-01

The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital. © 2010 National Association for Healthcare Quality.
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 ...
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.
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.
Evaluation of implementation an Integrated Safety and Preventive Maintenance System for Improving of Safety Indexes

Directory of Open Access Journals (Sweden)

I mohammadfam

2014-03-01

Full Text Available Accident analysis shows that one of the main reasons for accidents is non-integration of maintenance units with safety. Merging these two processes through an integrated system can reduce and or eliminate accidents, diseases, and environmental pollution. These issues lead to improvement in organizational performance, as well. The aim of this study is to design and establish an integrated system for obtaining the aforementioned goal. Integration was carried out at Nirou Moharreke Machine Tools Company via Structured System Analysis & Design Method (SSADM. In order to measure the effectiveness of the system, selected indexes were compared using statistical methods prior and after system establishment. Results show that the accident severity index reduced from 135.46 in 2010, to 43.85 in 2012. Moreover, system effectiveness improved equipment reliability and availability (e.g. reliability of the Pfeiffer Milling machine (P (t>50 increased from 0.89 in 2010, to 0.9 in 2012. This system by forecasting various failures, and planning and designing the required operations for preventing occurrence of these failures, plays an important role in improving safety conditions of equipment, and increasing organizational performance, and is capable of presenting an excellent accident prevention program.
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
Safety analyses for reprocessing and waste processing

International Nuclear Information System (INIS)

1983-03-01

Presentation of an incident analysis of process steps of the RP, simplified considerations concerning safety, and safety analyses of the storage and solidification facilities of the RP. A release tree method is developed and tested. An incident analysis of process steps, the evaluation of the SRL-study and safety analyses of the storage and solidification facilities of the RP are performed in particular. (DG) [de
Measures to Improve Diagnostic Safety in Clinical Practice.

Science.gov (United States)

Singh, Hardeep; Graber, Mark L; Hofer, Timothy P

2016-10-20

Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic process through better measurement of diagnostic performance. The diagnostic process is a dynamic team-based activity that involves uncertainty, plays out over time, and requires effective communication and collaboration among multiple clinicians, diagnostic services, and the patient. Thus, it poses special challenges for measurement. In this paper, we discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. We highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, we propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined. This would enable safe diagnosis to become an organizational priority and facilitate quality improvement. Health-care systems should consider measurement and evaluation of diagnostic performance as essential to timely and accurate diagnosis and to the reduction of preventable diagnostic harm.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
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.
Human-centred radiological software techniques supporting improved nuclear safety

International Nuclear Information System (INIS)

Szoeke, Istvan; Johnsen, Terje

2013-01-01

The Institute for Energy Technology (IFE) is an international research foundation for energy and nuclear technology. IFE is also the host for the international OECD Halden Reactor Project. The Software Engineering Department in the Man Technology Organisation at IFE is a leading international centre of competence for the development and evaluation of human-centred technologies, process visualisation, and the lifecycle of high integrity software important to safety. This paper is an attempt to give a general overview of the current, and some of the foreseen, research and development of human-centred radiological software technologies at the Software Engineering department to meet with the need of improved radiological safety for not only nuclear industry but also other industries around the world. (author)
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

Management by process based systems and safety focus

International Nuclear Information System (INIS)

Rydnert, Bo; Groenlund, Bjoern

2005-12-01

An initiative from The Swedish Nuclear Power Inspectorate led to this study carried out in the late autumn of 2005. The objective was to understand in more detail how an increasing use of process management affects organisations, on the one hand regarding risks and security, on the other hand regarding management by objectives and other management and operative effects. The main method was interviewing representatives of companies and independent experts. More than 20 interviews were carried out. In addition a literature study was made. All participating companies are using Management Systems based on processes. However, the methods chosen, and the results achieved, vary extensively. Thus, there are surprisingly few examples of complete and effective management by processes. Yet there is no doubt that management by processes is effective and efficient. Overall goals are reached, business results are achieved in more reliable ways and customers are more satisfied. The weaknesses found can be translated into a few comprehensive recommendations. A clear, structured and acknowledged model should be used and the processes should be described unambiguously. The changed management roles should be described and obeyed extremely legibly. New types of process objectives need to be formulated. In addition one fact needs to be observed and effectively fended off. Changes are often met by mental opposition on management level, as well as among co-workers. This fact needs attention and leadership. Safety development is closely related to the design and operation of a business management system and its continual improvement. A deep understanding of what constitutes an efficient and effective management system affects the understanding of safety. safety culture and abilities to achieve safety goals. Concerning risk, the opinions were unambiguous. Management by processes as such does not result in any further risks. On the contrary. Processes give a clear view of production and
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
[Patient identification errors and biological samples in the analytical process: Is it possible to improve patient safety?].

Science.gov (United States)

Cuadrado-Cenzual, M A; García Briñón, M; de Gracia Hills, Y; González Estecha, M; Collado Yurrita, L; de Pedro Moro, J A; Fernández Pérez, C; Arroyo Fernández, M

2015-01-01

Patient identification errors and biological samples are one of the problems with the highest risk factor in causing an adverse event in the patient. To detect and analyse the causes of patient identification errors in analytical requests (PIEAR) from emergency departments, and to develop improvement strategies. A process and protocol was designed, to be followed by all professionals involved in the requesting and performing of laboratory tests. Evaluation and monitoring indicators of PIEAR were determined, before and after the implementation of these improvement measures (years 2010-2014). A total of 316 PIEAR were detected in a total of 483,254 emergency service requests during the study period, representing a mean of 6.80/10,000 requests. Patient identification failure was the most frequent in all the 6-monthly periods assessed, with a significant difference (Perrors. However, we must continue working with this strategy, promoting a culture of safety for all the professionals involved, and trying to achieve the goal that 100% of the analytical and samples are properly identified. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.
ESTIMATION OF PROCESSES REALIZATION RISK AS A MANNER OF SAFETY MANAGEMENT IN THE INTEGRATED SYSTEMS

Directory of Open Access Journals (Sweden)

Tatiana Karkoszka

2011-12-01

Full Text Available Realization of quality, environmental and occupational health and safety policy using the proposed model of processes' integrated risk estimation leads to the improvement of the analyzed productive processes by the preventive and corrective actions, and in consequence - to their optimization from the point of view of products' quality and in the aspect of quality of environmental influence and occupational health and safety.
ESTIMATION OF PROCESSES REALIZATION RISK AS A MANNER OF SAFETY MANAGEMENT IN THE INTEGRATED SYSTEMS

Directory of Open Access Journals (Sweden)

Tatiana Karkoszka

2011-06-01

Full Text Available Realization of quality, environmental and occupational health and safety policy using the proposed model of processes' integrated risk estimation leads to the improvement of the analyzed productive processes by the preventive and corrective actions, and in consequence - to their optimization from the point of view of products' quality and in the aspect of quality of environmental influence and occupational health and safety.
To improve nuclear plant safety by learning from accident's experience

International Nuclear Information System (INIS)

Matsumoto, Hidezo; Kida, Masanori; Kato, Hiroyuki; Hara, Shin-ichi

1994-01-01

The ultimate goal of this study is to produce an expert system that enables the experience (records and information) gained from accidents to be put to use towards improving nuclear plant safety. A number of examples have been investigated, both domestic and overseas, in which experience gained from accidents was utilized by utilities in managing and operating their nuclear power stations to improve safety. The result of investigation has been used to create a general 'basic flow' to make the best use of experience. The ultimate goal is achieved by carrying out this 'basic flow' with artificial intelligence (AI). To do this, it is necessary (1) to apply language analysis to process the source information (primary data base; domestic and overseas accident's reports) into the secondary data base, and (2) to establish an expert system for selecting (screening) significant events from the secondary data base. In the processing described in item (1), a multi-lingual thesaurus for nuclear-related terms become necessary because the source information (primary data bases) itself is multi-lingual. In the work described in item (2), the utilization of probabilistic safety assessment (PSA), for example, is a candidate method for judging the significance of events. Achieving the goal thus requires developing various new techniques. As the first step of the above long-term study project, this report proposes the 'basic flow' and presents the concept of how the nuclear-related AI can be used to carry out this 'basic flow'. (author)
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

investigation result in timely corrective actions that effectively address vulnerabilities in existing work systems. Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.
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...
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
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.
Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.

Science.gov (United States)

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

2010-01-01

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

International Nuclear Information System (INIS)

Pasman, H.J.; Knegtering, B.; Rogers, W.J.

2013-01-01

system, the process industry is monitoring safety performance indicators. The critical intensity level upon which management must be alarmed is less simple. Risk assessment may be improved, made dynamic, and be a tool of process control by taking account of short-term risk fluctuations based on sensor signals and the influence of human factors with its long-term changes via indicators. Bayesian network can provide the infrastructure. The paper will describe various complexities when applying a holistic control of safety to a process plant in general, and it will more specifically focus on safeguarding measures such as barriers and other controls with some examples. -- Highlights: • Complexity of process installations makes risk control of a process challenging. • Erosive drift by cost pressure and efficiency increase may undermine safety level. • Resilience engineering in socio-psychological context analyzed this successfully. • There is prospect too to develop the technical side of process safety resilience. • Process safety performance indicator information may help to establish risk level
Demystifying process mapping: a key step in neurosurgical quality improvement initiatives.

Science.gov (United States)

McLaughlin, Nancy; Rodstein, Jennifer; Burke, Michael A; Martin, Neil A

2014-08-01

Reliable delivery of optimal care can be challenging for care providers. Health care leaders have integrated various business tools to assist them and their teams in ensuring consistent delivery of safe and top-quality care. The cornerstone to all quality improvement strategies is the detailed understanding of the current state of a process, captured by process mapping. Process mapping empowers caregivers to audit how they are currently delivering care to subsequently strategically plan improvement initiatives. As a community, neurosurgery has clearly shown dedication to enhancing patient safety and delivering quality care. A care redesign strategy named NERVS (Neurosurgery Enhanced Recovery after surgery, Value, and Safety) is currently being developed and piloted within our department. Through this initiative, a multidisciplinary team led by a clinician neurosurgeon has process mapped the way care is currently being delivered throughout the entire episode of care. Neurosurgeons are becoming leaders in quality programs, and their education on the quality improvement strategies and tools is essential. The authors present a comprehensive review of process mapping, demystifying its planning, its building, and its analysis. The particularities of using process maps, initially a business tool, in the health care arena are discussed, and their specific use in an academic neurosurgical department is presented.
Software Design Improvements. Part 2; Software Quality and the Design and Inspection Process

Science.gov (United States)

Lalli, Vincent R.; Packard, Michael H.; Ziemianski, Tom

1997-01-01

The application of assurance engineering techniques improves the duration of failure-free performance of software. The totality of features and characteristics of a software product are what determine its ability to satisfy customer needs. Software in safety-critical systems is very important to NASA. We follow the System Safety Working Groups definition for system safety software as: 'The optimization of system safety in the design, development, use and maintenance of software and its integration with safety-critical systems in an operational environment. 'If it is not safe, say so' has become our motto. This paper goes over methods that have been used by NASA to make software design improvements by focusing on software quality and the design and inspection process.
[Improving inpatient pharmacoterapeutic process by Lean Six Sigma methodology].

Science.gov (United States)

Font Noguera, I; Fernández Megía, M J; Ferrer Riquelme, A J; Balasch I Parisi, S; Edo Solsona, M D; Poveda Andres, J L

2013-01-01

Lean Six Sigma methodology has been used to improve care processes, eliminate waste, reduce costs, and increase patient satisfaction. To analyse the results obtained with Lean Six Sigma methodology in the diagnosis and improvement of the inpatient pharmacotherapy process during structural and organisational changes in a tertiary hospital. 1.000 beds tertiary hospital. prospective observational study. The define, measure, analyse, improve and control (DMAIC), were deployed from March to September 2011. An Initial Project Charter was updated as results were obtained. 131 patients with treatments prescribed within 24h after admission and with 4 drugs. safety indicators (medication errors), and efficiency indicators (complaints and time delays). Proportion of patients with a medication error was reduced from 61.0% (25/41 patients) to 55.7% (39/70 patients) in four months. Percentage of errors (regarding the opportunities for error) decreased in the different phases of the process: Prescription: from 5.1% (19/372 opportunities) to 3.3% (19/572 opportunities); Preparation: from 2.7% (14/525 opportunities) to 1.3% (11/847 opportunities); and administration: from 4.9% (16/329 opportunities) to 3.0% (13/433 opportunities). Nursing complaints decreased from 10.0% (2119/21038 patients) to 5.7% (1779/31097 patients). The estimated economic impact was 76,800 euros saved. An improvement in the pharmacotherapeutic process and a positive economic impact was observed, as well as enhancing patient safety and efficiency of the organization. Standardisation and professional training are future Lean Six Sigma candidate projects. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.
Improved technical specifications and related improvements to safety in commercial Nuclear power plants

International Nuclear Information System (INIS)

Hoffman, D.R.; Demitrack, T.; Schiele, R.; Jones, J.C.

2004-01-01

Many of the commercial nuclear power plants in the United States (US) have been converting a portion of the plant operating license known as the Technical Specifications (TS) in accordance with a document published by the US Nuclear Regulatory Commission (NRC). The TS prescribe commercial nuclear power plant operating requirements. There are several types of nuclear power plants in the US, based on the technology of different vendors, and there is an NRC document that supports each of the five different vendor designs. The NRC documents are known as the Improved Standard Technical Specifications (ISTS) and are contained in a separate document (NUREG series) for each one of the designs. EXCEL Services Corporation (hereinafter EXCEL) has played a major role in the development of the ISTS and in the development, licensing, and implementation of the plant specific Improved Technical Specifications (ITS) (which is based on the ISTS) for the commercial nuclear power plants in the US that have elected to make this conversion. There are currently 103 operating commercial nuclear power plants in the US and 68 of them have successfully completed the conversion to the ITS and are now operating in accordance with their plant specific ITS. The ISTS is focused mainly on safety by ensuring the commercial nuclear reactors can safely shut down and mitigate the consequences of any postulated transient and accident. It accomplishes this function by including requirements directly associated with safety in a document structured systematically and taking into account some key human factors and technical initiatives. This paper discusses the ISTS including its format, content, and detail, the history of the ISTS, the ITS development, licensing, and implementation process, the safety improvements resulting from a plant conversion to ITS, and the importance of the ITS Project to the industry. (Author)
Improved technical specifications and related improvements to safety in commercial Nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Hoffman, D.R.; Demitrack, T.; Schiele, R.; Jones, J.C. [EXCEL Services Corporation, 11921 Rockville Pike, Suite 100, Rockville, MD 20852 (United States)]. e-mail: donaldh@excelservices.com

2004-07-01

Many of the commercial nuclear power plants in the United States (US) have been converting a portion of the plant operating license known as the Technical Specifications (TS) in accordance with a document published by the US Nuclear Regulatory Commission (NRC). The TS prescribe commercial nuclear power plant operating requirements. There are several types of nuclear power plants in the US, based on the technology of different vendors, and there is an NRC document that supports each of the five different vendor designs. The NRC documents are known as the Improved Standard Technical Specifications (ISTS) and are contained in a separate document (NUREG series) for each one of the designs. EXCEL Services Corporation (hereinafter EXCEL) has played a major role in the development of the ISTS and in the development, licensing, and implementation of the plant specific Improved Technical Specifications (ITS) (which is based on the ISTS) for the commercial nuclear power plants in the US that have elected to make this conversion. There are currently 103 operating commercial nuclear power plants in the US and 68 of them have successfully completed the conversion to the ITS and are now operating in accordance with their plant specific ITS. The ISTS is focused mainly on safety by ensuring the commercial nuclear reactors can safely shut down and mitigate the consequences of any postulated transient and accident. It accomplishes this function by including requirements directly associated with safety in a document structured systematically and taking into account some key human factors and technical initiatives. This paper discusses the ISTS including its format, content, and detail, the history of the ISTS, the ITS development, licensing, and implementation process, the safety improvements resulting from a plant conversion to ITS, and the importance of the ITS Project to the industry. (Author)
Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.

Science.gov (United States)

Burnett, Susan; Benn, Jonathan; Pinto, Anna; Parand, Anam; Iskander, Sandra; Vincent, Charles

2010-08-01

Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding 'readiness' at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.
Guidelines regarding the Review Process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2011-01-01

These guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views [fr

Guidelines regarding the review process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2002-01-01

These guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views
Guidelines regarding the review process under the convention on nuclear safety

International Nuclear Information System (INIS)

1998-01-01

These guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing national reports submitted in accordance with Article 5 and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of national reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views
Guidelines regarding the Review Process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2011-01-01

These guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views
Guidelines regarding the review process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

1999-01-01

These guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing national reports submitted in accordance with Article 5 and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of national reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views
Guidelines regarding the Review Process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2011-01-01

These guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views [es
Safety monitoring in process and control

International Nuclear Information System (INIS)

Esparza, V. Jr.; Sebo, D.E.

1984-01-01

Safety Functions provide a method of ensuring the safe operation of any large-scale processing plant. Successful implementation of safety functions requires continuous monitoring of safety function values and trends. Because the volume of information handled by a plant operator occassionally can become overwhelming, attention may be diverted from the primary concern of maintaining plant safety. With this in mind EG and G, Idaho developed various methods and techniques for use in a computerized Safety Function Monitoring System and tested the application of these techniques using a simulated nuclear power plant, the Loss-of-Fluid Test Facility (LOFT) at the Idaho National Engineering Laboratory (INEL). This paper presents the methods used in the development of a Safety Function Monitoring System
Fire safety improvement of para-aramid fiber in thermoplastic polyurethane elastomer

International Nuclear Information System (INIS)

Chen, Xilei; Wang, Wenduo; Li, Shaoxiang; Jiao, Chuanmei

2017-01-01

Highlights: • Fire safety of para-aramid fiber on TPU has been investigated. • Para-aramid fiber has excellent flame retardant abilities and smoke suppression properties on TPU. • A new technique to improve the fire safety polymer is provided in this article. - Abstract: This article mainly studied fire safety effects of para-aramid fiber (AF) in thermoplastic polyurethane (TPU). The TPU/AF composites were prepared by molten blending method, and then the fire safety effects of all TPU composites were tested using cone calorimeter test (CCT), microscale combustion colorimeter test (MCC), smoke density test (SDT), and thermogravimetric/fourier transform infrared spectroscopy (TG-IR). The CCT test showed that AF could improve the fire safety of TPU. Remarkably, the peak value of heat release rate (pHRR) and the peak value of smoke production rate (pSPR) for the sample with 1.0 wt% content of AF were decreased by 52.0% and 40.5% compared with pure TPU, respectively. The MCC test showed that the HRR value of AF-2 decreased by 27.6% compared with pure TPU. TG test showed that AF promoted the char formation in the degradation process of TPU; as a result the residual carbon was increased. The TG-IR test revealed that AF had increased the thermal stability of TPU at the beginning and reduced the release of CO_2 with the decomposition going on. Through the analysis of the results of this experiment, it will make a great influence on the study of the para-aramid fiber in the aspect of fire safety of polymer.
Fire safety improvement of para-aramid fiber in thermoplastic polyurethane elastomer

Energy Technology Data Exchange (ETDEWEB)

Chen, Xilei; Wang, Wenduo; Li, Shaoxiang; Jiao, Chuanmei, E-mail: jiaochm@qust.edu.cn

2017-02-15

Highlights: • Fire safety of para-aramid fiber on TPU has been investigated. • Para-aramid fiber has excellent flame retardant abilities and smoke suppression properties on TPU. • A new technique to improve the fire safety polymer is provided in this article. - Abstract: This article mainly studied fire safety effects of para-aramid fiber (AF) in thermoplastic polyurethane (TPU). The TPU/AF composites were prepared by molten blending method, and then the fire safety effects of all TPU composites were tested using cone calorimeter test (CCT), microscale combustion colorimeter test (MCC), smoke density test (SDT), and thermogravimetric/fourier transform infrared spectroscopy (TG-IR). The CCT test showed that AF could improve the fire safety of TPU. Remarkably, the peak value of heat release rate (pHRR) and the peak value of smoke production rate (pSPR) for the sample with 1.0 wt% content of AF were decreased by 52.0% and 40.5% compared with pure TPU, respectively. The MCC test showed that the HRR value of AF-2 decreased by 27.6% compared with pure TPU. TG test showed that AF promoted the char formation in the degradation process of TPU; as a result the residual carbon was increased. The TG-IR test revealed that AF had increased the thermal stability of TPU at the beginning and reduced the release of CO{sub 2} with the decomposition going on. Through the analysis of the results of this experiment, it will make a great influence on the study of the para-aramid fiber in the aspect of fire safety of polymer.
Safety assessment of the liquid-fed ceramic melter process

International Nuclear Information System (INIS)

Buelt, J.L.; Partain, W.L.

1980-08-01

As part of its development program for the solidification of high-level nuclear waste, Pacific Northwest Laboratory assessed the safety issues for a complete liquid-fed ceramic melter (LFCM) process. The LFCM process, an adaption of commercial glass-making technology, is being developed to convert high-level liquid waste from the nuclear fuel cycle into glass. This safety assessment uncovered no unresolved or significant safety problems with the LFCM process. Although in this assessment the LFCM process was not directly compared with other solidification processes, the safety hazards of the LFCM process are comparable to those of other processes. The high processing temperatures of the glass in the LFCM pose no additional significant safety concerns, and the dispersible inventory of dried waste (calcine) is small. This safety assessment was based on the nuclear power waste flowsheet, since power waste is more radioactive than defense waste at the time of solidification, and all accident conditions for the power waste would have greater radiological consequences than those for defense waste. An exhaustive list of possible off-standard conditions and equipment failures was compiled. These accidents were then classified according to severity of consequence and type of accident. Radionuclide releases to the stack were calculated for each group of accidents using conservative assumptions regarding the retention and decontamination features of the process and facility. Two recommendations that should be considered by process designers are given in the safety assessment
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.
Improvement in Patient Transfer Process From the Operating Room to the PICU Using a Lean and Six Sigma-Based Quality Improvement Project.

Science.gov (United States)

Gleich, Stephen J; Nemergut, Michael E; Stans, Anthony A; Haile, Dawit T; Feigal, Scott A; Heinrich, Angela L; Bosley, Christopher L; Tripathi, Sandeep

2016-08-01

Ineffective and inefficient patient transfer processes can increase the chance of medical errors. Improvements in such processes are high-priority local institutional and national patient safety goals. At our institution, nonintubated postoperative pediatric patients are first admitted to the postanesthesia care unit before transfer to the PICU. This quality improvement project was designed to improve the patient transfer process from the operating room (OR) to the PICU. After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of the process to determine error-prone and inefficient areas. We evaluated primary outcome measures of handoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction was evaluated as a counterbalance measure. With the introduction of the new direct OR-PICU patient transfer process, the handoff communication error rate improved from 1.9 to 0.3 errors per patient handoff (P = .002). Inefficiency (patient wait time and non-value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved with fewer information omissions (P improved among nearly all PICU providers. By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustained improvements in patient safety and efficiency. Handoff communication was enhanced, with fewer errors and content omissions. The new process improved efficiency, with high staff satisfaction. Copyright © 2016 by the American Academy of Pediatrics.
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
Analysis of the Convention on Nuclear Safety and Suggestions for Improvement

International Nuclear Information System (INIS)

Choi, K. S.; Viet, Phuong Nguyen

2013-01-01

The innovative approach of the Convention, which is based on incentive after than legal binding, had been considered successful in strengthening the nuclear safety worldwide. However, the nuclear accident at the Fukushima Dai-ichi Nuclear Power Plant (Japan) in March 2011 has exposed a number of weaknesses of the Convention. Given that context, this paper will analyse the characteristics of the CNS in order to understand the advantages and disadvantages of the Convention, and finally to suggest some possible improvements. The analysis in this paper shows that the incentive approach of the CNS has succeeded in facilitating the active roles of its Contracting Parties in making the National Reports and participating in the peer review of these reports. However, the incoherent quality of the National Reports, the different level of participation in the peer review process by different Contracting Parties, and the lack of transparency of the peer review have undermined the effectiveness of the Convention in strengthening the international safety regime as well as preventing serious regulatory errors that had happened in Japan before the Fukushima accident. Therefore, the peer review process should be reformed into a more transparent and independent direction, while an advisory group of regulators within the CNS might also be useful in improving the effectiveness of the Convention as already proven by the good practice in the European Union. Only with such effective change, the CNS can maintain its pivotal role in the international safety regime
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
Issues to improve the safety of 18K370 steam turbine operation

Directory of Open Access Journals (Sweden)

Bzymek Grzegorz

2017-01-01

Full Text Available The paper presents the process of improving the safety and reliability of operation the 18K370 steam turbines Opole Power Plant since the first failure in 2010 [1], up to install the on-line monitoring system [2]. It shows how the units work and how to analyse the contol stage as a critical node in designing the turbine. Selected results of the analysis of the strength of CSD (Computational Solid Dynamic and the nature of the flow in different operating regimes - thanks to CFD (Computational Fluid Dynamic analysis have been included. We have also briefly discussed the way of lifecycle management of individual elements [2,3]. The presented actions could be considered satisfactory, and improve the safety of operating steam turbines of type 18K370.
Improving medication safety in primary care. A review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

NARCIS (Netherlands)

Lainer, M.; Vogele, A.; Wensing, M.; Sonnichsen, A.

2015-01-01

BACKGROUND: Drug treatment is an important clinical process in primary care that is associated with risk of error and adverse events. OBJECTIVE: To review currently available research evidence on the topic and to develop a framework, which can help to guide improvement of medication safety. METHODS:
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)

Are classical process safety concepts relevant to nanotechnology applications?

International Nuclear Information System (INIS)

Amyotte, Paul R

2011-01-01

The answer to the question posed by the title of this paper is yes - with adaptation to the specific hazards and challenges found in the field of nanotechnology. The validity of this affirmative response is demonstrated by relating key process safety concepts to various aspects of the nanotechnology industry in which these concepts are either already practised or could be further applied. This is accomplished by drawing on the current author's experience in process safety practice and education as well as a review of the relevant literature on the safety of nanomaterials and their production. The process safety concepts selected for analysis include: (i) risk management, (ii) inherently safer design, (iii) human error and human factors, (iv) safety management systems, and (v) safety culture.
Process and plant safety

CERN Document Server

Hauptmanns, Ulrich

2015-01-01

Accidents in technical installations are random events. Hence they cannot be totally avoided. Only the probability of their occurrence may be reduced and their consequences be mitigated. The book proceeds from hazards caused by materials and process conditions to indicating technical and organizational measures for achieving the objectives of reduction and mitigation. Qualitative methods for identifying weaknesses of design and increasing safety as well as models for assessing accident consequences are presented. The quantitative assessment of the effectiveness of safety measures is explained. The treatment of uncertainties plays a role there. They stem from the random character of the accident and from lacks of knowledge on some of the phenomena to be addressed. The reader is acquainted with the simulation of accidents, safety and risk analyses and learns how to judge the potential and limitations of mathematical modelling. Risk analysis is applied amongst others to “functional safety” and the determinat...
Implementing electronic handover: interventions to improve efficiency, safety and sustainability.

Science.gov (United States)

Alhamid, Sharifah Munirah; Lee, Desmond Xue-Yuan; Wong, Hei Man; Chuah, Matthew Bingfeng; Wong, Yu Jun; Narasimhalu, Kaavya; Tan, Thuan Tong; Low, Su Ying

2016-10-01

Effective handovers are critical for patient care and safety. Electronic handover tools are increasingly used today to provide an effective and standardized platform for information exchange. The implementation of an electronic handover system in tertiary hospitals can be a major challenge. Previous efforts in implementing an electronic handover tool failed due to poor compliance and buy-in from end-users. A new electronic handover tool was developed and incorporated into the existing electronic medical records (EMRs) for medical patients in Singapore General Hospital (SGH). There was poor compliance by on-call doctors in acknowledging electronic handovers, and lack of adherence to safety rules, raising concerns about the safety and efficiency of the electronic handover tool. Urgent measures were needed to ensure its safe and sustained use. A quality improvement group comprising stakeholders, including end-users, developed multi-faceted interventions using rapid PDSA (P-Plan, D-Do, S-Study, A-Act ) cycles to address these issues. Innovative solutions using media and online software provided cost-efficient measures to improve compliance. The percentage of unacknowledged handovers per day was used as the main outcome measure throughout all PDSA cycles. Doctors were also assessed for improvement in their knowledge of safety rules and their perception of the electronic handover tool. An electronic handover tool complementing daily clinical practice can be successfully implemented using solutions devised through close collaboration with end-users supported by the senior leadership. A combined 'bottom-up' and 'top-down' approach with regular process evaluations is crucial for its long-term sustainability. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
Guidelines regarding the Review Process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2013-01-01

These Guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 of the Convention and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views. [fr
Guidelines regarding the Review Process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2013-01-01

These Guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 of the Convention and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views.
Guidelines regarding the Review Process under the Convention on Nuclear Safety

International Nuclear Information System (INIS)

2013-01-01

These Guidelines, established by the Contracting Parties pursuant to Article 22 of the Convention, are intended to be read in conjunction with the text of the Convention. Their purpose is to provide guidance to the Contracting Parties on the process for reviewing National Reports submitted in accordance with Article 5 of the Convention and thereby to facilitate the efficient review of implementation by the Contracting Parties of their obligations under the Convention. The aim of the review process should be to achieve a thorough examination of National Reports submitted in accordance with Article 5 of the Convention, so that Contracting Parties can learn from each other's solutions to common and individual nuclear safety problems and, above all, contribute to improving nuclear safety worldwide through a constructive exchange of views. [es
Effectiveness evaluation methodology for safety processes to enhance organisational culture in hazardous installations

International Nuclear Information System (INIS)

Mengolini, A.; Debarberis, L.

