Undetected latent failures of safety-related systems. Preliminary survey of events in nuclear power plants 1980-1997

Energy Technology Data Exchange (ETDEWEB)

Lydell, B. [RSA Technologies, Vista, CA (United States)

1998-03-01

This report summarizes results and insights from a preliminary survey of events involving undetected, latent failures of safety-related systems. The survey was limited to events where mispositioned equipment (e.g., valves, switches) remained undetected, thus rendering standby equipment or systems unavailable for short or long time periods. Typically, these events were symptoms of underlying latent errors (e.g., design errors, procedure errors, unanalyzed safety conditions) and programmatic errors. The preliminary survey identified well over 300 events. Of these, 95 events are documented in this report. Events involving mispositioned equipment are commonplace. Most events are discovered soon after occurrence, however. But as evidenced by the survey results, some events remained undetected beyond several shift changes. The recommendations developed by the survey emphasize the importance of applying modern root cause analysis techniques to the event analysis to ensure that the causes and implications of occurred events are fully understood. 7 refs, 4 tabs, 3 figs. Also available at the SKI Home page: //www.ski.se.

Technical report on design base events related to the safety assessment of a Low-level Waste Storage Facility (LWSF)

International Nuclear Information System (INIS)

Karino, Motonobu; Uryu, Mitsuru; Miyata, Kazutoshi; Matsui, Norio; Imamoto, Nobuo; Kawamata, Tatsuo; Saito, Yasuo; Nagayama, Mineo; Wakui, Yasuyuki

1999-07-01

The construction of a new Low-level Waste Storage Facility (LWSF) is planned for storage of concentrated liquid waste from existing Low-level Radioactive Waste Treatment Facility in Tokai Reprocessing Plant of JNC. An essential base for the safety designing of the facility is correctly implemented the adoption of the defence in depth principle. This report summarized criteria for judgement, selection of postulated events, major analytical conditions for anticipated operational occurrences and accidents for the safety assessment and evaluation of each event were presented. (Itami, H.)

Adverse event reporting in Slovenia - the influence of safety culture, supervisors and communication

Directory of Open Access Journals (Sweden)

Birk Karin

2016-01-01

Full Text Available Background/Aim. The provision of safe healthcare is considered a priority in European Union (EU member states. Along with other preventative measures in healthcare, the EU also strives to eliminate the “causes of harm to human health”. The aim of this survey was to determine whether safety culture, supervisors and communication between co-workers influence the number of adverse event reports submitted to the heads of clinical departments and to the management of an institution. Methods. This survey is based on cross-sectional analysis. It was carried out in the largest Slovenian university hospital. We received 235 completed questionnaires. Respondents included professionals in the fields of nursingcare, physiotherapy, occupational therapy and radiological technology. Results. Safety culture influences the number of adverse event reports submitted to the head of a clinical department from the organizational point of view. Supervisors and communication between co-workers do not influence the number of adverse event reports. Conclusion. It can be concluded that neither supervisors nor the level of communication between co-workers influence the frequency of adverse event reporting, while safety culture does influence it from an organizational point of view. The presumed factors only partly influence the number of submitted adverse event reports, thus other causes of under-reporting must be sought elsewhere.

Guide on a national system for collecting, assessing and disseminating information on safety-related events in nuclear power plants

International Nuclear Information System (INIS)

1983-02-01

There is a wide spectrum of safety significance in the events that can occur during nuclear power plant operations. It is important that lessons be learned from safety-related events (hereinafter referred to as unusual events) so as to improve the safety of nuclear power plants. Hence formal procedures should be established for this purpose. The purpose of this document is to provide guidance to Member States for establishing a system (hereinafter referred to as a national system) for collecting, storing, retrieving, assessing and disseminating information on unusual events in nuclear power plants. The guidance given is based on experience gained in the use of existing national and international systems. This guide covers a national system that is part of a programme to improve nuclear power plant safety using experience gained from operating plants both within and outside the country. Implementing the recommendations in this guide would render any national system compatible with other national systems and facilitate the participation in the IAEA System for Reporting Unusual Events with Safety Significance (hereinafter referred to as the IAEA Incident Reporting System, IAEA-IRS) for more widespread dissemination of lessons learned from nuclear power plant operation

Trends and characteristics observed in nuclear events based on international nuclear event scale reports

International Nuclear Information System (INIS)

Watanabe, Norio

2001-01-01

The International Nuclear Event Scale (INES) is jointly operated by the IAEA and the OECD-NEA as a means designed for providing prompt, clear and consistent information related to nuclear events, that occurred at nuclear facilities, and facilitating communication between the nuclear community, the media and the public. Nuclear events are reported to the INES with the Scale', a consistent safety significance indicator, which runs from level 0, for events with no safety significance, to level 7 for a major accident with widespread health and environmental effects. Since the operation of INES was initiated in 1990, approximately 500 events have been reported and disseminated. The present paper discusses the trends observed in nuclear events, such as overall trends of the reported events and characteristics of safety significant events with level 2 or higher, based on the INES reports. (author)

Operational safety experience feedback by means of unusual event reports

International Nuclear Information System (INIS)

1996-07-01

Operational experience of nuclear power plants can be used to great advantage to enhance safety performance provided adequate measures are in place to collect and analyse it and to ensure that the conclusions drawn are acted upon. Feedback of operating experience is thus an extremely important tool to ensure high standards of safety in operational nuclear power plants and to improve the capability to prevent serious accidents and to learn from minor deviations and equipment failures - which can serve as early warnings -to prevent even minor events from occurring. Mechanisms also need to be developed to ensure that operating experience is shared both nationally as well as internationally. The operating experience feedback process needs to be fully and effectively established within the nuclear power plant, the utility, the regulatory organization as well as in other institutions such as technical support organizations and designers. The main purpose of this publication is to reflect the international consensus as to the general principles and practices in the operational safety experience feedback process. The examples of national practices for the whole or for particular parts of the process are given in annexes. The publication complements the IAEA Safety Series No.93 ''Systems for Reporting Unusual Events in Nuclear Power Plants'' (1989) and may also give a general guidance for Member States in fulfilling their obligations stipulated in the Nuclear Safety Convention. Figs, tabs

Operational safety experience feedback by means of unusual event reports

Energy Technology Data Exchange (ETDEWEB)

NONE

1996-07-01

Operational experience of nuclear power plants can be used to great advantage to enhance safety performance provided adequate measures are in place to collect and analyse it and to ensure that the conclusions drawn are acted upon. Feedback of operating experience is thus an extremely important tool to ensure high standards of safety in operational nuclear power plants and to improve the capability to prevent serious accidents and to learn from minor deviations and equipment failures - which can serve as early warnings -to prevent even minor events from occurring. Mechanisms also need to be developed to ensure that operating experience is shared both nationally as well as internationally. The operating experience feedback process needs to be fully and effectively established within the nuclear power plant, the utility, the regulatory organization as well as in other institutions such as technical support organizations and designers. The main purpose of this publication is to reflect the international consensus as to the general principles and practices in the operational safety experience feedback process. The examples of national practices for the whole or for particular parts of the process are given in annexes. The publication complements the IAEA Safety Series No.93 ``Systems for Reporting Unusual Events in Nuclear Power Plants`` (1989) and may also give a general guidance for Member States in fulfilling their obligations stipulated in the Nuclear Safety Convention. Figs, tabs.

Analysis of Paks NPP Personnel Activity during Safety Related Event Sequences

International Nuclear Information System (INIS)

Bareith, A.; Hollo, Elod; Karsa, Z.; Nagy, S.

1998-01-01

Within the AGNES Project (Advanced Generic and New Evaluation of Safety) the Level-1 PSA model of the Paks NPP Unit 3 was developed in form of a detailed event tree/fault tree structure (53 initiating events, 580 event sequences, 6300 basic events are involved). This model gives a good basis for quantitative evaluation of potential consequences of actually occurred safety-related events, i.e. for precursor event studies. To make these studies possible and efficient, the current qualitative event analysis practice should be reviewed and a new additional quantitative analysis procedure and system should be developed and applied. The present paper gives an overview of the method outlined for both qualitative and quantitative analyses of the operator crew activity during off-normal situations. First, the operator performance experienced during past operational events is discussed. Sources of raw information, the qualitative evaluation process, the follow-up actions, as well as the documentation requirements are described. Second, the general concept of the proposed precursor event analysis is described. Types of modeled interactions and the considered performance influences are presented. The quantification of the potential consequences of the identified precursor events is based on the task-oriented, Level-1 PSA model of the plant unit. A precursor analysis system covering the evaluation of operator activities is now under development. Preliminary results gained during a case study evaluation of a past historical event are presented. (authors)

The reasons for Chinese nursing staff to report adverse events: a questionnaire survey.

Science.gov (United States)

Hong, Su; Li, QiuJie

2017-04-01

To investigate the impact of nurses' perception of patient safety culture and adverse event reporting, and demographic factors on adverse event reporting in Chinese hospitals. Accurate and timely adverse event reporting is integral in promoting patient safety and professional learning around the incident. In a cross-sectional survey, a sample of 919 nurses completed a structured questionnaire composed of two validated instruments measuring nurses' perception of patient safety culture and adverse event reporting. Associations between the variables were examined using multiple linear regression analysis. The positive response rates of five dimensions of the Patient Safety Culture Assessment Scale varied from 47.55% to 80.62%. The accuracy rate of Adverse Event Reporting Perception Scale was 63.16%. Five hundred and thirty-one (58.03%) nurses did not report adverse event in past 12 months. Six variables were found to be associated with nurses' adverse event reporting: total work experience (P = 0.003), overall patient safety culture score (P teamwork climate (P importance or reporting (P = 0.002). The results confirmed that improvements in the patient safety culture and nurses' perception of adverse event reporting were related to an increase in voluntary adverse event reporting. The knowledge of adverse event reporting should be integrated into the patient safety curriculum. Interventions that target a specific domain are necessary to improve the safety culture. © 2017 John Wiley & Sons Ltd.

[Description of contributing factors in adverse events related to patient safety and their preventability].

Science.gov (United States)

Guerra-García, María Mercedes; Campos-Rivas, Beatriz; Sanmarful-Schwarz, Alexandra; Vírseda-Sacristán, Alicia; Dorrego-López, M Aránzazu; Charle-Crespo, Ángeles

2017-11-25

To assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. Retrospective descriptive study. Porriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. Reported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP). The variables measured were: Near Incident (NI) an occurrence with no effect or harm on the patient; Adverse Event (AE) an occurrence that affects or harms a patient. The level of harm is classified as minimal, minor, moderate, critical, and catastrophic. Preventability was classified as little evidence of being preventable, 50% preventable, and sound evidence of being preventable. percentages and Chi-squared test for qualitative variables; P<.05 with SPSS.15. SiNASP. Ethical considerations: approved by the Research Ethics Committee (2016/344). There were 166 recorded AEs (50.6% in males, and 46.4% in women. The mean age was 60.80years). Almost two-thirds 62.7% of AEs affected the patient, with 45.8% causing minimal damage, while 2.4% caused critical damages. Healthcare professionals were a contributing factor in 71.7% of the AEs, with the trend showing that poor communication and lack of protocols were related to the damage caused. Degree of preventability: 96.4%. Most AEs affected the patient, and were related to medication, diagnostic tests, and laboratory errors. The level of harm was related to communication problems, lack of, or deficient, protocols and a poor safety culture. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events.

Science.gov (United States)

Schneider, Eric C; Ridgely, M Susan; Quigley, Denise D; Hunter, Lauren E; Leuschner, Kristin J; Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C

2017-06-01

This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.

Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events.

Science.gov (United States)

Whitehurst, Julie M; Schroder, John; Leonard, Dave; Horvath, Monica M; Cozart, Heidi; Ferranti, Jeffrey

2012-05-18

Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined. To address this problem, we sought to create a "best-of-breed" patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint. A

Review of safety reports involving electronic flight bags

Science.gov (United States)

2009-04-27

Electronic Flight Bags (EFBs) are a relatively new device used by pilots. Even so, 37 safety-related events involving EFBs were identified from the public online Aviation Safety Reporting System (ASRS) database as of June 2008. In addition, two accid...

Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.

Science.gov (United States)

Pietrobon, Ricardo; Lima, Raquel; Shah, Anand; Jacobs, Danny O; Harker, Matthew; McCready, Mariana; Martins, Henrique; Richardson, William

2007-05-01

Studies have shown that 4% of hospitalized patients suffer from an adverse event caused by the medical treatment administered. Some institutions have created systems to encourage medical workers to report these adverse events. However, these systems often prove to be inadequate and/or ineffective for reviewing the data collected and improving the outcomes in patient safety. To describe the Web-application Duke Surgery Patient Safety, designed for the anonymous reporting of adverse and near-miss events as well as scheduled reporting to surgeons and hospital administration. SOFTWARE ARCHITECTURE: DSPS was developed primarily using Java language running on a Tomcat server and with MySQL database as its backend. Formal and field usability tests were used to aid in development of DSPS. Extensive experience with DSPS at our institution indicate that DSPS is easy to learn and use, has good speed, provides needed functionality, and is well received by both adverse-event reporters and administrators. This is the first description of an open-source application for reporting patient safety, which allows the distribution of the application to other institutions in addition for its ability to adapt to the needs of different departments. DSPS provides a mechanism for anonymous reporting of adverse events and helps to administer Patient Safety initiatives. The modifiable framework of DSPS allows adherence to evolving national data standards. The open-source design of DSPS permits surgical departments with existing reporting mechanisms to integrate them with DSPS. The DSPS application is distributed under the GNU General Public License.

Unusual event report from Oskarshamn

International Nuclear Information System (INIS)

1996-01-01

The title of the report was intended to reflect the cause of the shutdown and the report to be regarded as a summary of the deficiencies that had been revealed and remedied. No single deficiency was regarded as reportable as an unusual event, but taken together the identified deficiencies deviated from the assumed safety level to the extent that it should be reported. The unusual event report refers to two main documents presenting measures taken to return to reported safety level, one concerning technical and one organizational measures

75 FR 16140 - Common Formats for Patient Safety Data Collection and Event Reporting

Science.gov (United States)

2010-03-31

... FR 45457-45458. Definition of Common Formats The term ``Common Formats'' is used to describe clinical... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats for Patient Safety Data Collection and Event Reporting AGENCY: Agency for Healthcare Research and...

An analysis of electronic health record-related patient safety concerns

Science.gov (United States)

Meeks, Derek W; Smith, Michael W; Taylor, Lesley; Sittig, Dean F; Scott, Jean M; Singh, Hardeep

2014-01-01

Objective A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system. Methods The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports. Results We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR. Discussion EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA. Conclusions Because EHR-related safety concerns have complex

Safety of laboratories, plants, facilities being dismantled, waste processing, interim storage and disposal facilities. Lessons learned from events reported in 2009 and 2010

International Nuclear Information System (INIS)

2013-01-01

This report presents the cross-disciplinary analysis performed by IRSN relating to significant events reported to the French Nuclear Safety Authority (ASN) during 2009 - 2010 for LUDD-type facilities (laboratories, plants, facilities being dismantled, and waste processing, interim storage and disposal facilities). It constitutes a follow-up to DSU Report 215 published in December 2009, relating to events reported to ASN during 2005 to 2008. The main developments observed since the analysis presented in that report have been underlined here, in order to highlight improvements, opportunities for progress and the main areas requiring careful attention. The present report is a continuation of DSU Report 215. Without claiming to be exhaustive, it presents lessons from IRSN's cross-disciplinary analysis of events reported to ASN during 2009 and 2010 at LUDD facilities while highlighting major changes from the previous analysis in order to underline improvements, areas where progress has been made, and main points for monitoring. The report has four sections: - the first gives a brief introduction to the various kinds of LUDD facilities and highlights changes with DSU Report 215; - the second provides a summary of major trends involving events reported to ASN during 2007-2010 as well as overall results of consequences of events reported during 2009 and 2010 for workers, the general public and the environment; - the third section gives a cross-disciplinary analysis of significant events reported during 2009 and 2010, performed from two complementary angles (analysis of main types of events grouped by type of risk and analysis of generic causes). Main changes from the analysis given in DSU Report 215 are considered in detail; - the last section describes selected significant events that occurred in 2009 and 2010 in order to illustrate the cross-disciplinary analysis with concrete examples. IRSN will publish this type of report periodically in coming years in order to

Guide to the declaration procedure and coding system for criteria concerning significant events related to safety, radiation protection or the environment, applicable to basic nuclear installations and the transport of radioactive materials

International Nuclear Information System (INIS)

Lacoste, Andre-Claude

2005-01-01

This guide notably contains various forms associated with the declaration of significant events, and explanations to fill them in: significant event declaration form for a basic nuclear installation, significant event declaration form for radioactive material transport, significant event report for a basic nuclear installation, significant event report for radioactive material transport, declaration criteria for significant events related to the safety of non-PWR basic nuclear installations, declaration criteria for significant events related to PWR safety, significant events declared further to events resulting in group 1 unavailability and non-compliance with technical operating specifications, declaration criteria for significant events concerning radiation protection for basic nuclear installations, declaration criteria for significant events concerning environmental protection, applicable to basic nuclear installations, and declaration criteria for significant events concerning radioactive material transport

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

International Nuclear Information System (INIS)

1998-01-01

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

The complexity of patient safety reporting systems in UK dentistry.

Science.gov (United States)

Renton, T; Master, S

2016-10-21

Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

Preliminary safety analysis of unscrammed events for KLFR

International Nuclear Information System (INIS)

Kim, S.J.; Ha, G.S.

2005-01-01

The report presents the design features of KLFR; Safety Analysis Code; steady-state calculation results and analysis results of unscrammed events. The calculations of the steady-state and unscrammed events have been performed for the conceptual design of KLFR using SSC-K code. UTOP event results in no fuel damage and no centre-line melting. The inherent safety features are demonstrated through the analysis of ULOHS event. Although the analysis of ULOF has much uncertainties in the pump design, the analysis results show the inherent safety characteristics. 6% flow of rated flow of natural circulation is formed in the case of ULOF. In the metallic fuel rod, the cladding temperature is somewhat high due to the low heat transfer coefficient of lead. ULOHS event should be considered in design of RVACS for long-term cooling

Barriers to Safety Event Reporting in an Academic Radiology Department: Authority Gradients and Other Human Factors.

Science.gov (United States)

Siewert, Bettina; Swedeen, Suzanne; Brook, Olga R; Eisenberg, Ronald L; Hochman, Mary

2018-05-15

Purpose To investigate barriers to reporting safety concerns in an academic radiology department and to evaluate the role of human factors, including authority gradients, as potential barriers to safety concern reporting. Materials and Methods In this institutional review board-approved, HIPAA-compliant retrospective study, an online questionnaire link was emailed four times to all radiology department staff members (n = 648) at a tertiary care institution. Survey questions included frequency of speaking up about safety concerns, perceived barriers to speaking up, and the annual number of safety concerns that respondents were unsuccessful in reporting. Respondents' sex, role in the department, and length of employment were recorded. Statistical analysis was performed with the Fisher exact test. Results The survey was completed by 363 of the 648 employees (56%). Of those 363 employees, 182 (50%) reported always speaking up about safety concerns, 134 (37%) reported speaking up most of the time, 36 (10%) reported speaking up sometimes, seven (2%) reported rarely speaking up, and four (1%) reported never speaking up. Thus, 50% of employees spoke up about safety concerns less than 100% of the time. The most frequently reported barriers to speaking up included high reporting threshold (69%), reluctance to challenge someone in authority (67%), fear of disrespect (53%), and lack of listening (52%). Conclusion Of employees in a large academic radiology department, 50% do not attain 100% reporting of safety events. The most common human barriers to speaking up are high reporting threshold, reluctance to challenge authority, fear of disrespect, and lack of listening, which suggests that existing authority gradients interfere with full reporting of safety concerns. © RSNA, 2018.

Safety at basic nuclear facilities other than nuclear power plants. Lessons learned from significant events reported in 2011 and 2012

International Nuclear Information System (INIS)

2014-01-01

The third report on the safety of basic nuclear installations in France other than power reactors presents an IRSN's analysis of significant events reported to the Nuclear Safety Authority in the years 2011 and 2012. It covers plants, laboratories, research reactors and facilities for the treatment, storage or disposal of waste. This report aims to contribute to a better understanding by stakeholders and more widely by the public of the safety and radiation protection issues associated with the operation of nuclear facilities, the progress made in terms of safety as well as the identified deficiencies. The main trend shows, once again, the significant role of organizational and human factors in the significant events that occurred in 2011 and 2012, of which the vast majority are without noteworthy consequences. Aging mechanisms are another major cause of equipment failure and require special attention. The report also provides IRSN's analysis of specific events that are particularly instructive for facility safety and a synthesis of assessments performed by IRSN on topics that are important for safety and radiation protection. IRSN also includes an overview of its analysis of measures proposed by licensees for increasing the safety of their facilities after the March 2011 accident at the Fukushima Daiichi nuclear power plant in Japan, which consist of providing a 'hardened safety core' to confront extreme situations (earthquake, flooding, etc.) that are unlikely but plausible and can bring about levels of hazards higher than those taken into account in the design of the facilities

Safety-related LWR research. Annual report 1989

International Nuclear Information System (INIS)

1990-11-01

The main topics in this annual report 1989 are phenomena of heavy fuel damage and single aspects of a core meltdown accident. The examined single aspects refer to aerosol behavior and filter engineering and to methods for assessment and minimization of the radiological consequences of reactor accidents. Different contributions to selected, safety-related problems of an advanced pressurized-water reactor complete the topic spectrum. The annual report 1989 describes the progress of the research work wich was carried out in the area of safety research by institutes and departments of the KfK, and on behalf of the KfK by external institutions. The individual contributions represent the status of work at the end of the year under review, 1989. (orig./HP) [de

Safety of the Transport of Radioactive Materials for Civilian Use in France. Lessons learned by IRSN from analysis of significant events reported in 2014 and 2015. Mission report 2016

International Nuclear Information System (INIS)

2017-01-01

IRSN publishes its report on the safety of transport of radioactive materials for civilian use in France for the years 2014 and 2015. It is based on an overall review of the significant events that occurred during this period during transport operations in France by road, railway, inland waterway, sea and air of 980 000 parcels loaded with radioactive substances. In 2014 and 2015, respectively 139 and 122 events were reported, which is about one event reported for 7,500 packages carried. While these figures are up significantly compared to 2013 (93 reported events, or 1 in 10,000 packages carried), IRSN believes that this trend should not however be interpreted as a deterioration of the safety level of the transport of radioactive materials. Indeed, it is largely explained by better detection of events relevant to safety by the actors concerned and therefore their declaration to the authorities. None of these events had significant radiological consequences for the workers, the population or the environment. As part of progress made, IRSN notes a sharp decrease, in 2015, in the number of damage of packages intended for medical activities during their handling in airport areas. This decrease is linked to awareness actions conducted for airlines companies and staff involved in the handling of packages. Finally, three themes must be the subject of particular vigilance of the actors concerned and of corrective actions: - Compliance with the requirements for the transport of gamma radiography devices, in particular those associated with the locking of the source; events related to the transport of gamma radiography devices appeared as remarkable events over the period (3 level 1 events and 1 level 2 events); - The tie-down of packages on their means of transport, given the risks of fall of the package during transport, as well as tie-down of the objects in their transport container; - The operations of filling and closing of drums containing uranium ore in order to

Report on transparency and nuclear safety - Saclay - 2012

International Nuclear Information System (INIS)

2013-01-01

This report presents the different nuclear base installations (INB) of the Saclay CEA centre, gives an overview of measures regarding safety within these installations (organisation, technical general arrangements, technical arrangements related to different risks, management of emergency situations, inspections, audits and second-level controls, arrangements and main events specific to the different installations and buildings) and of measures related to radiation protection (organisation and dosimetry results, internal dosimetry). It reports the significant events related to safety and radiation protection which occurred in 2012 and were declared to the ASN. It reports and comments the results of measurements of gaseous and liquid effluents, of their impact on the environment, and of surveys of the environment. The next part addresses the management of radioactive wastes which are warehoused on this site: arrangements aimed at limiting their volume, and at limiting their impact on health and on the environment, nature and quantities of warehoused wastes. Remarks and recommendations of the CHSCT are given

A Study of Time Response for Safety-Related Operator Actions in Non-LOCA Safety Analysis

Energy Technology Data Exchange (ETDEWEB)

Lee, Min Seok; Lee, Sang Seob; Park, Min Soo; Lee, Gyu Cheon; Kim, Shin Whan [KEPCO E and C Company, Daejeon (Korea, Republic of)

2014-10-15

The classification of initiating events for safety analysis report (SAR) chapter 15 is categorized into moderate frequency events (MF), infrequent events (IF), and limiting faults (LF) depending on the frequency of its occurrence. For the non-LOCA safety analysis with the purpose to get construction or operation license, however, it is assumed that the operator response action to mitigate the events starts at 30 minutes after the initiation of the transient regardless of the event categorization. Such an assumption of corresponding operator response time may have over conservatism with the MF and IF events and results in a decrease in the safety margin compared to its acceptance criteria. In this paper, the plant conditions (PC) are categorized with the definitions in SAR 15 and ANS 51.1. Then, the consequence of response for safety-related operator action time is determined based on the PC in ANSI 58.8. The operator response time for safety analysis regarding PC are reviewed and suggested. The clarifying alarm response procedure would be required for the guideline to reduce the operator response time when the alarms indicate the occurrence of the transient.

Review of licensee event reports, 1976 to 1978

International Nuclear Information System (INIS)

1979-09-01

This report was prepared in response to a request by the Chairman of the US Nuclear Regulatory Commission for the Advisory Committee on Reactor Safeguards to review, with specific objectives, the Licensee Event Reports (LERs) issued fom 1976 through 1978. A principal objective of the present study was to identify those events which have implications for improved reactor safety. Approximately 8,700 LERs were filed during the three-year period under review. These described events ranging from the trivial to those of major safety significance. This study has confirmed that LERs represent a source of valuable data and information. However, it must be recognized that a detailed review of LERs will not identify all safety problems likely to be encountered in the operation of nuclear power plants. As a result of this review, a number of classes of events were identified. These classes were subsequently categorized into three groups: (a) those having potentially serious safety implications, (b) events that must be regarded as matters of concern, and (c) events of lower safety significance but with excessive frequency

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

International Nuclear Information System (INIS)

2015-03-01

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

Assessing the association between omalizumab and arteriothrombotic events through spontaneous adverse event reporting

Directory of Open Access Journals (Sweden)

Ali AK

2012-05-01

Full Text Available Ayad K Ali, Abraham G HartzemaDepartment of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USABackground: Omalizumab is a monoclonal antibody, indicated for the treatment of severe allergic asthma. In Europe, there have been concerns about the cardiovascular safety of omalizumab. The objective of this study was to analyze the association between omalizumab and arterial thrombotic events in a spontaneous adverse drug reaction reporting database in the US.Methods and materials: Reports of arterial thrombotic events submitted to the US Food and Drug Administration's Adverse Event Reporting System (AERS between 2004 and 2011 were retrieved and analyzed by the reporting odds ratio data mining algorithm. The reporting odds ratio of arterial thrombotic events for omalizumab was compared with specific asthma medications and all drugs in the AERS. Values ≥2 were considered significant safety signals. The Medical Dictionary for Regulatory Activities Preferred Terms were used to identify arterial thrombotic events (eg, stroke, myocardial infarction.Results: In total, 293,783 reports of arterial thrombotic events were retrieved (about 2% of all adverse drug reaction reports, corresponding to 2274 asthma drug-arterial thrombotic events pairs (omalizumab, 222; inhaled corticosteroids [ICS], 131; long-acting beta-agonists [LABA], 102; single-device combination ICS-LABA, 506; inhaled short-acting beta-agonists [SABA], 475; oral SABA, 6; inhaled antimuscarinics [AMC], 477; single-device combination AMC-SABA, 127; xanthines, 50; leukotriene modifiers, 174; and mast cell stabilizers, 4. Reporting odds ratio and 95% confidence interval values for omalizumab compared with other asthma drugs and all drugs in AERS were 2.75 (2.39–316 and 1.09 (0.95–1.24, respectively. Omalizumab ranked second after ICS in the risk of arterial thrombotic events, followed by AMC, AMC-SABA, and ICS-LABA.Conclusion: Omalizumab is

Insight and Lessons Learned on Organizational Factors and Safety Culture from the Review of Human Error-related Events of NPPs in Korea

International Nuclear Information System (INIS)

Kim, Ji Tae; Lee, Dhong Hoon; Choi, Young Sung

2014-01-01

Event investigation is one of the key means of enhancing nuclear safety deriving effective measures and preventing recurrences. However, it is difficult to analyze organizational factors and safety culture. This paper tries to review human error-related events from perspectives of organizational factors and safety culture, and to derive insights and lessons learned in developing the regulatory infrastructure of plant oversight on safety culture

Insight and Lessons Learned on Organizational Factors and Safety Culture from the Review of Human Error-related Events of NPPs in Korea

Energy Technology Data Exchange (ETDEWEB)

Kim, Ji Tae; Lee, Dhong Hoon; Choi, Young Sung [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2014-08-15

Event investigation is one of the key means of enhancing nuclear safety deriving effective measures and preventing recurrences. However, it is difficult to analyze organizational factors and safety culture. This paper tries to review human error-related events from perspectives of organizational factors and safety culture, and to derive insights and lessons learned in developing the regulatory infrastructure of plant oversight on safety culture.

Report on transparency and nuclear safety - 2015. Nuclear facilities exploited by CEA Marcoule

International Nuclear Information System (INIS)

Guiberteau, Philippe

2016-01-01

This report presents the different basic nuclear installations (INB) of the Marcoule CEA centre, gives an overview of measures regarding safety within these installations (organisation, general arrangements, arrangements related to different risks, management of emergency situations, inspections, audits and second-level controls, arrangements and main events specific to the different installations and buildings) and of measures related to radiation protection (organisation and results, main events). It reports the significant events related to safety and radiation protection which occurred in 2015 and which were declared to the nuclear safety authority (ASN), and discusses how experience feedback has been used. It reports and comments the results of measurements of gaseous and liquid effluents, of their impact on the environment, and of surveys of the environment. It also presents the environmental management approach. The next part addresses the management of radioactive wastes which are warehoused on this site: arrangements aimed at limiting their volume, and at limiting their impact on health and on the environment, nature and quantities of warehoused wastes. Remarks and recommendations of the health, safety and work conditions committee (CHSCT) are given

Assessing propensity to learn from safety-related events

NARCIS (Netherlands)

Drupsteen, L.; Wybo, J.L.

2015-01-01

Most organisations aim to use experience from the past to improve safety, for instance through learning from safety-related incidents and accidents. Whether an organisation is able to learn successfully can however only be determined afterwards. So far, there are no proactive measures to assess

Implementation and evaluation of a prototype consumer reporting system for patient safety events.

Science.gov (United States)

Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C; Quigley, Denise D; Hunter, Lauren E; Ridgely, M Susan; Schneider, Eric C

2017-08-01

No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline. Mixed methods evaluation. The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015. Patients, family members and caregivers associated with two US healthcare systems. A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries. Key informant interviews, measurement of website traffic and analysis of completed reports. Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups. While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems. © The Author 2017. 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

Earthquake-associated events. Annual safety research report, JFY 2011

International Nuclear Information System (INIS)

2012-01-01

For the tsunami and slope stability as the earthquake-associated events that increased with the revision of the regulatory guide for reviewing seismic design of nuclear power reactor facilities, related technical standard and analysis code were leveled up to support the safety examination of the country. For tsunami study, the original plan was changed due to the 2011 Tohoku earthquake tsunami, analysis code of river run-up, sedimentation, probabilistic tsunami hazard and tsunami trace database were developed. For slope study, in addition to conventional stress criteria, in order to build a slope stability evaluation method, incorporating new indicators, such as deformation and strain, the following study was conducted. The large-scale shaking table test for E-defense, the test data were obtained. The applicability of slope stability analysis code was examined by using the shaking table test data. (author)

Identification of new unresolved safety issues relating to nuclear power plants - special report to Congress. Congressional report

International Nuclear Information System (INIS)

1981-03-01

As a result of NRC staff review and extended collegial consultations and investigations within the NRC, the Commission has designated four new Unresolved Safety Issues (USIs). This report describes the process used to evaluate the large number of concerns and recommendations which resulted from the major investigations of the Three Mile Island-2 accident as well as other events and investigations of the past year, and the report identifies the four new USIs selected as follows: (1) Shutdown decay heat removal requirements (Task A-45); (2) Seismic qualification of equipment in operating plants (Task A-46); (3) Safety implications of control systems (Task A-47); and (4) Hydrogen control measures and effects of hydrogen burns on safety equipment (Task A-48). Appendix A of the report presents an expanded discussion of each new USI including issue definition, a preliminary discussion of the action plan and a basis for continued plant operations and licensing. Appendix B of the report provides a brief discussion of each of the candidate safety issues not designated as an USI

Systems for reporting unusual events in nuclear power plants

International Nuclear Information System (INIS)

1989-01-01

Many Member States with nuclear power programmes have established, and are operating, systems for collecting, assessing and disseminating information on safety related events in nuclear power plants. The Agency has recognized the importance of such systems and of achieving compatibility between them. It also recognizes the advantage to be derived from international efforts to exchange operational experience on a worldwide basis. In response to requests put forward during the Special Session of the IAEA General Conference held in September 1986, and to the recommendations made by the International Nuclear Safety Advisory Group (INSAG) to strengthen international co-operation in nuclear safety and the exchange of information on operating experience, the IAEA has been following a two-step approach. Firstly, it continues to assist Member States to establish, improve or harmonize their national systems for collecting, assessing and disseminating safety related operational experience, and secondly, it continues to reinforce the IAEA system for reporting unusual events with safety significance (IAEA Incident Reporting System - IAEA-IRS). Although the prime objective of both activities is to assist regulatory bodies and operating organizations to improve operational safety, operating organizations may also benefit if a similar approach is used to improve equipment reliability and plant availability. The present Guide contains a recommended scheme based on national and international practice applicable to the management of safety related operational experience in nuclear power plants. The user will have to adapt this guidance for specific national conditions and practices. It is important to realize however that for an effective exchange of information through the IAEA-IRS it is a prerequisite to follow the procedures given in the relevant part of this Guide

The nature and causes of unintended events reported at ten emergency departments

Directory of Open Access Journals (Sweden)

van der Wal Gerrit

2009-09-01

Full Text Available Abstract Background Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure. Methods Study at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA by an experienced researcher. Results 522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%, followed by organisational (25% and technical causes (11%. Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital. Conclusion Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.

Report on transparency and nuclear safety - Grenoble CEA centre - 2012

International Nuclear Information System (INIS)

2013-01-01

This report presents the different nuclear base installations (INB) of the Grenoble CEA centre, gives an overview of measures regarding safety within these installations (organisation, general arrangements, human and organizational factors, arrangements related to different risks, management of emergency situations, inspections, audits and second-level controls, arrangements and main events specific to the different installations and buildings) and of measures related to radiation protection (organisation and results, main events). It reports the significant events related to safety and radiation protection which occurred in 2012 and were declared to the ASN, and discusses how the return-on-experience has been used. It reports and comments the results of measurements of radiological and chemical gaseous and liquid effluents, of surveys of the environment. It also presents the environmental management approach. The next part addresses the management of radioactive wastes which are warehoused on this site: arrangements aimed at limiting their volume, and at limiting their impact on health and on the environment, waste production and removal, nature and quantities of warehoused wastes. Remarks and recommendations of the CHSCT are given

Criteria for safety-related operator actions

International Nuclear Information System (INIS)

Gray, L.H.; Haas, P.M.

