WorldWideScience

Sample records for significant safety improvements

  1. Safety significance evaluation system

    International Nuclear Information System (INIS)

    Lew, B.S.; Yee, D.; Brewer, W.K.; Quattro, P.J.; Kirby, K.D.

    1991-01-01

    This paper reports that the Pacific Gas and Electric Company (PG and E), in cooperation with ABZ, Incorporated and Science Applications International Corporation (SAIC), investigated the use of artificial intelligence-based programming techniques to assist utility personnel in regulatory compliance problems. The result of this investigation is that artificial intelligence-based programming techniques can successfully be applied to this problem. To demonstrate this, a general methodology was developed and several prototype systems based on this methodology were developed. The prototypes address U.S. Nuclear Regulatory Commission (NRC) event reportability requirements, technical specification compliance based on plant equipment status, and quality assurance assistance. This collection of prototype modules is named the safety significance evaluation system

  2. The patient's safety - For a dynamics of improvement. Nr 3. How to analyze your significant radiation protection events?

    International Nuclear Information System (INIS)

    2012-07-01

    The objective of this publication is to present event analysis methods which are the most frequently used by radiotherapy departments. After an indication of key figures concerning radiotherapy patients, sessions and events, the document indicates the objectives and steps of an event analysis. It presents various analysis methods: Ishikawa diagram (or 5M method or causes-effects diagram), the cause tree, the ALARM method (association of litigation and risk management), the ORION method. It proposes a comparison between these five methods, their possibilities, their limits. Good practices are outlined in terms of data acquisition, method choice, event analysis, and improvement actions. The use of the cause tree analysis is commented by members of the Limoges hospital radiotherapy department, and that of the Ishikawa method by a member of the Beauvais hospital

  3. Improving operating room safety

    Directory of Open Access Journals (Sweden)

    Garrett Jill

    2009-11-01

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

  4. How Good Is Good: Improved Tracking and Managing of Safety Goals, Performance Indicators, Production Targets and Significant Events Using Learning Curves

    International Nuclear Information System (INIS)

    Duffey, Rommey B.; Saull, John W.

    2002-01-01

    We show a new way to track and measure safety and performance using learning curves derived on a mathematical basis. When unusual or abnormal events occur in plants and equipment, the regulator and good management practice requires they be reported, investigated, understood and rectified. In addition to reporting so-called 'significant events', both management and the regulator often set targets for individual and collective performance, which are used for both reward and criticism. For almost completely safe systems, like nuclear power plants, commercial aircraft and chemical facilities, many parameters are tracked and measured. Continuous improvement has to be demonstrated, as well as meeting reduced occurrence rates, which are set as management goals or targets. This process usually takes the form of statistics for availability of plant and equipment, forced or unplanned maintenance outage, loss of safety function, safety or procedural violations, etc. These are often rolled up into a set of so-called 'Performance Indicators' as measures of how well safety and operation is being managed at a given facility. The overall operating standards of an industry are also measured. A whole discipline is formed of tracking, measuring, reporting, managing and understanding the plethora of indicators and data. Decreasing occurrence rates and meeting or exceeding goals are seen and rewarded as virtues. Managers and operators need to know how good is their safety management system that has been adopted and used (and paid for), and whether it can itself be improved. We show the importance of accumulated experience in correctly measuring and tracking the decreasing event and error rates speculating a finite minimum rate. We show that the rate of improvement constitutes a measurable 'learning curve', and the attainment of the goals and targets can be affected by the adopted measures. We examine some of the available data on significant events, reportable occurrences, and loss of

  5. Improving Patient Safety: Improving Communication.

    Science.gov (United States)

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

    2017-12-01

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

  6. Nuclear safety. Improvement programme

    International Nuclear Information System (INIS)

    2000-01-01

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

  7. Safety significance of ATR passive safety response attributes

    International Nuclear Information System (INIS)

    Atkinson, S.A.

    1990-01-01

    The Advanced Test Reactor (ATR) at the Idaho National Engineering Laboratory was designed with some passive safety response attributes which contribute to the safety of the facility. The three passive safety attributes being evaluated in the paper are: 1) In-core and in-vessel natural convection cooling, 2) a passive heat sink capability of the ATR primary coolant system (PCS) for the transfer of decay power from the uninsulated piping to the confinement, and 3) gravity feed of emergency coolant makeup. The safety significance of the ATR passive safety response attributes is that the reactor can passively respond to most transients, given a reactor scram, to provide adequate decay power removal and a significant time for operator action should the normal active heat removal systems and their backup systems both fail. The ATR Interim Level 1 Probabilistic Risk Assessment (PRA) models and results were used to evaluate the significance to ATR fuel damage frequency (or probability) of the above three passive response attributes. The results of the evaluation indicate that the first attribute is a major safety characteristic of the ATR. The second attribute has a noticeable but only minor safety significance. The third attribute has no significant influence on the ATR firewater injection system (emergency coolant system)

  8. IMPROVING PATIENT SAFETY:

    DEFF Research Database (Denmark)

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

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

  9. Safety culture : a significant influence on safety in transportation

    Science.gov (United States)

    2017-08-01

    An organizations safety culture can influence safety outcomes. Research and experience show that when safety culture is strong, accidents are less frequent and less severe. As a result, building and maintaining strong safety cultures should be a t...

  10. Planned activities to improve safety

    International Nuclear Information System (INIS)

    1998-01-01

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

  11. 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.

  12. 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.

  13. Improved safety at CERN

    CERN Multimedia

    2006-01-01

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

  14. Improving safety in mining

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2007-08-15

    AcuMine is a spin-out company from CRC Mining Australia and the University of Sydney's Australian Centre for Field Robotics (ACFR). Its focus is to provide safety and fatigue management in mining environments. The AcuLine Haul Check system was its first development. Of greater benefit to safety in mines will be the AcuMine Proximity System (APPS) developed to reliably detect and warn drivers when in proximity to other trucks and utility vehicles and to detect personnel near to those heavy vehicles. 6 figs.

  15. Methods for safety culture improvement

    International Nuclear Information System (INIS)

    Sivintsev, Yu.V.

    1998-01-01

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

  16. Elevating standards, improving safety.

    Science.gov (United States)

    Clarke, Richard

    2014-08-01

    In our latest 'technical guidance' article, Richard Clarke, sales and marketing director at one of the UK's leading lift and escalator specialists, Schindler, examines some of the key issues surrounding the specification, maintenance, and operation of lifts in hospitals to help ensure the highest standards of safety and reliability.

  17. Improving versus maintaining nuclear safety

    International Nuclear Information System (INIS)

    2002-01-01

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

  18. Safety improvements of Temelin NPP

    International Nuclear Information System (INIS)

    Vita, J.

    2000-01-01

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

  19. Improved safety in ski jumping.

    Science.gov (United States)

    Wester, K

    1988-01-01

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

  20. Improving safety on rural local and tribal roads safety toolkit.

    Science.gov (United States)

    2014-08-01

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

  1. EC6 safety design improvements

    Energy Technology Data Exchange (ETDEWEB)

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

    2014-07-01

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

  2. More safety by improving the safety culture

    International Nuclear Information System (INIS)

    Laaksonen, J.

    1993-01-01

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

  3. Safety improvement of Paks nuclear power plant

    International Nuclear Information System (INIS)

    Vamos, G.

    1999-01-01

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

  4. Safety significance of steam generator tube degradation mechanisms

    Energy Technology Data Exchange (ETDEWEB)

    Roussel, G; Mignot, P [AIB-Vincotte Nuclear - AVN, Brussels (Belgium)

    1991-07-01

    Steam generator (SG) tube bundle is a part of the Reactor Coolant Pressure Boundary (RCPB): this means that its integrity must be maintained. However, operating experience shows various types of tube degradation to occur in the SG tubing, which may lead to SG tube leaks or SG tube ruptures and create a loss of primary system coolant through the SG, therefore providing a direct path to the environment outside the primary containment structure. In this paper, the major types of known SG tube degradations are described and analyzed in order to assess their safety significance with regard to SG tube integrity. In conclusion: The operational reliability and the safety of the PWR steam generator s requires a sufficient knowledge of the degradation mechanisms to determine the amount of degradation that a tube can withstand and the time that it may remain in operation. They also require the availability of inspection techniques to accurately detect and characterize the various degradations. The status of understanding of the major types of degradation summarized in this paper shows and justifies why efforts are being performed to improve the management of the steam generator tube defects.

  5. Assessment of the factors with significant influence on safety culture

    International Nuclear Information System (INIS)

    Farcasiu, M.; Nitoi, M.

    2013-01-01

    In this paper, a qualitative and a quantitative evaluation of the factors with significant impact on safety culture were performed. These techniques were established and applied in accordance with IAEA standards. In order to show the applicability and opportunity of the methodology a specific case study was prepared: safety culture evaluation for INR Pitesti. The qualitative evaluation was performed using specific developed questionnaires. Through analysis of the completed questionnaires was established the development stage of safety culture at INR. The quantitative evaluation was performed using a guide to rate the influence factors. For each factor was identified the influence (negative or positive) and ranking score was estimated using scoring criteria. The results have emphasized safety culture stages. The paper demonstrates the fact that using both quantitative and qualitative assessment techniques, a practical value of the safety culture concept is given. (authors)

  6. Optimization of safety equipment outages improves safety

    International Nuclear Information System (INIS)

    Cepin, Marko

    2002-01-01

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

  7. Can we improve patient safety?

    Science.gov (United States)

    Corbally, Martin Thomas

    2014-01-01

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

  8. Organizational factors influencing improvements in safety

    International Nuclear Information System (INIS)

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

    1992-01-01

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

  9. 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

  10. Carotid endarterectomy significantly improves postoperative laryngeal sensitivity.

    Science.gov (United States)

    Hammer, Georg Philipp; Tomazic, Peter Valentin; Vasicek, Sarah; Graupp, Matthias; Gugatschka, Markus; Baumann, Anneliese; Konstantiniuk, Peter; Koter, Stephan Herwig

    2016-11-01

    sensory threshold on the operated-on side (6.08 ± 2.02 mm Hg) decreased significantly at the 6-week follow-up, even in relation to the preoperative measure (P = .022). With the exception of one patient with permanent unilateral vocal fold immobility, no signs of nerve injury were detected. In accordance with previous reports, injuries to the recurrent laryngeal nerve during CEA seem to be rare. In most patients, postoperative symptoms (globus, dysphagia, dysphonia) and signs fade within a few weeks without any specific therapeutic intervention. This study shows an improved long-term postoperative superior laryngeal nerve function with regard to laryngopharyngeal sensitivity. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

  11. Assessment of the nuclear installation's safety significant events

    International Nuclear Information System (INIS)

    Vidican, D.

    2005-01-01

    This document tries to establish, based on the available documentation, the main steps in development of Assessment of the Events in Nuclear Installations. It takes into account: selection of the safety significant occurrences, establishing the direct cause and contributors as well as the root cause and contributors. Also, the document presents the necessary corrective actions and generic lessons to be learned from the event. The document is based especially on IAEA - ASSET guidelines and DOE root cause analysis Guidance. (author)

  12. Leadership Actions to Improve Nuclear Safety Culture

    International Nuclear Information System (INIS)

    Clewett, L.K.

    2016-01-01

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

  13. Researchers' Roles in Patient Safety Improvement.

    Science.gov (United States)

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

    2016-03-01

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

  14. Augmented reality for improved safety

    CERN Multimedia

    Stefania Pandolfi

    2016-01-01

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

  15. [Improving patient safety through voluntary peer review].

    Science.gov (United States)

    Kluge, S; Bause, H

    2015-01-01

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

  16. Design safety improvements of Kozloduy NPP

    International Nuclear Information System (INIS)

    Hinovski, I.

    1999-01-01

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

  17. Safety significance of ATR [Advanced Test Reactor] passive safety response attributes

    International Nuclear Information System (INIS)

    Atkinson, S.A.

    1989-01-01

    The Advanced Test Reactor (ATR) at the Idaho National Engineering Laboratory was designed with some passive safety response attributes which contribute to the safety posture of the facility. The three passive safety attributes being evaluated in the paper are: (1) In-core and in-vessel natural convection cooling, (2) a passive heat sink capability of the ATR primary coolant system (PCS) for the transfer of decay power from the uninsulated piping to the confinement, and (3) gravity feed of emergency coolant makeup. The safety significance of the ATR passive safety response attributes is that the reactor can passively respond for most transients, given a reactor scram, to provide adequate decay power removal and a significant time for operator action should the normal active heat removal systems and their backup systems both fail. The ATR Interim Level 1 Probabilistic Risk Assessment (PRA) model ands results were used to evaluate the significance to ATR fuel damage frequency (or probability) of the above three passive response attributes. The results of the evaluation indicate that the first attribute is a major safety characteristic of the ATR. The second attribute has a noticeable but only minor safety significance. The third attribute has no significant influence on the ATR Level 1 PRA because of the diversity and redundancy of the ATR firewater injection system (emergency coolant system). 8 refs., 4 figs., 1 tab

  18. PROPOSAL OF VOIVODESHIP ROAD SAFETY IMPROVEMENT PROGRAMME

    OpenAIRE

    Tomasz SZCZURASZEK; Jan KEMPA

    2016-01-01

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

  19. Total safety management: An approach to improving safety culture

    International Nuclear Information System (INIS)

    Blush, S.M.

    1993-01-01

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

  20. Technical specification improvement through safety margin considerations

    International Nuclear Information System (INIS)

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

    1986-01-01

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

  1. An optimization model for improving highway safety

    Directory of Open Access Journals (Sweden)

    Promothes Saha

    2016-12-01

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

  2. Nuclear safety in Slovak Republic. Status of safety improvements

    International Nuclear Information System (INIS)

    Toth, A.

    1999-01-01

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

  3. Research on the improvement of nuclear safety

    International Nuclear Information System (INIS)

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

    1993-06-01

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

  4. Current collectors for improved safety

    Science.gov (United States)

    Abdelmalak, Michael Naguib; Allu, Srikanth; Dudney, Nancy J.; Li, Jianlin; Simunovic, Srdjan; Wang, Hsin

    2017-12-19

    A battery electrode assembly includes a current collector with conduction barrier regions having a conductive state in which electrical conductivity through the conduction barrier region is permitted, and a safety state in which electrical conductivity through the conduction barrier regions is reduced. The conduction barrier regions change from the conductive state to the safety state when the current collector receives a short-threatening event. An electrode material can be connected to the current collector. The conduction barrier regions can define electrical isolation subregions. A battery is also disclosed, and methods for making the electrode assembly, methods for making a battery, and methods for operating a battery.