2008-01-01

Safety performance indicators are widely collected and used in hazardous installations. The IAEA, OECD and other international organisations have developed approaches that strongly promote deployment of safety performance indicators. These indicators focus mainly on operational performance, but some of them also address organisational and safety culture aspects. However, operators of hazardous installations, in particular those with limited resources and time constraints, often find it difficult to collect the large number of different safety performance indicators. Moreover, they also have difficulties with giving a meaning to the numbers and trends recorded, especially to those that should reflect a positive safety culture. In this light, the aim of this article is to address the need to monitor and assess progress on implementation of a programme to enhance safety and organisational culture. It proposes a specific process-view approach to effectiveness evaluation of organisational and safety culture indicators by means of a multi-level system in which safety processes and staff involvement in defining improvement activities are central. In this way safety becomes fully embedded in staff activities. Key members of personnel become directly involved in identifying and supplying leading indicators relating to their own daily activity and become responsible and accountable for keeping the measurement system alive. Besides use of lagging indicators, particular emphasis is placed on the importance of identifying and selecting leading indicators which can be used to drive safety performance for organisational and safety culture aspects as well
Effectiveness evaluation methodology for safety processes to enhance organisational culture in hazardous installations.

Science.gov (United States)

Mengolini, A; Debarberis, L

2008-06-30

Safety performance indicators are widely collected and used in hazardous installations. The IAEA, OECD and other international organisations have developed approaches that strongly promote deployment of safety performance indicators. These indicators focus mainly on operational performance, but some of them also address organisational and safety culture aspects. However, operators of hazardous installations, in particular those with limited resources and time constraints, often find it difficult to collect the large number of different safety performance indicators. Moreover, they also have difficulties with giving a meaning to the numbers and trends recorded, especially to those that should reflect a positive safety culture. In this light, the aim of this article is to address the need to monitor and assess progress on implementation of a programme to enhance safety and organisational culture. It proposes a specific process-view approach to effectiveness evaluation of organisational and safety culture indicators by means of a multi-level system in which safety processes and staff involvement in defining improvement activities are central. In this way safety becomes fully embedded in staff activities. Key members of personnel become directly involved in identifying and supplying leading indicators relating to their own daily activity and become responsible and accountable for keeping the measurement system alive. Besides use of lagging indicators, particular emphasis is placed on the importance of identifying and selecting leading indicators which can be used to drive safety performance for organisational and safety culture aspects as well.
IAEA Issues Report on Mission to Review Japan's Nuclear Power Plant Safety Assessment Process

International Nuclear Information System (INIS)

2012-01-01

, the team highlighted good practices and also identified improvements that would enhance the overall effectiveness of the Comprehensive Safety Assessment process. 'I hope nuclear regulators around the world use this report as a tool to evaluate their own safety assessment processes'. Lyons said. 'We must learn the lessons of the Fukushima Daiichi accident so we can prevent a repeat of those terrible events a year ago.'' (IAEA)
Improvements of the Regulatory Framework for Nuclear Installations in the Areas of Human and Organizational Factors and Safety Culture

International Nuclear Information System (INIS)

Tronea, M.; Ciurea, C.

2016-01-01

The paper presents the development of regulatory requirements in the area of human and organizational factors taking account of the lessons learned from major accidents in the nuclear industry and in particular of the factors that contributed to the Fukushima Daiichi accident and the improvement of the regulatory oversight of nuclear safety culture. New requirements have been elaborated by the National Commission for Nuclear Activities Control (CNCAN) on the nuclear safety policy of licencees for nuclear installations, on independent nuclear safety oversight, on safety conscious work environment and on the assessment of nuclear safety culture. The regulatory process for the oversight of nuclear safety culture within licencees’ organizations operating nuclear installations and the associated procedure and guidelines, based on the IAEA Safety Standards, have been developed in 2010-2011. CNCAN has used the 37 IAEA attributes for a strong safety culture, grouped into five areas corresponding to safety culture characteristics, as the basis for its regulatory guidelines providing support to the reviewers and inspectors, in their routine activities, for recognising and gathering information relevant to safety culture. The safety culture oversight process, procedure and guidelines are in process of being reviewed and revised to improve their effectiveness and to align with the current international practices, using lessons learned from the Fukushima Daiichi accident. Starting with July 2014, Romania has a National Strategy for Nuclear Safety and Security, which includes strategic objectives, associated directions for action and concrete actions for promoting nuclear safety culture in all the organizations in the nuclear sector. The progress with the implementation of this strategy with regard to nuclear safety culture is described in the paper. CNCAN started to define its own organizational culture model and identifying the elements that promote and support safety
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.
Preventing hospital-acquired venous thromboembolism: Improving patient safety with interdisciplinary teamwork, quality improvement analytics, and data transparency.

Science.gov (United States)

Schleyer, Anneliese M; Robinson, Ellen; Dumitru, Roxana; Taylor, Mark; Hayes, Kimberly; Pergamit, Ronald; Beingessner, Daphne M; Zaros, Mark C; Cuschieri, Joseph

2016-12-01

Hospital-acquired venous thromboembolism (HA-VTE) is a potentially preventable cause of morbidity and mortality. Despite high rates of venous thromboembolism (VTE) prophylaxis in accordance with an institutional guideline, VTE remains the most common hospital-acquired condition in our institution. To improve the safety of all hospitalized patients, examine current VTE prevention practices, identify opportunities for improvement, and decrease rates of HA-VTE. Pre/post assessment. Urban academic tertiary referral center, level 1 trauma center, safety net hospital; all patients. We formed a multidisciplinary VTE task force to review all HA-VTE events, assess prevention practices relative to evidence-based institutional guidelines, and identify improvement opportunities. The task force developed an electronic tool to facilitate efficient VTE event review and designed decision-support and reporting tools, now integrated into the electronic health record, to bring optimal VTE prevention practices to the point of care. Performance is shared transparently across the institution. Harborview benchmarks process and outcome performance, including patient safety indicators and core measures, against hospitals nationally using Hospital Compare and Vizient data. Our program has resulted in >90% guideline-adherent VTE prevention and zero preventable HA-VTEs. Initiatives have resulted in a 15% decrease in HA-VTE and a 21% reduction in postoperative VTE. Keys to success include the multidisciplinary approach, clinical roles of task force members, senior leadership support, and use of quality improvement analytics for retrospective review, prospective reporting, and performance transparency. Ongoing task force collaboration with frontline providers is critical to sustained improvements. Journal of Hospital Medicine 2016;11:S38-S43. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.
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 construction site safety through leader-based verbal safety communication.

Science.gov (United States)

Kines, Pete; Andersen, Lars P S; Spangenberg, Soren; Mikkelsen, Kim L; Dyreborg, Johnny; Zohar, Dov

2010-10-01

. Coaching construction site foremen to include safety in their daily verbal exchanges with workers has a significantly positive and lasting effect on the level of safety, which is a proximal estimate for work-related accidents. It is recommended that future studies include coaching and feedback at all organizational levels and for all involved parties in the construction process. Building client regulations could assign the task of coaching to the client appointed safety coordinators or a manager/supervisor, and studies should measure longitudinal effects of coaching by following foremen and their work gangs from site to site. Copyright © 2010 National Safety Council and Elsevier Ltd. Published by Elsevier Ltd. All rights reserved.
Behavioral Emergency Response Team: Implementation Improves Patient Safety, Staff Safety, and Staff Collaboration.

Science.gov (United States)

Zicko, Cdr Jennifer M; Schroeder, Lcdr Rebecca A; Byers, Cdr William S; Taylor, Lt Adam M; Spence, Cdr Dennis L

2017-10-01

Staff members working on our nonmental health (non-MH) units (i.e., medical-surgical [MS] units) were not educated in recognizing or deescalating behavioral emergencies. Published evidence suggests a behavioral emergency response team (BERT) composed of MH experts who assist with deescalating behavioral emergencies may be beneficial in these situations. Therefore, we sought to implement a BERT on the inpatient non-MH units at our military treatment facility. The objectives of this evidence-based practice process improvement project were to determine how implementation of a BERT affects staff and patient safety and to examine nursing staffs' level of knowledge, confidence, and support in caring for psychiatric patients and patients exhibiting behavioral emergencies. A BERT was piloted on one MS unit for 5 months and expanded to two additional units for 3 months. Pre- and postimplementation staff surveys were conducted, and the number of staff assaults and injuries, restraint usage, and security intervention were compared. The BERT responded to 17 behavioral emergencies. The number of assaults decreased from 10 (pre) to 1 (post); security intervention decreased from 14 to 1; and restraint use decreased from 8 to 1. MS staffs' level of BERT knowledge and rating of support between MH staff and their staff significantly increased. Both MS and MH nurses rated the BERT as supportive and effective. A BERT can assist with deescalating behavioral emergencies, and improve staff collaboration and patient and staff safety. © 2017 Sigma Theta Tau International.
Monitoring the Long-Term Effectiveness of Integrated Safety Management System (ISMS) Implementation Through Use of a Performance Dashboard Process

International Nuclear Information System (INIS)

Kinney, Michael D.; Barrick, William D.

2008-01-01

This session will examine a method developed by Federal and Contractor personnel at the U.S. Department of Energy, National Nuclear Security Administration Nevada Site Office (NNSA/NSO) to examine long-term maintenance of DOE Integrated Safety Management System (ISMS) criteria, including safety culture attributes, as well as identification of process improvement opportunities. This process was initially developed in the summer of 2000 and has since been expanded to recognize the importance of safety culture attributes, and associated safety culture elements, as defined in DOE M 450.4-1, 'Integrated Safety Management System Manual'. This process has proven to significantly enhance collective awareness of the importance of long-term ISMS implementation as well as support commitments by NNSA/NSO personnel to examine the continued effectiveness of ISMS processes
Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

DEFF Research Database (Denmark)

Kristensen, Solvejg; Mainz, Jan; Bartels, Paul

2009-01-01

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

Science.gov (United States)

Halbesleben, Jonathon R B; Savage, Grant T; Wakefield, Douglas S; Wakefield, Bonnie J

2010-01-01

Health care organizations have redesigned existing and implemented new work processes intended to improve patient safety. As a consequence of these process changes, there are now intentionally designed "blocks" or barriers that limit how specific work actions, such as ordering and administering medication, are to be carried out. Health care professionals encountering these designed barriers can choose to either follow the new process, engage in workarounds to get past the block, or potentially repeat work (rework). Unfortunately, these workarounds and rework may lead to other safety concerns. The aim of this study was to examine rework and workarounds in hospital medication administration processes. Observations and semistructured interviews were conducted with 58 nurses from four hospital intensive care units focusing on the medication administration process. Using the constant comparative method, we analyzed the observation and interview data to develop themes regarding rework and workarounds. From this analysis, we developed an integrated process map of the medication administration process depicting blocks. A total of 12 blocks were reported by the participants. Based on the analysis, we categorized them as related to information exchange, information entry, and internal supply chain issues. Whereas information exchange and entry blocks tended to lead to rework, internal supply chain issues were more likely to lead to workarounds. A decentralized pharmacist on the unit may reduce work flow blocks (and, thus, workarounds and rework). Work process redesign may further address the problems of workarounds and rework.
Management by process based systems and safety focus; Verksamhetsstyrning med process-baserade ledningssystem och saekerhetsfokus

Energy Technology Data Exchange (ETDEWEB)

Rydnert, Bo; Groenlund, Bjoern [SIS Forum AB, Stockholm (Sweden)

2005-12-15

An initiative from The Swedish Nuclear Power Inspectorate led to this study carried out in the late autumn of 2005. The objective was to understand in more detail how an increasing use of process management affects organisations, on the one hand regarding risks and security, on the other hand regarding management by objectives and other management and operative effects. The main method was interviewing representatives of companies and independent experts. More than 20 interviews were carried out. In addition a literature study was made. All participating companies are using Management Systems based on processes. However, the methods chosen, and the results achieved, vary extensively. Thus, there are surprisingly few examples of complete and effective management by processes. Yet there is no doubt that management by processes is effective and efficient. Overall goals are reached, business results are achieved in more reliable ways and customers are more satisfied. The weaknesses found can be translated into a few comprehensive recommendations. A clear, structured and acknowledged model should be used and the processes should be described unambiguously. The changed management roles should be described and obeyed extremely legibly. New types of process objectives need to be formulated. In addition one fact needs to be observed and effectively fended off. Changes are often met by mental opposition on management level, as well as among co-workers. This fact needs attention and leadership. Safety development is closely related to the design and operation of a business management system and its continual improvement. A deep understanding of what constitutes an efficient and effective management system affects the understanding of safety. safety culture and abilities to achieve safety goals. Concerning risk, the opinions were unambiguous. Management by processes as such does not result in any further risks. On the contrary. Processes give a clear view of production and

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
Improving Safety through Human Factors Engineering.

Science.gov (United States)

Siewert, Bettina; Hochman, Mary G

2015-10-01

Human factors engineering (HFE) focuses on the design and analysis of interactive systems that involve people, technical equipment, and work environment. HFE is informed by knowledge of human characteristics. It complements existing patient safety efforts by specifically taking into consideration that, as humans, frontline staff will inevitably make mistakes. Therefore, the systems with which they interact should be designed for the anticipation and mitigation of human errors. The goal of HFE is to optimize the interaction of humans with their work environment and technical equipment to maximize safety and efficiency. Special safeguards include usability testing, standardization of processes, and use of checklists and forcing functions. However, the effectiveness of the safety program and resiliency of the organization depend on timely reporting of all safety events independent of patient harm, including perceived potential risks, bad outcomes that occur even when proper protocols have been followed, and episodes of "improvisation" when formal guidelines are found not to exist. Therefore, an institution must adopt a robust culture of safety, where the focus is shifted from blaming individuals for errors to preventing future errors, and where barriers to speaking up-including barriers introduced by steep authority gradients-are minimized. This requires creation of formal guidelines to address safety concerns, establishment of unified teams with open communication and shared responsibility for patient safety, and education of managers and senior physicians to perceive the reporting of safety concerns as a benefit rather than a threat. © RSNA, 2015.
IAEA Expert Team Completes Mission to Review Japan's Nuclear Power Plant Safety Assessment Process, 31 January 2012, Tokyo, Japan

International Nuclear Information System (INIS)

2012-01-01

Full text: A team of international nuclear safety experts today completed a review of Japan's two-stage process for assessing nuclear safety at the nation's nuclear power plants. The team began its work on 23 January and delivered a Preliminary Summary Report to Japanese officials today and plans to finish the final report by the end of February. National safety assessments and their peer review by the IAEA are a key component of the IAEA's Action Plan on Nuclear Safety, which was approved by the Agency's 152 Member States following last year's nuclear accident at Fukushima Daiichi Nuclear Power Station. At the request of the Government of Japan, the International Atomic Energy Agency (IAEA) organized a 10-person team to review the Japanese Nuclear and Industrial Safety Agency's (NISA) approach to the Comprehensive Assessments for the Safety of Existing Power Reactor Facilities and how NISA examines the results submitted by nuclear operators. The IAEA safety review mission consisted of five IAEA and three international nuclear safety experts. To help its review, the team held meetings in Tokyo with officials from NISA, the Japanese Nuclear Energy Safety (JNES) Organization, and the Kansai Electric Power Company (KEPCO), and the team visited the Ohi Nuclear Power Station to see an example of how Japan's Comprehensive Safety Assessment is being implemented by nuclear operators. 'We concluded that NISA's instructions to power plants and its review process for the Comprehensive Safety Assessments are generally consistent with IAEA Safety Standards', said team leader James Lyons, director of the IAEA's Nuclear Installation Safety Division. In its Preliminary Summary Report delivered today, the team highlighted a number of good practices and identified some improvements that would enhance the overall effectiveness of the Comprehensive Safety Assessment process. Good practices identified by the mission team include: Based on NISA instructions and commitments of the
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
Processes on Uncontrolled Aerodromes and Safety Indicators - Part II

Directory of Open Access Journals (Sweden)

Vladimír Plos

2014-01-01

Full Text Available This article follows on the Part I, where the basic processes on uncontrolled aerodromes were introduced. The uncontrolled aerodromes face with the growing traffic and from that result the higher workload on AFIS officer. This means a higher potential for dangerous situations.The article describes some models of sub-processes and creates several safety indicators related to the operation at uncontrolled aerodromes. Thanks to monitoring and evaluation of safety indicators can be adopted targeted safety measures and thus increase safety on small uncontrolled aerodromes.
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
Use of irradiation to ensure the microbiological safety of processed meats

International Nuclear Information System (INIS)

Thayer, D.W.; Lachica, R.V.; Huhtanen, C.N.; Wierbicki, E.

1986-01-01

Research studies are reviewed, concerning the use of ionizing radiation to extend the shelf life and improve the safety of processed meats. Topics include: the historical background of food irradiation research; the determination of fractional destruction (D) values for a microorganism at a given irradiation dose; the effect of chilling and of NaCl on D values; and a brief review of the irradiation research for different cured and uncured meats (bacon; ham; frankfurters; corned beef and pork sausage; and beef, chicken, and pork). Guidelines for producing safe processed meats through irradiation are included
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.
Improving patient safety in the radiation oncology setting through crew resource management.

Science.gov (United States)

Sundararaman, Srinath; Babbo, Angela E; Brown, John A; Doss, Richard

2014-01-01

This paper demonstrates how the communication patterns and protocol rigors of a methodology called crew resource management (CRM) can be adapted to a radiation oncology environment to create a culture of patient safety. CRM training was introduced to our comprehensive radiation oncology department in the autumn of 2009. With 34 full-time equivalent staff, we see 100-125 patients daily on 2 hospital campuses. We were assisted by a consulting group with considerable experience in helping hospitals incorporate CRM principles and practices. Implementation steps included developing change initiative skills for key leaders, providing training in teamwork and communications, creating site-specific tools for safety and efficiency, and collecting data to document results. Our goals were to improve patient safety, teamwork, communication, and efficiency through the use of tools we developed that emphasized teamwork and communication, cross-checking, and routinizing specific protocols. Our CRM plan relies on the following 4 pillars: patient identification methods; "pause for the cause"; enabling all staff to halt treatment and question decisions; and daily morning meetings. We discuss some of the hurdles to change we encountered. Our safety record has improved. Our near-miss rate before CRM implementation averaged 11 per month; our near-miss rate currently averages 1.2 per month. In the 5 years prior to CRM implementation, we experienced 1 treatment deviation per year, although none rose to the level of "mis-administration." Since implementing CRM, our current patient treatment setup and delivery process has eliminated all treatment deviations. Our practices have identified situations where ambiguity or conflicting documentation could have resulted in inappropriate treatment or treatment inefficiencies. Our staff members have developed an extraordinary sense of teamwork combined with a high degree of personal responsibility to assure patient safety and have spoken up when
The Evolution of Process Safety: Current Status and Future Direction.

Science.gov (United States)

Mannan, M Sam; Reyes-Valdes, Olga; Jain, Prerna; Tamim, Nafiz; Ahammad, Monir

2016-06-07

The advent of the industrial revolution in the nineteenth century increased the volume and variety of manufactured goods and enriched the quality of life for society as a whole. However, industrialization was also accompanied by new manufacturing and complex processes that brought about the use of hazardous chemicals and difficult-to-control operating conditions. Moreover, human-process-equipment interaction plus on-the-job learning resulted in further undesirable outcomes and associated consequences. These problems gave rise to many catastrophic process safety incidents that resulted in thousands of fatalities and injuries, losses of property, and environmental damages. These events led eventually to the necessity for a gradual development of a new multidisciplinary field, referred to as process safety. From its inception in the early 1970s to the current state of the art, process safety has come to represent a wide array of issues, including safety culture, process safety management systems, process safety engineering, loss prevention, risk assessment, risk management, and inherently safer technology. Governments and academic/research organizations have kept pace with regulatory programs and research initiatives, respectively. Understanding how major incidents impact regulations and contribute to industrial and academic technology development provides a firm foundation to address new challenges, and to continue applying science and engineering to develop and implement programs to keep hazardous materials within containment. Here the most significant incidents in terms of their impact on regulations and the overall development of the field of process safety are described.
Safety evaluation report of hot cell facilities for demonstration of advanced spent fuel conditioning process

International Nuclear Information System (INIS)

You, Gil Sung; Choung, W. M.; Ku, J. H.; Cho, I. J.; Kook, D. H.; Park, S. W.; Bek, S. Y.; Lee, E. P.

2004-10-01

The advanced spent fuel conditioning process(ACP) proposed to reduce the overall volume of the PWR spent fuel and improve safety and economy of the long-term storage of spent fuel. In the next phase(2004∼2006), the hot test will be carried out for verification of the ACP in a laboratory scale. For the hot test, the hot cell facilities of α- type and auxiliary facilities are required essentially for safe handling of high radioactive materials. As the hot cell facilities for demonstration of the ACP, a existing hot cell of β- type will be refurbished to minimize construction expenditures of hot cell facility. Up to now, the detail design of hot cell facilities and process were completed, and the safety analysis was performed to substantiate secure of conservative safety. The design data were submitted for licensing which was necessary for construction and operation of hot cell facilities. The safety investigation of KINS on hot cell facilities was completed, and the license for construction and operation of hot cell facilities was acquired already from MOST. In this report, the safety analysis report submitted to KINS was summarized. And also, the questionnaires issued from KINS and answers of KAERI in process of safety investigation were described in detail
[Improvement of medical processes with Six Sigma - practicable zero-defect quality in preparation for surgery].

Science.gov (United States)

Sobottka, Stephan B; Töpfer, Armin; Eberlein-Gonska, Maria; Schackert, Gabriele; Albrecht, D Michael

2010-01-01

Six Sigma is an innovative management- approach to reach practicable zero- defect quality in medical service processes. The Six Sigma principle utilizes strategies, which are based on quantitative measurements and which seek to optimize processes, limit deviations or dispersion from the target process. Hence, Six Sigma aims to eliminate errors or quality problems of all kinds. A pilot project to optimize the preparation for neurosurgery could now show that the Six Sigma method enhanced patient safety in medical care, while at the same time disturbances in the hospital processes and failure costs could be avoided. All six defined safety relevant quality indicators were significantly improved by changes in the workflow by using a standardized process- and patient- oriented approach. Certain defined quality standards such as a 100% complete surgical preparation at start of surgery and the required initial contact of the surgeon with the patient/ surgical record on the eve of surgery could be fulfilled within the range of practical zero- defect quality. Likewise, the degree of completion of the surgical record by 4 p.m. on the eve of surgery and their quality could be improved by a factor of 170 and 16, respectively, at sigma values of 4.43 and 4.38. The other two safety quality indicators "non-communicated changes in the OR- schedule" and the "completeness of the OR- schedule by 12:30 a.m. on the day before surgery" also show an impressive improvement by a factor of 2.8 and 7.7, respectively, corresponding with sigma values of 3.34 and 3.51. The results of this pilot project demonstrate that the Six Sigma method is eminently suitable for improving quality of medical processes. In our experience this methodology is suitable, even for complex clinical processes with a variety of stakeholders. In particular, in processes in which patient safety plays a key role, the objective of achieving a zero- defect quality is reasonable and should definitely be aspirated. Copyright
Improving patient safety and physician accountability using the hospital credentialing process

OpenAIRE

Forster, Alan J; Turnbull, Jeff; McGuire, Shaun; Ho, Michael L; Worthington, JR

2011-01-01

Abstract The lack of systematic oversight of physician performance has led to some serious cases related to physician competence and behaviour. We are currently implementing a hospital-wide approach to improve physician oversight by incorporating it into the hospital credentialing process. Our proposed credentialing method involves four systems: (1) a system for monitoring and reporting clinical performance; (2) a system for evaluating physician behaviour; (3) a complaints management system; ...
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.
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.
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.
Interim process report for the safety assessment SR-Can

International Nuclear Information System (INIS)

Sellin, Patrick

2004-08-01

This report is a documentation of buffer processes identified as relevant to the long-term safety of a KBS-3 repository. The report is part of the interim reporting of the safety assessment SR-Can, see further the Interim main report. The final SR-Can reporting will support SKB's application to build an Encapsulation plant for spent nuclear fuel and is to be produced in 2006. The purpose of this report is to document the scientific knowledge of the processes to a level required for an adequate treatment in the safety assessment. The documentation is thus from a scientific point of not exhaustive since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of an assessment. The purpose is further to determine the handling of each process in the safety assessment and to demonstrate how uncertainties are taken care of, given the suggested handling. The process documentation in the SR 97 version of the Process report is a starting point for this SR-Can interim version. As further described in the Interim main report, the list of relevant processes has been reviewed and slightly extended by comparison to other databases. Furthermore, the backfill has been included as a system part of its own, rather than being described together with the buffer as in SR 97. Apart from giving an interim account of the documentation and handling of buffer processes in SR-Can, this report is meant to serve as a template for the forthcoming documentation of processes occurring in other parts of the repository system. A complete list of processes can be found in the Interim FEP report for the safety assessment SR-Can. All material presented in this document is preliminary in nature and will possibly be updated as the SR-Can project progresses
Interim process report for the safety assessment SR-Can

Energy Technology Data Exchange (ETDEWEB)

Sellin, Patrick (ed.)

2004-08-01

This report is a documentation of buffer processes identified as relevant to the long-term safety of a KBS-3 repository. The report is part of the interim reporting of the safety assessment SR-Can, see further the Interim main report. The final SR-Can reporting will support SKB's application to build an Encapsulation plant for spent nuclear fuel and is to be produced in 2006. The purpose of this report is to document the scientific knowledge of the processes to a level required for an adequate treatment in the safety assessment. The documentation is thus from a scientific point of not exhaustive since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of an assessment. The purpose is further to determine the handling of each process in the safety assessment and to demonstrate how uncertainties are taken care of, given the suggested handling. The process documentation in the SR 97 version of the Process report is a starting point for this SR-Can interim version. As further described in the Interim main report, the list of relevant processes has been reviewed and slightly extended by comparison to other databases. Furthermore, the backfill has been included as a system part of its own, rather than being described together with the buffer as in SR 97. Apart from giving an interim account of the documentation and handling of buffer processes in SR-Can, this report is meant to serve as a template for the forthcoming documentation of processes occurring in other parts of the repository system. A complete list of processes can be found in the Interim FEP report for the safety assessment SR-Can. All material presented in this document is preliminary in nature and will possibly be updated as the SR-Can project progresses.
Integrating system safety into the basic systems engineering process

Science.gov (United States)

Griswold, J. W.

1971-01-01

The basic elements of a systems engineering process are given along with a detailed description of what the safety system requires from the systems engineering process. Also discussed is the safety that the system provides to other subfunctions of systems engineering.
Event (error and near-miss) reporting and learning system for process improvement in radiation oncology.

Science.gov (United States)

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

2010-09-01

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

Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum.

Science.gov (United States)

Lin, Yihan; Scott, John W; Yi, Sojung; Taylor, Kathryn K; Ntakiyiruta, Georges; Ntirenganya, Faustin; Banguti, Paulin; Yule, Steven; Riviello, Robert

2017-10-23

A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety. The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety. The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda. Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%). In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, pskills would improve patient outcomes. Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global
Test process for the safety-critical embedded software

International Nuclear Information System (INIS)

Sung, Ahyoung; Choi, Byoungju; Lee, Jangsoo

2004-01-01

Digitalization of nuclear Instrumentation and Control (I and C) system requires high reliability of not only hardware but also software. Verification and Validation (V and V) process is recommended for software reliability. But a more quantitative method is necessary such as software testing. Most of software in the nuclear I and C system is safety-critical embedded software. Safety-critical embedded software is specified, verified and developed according to V and V process. Hence two types of software testing techniques are necessary for the developed code. First, code-based software testing is required to examine the developed code. Second, after code-based software testing, software testing affected by hardware is required to reveal the interaction fault that may cause unexpected results. We call the testing of hardware's influence on software, an interaction testing. In case of safety-critical embedded software, it is also important to consider the interaction between hardware and software. Even if no faults are detected when testing either hardware or software alone, combining these components may lead to unexpected results due to the interaction. In this paper, we propose a software test process that embraces test levels, test techniques, required test tasks and documents for safety-critical embedded software. We apply the proposed test process to safety-critical embedded software as a case study, and show the effectiveness of it. (author)
Buffer and backfill process report for the safety assessment SR-Can

Energy Technology Data Exchange (ETDEWEB)

Sellin, Patrik (comp.)