1983-01-01

The Safety-Related Operator Actions (SROA) Program was designed to provide information and data for use by NRC in assessing the performance of nuclear power plant (NPP) control room operators in responding to abnormal/emergency events. The primary effort involved collection and assessment of data from simulator training exercises and from historical records of abnormal/emergency events that have occurred in operating plants (field data). These data can be used to develop criteria for acceptability of the use of manual operator action for safety-related functions. Development of criteria for safety-related operator actions are considered

Adverse events following quadrivalent meningococcal CRM-conjugate vaccine (Menveo®) reported to the Vaccine Adverse Event Reporting system (VAERS), 2010-2015.

Science.gov (United States)

Myers, Tanya R; McNeil, Michael M; Ng, Carmen S; Li, Rongxia; Lewis, Paige W; Cano, Maria V

2017-03-27

Limited data are available describing the post-licensure safety of meningococcal vaccines, including Menveo®. We reviewed reports of adverse events (AEs) to the Vaccine Adverse Event Reporting System (VAERS) to assess safety in all age groups. VAERS is a national spontaneous vaccine safety surveillance system co-administered by the Centers for Disease Control and Prevention and the US Food and Drug Administration. We searched the VAERS database for US reports of adverse events in persons who received Menveo from 1 January 2010 through 31 December 2015. We clinically reviewed reports and available medical records for serious AEs, selected pre-specified outcomes, and vaccination during pregnancy. We used empirical Bayesian data mining to identify AEs that were disproportionately reported after receipt of Menveo. During the study period, VAERS received 2614 US reports after receipt of Menveo. Of these, 67 were classified as serious, including 1 report of death. Adolescents (aged 11-18years) accounted for 74% of reports. Most of the reported AEs were non-serious and described AEs consistent with data from pre-licensure studies. Anaphylaxis and syncope were the two most common events in the serious reports. We did not identify any new safety concerns after review of AEs that exceeded the data mining threshold, although we did observe disproportionate reporting for terms that were not associated with an adverse event (e.g., "incorrect drug dosage form administered", "wrong technique in drug usage process"). Although reports were limited, we did not find any evidence for concern regarding the use of Menveo during pregnancy. In our review of VAERS reports, findings of AEs were consistent with the data from pre-licensure studies. Vaccine providers should continue to emphasize and adhere to proper administration of the vaccine. Copyright © 2017 Elsevier Ltd. All rights reserved.

Adverse Event Reporting System (AERS)

Data.gov (United States)

U.S. Department of Health & Human Services — The Adverse Event Reporting System (AERS) is a computerized information database designed to support the FDA's post-marketing safety surveillance program for all...

Safety-related LWR research. Annual report 1993

International Nuclear Information System (INIS)

Hueper, R.

1994-06-01

The reactor safety R and D work of the Karlsruhe Nuclear Research Centre (KfK) has been part of the Nuclear Safety Research Project (PSF) since 1990. The present annual report 1993 summarizes the results on LWR safety. The research tasks are coordinated in agreement with internal and external working groups. The contributions to this report correspond to the status at the end of 1993. (orig./HP) [de

Safety design guide for safety related systems for CANDU 9

International Nuclear Information System (INIS)

Lee, Duk Su; Chang, Woo Hyun; Lee, Nam Young; A. C. D. Wright

1996-03-01

In general, two types of safety related systems and structures exist in the nuclear plant; The one is a systems and structures which perform safety functions during the normal operation of the plant, and the other is a systems and structures which perform safety functions to mitigate events caused by failure of the normally operating systems or by naturally occurring phenomena. In this safety design guide, these systems are identified in detail, and the major events for which the safety functions are required and the major safety requirements are identified in the list. As the probabilistic safety assessments are completed during the course of the project, additions or deletions to the list may be justified. 3 tabs. (Author) .new

Safety design guide for safety related systems for CANDU 9

Energy Technology Data Exchange (ETDEWEB)

Lee, Duk Su; Chang, Woo Hyun; Lee, Nam Young [Korea Atomic Energy Research Institute, Daeduk (Korea, Republic of); Wright, A.C.D. [Atomic Energy of Canada Ltd., Toronto (Canada)

1996-03-01

In general, two types of safety related systems and structures exist in the nuclear plant; The one is a systems and structures which perform safety functions during the normal operation of the plant, and the other is a systems and structures which perform safety functions to mitigate events caused by failure of the normally operating systems or by naturally occurring phenomena. In this safety design guide, these systems are identified in detail, and the major events for which the safety functions are required and the major safety requirements are identified in the list. As the probabilistic safety assessments are completed during the course of the project, additions or deletions to the list may be justified. 3 tabs. (Author) .new.

Safety-related operator actions: methodology for developing criteria

International Nuclear Information System (INIS)

Kozinsky, E.J.; Gray, L.H.; Beare, A.N.; Barks, D.B.; Gomer, F.E.

1984-03-01

This report presents a methodology for developing criteria for design evaluation of safety-related actions by nuclear power plant reactor operators, and identifies a supporting data base. It is the eleventh and final NUREG/CR Report on the Safety-Related Operator Actions Program, conducted by Oak Ridge National Laboratory for the US Nuclear Regulatory Commission. The operator performance data were developed from training simulator experiments involving operator responses to simulated scenarios of plant disturbances; from field data on events with similar scenarios; and from task analytic data. A conceptual model to integrate the data was developed and a computer simulation of the model was run, using the SAINT modeling language. Proposed is a quantitative predictive model of operator performance, the Operator Personnel Performance Simulation (OPPS) Model, driven by task requirements, information presentation, and system dynamics. The model output, a probability distribution of predicted time to correctly complete safety-related operator actions, provides data for objective evaluation of quantitative design criteria

Methodological Considerations for Comparison of Brand Versus Generic Versus Authorized Generic Adverse Event Reports in the US Food and Drug Administration Adverse Event Reporting System (FAERS).

Science.gov (United States)

Rahman, Md Motiur; Alatawi, Yasser; Cheng, Ning; Qian, Jingjing; Peissig, Peggy L; Berg, Richard L; Page, David C; Hansen, Richard A

2017-12-01

The US Food and Drug Administration Adverse Event Reporting System (FAERS), a post-marketing safety database, can be used to differentiate brand versus generic safety signals. To explore the methods for identifying and analyzing brand versus generic adverse event (AE) reports. Public release FAERS data from January 2004 to March 2015 were analyzed using alendronate and carbamazepine as examples. Reports were classified as brand, generic, and authorized generic (AG). Disproportionality analyses compared reporting odds ratios (RORs) of selected known labeled serious adverse events stratifying by brand, generic, and AG. The homogeneity of these RORs was compared using the Breslow-Day test. The AG versus generic was the primary focus since the AG is identical to brand but marketed as a generic, therefore minimizing generic perception bias. Sensitivity analyses explored how methodological approach influenced results. Based on 17,521 US event reports involving alendronate and 3733 US event reports involving carbamazepine (immediate and extended release), no consistently significant differences were observed across RORs for the AGs versus generics. Similar results were obtained when comparing reporting patterns over all time and just after generic entry. The most restrictive approach for classifying AE reports yielded smaller report counts but similar results. Differentiation of FAERS reports as brand versus generic requires careful attention to risk of product misclassification, but the relative stability of findings across varying assumptions supports the utility of these approaches for potential signal detection.

RB research reactor Safety Report

International Nuclear Information System (INIS)

Sotic, O.; Pesic, M.; Vranic, S.

1979-04-01

This RB reactor safety report is a revised and improved version of the Safety report written in 1962. It contains descriptions of: reactor building, reactor hall, control room, laboratories, reactor components, reactor control system, heavy water loop, neutron source, safety system, dosimetry system, alarm system, neutron converter, experimental channels. Safety aspects of the reactor operation include analyses of accident causes, errors during operation, measures for preventing uncontrolled activity changes, analysis of the maximum possible accident in case of different core configurations with natural uranium, slightly and highly enriched fuel; influence of possible seismic events

Report on transparency and nuclear safety - Fontenay-aux-Roses CEA centre - 2012

International Nuclear Information System (INIS)

2013-01-01

This report presents the different nuclear base installations (INB) of the Fontenay-aux-Roses CEA centre, gives an overview of measures regarding safety within these installations (organisation, general arrangements, arrangements related to different risks, defence in-depth, management of emergency situations, inspections, audits and second-level controls, arrangements and main events specific to the different installations and buildings, issues related to transports, soil radiological assessment) and measures related to radiation protection (organisation and results). It reports the significant events related to safety and radiation protection which occurred in 2012 and were declared to the ASN, and discusses how the return-on-experience has been used. It reports and comments the results of measurements of radiological and chemical gaseous and liquid effluents, of surveys of the environment. It also evokes important events related to these measurement and survey processes, presents the environmental management approach. The next part addresses the management of radioactive wastes: arrangements aimed at limiting the volume of warehoused wastes, and at limiting their impact on health and on the environment, nature and quantities of warehoused wastes. The different arrangements regarding transparency and information are reviewed (TSN report, newsletter, and so on)

Saclay transparency and nuclear safety report 2009

International Nuclear Information System (INIS)

2006-01-01

After a general presentation of the Saclay CEA Centre, this report presents the various safety arrangements in the different basic nuclear installations it possesses. These arrangements can be administrative, technical, or related to emergency situations or to inspections. It describes the organisation of radioprotection in the Saclay CEA Centre, indicates highlights for 2009, and gives results of dose measurements performed on the personnel. It reports significant events regarding nuclear safety and radioprotection in the various installations, gives and comments release measurements results and their impact on the environment (gaseous and liquid releases). It gives an overview of radioactive wastes stored in the different installations

Commercial-grade motors in safety-related applications: Final report

International Nuclear Information System (INIS)

Holzman, P.M.

1988-04-01

The objective of this project was to discuss the process necessary to utilize commercial grade equipment in safety related applications and to provide utilities with guidance for accepting commercial grade motors for safety-related applications. The generic commercial-grade concepts presented in this report can be successfully applied to motors. Commercial grade item utilization has the greatest applicability to motors in ''mild'' environments, because these motors are essentially similar to commercial grade motors in materials, construction methods, and capabilities. The acceptance process is less applicable to motors that are subject to ''harsh'' environments during postulated accidents, because of the unique design features and testing required to qualify these motors

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

DEFF Research Database (Denmark)

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

2010-01-01

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

Assessing the association between omalizumab and arteriothrombotic events through spontaneous adverse event reporting.

Science.gov (United States)

Ali, Ayad K; Hartzema, Abraham G

2012-01-01

Omalizumab is a monoclonal antibody, indicated for the treatment of severe allergic asthma. In Europe, there have been concerns about the cardiovascular safety of omalizumab. The objective of this study was to analyze the association between omalizumab and arterial thrombotic events in a spontaneous adverse drug reaction reporting database in the US. Reports of arterial thrombotic events submitted to the US Food and Drug Administration's Adverse Event Reporting System (AERS) between 2004 and 2011 were retrieved and analyzed by the reporting odds ratio data mining algorithm. The reporting odds ratio of arterial thrombotic events for omalizumab was compared with specific asthma medications and all drugs in the AERS. Values ≥2 were considered significant safety signals. The Medical Dictionary for Regulatory Activities Preferred Terms were used to identify arterial thrombotic events (eg, stroke, myocardial infarction). In total, 293,783 reports of arterial thrombotic events were retrieved (about 2% of all adverse drug reaction reports), corresponding to 2274 asthma drug-arterial thrombotic events pairs (omalizumab, 222; inhaled corticosteroids [ICS], 131; long-acting beta-agonists [LABA], 102; single-device combination ICS-LABA, 506; inhaled short-acting beta-agonists [SABA], 475; oral SABA, 6; inhaled antimuscarinics [AMC], 477; single-device combination AMC-SABA, 127; xanthines, 50; leukotriene modifiers, 174; and mast cell stabilizers, 4). Reporting odds ratio and 95% confidence interval values for omalizumab compared with other asthma drugs and all drugs in AERS were 2.75 (2.39-316) and 1.09 (0.95-1.24), respectively. Omalizumab ranked second after ICS in the risk of arterial thrombotic events, followed by AMC, AMC-SABA, and ICS-LABA. Omalizumab is associated with higher than expected reporting of arterial thrombotic events in asthmatic patients. This hypothesis needs further testing in robust epidemiological studies.

The relationship between organizational leadership for safety and learning from patient safety events.

Science.gov (United States)

Ginsburg, Liane R; Chuang, You-Ta; Berta, Whitney Blair; Norton, Peter G; Ng, Peggy; Tregunno, Deborah; Richardson, Julia

2010-06-01

To examine the relationship between organizational leadership for patient safety and five types of learning from patient safety events (PSEs). Forty-nine general acute care hospitals in Ontario, Canada. A nonexperimental design using cross-sectional surveys of hospital patient safety officers (PSOs) and patient care managers (PCMs). PSOs provided data on organization-level learning from (a) minor events, (b) moderate events, (c) major near misses, (d) major event analysis, and (e) major event dissemination/communication. PCMs provided data on organizational leadership (formal and informal) for patient safety. Hospitals were the unit of analysis. Seemingly unrelated regression was used to examine the influence of formal and informal leadership for safety on the five types of learning from PSEs. The interaction between leadership and hospital size was also examined. Formal organizational leadership for patient safety is an important predictor of learning from minor, moderate, and major near-miss events, and major event dissemination. This relationship is significantly stronger for small hospitals (learning from safety events. Formal leadership support for safety is of particular importance in small organizations where the economic burden of safety programs is disproportionately large and formal leadership is closer to the front lines.

Safety and Radiation Protection at Nuclear Power Plants in France in 2014. IRSN's position - Report 2015

International Nuclear Information System (INIS)

2016-01-01

In 2014, none of the significant events reported affected reactor safety. The number of significant radiation protection events fell by 8% compared to 2013 and few of them had any impact on the plants' workers' health, the public's health or the environment. IRSN's point on view on safety and radiation protection of the 58 French nuclear power reactors currently operated by electric utility company EDF. This report is based on the Institute's scientific and technical expertise of significant events, and its analysis of several events that it found to be the most noteworthy for the year. In 2014, the number of significant safety events reported by EDF dropped by 8% compared with 2013, confirming the decrease already observed in 2013 compared with 2012. Early detection by EDF teams of anomalies may have contributed to the fact that none of the events reported in 2014 had a very significant impact on safety. In 2014, ASN did not class any of the events reported on Level 2 on the INES Scale. IRSN points out organisational improvements made by EDF regarding maintenance activities and equipment changes. Nevertheless, half the significant safety events reported by EDF were caused by maintenance errors. Noteworthy, the number of anomalies affecting safety-related equipment in reactors was generally lower in 2014 than in 2013. In 2014, the number of significant radiation protection events fell by 8% compared to 2013, and was just below the number of similar events reported in 2012. Among the factors contributing to this decrease: - the number of events related to gamma radiography inspections for checking welds was halved, despite a nearly identical number of interventions; - the number of non-compliancies related to the access to or time spent in radiologically controlled areas is falling, although these non-compliancies still represent the largest number of reported events. The most notable trend compared to previous years concern worker dosimetry

Post-licensure safety monitoring of quadrivalent human papillomavirus vaccine in the Vaccine Adverse Event Reporting System (VAERS), 2009-2015.

Science.gov (United States)

Arana, Jorge E; Harrington, Theresa; Cano, Maria; Lewis, Paige; Mba-Jonas, Adamma; Rongxia, Li; Stewart, Brock; Markowitz, Lauri E; Shimabukuro, Tom T

2018-03-20

The Food and Drug Administration (FDA) approved quadrivalent human papillomavirus vaccine (4vHPV) for use in females and males aged 9-26 years, since 2006 and 2009 respectively. We characterized reports to the Vaccine Adverse Event Reporting System (VAERS), a US spontaneous reporting system, in females and males who received 4vHPV vaccination. We searched VAERS for US reports of adverse events (AEs) following 4vHPV from January 2009 through December 2015. Signs and symptoms were coded using Medical Dictionary for Regulatory Activities (MedDRA). We calculated reporting rates and conducted empirical Bayesian data mining to identify disproportional reports. Clinicians reviewed available information, including medical records, and reports of selected pre-specified conditions. VAERS received 19,760 reports following 4vHPV; 60.2% in females, 17.2% in males, and in 22.6% sex was missing. Overall, 94.2% of reports were non-serious; dizziness, syncope and injection site reactions were commonly reported in both males and females. Headache, fatigue and nausea were commonly reported serious AEs. More than 60 million 4vHPV doses were distributed during the study period. Crude AE reporting rates were 327 reports per million 4vHPV doses distributed for all reports, and 19 per million for serious reports. Among 29 verified reports of death, there was no pattern of clustering of deaths by diagnosis, co-morbidities, age, or interval from vaccination to death. No new or unexpected safety concerns or reporting patterns of 4vHPV with clinically important AEs were detected. Safety profile of 4vHPV is consistent with data from pre-licensure trials and postmarketing safety data. Published by Elsevier Ltd.

Consumer reporting of adverse events following immunization.

Science.gov (United States)

Clothier, Hazel J; Selvaraj, Gowri; Easton, Mee Lee; Lewis, Georgina; Crawford, Nigel W; Buttery, Jim P

2014-01-01

Surveillance of adverse events following immunisation (AEFI) is an essential component of vaccine safety monitoring. The most commonly utilized passive surveillance systems rely predominantly on reporting by health care providers (HCP). We reviewed adverse event reports received in Victoria, Australia since surveillance commencement in July 2007, to June 2013 (6 years) to ascertain the contribution of consumer (vaccinee or their parent/guardian) reporting to vaccine safety monitoring and to inform future surveillance system development directions. Categorical data included were: reporter type; serious and non-serious AEFI category; and, vaccinee age group. Chi-square test and 2-sample test of proportions were used to compare categories; trend changes were assessed using linear regression. Consumer reporting increased over the 6 years, reaching 21% of reports received in 2013 (PConsumer reports were 5% more likely to describe serious AEFI than HCP (P=0.018) and 10% more likely to result in specialist clinic attendance (Preporting increased to 32% of all report since its introduction in 2010, 85% of consumers continued to report by phone. Consumer reporting of AEFI is a valuable component of vaccine safety surveillance in addition to HCP reporting. Changes are required to AEFI reporting systems to implement efficient consumer AEFI reporting, but may be justified for their potential impact on signal detection sensitivity.

Summary and bibliography of safety-related events at boiling-water nuclear power plants as reported in 1980

Energy Technology Data Exchange (ETDEWEB)

McCormack, K.E.; Gallaher, R.B.

1982-03-01

This document presents a bibliography that contains 100-word abstracts of event reports submitted to the US Nuclear Regulatory Commission concerning operational events that occurred at boiling-water-reactor nuclear power plants in 1980. The 1547 abstracts included on microfiche in this bibliography describe incidents, failures, and design or construction deficiencies that were experienced at the facilities. These abstracts are arranged alphabetically by reactor name and then chronologically for each reactor. Full-size keyword and permuted-title indexes to facilitate location of individual abstracts are provided following the text. Tables that summarize the information contained in the bibliography are also provided. The information in the tables includes a listing of the equipment items involved in the reported events and the associated number of reports for each item. Similar information is given for the various kinds of instrumentation and systems, causes of failures, deficiencies noted, and the time of occurrence (i.e., during refueling, operation, testing, or construction).

AREVA General Inspectorate Annual Report 2013 - Status of safety in nuclear facilities

International Nuclear Information System (INIS)

Oursel, Luc; Riou, Jean

2014-06-01

This annual report by AREVA's General Inspectorate deals with the status of nuclear safety and radiation protection in the group's facilities and operations over the course of 2013. Based on the findings made during implementation of the annual inspection program, this annual report also includes the results of the analysis of significant events and the observations and assessments of specialists in the Safety Health Security Sustainable Development Department (SHSSDD), supplemented by regular interaction with the safety regulators, different government agencies, stakeholders and other nuclear operators. Additionally, this report presents the action plans put into motion and the directions taken for continuous improvement in risk prevention for operations conducted in France and internationally. In 2013, the level of safety in the group's nuclear facilities and operations remained satisfactory, although improvements are necessary in some domains. This report is based on established indicators, analyses of reported events, responses to commitments made to the regulators, and the results of different improvement actions reported on in the inspected and supported entities. In 2013, no level 2 event on the International Nuclear and Radiological Event Scale (INES) was reported, the bottom-up reporting of weak signals was confirmed, dose levels were low and there were no radiological impacts on the environment. The General Inspectorate conducted 45 inspections in 30 of the group's entities in 2013. Of these, 10 concerned sites outside France and 7 were conducted following events or particular situations. These inspections gave rise to 176 recommendations, which the inspected entities have translated into action plans. Verification of these different action plans according to planned procedures and announced schedules gave rise to 16 follow-up inspections. The major lessons learned from these inspections relate to project management, facility compliance and operational

NPP Temelin safety analysis reports and PSA status

International Nuclear Information System (INIS)

Mlady, O.

1999-01-01

To enhance the safety level of Temelin NPP, recommendations of the international reviews were implemented into the design as well as into organization of the plant construction and preparation for operation. The safety assessment of these design changes has been integrated and reflected in the Safety Analysis Reports, which follow the internationally accepted guidelines. All safety analyses within Safety Analysis Reports were repeated carefully considering technical improvements and replacements to complement preliminary safety documentation. These analyses were performed by advanced western computer codes to the depth and in the structure required by western standards. The Temelin NPP followed a systematic approach in the functional design of the Reactor Protection System and related safety analyses. Modifications of reactor protection system increase defense in depth and facilitate demonstrating that LOCA and radiological limits are met for non-LOCA events. The rigorous safety analysis methodology provides assurance that LOCA and radiological limits are met. Established and accepted safety analysis methodology and accepted criteria were applied to Temelin NPP meeting US NRC and Czech Republic requirements. IAEA guidelines and recommendations

KKP 1. Report to inform the Reactor Safety Commission

International Nuclear Information System (INIS)

1987-01-01

This report goes into details of the operation during its reporting period, giving the total activity in the primary events. Radiation exposure, activities, dose rates of persons, collective doses from activity and radioactive emission to water and waste air are given. Account is given of all modifications or extensions made on safety-related parts of the plant, on controls and regulation. (DG) [de

Report on safety related occurrences and reactor trips July 1, 1976-December 31, 1976

International Nuclear Information System (INIS)

Andermo, L.

1977-04-01

This is a systematically arranged report on all reported safety related occurrences and reactor trips in Swedish nuclear power plants in operation during July 1, 1976 to December 31, 1976 inclusive. The facilities involved are Oskarshamn 1 and 2, Ringhals 1 and 2 and Barsebaeck 1. During this period of the 6 months 37 safety related occurrences and 34 reactor trips have been reported to the Nuclear Power Inspectorate. As earlier experiences have shown it is to the greatest extent the conventional components which bring about the safety related occurrences or occurrences leading to outages or power reductions. However, the component errors discovered in the safety related systems have not affected the function of their redundant systems and other diverse systems have not been involved. Therefore the reactor safety has been satisfactory. The fact that even small deviations from prescribed operation results in automatic and safe shut down of the reactor, does not always imply a conflict with operational availability. The number of reactor trips are almost as low as during the last period, which is a drastic reduction compared to earlier time periods. The greatest outages are caused by occurrences without safety significance.(author)

NASA Aviation Safety Reporting System (ASRS)

Science.gov (United States)

Connell, Linda J.

2017-01-01

The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

Report of the ASSET (Assessment of Safety Significant Events Team) mission to the Cernavoda nuclear power plant in Romania 8-12 August 1994 Division of Nuclear Safety. Root cause analysis of a significant event that occurred during commissioning of unit 1

International Nuclear Information System (INIS)

1994-01-01

The IAEA Assessment of Safety Significant Events Team (ASSET) report presents the results of the team's investigation of a significant event that occurred during commissioning of Unit 1 of Cernavoda nuclear power plant. The results, conclusions and suggestions presented herein reflect the views of the ASSET experts. They are provided for consideration by the responsible authorities in Romania. The ASSET team's views presented in this report are based on visits to the plant, on review of documentation made available by the operating organization and on discussions with utility personnel. The report is intended to enhance operational safety at Cernavoda by proposing improvements to the policy for the prevention of incidents at the plant. The report includes, as a usual practice, the official response of the Regulatory Body and Operating Organization to the ASSET recommendations. Figs

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

Science.gov (United States)

McGreevy, Michael W.

1996-01-01

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

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.

Aging related degradation in turbine drives and governors for safety related pumps

International Nuclear Information System (INIS)

Cox, D.F.

1991-01-01

This study is being performed to examine the relationship between time dependent degradation, and current industry practices in the areas of maintenance, surveillance, and operation of stem turbine drive for safety related pumps. These pumps are located in the Auxiliary Feedwater (AFW) system for pressurized water reactor (PWR) plants, and the Reactor Core Isolation Cooking (RCIC) and High Pressure Coolant Injection (HPCI) systems for Boiling Water Reactor (BWR) facilities. This research has been conducted by examining current information in the Nuclear Plant Reliability Data System (NPRDS), reviewing Licensee Event Reports, thoroughly investigating contacts with operating plant personnel, and by personal observation. This information was reviewed to determine the cause of each reported event and the method of discovery. From this data attempts have been made at determining the predictability of events and possible preventive measures that may be implemented

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

Effects of organizational safety practices and perceived safety climate on PPE usage, engineering controls, and adverse events involving liquid antineoplastic drugs among nurses.

Science.gov (United States)

DeJoy, David M; Smith, Todd D; Woldu, Henok; Dyal, Mari-Amanda; Steege, Andrea L; Boiano, James M

2017-07-01

Antineoplastic drugs pose risks to the healthcare workers who handle them. This fact notwithstanding, adherence to safe handling guidelines remains inconsistent and often poor. This study examined the effects of pertinent organizational safety practices and perceived safety climate on the use of personal protective equipment, engineering controls, and adverse events (spill/leak or skin contact) involving liquid antineoplastic drugs. Data for this study came from the 2011 National Institute for Occupational Safety and Health (NIOSH) Health and Safety Practices Survey of Healthcare Workers which included a sample of approximately 1,800 nurses who had administered liquid antineoplastic drugs during the past seven days. Regression modeling was used to examine predictors of personal protective equipment use, engineering controls, and adverse events involving antineoplastic drugs. Approximately 14% of nurses reported experiencing an adverse event while administering antineoplastic drugs during the previous week. Usage of recommended engineering controls and personal protective equipment was quite variable. Usage of both was better in non-profit and government settings, when workers were more familiar with safe handling guidelines, and when perceived management commitment to safety was higher. Usage was poorer in the absence of specific safety handling procedures. The odds of adverse events increased with number of antineoplastic drugs treatments and when antineoplastic drugs were administered more days of the week. The odds of such events were significantly lower when the use of engineering controls and personal protective equipment was greater and when more precautionary measures were in place. Greater levels of management commitment to safety and perceived risk were also related to lower odds of adverse events. These results point to the value of implementing a comprehensive health and safety program that utilizes available hazard controls and effectively communicates

Report on safety related occurrences and reactor trips July 1, 1979 - December 31, 1979

International Nuclear Information System (INIS)

Olsson, S.; Andermo, L.

1980-01-01

This is a report on all reported safety related occurrences and reactor trips in Swedish nuclear power plants in operation during July 1 to December 31, 1979 inclusive. The facilities involved are Barsebaeck 1 and 2, Oskarshamn 1 and 2 and Ringhals 1 and 2. During this period of 6 months 76 safety related occurrences and 27 reactor trips have been reported to the Nuclear Power Inspectorate. It is to the greatest extent conventional components such as valves and pumps which bring about the safety related occurrences or occurrences leading to outages or power reductions. However, the component errors discovered in the safety related systems have not affected the function of their redundant system and other diverse systems have not been involved. Therefore the reactor safety has been satisfactory. The total number of reactor trips are normal. The average value for these 6 months is 4.5 trips/unit. Approximetely one half of the reactor trips happened at zero or very low power operation. The fact that even small deviations from prescribed operation result in an automatic and safe shut down of the reactor, does not always imply a conflict with operational availability. The greatest outages are caused by occurrences without safety significance. (author)

Safety evaluation report related to Babcock and Wilcox Owners Group Plant Reassessment Program: [Final report

International Nuclear Information System (INIS)

1987-11-01

After the accident of Three Mile Island, Unit 2, nuclear power plant owners made a number of improvements to their nuclear facilities. Despite these improvements, the US Nuclear Regulatory Commission (NRC) staff is concerned that the number and complexity of events at Babcock and Wilcox (B and W) nuclear plants have not decreased as expected. This concern was reinforced by the June 9, 1985 total-loss-of-feedwater event at Davis-Besse Nuclear Power Station and the December 26, 1985 overcooling transient at Rancho Seco Nuclear Generating Station. By letter dated January 24, 1986, the Executive Director for Operations (EDO) informed the Chairman of the B and W Owners Group (BWOG) that a number of recent events at B and W-designed reactors have led the NRC staff to conclude that the basic requirements for B and W reactors need to be reexamined. In its February 13, 1986 response to the EDO's letter, the BWOG committed to lead an effort to define concerns relative to reducing the frequency of reactor trips and the complexity of post-trip response in B and W plants. The BWOG submitted a description of the B and W program entitled ''Safety and Performance Improvement Program'' (BAW-1919) on May 15, 1986. Five revisions to BAW-1919 have also been submitted. The NRC staff has reviewed BAW-1919 and its revisions and presents its evaluation in this report. 2 figs., 34 tabs

The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events.

Science.gov (United States)

Blanchfield, Bonnie B; Acharya, Bijay; Mort, Elizabeth

2018-04-01

More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs. This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013. A framework of tasks and a model to categorize costs was created. Time was summarized and costs were estimated for each SRE. The administrative cost to process 44 SREs was estimated at $353,291, an average cost of $8,029 per SRE, ranging $6,653 for an environmental-related SRE to $21,276 for a device-related SRE. Care management SREs occurred most frequently, costing an average $7,201 per SRE. Surgical SREs, the most expensive on average, cost $9,123 per SRE. Investigation of events accounted for 64.5% of total cost; public reporting, 17.2%; internal reporting, 10.2%; finance and administration, 6.0%; and 2.1%, other. Even with 26 states mandating reporting, the 17.2% incremental cost of public reporting is substantial. Policy makers should consider the opportunity costs of these resources, averaging $8,029 per SRE, when mandating reporting. The benefits of public reporting should be collectively reviewed to ensure that the incremental costs in this resource-constrained environment continue to improve patient safety and that trade-offs are acknowledged. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

Probabilistic safety analysis for fire events for the NPP Isar 2

International Nuclear Information System (INIS)

Schmaltz, H.; Hristodulidis, A.

2007-01-01

The 'Probabilistic Safety Analysis for Fire Events' (Fire-PSA KKI2) for the NPP Isar 2 was performed in addition to the PSA for full power operation and considers all possible events which can be initiated due to a fire. The aim of the plant specific Fire-PSA was to perform a quantitative assessment of fire events during full power operation, which is state of the art. Based on simplistic assumptions referring to the fire induced failures, the influence of system- and component-failures on the frequency of the core damage states was analysed. The Fire-PSA considers events, which will result due to fire-induced failures of equipment on the one hand in a SCRAM and on the other hand in events, which will not have direct operational effects but because of the fire-induced failure of safety related installations the plant will be shut down as a precautionary measure. These events are considered because they may have a not negligible influence on the frequency of core damage states in case of failures during the plant shut down because of the reduced redundancy of safety related systems. (orig.)

RB research reactor safety report

International Nuclear Information System (INIS)

Sotic, O.; Pesic, M.; Vranic, S.

1979-04-01

This new version of the safety report is a revision of the safety report written in 1962 when the RB reactor started operation after reconstruction. The new safety report was needed because reactor systems and components have been improved and the administrative procedures were changed. the most important improvements and changes were concerned with the use of highly enriched fuel (80% enriched), construction of reactor converter outside the reactor vessel, improved control system by two measuring start-up channels, construction of system for heavy water leak detection, new inter phone connection between control room and other reactor rooms. This report includes description of reactor building with installations, rector vessel, reactor core, heavy water system, control system, safety system, dosimetry and alarm systems, experimental channels, neutron converter, reactor operation. Safety aspects contain analyses of accident reasons, method for preventing reactivity insertions, analyses of maximum hypothetical accidents for cores with natural uranium, 2% enriched and 80% enriched fuel elements. Influence of seismic events on the reactor safety and well as coupling between reactor and the converter are parts of this document

Licensee Event Report (LER) compilation, December 1991

International Nuclear Information System (INIS)

1992-01-01

This monthly report contains licensee event report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 - Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System - Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule

Report on transparency and nuclear safety - 2013. Nuclear facilities exploited by CEA Marcoule

International Nuclear Information System (INIS)

2014-01-01

This report presents the different basic nuclear installations (INB) of the Marcoule CEA centre, gives an overview of measures regarding safety within these installations (organisation, general arrangements, arrangements related to different risks, management of emergency situations, inspections, audits and second-level controls, arrangements and main events specific to the different installations and buildings) and of measures related to radiation protection (organisation and results, main events). It reports the significant events related to safety and radiation protection which occurred in 2013 and were declared to the ASN, and discusses how the return-on-experience has been used. It reports and comments the results of measurements of gaseous and liquid effluents, of their impact on the environment, and of surveys of the environment. It also presents the environmental management approach. The next part addresses the management of radioactive wastes which are warehoused on this site: arrangements aimed at limiting their volume, and at limiting their impact on health and on the environment, nature and quantities of warehoused wastes. Remarks and recommendations of the CHSCT are given

Initiating events in the safety probabilistic analysis of nuclear power plants

International Nuclear Information System (INIS)

Stasiulevicius, R.

1989-01-01

The importance of the initiating event in the probabilistic safety analysis of nuclear power plants are discussed and the basic procedures necessary for preparing reports, quantification and grouping of the events are described. The examples of initiating events with its occurence medium frequency, included those calculated for OCONEE reactor and Angra-1 reactor are presented. (E.G.)

Experience feedback from event reports: the human contribution

International Nuclear Information System (INIS)

Swaton, E.; Tolstykh, V.

1990-01-01

Analysis of reported events reveals that in a large number of areas human intervention contributed to the initiation and/or development of these events. Since an accident at any nuclear power plant can have a world-wide effect on public acceptance, the need for attentive and reliable human behavior assumes an even greater significance. The identification of areas where human interaction can have an impact on safe operation is mainly relying on the analysis of events reported to the nuclear community. Any substantial compilation of safety significant operational events such as contained in the IAEA-IRS (Incident Reporting System) is bound to provide valuable and factual insights into problem areas, their origin, development, impact and some remedial actions. Thus a systematic analysis has been carried out on over 200 events where a human contribution could be identified. Some events of particular interest will be discussed and furthermore generic lessons will be presented. In addition the Assessment of Safety Significant Event Technique (ASSET) developed within IAEA which provides a structured methodology to identify not only the direct cause explaining why an individual failed but more important, insights on the root causes explaining why this latent deficiency was not detected earlier through the plant surveillance programme was applied. (author)

Why Clinicians Don't Report Adverse Drug Events: Qualitative Study.