  5. Mochovce NPP safety improvement and completion

    International Nuclear Information System (INIS)

    1997-01-01

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

  6. Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

    Science.gov (United States)

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

    2014-10-01

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

  7. Safety Significance of the Halden IFA-650 LOCA Test Results

    International Nuclear Information System (INIS)

    Fuketa, Toyoshi; Nagase, Fumihisa; Grandjean, Claude; Petit, Marc; Hozer, Zoltan; Kelppe, Seppo; Khvostov, Grigori; Hafidi, Biya; Therache, Benjamin; Heins, Lothar; Valach, Mojmir; Voglewede, John; Wiesenack, Wolfgang

    2010-01-01

    CSNI therefore posed the question to the Working Group on Fuel Safety (WGFS): How could the Halden LOCA tests affect regulation? The WGFS agreed that the main safety concern would be fuel dispersal (and hence the potential for loss of coolable geometry) occurring at relatively low temperature, i.e. 800 deg. C. In order to assess the applicability of the IFA-650.4 results to actual power plant situations and the possible impact on safety criteria, a number of aspects should be clarified before considering a safety significance of the Halden IFA-650 series results: - Representativeness for NPP cases - Gas flow - Relocation - Burnup effect - Repeatability - Power history These items will be discussed one by one in this CSNI report. On April 17, 2009, test 650.9 was carried out with 650.4 sibling fuel. The target cladding peak temperature was 1100 deg. C in this case, but otherwise the experimental conditions were very similar. In many respects, 650.9 repeated the 650.4 experiment, e.g. by showing clear signs of fuel relocation which was confirmed by gamma scanning later on. The WGFS therefore decided that 650.9 should be considered as well for this CSNI report. Mention is also made of IFA-650.3, which failed with a small crack in a weak spot induced by thermocouple welding, and IFA-650.5 which involved ballooning and fuel ejection under conditions of restricted gas flow

  8. Can we Improve Patient Safety?

    Directory of Open Access Journals (Sweden)

    Martin Thomas Corbally

    2014-09-01

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

  9. Process safety improvement--quality and target zero.

    Science.gov (United States)

    Van Scyoc, Karl

    2008-11-15

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

  10. Process safety improvement-Quality and target zero

    International Nuclear Information System (INIS)

    Van Scyoc, Karl

    2008-01-01

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

  11. Process safety improvement-Quality and target zero

    Energy Technology Data Exchange (ETDEWEB)

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

    2008-11-15

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

  12. Use of a Surgical Safety Checklist to Improve Team Communication.

    Science.gov (United States)

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

    2016-09-01

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

  13. Sign up to Safety: developing a safety improvement plan.

    Science.gov (United States)

    Dight, Carol; Peters, Hayley

    2015-04-01

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

  14. PROPOSAL OF VOIVODESHIP ROAD SAFETY IMPROVEMENT PROGRAMME

    Directory of Open Access Journals (Sweden)

    Tomasz SZCZURASZEK

    2016-07-01

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

  15. Twenty years of improvements in LWR safety

    International Nuclear Information System (INIS)

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

    1996-01-01

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

  16. Improving the safety and reliability of Monju

    International Nuclear Information System (INIS)

    Itou, Kazumoto; Maeda, Hiroshi; Moriyama, Masatoshi

    1998-01-01

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

  17. Improving patient safety: lessons from rock climbing.

    Science.gov (United States)

    Robertson, Nic

    2012-02-01

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

  18. Audit Report The Procurement of Safety Class/Safety-Significant Items at the Savannah River Site

    International Nuclear Information System (INIS)

    2009-01-01

    The Department of Energy operates several nuclear facilities at its Savannah River Site, and several additional facilities are under construction. This includes the National Nuclear Security Administration's Tritium Extraction Facility (TEF) which is designated to help maintain the reliability of the U.S. nuclear stockpile. The Mixed Oxide Fuel Fabrication Facility (MOX Facility) is being constructed to manufacture commercial nuclear reactor fuel assemblies from weapon-grade plutonium oxide and depleted uranium. The Interim Salt Processing (ISP) project, managed by the Office of Environmental Management, will treat radioactive waste. The Department has committed to procuring products and services for nuclear-related activities that meet or exceed recognized quality assurance standards. Such standards help to ensure the safety and performance of these facilities. To that end, it issued Departmental Order 414.1C, Quality Assurance (QA Order). The QA Order requires the application of Quality Assurance Requirements for Nuclear Facility Applications (NQA-1) for nuclear-related activities. The NQA-1 standard provides requirements and guidelines for the establishment and execution of quality assurance programs during the siting, design, construction, operation, and decommissioning of nuclear facilities. These requirements, promulgated by the American Society of Mechanical Engineers, must be applied to 'safety-class' and 'safety-significant' structures, systems and components (SSCs). Safety-class SSCs are defined as those necessary to prevent exposure off site and to protect the public. Safety-significant SSCs are those whose failure could irreversibly impact worker safety such as a fatality, serious injury, or significant radiological or chemical exposure. Due to the importance of protecting the public, workers, and environment, we initiated an audit to determine whether the Department of Energy procured safety-class and safety-significant SSCs that met NQA-1 standards at

  19. Recipe Modification Improves Food Safety Practices during Cooking of Poultry.

    Science.gov (United States)

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

    2016-08-01

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

  20. Safety culture improvement. An adaptive management framework

    International Nuclear Information System (INIS)

    Obadia, Isaac Jose

    2005-01-01

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

  1. Health innovation for patient safety improvement

    Directory of Open Access Journals (Sweden)

    Renukha Sellappans

    2013-01-01

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

  2. Health innovation for patient safety improvement.

    Science.gov (United States)

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

    2013-01-01

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

  3. Improving the safety of LWR power plants. Final report

    International Nuclear Information System (INIS)

    1980-04-01

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

  4. How to improve safety of laparoscopic cholecystectomy

    Directory of Open Access Journals (Sweden)

    ZHANG Yong

    2013-06-01

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

  5. Operational safety improvement in OPR 1000

    International Nuclear Information System (INIS)

    Jung, Y.-E.

    2005-01-01

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

  6. Significance of Waterway Navigation Positioning Systems On Ship's Manoeuvring Safety

    Science.gov (United States)

    Galor, W.

    The main goal of navigation is to lead the ship to the point of destination safety and efficiently. Various factors may affect ship realisating this process. The ship movement on waterway are mainly limited by water area dimensions (surface and depth). These limitations cause the requirement to realise the proper of ship movement trajectory. In case when this re requirement cant't fulfil then marine accident may happend. This fact is unwanted event caused losses of human health and life, damage or loss of cargo and ship, pollution of natural environment, damage of port structures or blocking the port of its ports and lost of salvage operation. These losses in same cases can be catas- trophical especially while e.i. crude oil spilling could be place. To realise of safety navigation process is needed to embrace the ship's movement trajectory by waterways area. The ship's trajectory is described by manoeuvring lane as a surface of water area which is require to realise of safety ship movement. Many conditions affect to ship manoeuvring line. The main are following: positioning accuracy, ship's manoeuvring features and phenomena's of shore and ship's bulk common affecting. The accuracy of positioning system is most important. This system depends on coast navigation mark- ing which can range many kinds of technical realisation. Mainly used systems based on lights (line), radionavigation (local system or GPS, DGPS), or radars. If accuracy of positiong is higer, then safety of navigation is growing. This article presents these problems exemplifying with approaching channel to ports situated on West Pomera- nian water region.

  7. THE FLUORBOARD A STATISTICALLY BASED DASHBOARD METHOD FOR IMPROVING SAFETY

    International Nuclear Information System (INIS)

    PREVETTE, S.S.

    2005-01-01

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

  8. A BWR Safety and Operability Improvements

    International Nuclear Information System (INIS)

    Sawyer, Craig D.

    1993-01-01

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

  9. A tool for safety evaluations of road improvements.

    Science.gov (United States)

    Peltola, Harri; Rajamäki, Riikka; Luoma, Juha

    2013-11-01

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

  10. Transportation Safety Excellence in Operations Through Improved Transportation Safety Document

    International Nuclear Information System (INIS)

    Dr. Michael A. Lehto; MAL

    2007-01-01

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

  11. NPP Temelin. Status of safety improvements

    International Nuclear Information System (INIS)

    1999-01-01

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

  12. Ways of improving safety for future PWRs in France

    International Nuclear Information System (INIS)

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

    1994-06-01

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

  13. Most significant preliminary results of the probabilistic safety analysis on the Juragua nuclear power plant

    International Nuclear Information System (INIS)

    Perdomo, Manuel

    1995-01-01

    Since 1990 the Group for PSA Development and Applications (GDA/APS) is working on the Level-1 PSA for the Juragua-1 NPP, as a part of an IAEA Technical Assistance Project. The main objective of this study, which is still under way, is to assess, in a preliminary way, the Reactor design safety to find its potential 'weak points' at the construction stage, using a eneric data base. At the same time, the study allows the PSA team to familiarize with the plant design and analysis techniques for the future operational PSA of the plant. This paper presents the most significant preliminary results of the study, which reveal some advantages of the safety characteristics of the plant design in comparison with the homologous VVER-440 reactors and some areas, where including slight modifications would improve the plant safety, considering the level of detail at which the study is carried out. (author). 13 refs, 1 fig, 2 tabs

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

    Science.gov (United States)

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

    2013-10-01

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

  15. Patient Education May Improve Perioperative Safety.

    NARCIS (Netherlands)

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

    2016-01-01

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

  16. Significant Guidance Issued by the Federal Motor Carrier Safety Administration

    Data.gov (United States)

    Department of Transportation — A list of Significant Guidance documents, which include guidance document disseminated to regulated entities or the general public that may reasonably be anticipated...

  17. Improving nuclear safety of VVER-440 units

    International Nuclear Information System (INIS)

    Nochev, T.; Sabinov, S.

    2001-01-01

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

  18. USSR orders computers to improve nuclear safety

    International Nuclear Information System (INIS)

    Anon.

    1990-01-01

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

  19. Improving patient safety in radiation oncology

    International Nuclear Information System (INIS)

    Hendee, William R.; Herman, Michael G.

    2011-01-01

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

  20. Inhaler Reminders Significantly Improve Asthma Patients' Use of Controller Medications

    Science.gov (United States)

    ... controller medications Share | Inhaler reminders significantly improve asthma patients’ use of controller medications Published Online: July 22, ... the burden and risk of asthma, but many patients do not use them regularly. This poor adherence ...

  1. Significant improvement in the thermal annealing process of optical resonators

    Science.gov (United States)

    Salzenstein, Patrice; Zarubin, Mikhail

    2017-05-01

    Thermal annealing performed during process improves the quality of the roughness of optical resonators reducing stresses at the periphery of their surface thus allowing higher Q-factors. After a preliminary realization, the design of the oven and the electronic method were significantly improved thanks to nichrome resistant alloy wires and chopped basalt fibers for thermal isolation during the annealing process. Q-factors can then be improved.

  2. Do clinical safety charts improve paramedic key performance indicator results? (A clinical improvement programme evaluation).

    Science.gov (United States)

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

    2012-07-01

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

  3. ELECTRICAL SAFETY IMPROVEMENT PROJECT A COMPLEX WIDE TEAMING INITIATIVE

    Energy Technology Data Exchange (ETDEWEB)

    GRAY BJ

    2007-11-26

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

  4. Housing improvement and home safety Effectiveness Matters

    OpenAIRE

    , Crd; Sphr@, L; , MrcSphsu

    2014-01-01

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

  5. Improving patient safety through quality assurance.

    Science.gov (United States)

    Raab, Stephen S

    2006-05-01

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

  6. Advanced power reactors with improved safety characteristics

    International Nuclear Information System (INIS)

    Birkhofer, A.

    1994-01-01

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

  7. Speech Recognition Interfaces Improve Flight Safety

    Science.gov (United States)

    2013-01-01

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

  8. Improving the safety of fresh fruit and vegetables

    NARCIS (Netherlands)

    Jongen, W.M.F.

    2005-01-01

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

  9. Continuous restraint control systems: safety improvement for various occupants

    NARCIS (Netherlands)

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

    2009-01-01

    Occupant safety can be significantly improved by continuous restraint control systems. These restraint systems adjust their configuration during the impact according to the actual operating conditions, such as occupant size, weight, occupant position, belt usage and crash severity. In this study,

  10. Improvements in operational safety performance of the Magnox power stations

    Energy Technology Data Exchange (ETDEWEB)

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

    2000-10-01

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

  11. Significance of coast down time on safety and availability of a pool type fast breeder reactor

    International Nuclear Information System (INIS)

    Natesan, K.; Velusamy, K.; Selvaraj, P.; Chellapandi, P.

    2015-01-01

    Highlights: • Plant dynamics studies for quantifying the benefits of flow coast down time. • Establishment of minimum flow coast down time required for safety. • Assessment of influence of flow coast down on enhancing plant availability. • Synthesis of thermo mechanical benefits of flow coast down time on component design. - Abstract: Plant dynamic investigation towards establishing the influence of flow coast down time of primary and secondary sodium systems on safety and availability of plant has been carried out based on one dimensional analysis. From safety considerations, a minimum flow coast down time for primary sodium circuit is essential to be provided to limit the consequences of loss of flow event within allowable limits. Apart from safety benefits, large primary coast down time also improves plant availability by the elimination of reactor SCRAM during short term power failure events. Threshold values of SCRAM parameters also need optimization. By suitably selecting the threshold values for SCRAM parameters, significant reduction in the inertia of pumping systems can be derived to obtain desirable results on plant availability. With the optimization of threshold values and primary flow coast down behaviour equivalent to a halving time of 8 s, there is a possibility to eliminate reactor SCRAM during short term power failure events extending up to 0.75 s duration. Benefits of secondary flow halving on reducing transient thermal loading on components have also been investigated and mixed effects have been observed

  12. Improved obstetric safety through programmatic collaboration.

    Science.gov (United States)

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

    2014-01-01

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

  13. How to Improve Patient Safety Culture in Croatian Hospitals?

    Science.gov (United States)

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

    2016-09-01

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

  14. Organizational factors influencing improvements in safety

    International Nuclear Information System (INIS)

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

    1991-01-01

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

  15. BRICS: opportunities to improve road safety.

    Science.gov (United States)

    Hyder, Adnan A; Vecino-Ortiz, Andres I

    2014-06-01

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

  16. Improving ICU risk management and patient safety.

    Science.gov (United States)

    Kielty, Lucy Ann

    2017-06-12

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

  17. CORPORATE CULTURE AS A TOOL TO IMPROVE SAFETY CULTURE

    Directory of Open Access Journals (Sweden)

    Erika SUJOVÁ

    2013-07-01

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

  18. Training directionally selective motion pathways can significantly improve reading efficiency

    Science.gov (United States)

    Lawton, Teri

    2004-06-01

    This study examined whether perceptual learning at early levels of visual processing would facilitate learning at higher levels of processing. This was examined by determining whether training the motion pathways by practicing leftright movement discrimination, as found previously, would improve the reading skills of inefficient readers significantly more than another computer game, a word discrimination game, or the reading program offered by the school. This controlled validation study found that practicing left-right movement discrimination 5-10 minutes twice a week (rapidly) for 15 weeks doubled reading fluency, and significantly improved all reading skills by more than one grade level, whereas inefficient readers in the control groups barely improved on these reading skills. In contrast to previous studies of perceptual learning, these experiments show that perceptual learning of direction discrimination significantly improved reading skills determined at higher levels of cognitive processing, thereby being generalized to a new task. The deficits in reading performance and attentional focus experienced by the person who struggles when reading are suggested to result from an information overload, resulting from timing deficits in the direction-selectivity network proposed by Russell De Valois et al. (2000), that following practice on direction discrimination goes away. This study found that practicing direction discrimination rapidly transitions the inefficient 7-year-old reader to an efficient reader.