2006-09-15

This document compiles information on processes in the buffer and deposition tunnel backfill relevant for long-term safety of a KBS-repository. It supports the safety assessment SR-Can, which is a preparatory step for a safety assessment that will support the licence application for a final repository in Sweden. The purpose of the process reports is to document the scientific knowledge of the processes to a level required for an adequate treatment of the processes in the safety assessment. The documentation is not exhaustive from a scientific point of view, since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of an assessment. However, it must be sufficiently detailed to motivate, by arguments founded on scientific understanding, the treatment of each process in the safety assessment. The purpose is further to determine how to handle each process in the safety assessment at an appropriate degree of detail, and to demonstrate how uncertainties are taken care of, given the suggested handling.
Buffer and backfill process report for the safety assessment SR-Can

International Nuclear Information System (INIS)

Sellin, Patrik

2006-09-01

This document compiles information on processes in the buffer and deposition tunnel backfill relevant for long-term safety of a KBS-repository. It supports the safety assessment SR-Can, which is a preparatory step for a safety assessment that will support the licence application for a final repository in Sweden. The purpose of the process reports is to document the scientific knowledge of the processes to a level required for an adequate treatment of the processes in the safety assessment. The documentation is not exhaustive from a scientific point of view, since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of an assessment. However, it must be sufficiently detailed to motivate, by arguments founded on scientific understanding, the treatment of each process in the safety assessment. The purpose is further to determine how to handle each process in the safety assessment at an appropriate degree of detail, and to demonstrate how uncertainties are taken care of, given the suggested handling
SU-E-T-452: Identifying Inefficiencies in Radiation Oncology Workflow and Prioritizing Solutions for Process Improvement and Patient Safety

Energy Technology Data Exchange (ETDEWEB)

Bennion, N; Driewer, J; Denniston, K; Zhen, W; Enke, C [University of Nebraska Medical Center, Omaha, NE (United States); Jacobs, K; Poole, M; McMahon, R; Wilson, K; Yager, A [Nebraska Medicine, Omaha, NE (United States)

2015-06-15

Purpose: Successful radiation therapy requires multi-step processes susceptible to unnecessary delays that can negatively impact clinic workflow, patient satisfaction, and safety. This project applied process improvement tools to assess workflow bottlenecks and identify solutions to barriers for effective implementation. Methods: We utilized the DMAIC (define, measure, analyze, improve, control) methodology, limiting our scope to the treatment planning process. From May through December of 2014, times and dates of each step from simulation to treatment were recorded for 507 cases. A value-stream map created from this dataset directed our selection of outcome measures (Y metrics). Critical goals (X metrics) that would accomplish the Y metrics were identified. Barriers to actions were binned into control-impact matrices, in order to stratify them into four groups: in/out of control and high/low impact. Solutions to each barrier were then categorized into benefit-effort matries to identify those of high benefit and low effort. Results: For 507 cases, the mean time from simulation to treatment was 235 total hours. The mean process and wait time were 60 and 132 hours, respectively. The Y metric was to increase the ratio of all non-emergent plans completed the business day prior to treatment from 47% to 75%. Project X metrics included increasing the number of IMRT QAs completed at least 24 hours prior to treatment from 19% to 80% and the number of non-IMRT plans approved at least 24 hours prior to treatment from 33% to 80%. Intervals from simulation to target contour and from initial plan completion to plan approval were identified as periods that could benefit from intervention. Barriers to actions were binned into control-impact matrices and solutions by benefit-effort matrices. Conclusion: The DMAIC method can be successfully applied in radiation therapy clinics to identify inefficiencies and prioritize solutions for the highest impact.
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.)
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)
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.
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)
A participatory model for improving occupational health and safety: improving informal sector working conditions in Thailand.

Science.gov (United States)

Manothum, Aniruth; Rukijkanpanich, Jittra; Thawesaengskulthai, Damrong; Thampitakkul, Boonwa; Chaikittiporn, Chalermchai; Arphorn, Sara

2009-01-01

The purpose of this study was to evaluate the implementation of an Occupational Health and Safety Management Model for informal sector workers in Thailand. The studied model was characterized by participatory approaches to preliminary assessment, observation of informal business practices, group discussion and participation, and the use of environmental measurements and samples. This model consisted of four processes: capacity building, risk analysis, problem solving, and monitoring and control. The participants consisted of four local labor groups from different regions, including wood carving, hand-weaving, artificial flower making, and batik processing workers. The results demonstrated that, as a result of applying the model, the working conditions of the informal sector workers had improved to meet necessary standards. This model encouraged the use of local networks, which led to cooperation within the groups to create appropriate technologies to solve their problems. The authors suggest that this model could effectively be applied elsewhere to improve informal sector working conditions on a broader scale.
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
Lessons learned from process incident databases and the process safety incident database (PSID) approach sponsored by the Center for Chemical Process Safety

International Nuclear Information System (INIS)

Sepeda, Adrian L.

2006-01-01

Learning from the experiences of others has long been recognized as a valued and relatively painless process. In the world of process safety, this learning method is an essential tool since industry has neither the time and resources nor the willingness to experience an incident before taking corrective or preventative steps. This paper examines the need for and value of process safety incident databases that collect incidents of high learning value and structure them so that needed information can be easily and quickly extracted. It also explores how they might be used to prevent incidents by increasing awareness and by being a tool for conducting PHAs and incident investigations. The paper then discusses how the CCPS PSID meets those requirements, how PSID is structured and managed, and its attributes and features
Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients.

Science.gov (United States)

Viejo Moreno, R; Sánchez-Izquierdo Riera, J Á; Molano Álvarez, E; Barea Mendoza, J A; Temprano Vázquez, S; Díaz Castellano, L; Montejo González, J C

2016-11-01

thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
Safety cases and siting processes

International Nuclear Information System (INIS)

Metlay, Daniel; Ewing, Rodney

2014-01-01

Central to any process for building a deep-mined geologic repository for high-activity radioactive waste is the development of a safety case. To date, such cases, in various forms have been elaborated for a variety of concepts for geologic disposal, including in salt, clay, argillite, crystalline rock (granite and gneiss) and volcanic tuff formations. In addition to the technical effort required to develop a safety case, increasingly nations have come to believe that it is also critical to obtain the consent of the region or community where the facility might be located. The purpose of this paper is to explore issues associated with just one aspect of consent-based siting: How can such a process be designed so that willingness to accept a site for a repository continues to be meaningful even as new technical knowledge and insights emerge during site characterisation? In short, what is the meaning of 'informed consent' in the context of repository development? (authors)
Strategies to Improve Management of Shoulder Dystocia Under the AHRQ Safety Program for Perinatal Care.

Science.gov (United States)

McArdle, Jill; Sorensen, Asta; Fowler, Christina I; Sommerness, Samantha; Burson, Katrina; Kahwati, Leila

2018-03-01

To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Mixed-methods implementation evaluation. Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action. Key informants were labor and delivery unit staff who implemented SPPC safety strategies. The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation. Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation. Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances. Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights
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
Investigating road safety management processes in Europe.

NARCIS (Netherlands)

Jähi, H. Muhlrad, N. Buttler, I. Gitelman, V. Bax, C. Dupont, E. Giustiniani, G. Machata, K. Martensen, H. Papadimitriou, E. Persia, L. Talbot, R. Vallet, G. & Yannis, G.

2012-01-01

The work package 1 of the EC FP7 project DaCoTA investigates road safety management processes in Europe. It has drafted a model to investigate the state of the art of road safety policy-making and management at the national level and to define “good practice”. The DaCoTA “good practice”
A toolbox for safety instrumented system evaluation based on improved continuous-time Markov chain

Science.gov (United States)

Wardana, Awang N. I.; Kurniady, Rahman; Pambudi, Galih; Purnama, Jaka; Suryopratomo, Kutut

2017-08-01

Safety instrumented system (SIS) is designed to restore a plant into a safe condition when pre-hazardous event is occur. It has a vital role especially in process industries. A SIS shall be meet with safety requirement specifications. To confirm it, SIS shall be evaluated. Typically, the evaluation is calculated by hand. This paper presents a toolbox for SIS evaluation. It is developed based on improved continuous-time Markov chain. The toolbox supports to detailed approach of evaluation. This paper also illustrates an industrial application of the toolbox to evaluate arch burner safety system of primary reformer. The results of the case study demonstrates that the toolbox can be used to evaluate industrial SIS in detail and to plan the maintenance strategy.
A graded approach to safety documentation at processing facilities

International Nuclear Information System (INIS)

Cowen, M.L.

1992-01-01

Westinghouse Savannah River Company (WSRC) has over 40 major Safety Analysis Reports (SARs) in preparation for non-reactor facilities. These facilities include nuclear material production facilities, waste management facilities, support laboratories and environmental remediation facilities. The SARs for these various projects encompass hazard levels from High to Low, and mission times from startup, through operation, to shutdown. All of these efforts are competing for scarce resources, and therefore some mechanism is required for balancing the documentation requirements. Three of the key variables useful for the decision making process are Depth of Safety Analysis, Urgency of Safety Analysis, and Resource Availability. This report discusses safety documentation at processing facilities

[A systemic risk analysis of hospital management processes by medical employees--an effective basis for improving patient safety].

Science.gov (United States)

Sobottka, Stephan B; Eberlein-Gonska, Maria; Schackert, Gabriele; Töpfer, Armin

2009-01-01

Due to the knowledge gap that exists between patients and health care staff the quality of medical treatment usually cannot be assessed securely by patients. For an optimization of safety in treatment-related processes of medical care, the medical staff needs to be actively involved in preventive and proactive quality management. Using voluntary, confidential and non-punitive systematic employee surveys, vulnerable topics and areas in patient care revealing preventable risks can be identified at an early stage. Preventive measures to continuously optimize treatment quality can be defined by creating a risk portfolio and a priority list of vulnerable topics. Whereas critical incident reporting systems are suitable for continuous risk assessment by detecting safety-relevant single events, employee surveys permit to conduct a systematic risk analysis of all treatment-related processes of patient care at any given point in time.
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.
Initialization of Safety Assessment Process for the Croatian Radioactive Waste repository on Trgovska gora

International Nuclear Information System (INIS)

Lokner, V.; Levanat, I.; Subasic, D.

2000-01-01

An iterative process of safety assessment, presently focusing on the site-specific evaluation of the post-closure phase for the prospective LILW repository on Trgovska gora in Croatia, has recently been initiated. The primary aim of the first assessment iterations is to provide the experts involved, the regulators and the general public with a reasonable assurance that the applicable long term performance and safety objectives can be met. Another goal is to develop a sufficient understanding of the system behavior to support decisions about the site investigation, the facility design, the waste acceptance criteria and the closure conditions. In this initial phase, the safety assessment is structured in a manner following closely methodology of the ISAM. The International Programme for Improving Long Term Safety Assessment Methodologies for Near Surface Radioactive Waste Disposal Facilities the IAEA coordinated research program started in 1997. Results of the safety assessment first iteration will be organized and presented in the form of a preliminary safety analysis report (PSAR), expected to be completed in the second part of the year 2000. As the first report on the initiated safety assessment activities, the PSAR will describe the concept and aims of the assessment process. Particular emphasis will be placed on description of the key elements of a safety assessment approach by: a) defining the assessment context; b) providing description of the disposal system; c) developing and justifying assessment scenarios; d) formulating and implementing models; and e) interpreting the scoping calculations. (author)
Improved nuclear power plant operations through performance-based safety regulation

International Nuclear Information System (INIS)

Golay, M.W.

1998-01-01

The US Nuclear Regulatory Commission (NRC) has recently instituted use of Risk-Informed, Performance-Based Regulation (RIPBR) for protecting public safety in the use of nuclear power. This was done most importantly during June 1997 in issuance of revised Regulatory Guides and Standard Review Plan (SRP) guidance to licensees and the NRC staff. The propose of RIPBR is to replace the previously-used system of prescriptive regulation, which focuses upon what licensees must do, to a system which focuses upon what they must achieve. RIPBR is goals-oriented and the previous system is means-oriented. This regulatory change is potentially revolutionary, and offers many opportunities for improving the efficiency of improving both nuclear power operations and safety. However, it must be nurtured carefully if is to be successful. The work reported in this paper is concerned with showing how RIPBR can be implemented successfully, with benefits in both areas being attained. It is also concerned with how several of the practical barriers to establishing a workable new regulatory system can be overcome. This work, sponsored by the US Dept. of Energy, is being performed in collaboration with Northeast Utilities Services Crop. and the Idaho National Engineering Laboratory. In our work we have examined a practical safety-related example at the Millstone 3 nuclear power station for implementation of RIPBR. In this examination we have formulated a set of modifications to the plant's technical specifications, and are in the process of investigating their bases and refining the modifications. (author)
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
[Experience feedback committee: a method for patient safety improvement].

Science.gov (United States)

François, P; Sellier, E; Imburchia, F; Mallaret, M-R

2013-04-01

An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
Contractor Work Preparation Process Improvement Using Lean Six Sigma

Directory of Open Access Journals (Sweden)

Asana Kusnadi

2016-06-01

Full Text Available To ensure the health and safety of their workforce and protection of their assets and the environment, a global oil and gas company operating in Indonesia requires comprehensive identification and evaluation of job hazards that were included in work permitting process prior work execution in the field. Based on 20 data points obtained in August 2013, start-working time for contractors who worked for Capital Project Management (CPM Team in Facility B was in average at 09.05 a.m. The aim of this paper is to present how the firm implemented Lean Six Sigma to reduce non-added value activities while fulfilling to its safety requirements and to share lessons learned from practical and theory testing perspective. The methodology used is Lean Six Sigma’s DMAIC (Define, Measure, Analyze, Improve, Control as mandated by the corporate policy of the firm. This research adopts a mix-methods approach, by using both qualitative and quantitative data. This study was a one year longitudinal study of the Lean Six Sigma implementation to improve contractors’ work preparation process. The improvement resulted in reduction of non-value added activities and successfully increased the available working time per day by 59.3 minutes in average. The results of this case study reconfirm Lean Six Sigma as a good management theory since it shows a consistency between the theory and the real practice in a global oil and gas company in Indonesia.
Licensing process for safety-critical software-based systems

Energy Technology Data Exchange (ETDEWEB)

Haapanen, P. [VTT Automation, Espoo (Finland); Korhonen, J. [VTT Electronics, Espoo (Finland); Pulkkinen, U. [VTT Automation, Espoo (Finland)

2000-12-01

System vendors nowadays propose software-based technology even for the most critical safety functions in nuclear power plants. Due to the nature of software faults and the way they cause system failures new methods are needed for the safety and reliability evaluation of these systems. In the research project 'Programmable automation systems in nuclear power plants (OHA)', financed together by the Radiation and Nuclear Safety Authority (STUK), the Ministry of Trade and Industry (KTM) and the Technical Research Centre of Finland (VTT), various safety assessment methods and tools for software based systems are developed and evaluated. As a part of the OHA-work a reference model for the licensing process for software-based safety automation systems is defined. The licensing process is defined as the set of interrelated activities whose purpose is to produce and assess evidence concerning the safety and reliability of the system/application to be licensed and to make the decision about the granting the construction and operation permissions based on this evidence. The parties of the licensing process are the authority, the licensee (the utility company), system vendors and their subcontractors and possible external independent assessors. The responsibility about the production of the evidence in first place lies at the licensee who in most cases rests heavily on the vendor expertise. The evaluation and gauging of the evidence is carried out by the authority (possibly using external experts), who also can acquire additional evidence by using their own (independent) methods and tools. Central issue in the licensing process is to combine the quality evidence about the system development process with the information acquired through tests, analyses and operational experience. The purpose of the licensing process described in this report is to act as a reference model both for the authority and the licensee when planning the licensing of individual applications
Licensing process for safety-critical software-based systems

International Nuclear Information System (INIS)

Haapanen, P.; Korhonen, J.; Pulkkinen, U.

2000-12-01

System vendors nowadays propose software-based technology even for the most critical safety functions in nuclear power plants. Due to the nature of software faults and the way they cause system failures new methods are needed for the safety and reliability evaluation of these systems. In the research project 'Programmable automation systems in nuclear power plants (OHA)', financed together by the Radiation and Nuclear Safety Authority (STUK), the Ministry of Trade and Industry (KTM) and the Technical Research Centre of Finland (VTT), various safety assessment methods and tools for software based systems are developed and evaluated. As a part of the OHA-work a reference model for the licensing process for software-based safety automation systems is defined. The licensing process is defined as the set of interrelated activities whose purpose is to produce and assess evidence concerning the safety and reliability of the system/application to be licensed and to make the decision about the granting the construction and operation permissions based on this evidence. The parties of the licensing process are the authority, the licensee (the utility company), system vendors and their subcontractors and possible external independent assessors. The responsibility about the production of the evidence in first place lies at the licensee who in most cases rests heavily on the vendor expertise. The evaluation and gauging of the evidence is carried out by the authority (possibly using external experts), who also can acquire additional evidence by using their own (independent) methods and tools. Central issue in the licensing process is to combine the quality evidence about the system development process with the information acquired through tests, analyses and operational experience. The purpose of the licensing process described in this report is to act as a reference model both for the authority and the licensee when planning the licensing of individual applications. Many of the
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)
Use of a risk assessment method to improve the safety of negative pressure wound therapy.

Science.gov (United States)

Lelong, Anne-Sophie; Martelli, Nicolas; Bonan, Brigitte; Prognon, Patrice; Pineau, Judith

2014-06-01

To conduct a risk analysis of the negative pressure wound therapy (NPWT) care process and to improve the safety of NPWT, a working group of nurses, hospital pharmacists, physicians and hospital managers performed a risk analysis for the process of NPWT care. The failure modes, effects and criticality analysis (FMECA) method was used for this analysis. Failure modes and their consequences were defined and classified as a function of their criticality to identify priority actions for improvement. By contrast to classical FMECA, the criticality index (CI) of each consequence was calculated by multiplying occurrence, severity and detection scores. We identified 13 failure modes, leading to 20 different consequences. The CI of consequences was initially 712, falling to 357 after corrective measures were implemented. The major improvements proposed included the establishment of 6-monthly training cycles for nurses, physicians and surgeons and the introduction of computerised prescription for NPWT. The FMECA method also made it possible to prioritise actions as a function of the criticality ranking of consequences and was easily understood and used by the working group. This study is, to our knowledge, the first to use the FMECA method to improve the safety of NPWT. © 2012 The Authors. International Wound Journal © 2012 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
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
Safety applications of computer based systems for the process industry

International Nuclear Information System (INIS)

Bologna, Sandro; Picciolo, Giovanni; Taylor, Robert

1997-11-01

Computer based systems, generally referred to as Programmable Electronic Systems (PESs) are being increasingly used in the process industry, also to perform safety functions. The process industry as they intend in this document includes, but is not limited to, chemicals, oil and gas production, oil refining and power generation. Starting in the early 1970's the wide application possibilities and the related development problems of such systems were recognized. Since then, many guidelines and standards have been developed to direct and regulate the application of computers to perform safety functions (EWICS-TC7, IEC, ISA). Lessons learnt in the last twenty years can be summarised as follows: safety is a cultural issue; safety is a management issue; safety is an engineering issue. In particular, safety systems can only be properly addressed in the overall system context. No single method can be considered sufficient to achieve the safety features required in many safety applications. Good safety engineering approach has to address not only hardware and software problems in isolation but also their interfaces and man-machine interface problems. Finally, the economic and industrial aspects of the safety applications and development of PESs in process plants are evidenced throughout all the Report. Scope of the Report is to contribute to the development of an adequate awareness of these problems and to illustrate technical solutions applied or being developed
Safety indicators: an efficient tool for a better safety

International Nuclear Information System (INIS)

Aufort, P.; Lars, R.

1993-01-01

Safety indicators based on the examination of the Operating Technical Specifications have been defined with the aim of following the in-operation safety level of French nuclear power plants. These safety indicators are operation feedback tools which permit the a posteriori justification and the adjustment of actual procedures. They would allow detection of an abnormal unavailability occurrence rate or a situation revealing a potential safety problem. So, data acquisition, processing, analysis and display software allowing trend analysis of these indicators has been developed so far as: a reflexion tool for the power plant operators about the safety instructions and the adjustment of preventive maintenance, and a help for decision making at a national level for the examination and the improvement of Operating Technical Specifications. This paper presents the objectives of these safety indicators, the processing tool associated, the preliminary results obtained and more elaborate processing of these indicators. These safety indicators may be very useful in framing probabilistic safety assessments. (author)
Learning from positively deviant wards to improve patient safety: an observational study protocol.

Science.gov (United States)

Baxter, Ruth; Taylor, Natalie; Kellar, Ian; Lawton, Rebecca

2015-12-11

Positive deviance is an asset-based approach to improvement which has recently been adopted to improve quality and safety within healthcare. The approach assumes that solutions to problems already exist within communities. Certain groups or individuals identify these solutions and succeed despite having the same resources as others. Within healthcare, positive deviance has previously been applied at individual or organisational levels to improve specific clinical outcomes or processes of care. This study explores whether the positive deviance approach can be applied to multidisciplinary ward teams to address the broad issue of patient safety among elderly patients. Preliminary work analysed National Health Service (NHS) Safety Thermometer data from 34 elderly medical wards to identify 5 'positively deviant' and 5 matched 'comparison' wards. Researchers are blinded to ward status. This protocol describes a multimethod, observational study which will (1) assess the concurrent validity of identifying positively deviant elderly medical wards using NHS Safety Thermometer data and (2) generate hypotheses about how positively deviant wards succeed. Patient and staff perceptions of safety will be assessed on each ward using validated surveys. Correlation and ranking analyses will explore whether this survey data aligns with the routinely collected NHS Safety Thermometer data. Staff focus groups and researcher fieldwork diaries will be completed and qualitative thematic content analysis will be used to generate hypotheses about the strategies, behaviours, team cultures and dynamics that facilitate the delivery of safe patient care. The acceptability and sustainability of strategies identified will also be explored. The South East Scotland Research Ethics Committee 01 approved this study (reference: 14/SS/1085) and NHS Permissions were granted from all trusts. Findings will be published in peer-reviewed, scientific journals, and presented at academic conferences. This study
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)
Nuclear safety culture and nuclear safety supervision

International Nuclear Information System (INIS)

Chai Jianshe

2013-01-01

In this paper, the author reviews systematically and summarizes up the development process and stage characteristics of nuclear safety culture, analysis the connotation and characteristics of nuclear safety culture, sums up the achievements of our country's nuclear safety supervision, dissects the challenges and problems of nuclear safety supervision. This thesis focused on the relationship between nuclear safety culture and nuclear safety supervision, they are essential differences, but there is a close relationship. Nuclear safety supervision needs to introduce some concepts of nuclear safety culture, lays emphasis on humanistic care and improves its level and efficiency. Nuclear safety supervision authorities must strengthen nuclear safety culture training, conduct the development of nuclear safety culture, make sure that nuclear safety culture can play significant roles. (author)
Do safety checklists improve teamwork and communication in the operating room? A systematic review.

Science.gov (United States)

Russ, Stephanie; Rout, Shantanu; Sevdalis, Nick; Moorthy, Krishna; Darzi, Ara; Vincent, Charles

2013-12-01

The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. Safety checklists are beneficial for OR teamwork and
Postharvest processes of edible insects in Africa: A review of processing methods, and the implications for nutrition, safety and new products development.

Science.gov (United States)

Mutungi, C; Irungu, F G; Nduko, J; Mutua, F; Affognon, H; Nakimbugwe, D; Ekesi, S; Fiaboe, K K M

2017-08-30

In many African cultures, insects are part of the diet of humans and domesticated animals. Compared to conventional food and feed sources, insects have been associated with a low ecological foot print because fewer natural resources are required for their production. To this end, the Food and Agriculture Organization of the United Nations recognized the role that edible insects can play in improving global food and nutrition security; processing technologies, as well as packaging and storage techniques that improve shelf-life were identified as being crucial. However, knowledge of these aspects in light of nutritional value, safety, and functionality is fragmentary and needs to be consolidated. This review attempts to contribute to this effort by evaluating the available evidence on postharvest processes for edible insects in Africa, with the aim of identifying areas that need research impetus. It further draws attention to potential postharvest technology options for overcoming hurdles associated with utilization of insects for food and feed. A greater research thrust is needed in processing and this can build on traditional knowledge. The focus should be to establish optimal techniques that improve presentation, quality and safety of products, and open possibilities to diversify use of edible insects for other benefits.

The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records.

Science.gov (United States)

Sittig, Dean F; Ash, Joan S; Singh, Hardeep

2014-05-01

Electronic health records (EHRs) have potential to improve quality and safety of healthcare. However, EHR users have experienced safety concerns from EHR design and usability features that are not optimally adapted for the complex work flow of real-world practice. Few strategies exist to address unintended consequences from implementation of EHRs and other health information technologies. We propose that organizations equipped with EHRs should consider the strategy of "proactive risk assessment" of their EHR-enabled healthcare system to identify and address EHR-related safety concerns. In this paper, we describe the conceptual underpinning of an EHR-related self-assessment strategy to provide institutions a foundation upon which they could build their safety efforts. With support from the Office of the National Coordinator for Health Information Technology (ONC), we used a rigorous, iterative process to develop a set of 9 self-assessment tools to optimize the safety and safe use of EHRs. These tools, referred to as the Safety Assurance Factors for EHR Resilience (SAFER) guides, could be used to self-assess safety and effectiveness of EHR implementations, identify specific areas of vulnerability, and create solutions and culture change to mitigate risks. A variety of audiences could conduct these assessments, including frontline clinicians or care teams in different practices, or clinical, quality, or administrative leaders within larger institutions. The guides use a multifaceted systems-based approach to assess risk and empower organizations to work with internal or external stakeholders (eg, EHR developers) on optimizing EHR functionality and using EHRs to drive improvements in the quality and safety of healthcare.
Geosphere process report for the safety assessment SR-Site

International Nuclear Information System (INIS)

Skagius, Kristina

2010-11-01

This report documents geosphere processes identified as relevant to the long-term safety of a KBS-3 repository, and forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/
Geosphere process report for the safety assessment SR-Site

Energy Technology Data Exchange (ETDEWEB)

Skagius, Kristina (ed.) (Kemakta Konsult AB, Stockholm (Sweden))

2010-11-15

This report documents geosphere processes identified as relevant to the long-term safety of a KBS-3 repository, and forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/
Safety assessment, safety performance indicators at the Paks Nuclear Power Plant

International Nuclear Information System (INIS)

Baji, C.; Vamos, G.; Toth, J.

2001-01-01

The Paks Nuclear Power Plant has been using different methods of safety assessment (event analysis, self-assessment, probabilistic safety analysis), including performance indicators characterizing both operational and safety performance since the early years of operation of the plant. Regarding the safety performance, the indicators include safety system performance, number of scrams, release of radioactive materials, number of safety significant events, industrial safety indicator, etc. The Paks NPP also reports a set of ten indicators to WANO Performance Indicator Programme which, among others, include safety related indicators as well. However, a more systematic approach to structuring and trending safety indicators is needed so that they can contribute to the enhancement of the operational safety. A more comprehensive set of indicators and a systematic evaluation process was introduced in 1996. The performance indicators framework proposed by the IAEA was adapted to Paks in this year to further improve the process. Safety culture assessment and characterizing safety culture is part of the assessment process. (author)
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...
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
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
EFFICIENT QUANTITATIVE RISK ASSESSMENT OF JUMP PROCESSES: IMPLICATIONS FOR FOOD SAFETY

OpenAIRE

Nganje, William E.

1999-01-01

This paper develops a dynamic framework for efficient quantitative risk assessment from the simplest general risk, combining three parameters (contamination, exposure, and dose response) in a Kataoka safety-first model and a Poisson probability representing the uncertainty effect or jump processes associated with food safety. Analysis indicates that incorporating jump processes in food safety risk assessment provides more efficient cost/risk tradeoffs. Nevertheless, increased margin of safety...
The safety relief valve handbook design and use of process safety valves to ASME and International codes and standards

CERN Document Server

Hellemans, Marc

2009-01-01

The Safety Valve Handbook is a professional reference for design, process, instrumentation, plant and maintenance engineers who work with fluid flow and transportation systems in the process industries, which covers the chemical, oil and gas, water, paper and pulp, food and bio products and energy sectors. It meets the need of engineers who have responsibilities for specifying, installing, inspecting or maintaining safety valves and flow control systems. It will also be an important reference for process safety and loss prevention engineers, environmental engineers, and plant and process designers who need to understand the operation of safety valves in a wider equipment or plant design context. . No other publication is dedicated to safety valves or to the extensive codes and standards that govern their installation and use. A single source means users save time in searching for specific information about safety valves. . The Safety Valve Handbook contains all of the vital technical and standards informat...
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 Healthcare Logistics Processes

DEFF Research Database (Denmark)

Feibert, Diana Cordes

logistics processes in hospitals and aims to provide theoretically and empirically based evidence for improving these processes to both expand the knowledge base of healthcare logistics and provide a decision tool for hospital logistics managers to improve their processes. Case studies were conducted...... processes. Furthermore, a method for benchmarking healthcare logistics processes was developed. Finally, a theoretically and empirically founded framework was developed to support managers in making an informed decision on how to improve healthcare logistics processes. This study contributes to the limited...... literature concerned with the improvement of logistics processes in hospitals. Furthermore, the developed framework provides guidance for logistics managers in hospitals on how to improve their processes given the circumstances in which they operate....
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 Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses.

Science.gov (United States)

Baldwin, Abigail; Rodriguez, Elizabeth S

2016-02-01

The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. This article will describe the role of the VN and details of the verification process. To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed. A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.
Making process improvement 'stick'.