Science.gov (United States)

Hohl, Corinne M; Small, Serena S; Peddie, David; Badke, Katherin; Bailey, Chantelle; Balka, Ellen

2018-02-27

Adverse drug events are unintended and harmful events related to medications. Adverse drug events are important for patient care, quality improvement, drug safety research, and postmarketing surveillance, but they are vastly underreported. Our objectives were to identify barriers to adverse drug event documentation and factors contributing to underreporting. This qualitative study was conducted in 1 ambulatory center, and the emergency departments and inpatient wards of 3 acute care hospitals in British Columbia between March 2014 and December 2016. We completed workplace observations and focus groups with general practitioners, hospitalists, emergency physicians, and hospital and community pharmacists. We analyzed field notes by coding and iteratively analyzing our data to identify emerging concepts, generate thematic and event summaries, and create workflow diagrams. Clinicians validated emerging concepts by applying them to cases from their clinical practice. We completed 238 hours of observations during which clinicians investigated 65 suspect adverse drug events. The observed events were often complex and diagnosed over time, requiring the input of multiple providers. Providers documented adverse drug events in charts to support continuity of care but never reported them to external agencies. Providers faced time constraints, and reporting would have required duplication of documentation. Existing reporting systems are not suited to capture the complex nature of adverse drug events or adapted to workflow and are simply not used by frontline clinicians. Systems that are integrated into electronic medical records, make use of existing data to avoid duplication of documentation, and generate alerts to improve safety may address the shortcomings of existing systems and generate robust adverse drug event data as a by-product of safer care. ©Corinne M Hohl, Serena S Small, David Peddie, Katherin Badke, Chantelle Bailey, Ellen Balka. Originally published in JMIR

76 FR 57045 - Announcement of Requirements and Registration for “Reporting Device Adverse Events Challenge”

Science.gov (United States)

2011-09-15

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Announcement of Requirements and Registration for ``Reporting Device Adverse Events Challenge'' Authority: 15 U.S.C. 3719. AGENCY: Office of the National..., specifically as it relates to monitoring product safety and effectiveness. The ``Reporting Device Adverse...

Safety of transport of radioactive substances for civil use on the French territory. Lessons learned by the IRSN from the analysis of significant events reported in 2012 and 2013

International Nuclear Information System (INIS)

2014-01-01

The first part of this report proposes an overview of significant aspects and events related to the transport of radioactive substances in France, and a comment on lessons learned by the IRSN. The second and main part first presents some aspects of this specific transport: regulatory framework, main safety issues, nature and flow of these transports, transports of radioactive substances per sector. The second part proposes an analysis of significant events: elements related to the reporting of an event, assessment of events and analysis of main trends noticed in 2012 and 2013 with respect to previous years, analysis of the main types of events which occurred in 2013 and 2013 with respect with those which occurred during the previous years. The next chapter describes significant events: damage of a parcel during its handling, a non conformal content, loss of a parcel on a public road, derailment of a car in Le Bourget. Some transverse topics are finally addressed: return on experience of crisis management in relationship with events in radioactive substance transport, IRSN study on the behaviour of packaging during long duration fires

Development of 4S and related technologies. (3) Statistical evaluation of safety performance of 4S on ULOF event

International Nuclear Information System (INIS)

Ishii, Kyoko; Matsumiya, Hisato; Horie, Hideki; Miyagi, Kazumi

2009-01-01

The purpose of this work is to evaluate quantitatively and statistically the safety performance of Super-Safe, Small, and Simple reactor (4S) by analyzing with ARGO code, a plant dynamics code for a sodium-cooled fast reactor. In this evaluation, an Anticipated Transient Without Scram (ATWS) is assumed, and an Unprotected Loss of Flow (ULOF) event is selected as a typical ATWS case. After a metric concerned with safety design is defined as performance factor a Phenomena Identification Ranking Table (PIRT) is produced in order to select the plausible phenomena that affect the metric. Then a sensitivity analysis is performed for the parameters related to the selected plausible phenomena. Finally the metric is evaluated with statistical methods whether it satisfies the given safety acceptance criteria. The result is as follows: The Cumulative Damage Fraction (CDF) for the cladding is defined as a metric, and the statistical estimation of the one-sided upper tolerance limit of 95 percent probability at a 95 percent confidence level in CDF is within the safety acceptance criterion; CDF < 0.1. The result shows that the 4S safety performance is acceptable in the ULOF event. (author)

Designing a Safety Reporting Smartphone Application to Improve Patient Safety After Total Hip Arthroplasty.

Science.gov (United States)

Krumsvik, Ole Andreas; Babic, Ankica

2017-01-01

This paper presents a safety reporting smartphone application which is expected to reduce the occurrence of postoperative adverse events after total hip arthroplasty (THA). A user-centered design approach was utilized to facilitate optimal user experience. Two main implemented functionalities capture patient pain levels and well-being, the two dimensions of patient status that are intuitive and commonly checked. For these and other functionalities, mobile technology could enable timely safety reporting and collection of patient data out of a hospital setting. The HCI expert, and healthcare professionals from the Haukeland University Hospital in Bergen have assessed the design with respect to the interaction flow, information content, and self-reporting functionalities. They have found it to be practical, intuitive, sufficient and simple for users. Patient self-reporting could help recognizing safety issues and adverse events.

Institutional glovebox safety committee (IGSC) annual report FY2010

Energy Technology Data Exchange (ETDEWEB)

Cournoyer, Michael E [Los Alamos National Laboratory; Roybal, Richard F [Los Alamos National Laboratory; Lee, Roy J [Los Alamos National Laboratory

2011-01-04

The Institutional Glovebox Safety Committee (IGSC) was chartered to minimize and/or prevent glovebox operational events. Highlights of the IGSC's third year are discussed. The focus of this working committee is to address glovebox operational and safety issues and to share Lessons Learned, best practices, training improvements, and glovebox glove breach and failure data. Highlights of the IGSC's third year are discussed. The results presented in this annual report are pivotal to the ultimate focus of the glovebox safety program, which is to minimize work-related injuries and illnesses. This effort contributes to the LANL Continuous Improvement Program by providing information that can be used to improve glovebox operational safety.

Study on the safety during transport of radioactive materials. Pt. 4. Events during transport. Final report work package 6; Untersuchungen zur Sicherheit bei der Befoerderung radioaktiver Stoffe. T. 4. Ereignisse bei der Befoerderung. Abschlussbericht zum Arbeitspaket 6

Energy Technology Data Exchange (ETDEWEB)

Sentuc, Florence-Nathalie

2014-09-15

This report presents the results from a data collection and an evaluation of the safety significance of events in the transportation of radioactive material by all modes on public routes in Germany. Systems for reporting and evaluation of the safety significance of events encountered in the transport of radioactive material are a central element in monitoring and judging the adequacy and effectiveness of the transport regulations and their underlying safety philosophy, this allows for revision by experience feedback (lessons learned). The nationwide survey performed covering the period from the mid 1990s through 2013 identified and analysed a total of 670 transport events varying in type and severity. The vast majority of recorded transport events relate to minor deviations from the provisions of the transport regulations (e.g. improper markings and error in transport documents) or inappropriate practices and operational procedures resulting in material damage of packages and equipment such as handling incidents. Severe traffic accidents and fires represented only a small fraction (ca. 3 percent) of the recorded transport events. Four transport events were identified in the reporting period to have given rise to environmental radioactive releases. Three transport events have reportedly resulted in minor radiation exposures to the transport personnel; in one case an exposure in excess of the statutory annual dose limit for the public seems possible. Based on the EVTRAM scale, with seven significance levels, the broad majority of transport events has been classified as ''non-incidents'' (Level 0) and ''events without affecting the safety functions of the package'' (Level 1). On the INES scale most transport events would be classified as events with ''no safety significance'' (Below Scale/Level 0). The survey results show no serious deficiencies in the transport of radioactive material, supporting the

Report on transparency and nuclear safety 2015 - Saclay

International Nuclear Information System (INIS)

2016-06-01

This document proposes, first, a presentation of the Saclay CEA centre, of its activities and installations. Then it gives a rather detailed overview of measures related to safety and to radiation protection within these activities and installations. Next, it reports significant events related to safety and to radiation protection which occurred in 2015 and which have been declared to the French nuclear safety authority (ASN). It discusses the results of release measurements (liquid and gaseous effluents, radiological assessment, and chemical assessment for various installations) and the control of the chemical and radiological impact of these gaseous and liquid effluents on the environment. Finally, it addresses the issue of radioactive wastes which are stored in the different nuclear base installations of the Centre. It indicates the different measures aimed at limiting the volume of these warehoused wastes and addresses their impact on health and environment. Nature and quantities of warehoused wastes are specified. Remarks and recommendations of the Health, Safety and Working Conditions Committee (CHSCT) are given

Report on transparency and nuclear safety 2015 - Grenoble

International Nuclear Information System (INIS)

2016-06-01

This document proposes, first, a presentation of the Grenoble CEA centre, of its activities and installations. Then it gives a rather detailed overview of measures related to safety and to radiation protection within these activities and installations. Next, it reports significant events related to safety and to radiation protection which occurred in 2015 and which have been declared to the French nuclear safety authority (ASN). It discusses the results of release measurements (liquid and gaseous effluents, radiological assessment, and chemical assessment for various installations) and the control of the chemical and radiological impact of these gaseous and liquid effluents on the environment. Finally, it addresses the issue of radioactive wastes which are stored in the different nuclear base installations of the Centre. It indicates the different measures aimed at limiting the volume of these warehoused wastes and addresses their impact on health and environment. Nature and quantities of warehoused wastes are specified. Remarks and recommendations of the Health, Safety and Working Conditions Committee (CHSCT) are given

World wide web for database of Japanese translation on international nuclear event scale reports

International Nuclear Information System (INIS)

Watanabe, Norio; Hirano, Masashi

1999-01-01

The International Nuclear Event Scale (INES) is a means designed for providing prompt, clear and consistent information related to nuclear events, that occurred at nuclear facilities, and facilitating communication between the nuclear community, the media and the public. The INES is jointly operated by the IAEA and the OECD-NEA. Nuclear events reported are rated by the Scale', a consistent safety significance indicator. The scale runs from level 0, for events with no safety significance, to level 7 for a major accident with widespread health and environmental effects. The Japan Atomic Energy Research Institute (JAERI) has been promptly translating the INES reports into Japanese and developing a world-wide-web database for the Japanese translation, aiming at more efficient utilization of the INES information inside Japan. The present paper briefly introduces the definitions of INES rating levels and the scope of the Scale, and describes the outlines of the database (the information stored in the database, its functions and how to use it). As well, technical use of the INES reports and the availability/ effectiveness of the database are discussed. (author)

Safety evaluation report related to operation of Fast Flux Test Facility. Supplement No. 1

International Nuclear Information System (INIS)

1979-05-01

This supplement provides (1) the staff's evaluation of additional information received since issuance of the Safety Evaluation Report regarding previously identified uncompleted review items, (2) a discussion of comments made by the ACRS in its report of November 8, 1978, and (3) the staff's evaluation of additional or revised information related to new or old issues that have arisen since the issuance of the Safety Evaluation Report

Climate and climate-related issues for the safety assessment SR-Can

International Nuclear Information System (INIS)

Naeslund, Jens-Ove

2006-11-01

The purpose of this report is to document current scientific knowledge of the climate-related conditions and processes relevant to the long-term safety of a KBS-3 repository to a level required for an adequate treatment in the safety assessment SR-Can. The report also includes a concise background description of the climate system. The report includes three main chapters: A description of the climate system (Chapter 2); Identification and discussion of climate-related issues (Chapter 3); and, A description of the evolution of climate-related conditions for the safety assessment (Chapter 4). Chapter 2 includes an overview of present knowledge of the Earth climate system and the climate conditions that can be expected to occur in Sweden on a 100,000 year time perspective. Based on this, climate-related issues relevant for the long-term safety of a KBS-3 repository are identified. These are documented in Chapter 3 'Climate-related issues' to a level required for an adequate treatment in the safety assessment. Finally, in Chapter 4, 'Evolution of climate-related conditions for the safety assessment' an evolution for a 120,000 year period is presented, including discussions of identified climate-related issues of importance for repository safety. The documentation is from a scientific point of view not exhaustive, since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of a safety assessment. As further described in the SR-Can Main Report and in the Features Events and Processes report, the content of the present report has been audited by comparison with FEP databases compiled in other assessment projects. This report follows as far as possible the template for documentation of processes regarded as internal to the repository system. However, the term processes is not used in this report, instead the term issue has been used. Each issue includes a set of processes together resulting in the behaviour of a

Climate and climate-related issues for the safety assessment SR-Can

Energy Technology Data Exchange (ETDEWEB)

Naeslund, Jens-Ove (comp.)

2006-11-15

The purpose of this report is to document current scientific knowledge of the climate-related conditions and processes relevant to the long-term safety of a KBS-3 repository to a level required for an adequate treatment in the safety assessment SR-Can. The report also includes a concise background description of the climate system. The report includes three main chapters: A description of the climate system (Chapter 2); Identification and discussion of climate-related issues (Chapter 3); and, A description of the evolution of climate-related conditions for the safety assessment (Chapter 4). Chapter 2 includes an overview of present knowledge of the Earth climate system and the climate conditions that can be expected to occur in Sweden on a 100,000 year time perspective. Based on this, climate-related issues relevant for the long-term safety of a KBS-3 repository are identified. These are documented in Chapter 3 'Climate-related issues' to a level required for an adequate treatment in the safety assessment. Finally, in Chapter 4, 'Evolution of climate-related conditions for the safety assessment' an evolution for a 120,000 year period is presented, including discussions of identified climate-related issues of importance for repository safety. The documentation is from a scientific point of view not exhaustive, since such a treatment is neither necessary for the purposes of the safety assessment nor possible within the scope of a safety assessment. As further described in the SR-Can Main Report and in the Features Events and Processes report, the content of the present report has been audited by comparison with FEP databases compiled in other assessment projects. This report follows as far as possible the template for documentation of processes regarded as internal to the repository system. However, the term processes is not used in this report, instead the term issue has been used. Each issue includes a set of processes together resulting in the

Report on safety related occurrences and reactor trips July 1, 1977 - December 31, 1977

International Nuclear Information System (INIS)

Andermo, L.; Sundman, B.

1974-04-01

This is a systematically arranged report on all reported safety related occurrences and reactor trips in Swedish nuclear power plants in operation during July 1 to December 31, 1977 inclusive. The facilities involved are Barsebaeck 1 and 2, Oskarshamn 1 and 2 and Ringhals 1 and 2. During this period of 6 months 48 safety related occurrences and 49 reactor trips have been reported to the Nuclear Power Inspectorate. Included is also one incident June 21 in Barsebaeck 2 which was not included in the last compilation of occurrences. As earlier experiences have shown it is to the greatest extent the conventional components which bring about the safety related occurrences or occurrences leading to outages or power reductions. However, the component errors discovered in the safety related systems have not affected the function of their redundant systems and other diverse systems have not been involved. Therefore the reactor safety has been satisfactory. The total number of reactor trips have increased nearly 30% since the last period. Those occurred during power operation however, were less. More than 50% of the reactor trips happened in the shutdown condition. The fact that even small deviations from prescribed operation result in automatic and safe shut down of the reactor, does not always imply a conflict with operational availability. The greatest outages are caused by occurrences withou02068NRM 0000169 450

Identification of the impacts of maintenance and testing upon the safety of LWR power plants. Final report

International Nuclear Information System (INIS)

Husseiny, A.A.; Sabri, Z.A.; Turnage, J.J.

1980-04-01

The present study was designed to identify the impact of maintenance and testing (M and T) upon the safety of LWR power plants. The study involved data extraction from various sources reporting safety-related and operation-related nuclear power plant experience. Primary sources reviewed, including Licensee Event Reports (LER's) submitted to the NRC, revealed that only ten percent of events reported could be identified as M and T problems. The collected data were collated in a manner that would allow identification of principal types of problems which are associated with the performance of M and T tasks in LWR power plants. Frequencies of occurrence of events and their general endemic nature were analyzed using data clustering and pattern recognition techniques, as well as chi-square analyses for sparse contingency tables. The results of these analyses identified seven major categories of M and T error modes which were related to individual facilities and reactor type. Data review indicated that few M and T problems were directly related to procedural inadequacies, with the majority of events being attributable to human error

Computer-based systems important to safety (COMPSIS) - Reporting guidelines

International Nuclear Information System (INIS)

1999-07-01

The objective of this procedure is to help the user to prepare an COMPSIS report on an event so that important lessons learned are most efficiently transferred to the database. This procedure focuses on the content of the information to be provided in the report rather than on its format. The established procedure follows to large extend the procedure chosen by the IRS incident reporting system. However this database is built for I and C equipment with the purpose of the event report database to collect and disseminate information on events of significance involving Computer-Based Systems important to safety in nuclear power plants, and feedback conclusions and lessons learnt from such events. For events where human performance is dominant to draw lessons, more detailed guidance on the specific information that should be supplied is spelled out in the present procedure. This guidance differs somewhat from that for the provision of technical information, and takes into account that the engineering world is usually less familiar with human behavioural analysis than with technical analysis. The events to be reported to the COMPSIS database should be based on the national reporting criteria in the participating member countries. The aim is that all reports including computer based systems that meet each country reporting criteria should be reported. The database should give a broad picture of events/incidents occurring in operation with computer control systems. As soon as an event has been identified, the insights and lessons learnt to be conveyed to the international nuclear community shall be clearly identified. On the basis of the description of the event, the event shall be analyzed in detail under the aspect of direct and potential impact to plant safety functions. The first part should show the common involvement of operation and safety systems and the second part should show the special aspects of I and C functions, hardware and software

Safety at civil basic nuclear installations other than nuclear power plants in France. Lessons learned by IRSN from significant events reported in 2013 and 2014

International Nuclear Information System (INIS)

2016-01-01

IRSN publishes the lessons learned from its analysis of significant events which have occurred in 2013 and 2014 at 82 civil basic nuclear installations (INBs) other than nuclear power plants (NPPs). Produced every two year since 2009, this report concerns 73 facilities such as plants, laboratories, facilities for the treatment, disposal and storage of waste, and facilities which have been decommissioned, and 9 research reactors, operated by around twenty different licensees in France. 210 and 227 significant events were respectively reported in 2013 and 2014 to the French Nuclear Safety Authority (ASN). This number remains similar to previous years and tends to 'stabilize' at around 200 to 220. On the one hand, among the improvements observed in 2013 and 2014, IRSN found two subjects of particular interest: - Efforts made by the licensees to increase reliability of organisational and human measures related to handling operations, in particular at the spent fuel reprocessing plant of AREVA NC La Hague and in the radioactive waste storage facilities operated by the CEA. - Important improvement program deployed by the licensee of the FBFC plant in Romans-sur-Isere (Drome) to enhance operating practices, particularly regarding management of criticality risks (prevention of uncontrolled chain reactions). On the other hand, three subjects still require special vigilance by licensees: - Ensuring full control over the safety documentation of facilities. IRSN's cross-cutting analysis of events reveal a large number of cases for which parts of the safety documentation are not fully understood at the facilities, are not applied, are inaccurate or not applicable to the situation. - Ensuring in-depth and comprehensive planning of installation clean-up and dismantling operations. Risks of worker exposure to ionising radiation are higher during these operations which may require personnel to work in close proximity to radioactive materials. - Ensuring more

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

evaluation of corrective measures and recognition of ineffective measures and efforts. The electronic system was relatively well accepted by personnel and resulted in minimal disruption of clinical work. Event reporting in the quarters with the fewest number of reported events, though voluntary, was almost four times greater than the most events reported in any one quarter with the paper-based system and remained consistent from the inception of the process through the date of this report. However, the acceptance was not universal, validating the need for improved education regarding reporting processes and systematic approaches to reporting culture development. Specially designed electronic event reporting systems in a radiotherapy setting can provide valuable data for process and patient safety improvement and are more effective reporting mechanisms than paper-based systems. Additional work is needed to develop methods that can more effectively utilize reported data for process improvement, including the development of standardized event taxonomy and a classification system for RT.

Adverse Events of Massage Therapy in Pain-Related Conditions: A Systematic Review

Directory of Open Access Journals (Sweden)

Ping Yin

2014-01-01

Full Text Available Pain-related massage, important in traditional Eastern medicine, is increasingly used in the Western world. So the widening acceptance demands continual safety assessment. This review is an evaluation of the frequency and severity of adverse events (AEs reported mainly for pain-related massage between 2003 and 2013. Relevant all-languages reports in 6 databases were identified and assessed by two coauthors. During the 11-year period, 40 reports of 138 AEs were associated with massage. Author, year of publication, country of occurrence, participant related (age, sex or number of patients affected, the details of manual therapy, and clinician type were extracted. Disc herniation, soft tissue trauma, neurologic compromise, spinal cord injury, dissection of the vertebral arteries, and others were the main complications of massage. Spinal manipulation in massage has repeatedly been associated with serious AEs especially. Clearly, massage therapies are not totally devoid of risks. But the incidence of such events is low.

Report on transparency and nuclear safety - Cadarache CEA centre - 2012

International Nuclear Information System (INIS)

2013-01-01

A first volume proposes a presentation of the Cadarache CEA centre, of its activities and installations, gives a rather detailed overview of measures related to safety and to radiation protection within these activities and installations. It also reports significant events related to safety and to radiation protection which occurred in 2012 and have been declared to the ASN. It discusses the results of release measurements (liquid and gaseous effluents, radiological assessment, and chemical assessment for various installations) and the control of the chemical and radiological impact of these gaseous and liquid effluents on the environment. It addresses the issue of radioactive wastes which are stored in the different nuclear base installations of the Centre, indicates the different measures aimed at limiting the volume of these warehoused wastes and addresses their impact on health and on the environment. Nature and quantities of warehoused wastes are specified. The second volume concerns some specific installations (INB 32 or ATPu, and INB 54 or LPC) which belong to AREVA NC. The same topics are addressed: presentation of the facilities, arrangements regarding safety and radiation protection, significant events related to safety and radiation protection, measurements of effluents and their impact on the environment, warehoused wastes. Remarks and recommendations of the CHSCT are given

Report on safety related occurrences and reactor trips January 1 - June 30, 1984

International Nuclear Information System (INIS)

1984-01-01

This is a systematically arranged report on all safety-related occurrences and reactor trips in Swedish nuclear power plants in operation during the period from January 1 to June 30 1984. It is based on the reports submitted by the utilities to the Swedish Nuclear Inspectorate according to Technical Specifications. Twice a year since 1974 the Inspectorate has issued a compilation on such reported occurrences and reactor trips. Starting with the compilation of the second half of 1982 some new features have been introduced. The most important change is that the volume of information has been increased. The full text, provided by the utilities when reporting the incidents, is now attached to the codified information and also the layout has been altered to facilitate reading. As in the previous reports the occurrences and reactor trips are arranged both alphabetically by facility name and chronologically by report number for each facility. Electricity generation charts for each facility are also presented. The primary purpose of this report is thus to present all the information furnished by the utilities when they submit their reports according to Technical Specifications. The only evaluation made by the Inspectorate is the categorization on the incidents. Like the previous reports this one also presents frequency of incidents as related to affected component, cause of incident etc. The difference is that only information reported by the utilities is used. This is the reason why a considerable proportion of the incidents are categorized as other component or other fault. Sometime in the future, however, the Inspectorate plants to put out a special report containing its own analyses of the most interesting events along with processed statistics and other information. (author)

NPP unusual events: data, analysis and application

International Nuclear Information System (INIS)

Tolstykh, V.

1990-01-01

Subject of the paper are the IAEA cooperative patterns of unusual events data treatment and utilization of the operating safety experience feedback. The Incident Reporting System (IRS) and the Analysis of Safety Significant Event Team (ASSET) are discussed. The IRS methodology in collection, handling, assessment and dissemination of data on NPP unusual events (deviations, incidents and accidents) occurring during operations, surveillance and maintenance is outlined by the reports gathering and issuing practice, the experts assessment procedures and the parameters of the system. After 7 years of existence the IAEA-IRS contains over 1000 reports and receives 1.5-4% of the total information on unusual events. The author considers the reports only as detailed technical 'records' of events requiring assessment. The ASSET approaches implying an in-depth occurrences analysis directed towards level-1 PSA utilization are commented on. The experts evaluated root causes for the reported events and some trends are presented. Generally, internal events due to unexpected paths of water in the nuclear installations, occurrences related to the integrity of the primary heat transport systems, events associated with the engineered safety systems and events involving human factor represent the large groups deserving close attention. Personal recommendations on how to use the events related information use for NPP safety improvement are given. 2 tabs (R.Ts)

[Field epidemiological study on news reports that related to public health emergencies].

Science.gov (United States)

Zhang, Shun-xiang; Li, Xue-mei; Luo, Nian-ci; Mei, Shu-jiang; Jiang, Li-juan

2013-12-01

All news reports (NR) that were related to public health emergency (PHE) were collected from the Southern Metropolis Daily (SMD) to explore the characteristics of epidemiology in the fields. Based on the theory of communication that including both case and text analysis, qualitative analysis on all the NR regarding PHE published in SMD from the years of 2008 to 2012, was carried out and input to database using the EpiData. Numbers of articles as indicators were compared to show the yearly change of different types of events. Various features of the NR including coverage, source of information, location of the incident, style and size of news, with or without editorials etc. were statistically analyzed by SPSS version 18.0. Among all the 998 reports related to PHE, higher proportion was found in the events of Infectious diseases (35.3%) and food safety (34.1%)respectively. Events on vaccines and drugs used for disease prevention and control (8.9%), environmental pollution caused incidents (8.0%)appeared to be less frequent. Events related to occupational disease, poisoning, bioterrorism and biochemical events were rare. Looking at the monthly distribution of reports, we noticed that the peaks occurred in 2008 and in 2009, which were caused by the Melamine-contamination events and the 2009 H1N1 pandemic. Between 2010 and 2012, figures of monthly reports were smooth, including some critical events from the interests of the media. Most events took place in Guangdong province (34.3%) and other provinces (50.9%), with some were from Hong Kong, Macao and Taiwan regions (9.5%). However, international events (5.2%)were less seen. Extensive coverage accounted for 17.6% of all of reports, and 11.5% allotted the editorials or other forms of in-depth reports. Most of the source of reports on infectious diseases and food safety were from the official release, however. The main sources of occupational diseases and poisoning, vaccines and drug incidents, environmental pollution

Probabilistic safety assessment for seismic events

International Nuclear Information System (INIS)

1993-10-01

This Technical Document on Probabilistic Safety Assessment for Seismic Events is mainly associated with the Safety Practice on Treatment of External Hazards in PSA and discusses in detail one specific external hazard, i.e. earthquakes

Engineering safety review mission Krsko NPP external events PSA. Ljubljana, Slovenia 19-23 February 1996. Final report

International Nuclear Information System (INIS)

Budnitz, R.J.; Smith, P.

1996-01-01

Within the scope of the TC Project RER/9/035, a review mission visited Ljubljana, Slovenia, 19-23 February 1996. Two outside experts, Messrs. R.J. Budnitz (USA) and Paul Smith (USA), as well as a staff member, A. Guerpinar (ESS-NSNI) took part in the review. The purpose of the mission was to assist the Slovenian Nuclear Safety Administration to review the external events PSA prepared by Krsko NPP consultants Westinghouse Energy Systems Europe and EQE International. Another seismic safety review was performed concurrently in Ljubljana involving the investigations in relation to the tectonic stability and reassessment of the design basis ground motion characterization for the Krsko NPP site

Health and safety annual report 1992

International Nuclear Information System (INIS)

1993-01-01

BNFL operates 6 sites in the United Kingdom concerned with the nuclear fuel cycle. The annual report on occupational health and safety gives information on all aspects of health and safety within BNFL with special reference to radiation doses received by the workforce and radiation protection measures taken by the company. BNFL's safety policy is set out. Radiation doses to all workers have remained low. Other industrial accidents are also listed and its safety measures for transport, radioactive effluents and in the event of an incident, are mentioned briefly. (UK)

Analysis on typical illegal events for nuclear safety class 1 valve

International Nuclear Information System (INIS)

Tian Dongqing; Gao Runsheng; Jiao Dianhui; Yang Lili; Chen Peng

2014-01-01

Illegal welding events of nuclear safety class l valve forging occurred to the manufacturer, while the valve was returned to be repaired. Illegal nondestructive test event of nuclear safety class valve occurred also to the manufacturer in the manufacturing process. The two events have resulted in quality incipient fault for the installed valves and the valves in the manufacturing process. It was reflected that operation of the factory quality assurance system isn't activated, and nuclear power engineering and operating company have insufficient supervision. The event-related parties should strengthen quality management and process control, get rid of the quality incipient fault, and experience feedback should be done well to guarantee quality of equipment in nuclear power plant. (authors)

Safety of Basic nuclear facilities (INB) other than electronuclear reactors. Lessons learned from declared significant events in 2011 and 2012

International Nuclear Information System (INIS)

2013-01-01

The first part of this report presents the different types of basic nuclear facilities other than electronuclear reactors. These installations can be industrial installations dedicated or not to the nuclear fuel cycle, research and support installations, be definitively stopped or being dismantled, or radioactive waste storage installations. After a comment of the main trends noticed in 2011 and 2012, the report proposes a transverse analysis of events which occurred in these installations. These events are related to various risks: dissemination of radioactive materials, exposure to ionizing radiations, criticality, fire and explosion, handling operations, loss of electric supplies or fluids, external aggression. Other events are those significant for the environment with a radiological component, or related to periodic controls and tests. The causes of these events are analysed. Specific events are presented which occurred on different sites (in the MELOX plant, in Areva sites in La Hague, Pierrelatte, in CEA sites in Cadarache and Saclay, in a fuel factory in Romans). Other topics are finally addressed: safety measures after the Fukushima accident, safety and radiation protection management systems of Areva and CEA, dismantling of nuclear installations

Event Safety-A Culture of Responsibility

Institute of Scientific and Technical Information of China (English)

Christian Alexander Buschhoff

2015-01-01

In this paper, the author introduces the concept of events and the importance of safety. And what is emphasized is that guests must set up the safety awareness in the process of the implementation of the safety, to ensure that every guest can move in the area according to their will, and won't produce any risk.

Licensee Event Report (LER) compilation, April 1991

International Nuclear Information System (INIS)

1991-05-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 -- Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System -- Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule. The LER summaries in this report are arranged alphabetically by facility name and then chronologically by event date for each facility. Component, system, keyword, and component vendor indexes follow the summaries. Vendors are those identified by the utility when the LER form is initiated; the keywords for the component, system, and general keyword indexes are assigned by the computer using correlation tables from the Sequence Coding and Search System

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

Directory of Open Access Journals (Sweden)

van der Wal Gerrit

2011-02-01

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

Analysis for Human-related Events during the Overhaul

Energy Technology Data Exchange (ETDEWEB)

Kim, Ji Tae; Kim, Min Chull; Choi, Dong Won; Lee, Durk Hun [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2011-10-15

The event frequency due to human error is decreasing among 20 operating Nuclear Power Plants (NPPs) excluding the NPP (Shin-Kori unit-1) in the commissioning stage since 2008. However, the events due to human error during an overhaul (O/H) occur annually (see Table I). An analysis for human-related events during the O/H was performed. Similar problems were identified for each event from the analysis and also, organizational and safety cultural factors were also identified

Report transparency and nuclear safety 2007 CEA Marcoule

International Nuclear Information System (INIS)

2007-01-01

This report presents the activities of the CEA Center of Marcoule for the year 2007. Since its creation in 1955 the center realizes industrial and scientific activities relative to the civil and military applications of the radioactivity. The actions concerning the safety, the radiation protection, the significant events, the release control and the environmental impacts and the wastes stored on the center are discussed. More especially the following two base activities are detailed: Atalante and Phenix. (A.L.B.)

An initial examination of aging related degradation in turbine drives and governors for safety related pumps

International Nuclear Information System (INIS)

Cox, D.F.

1991-01-01

This study is being performed to examine the relationship between time dependent degradation, and current industry practices in the areas of maintenance, surveillance, and operation of steam turbine drives for safety related pumps. These pumps are located in the Auxiliary Feedwater (AFW) system for pressurized water reactor (PWR) plants, and the Reactor Core Isolation Cooling (RCIC) and High Pressure Coolant Injection (HPCI) systems for Boiling Water Reactor (BWR) facilities. This research has been conducted by examining current information in NPRDS, reviewing Licensee Event Reports, and thoroughly investigating contacts with operating plant personnel, and by personal observation. The reported information was reviewed to determine the cause of the event and the method of discovery. From this data attempts have been made at determining the predictability of events and possible preventive measures that may be implemented. Findings in a recent study on the Auxiliary Feedwater System (NUREG/CR-5404) indicate that the turbine drive is the single largest contributor to AFW system degradation. Recent improvements in maintenance practices and procedures, combined with a stabilization of the design seem to indicate that this equipment can be a reliable component in safety systems

Extensive Analysis of Worldwide Events Related to The Construction and Commissioning of Nuclear Power Plants: Lessons Learned and Recommendations

International Nuclear Information System (INIS)

Noel, M.; Zerger, B.; Vuorio, U.; )

2011-01-01

Lessons learnt from past experience are extensively used to improve the safety of nuclear power plants (NPPs) worldwide. Although the process of analyzing operational experience is now widespread and well developed, the need for establishment of a similar process for construction experience was highlighted by several countries embarking on construction of new NPPs and in some international forums including the Working Group on the Regulation of New Reactors (WGRNR) of the OECD-NEA. In 2008, EU Member State Safety Authorities participating to the EU Clearinghouse on Operational Experience Feedback decided to launch a topical study on events related to pre-operational stages of NPPs. The aim of this topical study is to reduce the recurrence of events related to the construction, the initial component manufacturing and the commissioning of NPPs, by identifying the main recurring and safety significant issues. For this study, 1090 IRS event reports, 857 US Licensee Event Reports (LERs) and approximately 100 WGRNR reports have been preselected based on key word searches and screened. The screening period starts from the beginning of the databases operation (in the 1980's as far as IRS and LER database are concerned) and ends in November 2009. After this initial screening, a total of 582 reports have been found applicable (247 IRS reports, 309 LERs and 26 WGRNR reports). Events considered for this study were those which have been initiated before the start of commercial operation, and detected before or even long after commercial operation. The events have been classified into 3 main categories (construction, manufacturing and commissioning), and into further sub-categories (building structures, metallic liners, electrical components, anchors, I and C, penetrations and building seals, emergency diesel generators, pipes, valves, welds, pumps, etc.) in order to facilitate the detailed analysis with the final objective to formulate both equipment specific

NIKHEF-K safety report 1982

International Nuclear Information System (INIS)

1983-12-01

In this safety report, general information is offered about the safety policy at the NIKHEF-K institute Amsterdam. Costs, prevention, training courses and inspection related to (radiation) safety are briefly discussed. Small accidents are reported. Some measurements have been carried out, but no measurable increase of radiation doses have been found. (Auth.)

Accident sequence precursor events with age-related contributors

Energy Technology Data Exchange (ETDEWEB)

Murphy, G.A.; Kohn, W.E.

1995-12-31

The Accident Sequence Precursor (ASP) Program at ORNL analyzed about 14.000 Licensee Event Reports (LERs) filed by US nuclear power plants 1987--1993. There were 193 events identified as precursors to potential severe core accident sequences. These are reported in G/CR-4674. Volumes 7 through 20. Under the NRC Nuclear Plant Aging Research program, the authors evaluated these events to determine the extent to which component aging played a role. Events were selected that involved age-related equipment degradation that initiated an event or contributed to an event sequence. For the 7-year period, ORNL identified 36 events that involved aging degradation as a contributor to an ASP event. Except for 1992, the percentage of age-related events within the total number of ASP events over the 7-year period ({approximately}19%) appears fairly consistent up to 1991. No correlation between plant ape and number of precursor events was found. A summary list of the age-related events is presented in the report.