  19. Monitoring System For Improving Radiation Safety Management

    International Nuclear Information System (INIS)

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

    1999-01-01

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

  20. Improving occupational safety in Kuzbass mines

    Energy Technology Data Exchange (ETDEWEB)

    Evseev, V S

    1986-08-01

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

  1. Current activities on safety improvement at Ukrainian NPPs

    International Nuclear Information System (INIS)

    Stovbun, V.V.

    2000-01-01

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

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

    Science.gov (United States)

    1998-08-26

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

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

    Science.gov (United States)

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

    2017-08-02

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

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

    International Nuclear Information System (INIS)

    Tsutsumi, Ryosuke

    2001-01-01

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

  5. Significant Improvement of Catalytic Efficiencies in Ionic Liquids

    International Nuclear Information System (INIS)

    Song, Choong Eui; Yoon, Mi Young; Choi, Doo Seong

    2005-01-01

    The use of ionic liquids as reaction media can confer many advantages upon catalytic reactions over reactions in organic solvents. In ionic liquids, catalysts having polar or ionic character can easily be immobilized without additional structural modification and thus the ionic solutions containing the catalyst can easily be separated from the reagents and reaction products, and then, be reused. More interestingly, switching from an organic solvent to an ionic liquid often results in a significant improvement in catalytic performance (e.g., rate acceleration, (enantio)selectivity improvement and an increase in catalyst stability). In this review, some recent interesting results which can nicely demonstrate these positive 'ionic liquid effect' on catalysis are discussed

  6. Plutonium Finishing Plant (PFP) Safety Class and Safety Significant Commercial Grade Items (CGI) Critical Characteristic

    International Nuclear Information System (INIS)

    THOMAS, R.J.

    2000-01-01

    This document specifies the critical characteristics for Commercial Grade Items (CGI) procured for use in the Plutonium Finishing Plant as required by HNF-PRO-268 and HNF-PRO-1819. These are the minimum specifications that the equipment must meet in order to properly perform its safety function. There may be several manufacturers or models that meet the critical characteristics of any one item

  7. Bedtime Blood Pressure Chronotherapy Significantly Improves Hypertension Management.

    Science.gov (United States)

    Hermida, Ramón C; Ayala, Diana E; Fernández, José R; Mojón, Artemio; Crespo, Juan J; Ríos, María T; Smolensky, Michael H

    2017-10-01

    Consistent evidence of numerous studies substantiates the asleep blood pressure (BP) mean derived from ambulatory BP monitoring (ABPM) is both an independent and a stronger predictor of cardiovascular disease (CVD) risk than are daytime clinic BP measurements or the ABPM-determined awake or 24-hour BP means. Hence, cost-effective adequate control of sleep-time BP is of marked clinical relevance. Ingestion time, according to circadian rhythms, of hypertension medications of 6 different classes and their combinations significantly improves BP control, particularly sleep-time BP, and reduces adverse effects. Copyright © 2017 Elsevier Inc. All rights reserved.

  8. [Improvement of Phi bodies stain and its clinical significance].

    Science.gov (United States)

    Gong, Xu-Bo; Lu, Xing-Guo; Yan, Li-Juan; Xiao, Xi-Bin; Wu, Dong; Xu, Gen-Bo; Zhang, Xiao-Hong; Zhao, Xiao-Ying

    2009-02-01

    The aim of this study was to improve the dyeing method of hydroperoxidase (HPO), to analyze the morphologic features of Phi bodies and to evaluate the clinical application of this method. 128 bone marrow or peripheral blood smears from patients with myeloid and lymphoid malignancies were stained by improved HPO staining. The Phi bodies were observed with detection rate of Phi bodies in different leukemias. 69 acute myeloid leukemia (AML) specimens were chosen randomly, the positive rate and the number of Phi bodies between the improved HPO and POX stain based on the same substrate of 3, 3'diaminobenzidine were compared. The results showed that the shape of bundle-like Phi bodies was variable, long or short. while the nubbly Phi bodies often presented oval and smooth. Club-like Phi bodies were found in M(3). The detection rates of bundle-like Phi bodies in AML M(1)-M(5) were 42.9% (6/14), 83.3% (15/18), 92.0% (23/25), 52.3% (11/21), 33.3% (5/15) respectively, and those of nubbly Phi bodies were 28.6% (4/14), 66.7% (12/18), 11.1% (3/25), 33.3% (7/21), 20.0% (3/15) respectively. The detection rate of bundle-like Phi bodies in M(3) was significantly higher than that in (M(1) + M(2)) or (M(4) + M(5)) groups. The detection rate of nubbly Phi bodies in (M(1) + M(2)) group was higher than that in M(3) group. In conclusion, after improvement of staining method, the HPO stain becomes simple, the detection rate of Phi bodies is higher than that by the previous method, the positive granules are more obvious, and the results become stable. This improved method plays an important role in differentiating AML from ALL, subtyping AML, and evaluating the therapeutic results.

  9. Research reactor management. Safety improvement activities in HANARO

    International Nuclear Information System (INIS)

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

    2012-01-01

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

  10. 78 FR 48029 - Improving Chemical Facility Safety and Security

    Science.gov (United States)

    2013-08-07

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

  11. Critical Characteristics of Radiation Detection System Components to be Dedicated for use in Safety Class and Safety Significant System

    International Nuclear Information System (INIS)

    DAVIS, S.J.

    2000-01-01

    This document identifies critical characteristics of components to be dedicated for use in Safety Significant (SS) Systems, Structures, or Components (SSCs). This document identifies the requirements for the components of the common, radiation area, monitor alarm in the WESF pool cell. These are procured as Commercial Grade Items (CGI), with the qualification testing and formal dedication to be performed at the Waste Encapsulation Storage Facility (WESF) for use in safety significant systems. System modifications are to be performed in accordance with the approved design. Components for this change are commercially available and interchangeable with the existing alarm configuration This document focuses on the operational requirements for alarm, declaration of the safety classification, identification of critical characteristics, and interpretation of requirements for procurement. Critical characteristics are identified herein and must be verified, followed by formal dedication, prior to the components being used in safety related applications

  12. Safety improvement technologies for nuclear power generation

    International Nuclear Information System (INIS)

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

    2015-01-01

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

  13. A Scholarly Pathway in Quality Improvement and Patient Safety.

    Science.gov (United States)

    Ferguson, Catherine C; Lamb, Geoffrey

    2015-10-01

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

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

    Science.gov (United States)

    Gavriloff, Carrie

    2012-08-01

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

  15. Ullage Compatible Optical Sensor for Monitoring Safety Significant Malfunctions, Phase II

    Data.gov (United States)

    National Aeronautics and Space Administration — Significant emphasis has been placed on aircraft fuel tank safety following the TWA Flight 800 accident in July 1996. Upon investigation, the National Transportation...

  16. Economic approaches to measuring the significance of food safety in international trade.

    Science.gov (United States)

    Caswell, J A

    2000-12-20

    International trade in food products has expanded rapidly in recent years. This paper presents economic approaches for analyzing the effects on trade in food products of the food safety requirements of governments and private buyers. Important economic incentives for companies to provide improved food safety arise from (1) public incentives such as ex ante requirements for sale of a product with sufficient quality and ex post penalties (liability) for sale of products with deficient quality, and (2) private incentives for producing quality such as internal performance goals (self-regulation) and the external (certification) requirements of buyers. The World Trade Organization's Sanitary Phytosanitary Agreement facilitates scrutiny of the benefits and costs of country-level regulatory programs and encourages regulatory rapprochement on food safety issues. Economists can help guide risk management decisions by providing estimates of the benefits and costs of programs to improve food safety and by analyzing their effect on trade in food products.

  17. Ceramic Composite Intermediate Temperature Stress-Rupture Properties Improved Significantly

    Science.gov (United States)

    Morscher, Gregory N.; Hurst, Janet B.

    2002-01-01

    Silicon carbide (SiC) composites are considered to be potential materials for future aircraft engine parts such as combustor liners. It is envisioned that on the hot side (inner surface) of the combustor liner, composites will have to withstand temperatures in excess of 1200 C for thousands of hours in oxidizing environments. This is a severe condition; however, an equally severe, if not more detrimental, condition exists on the cold side (outer surface) of the combustor liner. Here, the temperatures are expected to be on the order of 800 to 1000 C under high tensile stress because of thermal gradients and attachment of the combustor liner to the engine frame (the hot side will be under compressive stress, a less severe stress-state for ceramics). Since these composites are not oxides, they oxidize. The worst form of oxidation for strength reduction occurs at these intermediate temperatures, where the boron nitride (BN) interphase oxidizes first, which causes the formation of a glass layer that strongly bonds the fibers to the matrix. When the fibers strongly bond to the matrix or to one another, the composite loses toughness and strength and becomes brittle. To increase the intermediate temperature stress-rupture properties, researchers must modify the BN interphase. With the support of the Ultra-Efficient Engine Technology (UEET) Program, significant improvements were made as state-of-the-art SiC/SiC composites were developed during the Enabling Propulsion Materials (EPM) program. Three approaches were found to improve the intermediate-temperature stress-rupture properties: fiber-spreading, high-temperature silicon- (Si) doped boron nitride (BN), and outside-debonding BN.

  18. Continuous improvement of the MHTGR safety and competitive performance

    International Nuclear Information System (INIS)

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

    1992-05-01

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

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

    Science.gov (United States)

    Momani, Amer; Hirzallah, Muʼath; Mumani, Ahmad

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

  20. Public safety risk management at socio-economic and / or historic-cultural significant dam sites

    Energy Technology Data Exchange (ETDEWEB)

    Earle, Gordon D.; Ryan, Katherine; Pyykonen, Nicole K.; Pitts, Lucas [Otonabee Region Conservation Authority, Peterborough, (Canada)

    2010-07-01

    The Lang Dam and adjoining gristmill, located near Peterborough are integral parts of the Lang Pioneer Village museum. Activities occurring within close proximity to the dam have led to safety issues. The owner (ORCA) has developed and implemented public safety management plans (PSMPs) for each of its water control structures, including the Lang Dam. ORCA gave special attention to the social, economic, aesthetic, historic and cultural dimensions associated the implementation of public safety management plans. These factors play a significant role in how well public safety measures (PSMs) are received by stakeholder groups and the general public. This paper reported the challenges of developing and implementing a PSMP for the Lang Dam, with the focus on property site-specific PSMS while preserving socio-economic and historic-cultural character and values. It was demonstrated that the dam owners, regulatory authorities, control agencies and preservationists need to come together to develop a holistic public safety management process.

  1. Intervention improves physician counseling on teen driving safety.

    Science.gov (United States)

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

    2009-07-01

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

  2. Improving Safety through Human Factors Engineering.

    Science.gov (United States)

    Siewert, Bettina; Hochman, Mary G

    2015-10-01

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

  3. Improved inherent safety in liquid fuel reactors

    International Nuclear Information System (INIS)

    Taube, M.

    1982-01-01

    The molten salt reactor system divided into core (thermal and fast) and breeding zone (fission breeder reactor, fusion hybrid system, accelerator-spallation system) has some unique inherent safety properties: a) reduced inventory of fission products during normal operation due to on-line chemical reprocessing and in-core gas purging; b) fast removal of freshly bred fissile nuclides and fission products from the breeding zone (the so called suppressed fission system); c) pressureless fuel and primary coolant system; d) elimination of the possibility of a violent exoenergetic chemical reaction with air, water or metals; e) elimination of the possibility of gaseous hydrogen production during an accident; f) provides a non-engineered feature of dumping of fuel from the core and heat exchanger to a safe drain tank; g) presence of a large heat sink in the form of an inactive diluent salt; h) possibility of natural convection heat removal during an accident and even normal operation (by means of gas lifting); i) dissipation of the remaining decayheat by spraying water on the containment from outside, which allows to manage the worst accident; i) Even in the case of the destruction in the war by conventional or nuclear weapon the contaminated land is significantly reduced. The world-wide present activity in the field of molten salt technology is reviewed. (orig.)

  4. Improving the safety of future nuclear fission power plants

    International Nuclear Information System (INIS)

    Frisch, W.; Gros, G.

    2001-01-01

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

  5. Quantifying the effectiveness of ITS in improving safety of VRUs

    NARCIS (Netherlands)

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

    2017-01-01

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

  6. To improve nuclear plant safety by learning from accident's experience

    International Nuclear Information System (INIS)

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

    1994-01-01

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

  7. Improving commercial motor vehicle safety in Oregon.

    Science.gov (United States)

    2010-08-01

    This study addressed the primary functions of the Oregon Department of Transportations (ODOTs) Motor Carrier Safety Assistance Program (MCSAP), which is administered by the Motor Carrier Transportation Division (MCTD). The study first documente...

  8. Improving road safety: Experiences from the Netherlands

    OpenAIRE

    Hagenzieker, M.P.

    2012-01-01

    Dr. Hagenzieker's research and education activities focus on the road safety effects of the transport system, with particular interest in road user behaviour aspects. Her PhD-research was on the effects of rewards on road user behaviour.

  9. Improving the rationality of nuclear safety regulations

    International Nuclear Information System (INIS)

    Choi, Byung Sun; Choi, Y. G.; Mun, G. H.

    2005-03-01

    This study focuses on human nature and institutions around the risk management in Korean Nuclear Installations. Nuclear safety regulatory system in Korea has had a tendency to overvalue the technical or engineering areas. But just like other risk management system, the knowledge of social science is also required to design more valid safety regulatory system. As a result of analysis, this study suggest that performance regulation need to be introduced to current nuclear safety regulation system. In this advanced regulatory system, each nuclear generation unit have to be evaluated by performance of its own regulatory implementation and would be treated differently by the performance. Additionally, self-regulation could be very effective was to guarantee nuclear safety. Because KHNP could be judged to have an considerable capabilities to manage its own regulatory procedures. To make self-regulatory system established successfully, it is also important to arrange the appropriate incentive and compensate structures

  10. A generic standard for assessing and managing activities with significant risk to health and safety

    International Nuclear Information System (INIS)

    Wilde, T.S.; Sandquist, G.M.

    2005-01-01

    Some operations and activities in industry, business, and government can present an unacceptable risk to health and safety if not performed according to established safety practices and documented procedures. The nuclear industry has extensive experience and commitment to assessing and controlling such risks. This paper provides a generic standard based upon DOE Standard DOE-STD-3007- 93, Nov 1993, Change Notice No. 1, Sep 1998. This generic standard can be used to assess practices and procedures employed by any industrial and government entity to ensure that an acceptable level of safety and control prevail for such operations. When any activity and operation is determined to involve significant risk to health and safety to workers or the public, the organization should adopt and establish an appropriate standard and methodology to ensure that adequate health and safety prevail. This paper uses DOE experience and standards to address activities with recognized potential for impact upon health and safety. Existing and future assessments of health and safety issues can be compared and evaluated against this generic standard for insuring that proper planning, analysis, review, and approval have been made. (authors)

  11. Experience of safety and performance improvement for fuel handling equipment

    International Nuclear Information System (INIS)

    Gyoon Chang, Sang; Hee Lee, Dae

    2014-01-01

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

  12. Applying principles from safety science to improve child protection.

    Science.gov (United States)

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

    2013-01-01

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

  13. Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice.

    Science.gov (United States)

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

    2017-11-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2012-10-15

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

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

    Science.gov (United States)

    Nielsen, Kent J

    2014-02-01

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

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

    International Nuclear Information System (INIS)

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

    2012-01-01

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

  17. Methylphenidate significantly improves declarative memory functioning of adults with ADHD.

    NARCIS (Netherlands)

    Verster, J.C.; Bekker, E.M.; Kooij, J.J.; Buitelaar, J.K.; Verbaten, M.N.; Volkerts, E.R.; Olivier, B.