Science.gov (United States)

Studer, Quint

2014-06-01

To sustain gains from a process improvement initiative, healthcare organizations should: Explain to staff why a process improvement initiative is needed. Encourage leaders within the organization to champion the process improvement, and tie their evaluations to its outcomes. Ensure that both leaders and employees have the skills to help sustain the sought-after process improvements.
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.
Multi-physics Modeling for Improving Li-Ion Battery Safety; NREL (National Renewable Energy Laboratory)

Energy Technology Data Exchange (ETDEWEB)

Pesaran, A.; Kim, G.; Santhanagopalan, S.; Yang, C.

2015-04-21

Battery performance, cost, and safety must be further improved for larger market share of HEVs/PEVs and penetration into the grid. Significant investment is being made to develop new materials, fine tune existing ones, improve cell and pack designs, and enhance manufacturing processes to increase performance, reduce cost, and make batteries safer. Modeling, simulation, and design tools can play an important role by providing insight on how to address issues, reducing the number of build-test-break prototypes, and accelerating the development cycle of generating products.
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.
Process Improvement Essentials

CERN Document Server

Persse, James R

2006-01-01

Process Improvement Essentials combines the foundation needed to understand process improvement theory with the best practices to help individuals implement process improvement initiatives in their organization. The three leading programs: ISO 9001:2000, CMMI, and Six Sigma--amidst the buzz and hype--tend to get lumped together under a common label. This book delivers a combined guide to all three programs, compares their applicability, and then sets the foundation for further exploration.
Integrating VR and knowledge-based technologies to facilitate the development of operator training systems and scenarios to improve process safety

NARCIS (Netherlands)

Shang, X.; Chung, P.W.H.; Vezzadini, L.; Loupos, K.; Hoekstra, W.

2006-01-01

Process safety can be regarded of paramount importance since any malfunction or mal-operation of a hazardous processing plant may lead to accidents that will cause damage to properties, injury to people and may even result in fatalities. This project investigates how Virtual Reality (VR) and
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

Safety Culture: Lessons Learned from the US Chemical Safety and Hazard Investigations Board

International Nuclear Information System (INIS)

Griffon, M.

2016-01-01

The U.S. Chemical Safety and Hazard Investigation Board (CSB) investigation of the 2005 BP Texas City Refinery disaster as well as the Baker Panel Report have set the stage for the consideration of human and organizational factors and safety culture as contributing causes of major accidents in the oil and gas industry. The investigation of the BP Texas City tragedy in many ways started a shift in the way the oil and chemical industry sectors looked at process safety and the importance of human and organizational factors in improving safety. Since the BP Texas City incident the CSB has investigated several incidents, including the 2010 Macondo disaster in the Gulf of Mexico, where organizational factors and safety culture, once again, were contributing causes of the incidents. In the Texas City incident the CSB found that “while most attention was focused on the injury rate, the overall safety culture and process safety management (PSM) program had serious deficiencies.” The CSB concluded that “safety campaigns, goals, and rewards focused on improving personal safety metrics and worker behaviors rather than on process safety and management safety systems.” The Baker panel, established as a result of a CSB recommendation, did a more extensive review of BPs safety culture. The Baker panel found that ‘while BP has aspirational goals of “no accidents, no harm to people” BP has not provided effective leadership in making certain it’s management and US refining workforce understand what is expected of them regarding process safety performance.’ This may have been in part due to a misinterpretation of positive trends in personal injury rates as an indicator of effective process safety. The panel also found that “at some of its US refineries BP has not established a positive, trusting and open environment with effective lines of communication between management and the workforce, including employee representatives.” In 2010 when the CSB began to
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…
Contribution of computerization to alarm processing: A French safety view

Energy Technology Data Exchange (ETDEWEB)

Cette, W [CEA Centre d` Etudes de Fontenay-aux-Roses, 92 (France). Inst. de Protection et de Surete Nucleaire

1997-09-01

Following the TMI accident and according to the requirement of the French safety authority, very important studies were performed by the French utility, Electricite de France (EDF), and assessed by the Institute for Nuclear Safety and Protection (IPSN) on reactor operation in conventional control rooms, particularly on alarm processing. These studies dealt with the man-machine interface, as well as design and exploitation requirements, presentation and management of alarm signals, and associated operating documents. The conclusions of these studies have led to improvements in French conventional control rooms. The current state of these control rooms and links between alarm sets and operating documents will be shortly presented in the first part of the paper. More recently, the computerized means implemented in the PWR 1400 MWe control rooms (N4) profoundly modified reactor operation. In particular, major advances concern alarm processing in comparison with conventional control rooms. The N4 plants provide a more rigorous approach in processing and presentation of alarms than in the past. Indeed, EDF wanted to have less alarms switched on during plant upsets and to make them more characteristic of a specific situation of the process. For example, computerization makes it easier to validate or inhibit alarms according to the situation, to allow the operator to manage alarm presentation and to propose on-line alarm sheets to the operator etc. This approach in comparison with conventional control rooms, and the IPSN assessment will be presented in the second part of this paper. (author).
Contribution of computerization to alarm processing: A French safety view

International Nuclear Information System (INIS)

Cette, W.

1997-01-01

Following the TMI accident and according to the requirement of the French safety authority, very important studies were performed by the French utility, Electricite de France (EDF), and assessed by the Institute for Nuclear Safety and Protection (IPSN) on reactor operation in conventional control rooms, particularly on alarm processing. These studies dealt with the man-machine interface, as well as design and exploitation requirements, presentation and management of alarm signals, and associated operating documents. The conclusions of these studies have led to improvements in French conventional control rooms. The current state of these control rooms and links between alarm sets and operating documents will be shortly presented in the first part of the paper. More recently, the computerized means implemented in the PWR 1400 MWe control rooms (N4) profoundly modified reactor operation. In particular, major advances concern alarm processing in comparison with conventional control rooms. The N4 plants provide a more rigorous approach in processing and presentation of alarms than in the past. Indeed, EDF wanted to have less alarms switched on during plant upsets and to make them more characteristic of a specific situation of the process. For example, computerization makes it easier to validate or inhibit alarms according to the situation, to allow the operator to manage alarm presentation and to propose on-line alarm sheets to the operator etc. This approach in comparison with conventional control rooms, and the IPSN assessment will be presented in the second part of this paper. (author)
A software engineering process for safety-critical software application

International Nuclear Information System (INIS)

Kang, Byung Heon; Kim, Hang Bae; Chang, Hoon Seon; Jeon, Jong Sun

1995-01-01

Application of computer software to safety-critical systems in on the increase. To be successful, the software must be designed and constructed to meet the functional and performance requirements of the system. For safety reason, the software must be demonstrated not only to meet these requirements, but also to operate safely as a component within the system. For longer-term cost consideration, the software must be designed and structured to ease future maintenance and modifications. This paper presents a software engineering process for the production of safety-critical software for a nuclear power plant. The presentation is expository in nature of a viable high quality safety-critical software development. It is based on the ideas of a rational design process and on the experience of the adaptation of such process in the production of the safety-critical software for the shutdown system number two of Wolsung 2, 3 and 4 nuclear power generation plants. This process is significantly different from a conventional process in terms of rigorous software development phases and software design techniques, The process covers documentation, design, verification and testing using mathematically precise notations and highly reviewable tabular format to specify software requirements and software requirements and software requirements and code against software design using static analysis. The software engineering process described in this paper applies the principle of information-hiding decomposition in software design using a modular design technique so that when a change is required or an error is detected, the affected scope can be readily and confidently located. it also facilitates a sense of high degree of confidence in the 'correctness' of the software production, and provides a relatively simple and straightforward code implementation effort. 1 figs., 10 refs. (Author)
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.
The Decision Making Trial and Evaluation Laboratory (Dematel) and Analytic Network Process (ANP) for Safety Management System Evaluation Performance

Science.gov (United States)

Rolita, Lisa; Surarso, Bayu; Gernowo, Rahmat

2018-02-01

In order to improve airport safety management system (SMS) performance, an evaluation system is required to improve on current shortcomings and maximize safety. This study suggests the integration of the DEMATEL and ANP methods in decision making processes by analyzing causal relations between the relevant criteria and taking effective analysis-based decision. The DEMATEL method builds on the ANP method in identifying the interdependencies between criteria. The input data consists of questionnaire data obtained online and then stored in an online database. Furthermore, the questionnaire data is processed using DEMATEL and ANP methods to obtain the results of determining the relationship between criteria and criteria that need to be evaluated. The study cases on this evaluation system were Adi Sutjipto International Airport, Yogyakarta (JOG); Ahmad Yani International Airport, Semarang (SRG); and Adi Sumarmo International Airport, Surakarta (SOC). The integration grades SMS performance criterion weights in a descending order as follow: safety and destination policy, safety risk management, healthcare, and safety awareness. Sturges' formula classified the results into nine grades. JOG and SMG airports were in grade 8, while SOG airport was in grade 7.
Beyond Texas City: the state of process safety in the unionized U.S. oil refining industry.

Science.gov (United States)

McQuiston, Thomas H; Lippin, Tobi Mae; Bradley-Bull, Kristin; Anderson, Joseph; Beach, Josie; Beevers, Gary; Frederick, Randy J; Frederick, James; Greene, Tammy; Hoffman, Thomas; Lefton, James; Nibarger, Kim; Renner, Paul; Ricks, Brian; Seymour, Thomas; Taylor, Ren; Wright, Mike

2009-01-01

The March 2005 British Petroleum (BP) Texas City Refinery disaster provided a stimulus to examine the state of process safety in the U.S. refining industry. Participatory action researchers conducted a nation-wide mail-back survey of United Steelworkers local unions and collected data from 51 unionized refineries. The study examined the prevalence of highly hazardous conditions key to the Texas City disaster, refinery actions to address those conditions, emergency preparedness and response, process safety systems, and worker training. Findings indicate that the key highly hazardous conditions were pervasive and often resulted in incidents or near-misses. Respondents reported worker training was insufficient and less than a third characterized their refineries as very prepared to respond safely to a hazardous materials emergency. The authors conclude that the potential for future disasters plagues the refining industry. In response, they call for effective proactive OSHA regulation and outline ten urgent and critical actions to improve refinery process safety.
How Differences Between Manager and Clinician Perceptions of Safety Culture Impact Hospital Processes of Care.

Science.gov (United States)

Richter, Jason; Mazurenko, Olena; Kazley, Abby Swanson; Ford, Eric W

2017-11-04

Evidenced-based processes of care improve patient outcomes, yet universal compliance is lacking, and perceptions of the quality of care are highly variable. The purpose of this study is to examine how differences in clinician and management perceptions on teamwork and communication relate to adherence to hospital processes of care. Hospitals submitted identifiable data for the 2012 Hospital Survey on Patient Safety Culture and the Centers for Medicare and Medicaid Services' Hospital Compare. The dependent variable was a composite, developed from the scores on adherence to acute myocardial infarction, heart failure, and pneumonia process of care measures. The primary independent variables reflected 4 safety culture domains: communication openness, feedback about errors, teamwork within units, and teamwork between units. We assigned each hospital into one of 4 groups based on agreement between managers and clinicians on each domain. Each hospital was categorized as "high" (above the median) or "low" (below) for clinicians and managers in communication and teamwork. We found a positive relationship between perceived teamwork and communication climate and processes of care measures. If managers and clinicians perceived the communication openness as high, the hospital was more likely to adhere with processes of care. Similarly, if clinicians perceived teamwork across units as high, the hospital was more likely to adhere to processes of care. Manager and staff perceptions about teamwork and communications impact adherence to processes of care. Policies should recognize the importance of perceptions of both clinicians and managers on teamwork and communication and seek to improve organizational climate and practices. Clinician perceptions of teamwork across units are more closely linked to processes of care, so managers should be cognizant and try to improve their perceptions.
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
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.
Radiation processing of minimally processed fruits and vegetables to ensure microbiological safety

International Nuclear Information System (INIS)

Bandekar, J.R.; Saroj, S.D.; Shashidhar, R.; Dhokane, V.S.; Hajare, S.N.; Nagar, V.; Sharma, A.

2009-01-01

Minimally processed fruits and vegetables are in demand as they offer ready rich source of nutrients and convenience to consumers. However, these products are often unsafe due to contamination with harmful pathogens. Therefore, a study was carried out to analyze microbiological quality of minimally processed fruits, vegetables and sprouts and to optimize radiation dose necessary to ensure safety of these commodities. Microbiological quality of these products was found to be poor. Decimal reduction dose (D 10 ) for Salmonella Typhimurium and Listeria monocytogenes in these minimally processed foods (MPF) were in the range of 164 to 588 Gy. Radiation processing with 2 kGy dose of gamma radiation resulted in 5 log reduction of S. Typhimurium and 4 log reduction of L. monocytogenes. The treatment did not significantly affect nutritional, organoleptic and textural properties. These results suggest that radiation processing can ensure safety of these products. (author)
System Safety in an IT Service Organization

Science.gov (United States)

Parsons, Mike; Scutt, Simon

Within Logica UK, over 30 IT service projects are considered safetyrelated. These include operational IT services for airports, railway infrastructure asset management, nationwide radiation monitoring and hospital medical records services. A recent internal audit examined the processes and documents used to manage system safety on these services and made a series of recommendations for improvement. This paper looks at the changes and the challenges to introducing them, especially where the service is provided by multiple units supporting both safety and non-safety related services from multiple locations around the world. The recommendations include improvements to service agreements, improved process definitions, routine safety assessment of changes, enhanced call logging, improved staff competency and training, and increased safety awareness. Progress is reported as of today, together with a road map for implementation of the improvements to the service safety management system. A proposal for service assurance levels (SALs) is discussed as a way forward to cover the wide variety of services and associated safety risks.
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)
Chemical process safety management within the Department of Energy

International Nuclear Information System (INIS)

Piatt, J.A.

1995-07-01

Although the Department of Energy (DOE) is not well known for its chemical processing activities, the DOE does have a variety of chemical processes covered under OSHA's Rule for Process Safety Management of Highly Hazardous Chemicals (the PSM Standard). DOE, like industry, is obligated to comply with the PSM Standard. The shift in the mission of DOE away from defense programs toward environmental restoration and waste management has affected these newly forming process safety management programs within DOE. This paper describes the progress made in implementing effective process safety management programs required by the PSM Standard and discusses some of the trends that have supported efforts to reduce chemical process risks within the DOE. In June of 1994, a survey of chemicals exceeding OSHA PSM or EPA Risk Management Program threshold quantities (TQs) at DOE sites found that there were 22 processes that utilized toxic or reactive chemicals over TQs; there were 13 processes involving flammable gases and liquids over TQs; and explosives manufacturing occurred at 4 sites. Examination of the survey results showed that 12 of the 22 processes involving toxic chemicals involved the use of chlorine for water treatment systems. The processes involving flammable gases and liquids were located at the Strategic Petroleum Reserve and Naval petroleum Reserve sites
Continuous improvement of the MHTGR safety and competitive performance

International Nuclear Information System (INIS)

Eichenberg, T.W.; Etzel, K.T.; Mascaro, L.L.; Rucker, R.A.

1992-05-01

An increase in reactor module power from 350 to 450 MW(t) would markedly improve the economics of the Modular High Temperature Gas-Cooled Reactor (MHTGR). The higher power level was recommended as the result of an in-depth cost reduction study undertaken to compete with the declining price of fossil fuel. The safety assessment confirms that the high level of safety, which relies on inherent characteristics and passive features, is maintained at the elevated power level. Preliminary systems, nuclear, and safety performance results are discussed for the recommended 450 MW(t) design. Optimization of plant parameters and design modifications accommodated the operation of the steam generator and circulator at the higher power level. Events in which forced cooling is lost, designated as conduction cooldowns are described in detail. For the depressurized conduction cooldown, without full helium inventory, peak fuel temperatures are significantly lowered. A more negative temperature coefficient of reactivity was achieved while maintaining an adequate fuel cycle and reactivity control. Continual improvement of the MHTGR delivers competitive performance without relinquishing the high safety margins demanded of the next generation of power plants
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.
Safety analysis of tritium processing system based on PHA

International Nuclear Information System (INIS)

Fu Wanfa; Luo Deli; Tang Tao

2012-01-01

Safety analysis on primary confinement of tritium processing system for TBM was carried out with Preliminary Hazard Analysis. Firstly, the basic PHA process was given. Then the function and safe measures with multiple confinements about tritium system were described and analyzed briefly, dividing the two kinds of boundaries of tritium transferring through, that are multiple confinement systems division and fluid loops division. Analysis on tritium releasing is the key of PHA. Besides, PHA table about tritium releasing was put forward, the causes and harmful results being analyzed, and the safety measures were put forward also. On the basis of PHA, several kinds of typical accidents were supposed to be further analyzed. And 8 factors influencing the tritium safety were analyzed, laying the foundation of evaluating quantitatively the safety grade of various nuclear facilities. (authors)
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)

Lactic acid bacteria and natural antimicrobials to improve the safety and shelf-life of minimally processed sliced apples and lamb's lettuce.

Science.gov (United States)

Siroli, Lorenzo; Patrignani, Francesca; Serrazanetti, Diana I; Tabanelli, Giulia; Montanari, Chiara; Gardini, Fausto; Lanciotti, Rosalba

2015-05-01

Outbreaks of food-borne disease associated with the consumption of fresh and minimally processed fruits and vegetables have increased dramatically over the last few years. Traditional chemical sanitizers are unable to completely eradicate or kill the microorganisms on fresh produce. These conditions have stimulated research to alternative methods for increasing food safety. The use of protective cultures, particularly lactic acid bacteria (LAB), has been proposed for minimally processed products. However, the application of bioprotective cultures has been limited at the industrial level. From this perspective, the main aims of this study were to select LAB from minimally processed fruits and vegetables to be used as biocontrol agents and then to evaluate the effects of the selected strains, alone or in combination with natural antimicrobials (2-(E)-hexenal/hexanal, 2-(E)-hexenal/citral for apples and thyme for lamb's lettuce), on the shelf-life and safety characteristics of minimally processed apples and lamb's lettuce. The results indicated that applying the Lactobacillus plantarum strains CIT3 and V7B3 to apples and lettuce, respectively, increased both the safety and shelf-life. Moreover, combining the selected strains with natural antimicrobials produced a further increase in the shelf-life of these products without detrimental effects on the organoleptic qualities. Copyright © 2014 Elsevier Ltd. All rights reserved.
Integrated Management System in construction company-effective tool of quality, environment and safety level improving

OpenAIRE

Gašparík, Jozef

2009-01-01

Contribution Presents the struCture of integrated M anageMent systeM ( iMs) according to international standards ISO 9001:2008, ISO 14001:2004 and STN OHSAS 18001:2009, which consists of 3 management systems focused to quality, environment and safety of building processes. The purpose of paper is to describe basic steps concerning the development of IMS. Paper analises basic processes of IMS like company vision, IMS planning, implementing, monitoring, revive and improving. The paper presents ...
The Implementation and Maintenance of a Behavioral Safety Process in a Petroleum Refinery

Science.gov (United States)

Myers, Wanda V.; McSween, Terry E.; Medina, Rixio E.; Rost, Kristen; Alvero, Alicia M.

2010-01-01

A values-centered and team-based behavioral safety process was implemented in a petroleum oil refinery. Employee teams defined the refinery's safety values and related practices, which were used to guide the process design and implementation. The process included (a) a safety assessment; (b) the clarification of safety-related values and related…
Status of the safety certification process of the TRANSRAPID system

Energy Technology Data Exchange (ETDEWEB)

Blomerius, J [TUEV Rheinland, Koeln (Germany). Inst. fuer Software, Elektronik, Bahntechnik

1996-12-31

Since 20 years TUeV Rheinland is involved in safety certification of maglev technology of the TRANSRAPID type. The process applied is called PASC (Programm Accompanying Safety Certification). The paper reports on safety assessment of relevant subsystems and components (TR07, OCS, guideway components) as well as safety certification in the final program. (HW)
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.
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.
Aviation Safety Reporting System: Process and Procedures

Science.gov (United States)

Connell, Linda J.

1997-01-01

The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.
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.
Microbial and preservative safety of fresh and processed fruit salads ...

African Journals Online (AJOL)

The producers and traders of fresh fruit and the processers should implement quality management practices and safety standards in farming, fresh fruit, processing and storage. This is to ensure safety, enhance consumption of fruits and fruit products for health of consumers and eliminate wastage. Key words: Fresh fruit, ...
Codifying knowledge to improve patient safety: a qualitative study of practice-based interventions.

Science.gov (United States)

Turner, Simon; Higginson, Juliet; Oborne, C Alice; Thomas, Rebecca E; Ramsay, Angus I G; Fulop, Naomi J

2014-07-01

Although it is well established that health care professionals use tacit and codified knowledge to provide front-line care, less is known about how these two forms of knowledge can be combined to support improvement related to patient safety. Patient safety interventions involving the codification of knowledge were co-designed by university and hospital-based staff in two English National Health Service (NHS) hospitals to support the governance of medication safety and mortality and morbidity (M&M) meetings. At hospital A, a structured mortality review process was introduced into three clinical specialities from January to December 2010. A qualitative approach of observing M&M meetings (n = 30) and conducting interviews (n = 40) was used to examine the impact on meetings and on front-line clinicians and hospital managers. At hospital B, a medication safety 'scorecard' was administered on a general medicine and elderly care ward from September to November 2011. Weekly feedback meetings were observed (n = 18) and interviews with front-line staff conducted (n = 10) to examine how knowledge codification influenced behaviour. Codification was shown to support learning related to patient safety at the micro (front-line service) level by structuring the sharing of tacit knowledge, but the presence of professional and managerial boundaries at the organisational level affected the codification initiatives' implementation. The findings suggest that codifying knowledge to support improvement presents distinct challenges at the group and organisational level; translating knowledge across these levels is contingent on the presence of enabling organisational factors, including the alignment of learning from clinical practice with its governance. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Probabilistic Safety Assessment of Waste from PyroGreen Processes

International Nuclear Information System (INIS)

Ju, Hee Jae; Ham, In hye; Hwang, Il Soon

2016-01-01

The main object of PyroGreen processes is decontaminating SNFs into intermediate level waste meeting U.S. WIPP contact-handled (CH) waste characteristics to achieve long-term radiological safety of waste disposal. In this paper, radiological impact of PyroGreen waste disposal is probabilistically assessed using domestic input parameters for safety assessment of disposal. PyroGreen processes is decontamination technology using pyro-chemical process developed by Seoul National University in collaboration with KAERI, Chungnam University, Korea Hydro-Nuclear Power and Yonsei University. Advanced Korean Reference Disposal System (A-KRS) design for vitrified waste is applied to develop safety assessment model using GoldSim software. The simulation result shows that PyroGreen vitrified waste is expected to satisfy the regulatory dose limit criteria, 0.1 mSv/yr. With small probability, however, radiological impact to public can be higher than the expected value after 2E5-year. Although the result implies 100 times safety margin even in that case, further study will be needed to assess the sensitivity of other input parameters which can affect the radiological impact for long-term.
Probabilistic Safety Assessment of Waste from PyroGreen Processes

Energy Technology Data Exchange (ETDEWEB)

Ju, Hee Jae; Ham, In hye; Hwang, Il Soon [Seoul National University, Seoul (Korea, Republic of)

2016-05-15

The main object of PyroGreen processes is decontaminating SNFs into intermediate level waste meeting U.S. WIPP contact-handled (CH) waste characteristics to achieve long-term radiological safety of waste disposal. In this paper, radiological impact of PyroGreen waste disposal is probabilistically assessed using domestic input parameters for safety assessment of disposal. PyroGreen processes is decontamination technology using pyro-chemical process developed by Seoul National University in collaboration with KAERI, Chungnam University, Korea Hydro-Nuclear Power and Yonsei University. Advanced Korean Reference Disposal System (A-KRS) design for vitrified waste is applied to develop safety assessment model using GoldSim software. The simulation result shows that PyroGreen vitrified waste is expected to satisfy the regulatory dose limit criteria, 0.1 mSv/yr. With small probability, however, radiological impact to public can be higher than the expected value after 2E5-year. Although the result implies 100 times safety margin even in that case, further study will be needed to assess the sensitivity of other input parameters which can affect the radiological impact for long-term.
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.
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.
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)
Process correlation analysis model for process improvement identification.

Science.gov (United States)

Choi, Su-jin; Kim, Dae-Kyoo; Park, Sooyong

2014-01-01

Software process improvement aims at improving the development process of software systems. It is initiated by process assessment identifying strengths and weaknesses and based on the findings, improvement plans are developed. In general, a process reference model (e.g., CMMI) is used throughout the process of software process improvement as the base. CMMI defines a set of process areas involved in software development and what to be carried out in process areas in terms of goals and practices. Process areas and their elements (goals and practices) are often correlated due to the iterative nature of software development process. However, in the current practice, correlations of process elements are often overlooked in the development of an improvement plan, which diminishes the efficiency of the plan. This is mainly attributed to significant efforts and the lack of required expertise. In this paper, we present a process correlation analysis model that helps identify correlations of process elements from the results of process assessment. This model is defined based on CMMI and empirical data of improvement practices. We evaluate the model using industrial data.
Advancing perinatal patient safety through application of safety science principles using health IT.

Science.gov (United States)

Webb, Jennifer; Sorensen, Asta; Sommerness, Samantha; Lasater, Beth; Mistry, Kamila; Kahwati, Leila

2017-12-19

The use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety. Semi-structured interviews were conducted with L&D units participating in the Agency for Healthcare Research and Quality's (AHRQ's) Safety Program for Perinatal Care (SPPC) to assess units' experience with program implementation. Analysis of interview transcripts was used to characterize the process and experience of using health IT for applying safety science principles to L&D unit processes. Forty-six L&D units from 10 states completed participation in SPPC program implementation; thirty-two (70%) reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects. L&D units standardized care processes through use of electronic health record (EHR)-based order sets and use of smart pumps and other technology to improve medication safety. Units also standardized EHR documentation, particularly related to electronic fetal monitoring (EFM) and shoulder dystocia. Cognitive aids and tools were integrated into EHR and care workflows to create independent checks such as checklists, risk assessments, and communication handoff tools. Units also used data from EHRs to monitor processes of care to learn from defects. Units experienced several challenges incorporating health IT, including obtaining organization approval, working with their busy IT departments, and retrieving standardized data from health IT systems. Use of health IT played an integral part in the planning and implementation of SPPC for participating L&D units. Use of health IT is an encouraging approach for incorporating safety science principles into care to improve perinatal safety and should be incorporated
Uncertainty in safety : new techniques for the assessment and optimisation of safety in process industry

NARCIS (Netherlands)

Rouvroye, J.L.; Nieuwenhuizen, J.K.; Brombacher, A.C.; Stavrianidis, P.; Spiker, R.Th.E.; Pyatt, D.W.

1995-01-01

At this moment there is no standardised method for the assessment for safety in the process industry. Many companies and institutes use qualitative techniques for safety analysis while other companies and institutes use quantitative techniques. The authors of this paper will compare different

Cost-Efficient Methods and Processes for Safety Relevant Embedded Systems (CESAR) - An Objective Overview

Science.gov (United States)

Jolliffe, Graham

For developing embedded safety critical systems, industrial companies have to face increasing complexity and variety coupled with increasing regulatory constraints, while costs, performances and time to market are constantly challenged. This has led to a profusion of enablers (new processes, methods and tools), which are neither integrated nor interoperable because they have been developed more or less independently (addressing only a part of the complexity: e.g. Safety) in the absence of internationally recognized open standards. CESAR has been established under ARTEMIS, the European Union's Joint Technology Initiative for research in embedded systems, with the aim to improve this situation and this pa-per will explain what CESAR's objectives are, how they are expected to be achieved and, in particular, how current best practice can ensure that safety engineering requirements can be met.
A concurrent diagnosis of microbiological food safety output and food safety management system performance: Cases from meat processing industries

NARCIS (Netherlands)

Luning, P.A.; Jacxsens, L.; Rovira, J.; Oses Gomez, S.; Uyttendaele, M.; Marcelis, W.J.

2011-01-01

Stakeholder requirements force companies to analyse their food safety management system (FSMS) performance to improve food safety. Performance is commonly analysed by checking compliance against preset requirements via audits/inspections, or actual food safety (FS) output is analysed by
Evaluation of industrial engineering students’ competencies for process improvement in hospitals

Directory of Open Access Journals (Sweden)

Lukasz Maciej Mazur

2010-12-01

Full Text Available The failures to properly educate students about process improvement can be seen as major factor leading to increased risks of patient safety and increased wastes in hospital settings. The purpose of this research was two-fold: 1 to identify characteristics that explain the efficacy of Plan-Do-Study-Act (PDSA based-tools while used by Industrial Engineering (IE students on multidisciplinary teams in hospital; 2 to identify competencies needed by IEs for effective process improvement in hospital using PDSA based-tools. Exploratory mixed method design approach with survey study, unstructured interviews, and focus group discussions was used to collect the data. A regression analysis was used to identify PDSA based-tool characteristics perceived by IE students as instrumental for process improvement. Next, the abductive inference was applied to analyze qualitative data in order to investigate competencies needed for effective process improvement using PDSA based-tools.Using regression analysis, we found the brainstorming via visualization, recognizing root-cause(s of the problem and selecting improvement measures via linking the process flow with task(s characteristics to be the significant characteristics. From qualitative data analysis, we learned that IE students strived in technical analysis but lacked competencies in analyzing qualitative data needed for change implementation efforts. There is increasing evidence that success in achieving process improvement goals is at least partially attributable to implementation processes and contexts and not just to the nature of the technical solution. Therefore, IE students interested in working in hospitals must develop new competencies related to qualitative data analysis to manage change initiatives.
The role of the PIRT process in identifying code improvements and executing code development

International Nuclear Information System (INIS)

Wilson, G.E.; Boyack, B.E.