Estimation of average hazardous-event-frequency for allocation of safety-integrity levels

International Nuclear Information System (INIS)

Misumi, Y.; Sato, Y.

1999-01-01

One of the fundamental concepts of the draft international standard, IEC 61508, is target failure measures to be allocated to Electric/Electronic/Programmable Electronic Safety-Related Systems, i.e. Safety Integrity Levels. The Safety Integrity Levels consist of four discrete probabilistic levels for specifying the safety integrity requirements or the safety functions to be allocated to Electric/Electronic/Programmable Electronic Safety-Related Systems. In order to select the Safety Integrity Levels the draft standard classifies Electric/Electronic/Programmable Electronic Safety-Related Systems into two modes of operation using demand frequencies only. It is not clear which modes of operation should be applied to Electric/Electronic/Programmable Electronic Safety-Related Systems taking into account the demand-state probability and the spurious demand frequency. It is essential for the allocation of Safety Integrity Levels that generic algorithms be derived by involving possible parameters, which make it possible to model the actuality of real systems. The present paper addresses this issue. First of all, the overall system including Electric/Electronic/programmable Electronic Safety-Related Systems is described using a simplified fault-tree. Then, the relationships among demands, demand-states and proof-tests are studied. Overall systems are classified into two groups: a non-demand-state-at-proof-test system which includes both repairable and non-repairable demand states and a constant-demand-frequency system. The new ideas such as a demand-state, spurious demand-state, mean time between detections, rates of d-failure and h-failure, and an h/d ratio are introduced in order to make the Safety Integrity Levels and modes of operation generic and comprehensive. Finally, the overall system is simplified and modeled by fault-trees using Priority-AND gates. At the same time the assumptions for modeling are described. Generic algorithms to estimate hazardous-event

Incidents in transport of radioactive materials for civil use: IRSN draws lessons from events reported between 1999 and 2007

International Nuclear Information System (INIS)

2008-01-01

Some 900,000 packages of radioactive materials for civil use are transported each year in France. The great majority of these shipments involve radioactive materials used in the fields of medicine, pharmaceuticals, industry or property. Transport of radioactive materials linked to the nuclear fuel cycle actually represents only 15% of transport. A great variety of material is transported, differing in weight (from a few grams to tens of tons), form, activity and packaging. The associated risks are also different: radioactive contamination, external exposure to ionising radiation, chemical risk etc. In its role of technical support to safety and radioprotection authorities, IRSN's mission is to assess the design, manufacturing, testing and use of packaging and transport systems. The Institute is also involved in the management and analysis of events that occur during transport of radioactive materials. To assist with this, the IRSN manages a database which lists reported deviations, anomalies, incidents and accidents (known in a generic way as 'events') relating to transport. With an aim of reduction of the risks related to transport, the feedback resulting from the thorough analysis of the notified events is capitalized by IRSN, just as the feedback of the assessments of the safety analysis reports of the various package designs. Based on these feedbacks, IRSN proposes axes of improvement relating to package designs and transport operations, and regulatory evolutions, as well as priority topics for the inspections carried out by the French Nuclear safety authority (ASN). The IRSN has carried out a transversal analysis of all events in transport of radioactive materials that occurred in France from 1999 to 2007 as listed in its database (i.e. 901 events). For each event, some 70 parameters have been recorded from the analysis of the notifications and reports of the events, transmitted by the operators (type of event, type of package, level on the INES scale). This

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

DEFF Research Database (Denmark)

Juul, Jonas; Paltved, Charlotte; Krogh, Kristian

2014-01-01

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

Impact of High-Reliability Education on Adverse Event Reporting by Registered Nurses.

Science.gov (United States)

McFarland, Diane M; Doucette, Jeffrey N

Adverse event reporting is one strategy to identify risks and improve patient safety, but, historically, adverse events are underreported by registered nurses (RNs) because of fear of retribution and blame. A program was provided on high reliability to examine whether education would impact RNs' willingness to report adverse events. Although the findings were not statistically significant, they demonstrated a positive impact on adverse event reporting and support the need to create a culture of high reliability.

Frequencies and trends of significant characteristics of reported events in Germany

Energy Technology Data Exchange (ETDEWEB)

Farber, G.; Matthes, H. [Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS) mbH, Koln (Germany)

2001-07-01

In the frame of its support to the German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety the GRS continuously performs in-depth technical analyses of reported events at operating nuclear power reactors in Germany which can be used for the determination of plant weaknesses with regard to reactor safety. During the last 18 months, in addition to those activities, the GRS has developed a data bank model for the statistical assessment of events. This model is based on a hierarchically structured, detailed coding system with respect to technical and safety relevant characteristics of the plants and the systematic characterization of plant-specific events. The data bank model is ready for practical application. Results of a first statistical evaluation, taking into account the data sets from the time period 1996 to 1999, are meanwhile available. By increasing the amount of data it will become possible to herewith improve the statements concerning trends of safety aspects. This report describes the coding system, the evaluation model, the data input and the evaluations performed during the period beginning in April 2000. (authors)

Frequencies and trends of significant characteristics of reported events in Germany

International Nuclear Information System (INIS)

Farber, G.; Matthes, H.

2001-01-01

In the frame of its support to the German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety the GRS continuously performs in-depth technical analyses of reported events at operating nuclear power reactors in Germany which can be used for the determination of plant weaknesses with regard to reactor safety. During the last 18 months, in addition to those activities, the GRS has developed a data bank model for the statistical assessment of events. This model is based on a hierarchically structured, detailed coding system with respect to technical and safety relevant characteristics of the plants and the systematic characterization of plant-specific events. The data bank model is ready for practical application. Results of a first statistical evaluation, taking into account the data sets from the time period 1996 to 1999, are meanwhile available. By increasing the amount of data it will become possible to herewith improve the statements concerning trends of safety aspects. This report describes the coding system, the evaluation model, the data input and the evaluations performed during the period beginning in April 2000. (authors)

Analysis of adverse events as a contribution to safety culture in the context of practice development

Science.gov (United States)

Hoffmann, Susanne; Frei, Irena Anna

2017-01-01

Background: Analysing adverse events is an effective patient safety measure. Aim: We show, how clinical nurse specialists have been enabled to analyse adverse events with the „Learning from Defects-Tool“ (LFD-Tool). Method: Our multi-component implementation strategy addressed both, the safety knowledge of clinical nurse specialists and their attitude towards patient safety. The culture of practice development was taken into account. Results: Clinical nurse specialists relate competency building on patient safety due to the application of the LFD-tool. Applying the tool, fosters the reflection of adverse events in care teams. Conclusion: Applying the „Learning from Defects-Tool“ promotes work-based learning. Analysing adverse events with the „Learning from Defects-Tool“ contributes to the safety culture in a hospital.

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

Science.gov (United States)

Schuerer, Douglas J E; Nast, Patricia A; Harris, Carolyn B; Krauss, Melissa J; Jones, Rebecca M; Boyle, Walter A; Buchman, Timothy G; Coopersmith, Craig M; Dunagan, W Claiborne; Fraser, Victoria J

2006-06-01

Medical errors are common, and physicians have notably been poor medical error reporters. In the SICU, reporting was generally poor and reporting by physicians was virtually nonexistent. This study was designed to observe changes in error reporting in an SICU when a new card-based system (SAFE) was introduced. Before implementation of the SAFE reporting system, education was given to all SICU healthcare providers. The SAFE system was introduced into the SICU for a 9-month period from March 2003 through November 2003, to replace an underused online system. Data were collected from the SAFE card reports and the online reporting systems during introduction, removal, and reimplementation of these cards. Reporting rates were calculated as number of reported events per 1,000 patient days. Reporting rates increased from 19 to 51 reports per 1,000 patient days after the SAFE cards were introduced into the ICU (preporting increased most, rising from 0.3 to 5.8 reports per 1,000 patient days; nursing reporting also increased from 18 to 39 reports per 1,000 patient days (both preporting declined to 0 reports per 1,000 patient days (p=0.01) and rose to 8.1 (p=0.001) when the cards were returned, similar to nursing results. A higher proportion of physician reports were events that caused harm compared with no effect (p reporting system, combined with appropriate education, improved overall reporting in the SICU, especially among physician providers. Nurses were more likely to use reporting systems than were physicians. Physician reports were more likely to be of events that caused harm.

Safety analysis on Non-LOCA events for the revision of Wolsong NPP unit 2,3,4 sar

International Nuclear Information System (INIS)

Kim, Jong Hyun; Jin, Dong Sik; Ryu, Eui Seung; Kho, Dong Wook; Kim, Sung Min

2015-01-01

Korean Wolsong Nuclear Power Plant Units 2,3,4 (CANDU-6 Type) has prepared the revision of safety analysis report (Final Safety Analysis Report (FSAR) chapter 15) from the original performed in the year of 1990s, using the updated and state-of-the-art methodology and tools including IST safety analysis codes and more detail modelling. Compared with the original FSAR15, the revised FSAR15 has significant improvement in both the scope and the depth of safety analysis, which has demonstrated the safety analysis results have complied with the safety requirements(acceptance criteria). This paper will present the analysis scope for Non-LOCA events re-analyzed or added for the FSAR15 revision, methodologies applied such as codes and modelling and some important analysis results will be demonstrated with comparison to acceptance criteria. Application of more detail and near-realistic assumptions and method including Dev-PDO options and uncertainty related to the CHF correlations has altogether brought about more safety margin compared with the original FSAR15 with respect to SDS trip effectiveness etc. (author)

Cognition- and Dementia-Related Adverse Effects With Sacubitril-Valsartan: Analysis of the FDA Adverse Event Report System Database.

Science.gov (United States)

Perlman, Amichai; Hirsh Raccah, Bruria; Matok, Ilan; Muszkat, Mordechai

2018-05-07

Because neprilysin is involved in the degradation of amyloid-beta, there is concern that the angiotensin-neprilysin inhibitor sacubitril-valsartan could increase the risk for dementia. We analyzed adverse event cases submitted to the Food and Drug Administration Adverse Event Report System from July 2015 to March 2017. Cognition- and dementia-related adverse event cases were defined with the use of broad and narrow structured medical queries. During the period evaluated, 9,004 adverse event reports (out of a total of 2,249,479) involved the use of sacubitril-valsartan. Based on the broad definition, sacubitril-valsartan was associated with cognition- and dementia-related adverse events in 459 reports (5.1%), but this was lower than the proportion of these reports among other medications (6.6%, reporting odds ratio [ROR] 0.72, 95% confidence interval [CI] 0.65-0.79). Restricting the comparison to cases with age >60 years and with the use of a comparator group with heart failure resulted in no association between sacubitril-valsartan and dementia-related adverse events, with the use of both the broad and the narrow definitions (ROR 0.87, 95% CI 0.76-1.02, and ROR 1.06, 95% CI 0.4-3.16, respectively). Sacubitril-valsartan is not associated with a disproportionately high rate of short-term dementia-related adverse effect reports. Long-term studies assessing cognitive outcomes are required to better establish the medication's cognition effects. Copyright © 2018 Elsevier Inc. All rights reserved.

Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine.

Science.gov (United States)

Martín Delgado, M C; Merino de Cos, P; Sirgo Rodríguez, G; Álvarez Rodríguez, J; Gutiérrez Cía, I; Obón Azuara, B; Alonso Ovies, Á

2015-01-01

To explore contributing factors (CF) associated to related critical patients safety incidents. SYREC study pos hoc analysis. A total of 79 Intensive Care Departments were involved. The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Dietary supplement adverse events: report of a one-year poison center surveillance project.

Science.gov (United States)

Haller, Christine; Kearney, Tom; Bent, Stephen; Ko, Richard; Benowitz, Neal; Olson, Kent

2008-06-01

The safety and efficacy of dietary supplements is of growing concern to regulators, health-care providers and consumers. Few scientific data exist on clinical effects and potential toxicities of marketed products. Harmful supplements may not be identified for months or years with existing adverse event monitoring mechanisms. Retrospective review of poison center statistics to capture supplement-associated toxicity also has limitations. We collaborated with the FDA Center for Food Safety and Nutrition (CFSAN) to conduct a 1-year prospective surveillance study of dietary supplement-related poison control center calls in 2006. Prompt follow-up of symptomatic cases, laboratory analysis of implicated dietary supplements, and causality assessment by a case review expert panel were performed. Of 275 dietary supplements calls, 41% involved symptomatic exposures; and two-thirds were rated as probably or possibly related to supplement use. Eight adverse events required hospital admission. Sympathomimetic toxicity was most common, with caffeine products accounting for 47%, and yohimbe products accounting for 18% of supplement-related symptomatic cases. Suspected drug-herb interactions occurred in 6 cases, including yohimbe co-ingested with buproprion (1) and methamphetamine (3), and additive anticoagulant/antiplatelet effects of NSAIDs taken with fish oils (1) and ginkgo (1). Laboratory analysis identified a pharmacologically active substance in 4 cases; supplement toxicity was ruled unlikely when analytical testing was negative in 5 cases. Most supplement-related adverse events were minor. Clinically significant toxic effects were most frequently reported with caffeine and yohimbe-containing products. Active surveillance of poison control center reports of dietary supplement adverse events enables rapid detection of potentially harmful products, which may facilitate regulatory oversight.

Report order and identification of multidimensional stimuli: a study of event-related brain potentials.

Science.gov (United States)

Shieh, Kong-King; Shen, I-Hsuan

2004-06-01

An experiment was conducted to investigate the effect of order of report on multidimensional stimulus identification. Subjects were required to identify each two-dimensional symbol by pushing corresponding buttons on the keypad on which there were two columns representing the two dimensions. Order of report was manipulated for the dimension represented by the left or right column. Both behavioral data and event-related potentials were recorded from 14 college students. Behavioral data analysis showed that order of report had a significant effect on response times. Such results were consistent with those of previous studies. Analysis of event-related brain potentials showed significant differences in peak amplitude and mean amplitude at time windows of 120-250 msec. at Fz, F3, and F4 and of 350-750 msec. at Fz, F3, F4, Cz, and Pz. Data provided neurophysiological evidence that reporting dimensional values according to natural language habits was appropriate and less cognitively demanding.

Procedure for conducting probabilistic safety assessment: level 1 full power internal event analysis

Energy Technology Data Exchange (ETDEWEB)

Jung, Won Dae; Lee, Y. H.; Hwang, M. J. [and others

2003-07-01

This report provides guidance on conducting a Level I PSA for internal events in NPPs, which is based on the method and procedure that was used in the PSA for the design of Korea Standard Nuclear Plants (KSNPs). Level I PSA is to delineate the accident sequences leading to core damage and to estimate their frequencies. It has been directly used for assessing and modifying the system safety and reliability as a key and base part of PSA. Also, Level I PSA provides insights into design weakness and into ways of preventing core damage, which in most cases is the precursor to accidents leading to major accidents. So Level I PSA has been used as the essential technical bases for risk-informed application in NPPs. The report consists six major procedural steps for Level I PSA; familiarization of plant, initiating event analysis, event tree analysis, system fault tree analysis, reliability data analysis, and accident sequence quantification. The report is intended to assist technical persons performing Level I PSA for NPPs. A particular aim is to promote a standardized framework, terminology and form of documentation for PSAs. On the other hand, this report would be useful for the managers or regulatory persons related to risk-informed regulation, and also for conducting PSA for other industries.

External Events Excluding Earthquakes in the Design of Nuclear Power Plants. Safety Guide

International Nuclear Information System (INIS)

2008-01-01

This Safety Guide provides recommendations and guidance on design for the protection of nuclear power plants from the effects of external events (excluding earthquakes), i.e. events that originate either off the site or within the boundaries of the site but from sources that are not directly involved in the operational states of the nuclear power plant units. In addition, it provides recommendations on engineering related matters in order to comply with the safety objectives and requirements established in the IAEA Safety Requirements publication, Safety of Nuclear Power Plants: Design. It is also applicable to the design and safety assessment of items important to the safety of land based stationary nuclear power plants with water cooled reactors. Contents: 1. Introduction; 2. Application of safety criteria to the design; 3. Design basis for external events; 4. Aircraft crash; 5. External fire; 6. Explosions; 7. Asphyxiant and toxic gases; 8. Corrosive and radioactive gases and liquids; 9. Electromagnetic interference; 10. Floods; 11. Extreme winds; 12. Extreme meteorological conditions; 13. Biological phenomena; 14. Volcanism; 15. Collisions of floating bodies with water intakes and UHS components; Annex I: Aircraft crashes; Annex II: Detonation and deflagration; Annex III: Toxicity limits.

Operating experience feedback from safety significant events at research reactors

Energy Technology Data Exchange (ETDEWEB)

Shokr, A.M. [Atomic Energy Authority, Abouzabal (Egypt). Egypt Second Research Reactor; Rao, D. [Bhabha Atomic Research Centre, Mumbai (India)

2015-05-15

Operating experience feedback is an effective mechanism to provide lessons learned from the events and the associated corrective actions to prevent recurrence of events, resulting in improving safety in the nuclear installations. This paper analyzes the events of safety significance that have been occurred at research reactors and discusses the root causes and lessons learned from these events. Insights from literature on events at research reactors and feedback from events at nuclear power plants that are relevant to research reactors are also presented along with discussions. The results of the analysis showed the importance of communication of safety information and exchange of operating experience are vital to prevent reoccurrences of events. The analysis showed also the need for continued attention to human factors and training of operating personnel, and the need for establishing systematic ageing management programmes of reactor facilities, and programmes for safety management of handling of nuclear fuel, core components, and experimental devices.

Operating experience feedback from safety significant events at research reactors

International Nuclear Information System (INIS)

Shokr, A.M.

2015-01-01

Operating experience feedback is an effective mechanism to provide lessons learned from the events and the associated corrective actions to prevent recurrence of events, resulting in improving safety in the nuclear installations. This paper analyzes the events of safety significance that have been occurred at research reactors and discusses the root causes and lessons learned from these events. Insights from literature on events at research reactors and feedback from events at nuclear power plants that are relevant to research reactors are also presented along with discussions. The results of the analysis showed the importance of communication of safety information and exchange of operating experience are vital to prevent reoccurrences of events. The analysis showed also the need for continued attention to human factors and training of operating personnel, and the need for establishing systematic ageing management programmes of reactor facilities, and programmes for safety management of handling of nuclear fuel, core components, and experimental devices.

2007 transparency and nuclear safety report. CEA Cadarache. Volumes 1 + 2

International Nuclear Information System (INIS)

2007-01-01

After a general presentation of the Cadarache site and of its nuclear installations, the first volume of this report describes the various measures concerning the site safety: safety organisation, general measures, measures related to various risks, control of emergency situations, inspections, audits and second level control, measures in basic nuclear installations. It describes the measures concerning the radioprotection on this site: organisation, significant facts, and dose measurement results. It describes significant events which occurred in relationship with nuclear safety and radioprotection, presents results of release measurements and of radiological and chemical assessments of the impact these releases on the environment. The report then describes measures implemented to limit the volume of stored radioactive wastes and also their impact on health and on the environment. It provides a series of tables indicating the nature and quantities of wastes which are stored in the different basic nuclear installations of Cadarache. It reports the recommendations expressed by the CHSCT (committee on hygiene, security and working conditions) after the 2006 report. The second volume proposes the same information for two specific nuclear installations belonging to Areva and located in Cadarache, the INB 32 and 54 (INB stands for basic nuclear installation), for which the significant events occurred on the 13. of March and on the 25. of May 2007. For these installations, release measurements concern gaseous and liquid releases

Licensee Event Report (LER) compilation for month of October 1990

International Nuclear Information System (INIS)

1990-11-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 -- Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983.NUREG-1022, Licensee Event Report System -- Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule

Licensee Event Report (LER) compilation for month of October 1988

International Nuclear Information System (INIS)

1988-11-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-1061, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73--Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System--Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule

Licensee Event Report (LER) compilation for month of August 1990

International Nuclear Information System (INIS)

1990-09-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 -- Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System -- Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule

Licensee Event Report (LER) compilation for month of March 1988

International Nuclear Information System (INIS)

1988-04-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one-month period identified on the cover of the document. The LERS, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-1061, Instructions for preparation of data entry sheets for licensee event reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 - Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System - Description of systems and guidelines for reporting, provides supporting guidance and information on the revised LER rule

Licensee Event Report (LER) compilation for month of August 1989

International Nuclear Information System (INIS)

1989-09-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to these events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 -- Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System -- Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule

Ethics of safety reporting of a clinical trial

Directory of Open Access Journals (Sweden)

Amrita Sil

2017-01-01

Full Text Available Clinical trial related injury and serious adverse events (SAE are a major area of concern. In all such scenarios the investigator is responsible for medical care of the trial participant and also ethically bound to report the event to all the stakeholders of the clinical trial. The trial sponsor is responsible for ongoing safety evaluation of the investigational product, reporting and compensating the participant in case of any SAE. The Ethics Committee and regulatory body of the country are to uphold the ethical principles of beneficence, justice, non-maleficence in such cases. Any unwanted and noxious effect of a drug when used in recommended doses is an adverse drug reaction (ADR whereas if causal association is not yet established it is termed adverse event (AE. An AE or ADR that is associated with death, in-patient hospitalization, prolongation of hospitalization, persistent or significant disability or incapacity, a congenital anomaly, or is otherwise life threatening is termed as an SAE. The principal investigator reports the event to the licensing authority (DCGI, sponsor and Chairperson of the Ethics Committee (EC within 24 hours of occurrence of the SAE. This report is furthered by a detailed report by both the investigator and the EC and given to the DCGI who then gives a final decision on the amount of compensation to be given by the sponsor or the sponsor's representative to the grieving party.

Annual report on occupational safety 1985

International Nuclear Information System (INIS)

1986-09-01

This report presents information on occupational safety relating to the Company's employees for the year 1985, and compares data with figures for the previous year. The following headings are listed: principle activities of BNFL, general policy and organisation, radiological safety, including whole body, skin and extremity, and internal organ doses, non-radiological safety, incidents reportable to the health and safety executive. (U.K.)

Program nuclear safety research: report 2000

International Nuclear Information System (INIS)

Muehl, B.

2001-09-01

The reactor safety R and D work of forschungszentrum karlsruhe (FZK) had been part of the nuclear safety research project (PSF) since 1990. In 2000, a new organisational structure was introduced and the Nuclear Safety Research Project was transferred into the nuclear safety research programme (NUKLEAR). In addition to the three traditional main topics - Light Water Reactor safety, Innovative systems, Studies related to the transmutation of actinides -, the new Programme NUKLEAR also covers Safety research related to final waste storage and Immobilisation of HAW. These new topics, however, will only be dealt with in the next annual report. Some tasks related to the traditional topics have been concluded and do no longer appear in the annual report; other tasks are new and are described for the first time. Numerous institutes of the research centre contribute to the work programme, as well as several external partners. The tasks are coordinated in agreement with internal and external working groups. The contributions to this report, which are either written in German or in English, correspond to the status of early/mid 2001. (orig.)

Engineering approach to relative quantitative assessment of safety culture and related social issues in NPP operation

International Nuclear Information System (INIS)

Sivokon, V.; Gladyshev, M.; Malkin, S.

2005-01-01

The report is devoted to presentation of engineering approach and software tool developed for Safety Culture (SC) assessment as well as to the results of their implementation at Smolensk NPP. The engineering approach is logic evolution of the IAEA ASSET method broadly used at European NPPs in 90-s. It was implemented at Russian and other plants including Olkiluoto NPP in Finland. The approach allows relative quantitative assessing and trending the aspects of SC by the analysis of evens features and causes, calculation and trending corresponding indicators. At the same time plant's operational performances and related social issues, including efficiency of plant operation and personnel reliability, can be monitored. With the help of developed tool the joint team combined from personnel of Smolensk NPP and RRC 'Kurchatov Institute' ('KI') issued the SC self-assessment report, which identifies: families of recurrent events, main safety and operational problems ; their trends and importance to SC and plant efficiency; recommendations to enhance SC and operational performance

76 FR 7131 - Safety Zones; Eleventh Coast Guard District Annual Fireworks Events

Science.gov (United States)

2011-02-09

...-AA00 Safety Zones; Eleventh Coast Guard District Annual Fireworks Events AGENCY: Coast Guard, DHS... permanent safety zones to ensure public safety during annual firework displays at various locations in the... events, delete events that are no longer occurring, add new unlisted annual fireworks events to the...

Nuclear power and nuclear safety 2009

International Nuclear Information System (INIS)

Lauritzen, B.; Oelgaard, P.L.; Kampmann, D.; Nystrup, P.E.; Thorlaksen, B.

2010-05-01

The report is the seventh report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe DTU and the Danish Emergency Management Agency. The report for 2009 covers the following topics: status of nuclear power production, regional trends, reactor development, safety related events, international relations, conflicts and the European safety directive. (LN)

Knowledge is power: averting safety-compromising events in the OR.

Science.gov (United States)

Catalano, Kathleen

2008-12-01

Surgical procedures can be unpredictable, and safety-compromising events can jeopardize patient safety. Perioperative nurses should be watchful for factors that can contribute to safety-compromising events, as well as the errors that can follow, and know how to avert them if possible. Knowledge is power and increased awareness of patient safety issues and the resources that are available to both health care practitioners and consumers can help perioperative nurses ward off patient safety problems before they occur.

["Re-evaluation upon suspected event" is an approach for post-marketing clinical study: lessons from adverse drug events related to Bupleuri Radix preparations].

Science.gov (United States)

Wu, Shu-Xin; Sun, Hong-Feng; Yang, Xiao-Hui; Long, Hong-Zhu; Ye, Zu-Guang; Ji, Shao-Liang; Zhang, Li

2014-08-01

We revisited the "Xiao Chaihu Decoction event (XCHDE)" occurred in late 1980s in Japan and the Bupleuri Radix related adverse drug reaction (ADR) reports in China After careful review, comparison, analysis and evaluation, we think the interstitial pneumonitis, drug induced Liver injury (DILI) and other severe adverse drug envents (ADEs) including death happened in Japan is probably results from multiple factors, including combinatory use of XCHDE with interferon, Kampo usage under modern medicine theory guidance, and use of XCHD on the basis of disease diagnosis instead of traditional Chinese syndrome complex differentiation. There are less ADE case reports related to XCHD preparation in China compared to Japan, mostly manifest with hypersensitivity responses of skin and perfuse perspiration. The symptoms of Radix Bupleuri injection related ADEs mainly manifest hypersensitivity-like response, 2 cases of intravenous infusion instead of intramuscular injection developed hypokalemia and renal failure. One case died from severe hypersensitivity shock. In Chinese literatures, there is no report of the interstitial pneumonitis and DILI associated with XCHDG in Japan. So far, there is no voluntary monitoring data and large sample clinical research data available. The author elaborated the classification of "reevaluation" and clarified "re-evaluation upon events" included the reaction to the suspected safety and efficacy events. Based on the current status of the clinical research on the Radix Bupleuri preparations, the author points out that post-marketing "re-evaluation upon suspected event" is not only a necessity of continuous evaluation of the safety, efficacy of drugs, it is also a necessity for providing objective clinical research data to share with the international and domestic drug administrations in the risk-benefit evaluation. It is also the unavoidable pathway to culture and push the excellent species and famous brands of TCM to the international market, in

Status of safety at Areva group facilities. 2007 annual report

International Nuclear Information System (INIS)

2007-01-01

This report describes the status of nuclear safety and radiation protection in the facilities of the AREVA group and gives information on radiation protection in the service operations, as observed through the inspection programs and analyses carried out by the General Inspectorate in 2007. Having been submitted to the group's Supervisory Board, this report is sent to the bodies representing the personnel. Content: 1 - A look back at 2007 by the AREVA General Inspector: Visible progress in 2007, Implementation of the Nuclear Safety Charter, Notable events; 2 - Status of nuclear safety and radiation protection in the nuclear facilities and service operations: Personnel radiation protection, Event tracking, Service operations, Criticality control, Radioactive waste and effluent management; 3 - Performance improvement actions; 4 - Description of the General Inspectorate; 5 - Glossary

Regulatory control of nuclear safety in Finland. Annual report 2008

International Nuclear Information System (INIS)

Kainulainen, E.

2009-06-01

facilities is examined using the employees' individual doses, the collective doses, and the results of emission and environmental radiation control. Summaries are also included for the regulation of the storage of spent nuclear fuel and the processing and storage of reactor waste. For the Olkiluoto 3 plant unit currently under construction, the report includes descriptions of the regulation of design, construction, manufacturing, installation and implementation preparations, as well as regulation of the operations of organisations participating in the construction project. The nuclear safety indicator system is used to examine the efficiency and effects of the regulatory activities targeted at nuclear power plants. Appendices to the report include detailed data and conclusions related to the indicators (Appendix 1) and any significant operational events (Appendix 3). The chapter concerning the regulation of the final disposal project for spent nuclear fuel describes the preparations for the final disposal project and the related regulatory activities. In addition, the oversight of the design and construction of the research facilities (Onkalo) under construction in Olkiluoto, as well as the assessment and oversight of the research, development and design work being carried out to further specify the safety case for final disposal are included in the report. The section concerning nuclear non-proliferation describes the nuclear non-proliferation control for Finnish nuclear facilities and final disposal of spent nuclear fuel, as well as measures required by the Additional Protocol of the Safeguards Agreement. Oversight of the nuclear test ban is also covered by the report. In addition to actual safety regulation, the report describes the enforcement of the regulatory oversight of nuclear facilities, regulatory indicators and the development of regulation, as well as safety research, emergency preparedness, communications and STUK's participation in international nuclear safety

Safety evaluation status report for the prototype license application safety analysis report

International Nuclear Information System (INIS)

1989-07-01

The US Nuclear Regulatory Commission (NRC) staff and consultants reviewed a Prototype License Application Safety Analysis Report (PLASAR) submitted by the US Department of Energy (DOE) for the earth-mounded concrete bunker (EMCB) alternative method of low-level radioactive waste disposal. The NRC reviewers relied extensively on the Standard Review Plan (SRP), Rev.1 (NUREG-1200), to evaluate the acceptability of the information provided in the EMCB PLASAR. The NRC staff selected certain review areas in the PLASAR for development of safety evaluation report input to provide examples of safety assessments that are necessary as part of a licensing review. Because of the fictitious nature of the assumed disposal site, and the decision to limit the review to essentially first-round review status, the NRC staff report is labeled a ''Safety Evaluation Status Report'' (SESR). Appendix A comprises the NRC review comments and questions on the information that DOE submitted in the PLASAR. The NRC concentrated its review on the design and operations-related portions of the EMCB PLASAR

Manche storage Centre. Information report on nuclear safety and radiation protection 2014. Annual report 2014

International Nuclear Information System (INIS)

2015-06-01

After a presentation of the Manche Storage Centre (CSM), the first French centre of surface storage of weakly and moderately radioactive wastes, of its history, its buildings and activities, of the multi-layer cover, of the water management system (installation, controls, sampling), this report then describes the measures related to nuclear safety (principles and objectives), the management of conventional and nuclear wastes produced by the Centre and its other environmental impacts. The follow up of the installations and of their effluents and releases are then addressed: origin, locations and results of radiological controls of rainfalls, of risky effluents, of underground waters, of rivers, impacts of the Centre on its environment (releases in the sea, in rivers, in sediments). The measures related to radiation protection are described: principles, staff dosimetry, and personnel safety. The next part presents the nuclear event scale (INES) and indicates that no incident occurred in 2014. Finally the actions related to public information and transparency are summarized. Recommendations of the CHSCT are reported at the end

Analysis of adverse events of renal impairment related to platinum-based compounds using the Japanese Adverse Drug Event Report database.

Science.gov (United States)

Naganuma, Misa; Motooka, Yumi; Sasaoka, Sayaka; Hatahira, Haruna; Hasegawa, Shiori; Fukuda, Akiho; Nakao, Satoshi; Shimada, Kazuyo; Hirade, Koseki; Mori, Takayuki; Yoshimura, Tomoaki; Kato, Takeshi; Nakamura, Mitsuhiro

2018-01-01

Platinum compounds cause several adverse events, such as nephrotoxicity, gastrointestinal toxicity, myelosuppression, ototoxicity, and neurotoxicity. We evaluated the incidence of renal impairment as adverse events are related to the administration of platinum compounds using the Japanese Adverse Drug Event Report database. We analyzed adverse events associated with the use of platinum compounds reported from April 2004 to November 2016. The reporting odds ratio at 95% confidence interval was used to detect the signal for each renal impairment incidence. We evaluated the time-to-onset profile of renal impairment and assessed the hazard type using Weibull shape parameter and used the applied association rule mining technique to discover undetected relationships such as possible risk factor. In total, 430,587 reports in the Japanese Adverse Drug Event Report database were analyzed. The reporting odds ratios (95% confidence interval) for renal impairment resulting from the use of cisplatin, oxaliplatin, carboplatin, and nedaplatin were 2.7 (2.5-3.0), 0.6 (0.5-0.7), 0.8 (0.7-1.0), and 1.3 (0.8-2.1), respectively. The lower limit of the reporting odds ratio (95% confidence interval) for cisplatin was >1. The median (lower-upper quartile) onset time of renal impairment following the use of platinum-based compounds was 6.0-8.0 days. The Weibull shape parameter β and 95% confidence interval upper limit of oxaliplatin were impairment during cisplatin use in real-world setting. The present findings demonstrate that the incidence of renal impairment following cisplatin use should be closely monitored when patients are hypertensive or diabetic, or when they are co-administered furosemide, loxoprofen, or pemetrexed. In addition, healthcare professionals should closely assess a patient's background prior to treatment.

Identifying and Synchronizing Health Information Technology (HIT) Events from FDA Medical Device Reports.

Science.gov (United States)

Kang, Hong; Wang, Frank; Zhou, Sicheng; Miao, Qi; Gong, Yang

2017-01-01

Health information technology (HIT) events, a subtype of patient safety events, pose a major threat and barrier toward a safer healthcare system. It is crucial to gain a better understanding of the nature of the errors and adverse events caused by current HIT systems. The scarcity of HIT event-exclusive databases and event reporting systems indicates the challenge of identifying the HIT events from existing resources. FDA Manufacturer and User Facility Device Experience (MAUDE) database is a potential resource for HIT events. However, the low proportion and the rapid evolvement of HIT-related events present challenges for distinguishing them from other equipment failures and hazards. We proposed a strategy to identify and synchronize HIT events from MAUDE by using a filter based on structured features and classifiers based on unstructured features. The strategy will help us develop and grow an HIT event-exclusive database, keeping pace with updates to MAUDE toward shared learning.

Analysis of area events as part of probabilistic safety assessment for Romanian TRIGA SSR 14 MW reactor

International Nuclear Information System (INIS)

Mladin, D.; Stefan, I.