    2010-01-01

    BACKGROUND: Declarative memory deficits are common in untreated adults with attention-deficit hyperactivity disorder (ADHD), but limited evidence exists to support improvement after treatment with methylphenidate. The objective of this study was to examine the effects of methylphenidate on memory

  18. Improvement of Managers’ Safety Knowledge through Scientifically Reasonable Interviews

    Directory of Open Access Journals (Sweden)

    Paas Õnnela

    2015-11-01

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

  19. Gap Analysis Approach for Construction Safety Program Improvement

    Directory of Open Access Journals (Sweden)

    Thanet Aksorn

    2007-06-01

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

  20. Radiotherapy professionals faced with the obligation of treatments safety improvement

    International Nuclear Information System (INIS)

    2011-01-01

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

  1. Knowledge Management Methodologies for Improving Safety Culture

    International Nuclear Information System (INIS)

    Rusconi, C.

    2016-01-01

    Epistemic uncertainties could affect operator’s capability to prevent rare but potentially catastrophic accident sequences. Safety analysis methodologies are powerful but fragile tools if basic assumptions are not sound and exhaustive. In particular, expert judgments and technical data could be invalidated by organizational context change (e.g., maintenance planning, supply systems etc.) or by unexpected events. In 1986 accidents like Chernobyl, the explosion of Shuttle Challenger and, two years before, the toxic release at Bhopal chemical plant represented the point of no return with respect to the previous vision of safety and highlighted the undelayable need to change paradigm and face safety issues in complex systems not only from a technical point of view but to adopt a systemic vision able to include and integrate human and organizational aspects.

  2. Can a robot improve mine safety?

    CSIR Research Space (South Africa)

    Green, JJ

    2010-09-01

    Full Text Available Safety in mines is of paramount importance, especially in the labour intensive operations of South Africa, where upward of 300 000 people are employed on a daily basis in an environment that is inherently dangerous. On average approximately 50...

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

    International Nuclear Information System (INIS)

    Shevaldin, V.

    1997-01-01

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

  4. Creating a Middle Grades Environment that Significantly Improves Student Achievement

    Science.gov (United States)

    L'Esperance, Mark E.; Lenker, Ethan; Bullock, Ann; Lockamy, Becky; Mason, Cathy

    2013-01-01

    This article offers an overview of the framework that Sampson County Public Schools (North Carolina) used to critically reflect on the current state of their middle grades schools. The article also highlights the changes that resulted from the district-wide analysis and the ways in which these changes led to a significant increase in the academic…

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2005-07-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2005-07-01

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

  7. Application of the AHP method to analyze the significance of the factors affecting road traffic safety

    Directory of Open Access Journals (Sweden)

    Justyna SORDYL

    2015-06-01

    Full Text Available Over the past twenty years, the number of vehicles registered in Poland has grown rapidly. At the same time, a relatively small increase in the length of the road network has been observed. As a result of the limited capacity of available infrastructure, it leads to significant congestion and to increase of the probability of road accidents. The overall level of road safety depends on many factors - the behavior of road users, infrastructure solutions and the development of automotive technology. Thus the detailed assessment of the importance of individual elements determining road safety is difficult. The starting point is to organize the factors by grouping them into categories which are components of the DVE system (driver - vehicle - environment. In this work, to analyze the importance of individual factors affecting road safety, the use of analytic hierarchy process method (AHP was proposed. It is one of the multi-criteria methods which allows us to perform hierarchical analysis of the decision process, by means of experts’ opinions. Usage of AHP method enabled us to evaluate and rank the factors affecting road safety. This work attempts to link the statistical data and surveys in significance analysis of the elements determining road safety.

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

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1999-06-01

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

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

    International Nuclear Information System (INIS)

    1999-06-01

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

  10. A word from the DG: Improved safety at CERN

    CERN Multimedia

    2006-01-01

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

  11. Low-dose vaporized cannabis significantly improves neuropathic pain.

    Science.gov (United States)

    Wilsey, Barth; Marcotte, Thomas; Deutsch, Reena; Gouaux, Ben; Sakai, Staci; Donaghe, Haylee

    2013-02-01

    We conducted a double-blind, placebo-controlled, crossover study evaluating the analgesic efficacy of vaporized cannabis in subjects, the majority of whom were experiencing neuropathic pain despite traditional treatment. Thirty-nine patients with central and peripheral neuropathic pain underwent a standardized procedure for inhaling medium-dose (3.53%), low-dose (1.29%), or placebo cannabis with the primary outcome being visual analog scale pain intensity. Psychoactive side effects and neuropsychological performance were also evaluated. Mixed-effects regression models demonstrated an analgesic response to vaporized cannabis. There was no significant difference between the 2 active dose groups' results (P > .7). The number needed to treat (NNT) to achieve 30% pain reduction was 3.2 for placebo versus low-dose, 2.9 for placebo versus medium-dose, and 25 for medium- versus low-dose. As these NNTs are comparable to those of traditional neuropathic pain medications, cannabis has analgesic efficacy with the low dose being as effective a pain reliever as the medium dose. Psychoactive effects were minimal and well tolerated, and neuropsychological effects were of limited duration and readily reversible within 1 to 2 hours. Vaporized cannabis, even at low doses, may present an effective option for patients with treatment-resistant neuropathic pain. The analgesia obtained from a low dose of delta-9-tetrahydrocannabinol (1.29%) in patients, most of whom were experiencing neuropathic pain despite conventional treatments, is a clinically significant outcome. In general, the effect sizes on cognitive testing were consistent with this minimal dose. As a result, one might not anticipate a significant impact on daily functioning. Published by Elsevier Inc.

  12. Development of Safety Significance Evaluation Program for Accidents and Events in NPPs

    International Nuclear Information System (INIS)

    Yang, Hui Chang; Hong, Seok Jin; Cho, Nam Chul; Chung, Dae Wook; Lee, Chang Joo

    2010-01-01

    To evaluate the significance in terms of safety for the accidents and events occurred in nuclear power plants using probabilistic safety assessment techniques can provide useful insights to the regulator. Based on the quantified risk information of accident or event occurred, regulators can decide which regulatory areas should be focused than the others. To support these regulatory analysis activities, KINS-ASP program was developed. KINS-ASP program can supports the risk increase due to the occurred accidents or events by providing the graphic interfaces and linked quantification engines for the PSA experts and non- PSA acquainted regulators both

  13. Cognitive human reliability analysis for an assessment of the safety significance of complex transients

    International Nuclear Information System (INIS)

    Amico, P.J.; Hsu, C.J.; Youngblood, R.W.; Fitzpatrick, R.G.

    1989-01-01

    This paper reports that as part of a probabilistic assessment of the safety significance of complex transients at certain PWR power plants, it was necessary to perform a cognitive human reliability analysis. To increase the confidence in the results, it was desirable to make use of actual observations of operator response which were available for the assessment. An approach was developed which incorporated these observations into the human cognitive reliability (HCR) modeling approach. The results obtained provided additional insights over what would have been found using other approaches. These insights were supported by the observations, and it is suggested that this approach be considered for use in future probabilistic safety assessments

  14. Significance of the existing normative and technical documentation to promote ecologic safety

    OpenAIRE

    Fatima Ermakhanova

    2010-01-01

    The author justifies the need to develop new standards for gas purification process. It is believed that these standards should assume introduction of new resource-saving technologies and also meet the modern international requirements to improve environmental safety. The article shows the need for the introduction and development of environmental management system according to ISO 14000 standards to reduce the industrial impact of gas deposits on the environment.

  15. Use of safety management practices for improving project performance.

    Science.gov (United States)

    Cheng, Eddie W L; Kelly, Stephen; Ryan, Neal

    2015-01-01

    Although site safety has long been a key research topic in the construction field, there is a lack of literature studying safety management practices (SMPs). The current research, therefore, aims to test the effect of SMPs on project performance. An empirical study was conducted in Hong Kong and the data collected were analysed with multiple regression analysis. Results suggest that 3 of the 15 SMPs, which were 'safety committee at project/site level', 'written safety policy', and 'safety training scheme' explained the variance in project performance significantly. Discussion about the impact of these three SMPs on construction was provided. Assuring safe construction should be an integral part of a construction project plan.

  16. Using game theory to improve safety within chemical industrial parks

    CERN Document Server

    Reniers, Genserik

    2013-01-01

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

  17. Low Dose Vaporized Cannabis Significantly Improves Neuropathic Pain

    Science.gov (United States)

    Wilsey, Barth; Marcotte, Thomas D.; Deutsch, Reena; Gouaux, Ben; Sakai, Staci; Donaghe, Haylee

    2013-01-01

    We conducted a double-blind, placebo-controlled, crossover study evaluating the analgesic efficacy of vaporized cannabis in subjects, the majority of whom were experiencing neuropathic pain despite traditional treatment. Thirty-nine patients with central and peripheral neuropathic pain underwent a standardized procedure for inhaling either medium dose (3.53%), low dose (1.29%), or placebo cannabis with the primary outcome being VAS pain intensity. Psychoactive side-effects, and neuropsychological performance were also evaluated. Mixed effects regression models demonstrated an analgesic response to vaporized cannabis. There was no significant difference between the two active dose groups’ results (p>0.7). The number needed to treat (NNT) to achieve 30% pain reduction was 3.2 for placebo vs. low dose, 2.9 for placebo vs. medium dose, and 25 for medium vs. low dose. As these NNT are comparable to those of traditional neuropathic pain medications, cannabis has analgesic efficacy with the low dose being, for all intents and purposes, as effective a pain reliever as the medium dose. Psychoactive effects were minimal and well-tolerated, and neuropsychological effects were of limited duration and readily reversible within 1–2 hours. Vaporized cannabis, even at low doses, may present an effective option for patients with treatment-resistant neuropathic pain. PMID:23237736

  18. Improving Patient Safety Culture in Primary Care: A Systematic Review

    NARCIS (Netherlands)

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

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

  19. Application of VR and HF technologies for improving industrial safety

    NARCIS (Netherlands)

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

    2007-01-01

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

  20. Nature-based strategies for improving urban health and safety

    Science.gov (United States)

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

    2015-01-01

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

  1. Improving Patient Safety With the Military Electronic Health Record

    National Research Council Canada - National Science Library

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

    2005-01-01

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

  2. TEL4Health – Mobile tools to improve patient safety

    NARCIS (Netherlands)

    Drachsler, Hendrik; Kalz, Marco; Specht, Marcus

    2013-01-01

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

  3. Improving safety through quality management system: SINAGAMA experience

    International Nuclear Information System (INIS)

    Muhammad Lebai Juri

    2000-01-01

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

  4. Federal Aviation Administration weather program to improve aviation safety

    Science.gov (United States)

    Wedan, R. W.

    1983-01-01

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

  5. 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

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

    Science.gov (United States)

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

    2017-11-01

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

  7. Improving patient safety in radiology: a work in progress

    International Nuclear Information System (INIS)

    Sze, Raymond W.

    2008-01-01

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

  8. Enhancement of pressurizer safety valve operability by seating design improvement

    International Nuclear Information System (INIS)

    Moisidis, N.T.; Ratiu, M.D.

    1995-01-01

    Operating conditions specific to pressurizer safety valves (PSVs) have led to numerous problems and have caused industry and NRC concerns regarding the adequacy of spring-loaded self-actuated safety valves for reactor coolant system (RCS) overpressure protection. Specific concerns are: setpoint drift, spurious actuations, and pressure protection. Specific concerns are: setpoint drift, spurious actuations, and leakage. Based on testing and valve construction analysis of a Crosby model 6M6 PSV (Moisidis and Ratiu, 1992), it was established that the primary contributor to the valve problems is a susceptibility to weak seating. To eliminate spring instability, a new spring washer was designed, which guides the spring and precludes its rotation from the reference installed position. Results of tests performed on a prototype PSV equipped with the modified upper spring washer has shown significant improvements in valve operability and a consistent setpoint reproducibility to less than ±1% of the PSV setpoint (testing of baseline, unmodified valve, resulted in a setpoint drift of ± 2%). Enhanced valve operability will result in a significant decrease in operating and maintenance costs associated with valve maintenance and testing. In addition, the enhanced setpoint reproducibility will allow the development of a nitrogen to steam correlation for future in-house PSV testing which will result in further reductions in costs associated with valve testing

  9. Enhancement of pressurizer safety valve operability by seating design improvement

    International Nuclear Information System (INIS)

    Moisidis, N.T.; Ratiu, M.D.

    1994-01-01

    Operating conditions specific to Pressurizer Safety Valves (PSVs) have led to numerous problems and have caused industry and NRC concerns regarding the adequacy of spring loaded self-actuated safety valves for Reactor Coolant System (RCS) overpressure protection. Specific concerns are: setpoint drift, spurious actuations and leakage. Based on testing and valve construction analysis of a Crosby model 6M6 PSV, it was established that the primary contributor to the valve problems is a susceptibility to weak seating. To eliminate spring instability, a new spring washer was designed, which guides the spring and precludes its rotation from the reference installed position. Results of tests performed on a prototype PSV equipped with the modified upper spring washer has shown significant improvements in valve operability and a consistent setpoint reproducibility to less than ±1% of the PSV setpoint (testing of baseline, unmodified valve, resulted in a setpoint drift of ±2%). Enhanced valve operability will result in a significant decrease in operating and maintenance costs associated with valve maintenance and testing. In addition, the enhanced setpoint reproducibility will allow the development of a nitrogen to steam correlation for future in-house PSV testing which will result in further reductions in costs associated with valve testing

  10. Safety culture improvements in a nuclear laboratory setting

    Energy Technology Data Exchange (ETDEWEB)

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

    2014-07-01

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

  11. Safety culture improvements in a nuclear laboratory setting

    International Nuclear Information System (INIS)

    Smith, K.L.; McKenna, J.

    2014-01-01

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

  12. Safety Culture Improvement Activities of YGN 3 and 4

    International Nuclear Information System (INIS)

    Cho, Il Hoon

    2006-01-01

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

  13. Improving construction site safety through leader-based verbal safety communication.

    Science.gov (United States)

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

    2010-10-01

    The construction industry is one of the most injury-prone industries, in which production is usually prioritized over safety in daily on-site communication. Workers have an informal and oral culture of risk, in which safety is rarely openly expressed. This paper tests the effect of increasing leader-based on-site verbal safety communication on the level of safety and safety climate at construction sites. A pre-post intervention-control design with five construction work gangs is carried out. Foremen in two intervention groups are coached and given bi-weekly feedback about their daily verbal safety communications with their workers. Foremen-worker verbal safety exchanges (experience sampling method, n=1,693 interviews), construction site safety level (correct vs. incorrect, n=22,077 single observations), and safety climate (seven dimensions, n=105 questionnaires) are measured over a period of up to 42 weeks. Baseline measurements in the two intervention and three control groups reveal that foremen speak with their workers several times a day. Workers perceive safety as part of their verbal communication with their foremen in only 6-16% of exchanges, and the levels of safety at the sites range from 70-87% (correct observations). Measurements from baseline to follow-up in the two intervention groups reveal that safety communication between foremen and workers increases significantly in one of the groups (factor 7.1 increase), and a significant yet smaller increase is found when the two intervention groups are combined (factor 4.6). Significant increases in the level of safety are seen in both intervention groups (7% and 12% increases, respectively), particularly in regards to 'access ways' and 'railings and coverings' (39% and 84% increases, respectively). Increases in safety climate are seen in only one of the intervention groups with respect to their 'attention to safety.' No significant trend changes are seen in the three control groups on any of the three measures

  14. Errors in laboratory medicine: practical lessons to improve patient safety.

    Science.gov (United States)

    Howanitz, Peter J

    2005-10-01

    Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification

  15. An approach toward estimating the safety significance of normal and abnormal operating procedures in nuclear power plants

    International Nuclear Information System (INIS)

    Grant, T.F.; Harris, M.S.