1997-01-01

In September 1988, the USNRC issued a revised ECCS rule for light water reactors that allows, as an option, the use of best estimate (BE) plus uncertainty methods in safety analysis. The key feature of this licensing option relates to quantification of the uncertainty in the determination that an NPP has a low probability of violating the safety criteria specified in 10 CFR 50. To support the 1988 licensing revision, the USNRC and its contractors developed the CSAU evaluation methodology to demonstrate the feasibility of the BE plus uncertainty approach. The PIRT process, Step 3 in the CSAU methodology, was originally formulated to support the BE plus uncertainty licensing option as executed in the CSAU approach to safety analysis. Subsequent work has shown the PIRT process to be a much more powerful tool than conceived in its original form. Through further development and application, the PIRT process has shown itself to be a robust means to establish safety analysis computer code phenomenological requirements in their order of importance to such analyses. Used early in research directed toward these objectives, PIRT results also provide the technical basis and cost effective organization for new experimental programs needed to improve the safety analysis codes for new applications. The primary purpose of this paper is to describe the generic PIRT process, including typical and common illustrations from prior applications. The secondary objective is to provide guidance to future applications of the process to help them focus, in a graded approach, on systems, components, processes and phenomena that have been common in several prior applications
49 CFR 1106.4 - The Safety Integration Plan process.

Science.gov (United States)

2010-10-01

... 49 Transportation 8 2010-10-01 2010-10-01 false The Safety Integration Plan process. 1106.4 Section 1106.4 Transportation Other Regulations Relating to Transportation (Continued) SURFACE... CONSIDERATION OF SAFETY INTEGRATION PLANS IN CASES INVOLVING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS...
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.
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
Study on 'Safety qualification of process computers used in safety systems of nuclear power plants'

International Nuclear Information System (INIS)

Bertsche, K.; Hoermann, E.

1991-01-01

The study aims at developing safety standards for hardware and software of computer systems which are increasingly used also for important safety systems in nuclear power plants. The survey of the present state-of-the-art of safety requirements and specifications for safety-relevant systems and, additionally, for process computer systems has been compiled from national and foreign rules. In the Federal Republic of Germany the KTA safety guides and the BMI/BMU safety criteria have to be observed. For the design of future computer-aided systems in nuclear power plants it will be necessary to apply the guidelines in [DIN-880] and [DKE-714] together with [DIN-192]. With the aid of a risk graph the various functions of a system, or of a subsystem, can be evaluated with regard to their significance for safety engineering. (orig./HP) [de
SHEAR Kit case study : ConocoPhillips Canada leverages technology for health, safety and environmental operations to improve program effectiveness

Energy Technology Data Exchange (ETDEWEB)

Hayter, J. [Pangaea Systems Inc., Calgary, AB (Canada)

2003-07-01

This PowerPoint presentation outlined the elements of an automated safety program that Pangaea Systems Inc. has provided to ConocoPhillips Canada Ltd. SHEAR is a web-based computer application that centralizes health, safety and environment documentation to enable better reporting and improved business analysis of management involvement; hazard identification and risk control; rules and work procedures; training; communication; and, incident and accident reporting and investigation. SHEAR collects findings from audits, site inspections, safety meetings, hazards and risks, and accidents. Its purpose is to identify, classify and better understand events and to develop a process for remedial action. This presentation described SHEAR's incident severity potential index, the incident reporting process, and the elements of the management system. 8 figs.
Safety performance indicators used by the Russian Safety Regulatory Authority in its practical activities on nuclear power plant safety regulation

International Nuclear Information System (INIS)

Khazanov, A.L.

2005-01-01

The Sixth Department of the Nuclear, Industrial and Environmental Regulatory Authority of Russia, Scientific and Engineering Centre for Nuclear and Radiation Safety process, analyse and use the information on nuclear power plants (NPPs) operational experience or NPPs safety improvement. Safety performance indicators (SPIs), derived from processing of information on operational violations and analysis of annual NPP Safety Reports, are used as tools to determination of trends towards changing of characteristics of operational safety, to assess the effectiveness of corrective measures, to monitor and evaluate the current operational safety level of NPPs, to regulate NPP safety. This report includes a list of the basic SPIs, those used by the Russian safety regulatory authority in regulatory activity. Some of them are absent in list of IAEA-TECDOC-1141 ('Operational safety performance indicators for nuclear power plants'). (author)
Developing Process Maps as a Tool for a Surgical Infection Prevention Quality Improvement Initiative in Resource-Constrained Settings.

Science.gov (United States)

Forrester, Jared A; Koritsanszky, Luca A; Amenu, Demisew; Haynes, Alex B; Berry, William R; Alemu, Seifu; Jiru, Fekadu; Weiser, Thomas G

2018-06-01

Surgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety. We introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements. Process mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals. Enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
[Innovative technology and blood safety].

Science.gov (United States)

Begue, S; Morel, P; Djoudi, R

2016-11-01

If technological innovations are not enough alone to improve blood safety, their contributions for several decades in blood transfusion are major. The improvement of blood donation (new apheresis devices, RFID) or blood components (additive solutions, pathogen reduction technology, automated processing of platelets concentrates) or manufacturing process of these products (by automated processing of whole blood), all these steps where technological innovations were implemented, lead us to better traceability, more efficient processes, quality improvement of blood products and therefore increased blood safety for blood donors and patients. If we are on the threshold of a great change with the progress of pathogen reduction technology (for whole blood and red blood cells), we hope to see production of ex vivo red blood cells or platelets who are real and who open new conceptual paths on blood safety. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
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
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
Potential use of advanced process control for safety purposes during attack of a process plant

International Nuclear Information System (INIS)

Whiteley, James R.

2006-01-01

Many refineries and commodity chemical plants employ advanced process control (APC) systems to improve throughputs and yields. These APC systems utilize empirical process models for control purposes and enable operation closer to constraints than can be achieved with traditional PID regulatory feedback control. Substantial economic benefits are typically realized from the addition of APC systems. This paper considers leveraging the control capabilities of existing APC systems to minimize the potential impact of a terrorist attack on a process plant (e.g., petroleum refinery). Two potential uses of APC are described. The first is a conventional application of APC and involves automatically moving the process to a reduced operating rate when an attack first begins. The second is a non-conventional application and involves reconfiguring the APC system to optimize safety rather than economics. The underlying intent in both cases is to reduce the demands on the operator to allow focus on situation assessment and optimal response planning. An overview of APC is provided along with a brief description of the modifications required for the proposed new applications of the technology
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...
Process management - critical safety issues with focus on risk management; Processtyrning - kritiska saekerhetsfraagor med inriktning paa riskhantering

Energy Technology Data Exchange (ETDEWEB)

Sanne, Johan M. [Linkoeping Univ. (Sweden). The Tema Inst. - Technology and Social Change

2005-12-15

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

Science.gov (United States)

Bell, Ashley M; Bohannon, Jessica; Porthouse, Lisa; Thompson, Heather; Vago, Tony

The goal of the perinatal team at Mercy Hospital St. Louis is to provide a quality patient experience during labor and birth. After the move to a new labor and birth unit in 2013, the team recognized many of the routines and practices needed to be modified based on different demands. The Lean process was used to plan and implement required changes. This technique was chosen because it is based on feedback from clinicians, teamwork, strategizing, and immediate evaluation and implementation of common sense solutions. Through rapid improvement events, presence of leaders in the work environment, and daily huddles, team member engagement and communication were enhanced. The process allowed for team members to offer ideas, test these ideas, and evaluate results, all within a rapid time frame. For 9 months, frontline clinicians met monthly for a weeklong rapid improvement event to create better experiences for childbearing women and those who provide their care, using Lean concepts. At the end of each week, an implementation plan and metrics were developed to help ensure sustainment. The issues that were the focus of these process improvements included on-time initiation of scheduled cases such as induction of labor and cesarean birth, timely and efficient assessment and triage disposition, postanesthesia care and immediate newborn care completed within approximately 2 hours, transfer from the labor unit to the mother baby unit, and emergency transfers to the main operating room and intensive care unit. On-time case initiation for labor induction and cesarean birth improved, length of stay in obstetric triage decreased, postanesthesia recovery care was reorganized to be completed within the expected 2-hour standard time frame, and emergency transfers to the main hospital operating room and intensive care units were standardized and enhanced for efficiency and safety. Participants were pleased with the process improvements and quality outcomes. Working together as a team
Applying Sensor-Based Technology to Improve Construction Safety Management.

Science.gov (United States)

Zhang, Mingyuan; Cao, Tianzhuo; Zhao, Xuefeng

2017-08-11

Construction sites are dynamic and complicated systems. The movement and interaction of people, goods and energy make construction safety management extremely difficult. Due to the ever-increasing amount of information, traditional construction safety management has operated under difficult circumstances. As an effective way to collect, identify and process information, sensor-based technology is deemed to provide new generation of methods for advancing construction safety management. It makes the real-time construction safety management with high efficiency and accuracy a reality and provides a solid foundation for facilitating its modernization, and informatization. Nowadays, various sensor-based technologies have been adopted for construction safety management, including locating sensor-based technology, vision-based sensing and wireless sensor networks. This paper provides a systematic and comprehensive review of previous studies in this field to acknowledge useful findings, identify the research gaps and point out future research directions.

Software Process Improvement Defined

DEFF Research Database (Denmark)

Aaen, Ivan

2002-01-01

This paper argues in favor of the development of explanatory theory on software process improvement. The last one or two decades commitment to prescriptive approaches in software process improvement theory may contribute to the emergence of a gulf dividing theorists and practitioners....... It is proposed that this divide be met by the development of theory evaluating prescriptive approaches and informing practice with a focus on the software process policymaking and process control aspects of improvement efforts...
How important is vehicle safety in the new vehicle purchase process?

Science.gov (United States)

Koppel, Sjaanie; Charlton, Judith; Fildes, Brian; Fitzharris, Michael

2008-05-01

Whilst there has been a significant increase in the amount of consumer interest in the safety performance of privately owned vehicles, the role that it plays in consumers' purchase decisions is poorly understood. The aims of the current study were to determine: how important vehicle safety is in the new vehicle purchase process; what importance consumers place on safety options/features relative to other convenience and comfort features, and how consumers conceptualise vehicle safety. In addition, the study aimed to investigate the key parameters associated with ranking 'vehicle safety' as the most important consideration in the new vehicle purchase. Participants recruited in Sweden and Spain completed a questionnaire about their new vehicle purchase. The findings from the questionnaire indicated that participants ranked safety-related factors (e.g., EuroNCAP (or other) safety ratings) as more important in the new vehicle purchase process than other vehicle factors (e.g., price, reliability etc.). Similarly, participants ranked safety-related features (e.g., advanced braking systems, front passenger airbags etc.) as more important than non-safety-related features (e.g., route navigation systems, air-conditioning etc.). Consistent with previous research, most participants equated vehicle safety with the presence of specific vehicle safety features or technologies rather than vehicle crash safety/test results or crashworthiness. The key parameters associated with ranking 'vehicle safety' as the most important consideration in the new vehicle purchase were: use of EuroNCAP, gender and education level, age, drivers' concern about crash involvement, first vehicle purchase, annual driving distance, person for whom the vehicle was purchased, and traffic infringement history. The findings from this study are important for policy makers, manufacturers and other stakeholders to assist in setting priorities with regard to the promotion and publicity of vehicle safety features
The safety culture change process performed in Polish research reactor MARIA

International Nuclear Information System (INIS)

Golab, Andrzej

2002-01-01

The Safety Culture Change Process Performed in research reactor MARIA is described in this paper. The essential issues fulfilled in realization of the Safety Culture Enhancement Programme are related to the attitude and behaviour of top management, co-operating groups, operational personnel, relations between the operating organization and the supervising and advising organizations. Realization of this programme is based on changing the employees understanding of safety, changing their attitudes and behaviours by means of adequate training, requalification process and performing the broad self-assessment programme. Also a high level Quality Assurance Programme helps in development of the Safety Culture. (author)
The role of the PIRT process in identifying code improvements and executing code development

Energy Technology Data Exchange (ETDEWEB)

Wilson, G.E. [Idaho National Engineering Lab., Idaho Falls, ID (United States); Boyack, B.E. [Los Alamos National Lab., NM (United States)

1997-07-01

In September 1988, the USNRC issued a revised ECCS rule for light water reactors that allows, as an option, the use of best estimate (BE) plus uncertainty methods in safety analysis. The key feature of this licensing option relates to quantification of the uncertainty in the determination that an NPP has a {open_quotes}low{close_quotes} probability of violating the safety criteria specified in 10 CFR 50. To support the 1988 licensing revision, the USNRC and its contractors developed the CSAU evaluation methodology to demonstrate the feasibility of the BE plus uncertainty approach. The PIRT process, Step 3 in the CSAU methodology, was originally formulated to support the BE plus uncertainty licensing option as executed in the CSAU approach to safety analysis. Subsequent work has shown the PIRT process to be a much more powerful tool than conceived in its original form. Through further development and application, the PIRT process has shown itself to be a robust means to establish safety analysis computer code phenomenological requirements in their order of importance to such analyses. Used early in research directed toward these objectives, PIRT results also provide the technical basis and cost effective organization for new experimental programs needed to improve the safety analysis codes for new applications. The primary purpose of this paper is to describe the generic PIRT process, including typical and common illustrations from prior applications. The secondary objective is to provide guidance to future applications of the process to help them focus, in a graded approach, on systems, components, processes and phenomena that have been common in several prior applications.
Digital Signal Processing for In-Vehicle Systems and Safety

CERN Document Server

Boyraz, Pinar; Takeda, Kazuya; Abut, Hüseyin

2012-01-01

Compiled from papers of the 4th Biennial Workshop on DSP (Digital Signal Processing) for In-Vehicle Systems and Safety this edited collection features world-class experts from diverse fields focusing on integrating smart in-vehicle systems with human factors to enhance safety in automobiles. Digital Signal Processing for In-Vehicle Systems and Safety presents new approaches on how to reduce driver inattention and prevent road accidents. The material addresses DSP technologies in adaptive automobiles, in-vehicle dialogue systems, human machine interfaces, video and audio processing, and in-vehicle speech systems. The volume also features: Recent advances in Smart-Car technology – vehicles that take into account and conform to the driver Driver-vehicle interfaces that take into account the driving task and cognitive load of the driver Best practices for In-Vehicle Corpus Development and distribution Information on multi-sensor analysis and fusion techniques for robust driver monitoring and driver recognition ...
Responsible management for Health, Safety and Environment (HSE) in uranium mining and processing, starting from public support

International Nuclear Information System (INIS)

Saint-Pierre, S.

2014-01-01

Seeking, gaining and maintaining public support is inherent to mining and to responsible management in this sector. In particular, it holds special relevance for remote mining sites for which the buy in from the regional and local workforce and populations is a necessity all along the life span of a mining project from exploration to development, commissioning, operation, closure and restoration. This paper briefly highlights some key features to be accounted for nowadays for the successful development, shaping and implementation of mining projects with a view to improve public support. It is essential to address responsible management for health, safety and environment (HSE) in uranium mining and processing through key program elements such as policy; baseline; operational preparation for implementation; monitoring, reporting, review and continued improvements; as well as some insights on site closure and restoration. In particular, examples illustrate how these program elements are implemented in practice in uranium mining and processing. Some emphasis is put on radiation safety as responsible management for the other HSE dimensions tends to be analogous for all mines and mineral processing sites. (author)
A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

Science.gov (United States)

Rodriguez-Paz, Jose M; Mark, Lynette J; Herzer, Kurt R; Michelson, James D; Grogan, Kelly L; Herman, Joseph; Hunt, David; Wardlow, Linda; Armour, Elwood P; Pronovost, Peter J

2009-01-01

Since the Institute of Medicine's report, To Err is Human, was published, numerous interventions have been designed and implemented to correct the defects that lead to medical errors and adverse events; however, most efforts were largely reactive. Safety, communication, team performance, and efficiency are areas of care that attract a great deal of attention, especially regarding the introduction of new technologies, techniques, and procedures. We describe a multidisciplinary process that was implemented at our hospital to identify and mitigate hazards before the introduction of a new technique: high-dose-rate intraoperative radiation therapy, (HDR-IORT). A multidisciplinary team of surgeons, anesthesiologists, radiation oncologists, physicists, nurses, hospital risk managers, and equipment specialists used a structured process that included in situ clinical simulation to uncover concerns among care providers and to prospectively identify and mitigate defects for patients who would undergo surgery using the HDR-IORT technique. We identified and corrected 20 defects in the simulated patient care process before application to actual patients. Subsequently, eight patients underwent surgery using the HDR-IORT technique with no recurrence of simulation-identified or unanticipated defects. Multiple benefits were derived from the use of this systematic process to introduce the HDR-IORT technique; namely, the safety and efficiency of care for this select patient population was optimized, and this process mitigated harmful or adverse events before the inclusion of actual patients. Further work is needed, but the process outlined in this paper can be universally applied to the introduction of any new technologies, treatments, or procedures.
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)
Evaluation of transport safety analysis processes of radioactive material performed by a regulatory body

International Nuclear Information System (INIS)

Mattar, Patricia Morais

2017-01-01

Radioactive substances have many beneficial applications, ranging from power generation to uses in medicine, industry and agriculture. As a rule, they are produced in different places from where they are used, needing to be transported. In order for transport to take place safely and efficiently, national and international standards must be complied with. This research aims to assess the safety analysis processes for the transport of radioactive material carried out by the regulatory body in Brazil, from the point of view of their compliance with the International Atomic Energy Agency (IAEA) standards. The self-assessment methodology named SARIS, developed by the AIEA, was used. The following steps were carried out: evaluation of the Diagnosis and Processes Mapping; responses to the SARIS Question Set and complementary questions; SWOT analysis; interviews with stakeholders and evaluation of a TranSAS mission conducted by the IAEA in 2002. Considering only SARIS questions, processes are 100% adherent. The deepening of the research, however, led to the development of twenty-two improvement proposals and the identification of nine good practices. The results showed that the safety analysis processes of the transport of radioactive material are being carried out in a structured, safe and reliable way but also that there is much opportunity for improvement. The formulation of an action plan, based on the presented proposals, can bring to the regulatory body many benefits. This would be an important step towards convening an external evaluation, providing greater reliability and transparency to the regulatory body´s processes. (author)
Laboratory safety and the WHO World Alliance for Patient Safety.

Science.gov (United States)

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

2009-06-01

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

International Nuclear Information System (INIS)

Nascimento, Adelaide

2009-01-01

This research thesis aims at a better understanding of safety management in radiotherapy and at proposing improvements for patient safety through the development of a collective safety culture. A first part presents the current context in France and abroad, addresses the transposition of other safety methods to the medical domain, and discusses the peculiarities of radiotherapy in terms of risks and the existing quality-assurance approaches. The second part presents the theoretical framework by commenting the intellectual evolution with respect to system safety and the emergence of the concept of safety culture, and by presenting the labour collective aspects and their relationship with system safety. The author then comments the variety of safety cultures among the different professions present in radiotherapy, highlights the importance of the collective dimension in correcting discrepancies at the end of the treatment process, and highlights how physicians take their colleagues work into account. Recommendations are made to improve patient safety in radiotherapy
Idaho Chemical Processing Plant Process Efficiency improvements

International Nuclear Information System (INIS)

Griebenow, B.

1996-03-01

In response to decreasing funding levels available to support activities at the Idaho Chemical Processing Plant (ICPP) and a desire to be cost competitive, the Department of Energy Idaho Operations Office (DOE-ID) and Lockheed Idaho Technologies Company have increased their emphasis on cost-saving measures. The ICPP Effectiveness Improvement Initiative involves many activities to improve cost effectiveness and competitiveness. This report documents the methodology and results of one of those cost cutting measures, the Process Efficiency Improvement Activity. The Process Efficiency Improvement Activity performed a systematic review of major work processes at the ICPP to increase productivity and to identify nonvalue-added requirements. A two-phase approach was selected for the activity to allow for near-term implementation of relatively easy process modifications in the first phase while obtaining long-term continuous improvement in the second phase and beyond. Phase I of the initiative included a concentrated review of processes that had a high potential for cost savings with the intent of realizing savings in Fiscal Year 1996 (FY-96.) Phase II consists of implementing long-term strategies too complex for Phase I implementation and evaluation of processes not targeted for Phase I review. The Phase II effort is targeted for realizing cost savings in FY-97 and beyond
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
Building the Child Safety Collaborative Innovation and Improvement Network: How does it work and what is it achieving?

Science.gov (United States)

Leonardo, Jennifer B; Spicer, Rebecca S; Katradis, Maria; Allison, Jennifer; Thomas, Rebekah

2018-02-16

This study investigated whether the Child Safety Collaborative Innovation and Improvement Network (CS CoIIN) framework could be applied in the field of injury and violence prevention to reduce fatalities, hospitalizations and emergency department visits among 0-19 year olds. Twenty-one states/jurisdictions were accepted into cohort 1 of the CS CoIIN, and 14 were engaged from March 2016 through April 2017. A quality improvement framework was used to test, implement and spread evidence-based change ideas (strategies and programs) in child passenger safety, falls prevention, interpersonal violence prevention, suicide and self-harm prevention and teen driver safety. Outcome and process measure data were analyzed using run chart rules. Descriptive data were analyzed for participation measures and descriptive statistics were produced. Qualitative data were analyzed to identify key themes. Seventy-six percent of CS CoIIN states/jurisdictions were engaged in activities and used data to inform decision making. Within a year, states/jurisdictions were able to test and implement evidence-based change ideas in pilot sites. A small group showed improvement in process measures and were ready to spread change ideas. Improvement in outcome measures was not achieved; however, 25% of states/jurisdictions identified data sources and reported on real-time outcome measures. Evidence indicates the CS CoIIN framework can be applied to make progress on process measures, but more time is needed to determine if this will result in progress on long-term outcome measures of fatalities, hospitalizations and emergency department visits. Seventeen states/jurisdictions will participate in cohort 2. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Improved reliability, maintainability and safety through elastomer upgrading

International Nuclear Information System (INIS)

Wensel, R.; Wittich, K.C.

1995-01-01

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

A cross-sectional study to identify organisational processes associated with nurse-reported quality and patient safety

Science.gov (United States)

Tvedt, Christine; Sjetne, Ingeborg Strømseng; Helgeland, Jon; Bukholm, Geir

2012-01-01

Objectives The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing. Design This is an observational cross-sectional study using survey methods. Setting Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey. Participants All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses' practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture. Outcome measures Nurses' assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures. Results Quality system, nurse–physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses’ affiliations to medical department and hospital type. Conclusions Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care. PMID:23263021
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
Safety improvement technologies for nuclear power generation

International Nuclear Information System (INIS)

Nishida, Koji; Adachi, Hirokazu; Kinoshita, Hirofumi; Takeshi, Noriaki; Yoshikawa, Kazuhiro; Itou, Kanta; Kurihara, Takao; Hino, Tetsushi

2015-01-01

As the Hitachi Group's efforts in nuclear power generation, this paper explains the safety improvement technologies that are currently under development or promotion. As efforts for the decommissioning of Fukushima Daiichi Nuclear Power Station, the following items have been developed. (1) As for the spent fuel removal of Unit 4, the following items have mainly been conducted: removal of the debris piled up on the top surface of existing reactor building (R/B), removal of the debris deposited in spent fuel pool (SFP), and fuel transfer operation by means of remote underwater work. The removal of all spent fuels was completed in 2014. (2) The survey robots inside R/B, which are composed of a basement survey robot to check leaking spots at upper pressure suppression chamber and a floor running robot to check leaking spots in water, were verified with a field demonstration test at Unit 1. These robots were able to find the leaking spots at midair pipe expansion joint. (3) As the survey robot for reactor containment shells, robots of I-letter posture and horizontal U-letter posture were developed, and the survey on the upper part of first-floor grating inside the containment shells was performed. (4) As the facilities for contaminated water measures, sub-drain purification equipment, Advanced Liquid Processing System, etc. were developed and supplied, which are now showing good performance. On the other hand, an advanced boiling water reactor with high safety of the United Kingdom (UK ABWR) is under procedure of approval for introduction. In addition, a next-generation light-water reactor of transuranic element combustion type is under development. (A.O.)
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
Organising a manuscript reporting quality improvement or patient safety research.

Science.gov (United States)

Holzmueller, Christine G; Pronovost, Peter J

2013-09-01

Peer-reviewed publication plays important roles in disseminating research findings, developing generalisable knowledge and garnering recognition for authors and institutions. Nonetheless, many bemoan the whole manuscript writing process, intimidated by the arbitrary and somewhat opaque conventions. This paper offers practical advice about organising and writing a manuscript reporting quality improvement or patient safety research for submission to a peer-reviewed journal. Each section of the paper discusses a specific manuscript component-from title, abstract and each section of the manuscript body, through to reference list and tables and figures-explaining key principles, offering content organisation tips and providing an example of how this section may read. The paper also offers a checklist of common mistakes to avoid in a manuscript.
Do clinical safety charts improve paramedic key performance indicator results? (A clinical improvement programme evaluation).

Science.gov (United States)

Ebbs, Phillip; Middleton, Paul M; Bonner, Ann; Loudfoot, Allan; Elliott, Peter

2012-07-01

Is the Clinical Safety Chart clinical improvement programme (CIP) effective at improving paramedic key performance indicator (KPI) results within the Ambulance Service of New South Wales? The CIP intervention area was compared with the non-intervention area in order to determine whether there was a statistically significant improvement in KPI results. The CIP was associated with a statistically significant improvement in paramedic KPI results within the intervention area. The strategies used within this CIP are recommended for further consideration.
Microbial safety of minimally processed foods

National Research Council Canada - National Science Library

Novak, John S; Sapers, Gerald M; Juneja, Vijay K

2003-01-01

...-course meals. All are expected to be portioned and minimally processed to balance the naturalness of unaltered foods with a concern for safety. Yet the responsibility for proper food preparation and handling remains with the naïve modern consumer, who may be less adept in food preparations than his or her less sophisticated ancestors. As a result,...
Controlled versus automatic processes: which is dominant to safety? The moderating effect of inhibitory control.

Directory of Open Access Journals (Sweden)

Yaoshan Xu

Full Text Available This study explores the precursors of employees' safety behaviors based on a dual-process model, which suggests that human behaviors are determined by both controlled and automatic cognitive processes. Employees' responses to a self-reported survey on safety attitudes capture their controlled cognitive process, while the automatic association concerning safety measured by an Implicit Association Test (IAT reflects employees' automatic cognitive processes about safety. In addition, this study investigates the moderating effects of inhibition on the relationship between self-reported safety attitude and safety behavior, and that between automatic associations towards safety and safety behavior. The results suggest significant main effects of self-reported safety attitude and automatic association on safety behaviors. Further, the interaction between self-reported safety attitude and inhibition and that between automatic association and inhibition each predict unique variances in safety behavior. Specifically, the safety behaviors of employees with lower level of inhibitory control are influenced more by automatic association, whereas those of employees with higher level of inhibitory control are guided more by self-reported safety attitudes. These results suggest that safety behavior is the joint outcome of both controlled and automatic cognitive processes, and the relative importance of these cognitive processes depends on employees' individual differences in inhibitory control. The implications of these findings for theoretical and practical issues are discussed at the end.
Geosphere process report for the safety assessment SR-Can

International Nuclear Information System (INIS)

Skagius, Kristina

2006-09-01

This report documents geosphere processes identified as relevant to the long-term safety of a KBS- repository, and forms an important part of the reporting of the safety assessment SR-Can. The detailed assessment methodology, including the role of the process report in the assessment, is described in the SR-Can Main report. The following excerpts describe the methodology, and clarify the role of this process report in the assessment. The repository system, broadly defined as the deposited spent nuclear fuel, the engineered barriers surrounding it, the host rock and the biosphere in the proximity of the repository, will evolve over time. Future states of the system will depend on the initial state of the system, a number of radiation related, thermal, hydraulic, mechanical, chemical and biological processes acting within the repository system over time, and external influences acting on the system. A methodology in ten steps has been developed for SR-Can described below. Identification of factors to consider (FEP processing): This step consists of identifying all the factors that need to be included in the analysis. Experience from earlier safety assessments and KBS-specific and international databases of relevant features, events and processes influencing long-term safety are utilised. Based on the results of the FEP processing, an SR-Can FEP catalogue, containing FEPs to be handled in SR-Can, has been established. The initial state of the system is described based on the design specifications of the KBS repository, a descriptive model of the repository site and a site-specific layout of the repository. The initial state of the fuel and the engineered components is that immediately after deposition, as described in the SR-Can Initial state report. The initial state of the geosphere and the biosphere is that of the natural system prior to excavation, as described in the site descriptive models. The repository layouts adapted to the sites are provided in underground
Geosphere process report for the safety assessment SR-Can

Energy Technology Data Exchange (ETDEWEB)

Skagius, Kristina [Kemakta Konsult AB, Stockholm (SE)] (ed.)