2005-01-01

The international experience has shown that the external events could be an important contributor to plant/ reactor risk. For this reason such events have to be included in the PSA studies. In the context of PSA for nuclear facilities, external events are defined as events originating from outside the plant, but with the potential to create an initiating event at the plant. To support plant safety assessment, PSA can be used to find methods for identification of vulnerable features of the plant and to suggest modifications in order to mitigate the impact of external events or the producing of initiating events. For that purpose, probabilistic assessment of area events concerning fire and flooding risk and impact is necessary. Due to the relatively large power level amongst research reactors, the approach to safety analysis of Romanian 14 MW TRIGA benefits from an ongoing PSA project. In this context, treatment of external events should be considered. The specific tasks proposed for the complete evaluation of area event analysis are: identify the rooms important for facility safety, determine a relative area event risk index for these rooms and a relative area event impact index if the event occurs, evaluate the rooms specific area event frequency, determine the rooms contribution to reactor hazard state frequencies, analyze power supply and room dependencies of safety components (as pumps, motor operated valves). The fire risk analysis methodology is based on Berry's method [1]. This approach provides a systematic procedure to carry out a relative index of different rooms. The factors, which affect the fire probability, are: personal presence in the room, number and type of ignition sources, type and area of combustibles, fuel available in the room, fuel location, and ventilation. The flooding risk analysis is based on the amount of piping in the room. For accuracy of the information regarding piping a facility walk-about is necessary. In case of flooding risk

Safety evaluation report related to the construction of the Clinch River Breeder Reactor Plant. Docket No. 50-537. Suppl. 1

International Nuclear Information System (INIS)

1983-05-01

Since the preparation of the Safety Evaluation Report the Advisory Committee on Reactor Safeguards considered the Clinch River construction permit license application at its 276th meeting and subsequently issued a favorable report, dated April 19, 1983 to the Commission (See Appendix I of this report). Additional documents associated with the application have been reviewed and a number of meetings have been held with the applicants. These events and documents are identified in Appendix E to this supplement. This supplement, SSER-1, to the Safety Evaluation Report, provides an evaluation of additional information received from the applicants since preparation of the SER regarding previously identified outstanding review items, and our response to the comments made by the Advisory Committee on Reactor Safeguards in its report

Safety in the operating room during orthopedic trauma surgery-incidence of adverse events related to technical equipment and logistics

NARCIS (Netherlands)

van Delft, E. A. K.; Schepers, T.; Bonjer, H. J.; Kerkhoffs, G. M. M. J.; Goslings, J. C.; Schep, N. W. L.

2017-01-01

Safety in the operating room is widely debated. Adverse events during surgery are potentially dangerous for the patient and staff. The incidence of adverse events during orthopedic trauma surgery is unknown. Therefore, we performed a study to quantify the incidence of these adverse events. Primary

Influence of Japanese Regulatory Action on Denosumab-Related Hypocalcemia Using Japanese Adverse Drug Event Report Database.

Science.gov (United States)

Takeyama, Mayu; Sai, Kimie; Imatoh, Takuya; Segawa, Katsunori; Hirasawa, Noriyasu; Saito, Yoshiro

2017-01-01

The anti-receptor activator of nuclear factor kappa-B ligand (RANKL) antibody, Denosumab (DEN), was approved in April 2012 in Japan, but a Dear Healthcare Professional Letter of Rapid Safety Communication was released in September, 2012 by the regulatory authority because of the severe hypocalcemia risks. Currently, the effectiveness of this regulatory action has not been evaluated and, therefore, this study aimed to assess its impact on DEN-induced hypocalcemia using the Japanese Adverse Drug Event Report database (JADER). The case reports from April 2012 to September 2014 were collected from the JADER, which included 151642 adverse events for the primary suspected drugs. The reporting odds ratio (ROR) of hypocalcemia as a signal of the target adverse event was analyzed for DEN and zoledronic acid (ZOL, a reference drug). Changes in RORs were compared between the pre- (Pre, April 2012 to September 2012) and post- (Post 1, October 2012 to September 2013 and Post 2, October 2013 to September 2014) periods of the regulatory action. A decrease in the hypocalcemia ROR was observed for DEN in the post-periods, especially Post 2. Multivariate logistic regression analysis showed a significant decrease in hypocalcemia signal in Post 1 (p=0.0306 vs. Pre) and Post 2 (p=0.0054 vs. Pre). ZOL caused no significant changes in ROR of hypocalcemia, and none of the drugs caused ROR changes in jaw osteonecrosis (a reference adverse event). This study suggests that the regulatory action against hypocalcemia in DEN effectively decreased hypocalcemia signal. Further studies using medical information databases are needed to confirm this result.

Feedback from peer review missions of the self-assessment of operational events reflecting safety culture (Leningrad, Smolemsk and Balakovo NPP's, the Russian Federation)

International Nuclear Information System (INIS)

Gantchev, T.

1997-01-01

The presentation discusses the following issues: criteria for reporting events inside NPP; screening of the plant operational events; third safety culture indicator; list of the pending safety problems; significance of the safety problems for plant reliability; prioritization of the safety culture issues. Tabs

The Aube Storage Centre. Information report on nuclear safety and radiation protection for 2014 - Annual report 2014

International Nuclear Information System (INIS)

2014-06-01

After a presentation of the installations of CSA (Aube Storage Centre), its equipment, its exploitation (deliveries, storage, compacting unit, injection unit, storage works), works performed and highlights in 2014, and perspectives of evolution for 2015 and 2016, this report presents the measures regarding nuclear safety: safety principles, technical measures to meet objectives, inspections performed by the Nuclear Safety Authority (ASN), and quality management. The next part presents measures regarding measures for radiation protection and safety: staff dosimetry (measurements results and evolutions), safety exercise. It outlines that no important incident occurred, and described three minor events which have been declared to the ASN. The next part addresses actions related to the control of the environment and of releases: water management, presentation and discussion of the main results of radiological measurements (rainfalls, air, brook waters, sediments, underground waters, radiation at the edge of the centre, ground vegetal, food chain, aquatic ecosystems), physical-chemical control of waters, actions for the protection of the environment. The report then gives an overview of the management of radioactive and conventional wastes produced by the Centre. The last part indicates and comments actions related to transparency and information (they may concern the public, local authorities, institutions, or media): visits, conferences, exhibitions, animations, partnerships, publications

Annotated bibliography of safety-related occurrences in nuclear power plans as reported in 1974

International Nuclear Information System (INIS)

Scott, R.L.; Gallaher, R.B.

1975-05-01

All abnormal occurrences at nuclear power plants reported in 1974 are reviewed and summarized. This bibliography covers the individual reports on each of the 1421 abnormal occurrences reported to the U. S. Nuclear Regulatory Commission, as well as some 455 other documents pertaining to these and other events of note. The review is intended to provide insight as to where additional effort can be expended to improve operations in nuclear power plants. The individual reports, abstracted by the Nuclear Safety Information Center, concern incidents and failures, design or construction deficiencies, and noncompliance citations for license violations. A bibliography is included which contains 100-word abstracts of each incident. For convenience, the bibliography is organized according to type of facility as follows: boiling-water reactors; pressurized-water reactors; non-water-cooled power reactors; and reactors, general. Key-word and permuted-title indexes are provided for each section. (U.S.)

Serious adverse events reported for anti-obesity medicines

DEFF Research Database (Denmark)

Aagaard, L; Hallgreen, C E; Hansen, Ebba Holme

2016-01-01

BACKGROUND: Use of anti-obesity medicines has been linked with serious cardiac and psychiatric adverse events (AEs). Spontaneous reports can provide information about serious, rare and unknown AEs occurring after time of marketing. In Europe, information about AEs reported for anti-obesity medici...... are being marketed, the utilisation of anti-obesity medicines is widespread, and therefore systematic monitoring of the safety of these medicines is necessary.International Journal of Obesity accepted article preview online, 01 August 2016. doi:10.1038/ijo.2016.135.......BACKGROUND: Use of anti-obesity medicines has been linked with serious cardiac and psychiatric adverse events (AEs). Spontaneous reports can provide information about serious, rare and unknown AEs occurring after time of marketing. In Europe, information about AEs reported for anti......-obesity medicines can be accessed in the EudraVigilance database (EV). Therefore, we aimed to identify and characterise adverse events (AEs) associated with use of anti-obesity medicines in Europe. METHODS: AE reports submitted for anti-obesity medicines (Anatomical Therapeutic Chemical [ATC] group A08A) from 2007...

Trending of low level events and near misses to enhance safety performance in nuclear power plants

International Nuclear Information System (INIS)

2005-11-01

The IAEA Safety Fundamentals publication, Safety of Nuclear Installations, Safety Series No. 110, states the need for operating organizations to establish a programme for the collection and analysis of operating experience in nuclear power plants. Such a programme ensures that operating experience is analysed, events important to safety are reviewed in depth, and lessons learned are disseminated to the staff of the organization and to relevant national and international organizations. As a result of the effort to enhance safety in operating organizations, incidents are progressively decreasing in number and significance. This means that in accordance with international reporting requirements the amount of collected data becomes less sufficient to draw meaningful statistical conclusions. This is where the collection and trend analysis of low level events and near misses can prove to be very useful. These trends can show which of the safety barriers are weak or failing more frequently. Evaluation and trending of low level events and near misses will help to prevent major incidents because latent weaknesses have been identified and corrective actions taken to prevent recurrence. This leads to improved safety and production. Low level events and near misses, which may reach several thousand per reactor operating year, need to be treated by the organizations as learning opportunities. A system for capturing these low level events and near misses truly needs to be an organization-wide system in which all levels of the organization, including contractors, participate. It is desirable that the overall operational experience feedback (OEF) process should integrate the lessons learned and the associated data from significant events with those of lower level events and near misses. To be able to effectively implement a process dealing with low level events and near misses, it is necessary that the organization have a well established OEF process for significant events

DOE Safety Metrics Indicator Program (SMIP) Fiscal Year 2000 Annual Report of Packaging- and Transportation-related Occurrences

International Nuclear Information System (INIS)

Dickerson, L.S.

2001-01-01

The U.S. Department of Energy (DOE) Occurrence Reporting and Processing System (ORPS) is an interactive computer system designed to support DOE-owned or -operated facilities in reporting and processing information concerning occurrences related to facility operations. The Oak Ridge National Laboratory has been charged by the DOE National Transportation Program Albuquerque (NTPA) with the responsibility of retrieving reports and information pertaining to packaging and transportation (P and T) incidents from the centralized ORPS database. These selected reports are analyzed for safety concerns, trends, potential impact on P and T operations, and ''lessons learned'' in P and T safety. To support this analysis and trending, the Safety Metrics Indicator Program (SMIP) was established by the NTPA in fiscal year (FY) 1998. Its chief goal is to augment historical reporting of occurrence-based information by providing (1) management notification of those incidents that require attention, (2) an accurate picture of contractors' P and T-related performance, and (3) meaningful statistics on occurrences at particular sites, including comparisons among different contractor sites and between DOE and the private sector. This annual report contains information on those P and T-related occurrences reported to the ORPS during the period from October 1, 1999, through September 30, 2000. Only those incidents that occur in preparation for transport, during transport, and during unloading of hazardous material are considered as packaging- or transportation-related occurrences

An Event Reporting and Early-Warning Safety System Based on the Internet of Things for Underground Coal Mines: A Case Study

Directory of Open Access Journals (Sweden)

Byung Wan Jo

2017-09-01

Full Text Available Fatal accidents associated with underground coal mines require the implementation of high-level gas monitoring and miner’s localization approaches to promote underground safety and health. This study introduces a real-time monitoring, event-reporting and early-warning platform, based on cluster analysis for outlier detection, spatiotemporal statistical analysis, and an RSS range-based weighted centroid localization algorithm for improving safety management and preventing accidents in underground coal mines. The proposed platform seamlessly integrates monitoring, analyzing, and localization approaches using the Internet of Things (IoT, cloud computing, a real-time operational database, application gateways, and application program interfaces. The prototype has been validated and verified at the operating underground Hassan Kishore coal mine. Sensors for air quality parameters including temperature, humidity, CH4, CO2, and CO demonstrated an excellent performance, with regression constants always greater than 0.97 for each parameter when compared to their commercial equivalent. This framework enables real-time monitoring, identification of abnormal events (>90%, and verification of a miner’s localization (with <1.8 m of error in the harsh environment of underground mines. The main contribution of this study is the development of an open source, customizable, and cost-effective platform for effectively promoting underground coal mine safety. This system is helpful for solving the problems of accessibility, serviceability, interoperability, and flexibility associated with safety in coal mines.

Design a Learning-Oriented Fall Event Reporting System Based on Kirkpatrick Model.

Science.gov (United States)

Zhou, Sicheng; Kang, Hong; Gong, Yang

2017-01-01

Patient fall has been a severe problem in healthcare facilities around the world due to its prevalence and cost. Routine fall prevention training programs are not as effective as expected. Using event reporting systems is the trend for reducing patient safety events such as falls, although some limitations of the systems exist at current stage. We summarized these limitations through literature review, and developed an improved web-based fall event reporting system. The Kirkpatrick model, widely used in the business area for training program evaluation, has been integrated during the design of our system. Different from traditional event reporting systems that only collect and store the reports, our system automatically annotates and analyzes the reported events, and provides users with timely knowledge support specific to the reported event. The paper illustrates the design of our system and how its features are intended to reduce patient falls by learning from previous errors.

Annual report on occupational safety 1987

International Nuclear Information System (INIS)

1988-01-01

This report presents detailed information on occupational safety relating to the Company's employees for 1987. Data are quoted in tables and text, together with data from the previous year for comparison where available. The report is presented under the following headings: radiological and non-radiological safety, incidents, appendices (statutory dose limits, nuclear incident criteria for reporting to ministers). (author)

2009 transparency and nuclear safety report. CEA Cadarache. Volumes 1 + 2

International Nuclear Information System (INIS)

2009-01-01

After a general presentation of the Cadarache site and of its nuclear installations, the first volume of this report describes the various measures concerning the site safety (safety organisation, general measures, measures related to various risks, inspections, control of emergency situations, audits and second level control, measures in basic nuclear installations) and radioprotection (organisation, significant facts, dosimeter results). It describes significant events which occurred in relationship with nuclear safety and radioprotection, presents results of measurements of releases and of their impact on the environment (chemical and radiological assessment). Then after a description of measures to limit the volume of stored radioactive wastes and their impact on health and on the environment, tables indicate the nature and quantities of wastes which are stored in the different basic nuclear installations of Cadarache. The second volume proposes the same information for two specific nuclear installations belonging to Areva and located in Cadarache, the INB 32 and 54 (INB stands for basic nuclear installation) for which a significant event occurred on the 6 October 2009. For these installations, release measurements concern gaseous and liquid releases

Geriatric Patient Safety Indicators Based on Linked Administrative Health Data to Assess Anticoagulant-Related Thromboembolic and Hemorrhagic Adverse Events in Older Inpatients: A Study Proposal.

Science.gov (United States)

Le Pogam, Marie-Annick; Quantin, Catherine; Reich, Oliver; Tuppin, Philippe; Fagot-Campagna, Anne; Paccaud, Fred; Peytremann-Bridevaux, Isabelle; Burnand, Bernard

2017-05-11

Frail older people with multiple interacting conditions, polypharmacy, and complex care needs are particularly exposed to health care-related adverse events. Among these, anticoagulant-related thromboembolic and hemorrhagic events are particularly frequent and serious in older inpatients. The growing use of anticoagulants in this population and their substantial risk of toxicity and inefficacy have therefore become an important patient safety and public health concern worldwide. Anticoagulant-related adverse events and the quality of anticoagulation management should thus be routinely assessed to improve patient safety in vulnerable older inpatients. This project aims to develop and validate a set of outcome and process indicators based on linked administrative health data (ie, insurance claims data linked to hospital discharge data) assessing older inpatient safety related to anticoagulation in both Switzerland and France, and enabling comparisons across time and among hospitals, health territories, and countries. Geriatric patient safety indicators (GPSIs) will assess anticoagulant-related adverse events. Geriatric quality indicators (GQIs) will evaluate the management of anticoagulants for the prevention and treatment of arterial or venous thromboembolism in older inpatients. GPSIs will measure cumulative incidences of thromboembolic and bleeding adverse events based on hospital discharge data linked to insurance claims data. Using linked administrative health data will improve GPSI risk adjustment on patients' conditions that are present at admission and will capture in-hospital and postdischarge adverse events. GQIs will estimate the proportion of index hospital stays resulting in recommended anticoagulation at discharge and up to various time frames based on the same electronic health data. The GPSI and GQI development and validation process will comprise 6 stages: (1) selection and specification of candidate indicators, (2) definition of administrative data

Meeting Report: 2013 PDA Virus & TSE Safety Forum.

Science.gov (United States)

Willkommen, Hannelore; Blümel, Johannes; Brorson, Kurt; Chen, Dayue; Chen, Qi; Gröner, Albrecht; Hubbard, Brian R; Kreil, Thomas R; Ruffing, Michel; Ruiz, Sol; Scott, Dorothy; Silvester, Glenda

2014-01-01

The report provides a summary of the presentations and discussions at the Virus & TSE Safety Forum 2013 organized by the Parenteral Drug Association (PDA) and held in Berlin, Germany, from June 4 to 6, 2013. The conference was accompanied by a workshop, "Virus Spike Preparations and Virus Removal by Filtration: New Trends and Developments". The presentations and the discussion at the workshop are summarized in a separate report that will be published in this issue of the journal as well. As with previous conferences of this series, the PDA Virus & TSE Safety Forum 2013 provided again an excellent opportunity to exchange information and opinions between the industry, research organizations, and regulatory bodies. Updates on regulatory considerations related to virus and transmissible spongiform encephalopathy (TSE) safety of biopharmaceuticals were provided by agencies of the European Union (EU), the United States (US), and Singapore. The epidemiology and detection methods of new emerging pathogens like hepatitis E virus and parvovirus (PARV 4) were exemplified, and the risk of contamination of animal-derived raw materials like trypsin was considered in particular. The benefit of using new sequence-based virus detection methods was discussed. Events of bioreactor contaminations in the past drew the attention to root cause investigations and preventive actions, which were illustrated by several examples. Virus clearance data of specific unit operations were provided; the discussion focused on the mechanism of virus clearance and on the strategic concept of viral clearance integration. As in previous years, the virus safety section was followed by a TSE section that covered recent scientific findings that may influence the risk assessment of blood and cell substrates. These included the realization that interspecies transmission of TSE by blood components in sheep is greater than predicted by assays in transgenic mice. Also, the pathogenesis and possibility of

Feedback from peer review missions of the self-assessment of operational events reflecting safety culture (Leningrad, Smolemsk and Balakovo NPP`s, the Russian Federation)

Energy Technology Data Exchange (ETDEWEB)

Gantchev, T [Committee on the Use of Atomic Energy for Peaceful Purposes (Bulgaria)

1997-10-01

The presentation discusses the following issues: criteria for reporting events inside NPP; screening of the plant operational events; third safety culture indicator; list of the pending safety problems; significance of the safety problems for plant reliability; prioritization of the safety culture issues. Tabs.

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

Energy Technology Data Exchange (ETDEWEB)

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

2002-03-01

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

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

International Nuclear Information System (INIS)

Svenson, Ola; Salo, Ilkka

2002-03-01

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

33 CFR 165.1191 - Safety zones: Northern California annual fireworks events.

Science.gov (United States)

2010-07-01

... annual fireworks events. 165.1191 Section 165.1191 Navigation and Navigable Waters COAST GUARD... § 165.1191 Safety zones: Northern California annual fireworks events. (a) General. Safety zones are.... Event Description Fireworks display. Date Last Saturday in May. Location 1,000 feet off Pier 30/32...

Report on transparency and nuclear safety. Saclay 2010

International Nuclear Information System (INIS)

2010-01-01

After a presentation of the Saclay site, this report indicates the measures implemented regarding nuclear safety in the different Saclay basic nuclear installations, in terms of organization, general technical aspects, technical aspects associated with the different risks, emergency situation management, inspections, audits, and controls. It indicates the organisation of radiation protection, reports important events which occurred in 2010, and comments dose measurements performed on the different personnel (belonging to the CEA or out-sourced personnel). It reports and comments significant events about nuclear safety and radiation protection, and which occurred in the different installations. It reports and comments results of release measurements and of the impact of the centre on the environment (gas and liquid releases and their impacts on the environment, impacts due to radionuclide gas releases, gas and liquid radiological impact, chemical impact of gas and liquid releases, environment monitoring). It addresses the issue of radioactive wastes which are stored in the Saclay nuclear installations (measures to limit their volume and their impact on health and on the environment, notably soils and waters, nature and quantities of stored wastes)

Report on transparency and nuclear safety. Saclay 2009

International Nuclear Information System (INIS)

2009-01-01

After a presentation of the Saclay site, this report indicates the measures implemented regarding nuclear safety in the different Saclay basic nuclear installations, in terms of organization, general technical aspects, technical aspects associated with the different risks, emergency situation management, inspections, audits, and controls. It indicates the organisation of radiation protection, reports important events which occurred in 2009, and comments dose measurements performed on different personnel (belonging to the CEA or out-sourced). It reports and comments significant events about nuclear safety and radiation protection, and which occurred in the different installations. It reports and comments results of release measurements and of the impact of the centre on the environment (gas and liquid releases and their impacts on the environment, impacts due to radionuclide gas releases, gas and liquid radiological impact, chemical impact of gas and liquid releases, environment monitoring). It addresses the issue of radioactive wastes which are stored in the Saclay nuclear installations (measures to limit their volume and their impact on health and on the environment, notably soils and waters, nature and quantities of stored wastes)

The practice of reporting adverse events in a teaching hospital

Directory of Open Access Journals (Sweden)

Andréia Guerra Siman

2017-10-01

Full Text Available Abstract OBJECTIVE Understanding the practice of reporting adverse events by health professionals. METHOD A qualitative case study carried out in a teaching hospital with participants of the Patient Safety Center and the nursing team. The collection took place from May to December 2015, and was conducted through interviews, observation and documentary research to treat the data using Content Analysis. RESULTS 31 professionals participated in the study. Three categories were elaborated: The practice of reporting adverse events; Barriers in the effective practice of notifications; The importance of reporting adverse events. CONCLUSION Notification was permeated by gaps in knowledge, fear of punishment and informal communication, generating underreporting. It is necessary to improve the interaction between leaders and professionals, with an emphasis on communication and educational practice.

Report of the ASSET (Assessment of Safety Significant Events Team) mission to the Zaporozhe nuclear power plant in Ukraine 13-24 June 1994 Division of Nuclear Safety. Root cause analysis of operational events with a view to enhancing the prevention of incidents

International Nuclear Information System (INIS)

1994-01-01

The IAEA Assessment of Safety Significant Events Team (ASSET) report presents the results of an ASSET team's assessment of their investigation of the effectiveness of the plant for prevention of incidents since 1990 at Zaporozhe nuclear power plant. The results, conclusions and suggestions presented herein reflect the views of the ASSET experts. They are provided for consideration by the responsible authorities in Ukraine. The ASSET team's views presented in this report are based on visits to the plant, on review of documentation made available by the operating organization and on discussions with utility personnel. The report is intended to enhance operational safety at Zaporozhe by proposing improvements to the policy for the prevention of incidents at the plant. The report includes, as a usual practice, the official response of the operating organization as well as of the regulatory body to the ASSET recommendations. Figs

Common cause failure data collection and analysis for safety-related components of TRIGA SSR-14MW Pitesti, Romania

International Nuclear Information System (INIS)

Radu, G.; Mladin, D.

2003-01-01

This paper presents a study performed on the set of common cause failures (CCF) of safety-related components of the research reactor TRIGA SSR-14 MW Pitesti. The data collected cover a period of 20 years, from 1979 to 2000. The sources of data are Shift Supervisor Reports, Work Authorizations, and Reactor Log Books. Events collected are analyzed by failure mode and degrees of failure. Qualitative analysis of root causes, coupling factors and corrective actions and quantitative analysis of CCF events are studied. The objective of this work is to develop qualitative insights in the nature of the reported events and to build a site-specific common cause events database. (author)

Root Cause Analysis: Learning from Adverse Safety Events.

Science.gov (United States)

Brook, Olga R; Kruskal, Jonathan B; Eisenberg, Ronald L; Larson, David B

2015-10-01

Serious adverse events continue to occur in clinical practice, despite our best preventive efforts. It is essential that radiologists, both as individuals and as a part of organizations, learn from such events and make appropriate changes to decrease the likelihood that such events will recur. Root cause analysis (RCA) is a process to (a) identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and (b) allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future. An RCA process should be performed within the environment of a culture of safety, focusing on underlying system contributors and, in a confidential manner, taking into account the emotional effects on the staff involved. The Joint Commission now requires that a credible RCA be performed within 45 days for all sentinel or major adverse events, emphasizing the need for all radiologists to understand the processes with which an effective RCA can be performed. Several RCA-related tools that have been found to be useful in the radiology setting include the "five whys" approach to determine causation; cause-and-effect, or Ishikawa, diagrams; causal tree mapping; affinity diagrams; and Pareto charts. © RSNA, 2015.

External main-induced events in relation to nuclear power plant siting

International Nuclear Information System (INIS)

1981-01-01

This safety Guide recomments procedures and provides information for use in implementing that part of the code of safety in Nuclear Power Plant Siting (IAEA Safety Series No. 50-C-S) which concerns man-induced events external to the plant, up to the evaluation of corresponding design basis parameters. Like the code, the Guide forms part of the IAEA's programme, referred to as the NUSS programme, for establishing codes of practice and safety Guides relating to land-based stationary thermal neutron power plants

A System for the Feedback of Experience from Events in Nuclear Installations. Safety Guide (Spanish Edition); Un sistema de retroinformacion sobre la experiencia derivada de sucesos ocurridos en establecimientos nucleares. Guia de seguridad

Energy Technology Data Exchange (ETDEWEB)

NONE

2012-07-15

This Safety Guide provides recommendations on all the main components of operating experience feedback systems, utilizing relevant information on events and abnormal conditions that have occurred at nuclear installations around the world. It focuses on the interaction between the different systems for using operating experience feedback and constitutes an update and an extension of Part I, A National System, of Systems for Reporting Unusual Events in Nuclear Power Plants (IAEA Safety Series No. 93). Contents: 1. Introduction; 2. Main elements of a national system for the feedback of operational experience; 3. Screening of events; 4. Investigation and analysis of events; 5. Corrective actions; 6. Trending and review to recognize emergent problems; 7. Utilization, dissemination and exchange of information on operating experience; 8. Reviewing the effectiveness of the process for feedback of operational experience; 9. Quality assurance; 10. Reporting of safety related events; Appendix I: Reporting criteria and categories; Appendix II: Types of event report, timing, format and content; Appendix III: Investigation and analysis of events; Appendix IV: Approval and implementation of corrective actions; Annex I: Data management for the feedback of operating experience; Annex II: Example of elements of a national feedback system for operating experience.

Report on nuclear safety and transparency 2011 - Saclay

International Nuclear Information System (INIS)

2012-06-01

After a brief presentation of the Saclay CEA centre, this report indicates the different safety measures related to different risks, to emergency situations, to inspections and audits, and to nuclear base installations (INB). It describes measures related to radiation protection (organisation, personnel dosimetry) and some remarkable facts which occurred in 2011. It presents the different significant events which occurred in 2011 and were declared to the ASN. It discusses the results of measurements of liquid and gaseous releases from the installations and their impact on the environment. It addresses the radioactive wastes which are warehoused on the site (measures to limit their volume and to limit their impact on health and on the environment, notably on water and soils, types and quantities of wastes stored in INBs

Report on nuclear safety and transparency 2011 - Grenoble

International Nuclear Information System (INIS)

2012-06-01

After a brief presentation of the Grenoble CEA centre, this report indicates the different safety measures related to different risks, to emergency situations, to inspections and audits, and to nuclear base installations (INB). It describes measures related to radiation protection organisation and some remarkable facts which occurred in 2011. It presents the different significant events which occurred in 2011 and were declared to the ASN. It discusses the results of measurements of liquid and gaseous releases from the installations and their impact on the environment. It addresses the radioactive wastes which are warehoused on the site (measures to limit their volume and to limit their impact on health and on the environment, notably on water and soils, types and quantities of wastes stored in INBs)

Development of an adverse events reporting form for Korean folk medicine.

Science.gov (United States)

Park, Jeong Hwan; Choi, Sun-Mi; Moon, Sujeong; Kim, Sungha; Kim, Boyoung; Kim, Min-Kyeoung; Lee, Sanghun

2017-05-01

We developed an adverse events (AEs) reporting form for Korean folk medicine. The first version of the form was developed and tested in the clinical setting for spontaneous reporting of AEs. Additional revisions to the reporting form were made based on collected data and expert input. We developed an AEs reporting form for Korean folk medicine. The items of this form were based on patient information, folk medicine properties, and AEs. For causality assessment, folk medicine properties such as classification, common and vernacular names, scientific name, part used, harvesting time, storage conditions, purchasing route, product licensing, prescription, persons with similar exposure, any remnant of raw natural products collected from the patient, and cautions or contraindications were added. This is the first reporting form for AEs that incorporates important characteristics of Korean folk medicine. This form would have an important role in reporting adverse events for Korean folk medicine. © 2016 The Authors. Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd. © 2016 The Authors. Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.

Technical Letter Report: Evaluation and Analysis of a Few International Periodic Safety Review Summary Reports

Energy Technology Data Exchange (ETDEWEB)

Chopra, Omesh K. [Argonne National Lab., IL (United States). Environmental Science Division; Diercks, Dwight R. [Argonne National Lab., IL (United States). Nuclear Engineering Division; Ma, David Chia-Chiun [Argonne National Lab., IL (United States). Environmental Science Division; Garud, Yogendra S. [Argonne National Lab., IL (United States). Environmental Science Division

2013-12-17

At the request of the United States (U.S.) government, the International Atomic Energy Agency (IAEA) assembled a team of 20 senior safety experts to review the regulatory framework for the safety of operating nuclear power plants in the United States. This review focused on the effectiveness of the regulatory functions implemented by the NRC and on its commitment to nuclear safety and continuous improvement. One suggestion resulting from that review was that the U.S. Nuclear Regulatory Commission (NRC) incorporate lessons learned from periodic safety reviews (PSRs) performed in other countries as an input to the NRC’s assessment processes. In the U.S., commercial nuclear power plants (NPPs) are granted an initial 40-year operating license, which may be renewed for additional 20-year periods, subject to complying with regulatory requirements. The NRC has established a framework through its inspection, and operational experience processes to ensure the safe operation of licensed nuclear facilities on an ongoing basis. In contrast, most other countries do not impose a specific time limit on the operating licenses for NPPs, they instead require that the utility operating the plant perform PSRs, typically at approximately 10-year intervals, to assure continued safe operation until the next assessment. The staff contracted with Argonne National Laboratory (Argonne) to perform a pilot review of selected translated PSR assessment reports and related documentation from foreign nuclear regulatory authorities to identify any potential new regulatory insights regarding license renewal-related topics and NPP operating experience (OpE). A total of 14 PSR assessment documents from 9 countries were reviewed. For all of the countries except France, individual reports were provided for each of the plants reviewed. In the case of France, three reports were provided that reviewed the performance assessment of thirty-four 900-MWe reactors of similar design commissioned between 1978

Technical Letter Report: Evaluation and Analysis of a Few International Periodic Safety Review Summary Reports

International Nuclear Information System (INIS)

Chopra, Omesh K.; Diercks, Dwight R.; Ma, David Chia-Chiun; Garud, Yogendra S.

2013-01-01

At the request of the United States (U.S.) government, the International Atomic Energy Agency (IAEA) assembled a team of 20 senior safety experts to review the regulatory framework for the safety of operating nuclear power plants in the United States. This review focused on the effectiveness of the regulatory functions implemented by the NRC and on its commitment to nuclear safety and continuous improvement. One suggestion resulting from that review was that the U.S. Nuclear Regulatory Commission (NRC) incorporate lessons learned from periodic safety reviews (PSRs) performed in other countries as an input to the NRC's assessment processes. In the U.S., commercial nuclear power plants (NPPs) are granted an initial 40-year operating license, which may be renewed for additional 20-year periods, subject to complying with regulatory requirements. The NRC has established a framework through its inspection, and operational experience processes to ensure the safe operation of licensed nuclear facilities on an ongoing basis. In contrast, most other countries do not impose a specific time limit on the operating licenses for NPPs, they instead require that the utility operating the plant perform PSRs, typically at approximately 10-year intervals, to assure continued safe operation until the next assessment. The staff contracted with Argonne National Laboratory (Argonne) to perform a pilot review of selected translated PSR assessment reports and related documentation from foreign nuclear regulatory authorities to identify any potential new regulatory insights regarding license renewal-related topics and NPP operating experience (OpE). A total of 14 PSR assessment documents from 9 countries were reviewed. For all of the countries except France, individual reports were provided for each of the plants reviewed. In the case of France, three reports were provided that reviewed the performance assessment of thirty-four 900-MWe reactors of similar design commissioned between 1978 and

When bad things happen: adverse event reporting and disclosure as patient safety and risk management tools in the neonatal intensive care unit.

Science.gov (United States)

Donn, Steven M; McDonnell, William M

2012-01-01

The Institute of Medicine has recommended a change in culture from "name and blame" to patient safety. This will require system redesign to identify and address errors, establish performance standards, and set safety expectations. This approach, however, is at odds with the present medical malpractice (tort) system. The current system is outcomes-based, meaning that health care providers and institutions are often sued despite providing appropriate care. Nevertheless, the focus should remain to provide the safest patient care. Effective peer review may be hindered by the present tort system. Reporting of medical errors is a key piece of peer review and education, and both anonymous reporting and confidential reporting of errors have potential disadvantages. Diagnostic and treatment errors continue to be the leading sources of allegations of malpractice in pediatrics, and the neonatal intensive care unit is uniquely vulnerable. Most errors result from systems failures rather than human error. Risk management can be an effective process to identify, evaluate, and address problems that may injure patients, lead to malpractice claims, and result in financial losses. Risk management identifies risk or potential risk, calculates the probability of an adverse event arising from a risk, estimates the impact of the adverse event, and attempts to control the risk. Implementation of a successful risk management program requires a positive attitude, sufficient knowledge base, and a commitment to improvement. Transparency in the disclosure of medical errors and a strategy of prospective risk management in dealing with medical errors may result in a substantial reduction in medical malpractice lawsuits, lower litigation costs, and a more safety-conscious environment. Thieme Medical Publishers, Inc.

Licensee Event Report (LER) compilation for month of September 1991

International Nuclear Information System (INIS)

1991-10-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For these events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 50.73 -- Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System -- Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule. The LER summaries in this report are arranged alphabetically by facility name and then chronologically by event data for each facility. Component, system, keyword, and component vendor indexes follow the summaries. Vendors are those identified by the utility when the LER form is initiated; the keywords for the component, system, and general keyword indexes are assigned by the computer using correlation tables from the Sequence Coding and Search System

Licensee Event Report (LER) compilation for month of August 1991

International Nuclear Information System (INIS)

1991-09-01

This monthly report contains Licensee Event Report (LER) operational information that was processed into the LER data file of the Nuclear Safety Information Center (NSIC) during the one month period identified on the cover of the document. The LERs, from which this information is derived, are submitted to the Nuclear Regulatory Commission (NRC) by nuclear power plant licensees in accordance with federal regulations. Procedures for LER reporting for revisions to those events occurring prior to 1984 are described in NRC Regulatory Guide 1.16 and NUREG-0161, Instructions for Preparation of Data Entry Sheets for Licensee Event Reports. For those events occurring on and after January 1, 1984, LERs are being submitted in accordance with the revised rule contained in Title 10 Part 50.73 of the Code of Federal Regulations (10 CFR 5.073 -- Licensee Event Report System) which was published in the Federal Register (Vol. 48, No. 144) on July 26, 1983. NUREG-1022, Licensee Event Report System -- Description of Systems and Guidelines for Reporting, provides supporting guidance and information on the revised LER rule. The LER summaries in this report are arranged alphabetically by facility name and then chronologically by event date for each facility. Component, system, keyword, and component vendor indexes follow the summaries. Vendors are those identified by the utility when the LER form is initiated; the keywords for the component, system, and general keyword indexes are assigned by the computer using correlation tables from the Sequence Coding and Search System

Nuclear power and nuclear safety 2011

International Nuclear Information System (INIS)

Lauritzen, B.; Oelgaard, P.L.; Aage, H.K.; Kampmann, D.; Nystrup, P.E.; Thomsen, J.