    1989-01-01

    The Nuclear Regulatory Commission's TMI Action Plan calls for a long-term plan to upgrade operating procedures in nuclear power plants. The scope of Generic Issue Human Factors 4.4, which stems from this requirement, includes the recommendation of improvements in nuclear power plant normal and abnormal operating procedures (NOPs and AOPs) and the implementation of appropriate regulatory action. This paper will describe the objectives, methodologies, and results of a Battelle-conducted value impact assessment to determine the costs and benefits of having the NRC implement regulatory action that would specify requirements for the preparation of acceptable NOPs and AOPs by the Commission's nuclear power plant licensees. The results of this value impact assessment are expressed in terms of ten cost/benefit attributes that can be affected by the NRC regulatory action. Five of these attributes require the calculation of change in public risk that could be expected to result from the action which, in this case, required determining the safety significance of NOPs and AOPs. In order to estimate this safety significance, a multi-step methodology was created that relies on an existing Probabilistic Risk Assessment (PRA) to provide a quantitative framework for modeling the role of operating procedures. The purpose of this methodology is to determine what impact the improvement of NOPs and AOPs would have on public health and safety

  16. PNRA: Practically Improving Safety Culture within the Regulatory Body

    International Nuclear Information System (INIS)

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

    2016-01-01

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

  17. Surgical resident education in patient safety: where can we improve?

    Science.gov (United States)

    Putnam, Luke R; Levy, Shauna M; Kellagher, Caroline M; Etchegaray, Jason M; Thomas, Eric J; Kao, Lillian S; Lally, Kevin P; Tsao, KuoJen

    2015-12-01

    Effective communication and patient safety practices are paramount in health care. Surgical residents play an integral role in the perioperative team, yet their perceptions of patient safety remain unclear. We hypothesized that surgical residents perceive the perioperative environment as more unsafe than their faculty and operating room staff despite completing a required safety curriculum. Surgeons, anesthesiologists, and perioperative nurses in a large academic children's hospital participated in multifaceted, physician-led workshops aimed at enhancing communication and safety culture over a 3-y period. All general surgery residents from the same academic center completed a hospital-based online safety curriculum only. All groups subsequently completed the psychometrically validated safety attitudes questionnaire to evaluate three domains: safety culture, teamwork, and speaking up. Results reflect the percent of respondents who slightly or strongly agreed. Chi-square analysis was performed. Sixty-three of 84 perioperative personnel (75%) and 48 of 52 surgical residents (92%) completed the safety attitudes questionnaire. A higher percentage of perioperative personnel perceived a safer environment than the surgical residents in all three domains, which was significantly higher for safety culture (68% versus 46%, P = 0.03). When stratified into two groups, junior residents (postgraduate years 1-2) and senior residents (postgraduate years 3-5) had lower scores for all three domains, but the differences were not statistically significant. Surgical residents' perceptions of perioperative safety remain suboptimal. With an enhanced safety curriculum, perioperative staff demonstrated higher perceptions of safety compared with residents who participated in an online-only curriculum. Optimal surgical education on patient safety remains unknown but should require a dedicated, systematic approach. Copyright © 2015 Elsevier Inc. All rights reserved.

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

    Science.gov (United States)

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

    2012-01-01

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

  19. Identifying the most significant indicators of the total road safety performance index.

    Science.gov (United States)

    Tešić, Milan; Hermans, Elke; Lipovac, Krsto; Pešić, Dalibor

    2018-04-01

    trauma management. This will help achieve the standardization of indicators including data collection procedures and selection of the key list of indicators that need to be monitored. Based on the results, it has been concluded that the use of the most contributing indicators will make it possible to assess the level of road safety on a territory, with an acceptable quality score by focusing on the low-ranked countries. A smaller set of significant indicators defined in this manner can serve for a fast and simple understanding of a road safety situation and assessment of effects of measures undertaken. Also, this universal index approach is applicable in cases when a broader comprehensive set of indicators is analyzed, which provides a more accurate identification of weaker points and rank the countries in a more meaningful way. Copyright © 2018 Elsevier Ltd. All rights reserved.

  20. The significance of thermohydraulic conditions for the corrosion safety of PWR steam generators

    International Nuclear Information System (INIS)

    Gulich, J.F.

    1975-04-01

    In several PWR nuclear power plants leakages have occurred in the steam generator which were caused by localised corrosion attack. While the attention of manufacturers and operators is focused on the influences of feedwater chemistry and tube material, the present work highlights the fact that the damage always occurred in those places where flow regimed are poorly defined. The investigation leads to the result that local dry out of the heating surface can be contributing cause of damage. A method is indicated for estimating the thermohydraulic conditions in the inflow region over the tube plate and measures to improve corrosion safety are discussed. (author)

  1. Ways of improving safety for future PWRs in France

    International Nuclear Information System (INIS)

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

    1994-01-01

    For the design of a new generation of nuclear power plants which could be ordered in France at the end of the nineties, there is a broad consensus on the choice of the evolutionary way, in view of the significant progress in the field of safety which appears possible with this approach, due to feedback of operating experience from a large number of reactors, results of extended safety research and development projects, general technical progress and findings from detailed probabilistic safety studies performed. This paper presents results of thinkings and studies, conducted within the Institute for Nuclear Safety and Protection (IPSN) in the various fields mentioned, in view of the definition of safety objectives and principles for future PWRs. These results contributed to the preparation of a common safety approach for future plants in France and Germany. (authors). 1 tab., 3 refs

  2. Behavioral Emergency Response Team: Implementation Improves Patient Safety, Staff Safety, and Staff Collaboration.

    Science.gov (United States)

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

    2017-10-01

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

  3. Safety significance of inadvertent operation of motor-operated valves in nuclear power plants

    International Nuclear Information System (INIS)

    Ruger, C.J.; Higgins, J.C.; Carbonaro, J.F.; Hall, R.E.

    1994-01-01

    Concerns about the consequences of valve mispositioning were brought to the forefront following an event at Davis Besse in 1985. The concern related to the ability to reposition open-quotes position-changeableclose quotes motor-operated valves (MOVs) from the control room in the event of their inadvertent operation and was documented in U.S. Nuclear Regulatory Commission (USNRC) Bulletin 85-03 and Generic Letter (GL) 89-10. The mispositioned MOVs may not be able to be returned to their required position due to high differential pressure or high flow conditions across the valves. The inability to reposition such valves may have significantly safety consequences, as in the Davis Besse event. However, full consideration of such mispositioning in safety analyses and in MOV test programs can be labor intensive and expensive. Industry raised concerns that consideration of position-changeable valves under GL 89-10 would not decrease the probability of core damage to an extent that would justify licensee costs. As a response, Brookhaven National Laboratory has conducted separate scoping studies for both boiling water reactors (BWRs) and pressurized water reactors (PWRs) using probabilistic risk assessment (PRA) techniques to determine if such valve mispositioning by itself is significant to safety. The approach used internal events PRA models to survey the order of magnitude of the risk-significance of valve mispositioning by considering the failure of selected position-changeable MOVs. The change in core damage frequency was determined for each valve considered, and the results were presented as a risk increase ratio for each of four assumed MOV failure rates. The risk increase ratios resulting from this failure rate sensitivity study can be used as a basis for a determination of the risk-significance of the MOV mispositioning issues for BWRs and PWRs

  4. Improved reliability, maintainability and safety through elastomer upgrading

    International Nuclear Information System (INIS)

    Wensel, R.; Wittich, K.C.

    1995-01-01

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

  5. Quality procedure management for improved nuclear safety

    International Nuclear Information System (INIS)

    Forzano, P.; Castagna, P.

    1995-01-01

    Emergency Operating Procedures and Accident Management Procedures are the next step in the computerization of NPP control rooms. Different improvements are presently conceivable for this operator aid tool, and research activities are in development. Undergoing activities regard especially formal aspects of knowledge representation, Human-Machine interface and procedure life cycle management. These aspects have been investigated deeply by Ansaldo, and partially incorporated in the DIAM prototype. Nuclear Power Plant Procedures can be seen from essentially two viewpoints: the process and the information management. From the first point of view, it is important to supply the knowledge apt to solve problems connected with the control of the process, from the second one the focus of attention is on the knowledge representation, its structure, elicitation and maintenance, and formal quality assurance. These two aspects of procedure representation can be considered and solved separately. In particular, methodological, formal and management issues require long and tedious activities, that in most cases constitute a great barrier for procedures development and upgrade. To solve these problems, Ansaldo is developing DIAM, a wide integrated tool for procedure management to support in procedure writing, updating, usage, and documentation. One of the most challenging features of DIAM is AUTO-LAY, a CASE sub-tool that, in a complete automatical way, structures parts or complete flow diagram. This is the feature that is partial present in some other CASE products, that, anyway, do not allow complex graph handling and isomorphism between video and paper representation. AUTO-LAY has the unique prerogative to draw graphs of any complexity to section them in pages, and to automatically compose a document. This has been recognized in the literature as the most important a second-generation CASE improvement. (Author) 9 Figs., 5 Refs

  6. Improvement of Safety Assessment Methodologies for Near Surface Disposal Facilities

    International Nuclear Information System (INIS)

    Batandjieva, B.; Torres-Vidal, C.

    2002-01-01

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

  7. Significance of FIZ Technik Databases in nuclear safety and environmental protection

    International Nuclear Information System (INIS)

    Das, N.K.

    1993-01-01

    The language of the abstracts of the FIZ Technik databases is primarly German (e.g. DOMA 80%, SDIM 70%). Furthermore FIZ Technik offers licence databases on engineering and technology, management, manufacturers, products, contacts, standards and specifications, geosciences and natural resources. The contents and structure of the databases are described in the FIZ Technik bluesheets and the database news. With some examples the significance of the FIZ Technik databases DOMA, ZDEE, SDIM, SILI and MEDI in nuclear safety and environmental protection is shown. (orig.)

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

    Science.gov (United States)

    Singh, Hardeep; Sittig, Dean F

    2016-04-01

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

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

    Science.gov (United States)

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

    2015-01-01

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

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

    Science.gov (United States)

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

    2010-01-01

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

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

    Science.gov (United States)

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

    2016-11-01

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

  12. Significance of actinide chemistry for the long-term safety of waste disposal

    International Nuclear Information System (INIS)

    Kim, Jae Il

    2006-01-01

    A geochemical approach to the long-term safety of waste disposal is discussed in connection with the significance of actinides, which shall deliver the major radioactivity inventory subsequent to the relatively short-term decay of fission products. Every power reactor generates transuranic (TRU) elements: plutonium and minor actinides (Np, Am, Cm), which consist chiefly of long-lived nuclides emitting alpha radiation. The amount of TRU actinides generated in a fuel life period is found to be relatively small (about 1 wt% or less in spent fuel) but their radioactivity persists many hundred thousands years. Geological confinement of waste containing TRU actinides demands, as a result, fundamental knowledge on the geochemical behavior of actinides in the repository environment for a long period of time. Appraisal of the scientific progress in this subject area is the main objective of the present paper. Following the introductory discussion on natural radioactivities, the nuclear fuel cycle is briefly brought up with reference to actinide generation and waste disposal. As the long-term disposal safety concerns inevitably with actinides, the significance of the aquatic actinide chemistry is summarized in two parts: the fundamental properties relevant to their aquatic behavior and the geochemical reactions in nanoscopic scale. The constrained space of writing allows discussion on some examples only, for which topics of the primary concern are selected, e.g. apparent solubility and colloid generation, colloid-facilitated migration, notable speciation of such processes, etc. Discussion is summed up to end with how to make a geochemical approach available for the long-term disposal safety of nuclear waste or for the Performance Assessment (PA) as known generally

  13. Patient handover in orthopaedics, improving safety using Information Technology.

    Science.gov (United States)

    Pearkes, Tim

    2015-01-01

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

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

    Science.gov (United States)

    Yassi, Annalee; Hancock, Tina

    2005-01-01

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

  15. A quantitative approach for risk-informed safety significance categorization in option-2

    International Nuclear Information System (INIS)

    Ha, Jun Su; Seong, Poong Hyun

    2004-01-01

    OPTION-2 recommends that Structures, Systems, or Components (SSCs) of Nuclear Power Plants (NPPs) should be categorized into four groups according to their safety significance as well as whether they are safety-related or not. With changes to the scope of SSCs covered by 10 CFR 50, safety-related components which categorized into low safety significant SSC (RISC-3 SSC) can be exempted from the existing conservative burden (or requirements). As OPTION-2 paradigm is applied, a lot of SSCs may be categorized into RISC-3 SSCs. Changes in treatment of the RISC-3 SSCs will be recommended and then finally the recommended changes shall be evaluated. Consequently, before recommending the changes in treatment, probable candidate SSCs for the changes in treatment need to be identified for efficient risk-informed regulation and application (RIRA). Hence, in this work, a validation focused on the RISC-3 SSCs is proposed to identify probable candidate SSCs. Burden to Importance Ratio (BIR) is utilized as a quantitative measure for the validation. BIR is a measure representing the extent of resources or requirements imposed on a SSC with respect to the value of the importance measure of the SSC. Therefore SSCs having high BIR can be considered as probable candidate SSCs for the changes in treatment. In addition, the final decision whether RISC-3 SSCs can be considered as probable candidate SSCs or not should be made by an expert panel. For the effective decision making, a structured mathematical decision-making process is constructed based on Belief Networks (BBN) to overcome demerits of conventional group meeting based on unstructured discussion for decision-making. To demonstrate the usefulness of the proposed approach, the approach is applied to 22 components selected from 512 In-Service Test (IST) components of Ulchin unit 3. The results of the application show that the proposed approach can identify probable candidate SSCs for changes in treatment. The identification of the

  16. Safety implications of standardized continuous quality improvement programs in community pharmacy.

    Science.gov (United States)

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

    2013-06-01

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

  17. Climate resilient crops for improving global food security and safety.

    Science.gov (United States)

    Dhankher, Om Parkash; Foyer, Christine H

    2018-05-01

    Food security and the protection of the environment are urgent issues for global society, particularly with the uncertainties of climate change. Changing climate is predicted to have a wide range of negative impacts on plant physiology metabolism, soil fertility and carbon sequestration, microbial activity and diversity that will limit plant growth and productivity, and ultimately food production. Ensuring global food security and food safety will require an intensive research effort across the food chain, starting with crop production and the nutritional quality of the food products. Much uncertainty remains concerning the resilience of plants, soils, and associated microbes to climate change. Intensive efforts are currently underway to improve crop yields with lower input requirements and enhance the sustainability of yield through improved biotic and abiotic stress tolerance traits. In addition, significant efforts are focused on gaining a better understanding of the root/soil interface and associated microbiomes, as well as enhancing soil properties. © 2018 The Authors Plant, Cell & Environment Published by John Wiley & Sons Ltd.