2006-09-15

This report documents geosphere processes identified as relevant to the long-term safety of a KBS- repository, and forms an important part of the reporting of the safety assessment SR-Can. The detailed assessment methodology, including the role of the process report in the assessment, is described in the SR-Can Main report. The following excerpts describe the methodology, and clarify the role of this process report in the assessment. The repository system, broadly defined as the deposited spent nuclear fuel, the engineered barriers surrounding it, the host rock and the biosphere in the proximity of the repository, will evolve over time. Future states of the system will depend on the initial state of the system, a number of radiation related, thermal, hydraulic, mechanical, chemical and biological processes acting within the repository system over time, and external influences acting on the system. A methodology in ten steps has been developed for SR-Can described below. Identification of factors to consider (FEP processing): This step consists of identifying all the factors that need to be included in the analysis. Experience from earlier safety assessments and KBS-specific and international databases of relevant features, events and processes influencing long-term safety are utilised. Based on the results of the FEP processing, an SR-Can FEP catalogue, containing FEPs to be handled in SR-Can, has been established. The initial state of the system is described based on the design specifications of the KBS repository, a descriptive model of the repository site and a site-specific layout of the repository. The initial state of the fuel and the engineered components is that immediately after deposition, as described in the SR-Can Initial state report. The initial state of the geosphere and the biosphere is that of the natural system prior to excavation, as described in the site descriptive models. The repository layouts adapted to the sites are provided in underground
Improving Earth/Prediction Models to Improve Network Processing

Science.gov (United States)

Wagner, G. S.

2017-12-01

The United States Atomic Energy Detection System (USAEDS) primaryseismic network consists of a relatively small number of arrays andthree-component stations. The relatively small number of stationsin the USAEDS primary network make it both necessary and feasibleto optimize both station and network processing.Station processing improvements include detector tuning effortsthat use Receiver Operator Characteristic (ROC) curves to helpjudiciously set acceptable Type 1 (false) vs. Type 2 (miss) errorrates. Other station processing improvements include the use ofempirical/historical observations and continuous background noisemeasurements to compute time-varying, maximum likelihood probabilityof detection thresholds.The USAEDS network processing software makes extensive use of theazimuth and slowness information provided by frequency-wavenumberanalysis at array sites, and polarization analysis at three-componentsites. Most of the improvements in USAEDS network processing aredue to improvements in the models used to predict azimuth, slowness,and probability of detection. Kriged travel-time, azimuth andslowness corrections-and associated uncertainties-are computedusing a ground truth database. Improvements in station processingand the use of improved models for azimuth, slowness, and probabilityof detection have led to significant improvements in USADES networkprocessing.
The effect of Health, Safety and Environment Management System (HSE-MS on the improvement of safety performance indices in Urea and Ammonia Kermanshah Petrochemical Company

Directory of Open Access Journals (Sweden)

M. S. Poursoleiman

2015-09-01

Full Text Available Introduction: Work-related accidents may cause damage to people, environment and lead to waste of time and money. Health, Safety and Environment Management System has been developed in order to reduce accidents. This study aimed to investigate the effect of implementation of this system on reduction of the accidents and its consequences and also on the safety performance indices in Kermanshah Petrochemical Company. Material and Method: In this study, records of accidents were collected by OSHA incident report form 301 over 4 years. Following, the mean annual accidents and its consequences and safety performance indices were calculated and reported. Then, using statistical analysis, the impacts of two years implementation of this system on the accidents and its consequences and safety performance indices were evaluated. Result: The results showed that the implementation of HSE system was significantly correlated with Frequency Severity Indicator, Accident Severity Rate, lost days, minor accidents and total incidents (P-value 0.05. Conclusion: The implementation of Health, Safety and the Environment Management System caused a reduction in accidents and its consequences and most of the safety performance indices in the entire process cycle of Kermanshah Petrochemical Company. Overall, safety condition has been improved considerably.
Improvement of Safety Features in Standard Operation Procedure of Tc-99m Generator

International Nuclear Information System (INIS)

Manisah Saedon; Mohd Khairul Hakimi; Shyen, A.K.S.

2011-01-01

This paper describes the improvements proposed to the original production procedures for Tc-99m generators. Improvements are intended to add safety and health features for workers into the existing procedures. The difference between the new safe work procedures from the original work procedures; is the concern about the safety and health of employees other than the product safety. One of the suggested safety characteristics is by using the visual aid so that the workers can easily see and read the procedures when they perform their duties, whereas the previous procedures are kept in the manual and difficult to access. The purpose of this paper is to share information about the importance of safety and health features for the workers in the procedures established in addition to provide awareness to all parties involved. (author)
Mandatory Rest Stops Improve Athlete Safety during Event Medical Coverage for Ultramarathons.

Science.gov (United States)

Joslin, Jeremy; Mularella, Joshua; Bail, Allison; Wojcik, Susan; Cooney, Derek R

2016-02-01

Provisions of medical direction and clinical services for ultramarathons require specific attention to heat illness. Heat stress can affect athlete performance negatively, and heat accumulation without acclimatization is associated with the development of exertional heat stroke (EHS). In order to potentially mitigate the risk of this safety concern, the Jungle Marathon (Para, Brazil) instituted mandatory rest periods during the first two days of this 7-day, staged, Brazilian ultramarathon. Race records were reviewed retrospectively to determine the number of runners that suffered an emergency medical complication related to heat stress and did not finish (DNF) the race. Review of records included three years before and three years after the institution of these mandatory rest periods. A total of 326 runners competed in the Jungle Marathon during the 2008-2013 period of study. During the pre-intervention years, a total of 46 athletes (21%) DNF the full race with 25 (54.3%) cases attributed to heat-related factors. During the post-intervention years, a total of 26 athletes (24.3%) DNF the full race with four (15.4%) cases attributed to heat-related factors. Mandatory rest stops during extreme running events in hot or tropical environments, like the Jungle Marathon, are likely to improve athlete safety and improve the heat acclimatization process.
The Conceptual Framework for Ensuring Economic Safety of Corporate Integration Processes

Directory of Open Access Journals (Sweden)

Gutsaliuk Oleksii M.

2016-08-01

Full Text Available The objective growth of the number of displays and influence of negative factors of threats from the environment actualizes the issue of ensuring economic safety of national economic entities. The article notes that simultaneously with counteracting threats enterprises are working for development, one form of which is the establishment of corporate structures and implementation of integration processes. It is proposed to ensure achieving the desired level of the corporate structure economic safety through optimizing the correlation of resources and competencies, skills and technologies for their use within the integrated logistics value chain. In this case it is the implementation of the integration process that serves as an instrument for achieving this optimal correlation, and the level of economic safety is considered as one of the optimization criteria. The system of authors’ hypotheses is taken as the basis for ensuring economic safety of the corporate integration process. Each of the hypotheses corresponds to a set of conceptual principles aimed at practical implementation of the proposed approaches. Within these conceptual principles the relationship between incentives and benefits of integration and the basis for ensuring their safety is presented, the differences between safety of functioning and safety of development are studied, the use of the methodology of logistics to harmonize the interests of participants of the corporate structure is justified, the relevance of applying the resource approach to manage the integration and development safety is proved. The graphical representation of causal relationships between the proposed conceptual principles allowed formalizing the subject area of studying corporate integration safety
Implementation of safety goals in NRC's regulatory process

International Nuclear Information System (INIS)

Murley, T.E.

1985-01-01

In May 1983 the Nuclear Regulatory Commission issued a policy statement on Safety Goals For Nuclear Power Plant Operation. The Commission at the same time judged that a two-year evaluation period was necessary to judge the effectiveness of the goals and design objectives, and directed the staff to develop information and understanding as to how to further define and use the design objectives and the cost-benefit guidelines. In carrying out the Commission's mandate, the staff framed three major questions to be addressed during the safety goal evaluation period. These three questions are: 1) to what extent is it practical to use safety goals in the regulatory process. 2) Should the quantitative design objectives be modified or supplemented. If so, how. 3) How should the safety goals be implemented at the end of the evaluation period. The staff's conclusions are discussed
Design of marine structures with improved safety for environment

International Nuclear Information System (INIS)

Klanac, Alan; Varsta, Petri

2011-01-01

The paper describes a method for design of marine structures with increased safety for environment, considering also the required investment costs as well as the aspects of risk distribution onto the maritime stakeholders. Practically, the paper seeks to answer what is the optimal amount that should be invested into certain safety measure for any given vessel. Due to the uneven distribution of risk, as well as the differing impact of costs emerging from safety improvements, stakeholders experience conflicting ranking of alternatives. To solve this multi-stakeholder decision-making problem, in which each stakeholder is a decision-maker, the method applies concepts of group decision-making theory, namely the Game Theory. The method fosters axiomatic definition of the optimum solution, arguing that the solution, or the final selected design, should satisfy the non-dominance, efficiency, and fairness. These three are thoroughly discussed in terms of structural design, especially the latter. Considering the coupling of environmental risk and structural design, the method also builds on the preference structure of four maritime stakeholders: yards, owners, oil receivers and the public, who either share the risks or directly influence structural design. Method is presented on a practical study of structural design of a tanker with a crashworthy side structure that is capable of reducing the risk of collision. The outcome of this study outlines a number of possibilities for successful improvement of tanker safety that can benefit, concurrently, all maritime stakeholders.
Taking up national safety alerts to improve patient safety in hospitals: The perspective of healthcare quality and risk managers.

Science.gov (United States)

Pfeiffer, Yvonne; Schwappach, David

2016-01-01

National safety alert systems publish relevant information to improve patient safety in hospitals. However, the information has to be transformed into local action to have an effect on patient safety. We studied three research questions: How do Swiss healthcare quality and risk managers (qm/rm(1)) see their own role in learning from safety alerts issued by the Swiss national voluntary reporting and analysis system? What are their attitudes towards and evaluations of the alerts, and which types of improvement actions were fostered by the safety alerts? A survey was developed and applied to Swiss healthcare risk and quality managers, with a response rate of 39 % (n=116). Descriptive statistics are presented. The qm/rm disseminate and communicate with a broad variety of professional groups about the alerts. While most respondents felt that they should know the alerts and their contents, only a part of them felt responsible for driving organizational change based on the recommendations. However, most respondents used safety alerts to back up their own patient safety goals. The alerts were evaluated positively on various dimensions such as usefulness and were considered as standards of good practice by the majority of the respondents. A range of organizational responses was applied, with disseminating information being the most common. An active role is related to using safety alerts for backing up own patient safety goals. To support an active role of qm/rm in their hospital's learning from safety alerts, appropriate organizational structures should be developed. Furthermore, they could be given special information or training to act as an information hub on the issues discussed in the alerts. Copyright © 2016. Published by Elsevier GmbH.
Practicing chemical process safety: a look at the layers of protection

International Nuclear Information System (INIS)

Sanders, Roy E.

2004-01-01

This presentation will review a few public perceptions of safety in chemical plants and refineries, and will compare these plant workplace risks to some of the more traditional occupations. The central theme of this paper is to provide a 'within-the-fence' view of many of the process safety practices that world class plants perform to pro-actively protect people, property, profits as well as the environment. It behooves each chemical plant and refinery to have their story on an image-rich presentation to stress stewardship and process safety. Such a program can assure the company's employees and help convince the community that many layers of safety protection within our plants are effective, and protect all from harm
Danish initiatives to improve the safety of meat products

DEFF Research Database (Denmark)

Wegener, Henrik Caspar

2010-01-01

and Campylobacter, and to a lesser extent Yersinia, Escherichia coli O157 and Listeria. Danish initiatives to improve the safety of meat products have focused on the entire production chain from the farm to the consumer, with a special emphasis on the pre-harvest stage of production. The control of bacterial......During the last two decades the major food safety problems in Denmark, as determined by the number of human patients, has been associated with bacterial infections stemming from meat products and eggs. The bacterial pathogens causing the majority of human infections has been Salmonella...

Safety case plan 2008

International Nuclear Information System (INIS)

2008-07-01

Following the guidelines set forth by the Ministry of Trade and Industry (now Ministry of Employment and Economy) Posiva is preparing to submit the construction license application for a spent fuel repository by the end of the year 2012. The long-term safety section supporting the license application is based on a safety case, which, according to the internationally adopted definition, is a compilation of the evidence, analyses and arguments that quantify and substantiate the safety and the level of expert confidence in the safety of the planned repository. In 2005, Posiva presented a plan to prepare such a safety case. The present report provides a revised plan of the safety case contents mentioned above. The update of the safety case plan takes into account the recommendations made by the Radiation and Nuclear Safety Authority (STUK) about improving the focus and further developing the plan. Accordingly, particular attention is given to the quality management of the safety case work, the management of uncertainties and the scenario methodology. The quality management is based on the ISO 9001:2000 standard process thinking enhanced with special features arising from STUK's YVL Guides. The safety case production process is divided into four main sub-processes. The conceptualisation and methodology sub-process defines the framework for the assessment. The critical data handling and modelling sub-process links Posiva's main technical and scientific activities to the production of the safety case. The assessment sub-process analyses the consequences of the evolution of the disposal system in various scenarios, classified either as part of the expected evolution or as disruptive scenarios. The compliance and confidence sub-process is responsible for final evaluation of compliance of the assessment results with the regulatory criteria and the overall confidence in the safety case. As in the previous safety case plan, the safety case will be based on several reports, but
Assessment of freeway work zone safety with improved cellular automata model

Directory of Open Access Journals (Sweden)

Guohua Liang

2014-08-01

Full Text Available To accurately assess the safety of freeway work zones, this paper investigates the safety of vehicle lane change maneuvers with improved cellular automata model. Taking the traffic conflict and standard deviation of operating speed as the evaluation indexes, the study evaluates the freeway work zone safety. With improved deceleration probability in car-following raies and the addition of lanechanging rules under critical state, the lane-changing behavior under critical state is defined as a conflict count. Through 72 schemes of simulation runs, the possible states of the traffic flow are carefully studied. The results show that under the condition of constant saturation traffic conflict count and vehicle speed standard deviation reach their maximums when the mixed rate of heave vehicles is 40%. Meanwhile, in the case of constant heavy vehicles mix, traffic conflict count and vehicle speed standard deviation reach maximum values when saturation rate is 0. 75. Integrating ail simulation results, it is known the traffic safety in freeway work zones is classified into four levels : safe, relatively safe, relatively dangerous, and dangerous.
Safety Assurance Process for FRMS : EJcase Implementation

NARCIS (Netherlands)

Stewart, S.; Koornneef, F.; Akselsson, R.; Barton, P.

2009-01-01

Chapter 6: Safety Assurance Process for FRMS - eJcase Implementation The European Commission HILAS project (Human Integration into the Lifecycle of Aviation Systems - a project supported by the European Commission’s 6th Framework between 2005-2009) was focused on using human factors knowledge and
Redox processes in the safety case of deep geological repositories of radioactive wastes. Contribution of the European RECOSY Collaborative Project

International Nuclear Information System (INIS)

Duro, L.; Bruno, J.; Grivé, M.; Montoya, V.; Kienzler, B.; Altmaier, M.; Buckau, G.

2014-01-01

Highlights: • The RECOSY project produced results relevant for the Safety Case of nuclear disposal. • We classify the safety related features where RECOSY has contributed. • Redox processes effect the retention of radionuclides in all repository subsystems. - Abstract: Redox processes influence key geochemical characteristics controlling radionuclide behaviour in the near and far field of a nuclear waste repository. A sound understanding of redox related processes is therefore of high importance for developing a Safety Case, the collection of scientific, technical, administrative and managerial arguments and evidence in support of the safety of a disposal facility. This manuscript presents the contribution of the specific research on redox processes achieved within the EURATOM Collaborative Project RECOSY (REdox phenomena COntrolling SYstems) to the Safety Case of nuclear waste disposal facilities. Main objectives of RECOSY were related to the improved understanding of redox phenomena controlling the long-term release or retention of radionuclides in nuclear waste disposal and providing tools to apply the results to Performance Assessment and the Safety Case. The research developed during the project covered aspects of the near-field and the far-field aspects of the repository, including studies relevant for the rock formations considered in Europe as suitable for hosting an underground repository for radioactive wastes. It is the intention of this paper to highlight in which way the results obtained from RECOSY can feed the scientific process understanding needed for the stepwise development of the Safety Case associated with deep geological disposal of radioactive wastes
Development and improvement of safety analysis code for geological disposal

Energy Technology Data Exchange (ETDEWEB)

NONE

2013-08-15

In order to confirm the long-term safety concerning geological disposal, probabilistic safety assessment code and other analysis codes, which can evaluate possibility of each event and influence on engineered barrier and natural barrier by the event, were introduced. We confirmed basic functions of those codes and studied the relation between those functions and FEP/PID which should be taken into consideration in safety assessment. We are planning to develop 'Nuclide Migration Assessment System' for the purpose of realizing improvement in efficiency of assessment work, human error prevention for analysis, and quality assurance of the analysis environment and analysis work for safety assessment by using it. As the first step, we defined the system requirements and decided the system composition and functions which should be mounted in them based on those requirements. (author)
Radiation Safety Professional Certification Process in a Multi-Disciplinary Association

International Nuclear Information System (INIS)

Wilson, G.; Jones, P.; Ilson, R.

2004-01-01

There is no one set of criteria that defines the radiation safety professional in Canada. The many varied positions, from university and medical to industry and mining, define different qualifications to manage radiation safety programs. The national regulatory body has to assess many different qualifications when determining if an individual is acceptable to be approved for the role of radiation safety officer under any given licence. Some professional organizations specify education requirements and work experience as a prerequisite to certification. The education component specifies a degree of some type but does not identify specific courses or competencies within that degree. This could result in individuals with varying levels of radiation safety experience and training. The Canadian Radiation Protection Association (CRPA), responding to a need identified by the membership of the association, has initiated a process where the varying levels of knowledge of radiation safety can be addressed for radiation safety professionals. By identifying a core level set of radiation safety competencies, the basic level of radiation safety officer for smaller organizations can be met. By adding specialty areas, education can be pursued to define the more complex needs of larger organizations. This competency based process meets the needs of licensees who do not require highly trained health physicists in order to meet the licensing requirements and at the same time provides a stepping stone for those who wish to pursue a more specialized health physics option. (Author) 8 refs
Continuous restraint control systems: safety improvement for various occupants

NARCIS (Netherlands)

Laan, E. van der; Jager, B. de; Veldpaus, F.; Steinbuch, M.; Nunen, E. van; Willemsen, D.

2009-01-01

Occupant safety can be significantly improved by continuous restraint control systems. These restraint systems adjust their configuration during the impact according to the actual operating conditions, such as occupant size, weight, occupant position, belt usage and crash severity. In this study,
Incorporation of Safety into Design Process : A Systems Engineering Perspective

NARCIS (Netherlands)

Rajabalinejad, M.

2018-01-01

This paper suggests integrating the best safety practices with the design process. This integration enriches the exploration experience for designers and adds extra values and competitor advantages for customers. The paper introduces the safety cube for combining common blocks for design, hazard
Fuel and canister process report for the safety assessment SR-Site

International Nuclear Information System (INIS)

Werme, Lars; Lilja, Christina

2010-12-01

This report documents fuel and canister processes identified as relevant to the long-term safety of a KBS-3 repository. It forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/
Fuel and canister process report for the safety assessment SR-Site

Energy Technology Data Exchange (ETDEWEB)

Werme, Lars; Lilja, Christina (eds.)

2010-12-15

This report documents fuel and canister processes identified as relevant to the long-term safety of a KBS-3 repository. It forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/
Plan for research to improve the safety of light-water nuclear power plants

International Nuclear Information System (INIS)

1978-03-01

This is the U.S. Nuclear Regulatory Commission's first annual report to Congress on recommendations for research on improving the safety of light-water nuclear power plants. Suggestions for reactor safety research were identified in, or received from, various sources, including the Advisory Committee on Reactor Safeguards, the NRC regulatory staff, and the consultants to the Research Review Group. After an initial screening to eliminate those not related to improved reactor safety, all the suggestions were consolidated into research topics. It is recommended that the following research projects be carried out: alternate containment concepts, especially vented containments; alternate decay heat removal concepts, especially add-on bunkered systems; alternate emergency core cooling concepts; improved in-plant accident response; and advanced seismic designs
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.
Nature-Based Strategies for Improving Urban Health and Safety.

Science.gov (United States)

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

2015-10-01

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 and greenery. In this paper, we describe the current understanding of place-based influences on public health and safety. We focus on nonchemical environmental factors, many of which are related to urban abandonment and blight. We then review findings from studies of nature-based interventions regarding impacts on health, perceptions of safety, and crime. Based on our findings, we suggest that further research in this area will require (1) refined measures of green space, nature, and health and safety for cities, (2) interdisciplinary science and cross-sector policy collaboration, (3) observational studies as well as randomized controlled experiments and natural experiments using appropriate spatial counterfactuals and mixed methods, and (4) return-on-investment calculations of potential economic, social, and health costs and benefits of urban greening initiatives.
Cultural safety as an ethic of care: a praxiological process.

Science.gov (United States)

McEldowney, Rose; Connor, Margaret J

2011-10-01

New writings broadening the construct of cultural safety, a construct initiated in Aotearoa New Zealand, are beginning to appear in the literature. Therefore, it is considered timely to integrate these writings and advance the construct into a new theoretical model. The new model reconfigures the constructs of cultural safety and cultural competence as an ethic of care informed by a postmodern perspective. Central to the new model are three interwoven, co-occurring components: an ethic of care, which unfolds within a praxiological process shaped by the context. Context is expanded through identifying the three concepts of relationality, generic competence, and collectivity, which are integral to each client-nurse encounter. The competence associated with cultural safety as an ethic of care is always in the process of development. Clients and nurses engage in a dialogue to establish the level of cultural safety achieved at given points in a care trajectory.
Quantitative safety goals for the regulatory process

International Nuclear Information System (INIS)

Joksimovic, V.; O'Donnell, L.F.

1981-01-01

The paper offers a brief summary of the current regulatory background in the USA, emphasizing nuclear, related to the establishment of quantitative safety goals as a way to respond to the key issue of 'how safe is safe enough'. General Atomic has taken a leading role in advocating the use of probabilistic risk assessment techniques in the regulatory process. This has led to understanding of the importance of quantitative safety goals. The approach developed by GA is discussed in the paper. It is centred around definition of quantitative safety regions. The regions were termed: design basis, safety margin or design capability and safety research. The design basis region is bounded by the frequency of 10 -4 /reactor-year and consequences of no identifiable public injury. 10 -4 /reactor-year is associated with the total projected lifetime of a commercial US nuclear power programme. Events which have a 50% chance of happening are included in the design basis region. In the safety margin region, which extends below the design basis region, protection is provided against some events whose probability of not happening during the expected course of the US nuclear power programme is within the range of 50 to 90%. Setting the lower mean frequency to this region of 10 -5 /reactor-year is equivalent to offering 90% assurance that an accident of given severity will not happen. Rare events with a mean frequency below 10 -5 can be predicted to occur. However, accidents predicted to have a probability of less than 10 -6 are 99% certain not to happen at all, and are thus not anticipated to affect public health and safety. The area between 10 -5 and 10 -6 defines the frequency portion of the safety research region. Safety goals associated with individual risk to a maximum-exposed member of public, general societal risk and property risk are proposed in the paper
Safety, Liveness and Run-time Refinement for Modular Process-Aware Information Systems with Dynamic Sub Processes

DEFF Research Database (Denmark)

Debois, Søren; Hildebrandt, Thomas; Slaats, Tijs

2015-01-01

and verification of flexible, run-time adaptable process-aware information systems, moved into practice via the Dynamic Condition Response (DCR) Graphs notation co-developed with our industrial partner. Our key contributions are: (1) A formal theory of dynamic sub-process instantiation for declarative, event......We study modularity, run-time adaptation and refinement under safety and liveness constraints in event-based process models with dynamic sub-process instantiation. The study is part of a larger programme to provide semantically well-founded technologies for modelling, implementation......-based processes under safety and liveness constraints, given as the DCR* process language, equipped with a compositional operational semantics and conservatively extending the DCR Graphs notation; (2) an expressiveness analysis revealing that the DCR* process language is Turing-complete, while the fragment cor...
Legacy data sharing to improve drug safety assessment: the eTOX project

DEFF Research Database (Denmark)

Sanz, Ferran; Pognan, François; Steger-Hartmann, Thomas

2017-01-01

The sharing of legacy preclinical safety data among pharmaceutical companies and its integration with other information sources offers unprecedented opportunities to improve the early assessment of drug safety. Here, we discuss the experience of the eTOX project, which was established through...
Preliminary Evaluation of an Aviation Safety Thesaurus' Utility for Enhancing Automated Processing of Incident Reports

Science.gov (United States)

Barrientos, Francesca; Castle, Joseph; McIntosh, Dawn; Srivastava, Ashok

2007-01-01

This document presents a preliminary evaluation the utility of the FAA Safety Analytics Thesaurus (SAT) utility in enhancing automated document processing applications under development at NASA Ames Research Center (ARC). Current development efforts at ARC are described, including overviews of the statistical machine learning techniques that have been investigated. An analysis of opportunities for applying thesaurus knowledge to improving algorithm performance is then presented.
Lessons Learned from a Five-year Evaluation of the Belgian Safety Culture Oversight Process

International Nuclear Information System (INIS)

Bernard, B.

2016-01-01

The Belgian Regulatory Body has implemented a Safety Culture oversight process since 2010. In a nutshell, this process is based on field observations provided by inspectors or safety analysts during any contact with a licencee (inspections, meetings, phone calls, etc). These observations are recorded within an observation (excel) sheet—aiming at describing factual and contextual issues — and are linked to IAEA Safety Culture attributes. It should be stressed that the purpose of the process is not to give a comprehensive view of a licencee safety culture but to address findings that require attention or action on the part of a licencee. In other words, gathering safety culture observations aims at identifying cultural, organizational or behavioural issues in order to feed a regulatory response to potential problems. Safety Culture Observations (SCO) are then fully integrated in routine inspection activities and must be seen as an input of the overall oversight process. As a result, the assessment of the SCO is inserted within the yearly safety evaluation report performed by Bel V and transmitted to the licencee. However, observing safety culture is not a natural approach for engineers. Guidance, training and coaching must be provided in order to open up safety dimensions to be captured. In other words, a SCO process requires a continuous support in order to promote a holistic and systemic view of safety.
Improvement of operational safety: The self-assessment at the Russian NPPs

International Nuclear Information System (INIS)

Kolotov, Aleksander

2002-01-01

The operating organization has scheduled for the forthcoming year to elaborate the NPP safety self-assessment standards and to settle precise criterion for its performance. Toward this end it was decided to form a Working Team including of NPP and VNIIAES representatives to elaborate major tasks on the self-assessment improvement, development and implementation of new documentation and training the personnel in new methodology. Actions developed by R osenergoatom , one of its items is the participation of 'Rosenergoatom' and VNIIAES representatives in the workshop, contains the sequence of Russian NPP safety self-assessment improvement at the first stage

Housing improvement and home safety Effectiveness Matters

OpenAIRE

, Crd; Sphr@, L; , MrcSphsu

2014-01-01

The homes we live in impact on health, wellbeing and health inequalities. Treating illnesses directly related to living in cold, damp and dangerous homes costs the NHS £2.5 billion per year. Ensuring affordable warmth through insulation and more efficient heating can improve health and wellbeing. Home safety assessment and modification can reduce falls and risk of falling in older people. Education, promotion of exercise and wearing of appropriate footwear, environmental modifications and tra...
The French Experience Regarding Peer Reviews to Improve the Safety and Security of Radioactive Sources

International Nuclear Information System (INIS)

Lachaume, J.-L.; Bélot, G.