2012-07-01

The report is the ninth report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe DTU and the Danish Emergency Management Agency. The report for 2011 covers the following topics: status of nuclear power production, regional trends, reactor development, safety related events, international relations and conflicts, and the Fukushima accident. (LN)

Nuclear power and nuclear safety 2008

International Nuclear Information System (INIS)

Lauritzen, B.; Oelgaard, P.L.; Kampmann, D.

2009-06-01

The report is the fifth report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe DTU and the Danish Emergency Management Agency. The report for 2008 covers the following topics: status of nuclear power production, regional trends, reactor development, safety related events of nuclear power, and international relations and conflicts. (LN)

Operating experience feedback report: Reliability of safety-related steam turbine-driven standby pumps. Commercial power reactors, Volume 10

International Nuclear Information System (INIS)

Boardman, J.R.

1994-10-01

This report documents a detailed analysis of failure initiators, causes and design features for steam turbine assemblies (turbines with their related components, such as governors and valves) which are used as drivers for standby pumps in the auxiliary feedwater systems of US commercial pressurized water reactor plants, and in the high pressure coolant injection and reactor core isolation cooling systems of US commercial boiling water reactor plants. These standby pumps provide a redundant source of water to remove reactor core heat as specified in individual plant safety analysis reports. The period of review for this report was from January 1974 through December 1990 for licensee event reports (LERS) and January 1985 through December 1990 for Nuclear Plant Reliability Data System (NPRDS) failure data. This study confirmed the continuing validity of conclusions of earlier studies by the US Nuclear Regulatory Commission and by the US nuclear industry that the most significant factors in failures of turbine-driven standby pumps have been the failures of the turbine-drivers and their controls. Inadequate maintenance and the use of inappropriate vendor technical information were identified as significant factors which caused recurring failures

Safety in transports of civil radioactive substances on the French territory. Lessons learned by the IRSN from the analysis of significant events declared in 2012 and 2013. Safety of transports of civil radioactive substances in France

International Nuclear Information System (INIS)

2016-11-01

After a presentation of some general elements regarding transports of radioactive substances in France, this report proposes a synthetic overview of the main lessons learned by the IRSN from the analysis of transport-related events in 2012 and 2013. Then, the body of this report presents the context of transports of radioactive substances: legal framework, main safety elements, nature and flows of these transports in France, transports per activity sector. It proposes a global analysis of significant events, with a comparison with previous years. The four main significant events are described. Some transverse issues are finally addressed: return on experience on crisis management in relationship with transport events, IRSN study on the behaviour of packagings during long duration fire

Nuclear safety regulation on nuclear safety equipment activities in relation to human and organizational factors

International Nuclear Information System (INIS)

Li Tianshu

2013-01-01

Based on years of knowledge in nuclear safety supervision and experience of investigating and dealing with violation events in repair welding of DFHM, this paper analyzes major faults in manufacturing and maintaining activities of nuclear safety equipment in relation to human and organizational factors. It could be deducted that human and organizational factors has definitely become key features in the development of nuclear energy and technology. Some feasible measures to reinforce supervision on nuclear safety equipment activities have also been proposed. (author)

Designing adverse event forms for real-world reporting: participatory research in Uganda.

Directory of Open Access Journals (Sweden)

Emma C Davies

Full Text Available The wide-scale roll-out of artemisinin combination therapies (ACTs for the treatment of malaria should be accompanied by continued surveillance of their safety. Post-marketing pharmacovigilance (PV relies on adverse event (AE reporting by clinicians, but as a large proportion of treatments are provided by non-clinicians in low-resource settings, the effectiveness of such PV systems is limited. To facilitate reporting, AE forms should be easily completed; however, most are challenging for lower-level health workers and non-clinicians to complete. Through participatory research, we sought to develop user-friendly AE report forms to capture information on events associated with ACTs.Following situation analysis, we undertook workshops with community medicine distributors and health workers in Jinja, Uganda, to develop a reporting form based on experiences and needs of users, and communication and visual perception principles. Participants gave feedback for revisions of subsequent versions. We then conducted 8 pretesting sessions with 77 potential end users to test and refine passive and active versions of the form.The development process resulted in a form that included a pictorial storyboard to communicate the rationale for the information needed and facilitate rapport between the reporter and the respondent, and a diary format to record the drug administration and event details in chronological relation to each other. Successive rounds of pretesting used qualitative and quantitative feedback to refine the form, with the final round showing over 80% of the form completed correctly by potential end users.We developed novel AE report forms that can be used by non-clinicians to capture pharmacovigilance data for anti-malarial drugs. The participatory approach was effective for developing forms that are intuitive for reporters, and motivating for respondents. The forms, or their key components, could be adapted for use in other low-literacy settings

Designing adverse event forms for real-world reporting: participatory research in Uganda.

Science.gov (United States)

Davies, Emma C; Chandler, Clare I R; Innocent, Simeon H S; Kalumuna, Charles; Terlouw, Dianne J; Lalloo, David G; Staedke, Sarah G; Haaland, Ane

2012-01-01

The wide-scale roll-out of artemisinin combination therapies (ACTs) for the treatment of malaria should be accompanied by continued surveillance of their safety. Post-marketing pharmacovigilance (PV) relies on adverse event (AE) reporting by clinicians, but as a large proportion of treatments are provided by non-clinicians in low-resource settings, the effectiveness of such PV systems is limited. To facilitate reporting, AE forms should be easily completed; however, most are challenging for lower-level health workers and non-clinicians to complete. Through participatory research, we sought to develop user-friendly AE report forms to capture information on events associated with ACTs.Following situation analysis, we undertook workshops with community medicine distributors and health workers in Jinja, Uganda, to develop a reporting form based on experiences and needs of users, and communication and visual perception principles. Participants gave feedback for revisions of subsequent versions. We then conducted 8 pretesting sessions with 77 potential end users to test and refine passive and active versions of the form.The development process resulted in a form that included a pictorial storyboard to communicate the rationale for the information needed and facilitate rapport between the reporter and the respondent, and a diary format to record the drug administration and event details in chronological relation to each other. Successive rounds of pretesting used qualitative and quantitative feedback to refine the form, with the final round showing over 80% of the form completed correctly by potential end users.We developed novel AE report forms that can be used by non-clinicians to capture pharmacovigilance data for anti-malarial drugs. The participatory approach was effective for developing forms that are intuitive for reporters, and motivating for respondents. The forms, or their key components, could be adapted for use in other low-literacy settings to improve quality

Contrasting safety assessments of a runway incursion scenario: Event sequence analysis versus multi-agent dynamic risk modelling

International Nuclear Information System (INIS)

Stroeve, Sybert H.; Blom, Henk A.P.; Bakker, G.J.

2013-01-01

In the safety literature it has been argued, that in a complex socio-technical system safety cannot be well analysed by event sequence based approaches, but requires to capture the complex interactions and performance variability of the socio-technical system. In order to evaluate the quantitative and practical consequences of these arguments, this study compares two approaches to assess accident risk of an example safety critical sociotechnical system. It contrasts an event sequence based assessment with a multi-agent dynamic risk model (MA-DRM) based assessment, both of which are performed for a particular runway incursion scenario. The event sequence analysis uses the well-known event tree modelling formalism and the MA-DRM based approach combines agent based modelling, hybrid Petri nets and rare event Monte Carlo simulation. The comparison addresses qualitative and quantitative differences in the methods, attained risk levels, and in the prime factors influencing the safety of the operation. The assessments show considerable differences in the accident risk implications of the performance of human operators and technical systems in the runway incursion scenario. In contrast with the event sequence based results, the MA-DRM based results show that the accident risk is not manifest from the performance of and relations between individual human operators and technical systems. Instead, the safety risk emerges from the totality of the performance and interactions in the agent based model of the safety critical operation considered, which coincides very well with the argumentation in the safety literature.

[Current movements of four serious adverse events induced by medicinal drugs based on spontaneous reports in Japan].

Science.gov (United States)

Sudo, Chie; Azuma, Yu-ichiro; Maekawa, Keiko; Kaniwa, Nahoko; Sai, Kimie; Saito, Yoshiro

2011-01-01

Spontaneous reports on suspected serious adverse events caused by medicines from manufacturing/distributing pharmaceutical companies or medical institutions/pharmacies are regulated by the Pharmaceutical Affairs Law of Japan, and this system is important for post-marketing safety features. Although causal relationship between the medicine and the adverse event is not evaluated, and one incidence may be redundantly reported, this information would be useful to roughly grasp the current movements of drug-related serious adverse events, We searched open-source data of the spontaneous reports publicized by Pharmaceutical and Medical Devices Agency for 4 serious adverse events (interstitial lung disease, rhabdomyolysis, anaphylaxis, and Stevens-Johnson syndrome/toxic epidermal necrolysis) from 2004 to 2010 fiscal year (for 2010, from April 1 st to January 31th). Major drug-classes suspected to the adverse events were antineoplastics for interstitial lung disease, hyperlipidemia agents and psychotropics for rhabdomyolysis, antibiotics/chemotherapeutics, antineoplastics and intracorporeal diagnostic agents for anaphylaxis (anaphylactic shock, anaphylactic reactions, anaphylactoid shock and anaphylactoid reactions), and antibiotics/chemotherapeutics, antipyretics and analgesics, anti-inflammatory agents/common cold drugs, and antiepileptics for Stevens-Johnson syndrome/toxic epidermal necrolysis. These results would help understanding of current situations of the 4 drug-related serious adverse events in Japan.

Nuclear power and nuclear safety 2012

International Nuclear Information System (INIS)

Lauritzen, B.; Nonboel, E.; Israelson, C.; Kampmann, D.; Nystrup, P.E.; Thomsen, J.

2013-11-01

The report is the tenth report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is prepared in collaboration between DTU Nutech and the Danish Emergency Management Agency. The report for 2012 covers the following topics: status of nuclear power production, regional trends, reactor development, safety related events, international relations and conflicts, and the results of the EU stress test. (LN)

Safety analysis for research reactors

International Nuclear Information System (INIS)

2008-01-01

The aim of safety analysis for research reactors is to establish and confirm the design basis for items important to safety using appropriate analytical tools. The design, manufacture, construction and commissioning should be integrated with the safety analysis to ensure that the design intent has been incorporated into the as-built reactor. Safety analysis assesses the performance of the reactor against a broad range of operating conditions, postulated initiating events and other circumstances, in order to obtain a complete understanding of how the reactor is expected to perform in these situations. Safety analysis demonstrates that the reactor can be kept within the safety operating regimes established by the designer and approved by the regulatory body. This analysis can also be used as appropriate in the development of operating procedures, periodic testing and inspection programmes, proposals for modifications and experiments and emergency planning. The IAEA Safety Requirements publication on the Safety of Research Reactors states that the scope of safety analysis is required to include analysis of event sequences and evaluation of the consequences of the postulated initiating events and comparison of the results of the analysis with radiological acceptance criteria and design limits. This Safety Report elaborates on the requirements established in IAEA Safety Standards Series No. NS-R-4 on the Safety of Research Reactors, and the guidance given in IAEA Safety Series No. 35-G1, Safety Assessment of Research Reactors and Preparation of the Safety Analysis Report, providing detailed discussion and examples of related topics. Guidance is given in this report for carrying out safety analyses of research reactors, based on current international good practices. The report covers all the various steps required for a safety analysis; that is, selection of initiating events and acceptance criteria, rules and conventions, types of safety analysis, selection of

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.

Science.gov (United States)

Schwappach, David L B; Frank, Olga; Buschmann, Ute; Babst, Reto

2013-04-01

Rationale, aims and objectives  The study aims to investigate the effects of a patient safety advisory on patients' risk perceptions, perceived behavioural control, performance of safety behaviours and experience of adverse incidents. Method  Quasi-experimental intervention study with non-equivalent group comparison was used. Patients admitted to the surgical department of a Swiss large non-university hospital were included. Patients in the intervention group received a safety advisory at their first clinical encounter. Outcomes were assessed using a questionnaire at discharge. Odds ratios for control versus intervention group were calculated. Regression analysis was used to model the effects of the intervention and safety behaviours on the experience of safety incidents. Results  Two hundred eighteen patients in the control and 202 in the intervention group completed the survey (75 and 77% response rates, respectively). Patients in the intervention group were less likely to feel poorly informed about medical errors (OR = 0.55, P = 0.043). There were 73.1% in the intervention and 84.3% in the control group who underestimated the risk for infection (OR = 0.51, CI 0.31-0.84, P = 0.009). Perceived behavioural control was lower in the control group (meanCon  = 3.2, meanInt  = 3.5, P = 0.010). Performance of safety-related behaviours was unaffected by the intervention. Patients in the intervention group were less likely to experience any safety-related incident or unsafe situation (OR for intervention group = 0.57, CI 0.38-0.87, P = 0.009). There were no differences in concerns for errors during hospitalization. There were 96% of patients (intervention) who would recommend other patients to read the advisory. Conclusions  The results suggest that the safety advisory decreases experiences of adverse events and unsafe situations. It renders awareness and perceived behavioural control without increasing concerns for safety and

Application of the Integrated Safety Assessment methodology to safety margins. Dynamic Event Trees, Damage Domains and Risk Assessment

International Nuclear Information System (INIS)

Ibánez, L.; Hortal, J.; Queral, C.; Gómez-Magán, J.; Sánchez-Perea, M.; Fernández, I.; Meléndez, E.; Expósito, A.; Izquierdo, J.M.; Gil, J.; Marrao, H.; Villalba-Jabonero, E.

2016-01-01

The Integrated Safety Assessment (ISA) methodology, developed by the Consejo de Seguridad Nuclear, has been applied to an analysis of Zion NPP for sequences with Loss of the Component Cooling Water System (CCWS). The ISA methodology proposal starts from the unfolding of the Dynamic Event Tree (DET). Results from this first step allow assessing the sequence delineation of standard Probabilistic Safety Analysis results. For some sequences of interest of the outlined DET, ISA then identifies the Damage Domain (DD). This is the region of uncertain times and/or parameters where a safety limit is exceeded, which indicates the occurrence of certain damage situation. This paper illustrates application of this concept obtained simulating sequences with MAAP and with TRACE. From information of simulation results of sequence transients belonging to the DD and the time-density probability distributions of the manual actions and of occurrence of stochastic phenomena, ISA integrates the dynamic reliability equations proposed to obtain the sequence contribution to the global Damage Exceedance Frequency (DEF). Reported results show a slight increase in the DEF for sequences investigated following a power uprate from 100% to 110%. This demonstrates the potential use of the method to help in the assessment of design modifications. - Highlights: • This paper illustrates an application of the ISA methodology to safety margins. • Dynamic Event Trees are useful tool for verifying the standard PSA Event Trees. • The ISA methodology takes into account the uncertainties in human action times. • The ISA methodology shows the Damage Exceedance Frequency increase in power uprates.

Nuclear fuel cycle facilities, laboratories, irradiators, particle accelerators, under-decommissioning reactors and radioactive waste management facilities safety. Lessons learned from events notified between 2005 and 2008

International Nuclear Information System (INIS)

2001-01-01

Maintaining high levels of safety in nuclear facilities requires constant vigilance by everyone involved, especially by plant operators who are first and foremost responsible for safety in their facilities. Safety can never be taken for granted; constant efforts must be made to improve it, by taking new knowledge and available operating feedback into account. In this respect, a substantial part of operating feedback is made up of lessons learned from analysing events, incidents or accidents occurring in France or in similar facilities abroad. To encourage the diffusion of operating feedback, IRSN has produced a report concerning events notified to the Nuclear Safety Authority (ASN) by operators of LUDD facilities between 2005 and 2008. The main objective is to make general lessons for safety in this type of facility available based on a cross-disciplinary analysis of notified events and noted evolution trends. IRSN has had tools for managing information concerning events occurring in France and abroad for many years. These tools are used to analyse the events in order to take into account the relevant lessons learned in the safety assessments performed on behalf of ASN and also to define study and research programmes to maintain its expertise and expand its knowledge. The report has 4 sections: - the first section (chapters 2 to 4) presents the LUDD facilities so that the facilities themselves, their diversity and the main associated risks can be better understood. It also includes a brief reminder of plant operator obligations in notifying events and describes the database used by the Institute to manage the data relating to the notified events; - the second section (chapter 5) summarises the main changes noted in the events notified to ASN during 2005 to 2008 and provides an overall assessment of the consequences of these events for the environment, the population and the workers; - the third section (chapter 6) describes significant events occurring in France

Implementation of a patient safety program at a tertiary health system: A longitudinal analysis of interventions and serious safety events.

Science.gov (United States)

Cropper, Douglas P; Harb, Nidal H; Said, Patricia A; Lemke, Jon H; Shammas, Nicolas W

2018-04-01

We hypothesize that implementation of a safety program based on high reliability organization principles will reduce serious safety events (SSE). The safety program focused on 7 essential elements: (a) safety rounding, (b) safety oversight teams, (c) safety huddles, (d) safety coaches, (e) good catches/safety heroes, (f) safety education, and (g) red rule. An educational curriculum was implemented focusing on changing high-risk behaviors and implementing critical safety policies. All unusual occurrences were captured in the Midas system and investigated by risk specialists, the safety officer, and the chief medical officer. A multidepartmental committee evaluated these events, and a root cause analysis (RCA) was performed. Events were tabulated and serious safety event (SSE) recorded and plotted over time. Safety success stories (SSSs) were also evaluated over time. A steady drop in SSEs was seen over 9 years. Also a rise in SSSs was evident, reflecting on staff engagement in the program. The parallel change in SSEs, SSSs, and the implementation of various safety interventions highly suggest that the program was successful in achieving its goals. A safety program based on high-reliability organization principles and made a core value of the institution can have a significant positive impact on reducing SSEs. © 2018 American Society for Healthcare Risk Management of the American Hospital Association.

Risk and sensitivity analysis in relation to external events

International Nuclear Information System (INIS)

Alzbutas, R.; Urbonas, R.; Augutis, J.

2001-01-01

This paper presents risk and sensitivity analysis of external events impacts on the safe operation in general and in particular the Ignalina Nuclear Power Plant safety systems. Analysis is based on the deterministic and probabilistic assumptions and assessment of the external hazards. The real statistic data are used as well as initial external event simulation. The preliminary screening criteria are applied. The analysis of external event impact on the NPP safe operation, assessment of the event occurrence, sensitivity analysis, and recommendations for safety improvements are performed for investigated external hazards. Such events as aircraft crash, extreme rains and winds, forest fire and flying parts of the turbine are analysed. The models are developed and probabilities are calculated. As an example for sensitivity analysis the model of aircraft impact is presented. The sensitivity analysis takes into account the uncertainty features raised by external event and its model. Even in case when the external events analysis show rather limited danger, the sensitivity analysis can determine the highest influence causes. These possible variations in future can be significant for safety level and risk based decisions. Calculations show that external events cannot significantly influence the safety level of the Ignalina NPP operation, however the events occurrence and propagation can be sufficiently uncertain.(author)

Information report on the nuclear safety and radiation protection of the Aube storage Centre - 2012

International Nuclear Information System (INIS)

2013-07-01

This report first present the site of the Aube Storage Centre (CSA), its storage areas, its buildings and equipment, describes the water treatment process, proposes some exploitation data for 2012 (deliveries, storage, compacting), and indicates highlights and works performed in 2012. The next part reviews measures related to nuclear safety: recall of safety principles and objectives, technical arrangements to meet safety objectives, inspections by the ASN, quality audits. The third part reviews measures related to safety and radiation protection: principles for radiation protection, staff dosimetry practices and results, personnel safety, works performed in 2012. The fourth part addresses incidents and accidents (none occurred in 2012) and other minor events classified according to the INES scale. The fifth part addresses the control of the environment and the releases by the centre: measurement locations, measurement results (in the atmosphere, in rivers, in underground waters, radiological control, control of ecosystems, assessment of the radiological impact), physical-chemical control of a local river, actions undertaken for the protection of the environment, highlights for 2012. The next chapter addresses the management of the various wastes produced by the Centre (radioactive wastes, conventional wastes) and the last part reports actions regarding information and transparency. Recommendations of the CHSCT are reported

Westinghouse Small Modular Reactor passive safety system response to postulated events

International Nuclear Information System (INIS)

Smith, M. C.; Wright, R. F.

2012-01-01

The Westinghouse Small Modular Reactor (SMR) is an 800 MWt (>225 MWe) integral pressurized water reactor. This paper is part of a series of four describing the design and safety features of the Westinghouse SMR. This paper focuses in particular upon the passive safety features and the safety system response of the Westinghouse SMR. The Westinghouse SMR design incorporates many features to minimize the effects of, and in some cases eliminates the possibility of postulated accidents. The small size of the reactor and the low power density limits the potential consequences of an accident relative to a large plant. The integral design eliminates large loop piping, which significantly reduces the flow area of postulated loss of coolant accidents (LOCAs). The Westinghouse SMR containment is a high-pressure, compact design that normally operates at a partial vacuum. This facilitates heat removal from the containment during LOCA events. The containment is submerged in water which also aides the heat removal and provides an additional radionuclide filter. The Westinghouse SMR safety system design is passive, is based largely on the passive safety systems used in the AP1000 R reactor, and provides mitigation of all design basis accidents without the need for AC electrical power for a period of seven days. Frequent faults, such as reactivity insertion events and loss of power events, are protected by first shutting down the nuclear reaction by inserting control rods, then providing cold, borated water through a passive, buoyancy-driven flow. Decay heat removal is provided using a layered approach that includes the passive removal of heat by the steam drum and independent passive heat removal system that transfers heat from the primary system to the environment. Less frequent faults such as loss of coolant accidents are mitigated by passive injection of a large quantity of water that is readily available inside containment. An automatic depressurization system is used to

SYSTEMS SAFETY ANALYSIS FOR FIRE EVENTS ASSOCIATED WITH THE ECRB CROSS DRIFT

International Nuclear Information System (INIS)

R. J. Garrett

2001-01-01

The purpose of this analysis is to systematically identify and evaluate fire hazards related to the Yucca Mountain Site Characterization Project (YMP) Enhanced Characterization of the Repository Block (ECRB) East-West Cross Drift (commonly referred to as the ECRB Cross-Drift). This analysis builds upon prior Exploratory Studies Facility (ESF) System Safety Analyses and incorporates Topopah Springs (TS) Main Drift fire scenarios and ECRB Cross-Drift fire scenarios. Accident scenarios involving the fires in the Main Drift and the ECRB Cross-Drift were previously evaluated in ''Topopah Springs Main Drift System Safety Analysis'' (CRWMS M and O 1995) and the ''Yucca Mountain Site Characterization Project East-West Drift System Safety Analysis'' (CRWMS M and O 1998). In addition to listing required mitigation/control features, this analysis identifies the potential need for procedures and training as part of defense-in-depth mitigation/control features. The inclusion of this information in the System Safety Analysis (SSA) is intended to assist the organization(s) (e.g., Construction, Environmental Safety and Health, Design) responsible for these aspects of the ECRB Cross-Drift in developing mitigation/control features for fire events, including Emergency Refuge Station(s). This SSA was prepared, in part, in response to Condition/Issue Identification and Reporting/Resolution System (CIRS) item 1966. The SSA is an integral part of the systems engineering process, whereby safety is considered during planning, design, testing, and construction. A largely qualitative approach is used which incorporates operating experiences and recommendations from vendors, the constructor and the operating contractor. The risk assessment in this analysis characterizes the scenarios associated with fires in terms of relative risk and includes recommendations for mitigating all identified hazards. The priority for recommending and implementing mitigation control features is: (1) Incorporate

Safety-Evaluation Report related to the D2/D3 steam-generator design modification

International Nuclear Information System (INIS)

1983-03-01

This Safety Evaluation Report (SER) related to the D2/D3 steam generator design modification has been prepared by the Office of Nuclear Reactor Regulation of the US Nuclear Regulatory Commission. The purpose of this SER is to issue the staff's evaluation of the acceptability of the design modification for both installation and full-power operation in the D2/D3 steam generators based on the Design Review Panel Report of January 1983

Report on transparency and nuclear safety 2015 - Fontenay-aux-Roses CEA centre

International Nuclear Information System (INIS)

2016-06-01

This document proposes, first, a presentation of the Fontenay-aux-Roses CEA centre, of its activities and installations. Then it gives a rather detailed overview of measures related to safety and to radiation protection within these activities and installations. Next, it reports significant events related to safety and to radiation protection which occurred in 2015 and which have been declared to the French nuclear safety authority (ASN). It discusses the results of release measurements (liquid and gaseous effluents, radiological assessment, and chemical assessment for various installations) and the control of the chemical and radiological impact of these gaseous and liquid effluents on the environment. Finally, it addresses the issue of radioactive wastes which are stored in the different nuclear base installations of the Centre. It indicates the different measures aimed at limiting the volume of these warehoused wastes and addresses their impact on health and environment. Nature and quantities of warehoused wastes are specified. Remarks and recommendations of the Health, Safety and Working Conditions Committee (CHSCT) are given

Interim safety evaluation report related to operation of Enrico Fermi Atomic Power Plant, Unit 2, Detroit Edison Company

International Nuclear Information System (INIS)

1977-09-01

This interim report summarizes the scope and results of the radiological safety review performed to date by the NRC staff with respect to the operating license phase for the Enrico Fermi Atomic Power Plant, Unit 2. The major effort was the review of the facility design and proposed operating procedures described in applicant's Final Safety Analysis Report. In the course of the review, several meetings were held with representatives of the applicant to discuss plant design, construction and proposed operation. Additional information was requested, which the applicant provided through Amendment 7 to the Final Safety Analysis Report. A chronology of the principal actions relating to the review of the application is attached as Appendix A to the report. The Final Safety Analysis Report and amendments thereto are available for public inspection at the Nuclear Regulatory Commission Public Document Room, 1717 H Street, N. W., Washington, D.C. and at Monroe County Library System, 3700 South Custer Road, Monroe, Michigan 48161

Social media for arthritis-related comparative effectiveness and safety research and the impact of direct-to-consumer advertising.

Science.gov (United States)

Curtis, Jeffrey R; Chen, Lang; Higginbotham, Phillip; Nowell, W Benjamin; Gal-Levy, Ronit; Willig, James; Safford, Monika; Coe, Joseph; O'Hara, Kaitlin; Sa'adon, Roee

2017-03-07

Social media may complement traditional data sources to answer comparative effectiveness/safety questions after medication licensure. The Treato platform was used to analyze all publicly available social media data including Facebook, blogs, and discussion boards for posts mentioning inflammatory arthritis (e.g. rheumatoid, psoriatic). Safety events were self-reported by patients and mapped to medical ontologies, resolving synonyms. Disease and symptom-related treatment indications were manually redacted. The units of analysis were unique terms in posts. Pre-specified conditions (e.g. herpes zoster (HZ)) were selected based upon safety signals from clinical trials and reported as pairwise odds ratios (ORs); drugs were compared with Fisher's exact test. Empirically identified events were analyzed using disproportionality analysis and reported as relative reporting ratios (RRRs). The accuracy of a natural language processing (NLP) classifier to identify cases of shingles associated with arthritis medications was assessed. As of October 2015, there were 785,656 arthritis-related posts. Posts were predominantly US posts (75%) from patient authors (87%) under 40 years of age (61%). For HZ posts (n = 1815), ORs were significantly increased with tofacitinib versus other rheumatoid arthritis therapies. ORs for mentions of perforated bowel (n = 13) were higher with tocilizumab versus other therapies. RRRs associated with tofacitinib were highest in conditions related to baldness and hair regrowth, infections and cancer. The NLP classifier had a positive predictive value of 91% to identify HZ. There was a threefold increase in posts following television direct-to-consumer advertisement (p = 0.04); posts expressing medication safety concerns were significantly more frequent than favorable posts. Social media is a challenging yet promising data source that may complement traditional approaches for comparative effectiveness research for new medications.

ASN report of the status of nuclear safety and radiation protection in France in 2012

International Nuclear Information System (INIS)

Chevet, Pierre-Franck; Delmestre, Alain; Bardet, Marie-Christine; Covard, Fabienne; Landrin, Sophie

2013-01-01

After a presentation of the French Nuclear Safety Authority (ASN), its missions, some key figures illustrating its activities and its organisation, this report proposes an overview of marking events and of actions undertaken by the ASN after the Fukushima accident. Then, the report proposes a detailed and commented overview of actions undertaken by the ASN in different fields and domains: nuclear activities, principles and actors of nuclear safety and radiation protection control, regulation, control of nuclear activities and of exposures to ionizing radiations, radiological and post-accidental emergency situations, public information and transparency, international relationships, regional overview of nuclear safety and radiation protection. The last part addresses activities controlled by the ASN: medical use of ionizing radiations, industrial, research and veterinary uses and source safety, transport of radioactive materials, electronuclear plants, installations related to nuclear fuel cycle, nuclear research and other nuclear installations, safety of dismantling of base nuclear installations, radioactive wastes and polluted sites

Nuclear power and nuclear safety 2006

International Nuclear Information System (INIS)

Lauritzen, B.; Oelgaard, P.L.; Kampmann, D.; Majborn, B.; Nonboel, E.; Nystrup, P.E.

2007-04-01

The report is the fourth report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe National Laboratory and the Danish Emergency Management Agency. The report for 2006 covers the following topics: status of nuclear power production, regional trends, reactor development and development of emergency management systems, safety related events of nuclear power, and international relations and conflicts. (LN)

Nuclear power and nuclear safety 2004

International Nuclear Information System (INIS)

2005-03-01

The report is the second report in a new series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe National Laboratory and the Danish Emergency Management Agency. The report for 2004 covers the following topics: status of nuclear power production, regional trends, reactor development and development of emergency management systems, safety related events of nuclear power and international relations and conflicts. (ln)

Nuclear power and nuclear safety 2005

International Nuclear Information System (INIS)

Lauritzen, B.; Oelgaard, P.L.; Kampman, D.; Majborn, B.; Nonboel, E.; Nystrup, P.E.

2006-03-01

The report is the third report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe National Laboratory and the Danish Emergency Management Agency. The report for 2005 covers the following topics: status of nuclear power production, regional trends, reactor development and development of emergency management systems, safety related events of nuclear power and international relations and conflicts. (ln)

Evaluation of Generic Issue 57: Effects of fire protection system actuation on safety-related equipment

International Nuclear Information System (INIS)

Lambright, J.; Bohn, M.; Lynch, J.; Ross, S.; Brosseau, D.

1992-12-01

Nuclear power plants have experienced actuations of fire protection systems (FPSs) under conditions for which these systems were not intended to actuate and also have experienced advertent actuations with the presence of a fire. These actuations have often damaged safety-related equipment. A review of the impact of past occurrences of both types of such events and their impact on plant safety systems, an analysis of the risk impacts of such events on nuclear power plant safety, and a cost-benefit analysis of potential corrective measures have been performed. Thirteen different scenarios leading to actuation of fire protection systems due to a variety of causes were identified. These scenarios ranged from inadvertent actuation caused by human error to hardware failure, and include seismic root causes and seismic/fire interactions. A quantification of these thirteen root causes, where applicable, was performed on generically applicable scenarios. This document, Volume 4, contains appendices E and F of this report

Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.

Science.gov (United States)

Smith, Scott Alan; Yount, Naomi; Sorra, Joann

2017-02-16

A number of private and public companies calculate and publish proprietary hospital patient safety scores based on publicly available quality measures initially reported by the U.S. federal government. This study examines whether patient safety culture perceptions of U.S. hospital staff in a large national survey are related to publicly reported patient safety ratings of hospitals. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (Hospital SOPS) assesses provider and staff perceptions of hospital patient safety culture. Consumer Reports (CR), a U.S. based non-profit organization, calculates and shares with its subscribers a Hospital Safety Score calculated annually from patient experience survey data and outcomes data gathered from federal databases. Linking data collected during similar time periods, we analyzed relationships between staff perceptions of patient safety culture composites and the CR Hospital Safety Score and its five components using multiple multivariate linear regressions. We analyzed data from 164 hospitals, with patient safety culture survey responses from 140,316 providers and staff, with an average of 856 completed surveys per hospital and an average response rate per hospital of 56%. Higher overall Hospital SOPS composite average scores were significantly associated with higher overall CR Hospital Safety Scores (β = 0.24, p Consumer Reports Hospital Safety Score, which is a composite of patient experience and outcomes data from federal databases. As hospital managers allocate resources to improve patient safety culture within their organizations, their efforts may also indirectly improve consumer-focused, publicly reported hospital rating scores like the Consumer Reports Hospital Safety Score.

2011 NASA Range Safety Annual Report

Science.gov (United States)

Dumont, Alan G.

2012-01-01

Welcome to the 2011 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides a NASA Range Safety overview for current and potential range users. As is typical with odd year editions, this is an abbreviated Range Safety Annual Report providing updates and links to full articles from the previous year's report. It also provides more complete articles covering new subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed and updated in the 2011 NASA Range Safety Annual Report include a program overview and 2011 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again the web-based format was used to present the annual report. We continually receive positive feedback on the web-based edition and hope you enjoy this year's product as well. As is the case each year, contributors to this report are too numerous to mention, but we thank individuals from the NASA Centers, the Department of Defense, and civilian organizations for their contributions. In conclusion, it has been a busy and productive year. I'd like to extend a personal Thank You to everyone who contributed to make this year a successful one, and I look forward to working with all of you in the upcoming year.

Report on transparency and nuclear safety 2014 - Cadarache CEA centre

International Nuclear Information System (INIS)

2015-07-01

This document proposes, first, a presentation of the Cadarache CEA centre, of its activities and installations, gives a rather detailed overview of measures related to safety and to radiation protection within these activities and installations. Then it reports significant events related to safety and to radiation protection which occurred in 2014 and have been declared to the ASN. Next, it discusses the results of release measurements (liquid and gaseous effluents, radiological assessment, and chemical assessment for various installations) and the control of the chemical and radiological impact of these gaseous and liquid effluents on the environment. Finally, it addresses the issue of radioactive wastes which are stored in the different nuclear base installations of the Centre, indicates the different measures aimed at limiting the volume of these warehoused wastes and addresses their impact on health and on the environment. Nature and quantities of warehoused wastes are specified. Remarks and recommendations of the CHSCT are given

Staff report on the environmental qualification of safety-related electrical equipment

International Nuclear Information System (INIS)

1977-12-01

The current NRC safety review process for nuclear power plants includes criteria related to the qualification of certain electrical equipment. These criteria require that electrical equipment important to safety must be qualified to function in the environment that might result from various accident conditions. Although such criteria have been applied since the early days of commercial nuclear power, the details of these criteria have been changed over the years. The evolution of environmental qualification of safety-related electrical equipment is described in Appendix A

report transparency and nuclear safety 2007- CISBIO

International Nuclear Information System (INIS)

2007-01-01

This report presents the activities of CISBIO, nuclear base installation, for the year 2007. CISBIO realizes at Saclay most of the radiopharmaceuticals and drugs distributed in France for the nuclear medicine. The actions concerning the safety, the radiation protection, the significant events, the release control and the environmental impacts and the wastes stored on the center are discussed. (A.L.B.)

Categorization of safety related motor operated valve safety significance for Ulchin Unit 3

International Nuclear Information System (INIS)

Kang, D. I.; Kim, K. Y.