  18. Development and improvement of safety analysis code for geological disposal

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2013-08-15

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

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

    DEFF Research Database (Denmark)

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

    2013-01-01

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

  20. 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.

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

    International Nuclear Information System (INIS)

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

    1996-01-01

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

  2. Analysis of events significant with regard to safety of Bohunice V-1 nuclear power plant

    International Nuclear Information System (INIS)

    Suchomel, J.; Maron, V.; Kmosena, J.

    1986-01-01

    An analysis was made of operating safety of the V-1 nuclear power plant in Jaslovske Bohunice for the years 1980 - 1983. Of the total number of 676 reported failures only three were events with special safety significance, namely a complete loss of power supply for own consumption from the power grid, a failure of pins on the collectors of steam generators, and a failure of the heads of heat technology inspection channels. The failures were categorized according to the systems used in the USSR and in the USA and compared with data on failures in nuclear power plants in the two countries. The conclusions show that the operation of the V-1 nuclear power plant achieves results which are fully comparable with those recorded in 9 WWER-440 power plants operating in various countries. The average coefficient of availability is 0.72 and ranks the power plant in the fourth place among the said 9 plants. A comparison of the individual power plant units showed that of the total number of 22, the first unit of the V-1 plant ranks fifth with a coefficient of 0.78 and the second unit with a coefficient of 0.69 ranks 15th. (Z.M.)

  3. Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

    DEFF Research Database (Denmark)

    Kristensen, Solvejg; Mainz, Jan; Bartels, Paul

    2009-01-01

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

  4. The Power of Collaboration for Improving Safety in Complex Systems

    International Nuclear Information System (INIS)

    Hart, C. A.

    2016-01-01

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

  5. NPP Krsko core calculations to improve operational safety

    International Nuclear Information System (INIS)

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

    2007-01-01

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

  6. Improving the safety of remote site emergency airway management.

    Science.gov (United States)

    Wijesuriya, Julian; Brand, Jonathan

    2014-01-01

    Airway management, particularly in non-theatre settings, is an area of anaesthesia and critical care associated with significant risk of morbidity & mortality, as highlighted during the 4th National Audit Project of the Royal College of Anaesthetists (NAP4). A survey of junior anaesthetists at our hospital highlighted a lack of confidence and perceived lack of safety in emergency airway management, especially in non-theatre settings. We developed and implemented a multifaceted airway package designed to improve the safety of remote site airway management. A Rapid Sequence Induction (RSI) checklist was developed; this was combined with new advanced airway equipment and drugs bags. Additionally, new carbon dioxide detector filters were procured in order to comply with NAP4 monitoring recommendations. The RSI checklists were placed in key locations throughout the hospital and the drugs and advanced airway equipment bags were centralised in the Intensive Care Unit (ICU). It was agreed with the senior nursing staff that an appropriately trained ICU nurse would attend all emergency situations with new airway resources upon request. Departmental guidelines were updated to include details of the new resources and the on-call anaesthetist's responsibilities regarding checks and maintenance. Following our intervention trainees reported higher confidence levels regarding remote site emergency airway management. Nine trusts within the Northern Region were surveyed and we found large variations in the provision of remote site airway management resources. Complications in remote site airway management due lack of available appropriate drugs, equipment or trained staff are potentially life threatening and completely avoidable. Utilising the intervention package an anaesthetist would be able to safely plan and prepare for airway management in any setting. They would subsequently have the drugs, equipment, and trained assistance required to manage any difficulties or complications

  7. Does external evaluation of laboratories improve patient safety?

    Science.gov (United States)

    Noble, Michael A

    2007-01-01

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

  8. Improving Aviation Safety in Indonesia: How Many More Accidents?

    Directory of Open Access Journals (Sweden)

    Ridha Aditya Nugraha

    2016-12-01

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

  9. Standardization and improvement of safety for radioisotope equipped instruments

    International Nuclear Information System (INIS)

    Sumi, Tetsuo

    1980-01-01

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

  10. Improving safety in small enterprises through an integrated safety management intervention.

    Science.gov (United States)

    Kines, Pete; Andersen, Dorte; Andersen, Lars Peter; Nielsen, Kent; Pedersen, Louise

    2013-02-01

    This study tests the applicability of a participatory behavior-based injury prevention approach integrated with safety culture initiatives. Sixteen small metal industry enterprises (10-19 employees) are randomly assigned to receive the intervention or not. Safety coaching of owners/managers result in the identification of 48 safety tasks, 85% of which are solved at follow-up. Owner/manager led constructive dialogue meetings with workers result in the prioritization of 29 tasks, 79% of which are accomplished at follow-up. Intervention enterprises have significant increases on six of eight safety-perception-survey factors, while comparisons increase on only one factor. Both intervention and comparison enterprises demonstrate significant increases in their safety observation scores. Interview data validate and supplement these results, providing some evidence for behavior change and the initiation of safety culture change. Given that over 95% of enterprises in most countries have less than 20 employees, there is great potential for adapting this integrated approach to other industries. Copyright © 2012 National Safety Council and Elsevier Ltd. All rights reserved.

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

    International Nuclear Information System (INIS)

    Hinovski, M.P.; Sabinov, S.

    2001-01-01

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

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

    Science.gov (United States)

    Basuni, Enas M; Bayoumi, Magda M

    2015-01-13

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

  13. Alternative off-site power supply improves nuclear power plant safety

    International Nuclear Information System (INIS)

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

    2014-01-01

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

  14. Use of PSA for improving the safety of French PWRs

    International Nuclear Information System (INIS)

    Lanore, J.M.; Chambon, J.L.

    1994-06-01

    Two French PWR Probabilistic Safety Assessment (PSA) studies were conducted for the standardized PWR series of 900 and 1300 MWe. Both PSA 900 and PSA 1300 are level 1 PSAs, that means their objective is the evaluation of core meltdown frequency. These studies have some specific features, in particular the treatment of shutdown conditions, the treatment of long term post-accidental situations, and a wide use of French experience feedback. The PSAs are used for safety improvements of the French PWRs. Following the PSA results, several modifications to plants concerning the dominant sequences were decided. (R.P.). 2 refs., 4 figs

  15. Danish initiatives to improve the safety of meat products

    DEFF Research Database (Denmark)

    Wegener, Henrik Caspar

    2010-01-01

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

  16. Significant clinical improvement in radiation-induced lumbosacral poly-radiculopathy by a treatment combining pentoxifylline, tocopherol, and clodronate (Pentoclo)

    Energy Technology Data Exchange (ETDEWEB)

    Delanian, S. [Hop St Louis, Serv Oncol Radiotherapie, APHP, F-75010 Paris, (France); Lefaix, J.L. [CEA-LARIA, CIRIL-GANIL, Caen, (France); Maisonobe, T. [Hop La Pitie Salpetriere, Federat Neurophysiol Clin, APHP, Paris, (France)

    2008-07-01

    Radiation-induced (RI) peripheral neuropathy is a rare and severe delayed complication of radiotherapy that is spontaneously irreversible, with no standard of treatment. We previously developed a successful antioxidant treatment in RI fibrosis and necrosis. Two patients with progressive worsening RI lumbosacral poly-radiculopathy experienced over several years a significant clinical improvement in their neurological sensorimotor symptoms with long-term pentoxifylline-tocopherol-clodronate treatment, and good safety. (authors)

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

    International Nuclear Information System (INIS)

    1999-01-01

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

  18. Progress toward international agreement to improve reactor safety

    International Nuclear Information System (INIS)

    Lieberman, J.I.; Graham, B.

    1993-01-01

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

  19. Development of the Continued Improvement System for Nuclear Safety Culture

    International Nuclear Information System (INIS)

    Park, H. C.; Park, H. G.; Park, Y. W.; Park, J. Y.

    2016-01-01

    It has been found that almost 80 % of the incidents and accidents occurred recently, such as the Fukushima Daiichi disaster and Domestic SBO accident etc. were analyzed to be caused from human errors. (IAEA NES NG-G-2.1) Which strongly claims the importance of the safety culture system. Accordingly, it should be away from a cursory approach like one-off field survey or Snap shop which were being conducted at present for the continued improvement of safety culture. This study introduces an analytical methodology which approaches the generic form of the safety both consciously and unconsciously expressed with behavior, thoughts, and attitude etc. This study was implemented only for open materials such as Inspection report, incidents and accidents reports, QA documents because of the limitation in accessibility to data. More effective use with securing operational data will be possible in future

  20. Navigating towards improved surgical safety using aviation-based strategies.

    Science.gov (United States)

    Kao, Lillian S; Thomas, Eric J

    2008-04-01

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

  1. Development of the Continued Improvement System for Nuclear Safety Culture

    Energy Technology Data Exchange (ETDEWEB)

    Park, H. C.; Park, H. G.; Park, Y. W.; Park, J. Y. [KAIST, Daejeon (Korea, Republic of)

    2016-05-15

    It has been found that almost 80 % of the incidents and accidents occurred recently, such as the Fukushima Daiichi disaster and Domestic SBO accident etc. were analyzed to be caused from human errors. (IAEA NES NG-G-2.1) Which strongly claims the importance of the safety culture system. Accordingly, it should be away from a cursory approach like one-off field survey or Snap shop which were being conducted at present for the continued improvement of safety culture. This study introduces an analytical methodology which approaches the generic form of the safety both consciously and unconsciously expressed with behavior, thoughts, and attitude etc. This study was implemented only for open materials such as Inspection report, incidents and accidents reports, QA documents because of the limitation in accessibility to data. More effective use with securing operational data will be possible in future.

  2. RADON-type disposal facility safety case for the co-ordinated research project on improvement of safety assessment methodologies for near surface radioactive waste disposal facilities (ISAM)

    International Nuclear Information System (INIS)

    Guskov, A.; Batanjieva, B.; Kozak, M.W.; Torres-Vidal, C.

    2002-01-01

    The ISAM safety assessment methodology was applied to RADON-type facilities. The assessments conducted through the ISAM project were among the first conducted for these kinds of facilities. These assessments are anticipated to lead to significantly improved levels of safety in countries with such facilities. Experience gained though this RADON-type Safety Case was already used in Russia while developing national regulatory documents. (author)

  3. Selling safety: the use of celebrities in improving awareness of safety in commercial aviation.

    Science.gov (United States)

    Molesworth, Brett R C; Seneviratne, Dimuth; Burgess, Marion

    2016-07-01

    The aim of this study was to investigate the influential power of a celebrity to convey key safety messages in commercial aviation using a pre-flight safety briefing video. In addition, the present research sought to examine the effectiveness of subtitles in aiding the recall of these important messages as well as how in-cabin aircraft noise affects recall of this information. A total of 101 participants were randomly divided into four groups (no noise without subtitles, no noise with subtitles, noise without subtitles and noise with subtitles) and following exposure to a pre-recorded pre-flight safety briefing video were tested for recall of key safety messages within that video. Participants who recognised and recalled the name of the celebrity in the safety briefing video recalled significantly more of the messages than participants who did not recognise the celebrity. Subtitles were also found to be effective, however, only in the presence of representative in-cabin aircraft noise. Practitioner Summary: Passenger attention to pre-flight safety briefings on commercial aircraft is poor. Utilising the celebrity status of a famous person may overcome this problem. Results suggest that celebrities do increase the recall of safety-related information.

  4. The role of individual diligence in improving safety.

    Science.gov (United States)

    Corbett, Angus; Travaglia, Jo; Braithwaite, Jeffrey

    2011-01-01

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

  5. Nature-Based Strategies for Improving Urban Health and Safety.

    Science.gov (United States)

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

    2015-10-01

    Place-based programs are being noticed as key opportunities to prevent disease and promote public health and safety for populations at-large. As one key type of place-based intervention, nature-based and green space strategies can play an especially large role in improving health and safety for dwellers in urban environments such as US legacy cities that lack nature and greenery. In this paper, we describe the current understanding of place-based influences on public health and safety. We focus on nonchemical environmental factors, many of which are related to urban abandonment and blight. We then review findings from studies of nature-based interventions regarding impacts on health, perceptions of safety, and crime. Based on our findings, we suggest that further research in this area will require (1) refined measures of green space, nature, and health and safety for cities, (2) interdisciplinary science and cross-sector policy collaboration, (3) observational studies as well as randomized controlled experiments and natural experiments using appropriate spatial counterfactuals and mixed methods, and (4) return-on-investment calculations of potential economic, social, and health costs and benefits of urban greening initiatives.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-12-15

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

  7. Patient Safety Based Knowledge Management SECI to Improve Nusrsing Students Competency

    Directory of Open Access Journals (Sweden)

    Joanggi Wiriatarina Harianto

    2015-10-01

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

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

    International Nuclear Information System (INIS)

    2008-01-01

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

  9. Improvement programme of safety performance indicators (SPIs) in Korea

    International Nuclear Information System (INIS)

    Lee, S.Y.

    2001-01-01

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

  10. Effect of generic issues program on improving safety

    International Nuclear Information System (INIS)

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

    2010-01-01

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

  11. Design of marine structures with improved safety for environment

    International Nuclear Information System (INIS)

    Klanac, Alan; Varsta, Petri

    2011-01-01

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

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

    International Nuclear Information System (INIS)

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

    2018-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2018-01-15

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

  14. Safety significance of component ageing, exemplary for MOV, based on French and German operating experience

    Energy Technology Data Exchange (ETDEWEB)

    Morlent, O. [CEA Fontenay-aux-Roses, 92 (France). Inst. de Protection et de Surete Nucleaire; Michel, F. [Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS) mbH, Garching (Germany)

    2001-07-01

    An outline is given of how IPSN and GRS assess the effects of physical ageing on the safety of French and German Nuclear Power Plants (NPPs) on the basis of the available knowledge and how investigations are carried out. The presentation is focused exemplary on a preliminary study illustrating approaches for the evaluation of the ageing behaviour of active components, the motor-operated valves (MOV). The results so far seems to demonstrate that the developed methodological approaches are suitable to obtain qualitative evidence with regard to the ageing behaviour of technical facilities such as MOV. The evaluation of the operating experience with French 900 MWe plants seems to reveal, for MOV of one system, a trend similar to some international findings about ageing-related events with increasing operating time; this trend will have to be confirmed. For the German NPPs so far, there appears to be no significant increase of ageing-related events concerning MOV as the plants get older. Future work on ageing scheduled at IPSN and GRS includes further cooperation on this issue, too; a deep analysis is necessary to explain the reasons of such apparent differences before any conclusion. (authors)

  15. Safety significance of component ageing, exemplary for MOV, based on French and German operating experience

    International Nuclear Information System (INIS)

    Morlent, O.