2015-01-01

France has a 50 year history of control over radioactive sources. Convinced that peer reviews may be helpful to improve any regulatory system, France decided to experience a ‘full scope’ Integrated Regulatory Review Service mission in 2006 and its follow-up mission in 2009, including a review of the implementation of the Code of Conduct. The reviews, interviews and observations performed during these missions enabled the experts to have a thorough knowledge of the French system and to highlight its strengths and ways for improvements. Following these reviews, France decided to rely on its good practices, extend them as much as possible and to define, implement and address an action plan to improve its regulatory control over radioactive sources, while maintaining the prime responsibility on the operators. While good practices in the tracking of sources were maintained and slight evolutions were conducted in the safety regulations, licensing process, and inspection and enforcement actions, the major outcome of these reviews will obviously consist of the entrustment of the French Nuclear Safety Authority with the role of the regulatory authority for the security of radioactive sources and the implementation of dedicated provisions. (author)
Safety cases for the co-ordinated research project on improvement of safety assessment methodologies for near surface radioactive waste disposal facilities (ISAM)

International Nuclear Information System (INIS)

Kozak, M.W.; Torres-Vidal, C.; Kelly, E.; Guskov, A.; Blerk, J. van

2002-01-01

A Co-ordinated Research Project (CRP) has recently been completed on the Improvement of Safety Assessment Methodologies for Near-Surface Radioactive Waste Disposal Facilities (ISAM). A major aspect of the project was the use of safety cases for the practical application of safety assessment. An overview of the ISAM safety cases is given in this paper. (author)
A Quantitative Feasibility Study on Potential Safety Improvement Effects of Advanced Safety Features in APR-1400 when Applied to OPR-1000

Energy Technology Data Exchange (ETDEWEB)

Ualikhan Zhiyenbayev [KAIST, Daejeon (Korea, Republic of); Chung, Dae Wook [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2015-10-15

This study aims to test the feasibility of the applications using Probabilistic Safety Assessment (PSA). Particularly, three of those advanced safety features are selected as follows: 1. Providing an additional Emergency Diesel Generator (EDG); 2. Increasing the capacity of Class 1E batteries; 3. Placing a Refueling Water Storage Tank (RWST) inside containment, i.e., change from RWST to IRWST. The Advanced Power Reactor 1400 (APR-1400) adopts several advanced safety features compared to its predecessor, the Optimized Power Reactor 1000 (OPR-1000), which includes an additional Emergency Diesel Generator, increase in battery capacity, in-containment refueling water storage tank (IRWST), and so on. Considering the remarkable advantages of these safety features in safety improvement and the design similarities between APR-1400 and OPR-1000, it is feasible to apply key advanced safety features of APR-1400 to OPR-1000 to enhance the safety. The selected safety features are incorporated into OPR-1000 PSA model using the Advanced Information Management System (AIMS) for PSA and CDFs are re-evaluated for each application and combination of three applications. Based on current results, it is concluded that three of key advanced safety features of APR-1400 can be effectively applied to OPR-1000, resulting in considerable safety improvement. In aggregate, three advanced safety features, which are an additional EDG, increased battery capacity and IRWST, can reduce the CDF of OPR-1000 by more than 15% when applied altogether.
A Quantitative Feasibility Study on Potential Safety Improvement Effects of Advanced Safety Features in APR-1400 when Applied to OPR-1000

International Nuclear Information System (INIS)

Ualikhan Zhiyenbayev; Chung, Dae Wook

2015-01-01

This study aims to test the feasibility of the applications using Probabilistic Safety Assessment (PSA). Particularly, three of those advanced safety features are selected as follows: 1. Providing an additional Emergency Diesel Generator (EDG); 2. Increasing the capacity of Class 1E batteries; 3. Placing a Refueling Water Storage Tank (RWST) inside containment, i.e., change from RWST to IRWST. The Advanced Power Reactor 1400 (APR-1400) adopts several advanced safety features compared to its predecessor, the Optimized Power Reactor 1000 (OPR-1000), which includes an additional Emergency Diesel Generator, increase in battery capacity, in-containment refueling water storage tank (IRWST), and so on. Considering the remarkable advantages of these safety features in safety improvement and the design similarities between APR-1400 and OPR-1000, it is feasible to apply key advanced safety features of APR-1400 to OPR-1000 to enhance the safety. The selected safety features are incorporated into OPR-1000 PSA model using the Advanced Information Management System (AIMS) for PSA and CDFs are re-evaluated for each application and combination of three applications. Based on current results, it is concluded that three of key advanced safety features of APR-1400 can be effectively applied to OPR-1000, resulting in considerable safety improvement. In aggregate, three advanced safety features, which are an additional EDG, increased battery capacity and IRWST, can reduce the CDF of OPR-1000 by more than 15% when applied altogether
Use of irradiation to improve the safety and quality of Thai prepared meal

Energy Technology Data Exchange (ETDEWEB)

Noomhorm, A [Food Engineering and Bioprocess Technology, Asian Institute of Technology (Thailand)

2002-07-01

There is a dynamic growth of market for chilled prepared meals in Thailand because of the growth of food services in supermarkets and convenient stores. However, the shelf life of this food is short furthermore it is implicated in a number of serious foodborne disease outbreaks. Irradiation could provide a potential to improve the microbiological safety and extend the shelf life of chilled prepared meals. It is possibly used alone or together with chilling. With the combination of irradiation and chilling, frozen condition could be replaced resulting to saving in energy and cost. However, there is a limitation of information about the application of irradiation on chilled prepared meals. Also, information relevant to the application of food safety control system like Hazard Analysis and Critical Control Point (HACCP) should be gathered to ensure more safety of the irradiated prepared meals. For Thai dishes, they are normally composed of herb and spicy with different types of meat. All dishes are eaten along with rice. Both Thai aromatic rice and herb are susceptible to deterioration in quality by processing factors. Therefore, the study of the effect of irradiation on Thai dishes, which compose of these two components, is necessary.
Road safety audits: The way forward

CSIR Research Space (South Africa)

Labuschagne, FJJ

2010-08-01

Full Text Available The South African Road Safety Manual (SARSM) was published in 1999 and includes guidelines on road safety audits (RSA). The development of SARSM was a proactive process for improving the road environment with respect to road safety but was never...
Intelligent Information Processing for Enhanced Safety in the NAS, Phase II

Data.gov (United States)

National Aeronautics and Space Administration — Our Phase I work focused on how improved information flow between actors in a flight deck environment can improve safety performance. An operational prototype was...
Intelligent Information Processing for Enhanced Safety in the NAS, Phase I

Data.gov (United States)

National Aeronautics and Space Administration — We propose a system that focuses on how improved information flow between agents acting in a flight deck environment can improve safety performance. Agents are...
78 FR 69433 - Executive Order 13650 Improving Chemical Facility Safety and Security Listening Sessions

Science.gov (United States)

2013-11-19

... Chemical Facility Safety and Security Listening Sessions AGENCY: National Protection and Programs... from stakeholders on issues pertaining to Improving Chemical Facility Safety and Security (Executive... regulations, guidance, and policies; and identifying best practices in chemical facility safety and security...
Process for improving metal production in steelmaking processes

Science.gov (United States)

Pal, Uday B.; Gazula, Gopala K. M.; Hasham, Ali

1996-01-01

A process and apparatus for improving metal production in ironmaking and steelmaking processes is disclosed. The use of an inert metallic conductor in the slag containing crucible and the addition of a transition metal oxide to the slag are the disclosed process improvements.
Assessing progress in the development of safety culture

International Nuclear Information System (INIS)

Rotaru, I.; Ghita, S.; Biro, L.

2002-01-01

This paper is focussed on the organizational culture and learning processes required for the implementation of all aspects of safety culture. There is no prescriptive formula for improving safety culture. However, some common characteristics and practices are emerging that can be adopted by organizations in order to make progress. The paper refers to some approaches that have been successful in a number of countries. The experience of the international nuclear industry in the development and improvement of safety culture could be extended and found useful in other nuclear activities, irrespective of scale. The examples given of specific practice cover a wide range of activities including analysis of events, the regulatory approach on safety culture, employee participation and safety performance measures. Many of these practices may be relevant to smaller organizations and could contribute to improving safety culture, whatever the size of the organization. The most effective approach is to pursue a range of practices that can be mutually supportive in the development of a progressive safety culture, supported by professional standards, organizational and management commitment. Some guidance is also given on the assessment of safety culture and on the detection of a weakening safety culture. Few suggestions for accelerating the safety culture development and improvement process are also provided. (author)
Continuous Improvement and the Safety Case for the Waste Isolation Pilot Plant Geologic Repository - 13467

Energy Technology Data Exchange (ETDEWEB)

Van Luik, Abraham; Patterson, Russell; Nelson, Roger [US Department of Energy, Carlsbad Field Office, 4021 S. National parks Highway, Carlsbad, NM 88220 (United States); Leigh, Christi [Sandia National Laboratories Carlsbad Operations, 4100 S. National parks Highway, Carlsbad, NM 88220 (United States)

2013-07-01

The Waste Isolation Pilot Plant (WIPP) is a geologic repository 2150 feet (650 m) below the surface of the Chihuahuan desert near Carlsbad, New Mexico. WIPP permanently disposes of transuranic waste from national defense programs. Every five years, the U.S. Department of Energy (DOE) submits an application to the U.S. Environmental Protection Agency (EPA) to request regulatory-compliance re-certification of the facility for another five years. Every ten years, DOE submits an application to the New Mexico Environment Department (NMED) for the renewal of its hazardous waste disposal permit. The content of the applications made by DOE to the EPA for re-certification, and to the NMED for permit-renewal, reflect any optimization changes made to the facility, with regulatory concurrence if warranted by the nature of the change. DOE points to such changes as evidence for its having taken seriously its 'continuous improvement' operations and management philosophy. Another opportunity for continuous improvement is to look at any delta that may exist between the re-certification and re-permitting cases for system safety and the consensus advice on the nature and content of a safety case as being developed and published by the Nuclear Energy Agency's Integration Group for the Safety Case (IGSC) expert group. DOE at WIPP, with the aid of its Science Advisor and teammate, Sandia National Laboratories, is in the process of discerning what can be done, in a reasonably paced and cost-conscious manner, to continually improve the case for repository safety that is being made to the two primary regulators on a recurring basis. This paper will discuss some aspects of that delta and potential paths forward to addressing them. (authors)
Performance improvement of the Annular Core Pulse Reactor for reactor safety experiments

International Nuclear Information System (INIS)

Reuscher, J.A.; Pickard, P.S.

1976-01-01

The Annular Core Pulse Reactor (ACPR) is a TRIGA type reactor which has been in operation at Sandia Laboratories since 1967. The reactor is utilized in a wide variety of experimental programs which include radiation effects, neutron radiography, activation analysis, and fast reactor safety. During the past several years, the ACPR has become an important experimental facility for the United States Fast Reactor Safety Research Program and questions of interest to the safety of the LMFBR are being addressed. In order to enhance the capabilities of the ACPR for reactor safety experiments, a project to improve the performance of the reactor was initiated. It is anticipated that the pulse fluence can be increased by a factor of 2.0 to 2.5 utilizing a two-region core concept with high heat capacity fuel elements around the central irradiation cavity. In addition, the steady-state power of the reactor will be increased by about a factor of two. The new features of the improvements are described
Statistical process control methods allow the analysis and improvement of anesthesia care.

Science.gov (United States)

Fasting, Sigurd; Gisvold, Sven E

2003-10-01

Quality aspects of the anesthetic process are reflected in the rate of intraoperative adverse events. The purpose of this report is to illustrate how the quality of the anesthesia process can be analyzed using statistical process control methods, and exemplify how this analysis can be used for quality improvement. We prospectively recorded anesthesia-related data from all anesthetics for five years. The data included intraoperative adverse events, which were graded into four levels, according to severity. We selected four adverse events, representing important quality and safety aspects, for statistical process control analysis. These were: inadequate regional anesthesia, difficult emergence from general anesthesia, intubation difficulties and drug errors. We analyzed the underlying process using 'p-charts' for statistical process control. In 65,170 anesthetics we recorded adverse events in 18.3%; mostly of lesser severity. Control charts were used to define statistically the predictable normal variation in problem rate, and then used as a basis for analysis of the selected problems with the following results: Inadequate plexus anesthesia: stable process, but unacceptably high failure rate; Difficult emergence: unstable process, because of quality improvement efforts; Intubation difficulties: stable process, rate acceptable; Medication errors: methodology not suited because of low rate of errors. By applying statistical process control methods to the analysis of adverse events, we have exemplified how this allows us to determine if a process is stable, whether an intervention is required, and if quality improvement efforts have the desired effect.
A simple intervention to improve patient safety, save time and improve staff experience in the AMU procedure room.

Science.gov (United States)

Misselbrook, Gary Peter; Kause, Juliane; Yeoh, Su-Ann

2016-01-01

Over the last decade, operating theatres and Intensive Care Units (ICUs) have established systematic methods for performing procedures on patients that have been shown to reduce complications and improve patient safety. Whilst the use of procedure rooms on Acute Medicine Units (AMUs) is highly recommended by patient safety groups and Royal College publications, they are not universally available or appropriately utilised. In this article we discuss a quality improvement project that was undertaken on an AMU at a large university teaching hospital in the United Kingdom, highlighting its successes and challenges.
Navigating towards improved surgical safety using aviation-based strategies.

Science.gov (United States)

Kao, Lillian S; Thomas, Eric J

2008-04-01

Safety practices in the aviation industry are being increasingly adapted to healthcare in an effort to reduce medical errors and patient harm. However, caution should be applied in embracing these practices because of limited experience in surgical disciplines, lack of rigorous research linking these practices to outcome, and fundamental differences between the two industries. Surgeons should have an in-depth understanding of the principles and data supporting aviation-based safety strategies before routinely adopting them. This paper serves as a review of strategies adapted to improve surgical safety, including the following: implementation of crew resource management in training operative teams; incorporation of simulation in training of technical and nontechnical skills; and analysis of contributory factors to errors using surveys, behavioral marker systems, human factors analysis, and incident reporting. Avenues and challenges for future research are also discussed.
Use of cut-off values as meaningfulness limits in probabilistic studies and its effect on NPPs risk assessment and safety improvement

International Nuclear Information System (INIS)

Petrangeli, G.; Valeri, A.; Zaffiro, C.

1991-01-01

This paper discusses the use of cut-off values in probabilistic risk assessment/probabilistic safety assessment (PRA/PSA) of nuclear power plants (NPPs), in order to explore under which conditions this practice may help improve the meaningfulness of the results of the analyses and safety of plants, and how it may affect the assessment of risk. Reference is made, in particular, to some past practical applications, also taken from the experience of the authors within the frame of the Italian licensing process. The paper describes the Italian probabilistic criteria which use probabilistic targets and cut-off values to assess safety and identify plant safety improvements. The rationale of the approach is also discussed in the paper and results of sample applications are illustrated. The paper concludes that the use of cut-off values, if properly implemented, could be productive to improve the plant safety as it helps the analyst to focus on a restricted field of analysis, ignoring lower probability and less known events. It also points out that cut-off values should be considered as living numbers to be lowered and even eliminated as soon as significant advancements are made, through research and operational experience, in the knowledge of the pertinent events
Using a Training Video to Improve Agricultural Workers' Knowledge of On-Farm Food Safety

Science.gov (United States)

Mathiasen, Lisa; Morley, Katija; Chapman, Benjamin; Powell, Douglas

2012-01-01

A training video was produced and evaluated to assess its impact on the food safety knowledge of agricultural workers. Increasing food safety knowledge on the farm may help to improve the safety of fresh produce. Surveys were used to measure workers' food safety knowledge before and after viewing the video. Focus groups were used to determine…
Augmented reality for improved safety

CERN Multimedia

Stefania Pandolfi

2016-01-01

Sometimes, CERN experts have to operate in low visibility conditions or in the presence of possible hazards. Minimising the duration of the operation and reducing the risk of errors is therefore crucial to ensuring the safety of personnel. The EDUSAFE project integrates different technologies to create a wearable personnel safety system based on augmented reality. The EDUSAFE integrated safety system uses a camera mounted on the helmet to monitor the working area. In its everyday operation of machines and facilities, CERN adopts a whole set of measures and safety equipment to ensure the safety of its personnel, including personal wearable safety devices and access control systems. However, sometimes, scheduled and emergency maintenance work needs to be done in zones with potential cryogenic hazards, in the presence of radioactive equipment or simply in demanding conditions where visibility is low and moving around is difficult. The EDUSAFE Marie Curie Innovative&...

[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
Model-based software process improvement

Science.gov (United States)

Zettervall, Brenda T.

1994-01-01

The activities of a field test site for the Software Engineering Institute's software process definition project are discussed. Products tested included the improvement model itself, descriptive modeling techniques, the CMM level 2 framework document, and the use of process definition guidelines and templates. The software process improvement model represents a five stage cyclic approach for organizational process improvement. The cycles consist of the initiating, diagnosing, establishing, acting, and leveraging phases.
National plan to enhance aviation safety through human factors improvements

Science.gov (United States)

Foushee, Clay

1990-01-01

The purpose of this section of the plan is to establish a development and implementation strategy plan for improving safety and efficiency in the Air Traffic Control (ATC) system. These improvements will be achieved through the proper applications of human factors considerations to the present and future systems. The program will have four basic goals: (1) prepare for the future system through proper hiring and training; (2) develop a controller work station team concept (managing human errors); (3) understand and address the human factors implications of negative system results; and (4) define the proper division of responsibilities and interactions between the human and the machine in ATC systems. This plan addresses six program elements which together address the overall purpose. The six program elements are: (1) determine principles of human-centered automation that will enhance aviation safety and the efficiency of the air traffic controller; (2) provide new and/or enhanced methods and techniques to measure, assess, and improve human performance in the ATC environment; (3) determine system needs and methods for information transfer between and within controller teams and between controller teams and the cockpit; (4) determine how new controller work station technology can optimally be applied and integrated to enhance safety and efficiency; (5) assess training needs and develop improved techniques and strategies for selection, training, and evaluation of controllers; and (6) develop standards, methods, and procedures for the certification and validation of human engineering in the design, testing, and implementation of any hardware or software system element which affects information flow to or from the human.
Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

Science.gov (United States)

Kuo, Calvin C; Robb, William J

2013-06-01

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.
Processes on Uncontrolled Aerodromes and Safety Indicators - Part I

Directory of Open Access Journals (Sweden)

Vladimír Plos

2013-09-01

Full Text Available This article describes the processes that take place at the beginning of each duty of dispatcher at uncontrolled aerodromes.Thanks to modeling and analysis of these processes, there is a possible to find critical ones and implement precise targeted safety measures.
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
TJC: HCOs need to be on alert for HIT problems related to sociotechnical factors, take steps to improve safety culture, process, and leadership.

Science.gov (United States)

2015-06-01

Noting that too many errors related to health information technology (HIT) are resulting in adverse consequences, The Joint Commission (TJC) has issued a Sentinel Event Alert, urging health care providers to take steps to improve their safety culture, approach to process improvement, and leadership in this area. In this latest alert, the accrediting agency is taking particular aim at risks posed by sociotechnical factors--or the ways in which HIT is implemented and used. Experts say that many of these risks are, in fact, exemplified at a higher level in the emergency setting, where providers are under constant pressure to see more patients and move them though the system faster. In an analysis of 3,375 sentinel events that resulted in permanent patient harm or death between January 1, 2010, and June 20, 2013, The Joint Commission (TJC) found that 120 events included HIT-related contributing factors. Many of the problems cited by TJC relate to orders or medicines being prescribed for the wrong patients. These can result from toggling errors or pop-up screens where providers are asked to click on the appropriate patient or medicine, and they mistakenly click on the wrong selection. In the ED, experts recommend the creation of a multidisciplinary performance improvement group to continuously monitor the ED information system (EDIS), recognize problems, and work with the vendor to resolve them. Also important is a quick and easy way for providers to report HIT-related problems. Experts add that emergency providers need to be fully engaged in the process of selecting HIT that they will be using, and that health care organizations should arrange for usability assessments before purchasing HIT.
Evaluating the Effectiveness of Two Teaching Strategies to Improve Nursing Students' Knowledge, Skills, and Attitudes About Quality Improvement and Patient Safety.

Science.gov (United States)

Maxwell, Karen L; Wright, Vivian H

The purpose of this study was to evaluate two teaching strategies with regard to quality and safety education for nurses content on quality improvement and safety. Two groups (total of 64 students) participated in online learning or online learning in conjunction with a flipped classroom. A pretest/posttest control group design was used. The use of online modules in conjunction with the flipped classroom had a greater effect on increasing nursing students' knowledge of quality improvement than the use of online modules only. There was no statistically significant difference between the groups for safety.
Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication.

Science.gov (United States)

Jain, Anshu K; Fennell, Mary L; Chagpar, Anees B; Connolly, Hannah K; Nembhard, Ingrid M

2016-11-01

Effective communication is a requirement in the teamwork necessary for improved coordination to deliver patient-centered, value-based cancer care. Communication is particularly important when care providers are geographically distributed or work across organizations. We review organizational and teams research on communication to highlight psychological safety as a key determinant of high-quality communication within teams. We first present the concept of psychological safety, findings about its communication effects for teamwork, and factors that affect it. We focus on five factors applicable to cancer care delivery: familiarity, clinical hierarchy-related status differences, geographic dispersion, boundary spanning, and leader behavior. To illustrate how these factors facilitate or hinder psychologically safe communication and teamwork in cancer care, we review the case of a patient as she experiences the treatment-planning process for early-stage breast cancer in a community setting. Our analysis is summarized in a key principle: Teamwork in cancer care requires high-quality communication, which depends on psychological safety for all team members, clinicians and patients alike. We conclude with a discussion of the implications of psychological safety in clinical care and suggestions for future research.
Evaluating the PRASE patient safety intervention - a multi-centre, cluster trial with a qualitative process evaluation: study protocol for a randomised controlled trial.

Science.gov (United States)

Sheard, Laura; O'Hara, Jane; Armitage, Gerry; Wright, John; Cocks, Kim; McEachan, Rosemary; Watt, Ian; Lawton, Rebecca

2014-10-29

Estimates show that as many as one in 10 patients are harmed while receiving hospital care. Previous strategies to improve safety have focused on developing incident reporting systems and changing systems of care and professional behaviour, with little involvement of patients. The need to engage with patients about the quality and safety of their care has never been more evident with recent high profile reviews of poor hospital care all emphasising the need to develop and support better systems for capturing and responding to the patient perspective on their care. Over the past 3 years, our research team have developed, tested and refined the PRASE (Patient Reporting and Action for a Safe Environment) intervention, which gains patient feedback about quality and safety on hospital wards. A multi-centre, cluster, wait list design, randomised controlled trial with an embedded qualitative process evaluation. The aim is to assess the efficacy of the PRASE intervention, in achieving patient safety improvements over a 12-month period.The trial will take place across 32 hospital wards in three NHS Hospital Trusts in the North of England. The PRASE intervention comprises two tools: (1) a 44-item questionnaire which asks patients about safety concerns and issues; and (2) a proforma for patients to report (a) any specific patient safety incidents they have been involved in or witnessed and (b) any positive experiences. These two tools then provide data which are fed back to wards in a structured feedback report. Using this report, ward staff are asked to hold action planning meetings (APMs) in order to action plan, then implement their plans in line with the issues raised by patients in order to improve patient safety and the patient experience.The trial will be subjected to a rigorous qualitative process evaluation which will enable interpretation of the trial results. fieldworker diaries, ethnographic observation of APMs, structured interviews with APM lead and collection
Using human factors engineering to improve patient safety in the cardiovascular operating room.

Science.gov (United States)

Gurses, Ayse P; Martinez, Elizabeth A; Bauer, Laura; Kim, George; Lubomski, Lisa H; Marsteller, Jill A; Pennathur, Priyadarshini R; Goeschel, Chris; Pronovost, Peter J; Thompson, David

2012-01-01

Despite significant medical advances, cardiac surgery remains a high risk procedure. Sub-optimal work system design characteristics can contribute to the risks associated with cardiac surgery. However, hazards due to work system characteristics have not been identified in the cardiovascular operating room (CVOR) in sufficient detail to guide improvement efforts. The purpose of this study was to identify and categorize hazards (anything that has the potential to cause a preventable adverse patient safety event) in the CVOR. An interdisciplinary research team used prospective hazard identification methods including direct observations, contextual inquiry, and photographing to collect data in 5 hospitals for a total 22 cardiac surgeries. We performed thematic analysis of the qualitative data guided by a work system model. 60 categories of hazards such as practice variations, high workload, non-compliance with evidence-based guidelines, not including clinicians' in medical device purchasing decisions were found. Results indicated that hazards are common in cardiac surgery and should be eliminated or mitigated to improve patient safety. To improve patient safety in the CVOR, efforts should focus on creating a culture of safety, increasing compliance with evidence based infection control practices, improving communication and teamwork, and designing better tools and technologies through partnership among all stakeholders.
Verification and validation process for the safety software in KNICS

International Nuclear Information System (INIS)

Kwon, Kee-Choon; Lee, Jang-Soo; Kim, Jang-Yeol

2004-01-01

This paper describes the Verification and Validation (V and V ) process for safety software of Programmable Logic Controller (PLC), Digital Reactor Protection System (DRPS), and Engineered Safety Feature-Component Control System (ESF-CCS) that are being developed in Korea Nuclear Instrumentation and Control System (KNICS) projects. Specifically, it presents DRPS V and V experience according to the software development life cycle. The main activities of DRPS V and V process are preparation of software planning documentation, verification of Software Requirement Specification (SRS), Software Design Specification (SDS) and codes, and testing of the integrated software and the integrated system. In addition, they include software safety analysis and software configuration management. SRS V and V of DRPS are technical evaluation, licensing suitability evaluation, inspection and traceability analysis, formal verification, preparing integrated system test plan, software safety analysis, and software configuration management. Also, SDS V and V of RPS are technical evaluation, licensing suitability evaluation, inspection and traceability analysis, formal verification, preparing integrated software test plan, software safety analysis, and software configuration management. The code V and V of DRPS are traceability analysis, source code inspection, test case and test procedure generation, software safety analysis, and software configuration management. Testing is the major V and V activity of software integration and system integration phase. Software safety analysis at SRS phase uses Hazard Operability (HAZOP) method, at SDS phase it uses HAZOP and Fault Tree Analysis (FTA), and at implementation phase it uses FTA. Finally, software configuration management is performed using Nu-SCM (Nuclear Software Configuration Management) tool developed by KNICS project. Through these activities, we believe we can achieve the functionality, performance, reliability and safety that are V
Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice.

Science.gov (United States)

Pitts, Samantha I; Maruthur, Nisa M; Luu, Ngoc-Phuong; Curreri, Kimberly; Grimes, Renee; Nigrin, Candace; Sateia, Heather F; Sawyer, Melinda D; Pronovost, Peter J; Clark, Jeanne M; Peairs, Kimberly S

2017-11-01

While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.
Implementation of cold risk management in occupational safety, occupational health and quality practices. Evaluation of a development process and its effects at the finnish maritime administration.

Science.gov (United States)

Risikko, Tanja; Remes, Jouko; Hassi, Juhani

2008-01-01

Cold is a typical environmental risk factor in outdoor work in northern regions. It should be taken into account in a company's occupational safety, health and quality systems. A development process for improving cold risk management at the Finnish Maritime Administration (FMA) was carried out by FMA and external experts. FMA was to implement it. Three years after the development phase, the outcomes and implementation were evaluated. The study shows increased awareness about cold work and few concrete improvements. Concrete improvements in occupational safety and health practices could be seen in the pilot group. However, organization-wide implementation was insufficient, the main reasons being no organization-wide practices, unclear process ownership, no resources and a major reorganization process. The study shows a clear need for expertise supporting implementation. The study also presents a matrix for analyzing the process.
The basic discussion on nuclear power safety improvement based on nuclear equipment design

International Nuclear Information System (INIS)

Zhao Feiyun; Yao Yangui; Yu Hao; He Yinbiao; Gao Lei; Yao Weida

2013-01-01

The safety of strengthening nuclear power design was described based on nuclear equipment design after Fukushima nuclear accident. From these aspects, such as advanced standard system, advanced design method, suitable test means, consideration of beyond design basis event, and nuclear safety culture construction, the importance of nuclear safety improvement was emphatically presented. The enlightenment was given to nuclear power designer. (authors)
Standardization and improvement of safety for radioisotope equipped instruments

International Nuclear Information System (INIS)

Sumi, Tetsuo

1980-01-01

The safety for radioisotope-equipped instruments is considered. The one is the safety for the source assembly. The radioisotopes employed for radioisotope-equipped instruments are sealed sources which are used in the state of being contained in the enclosures. Many of the enclosures are provided with shutter mechanism for the purpose of emitting radiation only during the period required. If the possible troubles that might lead to the accidents are sampled out of the results of field operation of radiation instruments, and the safety measures for source enclosures are considered in connection with these troubles, it is no exaggeration to say that the safety for source enclosures has been maintained by preventing the critical accidents by the management of users and the cooperation of manufactures though there were the chance for investigating the safety in the common field and the establishment of JIS Z 4614 standard. Another consideration is concerned with the measures to improve the safety. No accident in the past never guarantees no accident in the future. Accumulation of experience is most effective for those measures, and the more experiences the better. It may be most effective that the manufacturers disclose their experiences each other from the wide outlook overcoming the barrier of trade secret. Fortunately, such consciousness has risen since a few years ago, and the investigation group is doing the works in the Japan Radioisotope Association. On the other hand, the reasonable revision of the radiation injury prevention law is desired. (Wakatsuki, Y.)
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)
ABB engagement in efforts to improve the safety of RBMK reactors

International Nuclear Information System (INIS)

Tiren, L.I.; Bioere, S.; Molin, J.