2002-03-01

We performed a categorization of safety related Motor Operated Valve (MOV) safety significance for Ulchin Unit 3. The safety evaluation of MOV of domestic nuclear power plants affects the generic data used for the quantification of MOV common cause failure ( CCF) events in Ulchin Units 3 PSA. Therefore, in this study, we re-estimated the MGL(Multiple Greek Letter) parameter used for the evaluation of MOV CCF probabilities in Ulchin Units 3 Probabilistic Safety Assessment (PSA) and performed a classification of the MOV safety significance. The re-estimation results of the MGL parameter show that its value is decreased by 30% compared with the current value in Ulchin Unit 3 PSA. The categorization results of MOV safety significance using the changed value of MGL parameter shows that the number of HSSCs(High Safety Significant Components) is decreased by 54.5% compared with those using the current value of it in Ulchin Units 3 PSA

Retrospective Study of Reported Adverse Events Due to Complementary Health Products in Singapore From 2010 to 2016

Directory of Open Access Journals (Sweden)

Yimin Xu

2018-06-01

Full Text Available The objective of this study is to collate and analyse adverse event reports associated with the use of complementary health products (CHP submitted to the Health Sciences Authority (HSA of Singapore for the period 2010–2016 to identify various trends and signals for pharmacovigilance purposes. A total of 147,215 adverse event reports suspected to be associated with pharmaceutical products and CHP were received by HSA between 2010 and 2016. Of these, 143,191 (97.3% were associated with chemical drugs, 1,807 (1.2% with vaccines, 1,324 (0.9% with biological drugs (biologics, and 893 (0.6% with CHP. The number of adverse event reports associated with Chinese Proprietary Medicine, other complementary medicine and health supplements are presented. Eight hundred and ninety three adverse event reports associated with CHP in the 7-year period have been successfully collated and analyzed. In agreement with other studies, adverse events related to the “skin and appendages disorders” were the most commonly reported. Most of the cases involved dermal allergies (e.g., rashes associated with the use of glucosamine products and most of the adulterated products were associated with the illegal addition of undeclared drugs for pain relief. Dexamethasone, chlorpheniramine, and piroxicam were the most common adulterants detected. Reporting suspected adverse events is strongly encouraged even if the causality is not confirmed because any signs of clustering will allow rapid regulatory actions to be taken. The findings from this study help to create greater awareness on the health risks, albeit low, when consuming CHP and dispelling the common misconception that “natural” means “safe.” In particular, healthcare professionals and the general public should be aware of potential adulteration of CHP. The analysis of spontaneously reported adverse events is an important surveillance system in monitoring the safety of CHP and helps in the understanding of the

Safety evaluation report related to the operation of Enrico Fermi Atomic Power Plant, Unit No. 2. Docket No. 50-341

International Nuclear Information System (INIS)

1983-01-01

Supplement No. 3 to the Safety Evaluation Report related to the operation of the Enrico Fermi Atomic Power Plant, Unit 2, provides the staff's evaluation of additional information submitted by the applicant regarding outstanding review issues identified in Supplement No. 2 to the Safety Evaluation Report, dated January 1982

Information report on nuclear safety and radiation protection of MELOX - Issue 2012

International Nuclear Information System (INIS)

2013-06-01

Published in compliance with the French code of the environment, this report first presents different aspects of the MELOX plant which produces MOX fuel: location and environment, history of basic nuclear installation or INB 151, presentation of the nuclear operator and of the industrial operator, assets of MOX fuel, MOX customers, regulatory framework of the MELOX plant, policy for sustainable development and continuous progress. It addresses the various measures regarding nuclear safety and radiation protection: general overview of nuclear safety in France, presentation of the Areva's nuclear safety Charter, measures adopted in MELOX, review for 2012 and perspectives for 2013. The next part addresses nuclear events: presentation of the INES scale and of the event declaration procedure, review of events declared in 2012 and regarding MELOX. The report gives an overview of activities and measures regarding protection and control of the environment: environmental management, consumption of natural resources, control of effluent releases, measurement of the impact on the environment, waste management, and perspectives for 2013. The last chapter reviews the actions undertaken in the field of transparency and information. Recommendations of the CHSCT are reported

Information report on nuclear safety and radiation protection of MELOX - Issue 2013

International Nuclear Information System (INIS)

2014-06-01

Published in compliance with the French code of the environment, this report first presents different aspects of the MELOX plant which produces MOX fuel: location and environment, history of basic nuclear installation or INB 151, presentation of the nuclear operator and of the industrial operator, assets of MOX fuel, MOX customers, regulatory framework of the MELOX plant, policy for sustainable development and continuous progress. It addresses the various measures regarding nuclear safety and radiation protection: general overview of nuclear safety in France, presentation of the Areva's nuclear safety Charter, measures adopted in MELOX, review for 2013 and perspectives for 2014. The next part addresses nuclear events: presentation of the INES scale and of the event declaration procedure, review of events declared in 2013 and regarding MELOX. The report gives an overview of activities and measures regarding protection and control of the environment: environmental management, consumption of natural resources, control of effluent releases, measurement of the impact on the environment, waste management, and perspectives for 2014. The last chapter reviews the actions undertaken in the field of transparency and information. Recommendations of the CHSCT are reported

Information report on nuclear safety and radiation protection of MELOX - Issue 2014

International Nuclear Information System (INIS)

2015-06-01

Published in compliance with the French code of the environment, this report first presents different aspects of the MELOX plant which produces MOX fuel: location and environment, history of basic nuclear installation or INB 151, presentation of the nuclear operator and of the industrial operator, assets of MOX fuel, MOX customers, regulatory framework of the MELOX plant, policy for sustainable development and continuous progress. It addresses the various measures regarding nuclear safety and radiation protection: general overview of nuclear safety in France, presentation of the Areva's nuclear safety Charter, measures adopted in MELOX, review for 2014 and perspectives for 2015. The next part addresses nuclear events: presentation of the INES scale and of the event declaration procedure, review of events declared in 2014 and regarding MELOX. The report gives an overview of activities and measures regarding protection and control of the environment: environmental management, consumption of natural resources, control of effluent releases, measurement of the impact on the environment, waste management, and perspectives for 2015. The last chapter reviews the actions undertaken in the field of transparency and information. Recommendations of the CHSCT are reported

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

Sixth national report of Brazil for the nuclear safety convention

International Nuclear Information System (INIS)

2013-01-01

Brazil has presented periodically its National Report prepared by a group composed of representatives of the various Brazilian organizations with responsibilities related to nuclear safety. Due to the implications of the Fukushima nuclear accident in 2011, an Extraordinary National Report was presented in 2012. This Sixth National Report is an update of the Fifth National Report in relation to the Convention on Nuclear Safety articles and also an update of the Extraordinary Report with respect to the action taken related to lesson learned from the Fukushima accident. It includes relevant information for the period of 2010/2012. This document represents the national report prepared as a fulfillment of the brazilian obligations related to the Convention on Nuclear Safety. In chapter 2 some details are given about the existing nuclear installations. Chapter 3 provides details about the legislation and regulations, including the regulatory framework and the regulatory body. Chapter 4 covers general safety considerations as described in articles 10 to 16 of the Convention. Chapter 5 addresses to the safety of the installations during siting, design, construction and operation. Chapter 6 describes planned activities to further enhance nuclear safety. Chapter 7 presents the final remarks related to the degree of compliance with the Convention obligations

Sixth national report of Brazil for the nuclear safety convention

Energy Technology Data Exchange (ETDEWEB)

NONE

2013-07-01

Brazil has presented periodically its National Report prepared by a group composed of representatives of the various Brazilian organizations with responsibilities related to nuclear safety. Due to the implications of the Fukushima nuclear accident in 2011, an Extraordinary National Report was presented in 2012. This Sixth National Report is an update of the Fifth National Report in relation to the Convention on Nuclear Safety articles and also an update of the Extraordinary Report with respect to the action taken related to lesson learned from the Fukushima accident. It includes relevant information for the period of 2010/2012. This document represents the national report prepared as a fulfillment of the brazilian obligations related to the Convention on Nuclear Safety. In chapter 2 some details are given about the existing nuclear installations. Chapter 3 provides details about the legislation and regulations, including the regulatory framework and the regulatory body. Chapter 4 covers general safety considerations as described in articles 10 to 16 of the Convention. Chapter 5 addresses to the safety of the installations during siting, design, construction and operation. Chapter 6 describes planned activities to further enhance nuclear safety. Chapter 7 presents the final remarks related to the degree of compliance with the Convention obligations.

External human induced events in site evaluation for nuclear power plants. Safety guide

International Nuclear Information System (INIS)

2004-01-01

The purpose of the present Safety Guide is to provide recommendations and guidance for the examination of the region considered for site evaluation for a plant in order to identity hazardous phenomena associated with human induced events initiated by sources external to the plant. In some cases it also presents preliminary guidance for deriving values of relevant parameters for the design basis. This Safety Guide is also applicable for periodic site evaluation and site evaluation following a major human induced event, and for the design and operation of the site's environmental monitoring system. Site evaluation includes site characterization. Consideration of external events that could lead to a degradation of the safety features of the plant and cause a release of radioactive material from the plant and/or affect the dispersion of such material in the environment. And consideration of population issues and access issues significant to safety (such as the feasibility of evacuation, the population distribution and the location of resources). The process of site evaluation continues throughout the lifetime of the facility, from siting to design, construction, operation and decommissioning. The external human induced events considered in this Safety Guide are all of accidental origin. Considerations relating to the physical protection of the plant against wilful actions by third parties are outside its scope. However, the methods described herein may also have some application for the purposes of such physical protection. The present Safety Guide may also be used for events that may originate within the boundaries of the site, but from sources which are not directly involved in the operational states of the nuclear power plant units, such as fuel depots or areas for the storage of hazardous materials for the construction of other facilities at the same site. Special consideration should be given to the hazardous material handled during the construction, operation and

Time Based Workload Analysis Method for Safety-Related Operator Actions in Safety Analysis

Energy Technology Data Exchange (ETDEWEB)

Kim, Yun Goo; Oh, Eung Se [Korea Hydro and Nuclear Power Co., Daejeon (Korea, Republic of)

2016-05-15

During the design basis event, the safety system performs safety functions to mitigate the event. The most of safety system is actuated by automatic system however, there are operator manual actions that are needed for the plant safety. These operator actions are classified as important human actions in human factors engineering design. The human factors engineering analysis and evaluation is needed for these important human actions to assure that operator successfully perform their tasks for plant safety and operational goals. The work load analysis is one of the required analysis for the important human actions.

Time Based Workload Analysis Method for Safety-Related Operator Actions in Safety Analysis

International Nuclear Information System (INIS)

Kim, Yun Goo; Oh, Eung Se

2016-01-01

During the design basis event, the safety system performs safety functions to mitigate the event. The most of safety system is actuated by automatic system however, there are operator manual actions that are needed for the plant safety. These operator actions are classified as important human actions in human factors engineering design. The human factors engineering analysis and evaluation is needed for these important human actions to assure that operator successfully perform their tasks for plant safety and operational goals. The work load analysis is one of the required analysis for the important human actions.

Identification and assessment of organisational factors related to the safety of NPPs - State-of-the-Art Report

International Nuclear Information System (INIS)

Baumont, Genevieve; Bourrier, Mathilde; Frischknecht, Albert; Schoenfeld, Isabelle; Weber, Mike J.

1999-09-01

The initiation of this State-of-the-Art Report (SOAR) on Organisational Factors Identification and Assessment comes from operating experience associated with a number of major events world-wide which caused power plants to be shutdown for a significant period of time. Root cause assessments of these events identified weaknesses in organisational factors as contributing to these events. There is general recognition that organisational factors need to be evaluated for their contribution to plant safety performance and risk to prevent their recurrence in events. A special recommendation to create a SOAR was presented in the NEA report on Research Strategies for Human Performance [NEA/CSNI/R(97)24]. Based on this recommendation the Principle Working Group 1 (PWG1) requested, as a top priority, that the Expanded Task Force (ETF) on Human Factors develop a SOAR for the September 1998 meeting. The ETF members were aware that it was a challenging topic. The field of organisational behaviour is not yet fully developed for the nuclear organisation. There is a need to collect and analyse operational and event data from the nuclear environment to determine the safety and risk significance of organisational factors, to identify assessment methods for those factors, and to gain peer review of the results to ensure credibility and acceptability of these methods and possibly their measures. This SOAR reports on the results of the workshop on Organisational Factors Identification and Assessment held in Boettstein Castle, Switzerland, on 14-19 June 1998. Twenty-eight participants from twelve Member countries and Russia represented three different environments: nuclear utilities; regulatory bodies and inspectorates; and the research and academic community. The various approaches discussed in the SOAR reflect the perspective of these entities. The SOAR addresses the following topics: - identification of organisational factors; - identification of methods for the evaluation of

Evaluation of Adverse Events in Total Disc Replacement: A Meta-Analysis of FDA Summary of Safety and Effectiveness Data.

Science.gov (United States)

Anderson, Paul A; Nassr, Ahmad; Currier, Bradford L; Sebastian, Arjun S; Arnold, Paul M; Fehlings, Michael G; Mroz, Thomas E; Riew, K Daniel

2017-04-01

Systematic review and meta-analysis. The safety of new technology such as cervical total disc replacement (TDR) is of paramount importance and is best evaluated in randomized clinical trials (RCT). We compared complication risks of TDR to fusion using data from Investigational Device Exemptions. A systematic review of FDA Summary of Safety and Effectiveness reports of the 8 approved cervical TDRs was performed. These were all randomized controlled trials comparing anterior cervical discectomy and fusion (ACDF) to TDR. Important outcome variables were dysphagia, wound infection, neurologic injuries, heterotopic ossification, death, and secondary surgeries. A random effects model was selected a priori. Data on adverse events was abstracted and analyzed by calculating relative risk of ACDF to TDR by meta-analysis techniques. The study included 3027 patients with 1377 randomized to ACDF and 1652 to TDR. No statistical differences were present between the 2 groups in dysphagia/dysphonia, hardware related, heterotopic ossification, death, and overall neurologic adverse events and incidence of neurologic deterioration. The relative risk of wound-related problems ACDF to TDR was 0.76 (95% confidence interval [CI] = 0.59, 0.98) favoring ACDF, which was statistically significant, but these were minor and never required a second surgical procedure for deep wound infection. The relative risk of ACDF to TDR in surgical-related neurologic events and secondary surgeries was 1.62 (95% CI = 1.04, 2.53) and 1.79 (95% CI = 1.17, 2.74), both favoring TDR. Cervical TDR appears to be as safe as or safer than ACDF at 2-year follow-up.

Annual report on occupational safety 1989

International Nuclear Information System (INIS)

1990-01-01

This report presents detailed information on occupational safety relating to BNFL's employees for 1989 and data compared with the previous year. Routine monitoring, non-radiological safety and 'incidents' are discussed and 'statutory' whole-body exposures, nuclear incidents, lost-time accidents, and types of injury are tabulated. (author)

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)

Australian regulatory framework and reporting entities are hindering the lessons to be learned from adverse radiation events

International Nuclear Information System (INIS)

Denham, G.

2016-01-01

When adverse radiation events occur in the medical radiation science profession in Australia they are reported to the relevant state or territory authority. The details and cause of the incident are forwarded to the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) to be included in the Australian Radiation Incident Register. The aim of any error reporting system is to learn from previous errors and to prevent them occurring again. The information obtained from past errors is one of the most invaluable tools to prevent future adverse events. This article examines the current regulatory framework, reporting systems and radiation protection authorities in Australia and their effectiveness at improving patient safety. Several obstacles must be overcome if the systems and organisations responsible for radiation safety are to meet the expectations of both the community and the medical radiation science profession. - Highlights: • Adverse radiation events in Australia are reported to state and territory authorities. • Adverse radiation events are included in the Australian Radiation Incident Register State and territory radiation authorities have failed to implement changes agreed upon in 1999. • The Australian Radiation Incident Register requires reforms if it is to operate as an effective learning system.

Identification and assessment of organisational factors related to the safety of NPPs - State-of-the-Art Report

International Nuclear Information System (INIS)

Baumont, Genevieve; Bourrier, Mathilde; Frischknecht, Albert; Schoenfeld, Isabelle; Weber, Mike J.

1999-01-01

The initiation of this State-of-the-Art Report (SOAR) on Organisational Factors Identification and Assessment comes from operating experience associated with a number of major events world-wide which caused power plants to be shutdown for a significant period of time. Root cause assessments of these events identified weaknesses in organisational factors as contributing to these events. There is general recognition that organisational factors need to be evaluated for their contribution to plant safety performance and risk to prevent their recurrence in events. There is a need to collect and analyse operational and event data from the nuclear environment to determine the safety and risk significance of organisational factors, to identify assessment methods for those factors, and to gain peer review of the results to ensure credibility and acceptability of these methods and possibly their measures. The SOAR presents a representative view of developments in this field and addresses the following topics: - identification of organisational factors; - identification of methods for the evaluation of organisational factors; - identification of methods for the evaluation of whole organisations; - identification of gaps in knowledge and needed research to evaluate adequately the influence of organisation and management on safety and risk. The workshop participants identified 12 organisational factors as important to assess in determining organisational safety performance. They are: external influences; goals and strategies; management functions and overview; resource allocation; human resource management; training; co-ordination of work; organisational knowledge; proceduralization; organisational culture; organisational learning; and communication. Different cultural backgrounds of participants using their own terminology sometimes made it difficult to have a common definition for certain factors. Some factors could be defined by consensus; other factors such as

Evaluation of common mode failure of safety functions for limiting fault events

International Nuclear Information System (INIS)

Rezendes, J.P.; Hyde, A.W.

2004-01-01

The draft U.S. Nuclear Regulatory Commission (NRC) policy on digital protection system software requires all Advanced Light Water Reactors (ALWRs) to be evaluated assuming a hypothetical common mode failure (CMF) which incapacitates the normal automatic initiation of safety functions. The System 80 + ALWR has been evaluated for such hypothetical conditions. The results show that the diverse automatic and manual protective systems in System 80 + provide ample safety performance margins relative to core coolability, offsite radiological releases. Reactor Coolant System (RCS) pressurization and containment integrity. This deterministic evaluation served to quantify the significant inherent safety margins in the System 80 + Standard Plant design even in the event of this extremely low probability scenario of a common mode failure. (author)

Report on Fukushima Daiichi NPP precursor events

International Nuclear Information System (INIS)

2014-01-01

The main questions to be answered by this report were: The Fukushima Daiichi NPP accident, could it have been prevented? If there is a next severe accident, may it be prevented? To answer the first question, the report addressed several aspects. First, the report investigated whether precursors to the Fukushima Daiichi NPP accident existed in the operating experience; second, the reasons why these precursors did not evolve into a severe accident. Third, whether lessons learned from these precursor events were adequately considered by member countries; and finally, if the operating experience feedback system needs to be improved, based on the previous analysis. To address the second question which is much more challenging, the report considered precursor events identified through a search and analysis of the IRS database and also precursors events based on risk significance. Both methods can point out areas where further work may be needed, even if it depends heavily on design and site-specific factors. From the operating experience side, more efforts are needed to ensure timely and full implementation of lessons learnt from precursor events. Concerning risk considerations, a combined use of risk precursors and operating experience may drive to effective changes to plants to reduce risk. The report also contains a short description and evaluation of selected precursors that are related to the course of the Fukushima Daiichi NPP accident. The report addresses the question whether operating experience feedback can be effectively used to identify plant vulnerabilities and minimize potential for severe core damage accidents. Based on several of the precursor events national or international in-depth evaluations were started. The vulnerability of NPPs due to external and internal flooding has clearly been addressed. In addition to the IRS based investigation, the WGRISK was asked to identify important precursor events based on risk significance. These precursors have

Relation between water chemistry and operational safety

International Nuclear Information System (INIS)

Oliveira, M.F. de.

1991-01-01

This report describes the relation between chemistry/radiochemistry and operational safety, the technics bases for chemical and radiochemical parameters and an analysis of the Annual Report of Angra I Operation and OSRAT Mission report to 1989 in this area too. Furthermore it contains the transcription of the technical Specifications related to the chemistry and radiochemistry for Angra I. (author)

RB research reactor safety report; Izvestaj o sigurnsti istrazivackog reaktora RB

Energy Technology Data Exchange (ETDEWEB)

Sotic, O; Pesic, M; Vranic, S [Boris Kidric Institute of Nuclear Sciences Vinca, Beograd (Yugoslavia)

1979-04-15

This new version of the safety report is a revision of the safety report written in 1962 when the RB reactor started operation after reconstruction. The new safety report was needed because reactor systems and components have been improved and the administrative procedures were changed. the most important improvements and changes were concerned with the use of highly enriched fuel (80% enriched), construction of reactor converter outside the reactor vessel, improved control system by two measuring start-up channels, construction of system for heavy water leak detection, new inter phone connection between control room and other reactor rooms. This report includes description of reactor building with installations, rector vessel, reactor core, heavy water system, control system, safety system, dosimetry and alarm systems, experimental channels, neutron converter, reactor operation. Safety aspects contain analyses of accident reasons, method for preventing reactivity insertions, analyses of maximum hypothetical accidents for cores with natural uranium, 2% enriched and 80% enriched fuel elements. Influence of seismic events on the reactor safety and well as coupling between reactor and the converter are parts of this document.

A review of significant events analysed in general practice: implications for the quality and safety of patient care

Directory of Open Access Journals (Sweden)

Bradley Nick

2009-09-01

Full Text Available Abstract Background Significant event analysis (SEA is promoted as a team-based approach to enhancing patient safety through reflective learning. Evidence of SEA participation is required for appraisal and contractual purposes in UK general practice. A voluntary educational model in the west of Scotland enables general practitioners (GPs and doctors-in-training to submit SEA reports for feedback from trained peers. We reviewed reports to identify the range of safety issues analysed, learning needs raised and actions taken by GP teams. Method Content analysis of SEA reports submitted in an 18 month period between 2005 and 2007. Results 191 SEA reports were reviewed. 48 described patient harm (25.1%. A further 109 reports (57.1% outlined circumstances that had the potential to cause patient harm. Individual 'error' was cited as the most common reason for event occurrence (32.5%. Learning opportunities were identified in 182 reports (95.3% but were often non-specific professional issues not shared with the wider practice team. 154 SEA reports (80.1% described actions taken to improve practice systems or professional behaviour. However, non-medical staff were less likely to be involved in the changes resulting from event analyses describing patient harm (p Conclusion The study provides some evidence of the potential of SEA to improve healthcare quality and safety. If applied rigorously, GP teams and doctors in training can use the technique to investigate and learn from a wide variety of quality issues including those resulting in patient harm. This leads to reported change but it is unclear if such improvement is sustained.

Patients' identification and reporting of unsafe events at six hospitals in Japan.

Science.gov (United States)

Hasegawa, Tomonori; Fujita, Shigeru; Seto, Kanako; Kitazawa, Takefumi; Matsumoto, Kunichika

2011-11-01

Hospitals and other health care organizations have increasingly recognized the need to engage patients as participants in patient safety. A study was conducted to compare patients' and health care staff's identification and reporting of such events. A questionnaire was administered at six hospitals in Japan to outpatients and inpatients from November 2004 through February 2007. Patients were asked to respond to questions about experiences of possibly unsafe events. Patients experiencing such events were then asked about the events and whether they had reported their experience to health care staff. A specialist panel classified reported events as "uneasy-dissatisfying" or "unsafe." The response rates of outpatients and inpatients were 85.4% (1,506/1,764) and 54.3% (1,738/3,198), respectively. Among the respondents (> or = 20 years of age), 125 (8.7%) of the outpatients and 185 (10.9%) of the inpatients experienced uneasy-dissatisfying or unsafe events; 35 (2.4%) of the outpatients and 67 (4.0%) of the inpatients experienced unsafe events, the percent increasing with hospital stay. Only 38 (30.4%) of the outpatients and 62 (33.5%) of the inpatients reported the unsafe events to health care staff Only 17.1% of unsafe events reported by inpatients were identified by the in-house reporting systems of adverse events and near misses. For the uneasy-dissatisfying or unsafe events that patients did not think necessary to report, the patients often felt they were self-evident or easily identifiable by health care staff, had difficulty evaluating the event, did not expect their report to bring any improvement, or even felt that reporting it would create some disadvantage in their medical treatment. Patient reporting programs and in-house reporting systems, among other detection methods, should be regarded as complementary sources of information.

Enhancing nuclear safety. Annual report 2015. Financial report 2015

International Nuclear Information System (INIS)

Le Guludec, Dominique; Niel, Jean-Christophe; Mouton, Georges-Henri; Repussard, Jacques; Schuler, Matthieu; Marchal, Valerie; Albert, Marc-Gerard; Bigot, Marie-Pierre; Brisset, Yves; Bruna, Giovanni; Charron, Sylvie; Clavelle, Stephanie; Deschamps, Patrice; Delattre, Aleth; Demeillers, Didier; Laloi, Patrick; Lorthioir, Stephane; Monti, Pascale; Rollinger, Francois; Rouyer, Veronique; Tharaud, Christine; Jaunet, Camille; Pascal-Heuze, Charlotte

2016-01-01

After some introductory texts proposed by several IRSN head managers, and a brief presentation of some key data illustrating the activity, the annual report presents the main strategic orientations, notably in the field of knowledge management, and of information and communication. After some images illustrating the past year, activities are presented. They first deal with safety: safety of civil nuclear facilities, from decommissioning old reactors to designing those of the future, reactor ageing, severe accidents, fuel, criticality and neutronics, fire and containment, safety and radiation protection of defence-related facilities and activities, geological disposal of radioactive wastes. They secondly deal with security and non-proliferation (nuclear security, nuclear non-proliferation, chemical weapon ban), thirdly with radiation protection for human and environment health (environment monitoring, radionuclide transfer in the environment, radon and polluted sites, human exposure, radiation protection in the workplace, effects of chronic exposures, protection in health care), and fourthly with emergency and post-accident situations (emergency and post-accident preparedness and response). The next part of the activity report addresses issues related to efficiency: improved economic and financial management, property, computer security, quality and corporate social responsibility, human resources, organisation chart. The financial report proposes a management report, financial statements with an appendix to annual accounts, and an auditor's report

ASN report on nuclear safety and radioprotection status in France in 2010

International Nuclear Information System (INIS)

2011-01-01

After a general overview of the activity of the ASN (the French nuclear safety authority), of its missions and organisation, this activity report indicates the main events of 2010 concerning the actions performed by the ASN and the activities controlled by the ASN. These both aspects are then detailed. The actions performed by the ASN are dealing with nuclear activities (ionizing radiations and risks for health and for the environment), principles and actors of nuclear safety control, radioprotection and environment protection, regulation, control of nuclear activities and exposures to ionizing radiations, emergency situations, public information, international relationship, regional overview of nuclear safety and radioprotection. The activities controlled by the ASN are the medical uses of ionizing radiations, their non medical uses, the transport of radioactive materials, electronuclear plants, installations related to nuclear fuel cycle, nuclear research installations and other nuclear installations, the safety of nuclear installation dismantling, radioactive wastes and polluted sites

Prevalence of Topical Corticosteroids Related Adverse Drug Events and Associated Factors in Selected Community Pharmacies and Cosmetic Shops of Addis Ababa, Ethiopia

Directory of Open Access Journals (Sweden)

Mahlet Tsegaye

2018-03-01

Conclusion: Majority of the topical corticosteroids were obtained without prescription for the purpose of beautification rather than treatment. A higher proportion of cosmetic users reported to have experienced at least one adverse event. There needs to consider safety concerns related to topical corticosteroids use in the city.

Nuclear power and nuclear safety 2009; Kernekraft og nuklear sikkerhed 2009

Energy Technology Data Exchange (ETDEWEB)

Lauritzen, B.; OElgaard, P.L. (eds.); Nonboel, E. (Risoe DTU, Roskilde (Denmark)); Kampmann, D.; Nystrup, P.E.; Thorlaksen, B. (Beredskabsstyrelsen, Birkeroed (Denmark))

2010-05-15

The report is the seventh report in a series of annual reports on the international development of nuclear power production, with special emphasis on safety issues and nuclear emergency preparedness. The report is written in collaboration between Risoe DTU and the Danish Emergency Management Agency. The report for 2009 covers the following topics: status of nuclear power production, regional trends, reactor development, safety related events, international relations, conflicts and the European safety directive. (LN)

Pharmacovigilance and drug safety in Calabria (Italy): 2012 adverse events analysis.

Science.gov (United States)

Giofrè, Chiara; Scicchitano, Francesca; Palleria, Caterina; Mazzitello, Carmela; Ciriaco, Miriam; Gallelli, Luca; Paletta, Laura; Marrazzo, Giuseppina; Leporini, Christian; Ventrice, Pasquale; Carbone, Claudia; Saullo, Francesca; Rende, Pierandrea; Menniti, Michele; Mumoli, Laura; Chimirri, Serafina; Patanè, Marinella; Esposito, Stefania; Cilurzo, Felisa; Staltari, Orietta; Russo, Emilio; De Sarro, Giovambattista

2013-12-01

Pharmacovigilance (PV) is designed to monitor drugs continuously after their commercialization, assessing and improving their safety profile. The main objective is to increase the spontaneous reporting of adverse drug reactions (ADRs), in order to have a wide variety of information. The Italian Drug Agency (Agenzia Italiana del Farmaco [AIFA]) is financing several projects to increase reporting. In Calabria, a PV information center has been created in 2010. We obtained data using the database of the National Health Information System AIFA relatively to Italy and Calabria in the year 2012. Descriptive statistics were performed to analyze the ADRs. A total number of 461 ADRs have been reported in the year 2012 with an increase of 234% compared with 2011 (138 reports). Hospital doctors are the main source of this reporting (51.62%). Sorafenib (Nexavar(®)), the combination of amoxicillin/clavulanic acid and ketoprofen represent the drugs most frequently reported causing adverse reactions. Adverse events in female patients (61.83%) were more frequently reported, whereas the age groups "41-65" (39.07%) and "over 65" (27.9%) were the most affected. Calabria has had a positive increase in the number of ADRs reported, although it has not yet reached the gold standard set by World Health Organization (about 600 reports), the data have shown that PV culture is making inroads in this region and that PV projects stimulating and increasing PV knowledge are needed.

Safety on North Carolina and Kentucky trout farms.

Science.gov (United States)

Ogunsanya, T J; Durborow, R M; Myers, M L; Cole, H P; Thompson, S L

2011-01-01

The objective of this study was to identify and describe work-related safety hazards, injuries, and near-injury events (close calls) that occurred on trout farms in North Carolina and Kentucky. An interview instrument was used to collect information on occupational hazards, injuries, and near-injury events that resulted from work-related activities. Trout farmers reported occupational hazards including falling live tank lids, slippery surfaces on hauling trucks, lifting strains, falls from raceway walls and walkways, needlesticks while vaccinating fish, allergies, hypothermia/drowning, falls from cranes, chemical exposure, fire/explosions related to oxygen exposure, and electrical contact with overhead power lines. This study also reports solutions suggested by farm safety researchers or used by farmers to prevent the safety hazards found on trout farms.

Surface Movement Incidents Reported to the NASA Aviation Safety Reporting System

Science.gov (United States)

Connell, Linda J.; Hubener, Simone

1997-01-01

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

Annual report on reactor safety research projects. Reporting period 2011. Progress report

International Nuclear Information System (INIS)

2011-01-01

Within its competence for energy research the Federal Ministry of Economics and Technology (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS)mbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRSF- Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the Internet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. It has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties. (orig.)

Annual report on reactor safety research projects. Reporting period 2014. Progress report

Energy Technology Data Exchange (ETDEWEB)

NONE

2014-07-01

Within its competence for energy research the Federal Ministry for Economic Affairs and Energy (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS) gGmbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRS-F-Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the lnternet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. lt has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties.

Annual report on reactor safety research projects. Reporting period 2013. Progress report

International Nuclear Information System (INIS)

2013-01-01

Within its competence for energy research the Federal Ministry of Economics and Technology (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS)mbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRSF- Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the Internet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. It has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties. (orig.)

Annual report on reactor safety research projects. Reporting period 2015. Progress report

International Nuclear Information System (INIS)

2015-01-01

Within its competence for energy research the Federal Ministry for Economic Affairs and Energy (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft tor Anlagen- und Reaktorsicherheit (GRS) gGmbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRS-F-Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are ·' prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the lnternet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. it has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties.

Safety Evaluation Report related to the operation of Comanche Peak Steam Electric Station, Unit 2 (Docket No. 50-446)

International Nuclear Information System (INIS)

1993-02-01

Supplement 26 to the Safety Evaluation Report related to the operation of the Comanche Peak Steam Electric Station (CPSES), Unit 2, has been prepared by the Office of Nuclear Reactor Regulation of the US Nuclear Regulatory Commission (NRC). The facility is located in Somervell County, Texas, approximately 40 miles southwest of Fort Worth, Texas. This supplement reports the status of certain issues that had not been resolved when the Safety Evaluation Report and Supplements 1, 2, 3, 4, 6, 12, 21, 22, 23, 24, and 25 to that report were published. This supplement deals primarily with Unit 2 issues; however, it also references evaluations for several licensing issues that relate to Unit 1, which have been resolved since Supplement 25 was issued

Serious adverse events with infliximab: analysis of spontaneously reported adverse events.

Science.gov (United States)

Hansen, Richard A; Gartlehner, Gerald; Powell, Gregory E; Sandler, Robert S

2007-06-01

Serious adverse events such as bowel obstruction, heart failure, infection, lymphoma, and neuropathy have been reported with infliximab. The aims of this study were to explore adverse event signals with infliximab by using a long period of post-marketing experience, stratifying by indication. The relative reporting of infliximab adverse events to the U.S. Food and Drug Administration (FDA) was assessed with the public release version of the adverse event reporting system (AERS) database from 1968 to third quarter 2005. On the basis of a systematic review of adverse events, Medical Dictionary for Regulatory Activities (MedDRA) terms were mapped to predefined categories of adverse events, including death, heart failure, hepatitis, infection, infusion reaction, lymphoma, myelosuppression, neuropathy, and obstruction. Disproportionality analysis was used to calculate the empiric Bayes geometric mean (EBGM) and corresponding 90% confidence intervals (EB05, EB95) for adverse event categories. Infliximab was identified as the suspect medication in 18,220 reports in the FDA AERS database. We identified a signal for lymphoma (EB05 = 6.9), neuropathy (EB05 = 3.8), infection (EB05 = 2.9), and bowel obstruction (EB05 = 2.8). The signal for granulomatous infections was stronger than the signal for non-granulomatous infections (EB05 = 12.6 and 2.4, respectively). The signals for bowel obstruction and infusion reaction were specific to patients with IBD; this suggests potential confounding by indication, especially for bowel obstruction. In light of this additional evidence of risk of lymphoma, neuropathy, and granulomatous infections, clinicians should stress this risk in the shared decision-making process.

Annual report ''nuclear safety in France''

International Nuclear Information System (INIS)

2001-01-01

This document is the 2001 annual report of the French authority of nuclear safety (ASN). It summarizes the highlights of the year 2000 and details the following aspects: the nuclear safety in France, the organization of the control of nuclear safety, the regulation relative to basic nuclear facilities, the control of facilities, the information of the public, the international relations, the organisation of emergencies, the radiation protection, the transport of radioactive materials, the radioactive wastes, the PWR reactors, the experimental reactors and other laboratories and facilities, the nuclear fuel cycle facilities, and the shutdown and dismantling of nuclear facilities. (J.S.)