    2001-01-01

    An outline is given of how IPSN and GRS assess the effects of physical ageing on the safety of French and German Nuclear Power Plants (NPPs) on the basis of the available knowledge and how investigations are carried out. The presentation is focused exemplary on a preliminary study illustrating approaches for the evaluation of the ageing behaviour of active components, the motor-operated valves (MOV). The results so far seems to demonstrate that the developed methodological approaches are suitable to obtain qualitative evidence with regard to the ageing behaviour of technical facilities such as MOV. The evaluation of the operating experience with French 900 MWe plants seems to reveal, for MOV of one system, a trend similar to some international findings about ageing-related events with increasing operating time; this trend will have to be confirmed. For the German NPPs so far, there appears to be no significant increase of ageing-related events concerning MOV as the plants get older. Future work on ageing scheduled at IPSN and GRS includes further cooperation on this issue, too; a deep analysis is necessary to explain the reasons of such apparent differences before any conclusion. (authors)

  16. Significant Improvement in Chronic Persistent Headaches Caused by Small Rathke Cleft Cysts After Transsphenoidal Surgery.

    Science.gov (United States)

    Fukui, Issei; Hayashi, Yasuhiko; Kita, Daisuke; Sasagawa, Yasuo; Oishi, Masahiro; Tachibana, Osamu; Nakada, Mitsutoshi

    2017-03-01

    Rathke cleft cysts (RCC) usually are asymptomatic and can be observed via the use of conservative methods. Some patients with RCCs, however, have severe headaches even if they are small enough to be confined to the sella, and these small RCCs seldom have been discussed. This study presents an investigation into clinical characteristics of small RCCs associated with severe headaches, demonstrating efficacy and safety of endoscopic transsphenoidal surgery (ETSS) to relieve headaches. In this study, 13 patients with small RCCs (maximum diameter HIT-6) score was calculated both pre- and postoperatively to evaluate headache severity. All patients complained of severe headaches, which disturbed their daily life. Most headaches were nonpulsating and localized in the frontal area. Characteristically, 6 patients (46%) experienced severe headaches with sudden onset that continued chronically. HIT-6 score was 64 on average, meaning headaches affected daily life severely. After surgical decompression of the cyst, headache in all of the patients improved dramatically and HIT-6 score decreased significantly to 37, suggesting that headaches were diminished. No newly developed deficiencies of the anterior pituitary lobe function were detected. Postoperative occurrence of diabetes insipidus was found in 2 patients, both of which were transient. No recurring cysts were found. Severe headaches can develop from small RCCs. In the present study, ETSS was performed on such patients effectively and safely to relieve their headaches. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. Improving Patient Safety in Anesthesia: A Success Story?

    International Nuclear Information System (INIS)

    Botney, Richard

    2008-01-01

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

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

    Science.gov (United States)

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

    2016-01-01

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

  19. Significance of Phébus-FP results for plant safety in Switzerland

    International Nuclear Information System (INIS)

    Birchley, J.; Güntay, S.

    2013-01-01

    Highlights: • Prototypicality of Phebus is unique for severe accident integral code assessment. • MELCOR and SCDAP show good simulation capability. • Phebus revealed knowledge gaps concerning organic iodine source. • Complementary studies seek to reduce uncertainties. • New engineering technology is developed to resolve organic iodine issue. - Abstract: Switzerland, in common with other countries, uses source term estimates to formulate emergency plans in the unlikely event of an accident with release of activity to the environment. In the past estimates have typically been based on conservative treatments of the accident sequence, necessitated by the limited validation status of models used for the phenomena that control the reactor accident evolution. Although analyses using best-estimate tools frequently indicated substantially smaller releases – knowledge and data were insufficient to place reliance on the methods or the calculated results. The Phébus programme is unique in providing a source of integral transient data on fission product release, transport and chemical behaviour under prototypic conditions, capturing the entire portfolio of processes – transport, material and chemical – and their causal interaction. To this day, no other source of such data is available. These data provide a means to assess, improve and validate methods for source term evaluation and establish the needs for establishing new processes to mitigate the source term. There are strong synergies and complementarities between the Phébus project, the International Source Term Project, the iodine-related studies at PSI and the aerosol retention projects at PSI, and current moves toward improved management/mitigation of severe accidents. The Federal Nuclear Safety Inspectorate (ENSI), Paul Scherrer Institute (PSI) and the Swiss utilities running five nuclear power plants share in the findings. The need to strengthen the foundation on which we perform best

  20. THE INTRODUCTION OF THE METHODOLOGY TO IMPROVE ROAD SAFETY

    Directory of Open Access Journals (Sweden)

    D. V. Kapsky

    2013-01-01

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

  1. The significance of the probabilistic safety analysis (PSA) in administrative procedures under nuclear law

    International Nuclear Information System (INIS)

    Berg, H.P.

    1994-01-01

    The probabilistic safety analysis (PSA) is a useful tool for safety relevant evaluation of nuclear power plant designed on the basis of deterministic specifications. The PSA yields data identifying reliable or less reliable systems, or frequent or less frequent failure modes to be taken into account for safety engineering. Performance of a PSA in administrative procedures under nuclear law, e.g. licensing, is an obligation laid down in a footnote to criterion 1.1 of the BMI safety criteria catalogue, which has been in force unaltered since 1977. The paper explains the application and achievements of PSA in the phase of reactor development concerned with the conceptual design basis and design features, using as an example the novel PWR. (orig./HP) [de

  2. Factors Related to Significant Improvement of Estimated Glomerular Filtration Rates in Chronic Hepatitis B Patients Receiving Telbivudine Therapy

    Directory of Open Access Journals (Sweden)

    Te-Fu Lin

    2017-01-01

    Full Text Available Background and Aim. The improvement of estimated glomerular filtration rates (eGFRs in chronic hepatitis B (CHB patients receiving telbivudine therapy is well known. The aim of this study was to clarify the kinetics of eGFRs and to identify the significant factors related to the improvement of eGFRs in telbivudine-treated CHB patients in a real-world setting. Methods. Serial eGFRs were calculated every 3 months using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI equation. The patients were classified as CKD-1, -2, or -3 according to a baseline eGFR of ≥90, 60–89, or <60 mL/min/1.73 m2, respectively. A significant improvement of eGFR was defined as a more than 10% increase from the baseline. Results. A total of 129 patients were enrolled, of whom 36% had significantly improved eGFRs. According to a multivariate analysis, diabetes mellitus (DM (p=0.028 and CKD-3 (p=0.043 were both significantly related to such improvement. The rates of significant improvement of eGFR were about 73% and 77% in patients with DM and CKD-3, respectively. Conclusions. Telbivudine is an alternative drug of choice for the treatment of hepatitis B patients for whom renal safety is a concern, especially patients with DM and CKD-3.

  3. Implementing electronic handover: interventions to improve efficiency, safety and sustainability.

    Science.gov (United States)

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

    2016-10-01

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

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

    Science.gov (United States)

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

    2017-12-15

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

  5. National Emergency Preparedness and Response: Improving for Incidents of National Significance

    National Research Council Canada - National Science Library

    Clayton, Christopher M

    2006-01-01

    The national emergency management system has need of significant improvement in its contingency planning and early consolidation of effort and coordination between federal, state, and local agencies...

  6. 78 FR 69433 - Executive Order 13650 Improving Chemical Facility Safety and Security Listening Sessions

    Science.gov (United States)

    2013-11-19

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

  7. 78 FR 66326 - Hazardous Materials: Rail Petitions and Recommendations To Improve the Safety of Railroad Tank...

    Science.gov (United States)

    2013-11-05

    ...: Rail Petitions and Recommendations To Improve the Safety of Railroad Tank Car Transportation (RRR) AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA), DOT. ACTION: Advance Notice of... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration 49 CFR Parts...

  8. DASHBOARDS AND CONTROL CHARTS. EXPERIENCES IN IMPROVING SAFETY AT HANFORD WASHINGTON

    International Nuclear Information System (INIS)

    PREVETTE, S.S.

    2006-01-01

    The aim of this paper is to demonstrate the integration of safety methodology, quality tools, leadership, and teamwork at Hanford and their significant positive impact on safe performance of work. Dashboards, Leading Indicators, Control charts, Pareto Charts, Dr. W. Edward Deming's Red Bead Experiment, and Dr. Deming's System of Profound Knowledge have been the principal tools and theory of an integrated management system. Coupled with involved leadership and teamwork, they have led to significant improvements in worker safety and protection, and environmental restoration at one of the nation's largest nuclear cleanup sites

  9. National plan to enhance aviation safety through human factors improvements

    Science.gov (United States)

    Foushee, Clay

    1990-01-01

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

  10. Improving mine safety technology and training: establishing US global leadership

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2006-12-15

    In 2006, the USA's record of mine safety was interrupted by fatalities that rocked the industry and caused the National Mining Association and its members to recommit to returning the US underground coal mining industry to a global mine safety leadership role. This report details a comprehensive approach to increase the odds of survival for miners in emergency situations and to create a culture of prevention of accidents. Among its 75 recommendations are a need to improve communications, mine rescue training, and escape and protection of miners. Section headings of the report are: Introduction; Review of mine emergency situations in the past 25 years: identifying and addressing the issues and complexities; Risk-based design and management; Communications technology; Escape and protection strategies; Emergency response and mine rescue procedures; Training for preparedness; Summary of recommendations; and Conclusions. 37 refs., 3 figs., 5 apps.

  11. Human-centred radiological software techniques supporting improved nuclear safety

    International Nuclear Information System (INIS)

    Szoeke, Istvan; Johnsen, Terje

    2013-01-01

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

  12. Can cyclist safety be improved with intelligent transport systems?

    Science.gov (United States)

    Silla, Anne; Leden, Lars; Rämä, Pirkko; Scholliers, Johan; Van Noort, Martijn; Bell, Daniel

    2017-08-01

    In recent years, Intelligent Transport Systems (ITS) have assisted in the decrease of road traffic fatalities, particularly amongst passenger car occupants. Vulnerable Road Users (VRUs) such as pedestrians, cyclists, moped riders and motorcyclists, however, have not been that much in focus when developing ITS. Therefore, there is a clear need for ITS which specifically address VRUs as an integrated element of the traffic system. This paper presents the results of a quantitative safety impact assessment of five systems that were estimated to have high potential to improve the safety of cyclists, namely: Blind Spot Detection (BSD), Bicycle to Vehicle communication (B2V), Intersection safety (INS), Pedestrian and Cyclist Detection System+Emergency Braking (PCDS+EBR) and VRU Beacon System (VBS). An ex-ante assessment method proposed by Kulmala (2010) targeted to assess the effects of ITS for cars was applied and further developed in this study to assess the safety impacts of ITS specifically designed for VRUs. The main results of the assessment showed that all investigated systems affect cyclist safety in a positive way by preventing fatalities and injuries. The estimates considering 2012 accident data and full penetration showed that the highest effects could be obtained by the implementation of PCDS+EBR and B2V, whereas VBS had the lowest effect. The estimated yearly reduction in cyclist fatalities in the EU-28 varied between 77 and 286 per system. A forecast for 2030, taking into accounts the estimated accident trends and penetration rates, showed the highest effects for PCDS+EBR and BSD. Copyright © 2016 Elsevier Ltd. All rights reserved.

  13. An initiative to improve the management of clinically significant test results in a large health care network.

    Science.gov (United States)

    Roy, Christopher L; Rothschild, Jeffrey M; Dighe, Anand S; Schiff, Gordon D; Graydon-Baker, Erin; Lenoci-Edwards, Jennifer; Dwyer, Cheryl; Khorasani, Ramin; Gandhi, Tejal K

    2013-11-01

    The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged. In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action. The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics. This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.

  14. New reactor technology: safety improvements in nuclear power systems.

    Science.gov (United States)

    Corradini, M L

    2007-11-01

    Almost 450 nuclear power plants are currently operating throughout the world and supplying about 17% of the world's electricity. These plants perform safely, reliably, and have no free-release of byproducts to the environment. Given the current rate of growth in electricity demand and the ever growing concerns for the environment, nuclear power can only satisfy the need for electricity and other energy-intensive products if it can demonstrate (1) enhanced safety and system reliability, (2) minimal environmental impact via sustainable system designs, and (3) competitive economics. The U.S. Department of Energy with the international community has begun research on the next generation of nuclear energy systems that can be made available to the market by 2030 or earlier, and that can offer significant advances toward these challenging goals; in particular, six candidate reactor system designs have been identified. These future nuclear power systems will require advances in materials, reactor physics, as well as thermal-hydraulics to realize their full potential. However, all of these designs must demonstrate enhanced safety above and beyond current light water reactor systems if the next generation of nuclear power plants is to grow in number far beyond the current population. This paper reviews the advanced Generation-IV reactor systems and the key safety phenomena that must be considered to guarantee that enhanced safety can be assured in future nuclear reactor systems.

  15. Frameworks for improvement: clinical audit, the plan-do-study-act cycle and significant event audit.

    Science.gov (United States)

    Gillam, Steve; Siriwardena, A Niroshan

    2013-01-01

    This is the first in a series of articles about quality improvement tools and techniques. We explore common frameworks for improvement, including the model for improvement and its application to clinical audit, plan-do-study-act (PDSA) cycles and significant event analysis (SEA), examining the similarities and differences between these and providing examples of each.

  16. Applying different quality and safety models in healthcare improvement work: Boundary objects and system thinking

    International Nuclear Information System (INIS)

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

    2014-01-01

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

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

    Science.gov (United States)

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

    2018-04-17

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

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

    Directory of Open Access Journals (Sweden)

    Siriwong W

    2012-07-01

    safety precautions and the use of faulty protective gear. After 6 months, the intervention program showed significant improvements in the overall scores on knowledge, beliefs, behaviors, and home pesticide safety in the study group (P < 0.05. Therefore, this intervention model is effective in improving agrochemical safety behaviors among Khlong Seven Community rice farmers. These findings demonstrate that a multi-approach model for improving agrochemical safety behaviors can lead to sustainable prevention of agrochemical hazards for farmers.Keywords: rice farmer, agrochemical safety, community-based intervention, model

  19. Safety analysis of final disposal of nuclear waste - significance, development and challenges

    International Nuclear Information System (INIS)

    Andersson, Kjell; Norrby, Soeren; Simic, Eva; Wene, Clas-Otto

    2007-05-01

    The report starts with a review of the role and development of safety assessments from the middle of the 70's up until today. Then follows a section on how the assessment is performed today. The demands from the licensing authorities is then described. The report ends with a chapter on conclusions and reflections

  20. Operational safety and reactor life improvements of Kyoto University Reactor

    International Nuclear Information System (INIS)

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

    1990-01-01

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

  1. Critical Conversations and the Role of Dialogue in Delivering Meaningful Improvements in Safety and Security Culture

    International Nuclear Information System (INIS)

    Brissette, S.

    2016-01-01

    Significant scholarship has been devoted to research into safety culture assessment methodologies. These focus on the development, delivery and interpretations of safety culture surveys and other assessment techniques to assure reliable outcomes that provide insights into the safety culture of an organization across multiple dimensions. The lessons from this scholarship can be applied to the emerging area of security culture assessments as the nuclear industry broadens its focus on this topic. The aim of this paper is to discuss the value of establishing mechanisms, immediately after an assessment and regularly between assessments, to facilitate a structured dialogue among leaders around insights derived from an assessment, to enable ongoing improvements in safety and security culture. The leader’s role includes both understanding the current state of culture, the “what is”, and creating regular, open and informed dialogue around their role in shaping the culture to achieve “what should be”.