1993-01-01

ABB Atom is engaged in safety analysis for the Ignalinsk (RBMK) nuclear power plant. The analysis is done within the framework of two different initiatives of the Swedish Nuclear Power Inspectorate, namely: probabilistic safety assessment, i.e. the BARSELINA project, and analysis of containment safety issues. The aim is to enable decisions to be made for specific hardware modifications. The following items were considered by the Swedish Nuclear Power Inspectorate to be the most significant with regard to safety and were thus selected for further study or action: nondestructive testing of primary system components, fire and flooding protection, pressure relief from the reactor cavity in certain accident sequences, Accident Localization System improvements, and a separate auxiliary feedwater system. (Z.S.) 1 fig
Safety margins in older adults increase with improved control of a dynamic object

Science.gov (United States)

Hasson, Christopher J.; Sternad, Dagmar

2014-01-01

Older adults face decreasing motor capabilities due to pervasive neuromuscular degradations. As a consequence, errors in movement control increase. Thus, older individuals should maintain larger safety margins than younger adults. While this has been shown for object manipulation tasks, several reports on whole-body activities, such as posture and locomotion, demonstrate age-related reductions in safety margins. This is despite increased costs for control errors, such as a fall. We posit that this paradox could be explained by the dynamic challenge presented by the body or also an external object, and that age-related reductions in safety margins are in part due to a decreased ability to control dynamics. To test this conjecture we used a virtual ball-in-cup task that had challenging dynamics, yet afforded an explicit rendering of the physics and safety margin. The hypotheses were: (1) When manipulating an object with challenging dynamics, older adults have smaller safety margins than younger adults. (2) Older adults increase their safety margins with practice. Nine young and 10 healthy older adults practiced moving the virtual ball-in-cup to a target location in exactly 2 s. The accuracy and precision of the timing error quantified skill, and the ball energy relative to an escape threshold quantified the safety margin. Compared to the young adults, older adults had increased timing errors, greater variability, and decreased safety margins. With practice, both young and older adults improved their ability to control the object with decreased timing errors and variability, and increased their safety margins. These results suggest that safety margins are related to the ability to control dynamics, and may explain why in tasks with simple dynamics older adults use adequate safety margins, but in more complex tasks, safety margins may be inadequate. Further, the results indicate that task-specific training may improve safety margins in older adults. PMID:25071566

Safety Margins in Older Adults Increase with Improved Control of a Dynamic Object

Directory of Open Access Journals (Sweden)

Christopher James Hasson

2014-07-01

Full Text Available Older adults face decreasing motor capabilities due to pervasive neuromuscular degradations. As a consequence errors in movement control increase. Thus, older individuals should maintain larger safety margins than younger adults. While this has been shown for object manipulation tasks, several reports on whole-body activities, such as posture and locomotion, however demonstrate age-related reductions in safety margins. This is despite increased costs for control errors, such as a fall. We posit that this paradox could be explained by the dynamic challenge presented by the body or an external object, and that age-related reductions in safety margins are in part due to a decreased ability to control dynamics. To test this conjecture we used a virtual ball-in-cup task that had challenging dynamics, yet afforded an explicit rendering of the physics and safety margin. The hypotheses were: 1 When manipulating an object with challenging dynamics, older adults have smaller safety margins than younger adults. 2 Older adults increase their safety margins with practice. Nine young and 10 healthy older adults practiced moving the virtual ball-in-cup to a target location in exactly two seconds. The accuracy and precision of the timing error quantified skill and the ball energy relative to an escape threshold quantified the safety margin. Compared to the young adults, older adults had increased timing errors, greater variability, and decreased safety margins. With practice, both young and older adults improved their ability to control the object with decreased timing errors and variability, and increased their safety margins. These results suggest that safety margins are related to the ability to control dynamics, and may explain why in tasks with simple dynamics older adults use adequate safety margins, but in more complex tasks, safety margins may be inadequate. Further, the results indicate that task-specific training may improve safety margins in older
Use of safety analysis results to support process operation

International Nuclear Information System (INIS)

Karvonen, I.; Heino, P.

1990-01-01

Safety and risk analysis carried out during the design phase of a process plant produces useful knowledge about the behavior and the disturbances of the system. This knowledge, however, often remains to the designer though it would be of benefit to the operators and supervisors of the process plant, too. In Technical Research Centre of Finland a project has been started to plan and construct a prototype of an information system to make use of the analysis knowledge during the operation phase. The project belongs to a Nordic KRM project (Knowledge Based Risk Management System). The information system is planned to base on safety and risk analysis carried out during the design phase and completed with operational experience. The safety analysis includes knowledge about potential disturbances, their causes and consequences in the form of Hazard and Operability Study, faut trees and/or event trees. During the operation disturbances can however, occur, which are not included in the safety analysis, or the causes or consequences of which have been incompletely identified. Thus the information system must also have an interface for the documentation of the operational knowledge missing from the analysis results. The main tasks off the system when supporting the management of a disturbance are to identify it (or the most important of the coexistent ones) from the stored knowledge and to present it in a proper form (for example as a deviation graph). The information system may also be used to transfer knowledge from one shift to another and to train process personnel
Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

International Nuclear Information System (INIS)

Novak, Avrey; Nyflot, Matthew J.; Ermoian, Ralph P.; Jordan, Loucille E.; Sponseller, Patricia A.; Kane, Gabrielle M.; Ford, Eric C.; Zeng, Jing

2016-01-01

Purpose: Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. Methods: From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Results: Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically
Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

Energy Technology Data Exchange (ETDEWEB)

Novak, Avrey; Nyflot, Matthew J.; Ermoian, Ralph P.; Jordan, Loucille E.; Sponseller, Patricia A.; Kane, Gabrielle M.; Ford, Eric C.; Zeng, Jing, E-mail: jzeng13@uw.edu [Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195 (United States)

2016-05-15

Purpose: Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. Methods: From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Results: Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically
The use of in-situ simulation to improve safety in the plastic surgery office: a feasibility study.

Science.gov (United States)

Shapiro, Fred E; Pawlowski, John B; Rosenberg, Noah M; Liu, Xiaoxia; Feinstein, David M; Urman, Richard D

2014-01-01

Simulation-based interventions and education can potentially contribute to safer and more effective systems of care. We utilized in-situ simulation to highlight safety issues, regulatory requirements, and assess perceptions of safety processes by the plastic surgery office staff. A high-fidelity human patient simulator was brought to an office-based plastic surgery setting to enact a half-day full-scale, multidisciplinary medical emergency. Facilitated group debriefings were conducted after each scenario with special consideration of the principles of team training, communication, crisis management, and adherence to evidence-based protocols and regulatory standards. Abbreviated AHRQ Medical Office Safety Culture Survey was completed by the participants before and after the session. The in-situ simulations had a high degree of acceptance and face validity according to the participants. Areas highlighted by the simulation sessions included rapid communication, delegation of tasks, location of emergency materials, scope of practice, and logistics of transport. The participant survey indicated greater awareness of patient safety issues following participation in simulation and debriefing exercises in 3 areas (P issue (100% vs 75%), openness to ideas about improving office processes (100% vs 88%), and the need to discuss ways to prevent errors from recurring (88% vs 62%). Issues of safety and regulatory compliance can be assessed in an office-based setting through the short-term (half-day) use of in-situ simulation with facilitated debriefing and the review of audiovisual recordings by trained facilities inspectors.
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
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.
78 FR 32010 - Pipeline Safety: Public Workshop on Integrity Verification Process

Science.gov (United States)

2013-05-28

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... Hazardous Materials Safety Administration, DOT. ACTION: Notice of public meeting. SUMMARY: This notice is announcing a public workshop to be held on the concept of ``Integrity Verification Process.'' The Integrity...
PROCESS VARIABILITY REDUCTION THROUGH STATISTICAL PROCESS CONTROL FOR QUALITY IMPROVEMENT

Directory of Open Access Journals (Sweden)

B.P. Mahesh

2010-09-01

Full Text Available Quality has become one of the most important customer decision factors in the selection among the competing product and services. Consequently, understanding and improving quality is a key factor leading to business success, growth and an enhanced competitive position. Hence quality improvement program should be an integral part of the overall business strategy. According to TQM, the effective way to improve the Quality of the product or service is to improve the process used to build the product. Hence, TQM focuses on process, rather than results as the results are driven by the processes. Many techniques are available for quality improvement. Statistical Process Control (SPC is one such TQM technique which is widely accepted for analyzing quality problems and improving the performance of the production process. This article illustrates the step by step procedure adopted at a soap manufacturing company to improve the Quality by reducing process variability using Statistical Process Control.
Participatory approach to improving safety, health and working conditions in informal economy workplaces in Cambodia.

Science.gov (United States)

Kawakami, Tsuyoshi; Tong, Leng; Kannitha, Yi; Sophorn, Tun

2011-01-01

The present study aimed to improve safety and health in informal economy workplaces such as home workplaces, small construction sites, and rural farms in Cambodia by using "participatory" approach. The government, workers' and employers' organizations and NGOs jointly assisted informal economy workers in improving safety and health by using participatory training methodologies. The steps taken were: (1) to collect existing good practices in safety and health in Cambodia; (2) to develop new participatory training programmes for home workers and small construction sites referring to ILO's WISE training programme, and (3) to train government officers, workers, employers and NGOs as safety and health trainers. The participatory training programmes developed consisted of action-checklists associated with illustrations, good example photo sheets, and texts explaining practical, low-cost improvement measures. The established safety and health trainers reached many informal economy workers through their human networks, and trained them by using the developed participatory training programmes. More than 3,000 informal economy workers were trained and they implemented improvements by using low-cost methods. Participatory training methodologies and active cooperation between the government, workers, employers and NGOs made it possible to provide practical training for those involved in the informal economy workplaces.
Applying different quality and safety models in healthcare improvement work: Boundary objects and system thinking

International Nuclear Information System (INIS)

Wiig, Siri; Robert, Glenn; Anderson, Janet E.; Pietikainen, Elina; Reiman, Teemu; Macchi, Luigi; Aase, Karina

2014-01-01

A number of theoretical models can be applied to help guide quality improvement and patient safety interventions in hospitals. However there are often significant differences between such models and, therefore, their potential contribution when applied in diverse contexts. The aim of this paper is to explore how two such models have been applied by hospitals to improve quality and safety. We describe and compare the models: (1) The Organizing for Quality (OQ) model, and (2) the Design for Integrated Safety Culture (DISC) model. We analyze the theoretical foundations of the models, and show, by using a retrospective comparative case study approach from two European hospitals, how these models have been applied to improve quality and safety. The analysis shows that differences appear in the theoretical foundations, practical approaches and applications of the models. Nevertheless, the case studies indicate that the choice between the OQ and DISC models is of less importance for guiding the practice of quality and safety improvement work, as they are both systemic and share some important characteristics. The main contribution of the models lay in their role as boundary objects directing attention towards organizational and systems thinking, culture, and collaboration
A Checklist to Improve Patient Safety in Interventional Radiology

International Nuclear Information System (INIS)

Koetser, Inge C. J.; Vries, Eefje N. de; Delden, Otto M. van; Smorenburg, Susanne M.; Boermeester, Marja A.; Lienden, Krijn P. van

2013-01-01

To develop a specific RADiological Patient Safety System (RADPASS) checklist for interventional radiology and to assess the effect of this checklist on health care processes of radiological interventions. On the basis of available literature and expert opinion, a prototype checklist was developed. The checklist was adapted on the basis of observation of daily practice in a tertiary referral centre and evaluation by users. To assess the effect of RADPASS, in a series of radiological interventions, all deviations from optimal care were registered before and after implementation of the checklist. In addition, the checklist and its use were evaluated by interviewing all users. The RADPASS checklist has two parts: A (Planning and Preparation) and B (Procedure). The latter part comprises checks just before starting a procedure (B1) and checks concerning the postprocedural care immediately after completion of the procedure (B2). Two cohorts of, respectively, 94 and 101 radiological interventions were observed; the mean percentage of deviations of the optimal process per intervention decreased from 24 % before implementation to 5 % after implementation (p < 0.001). Postponements and cancellations of interventions decreased from 10 % before implementation to 0 % after implementation. Most users agreed that the checklist was user-friendly and increased patient safety awareness and efficiency. The first validated patient safety checklist for interventional radiology was developed. The use of the RADPASS checklist reduced deviations from the optimal process by three quarters and was associated with less procedure postponements.
The micro-processor controlled process radiation monitoring system for reactor safety systems

International Nuclear Information System (INIS)

Mizuno, K.; Noguchi, A.; Kumagami, S.; Gotoh, Y.; Kumahara, T.; Arita, S.

1986-01-01

Digital computers are soon expected to be applied to various real-time safety and safety-related systems in nuclear power plants. Hitachi is now engaged in the development of a micro-processor controlled process radiation monitoring system, which operates on digital processing methods employed with a log ratemeter. A newly defined methodology of design and test procedures is being applied as a means of software program verification for these safety systems. Recently implemented micro-processor technology will help to achieve an advanced man-machine interface and highly reliable performance. (author)
Effect of lean process improvement techniques on a university hospital inpatient pharmacy.

Science.gov (United States)

Hintzen, Barbara L; Knoer, Scott J; Van Dyke, Christie J; Milavitz, Brian S

2009-11-15

The effect of lean process improvement on an inpatient university hospital pharmacy was evaluated. The University of Minnesota Medical Center (UMMC), Fairview, implemented lean techniques in its inpatient pharmacy to improve workflow, reduce waste, and achieve substantial cost savings. The sterile products area (SPA) and the inventory area were prospectively identified as locations for improvement due to their potential to realize cost savings. Process-improvement goals for the SPA included the reduction of missing doses, errors, and patient-specific waste by 30%, 50%, and 30%, respectively, and the reallocation of two technician full-time equivalents (FTEs). Reductions in pharmaceutical inventory and returns due to outdating were also anticipated. Work-flow in the SPA was improved through the creation of accountability, standard work, and movement toward one-piece flow. Increasing the number of i.v. batches decreased pharmaceutical waste by 40%. Through SPA environment improvements and enhanced workload sharing, two FTE technicians from the SPA were redistributed within the department. SPA waste reduction yielded an annual saving of $275,500. Quality and safety were also improved, as measured by reductions in missing doses, expired products, and production errors. In the inventory area, visual control was improved through the use of a double-bin system, the number of outdated drugs decreased by 20%, and medication inventory was reduced by $50,000. Lean methodology was successfully implemented in the SPA and inventory area at the UMMC, Fairview, inpatient pharmacy. Benefits of this process included an estimated annual cost saving of $289,256 due to waste reduction, improvements in workflow, and decreased staffing requirements.
Entropy based software processes improvement

NARCIS (Netherlands)

Trienekens, J.J.M.; Kusters, R.J.; Kriek, D.; Siemons, P.

2009-01-01

Actual results of software process improvement projects show different levels of success. Although many software development organisations have adopted improvement models such as CMMI, it appears to be difficult to improve software development processes in the right way, e.g. tuned to the actual
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.
78 FR 55257 - Patient Safety and Quality Improvement: Civil Money Penalty Inflation Adjustment

Science.gov (United States)

2013-09-10

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Patient Safety and Quality Improvement: Civil Money... Civil Rights has determined that an adjustment to the maximum civil money penalty amount for violations... confidentiality and privilege protections of Patient Safety Work Product (PSWP), and procedures for enforcement...
TEL4Health – Mobile tools to improve patient safety

NARCIS (Netherlands)

Drachsler, Hendrik; Kalz, Marco; Specht, Marcus

2013-01-01

Drachsler, H., Kalz, M., & Specht, M. (2013, 10 October). TEL4Health – Mobile tools to improve patient safety. Presentation given at the blended learning platform of the Netherlands Organisation for Hospitals (Nederlandse Vereniging van Ziekenhuizen), Utrecht, The Netherlands.
THE INTRODUCTION OF THE METHODOLOGY TO IMPROVE ROAD SAFETY

Directory of Open Access Journals (Sweden)

D. V. Kapsky

2013-01-01

Full Text Available Recommendations for improving the road safety and quality of road traffic controlled junctions(crossings on individual parameters of traffic light control, improvement of traffic light control by optimizing the length of the transition interval in the traffic light cycle, increase awareness and early warning drivers about the upcoming change traffic lights division of transport and pedestrian traffic, road conditions , transportation planning and technical aids of road traffic, as well as recommendations for the use of the hump in the settlements, etc.
Critical review of controlled release packaging to improve food safety and quality.

Science.gov (United States)

Chen, Xi; Chen, Mo; Xu, Chenyi; Yam, Kit L

2018-03-19

Controlled release packaging (CRP) is an innovative technology that uses the package to release active compounds in a controlled manner to improve safety and quality for a wide range of food products during storage. This paper provides a critical review of the uniqueness, design considerations, and research gaps of CRP, with a focus on the kinetics and mechanism of active compounds releasing from the package. Literature data and practical examples are presented to illustrate how CRP controls what active compounds to release, when and how to release, how much and how fast to release, in order to improve food safety and quality.

A study in improvement of administrative system in the nuclear safety regulation

International Nuclear Information System (INIS)

Yook, Dong Il; Kuk, Doe Hyeong; Lee, Seong Min; Kim, Jong Sam; Hwang, Sun Ho

2001-03-01

One of the most important tasks to improve nuclear safety regulation system is to separate nuclear regulatory institutes from public agencies which promote the development nuclear power. Moreover, nuclear safety regulation should be not only specialized but optimized to be adapted for new environments such as high-tech information age. Especially, it is necessary to reform the current nuclear safety regulation systems both to be effective under the local self-administration which began to operate in recent years and to be supported by local residents
A study in improvement of administrative system in the nuclear safety regulation

Energy Technology Data Exchange (ETDEWEB)

Yook, Dong Il; Kuk, Doe Hyeong; Lee, Seong Min; Kim, Jong Sam; Hwang, Sun Ho [Chungnam National Univ., Taejon (Korea, Republic of)

2001-03-15

One of the most important tasks to improve nuclear safety regulation system is to separate nuclear regulatory institutes from public agencies which promote the development nuclear power. Moreover, nuclear safety regulation should be not only specialized but optimized to be adapted for new environments such as high-tech information age. Especially, it is necessary to reform the current nuclear safety regulation systems both to be effective under the local self-administration which began to operate in recent years and to be supported by local residents.
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.
Radiotherapy professionals faced with the obligation of treatments safety improvement; Les professionnels de la radiotherapie face a l'obligation d'ameliorer la securite des traitements

Energy Technology Data Exchange (ETDEWEB)

NONE

2011-07-01

their redundancy; - better take into account the need to adapt safety demands to the features of the various types of radiotherapy units; - promote mutualization of safety practices between radiotherapy units in order to optimize the associated workload; - improve knowledge of safety demand impacts on actual conditions of treatment achievement in order to control negative effects; - improve knowledge about decision-making processes implemented by health care facilities in order to match safety improvement objectives and resources; - expend reflection on the role and means of scientific comities and hospital federations in order to improve their contribution to the dynamics of treatment safety improvement. (authors)
The state of quality improvement and patient safety teaching in health professional education in New Zealand.

Science.gov (United States)

Robb, Gillian; Stolarek, Iwona; Wells, Susan; Bohm, Gillian

2017-10-27

To investigate how quality and patient safety domains are being taught in the pre-registration curricula of health profession education programmes in New Zealand. All tertiary institutions providing training for medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, dietetics and 11 other allied health professions in New Zealand were contacted and a person with relevant curriculum knowledge was invited to participate. Interviews were conducted using a semi-structured interview guide to explore nine quality and safety domains; improvement science, patient safety, quality and safety culture, evidence-based practice, patient-centred care, teamwork and communication, leadership for change, systems thinking and use of information technology (IT). Transcribed data were extracted and categorised by discipline and domain. Two researchers independently identified and categorised themes within each domain, using a general inductive approach. Forty-nine institutions were contacted and 43 (88%) people were interviewed. The inclusion and extent of quality and safety teaching was variable. Evidence-based practice, patient-centred care and teamwork and communication were the strongest domains and well embedded in programmes, while leadership, systems thinking and the role of IT were less explicitly included. Except for two institutions, improvement science was absent from pre-registration curricula. Patient safety teaching was focused mainly around incident reporting, and to a lesser extent learning from adverse events. Although a 'no blame' culture was articulated as important, the theme of individual accountability was still apparent. While participants agreed that all domains were important, the main barriers to incorporating improvement science and patient safety concepts into existing programmes included an 'already stretched curriculum' and having faculty with limited expertise in these areas. Although the building blocks for improving the quality and safety of
New approaches to food safety economics

NARCIS (Netherlands)

Velthuis, A.G.J.; Unnevehr, L.J.; Hogeveen, H.; Huirne, R.B.M.

2002-01-01

Food-safety economics is a new research field, which needs a solid framework of concepts, procedures and data to support the decision-making process in food-safety improvement. Food safety is a theme that plays at many levels in the community: at the consumer level, at the farm or business level, at
Process improvement : the creation and evaluation of process alternatives

NARCIS (Netherlands)

Netjes, M.

2010-01-01

Companies continuously strive to improve their processes to increase productivity and delivered quality against lower costs. With Business Process Redesign (BPR) projects such improvement goals can be achieved. BPR involves the restructuring of business processes, stimulated by the application of
Why Process Improvement Training Fails

Science.gov (United States)

Lu, Dawei; Betts, Alan

2011-01-01

Purpose: The purpose of this paper is to explore the underlying reasons why providing process improvement training, by itself, may not be sufficient to achieve the desired outcome of improved processes; and to attempt a conceptual framework of management training for more effective improvement. Design/methodology/approach: Two similar units within…
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.
Process value of care safety: women's willingness to pay for perinatal services.

Science.gov (United States)

Anezaki, Hisataka; Hashimoto, Hideki

2017-08-01

To evaluate the process value of care safety from the patient's view in perinatal services. Cross-sectional survey. Fifty two sites of mandated public neonatal health checkup in 6 urban cities in West Japan. Mothers who attended neonatal health checkups for their babies in 2011 (n = 1316, response rate = 27.4%). Willingness to pay (WTP) for physician-attended care compared with midwife care as the process-related value of care safety. WTP was estimated using conjoint analysis based on the participants' choice over possible alternatives that were randomly assigned from among eight scenarios considering attributes such as professional attendance, amenities, painless delivery, caesarean section rate, travel time and price. The WTP for physician-attended care over midwife care was estimated 1283 USD. Women who had experienced complications in prior deliveries had a 1.5 times larger WTP. We empirically evaluated the process value for safety practice in perinatal care that was larger than a previously reported accounting-based value. Our results indicate that measurement of process value from the patient's view is informative for the evaluation of safety care, and that it is sensitive to individual risk perception for the care process. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care.
Intervention improves physician counseling on teen driving safety.

Science.gov (United States)

Campbell, Brendan T; Borrup, Kevin; Saleheen, Hassan; Banco, Leonard; Lapidus, Garry

2009-07-01

As part of a statewide campaign, we surveyed physician attitudes and practice regarding teen driving safety before and after a brief intervention designed to facilitate in office counseling. A 31-item self-administered survey was mailed to Connecticut physicians, and this was followed by a mailing of teen driving safety materials to physician practices in the state. A postintervention survey was mailed 8 months after the presurvey. A total of 102 physicians completed both the pre and postsurveys. Thirty-nine percent (39%) reported having had a teen in their practice die in a motor vehicle crash in the presurvey, compared with 49% in the postsurvey. Physician counseling increased significantly for a number of issues: driving while impaired from 86% to 94%; restrictions on teen driving from 53% to 64%; teen driving laws from 53% to 63%; safe vehicle from 32% to 42%; parents model safe driving from 29% to 44%; and teen-parent written contract from 15% to 37%. At baseline, the majority of physicians who provide care to teenagers in Connecticut report discussing and counseling teens on first wave teen driver safety issues (seat belts, alcohol use), but most do not discuss graduate driver licensing laws or related issues. After a brief intervention, there was a significant increase in physician counseling of teens on teen driving laws and on the use of teen-parent contracts. Additional interventions targeting physician practices can improve physician counseling to teens and their parents on issues of teen driving safety.
16 CFR 1500.88 - Exemptions from lead limits under section 101 of the Consumer Product Safety Improvement Act for...

Science.gov (United States)

2010-01-01

... 101 of the Consumer Product Safety Improvement Act for certain electronic devices. 1500.88 Section... from lead limits under section 101 of the Consumer Product Safety Improvement Act for certain electronic devices. (a) The Consumer Product Safety Improvement Act (CPSIA) provides for specific lead limits...
A complex tool and three simple approaches to improving quality assurance and safety in external radiotherapy

International Nuclear Information System (INIS)

Salinas, F; Sansogne, R; Arbiser, S; Suarez, V; Franco, M; Escobar, J

2012-01-01

Quality assurance and safety controls in radiation therapy delivery processes that involve the Physics Department of an institution are commonly time consuming tasks. Carrying out daily controls in very busy clinics without compromising patient schedule is challenging. This work describes the usage of Electronic Portal Imaging Devices in combination with some in-house software to simplify and systematize three different tasks of the Physics Department Quality Assurance Program, improving the easiness, reliability and velocity of daily tests (author)
Tactile display landing safety and precision improvements for the Space Shuttle

Science.gov (United States)

Olson, John M.

A tactile display belt using 24 electro-mechanical tactile transducers (tactors) was used to determine if a modified tactile display system, known as the Tactile Situation Awareness System (TSAS) improved the safety and precision of a complex spacecraft (i.e. the Space Shuttle Orbiter) in guided precision approaches and landings. The goal was to determine if tactile cues enhance safety and mission performance through reduced workload, increased situational awareness (SA), and an improved operational capability by increasing secondary cognitive workload capacity and human-machine interface efficiency and effectiveness. Using both qualitative and quantitative measures such as NASA's Justiz Numerical Measure and Synwork1 scores, an Overall Workload (OW) measure, the Cooper-Harper rating scale, and the China Lake Situational Awareness scale, plus Pre- and Post-Flight Surveys, the data show that tactile displays decrease OW, improve SA, counteract fatigue, and provide superior warning and monitoring capacity for dynamic, off-nominal, high concurrent workload scenarios involving complex, cognitive, and multi-sensory critical scenarios. Use of TSAS for maintaining guided precision approaches and landings was generally intuitive, reduced training times, and improved task learning effects. Ultimately, the use of a homogeneous, experienced, and statistically robust population of test pilots demonstrated that the use of tactile displays for Space Shuttle approaches and landings with degraded vehicle systems, weather, and environmental conditions produced substantial improvements in safety, consistency, reliability, and ease of operations under demanding conditions. Recommendations for further analysis and study are provided in order to leverage the results from this research and further explore the potential to reduce the risk of spaceflight and aerospace operations in general.
Accounting software cost management on health and safety, legal framework and areas of improvement

Directory of Open Access Journals (Sweden)

K.I. Samchuk

2017-03-01

Full Text Available Awareness of human life and health as the highest value is a sign of a civilized society. The economic activity of enterprises accompanied the influence of dangerous and harmful factors. An urgent need for society development and European integration is to create an effective mechanism by which the whole complex will be implemented measures to create conditions that meet the health care workers. The article highlighted media mouthpieces and performers interests of occupational safety, responsibilities entities regarding safety, the place and importance of your support in the management of safety measures, the necessity and directions of its improvement. Improving your security management costs of safety measures based on the determination of the legal framework, which aims to provide legal protection for employees, agencies and organizations, entities in the relationship work.
Using IT to improve quality at NewYork-Presybterian Hospital: a requirements-driven strategic planning process.

Science.gov (United States)

Kuperman, Gilad J; Boyer, Aurelia; Cole, Curt; Forman, Bruce; Stetson, Peter D; Cooper, Mary

2006-01-01

At NewYork-Presbyterian Hospital, we are committed to the delivery of high quality care. We have implemented a strategic planning process to determine the information technology initiatives that will best help us improve quality. The process began with the creation of a Clinical Quality and IT Committee. The Committee identified 2 high priority goals that would enable demonstrably high quality care: 1) excellence at data warehousing, and 2) optimal use of automated clinical documentation to capture encounter-related quality and safety data. For each high priority goal, a working group was created to develop specific recommendations. The Data Warehousing subgroup has recommended the implementation of an architecture management process and an improved ability for users to get access to aggregate data. The Structured Documentation subgroup is establishing recommendations for a documentation template creation process. The strategic planning process at times is slow, but assures that the organization is focusing on the information technology activities most likely to lead to improved quality.
Present status and improvement approach of atomic energy laws and safety standards

International Nuclear Information System (INIS)

Oh, B. J.; An, H. J.; Kim, S. W.; Kim, C. B.; Kang, S. C.; Lee, J. I.

2000-01-01

Major revision to the atomic energy act, which is currently undergoing are introduced: increase of members of nuclear safety commission, adoption of standard design certification, periodic safety review, production license system of radioactive isotope facilities, preparation for implementation of IAEA convention. Improvement of the notice of ministry of science and technology are discussed in accordance with the new atomic energy act, enforcement detect, and enforcement regulations, whose revision were completed in May 2000. Allocation of the code number to the notice, development procedures for the safety and regulatory guides are also introduced
Safety performance monitoring of autonomous marine systems

International Nuclear Information System (INIS)

Thieme, Christoph A.; Utne, Ingrid B.

2017-01-01

The marine environment is vast, harsh, and challenging. Unanticipated faults and events might lead to loss of vessels, transported goods, collected scientific data, and business reputation. Hence, systems have to be in place that monitor the safety performance of operation and indicate if it drifts into an intolerable safety level. This article proposes a process for developing safety indicators for the operation of autonomous marine systems (AMS). The condition of safety barriers and resilience engineering form the basis for the development of safety indicators, synthesizing and further adjusting the dual assurance and the resilience based early warning indicator (REWI) approaches. The article locates the process for developing safety indicators in the system life cycle emphasizing a timely implementation of the safety indicators. The resulting safety indicators reflect safety in AMS operation and can assist in planning of operations, in daily operational decision-making, and identification of improvements. Operation of an autonomous underwater vehicle (AUV) exemplifies the process for developing safety indicators and their implementation. The case study shows that the proposed process leads to a comprehensive set of safety indicators. It is expected that application of the resulting safety indicators consequently will contribute to safer operation of current and future AMS. - Highlights: • Process for developing safety indicators for autonomous marine systems. • Safety indicators based on safety barriers and resilience thinking. • Location of the development process in the system lifecycle. • Case study on AUV demonstrating applicability of the process.
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)

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