The NASA Aviation Safety Reporting System

Science.gov (United States)

1983-01-01

This is the fourteenth in a series of reports based on safety-related incidents submitted to the NASA Aviation Safety Reporting System by pilots, controllers, and, occasionally, other participants in the National Aviation System (refs. 1-13). ASRS operates under a memorandum of agreement between the National Aviation and Space Administration and the Federal Aviation Administration. The report contains, first, a special study prepared by the ASRS Office Staff, of pilot- and controller-submitted reports related to the perceived operation of the ATC system since the 1981 walkout of the controllers' labor organization. Next is a research paper analyzing incidents occurring while single-pilot crews were conducting IFR flights. A third section presents a selection of Alert Bulletins issued by ASRS, with the responses they have elicited from FAA and others concerned. Finally, the report contains a list of publications produced by ASRS with instructions for obtaining them.

Report transparency and nuclear safety 2007 CEA Cadarache

International Nuclear Information System (INIS)

2007-01-01

This report presents the activities of the CEA Center of Cadarache for the year 2007. The actions concerning the safety, the radiation protection, the significant events, the release control and the environmental impacts and the wastes stored on the center are discussed. More especially the report discusses the beginning of the RJH reactor construction, the fourth generation reactors research programs, the implementing of la Rotonde the new radioactive wastes management installation, the renovation of the LECA. (A.L.B.)

Status of safety in nuclear facilities - 2012. AREVA General Inspectorate Annual report

International Nuclear Information System (INIS)

2013-05-01

After a message from the Areva's Chief Executive Officer and a message from the senior Vice President of safety, health, security, sustainable development, a text by the inspector general comments the key safety results (events, dose levels, radiological impacts), the inspection findings, the areas of vigilance (relationship with the ASN, the management of the criticality risk, and facility compliance), some significant topics after the Fukushima accident. Then this report addresses the status of nuclear safety and radiation protection in the group's facilities and operations. It more specifically addresses the context and findings (lessons learned from the inspections, operating experience from event, employee radiation monitoring, environmental monitoring), crosscutting processes (safety management, controlling facility compliance, subcontractor guidance and management, crisis management), specific risks (criticality risk, fire hazards, transportation safety, radioactive waste management, pollution prevention, liability mitigation and dismantling), and areas for improvement and outlook

Safety culture in design. Final report

International Nuclear Information System (INIS)

Macchi, L.; Pietikaeinen, E.; Liinasuo, M.; Savioja, P.; Reiman, T.; Wahlstroem, M.; Kahlbom, U.; Rollenhagen, C.

2013-04-01

In this report we approach design from a safety culture approach As this research area is new and understudied, we take a wide scope on the issue. Different theoretical perspectives that can be taken when improving safety of the design process are considered in this report. We suggest that in the design context the concept of safety culture should be expanded from an organizational level to the level of the network of organizations involved in the design activity. The implication of approaching the design process from a safety culture perspective are discussed and the results of the empirical part of the research are presented. In the interview study in Finland and Sweden we identified challenges and opportunities in the design process from safety culture perspective. Also, a small part of the interview study concentrated on state of the art human factors engineering (HFE) practices in Finland and the results relating to that are presented. This report provide a basis for future development of systematic good design practices and for providing guidelines that can lead to safe and robust technical solutions. (Author)

Safety culture in design. Final report

Energy Technology Data Exchange (ETDEWEB)

Macchi, L.; Pietikaeinen, E.; Liinasuo, M.; Savioja, P.; Reiman, T.; Wahlstroem, M. [VTT Technical Research Centre of Finland, Espoo (Finland); Kahlbom, U. [Risk Pilot AB, Stockholm (Sweden); Rollenhagen, C. [Vattenfall, Stockholm, (Sweden)

2013-04-15

In this report we approach design from a safety culture approach As this research area is new and understudied, we take a wide scope on the issue. Different theoretical perspectives that can be taken when improving safety of the design process are considered in this report. We suggest that in the design context the concept of safety culture should be expanded from an organizational level to the level of the network of organizations involved in the design activity. The implication of approaching the design process from a safety culture perspective are discussed and the results of the empirical part of the research are presented. In the interview study in Finland and Sweden we identified challenges and opportunities in the design process from safety culture perspective. Also, a small part of the interview study concentrated on state of the art human factors engineering (HFE) practices in Finland and the results relating to that are presented. This report provide a basis for future development of systematic good design practices and for providing guidelines that can lead to safe and robust technical solutions. (Author)

The preparation of reports of a significant event at a uranium processing or uranium handling facility

International Nuclear Information System (INIS)

1988-08-01

Licenses to operate uranium processing or uranium handling facilities require that certain events be reported to the Atomic Energy Control Board (AECB) and to other regulatory authorities. Reports of a significant event describe unusual events which had or could have had a significant impact on the safety of facility operations, the worker, the public or on the environment. The purpose of this guide is to suggest an acceptable method of reporting a significant event to the AECB and to describe the information that should be included. The reports of a significant event are made available to the public in accordance with the provisions of the Access to Information Act and the AECB's policy on public access to licensing information

Hot Cell Facility (HCF) Safety Analysis Report

Energy Technology Data Exchange (ETDEWEB)

MITCHELL,GERRY W.; LONGLEY,SUSAN W.; PHILBIN,JEFFREY S.; MAHN,JEFFREY A.; BERRY,DONALD T.; SCHWERS,NORMAN F.; VANDERBEEK,THOMAS E.; NAEGELI,ROBERT E.

2000-11-01

This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood of these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR.

Hot Cell Facility (HCF) Safety Analysis Report

International Nuclear Information System (INIS)

MITCHELL, GERRY W.; LONGLEY, SUSAN W.; PHILBIN, JEFFREY S.; MAHN, JEFFREY A.; BERRY, DONALD T.; SCHWERS, NORMAN F.; VANDERBEEK, THOMAS E.; NAEGELI, ROBERT E.

2000-01-01

This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood of these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR

Vaccine adverse event text mining system for extracting features from vaccine safety reports.

Science.gov (United States)

Botsis, Taxiarchis; Buttolph, Thomas; Nguyen, Michael D; Winiecki, Scott; Woo, Emily Jane; Ball, Robert

2012-01-01

To develop and evaluate a text mining system for extracting key clinical features from vaccine adverse event reporting system (VAERS) narratives to aid in the automated review of adverse event reports. Based upon clinical significance to VAERS reviewing physicians, we defined the primary (diagnosis and cause of death) and secondary features (eg, symptoms) for extraction. We built a novel vaccine adverse event text mining (VaeTM) system based on a semantic text mining strategy. The performance of VaeTM was evaluated using a total of 300 VAERS reports in three sequential evaluations of 100 reports each. Moreover, we evaluated the VaeTM contribution to case classification; an information retrieval-based approach was used for the identification of anaphylaxis cases in a set of reports and was compared with two other methods: a dedicated text classifier and an online tool. The performance metrics of VaeTM were text mining metrics: recall, precision and F-measure. We also conducted a qualitative difference analysis and calculated sensitivity and specificity for classification of anaphylaxis cases based on the above three approaches. VaeTM performed best in extracting diagnosis, second level diagnosis, drug, vaccine, and lot number features (lenient F-measure in the third evaluation: 0.897, 0.817, 0.858, 0.874, and 0.914, respectively). In terms of case classification, high sensitivity was achieved (83.1%); this was equal and better compared to the text classifier (83.1%) and the online tool (40.7%), respectively. Our VaeTM implementation of a semantic text mining strategy shows promise in providing accurate and efficient extraction of key features from VAERS narratives.

Characterization strategy report for the organic safety issues

International Nuclear Information System (INIS)

Goheen, S.C.; Campbell, J.A.; Fryxell, G.E.

1997-08-01

This report describes a logical approach to resolving potential safety issues resulting from the presence of organic components in hanford tank wastes. The approach uses a structured logic diagram (SLD) to provide a pathway for quantifying organic safety issue risk. The scope of the report is limited to selected organics (i.e., solvents and complexants) that were added to the tanks and their degradation products. The greatest concern is the potential exothermic reactions that can occur between these components and oxidants, such as sodium nitrate, that are present in the waste tanks. The organic safety issue is described in a conceptual model that depicts key modes of failure-event reaction processes in tank systems and phase domains (domains are regions of the tank that have similar contents) that are depicted with the SLD. Applying this approach to quantify risk requires knowing the composition and distribution of the organic and inorganic components to determine (1) how much energy the waste would release in the various domains, (2) the toxicity of the region associated with a disruptive event, and (3) the probability of an initiating reaction. Five different characterization options are described, each providing a different level of quality in calculating the risks involved with organic safety issues. Recommendations include processing existing data through the SLD to estimate risk, developing models needed to link more complex characterization information for the purpose of estimating risk, and examining correlations between the characterization approaches for optimizing information quality while minimizing cost in estimating risk

77 FR 22322 - Common Formats for Patient Safety Data Collection and Event Reporting

Science.gov (United States)

2012-04-13

... safety reporting systems. This inventory provides an evidence base that informs construction of the Common Formats. The inventory includes many systems from the private sector, including prominent academic... HHS Web site: http://www.PSO.AHRQ.gov/index.html . FOR FURTHER INFORMATION CONTACT: Cathryn Niane...

IRSN - Annual Report 2013. Financial Report 2013. Enhancing nuclear safety

International Nuclear Information System (INIS)

Schuler, Matthieu; Marchal, Valerie; Albert, Marc-Gerard; Aurelle, Jacques; Bigot, Marie-Pierre; Bruna, Giovanni; Charron, Sylvie; Clavelle, Stephanie; Cousinou, Patrick; Deschamps, Patrice; Delattre, Aleth; Demeillers, Didier; Dumas, Agnes; Franquard, Dominique; Laloi, Patrick; Lorthioir, Stephane; Monti, Pascale; Rollinger, Francois; Rouyer, Veronique; Rutschkovsky, Nathalie; Scott De Martinville, Edouard; Tharaud, Christine; Verpeaux, Jean-Luc; Jaunet, Camille; Hedouin, Jean-Christophe; Pascal-Heuze, Charlotte

2014-03-01

IRSN, a public entity with industrial and commercial activities, is placed under the joint authority of the Ministries of Defense, Environment, Industry, Research, and Health. It is the nation's public service expert in nuclear and radiation risks, and its activities cover all the related scientific and technical issues. Its areas of specialization include the environment and radiological emergency response, human radiation protection in both a medical and professional capacity, and in both normal and post-accident situations, the prevention of major accidents, nuclear reactor safety, as well as safety in nuclear plants and laboratories, transport and waste treatment, and nuclear defense and security expertise. IRSN interacts with all parties concerned by these risks (public authorities, in particular nuclear safety and security authorities, local authorities, companies, research organizations, stakeholders' associations, etc.) to contribute to public policy issues relating to nuclear safety, human and environmental protection against ionizing radiation, and the protection of nuclear materials, facilities, and transport against the risk of malicious acts. This document is the 2013 issue of IRSN's activity report. Content: 1 - Organization, key figures; 2 - Strategy: Progress and main activities in 2013, Transparency and communications policy, Promoting a safety and radiation protection culture; 3 - Activities: Safety (Safety of existing facilities, Studies and researches, About defense, Conducting assessments of future facilities); Nuclear security and non-proliferation (Nuclear security activities, International non-proliferation controls); Radiation protection - environment and human health (Environmental and population exposure, Radiation protection in the workplace, Effects of chronic exposure, Protection in health care); Emergency and post-accident situations efficiency; 4 - Efficiency: Health, safety, environmental, protection and quality, Human resources

Mobile physician reporting of clinically significant events-a novel way to improve handoff communication and supervision of resident on call activities.

Science.gov (United States)

Nabors, Christopher; Peterson, Stephen J; Aronow, Wilbert S; Sule, Sachin; Mumtaz, Arif; Shah, Tushar; Eskridge, Etta; Wold, Eric; Stallings, Gary W; Burak, Kathleen Kelly; Goldberg, Randy; Guo, Gary; Sekhri, Arunabh; Mathew, George; Khera, Sahil; Montoya, Jessica; Sharma, Mala; Paudel, Rajiv; Frishman, William H

2014-12-01

Reporting of clinically significant events represents an important mechanism by which patient safety problems may be identified and corrected. However, time pressure and cumbersome report entry procedures have discouraged the full participation of physicians. To improve the process, our internal medicine training program developed an easy-to-use mobile platform that combines the reporting process with patient sign-out. Between August 25, 2011, and January 25, 2012, our trainees entered clinically significant events into i-touch/i-phone/i-pad based devices functioning in wireless-synchrony with our desktop application. Events were collected into daily reports that were sent from the handoff system to program leaders and attending physicians to plan for rounds and to correct safety problems. Using the mobile module, residents entered 31 reportable events per month versus the 12 events per month that were reported via desktop during a previous 6-month study period. Advances in information technology now permit clinically significant events that take place during "off hours" to be identified and reported (via handoff) to next providers and to supervisors via collated reports. This information permits hospital leaders to correct safety issues quickly and effectively, while attending physicians are able to use information gleaned from the reports to optimize rounding plans and to provide additional oversight of trainee on call patient management decisions.

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

Criteria for safety-related nuclear-power-plant operator actions: 1982 pressurized-water-reactor (PWR) simulator exercises

International Nuclear Information System (INIS)

Crowe, D.S.; Beare, A.N.; Kozinsky, E.J.; Haas, P.M.

1983-06-01

The primary objective of the Safety-Related Operator Action (SROA) Program at Oak Ridge National Laboratory is to provide a data base to support development of criteria for safety-related actions by nuclear power plant operators. When compared to field data collected on similar events, a base of operator performance data developed from the simulator experiments can then be used to establish safety-related operator action design evaluation criteria, evaluate the effects of performance shaping factors, and support safety/risk assessment analyses. This report presents data obtained from refresher training exercises conducted in a pressurized water reactor (PWR) power plant control room simulator. The 14 exercises were performed by 24 teams of licensed operators from one utility, and operator performance was recorded by an automatic Performance Measurement System. Data tapes were analyzed to extract operator response times (RTs) and error rate information. Demographic and subjective data were collected by means of brief questionnaires and analyzed in an attempt to evaluate the effects of selected performance shaping factors on operator performance

Regulatory overview report 2013 concerning nuclear safety in Swiss nuclear installations

International Nuclear Information System (INIS)

2014-06-01

The Swiss Federal Nuclear Safety Inspectorate (ENSI) acting as the regulatory body of the Swiss Federation assesses and monitors nuclear facilities in Switzerland: these include five nuclear power plants, the interim storage facilities based at each plant, the Central Interim Storage Facility (ZWILAG) at Wuerenlingen together with the nuclear facilities at the Paul Scherrer Institute (PSI) and the two universities of Basel and Lausanne. Using a combination of inspections, regulatory meetings, examinations and analyses together with reports from the licensees of individual facilities, ENSI obtains the overview required concerning nuclear safety. It ensures that the facilities comply with regulations. Its regulatory responsibilities include the transport of radioactive materials from and to nuclear facilities and the preparations for a deep geological repository for nuclear waste. ENSI maintains its own emergency organisation, an integral part of the national emergency structure. It provides the public with information on particular events in nuclear facilities. This Surveillance Report describes operational experience, systems technology, radiological protection and management in all the nuclear facilities. Generic issues relevant to all facilities such as probabilistic safety analyses are described. In 2013, the five nuclear power plants in Switzerland (Beznau Units 1 and 2, Muehleberg, Goesgen and Leibstadt) were all operated safely and had complied with their approved operating conditions. The nuclear safety at all plants was rated as being good. 34 events were reported. During operation, no reactor scrams were recorded. On the INES scale, ranging from 0-7, ENSI rated all reportable events as Level 0. The ENSI safety evaluation reflects both reportable events and the results of the approximately 460 inspections conducted during 2013. ZWILAG consists of several storage halls, a conditioning plant and a plasma plant. At the end of 2013, the cask storage hall

Procedures as a Contributing Factor to Events in the Swedish Nuclear Power Plants. Analysis of a Database with Licensee Event Reports 1995-1999

International Nuclear Information System (INIS)

Bento, Jean-Pierre

2002-12-01

departure from the mean values presented herein, indicating for these units a need for focussed corrective actions. Finally, this report exemplifies how the plant operating experience can be used for the definition of corrective actions based on the detailed analysis of MTO-related causes contributing to event recurrence and to latent weaknesses in safety functions, systems and components

Improving patient safety in radiotherapy through error reporting and analysis

International Nuclear Information System (INIS)

Findlay, Ú.; Best, H.; Ottrey, M.

2016-01-01

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

Safety culture in nuclear installations: Bangladesh perspectives and key lessons learned from major events

International Nuclear Information System (INIS)

Jalil, A.; Rabbani, G.

2002-01-01

Steps necessary to be taken to ensure safety in nuclear installations are suggested. One of the steps suggested is enhancing the safety culture. It is necessary to gain a common understanding of the concept itself, the development stages of safety culture by way of good management practices and leadership for safety culture improvement in the long-term. International topical meetings on safety culture may serve as an important forum for exchange of experiences. From such conventions new initiatives and programmes may crop up which when implemented around the world is very likely to improve safety management and thus boost up the safety culture in nuclear installations. International co-operation and learning are to be prompted to facilitate the sharing of the achievements to face the challenges involved in the management of safety and fixing priorities for future work and identify areas of co-operations. Key lessons learned from some major events have been reported. Present status and future trend of nuclear safety culture in Bangladesh have been dealt with. (author)

Formulation of nuclear safety under various induced events. Part 1. Current status and challenges for risk-informed activities in nuclear safety

International Nuclear Information System (INIS)

Itoi, Tatsuya; Hayashi, Kentaro; Yamato, Masaaki

2016-01-01

The Nuclear Safety Subcommittee published in March 2013 a report on 'Seminar on the Fukushima Daiichi Nuclear Power Station accident' (hereinafter referred to as Seminar Report), and has thereafter continued discussions on the challenges that were pointed out in Seminar Report as the target of discussions. This commentary series summarizes the current situation and challenges for the ideal way of nuclear safety against a variety of causal events as one of the above challenges. This paper, as Part 1 of the above theme, firstly summarizes the current state of the challenges of regulatory bodies and business operators who are engaging risk information utilization. It secondly discusses the future risk information utilization of regulations and business operators, realization of integrated decision-making process, timeliness and promptness required in decision-making, and future efforts including incentives. (A.O.)

Information report on nuclear safety and radiation protection of the Manche storage Centre - 2012

International Nuclear Information System (INIS)

2013-06-01

After a presentation of the Manche Storage Centre (CSM), the first French centre of surface storage of weakly and moderately radioactive wastes, of its history, its buildings and activities, of the multi-layer cover, of the water management system (installation, controls, sampling), this report describes the measures related to nuclear safety (principles and objectives, prevention measures, technical measures, regulatory plan of control of the Centre and of its environment, control of releases from storage installations, quality organisation, archiving system). It describes measures related to radiation protection: principles, staff dosimetry, and personnel safety. The next part presents the nuclear event scale (INES) and indicates that no incident occurred. The effluents and releases from the Centre are then addressed: origin, locations and results of radiological controls of rainfalls, of risky effluents, of underground waters, of rivers, impacts of the Centre on its environment (releases in the sea, in rivers). The management of conventional and nuclear wastes produced by the Centre is reviewed as well as the actions related to information and transparency. Recommendations of the CHSCT are reported

NASA aviation safety reporting system

Science.gov (United States)

1981-01-01

Aviation safety reports that relate to loss of control in flight, problems that occur as a result of similar sounding alphanumerics, and pilot incapacitation are presented. Problems related to the go around maneuver in air carrier operations, and bulletins (and FAA responses to them) that pertain to air traffic control systems and procedures are included.

Revised licensee event report system

International Nuclear Information System (INIS)

Mays, G.T.; Poore, W.P.

1985-01-01

Licensee Event Reports (LERs) provide the basis for evaluating and assessing operating experience information from nuclear power plants. The reporting requirements for submitting LERs to the Nuclear Regulatory Commission have been revised. Effective Jan. 1, 1984, all events were to be submitted in accordance with 10 CFR 50.73 of the Code of Federal Regulations. Report NUREG-1022, Licensee Event Report System-Description of System and Guidelines for Reporting, describes the guidelines on reportability of events. This article summarizes the reporting requirements as presented in NUREG-1022, high-lights differences in data reported between the revised and previous LER systems, and presents results from a preliminary assessment of LERs submitted under the revised LER reporting system

EMS helicopter incidents reported to the NASA Aviation Safety Reporting System

Science.gov (United States)

Connell, Linda J.; Reynard, William D.

1993-01-01

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

Aging of turbine drives for safety-related pumps in nuclear power plants

International Nuclear Information System (INIS)

Cox, D.F.

1995-06-01

This study was performed to examine the relationship between time-dependent degradation and current industry practices in the areas of maintenance, surveillance, and operation of steam turbine drives for safety-related pumps. These pumps are located in the Auxiliary Feedwater (AFW) system for pressurized-water reactor plants and in the Reactor Core Isolation Cooling and High-Pressure Coolant Injection systems for boiling-water reactor plants. This research has been conducted by examination of failure data in the Nuclear Plant Reliability Data System, review of Licensee Event Reports, discussion of problems with operating plant personnel, and personal observation. The reported failure data were reviewed to determine the cause of the event and the method of discovery. Based on the research results, attempts have been made to determine the predictability of failures and possible preventive measures that may be implemented. Findings in a recent study of AFW systems indicate that the turbine drive is the single largest contributor to AFW system degradation. However, examination of the data shows that the turbine itself is a reliable piece of equipment with a good service record. Most of the problems documented are the result of problems with the turbine controls and the mechanical overspeed trip mechanism; these apparently stem from three major causes which are discussed in the text. Recent improvements in maintenance practices and procedures, combined with a stabilization of the design, have led to improved performance resulting in a reliable safety-related component. However, these improvements have not been universally implemented

Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety

Directory of Open Access Journals (Sweden)

Ali Reza Jeddian

2012-09-01

Full Text Available Errors prevention and patient safety in transfusion medicine are a serious concern. Errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. Root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. To specify system vulnerabilities and illustrate the potential of such an approach, we describe the root cause analysis of a case of transfusion error in emergency ward that could have been fatal. After reporting of the mentioned event, through reviewing records and interviews with the responsible personnel, the details of the incident were elaborated. Then, an expert panel meeting was held to define event timeline and the care and service delivery problems and discuss their underlying causes, safeguards and preventive measures. Root cause analysis of the mentioned event demonstrated that certain defects of the system and the ensuing errors were main causes of the event. It also points out systematic corrective actions. It can be concluded that health care organizations should endeavor to provide opportunities to discuss errors and adverse events and introduce preventive measures to find areas where resources need to be allocated to improve patient safety.

National report of Brazil. Nuclear Safety Convention

International Nuclear Information System (INIS)

1998-09-01

This document represents the national report prepared as a fulfillment of the brazilian obligations related to the Convention on Nuclear Safety. In chapter 2 some details are given about the existing nuclear installations. Chapter 3 provides details about the legislation and regulations, including the regulatory framework and the regulatory body. Chapter 4 covers general safety considerations as described in articles 10 to 16 of the Convention. Chapter 5 addresses to the safety of the installations during siting, design, construction and operation. Chapter 6 describes planned activities to further enhance nuclear safety. Chapter 7 presents the final remarks related to the degree of compliance with the Convention obligations

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

Science.gov (United States)

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

2017-01-30

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

Safety-related incidents at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Lehtinen, P.

1986-03-01

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

Safety-related incidents at the Finnish nuclear power plants

International Nuclear Information System (INIS)

Lehtinen, P.

1985-01-01

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

Plant to reduce reactor scrams and ASSET related analysis

International Nuclear Information System (INIS)

Piirto, A.

1997-01-01

The report of events at the plant follows established rules. Basically, three categories of reports exist: first, the reactor scram report, secondly, the operational disturbance report and thirdly, the special report. The last named category covers events defined by authorities. It concentrates on safety related events, for example on failures to follow the requirements stipulated in the plant's Technical Specifications. In general, special events are nuclear safety on the plant, the safety of the plant personnel or overall, the radiation safety in the plant's vicinity. In the TVO's experience feedback activity the greatest emphasis is put on events at the TVO plant. The events on the same type of plants come second. Due to limited resources, somewhat less attention is paid to events on the other types of plants. However, the experience feedback should become wider in practice so that it would be a part of everyday life in nuclear power plant operation

Plant to reduce reactor scrams and ASSET related analysis

Energy Technology Data Exchange (ETDEWEB)

Piirto, A [Teollisuuden Voima Oy (Finland)

1997-10-01

The report of events at the plant follows established rules. Basically, three categories of reports exist: first, the reactor scram report, secondly, the operational disturbance report and thirdly, the special report. The last named category covers events defined by authorities. It concentrates on safety related events, for example on failures to follow the requirements stipulated in the plant`s Technical Specifications. In general, special events are nuclear safety on the plant, the safety of the plant personnel or overall, the radiation safety in the plant`s vicinity. In the TVO`s experience feedback activity the greatest emphasis is put on events at the TVO plant. The events on the same type of plants come second. Due to limited resources, somewhat less attention is paid to events on the other types of plants. However, the experience feedback should become wider in practice so that it would be a part of everyday life in nuclear power plant operation.

Evaluating the impact of child safety seat check-up events on parental knowledge.

Science.gov (United States)

Herring, Ashley B; Jones, Ches; Nunez, Casandra

2002-12-01

Riding unrestrained is the greatest risk factor for death and injury among children in motor vehicles. Restraining a child can reduce the risk of death for that child by up to 71%. However, despite increased awareness, child safety seat usage rates are still disturbingly low. The purpose of this study was to evaluate the impact that child safety seat check-up events have on parental knowledge on child safety seats and installation. The subjects for this study were 101 parents/caregivers who attended child safety seat check-up events in northwest Arkansas from May 2000 through June 2001. A 20-item survey was conducted via the telephone. Results showed that the check-up events in northwest Arkansas have had an impact on self-efficacy. The participants of the events were primarily Caucasian and females in the 30-34 age group. Nine of 10 subjects scored in the high knowledge category. Conclusions are that check-up events do have an impact on parental knowledge and are accepted by the target group. Additionally, participants believed that car seats are of great importance and do protect their children in the event of a crash.

Screening of external hazards for NPP with bank type reactor. Modeling of safety related systems and equipment for RBMK. Probabilistic assessment of NPP safety on aircraft impact. Progress report

International Nuclear Information System (INIS)

Kostarev, V.

1999-01-01

This progress report was produced within the frame of IAEA research project on screening the hazards for NPP with bank type reactor. It covers the following tasks; development of the model for the primary loop system of RBMK; developing the models for safety related equipment of RBMK; developing of models for safety related models of EGP-6 type reactor (Bilibinskaya Nuclear Co-generated heat and Power Plant); and probabilistic assessment of NPP safety on aircraft impact

Status of safety at Areva group facilities. 2006 annual report

International Nuclear Information System (INIS)

2006-01-01

This report presents a snapshot of nuclear safety and radiation protection conditions in the AREVA group's nuclear installations in France and abroad, as well as of radiation protection aspects in service activities, as identified over the course of the annual inspections and analyses program carried out by the General Inspectorate in 2006. This report is presented to the AREVA Supervisory Board, communicated to the labor representation bodies concerned, and made public. In light of the inspections, appraisals and coordination missions it has performed, the General Inspectorate considers that the nuclear safety level of the AREVA group's nuclear installations is satisfactory. It particularly noted positive changes on numerous sites and efforts in the field of continuous improvement that have helped to strengthen nuclear safety. This has been possible through the full involvement of management teams, an improvement effort initiated by upper management, actions to increase personnel awareness of nuclear safety culture, and supervisors' heightened presence around operators. However, the occurrence of certain events in facilities has led us to question the nuclear safety repercussions that the changes to activities or organization on some sites have had. In these times of change, drifts in nuclear safety culture have been identified. The General Inspectorate considers that a preliminary analysis of the human and organizational factors of these changes, sized to match the impact the change has on nuclear safety, should be made to ensure that a guaranteed level of nuclear safety is maintained (allowance for changes to references, availability of the necessary skills, resources of the operating and support structures, etc.). Preparations should also be made to monitor the changes and spot any telltale signs of drift in the application phase. Managers should be extra vigilant and the occurrence of any drift should be systematically dealt with ahead of implementing

Enhancing nuclear safety. Annual report 2014. Financial report 2014

International Nuclear Information System (INIS)

2015-01-01

After some introductory texts proposed by several IRSN head managers, and a brief presentation of some key data illustrating the activity, the annual report presents the main strategic orientations, notably in the field of knowledge management, and of information and communication. After some images illustrating the past year, activities are presented. They first deal with safety: Reactor safety (operating experience feedback), From decommissioning old reactors to designing those of the future, Safety of laboratories and plants, Safety regarding risks due to infrastructure near nuclear facilities, Reactor aging, Fuel: research on corrosion and deformation, Research and assessments for improved understanding of accident situations, Earthquakes: research and assessments, About defense, Geological disposal of radioactive waste. They secondly deal with security and non-proliferation (nuclear security, nuclear non-proliferation, chemical weapon ban), thirdly with radiation protection for human and environment health (environment monitoring, radionuclide transfer in the environment, radon and polluted sites, human exposure, radiation protection in the workplace, effects of low-dose chronic exposures, Organization of radiation protection at the European level, protection in health care), and fourthly with emergency and post-accident situations (emergency and post-accident preparedness and response, Emergency response tools). The next part of the activity report addresses issues related to efficiency: Real estate program (construction projects get started), Hygiene, safety, social responsibility, Human resources, Organization chart, Board of directors, Steering committee for the nuclear defense expertise Division - CODEND, Scientific council, Ethics commission composition, Nuclear safety and radiation protection Research policy committee - COR. The financial report proposes a management report, financial statements with an appendix to annual accounts, and an auditor

Quarterly report on the Ferrocyanide Safety Program for the period ending June 30, 1995

International Nuclear Information System (INIS)

Meacham, J.E.; Cash, R.J.; Dukelow, G.T.

1995-07-01

This is the seventeenth quarterly report on the progress of activities addressing the Ferrocyanide Safety Issue associated with Hanford Site high-level radioactive waste tanks. Progress in the Ferrocyanide Safety Program is reviewed, including work addressing the six pans of Defense Nuclear Facilities Safety Board Recommendation 90-7 (FR 1990). All work activities are described in the revised program plan (DOE 1994b), and this report follows the same format presented there. A summary of the key events occurring this quarter is presented

Seismic fragility testing of naturally-aged, safety-related, class 1E battery cells

International Nuclear Information System (INIS)

Bonzon, L.L.; Hente, D.B.; Kukreti, B.M.; Schendel, J.S.; Black, D.A.; Paulsen, G.D.; Tulk, J.D.; Janis, W.J.; Aucoin, B.D.

1984-01-01

The concern over seismic susceptibility of naturally-aged lead-acid batteries used for safety-related emergency power in nuclear power stations was brought about by battery problems that periodically had been reported in Licensee Event Reports (LERs). The Turkey Point Station had reported cracked and buckled plates in several cells in October 1974 (LER 75-5). The Fitzpatrick Station had reported cracked battery cell cases in October 1977 (LER 77-55) and again in September 1979 (LER 79-59). The Browns Ferry Station had reported a cracked cell leaking a small quantity of electrolyte in July 1981 (LER 81-42). The Indian Point Station had reported cracked and leaking cells in both February (LER 82-7) and April 1982 (LER 82-16); both of these LERs indicated the cracked cells were due to expansion (i.e., growth) of the positive plates

Statistical analysis of events related to emergency diesel generators failures in the nuclear industry

Energy Technology Data Exchange (ETDEWEB)

Kančev, Duško, E-mail: dusko.kancev@ec.europa.eu [European Commission, DG-JRC, Institute for Energy and Transport, P.O. Box 2, NL-1755 ZG Petten (Netherlands); Duchac, Alexander; Zerger, Benoit [European Commission, DG-JRC, Institute for Energy and Transport, P.O. Box 2, NL-1755 ZG Petten (Netherlands); Maqua, Michael [Gesellschaft für Anlagen-und-Reaktorsicherheit (GRS) mbH, Schwetnergasse 1, 50667 Köln (Germany); Wattrelos, Didier [Institut de Radioprotection et de Sûreté Nucléaire (IRSN), BP 17 - 92262 Fontenay-aux-Roses Cedex (France)

2014-07-01

Highlights: • Analysis of operating experience related to emergency diesel generators events at NPPs. • Four abundant operating experience databases screened. • Delineating important insights and conclusions based on the operating experience. - Abstract: This paper is aimed at studying the operating experience related to emergency diesel generators (EDGs) events at nuclear power plants collected from the past 20 years. Events related to EDGs failures and/or unavailability as well as all the supporting equipment are in the focus of the analysis. The selected operating experience was analyzed in detail in order to identify the type of failures, attributes that contributed to the failure, failure modes potential or real, discuss risk relevance, summarize important lessons learned, and provide recommendations. The study in this particular paper is tightly related to the performing of statistical analysis of the operating experience. For the purpose of this study EDG failure is defined as EDG failure to function on demand (i.e. fail to start, fail to run) or during testing, or an unavailability of an EDG, except of unavailability due to regular maintenance. The Gesellschaft für Anlagen und Reaktorsicherheit mbH (GRS) and Institut de Radioprotection et de Sûreté Nucléaire (IRSN) databases as well as the operating experience contained in the IAEA/NEA International Reporting System for Operating Experience and the U.S. Licensee Event Reports were screened. The screening methodology applied for each of the four different databases is presented. Further on, analysis aimed at delineating the causes, root causes, contributing factors and consequences are performed. A statistical analysis was performed related to the chronology of events, types of failures, the operational circumstances of detection of the failure and the affected components/subsystems. The conclusions and results of the statistical analysis are discussed. The main findings concerning the testing

Statistical analysis of events related to emergency diesel generators failures in the nuclear industry

International Nuclear Information System (INIS)

Kančev, Duško; Duchac, Alexander; Zerger, Benoit; Maqua, Michael; Wattrelos, Didier

2014-01-01

Highlights: • Analysis of operating experience related to emergency diesel generators events at NPPs. • Four abundant operating experience databases screened. • Delineating important insights and conclusions based on the operating experience. - Abstract: This paper is aimed at studying the operating experience related to emergency diesel generators (EDGs) events at nuclear power plants collected from the past 20 years. Events related to EDGs failures and/or unavailability as well as all the supporting equipment are in the focus of the analysis. The selected operating experience was analyzed in detail in order to identify the type of failures, attributes that contributed to the failure, failure modes potential or real, discuss risk relevance, summarize important lessons learned, and provide recommendations. The study in this particular paper is tightly related to the performing of statistical analysis of the operating experience. For the purpose of this study EDG failure is defined as EDG failure to function on demand (i.e. fail to start, fail to run) or during testing, or an unavailability of an EDG, except of unavailability due to regular maintenance. The Gesellschaft für Anlagen und Reaktorsicherheit mbH (GRS) and Institut de Radioprotection et de Sûreté Nucléaire (IRSN) databases as well as the operating experience contained in the IAEA/NEA International Reporting System for Operating Experience and the U.S. Licensee Event Reports were screened. The screening methodology applied for each of the four different databases is presented. Further on, analysis aimed at delineating the causes, root causes, contributing factors and consequences are performed. A statistical analysis was performed related to the chronology of events, types of failures, the operational circumstances of detection of the failure and the affected components/subsystems. The conclusions and results of the statistical analysis are discussed. The main findings concerning the testing

Regulatory oversight of nuclear safety in Finland. Annual report 2011