  2. ABB engagement in efforts to improve the safety of RBMK reactors

    International Nuclear Information System (INIS)

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

    1993-01-01

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

  3. Recommendations to improve radiation safety during invasive cardiovascular procedures

    International Nuclear Information System (INIS)

    Miranda, Patricia; Ubeda, Carlos; Vano, Eliseo; Nocetti, Diego

    2014-01-01

    In this paper we present guidelines aimed to improve radiation safety during invasive cardiovascular procedures. Unwanted effects upon patients and medical personnel are conventionally classified. A program of Quality Assurance is proposed, an aspect of which is a program for radiologic protection, including operator protection, radiation monitoring, shielding and personnel training. Permanent and specific actions should be taken at every cardiovascular lab, before, during and after interventions. In order to implement these guidelines and actions, a fundamental step is a review of current legislation. Specific programs for quality control and radiologic protection along with a definition of acceptable radiation exposure doses are required

  4. Safety protection and technical improvement of 60Co irradiation facilities

    International Nuclear Information System (INIS)

    Zhou Yongxing; Liang Cannan

    1993-01-01

    To ensure personal safety, some improvements has been made in the design of 60 Co irradiation compartment. The shielding door was interlocked while the 60 Co source to be lifted to the irradiation position or lowered to the shielded position. A universal change-over switch was used to cut the power supply when the source moved beyond the limits. Both γ-ray alarm and a closed-TV system were adopted. The electromagnetic attraction method was employed to shift the 60 Co source from the Pb container to the source pipe

  5. An interprofessional approach to improving paediatric medication safety

    Directory of Open Access Journals (Sweden)

    Kennedy Neil

    2010-02-01

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

  6. Improving occupational safety and health by integration into product development

    DEFF Research Database (Denmark)

    Broberg, Ole

    1996-01-01

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

  7. 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

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

    Science.gov (United States)

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

    2015-02-01

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

  9. [Experience feedback committee: a method for patient safety improvement].

    Science.gov (United States)

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

    2013-04-01

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

  10. Light water reactor sequence timing: its significance to probabilistic safety assessment modeling

    International Nuclear Information System (INIS)

    Bley, D.C.; Buttemer, D.R.; Stetkar, J.W.

    1988-01-01

    This paper examines event sequence timing in light water reactor plants from the viewpoint of probabilistic safety assessment (PSA). The analytical basis for the ideas presented here come primarily from the authors' work in support of more than 20 PSA studies over the past several years. Timing effects are important for establishing success criteria for support and safety system response and for identifying the time available for operator recovery actions. The principal results of this paper are as follows: 1. Analysis of event sequence timing is necessary for meaningful probabilistic safety assessment - both the success criteria for systems performance and the probability of recovery are tightly linked to sequence timing. 2. Simple engineering analyses based on first principles are often sufficient to provide adequate resolution of the time available for recovery of PSA scenarios. Only those parameters that influence sequence timing and its variability and uncertainty need be examined. 3. Time available for recovery is the basic criterion for evaluation of human performance, whether time is an explicit parameter of the operator actions analysis or not. (author)

  11. Development of an adhesive surgical ward round checklist: a technique to improve patient safety.

    LENUS (Irish Health Repository)

    Dhillon, P

    2012-02-01

    Checklists have been shown to improve patient outcomes. Checklist use is seen in the pre-operative to post-operative phases of the patient pathway. An adhesive checklist was developed for ward rounds due to the positive impact it could have on improving patient safety. Over an eight day period data were collected from five consultant-led teams that were randomly selected from the surgical department and divided into sticker groups and control groups. Across the board percentage adherence to the Good Surgical Practice Guidelines (GSPG) was markedly higher in the sticker study group, 1186 (91%) in comparison with the control group 718 (55%). There was significant improvement of documentation across all areas measured. An adhesive checklist for ward round note taking is a simple and cost-effective way to improve documentation, communication, hand-over, and patient safety. Successfully implemented in a tertiary level centre in Dublin, Ireland it is easily transferable to other surgical departments globally.

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

    Science.gov (United States)

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

    2017-10-23

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

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

    Science.gov (United States)

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

    2018-01-01

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

  14. Selecting Optimal Control Portfolios to Improve Army Aviation Safety

    National Research Council Canada - National Science Library

    Shelton, Sarah

    2001-01-01

    .... The Safety Center chartered the Aviation Safety Investment Strategy Team to evaluate accidents to determine their hazards, or contributing conditions, and their controls, or reduction measures...

  15. Improving radiation worker safety at the Chernobyl Shelter

    International Nuclear Information System (INIS)

    Vargo, G.J.; Korneev, A.A.

    2000-01-01

    The Shelter (i.e. 'sarcophagus') enclosing the remains of the Chernobyl Nuclear Power Plant Unit 4 that was destroyed in the April 1986 accident presents a unique radiological and nuclear safety challenge. The Chomobyl Shelter holds over 190 tons of irradiated nuclear fuel in the form of lava fuel containing masses and dust. Hazards include very high radiation, surface contamination and transient airborne radioactivity concentrations. A state-of-the-art radiation protection program is needed to support international efforts stabilize the Chornobyl Shelter, reduce the potential for major structural failure, minimize the consequences of a such an event, and develop a long-term strategy and study for its conversion into an environmentally safe site. This project consists of the first phase of efforts to transfer health physics technology necessary to support stabilization of the Chornobyl Shelter. Technical specifications for each major system and component were jointly developed by staff from the U.S. Department of Energy's Pacific Northwest National Laboratory and the Chornobyl Shelter. Major elements of this technology transfer include equipment for external dose control (electronic dosimeters, thermoluminescent dosimeter (TLD) system, portable radiation survey instruments, and area radiation monitors), internal dose control (whole body counter, bioassay system design and technical support), health physics training, and other radiological technical support. A work planning system that includes the capability to collect data such as radiological surveys, photographs, video clips, and other data, was developed from a system demonstrated at the U.S. Department of Energy's Hanford Site. An access control system similar to one used at several commercial nuclear facilities in the U.S. was converted for bilingual support (Russian and English). Technology for improving contamination control includes HEPA-ventilation and vacuum cleaner systems, semi-permanent and portable

  16. New research opportunities for roadside safety barriers improvement

    Science.gov (United States)

    Cantisani, Giuseppe; Di Mascio, Paola; Polidori, Carlo

    2017-09-01

    Among the major topics regarding the protection of roads, restraint systems still represent a big opportunity in order to increase safety performances. When accidents happen, in fact, the infrastructure can substantially contribute to the reduction of consequences if its marginal spaces are well designed and/or effective restraint systems are installed there. Nevertheless, basic concepts and technology of road safety barriers have not significantly changed for the last two decades. The paper proposes a new approach to the study aimed to define possible enhancements of restraint safety systems performances, by using new materials and defining innovative design principles. In particular, roadside systems can be developed with regard to vehicle-barrier interaction, vehicle-oriented design (included low-mass and extremely low-mass vehicles), traffic suitability, user protection, working width reduction. In addition, thanks to sensors embedded into the barriers, it is also expected to deal with new challenges related to the guidance of automatic vehicles and I2V communication.

  17. Preliminary study on improving safety culture in Malaysian nuclear industries

    International Nuclear Information System (INIS)

    Ibrahim, Sabariah Kader; Lee, Y. E.

    2012-01-01

    This paper presents preliminary study on safety culture and its implementation in Malaysian nuclear industries by realizing the importance of safety culture; identification of important safety culture attributes; safety culture assessment and the practices to incorporate the identified safety culture attributes in organization. The first section of this paper explains the terms and definitions related to safety culture. Second, for the realization of importance of safety culture in organization, the international operational experiences emphasizing the importance of safety culture are described. Third, important safety culture attributes which are frequently cited in literature are provided. Fourth, methods to assess safety culture in operating organization are described. Finally, the practices to enhance the safety culture in an organization are discussed

  18. Preliminary study on improving safety culture in Malaysian nuclear industries

    Energy Technology Data Exchange (ETDEWEB)

    Ibrahim, Sabariah Kader [KAIST, Daejeon (Korea, Republic of); Lee, Y. E. [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

    2012-10-15

    This paper presents preliminary study on safety culture and its implementation in Malaysian nuclear industries by realizing the importance of safety culture; identification of important safety culture attributes; safety culture assessment and the practices to incorporate the identified safety culture attributes in organization. The first section of this paper explains the terms and definitions related to safety culture. Second, for the realization of importance of safety culture in organization, the international operational experiences emphasizing the importance of safety culture are described. Third, important safety culture attributes which are frequently cited in literature are provided. Fourth, methods to assess safety culture in operating organization are described. Finally, the practices to enhance the safety culture in an organization are discussed.

  19. Evaluation of implementation an Integrated Safety and Preventive Maintenance System for Improving of Safety Indexes

    Directory of Open Access Journals (Sweden)

    I mohammadfam

    2014-03-01

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

  20. A method for risk-informed safety significance categorization using the analytic hierarchy process and bayesian belief networks

    International Nuclear Information System (INIS)

    Ha, Jun Su; Seong, Poong Hyun

    2004-01-01

    A risk-informed safety significance categorization (RISSC) is to categorize structures, systems, or components (SSCs) of a nuclear power plant (NPP) into two or more groups, according to their safety significance using both probabilistic and deterministic insights. In the conventional methods for the RISSC, the SSCs are quantitatively categorized according to their importance measures for the initial categorization. The final decisions (categorizations) of SSCs, however, are qualitatively made by an expert panel through discussions and adjustments of opinions by using the probabilistic insights compiled in the initial categorization process and combining the probabilistic insights with the deterministic insights. Therefore, owing to the qualitative and linear decision-making process, the conventional methods have the demerits as follows: (1) they are very costly in terms of time and labor, (2) it is not easy to reach the final decision, when the opinions of the experts are in conflict and (3) they have an overlapping process due to the linear paradigm (the categorization is performed twice - first, by the engineers who propose the method, and second, by the expert panel). In this work, a method for RISSC using the analytic hierarchy process (AHP) and bayesian belief networks (BBN) is proposed to overcome the demerits of the conventional methods and to effectively arrive at a final decision (or categorization). By using the AHP and BBN, the expert panel takes part in the early stage of the categorization (that is, the quantification process) and the safety significance based on both probabilistic and deterministic insights is quantified. According to that safety significance, SSCs are quantitatively categorized into three categories such as high safety significant category (Hi), potentially safety significant category (Po), or low safety significant category (Lo). The proposed method was applied to the components such as CC-V073, CV-V530, and SI-V644 in Ulchin Unit

  1. The french-german safety approach for future PWRs and its significance for EPR licensing

    International Nuclear Information System (INIS)

    Frisch, W.; Gros, G.

    1997-06-01

    Three important general safety objectives are mentioned in this work: a further reduction of the core melt frequency, the practical elimination of accident situations which could lead to large early releases of radioactive material. If those situations cannot be considered as physically impossible, provisions have to be taken to design them out, the third point, for low pressure core melt situations the design has to be such that the associated maximum conceivable releases would necessitate only very limited protective measures in area and time ( no permanent relocation, no need for emergency evacuation outside the immediate vicinity of the plant, limited sheltering, no long term restrictions in consumption of food). (N.C.)

  2. Measures to Improve Diagnostic Safety in Clinical Practice.

    Science.gov (United States)

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

    2016-10-20

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

  3. Using human factors engineering to improve patient safety in the cardiovascular operating room.

    Science.gov (United States)

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

    2012-01-01

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

  4. Improved Process Used to Treat Aqueous Mixed Waste Results in Cost Savings and Improved Worker Safety

    International Nuclear Information System (INIS)

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

    2006-01-01

    This paper describes an improved process implemented at Argonne National Laboratory (ANL) to treat aqueous mixed waste. This waste is comprised of radioactively-contaminated corrosive liquids with heavy metals. The Aqueous Mixed Waste Treatment System (AMWTS) system components include a reaction tank and a post-treatment holding tank with ancillary piping and pumps; and a control panel with pumping/mixing controls; tank level, temperature and pH/Oxidation Reduction Potential (ORP) indicators. The process includes a neutralization step to remove the corrosive characteristic, a chromium reduction step to reduce hexavalent chromium to trivalent chromium, and a precipitation step to convert the toxic metals into an insoluble form. Once the toxic metals have precipitated, the resultant sludge is amenable to stabilization and can be reclassified as a low-level waste if the quantity of leachable toxic metals, as determined by the TCLP, is below Universal Treatment Standards (UTS). To date, six batches in eight have passed the UTS. The AMWTS is RCRA permitted and allows for the compliant treatment of mixed waste prior to final disposal at a Department of Energy (DOE) or commercial radioactive waste disposal facility. Mixed wastes eligible for treatment include corrosive liquids (pH 12.5) containing EPA-regulated toxic metals (As, Ba, Pb, Cd, Cr, Ag, Se, Hg) at concentrations greater than the RCRA Toxicity Characteristic Leaching Procedure (TCLP) limit. The system has also been used to treat corrosive wastes with small quantities of fissionable materials. The AMWTS is a significant engineered solution with many improvements over the more labor intensive on-site treatment method being performed within a ventilation hood used previously. The previously used treatment system allowed for batch sizes of only 15-20 gallons whereas the new AMWTS allows for the treatment of batches up to 75 gallons; thereby reducing batch labor and supply costs by 40-60% and reducing analytical

  5. South Ukraine NPP: Safety improvements through Plant Computer upgrade

    International Nuclear Information System (INIS)

    Brenman, O.; Chernyshov, M. A.; Denning, R. S.; Kolesov, S. A.; Balakan, H. H.; Bilyk, B. I.; Kuznetsov, V. I.; Trosman, G.

    2006-01-01

    This paper summarizes some results of the Plant Computer upgrade at the Units 2 and 3 of South Ukraine Nuclear Power Plant (NPP). A Plant Computer, which is also called the Computer Information System (CIS), is one of the key safety-related systems at VVER-1000 nuclear plants. The main function of the CIS is information support for the plant operators during normal and emergency operational modes. Before this upgrade, South Ukraine NPP operated out-of-date and obsolete systems. This upgrade project wax founded by the U.S. DOE in the framework of the International Nuclear Safety Program (INSP). The most efficient way to improve the quality and reliability of information provided to the plant operator is to upgrade the Human-System Interface (HSI), which is the Upper Level (UL) CIS. The upgrade of the CIS data-acquisition system (DAS), which is the Lower Level (LL) CIS, would have less effect on the unit safety. Generally speaking, the lifetime of the LL CIS is much higher than one of the UL CIS. Unlike Plant Computers at the Western-designed plants, the functionality of the WER-1000 CISs includes a control function (Centralized Protection Testing) and a number of the plant equipment monitoring functions, for example, Protection and Interlock Monitoring and Turbo-Generator Temperature Monitoring. The new system is consistent with a historical migration of the format by which information is presented to the operator away from the traditional graphic displays, for example, Piping and Instrument Diagrams (P and ID's), toward Integral Data displays. The cognitive approach to information presentation is currently limited by some licensing issues, but is adapted to a greater degree with each new system. The paper provides some lessons learned on the management of the international team. (authors)

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

    Science.gov (United States)

    Rall, M; Oberfrank, S

    2013-10-01

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

  7. Application of Bow-tie methodology to improve patient safety.

    Science.gov (United States)

    Abdi, Zhaleh; Ravaghi, Hamid; Abbasi, Mohsen; Delgoshaei, Bahram; Esfandiari, Somayeh

    2016-05-09

    Purpose - The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach - Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings - In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value - The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

  8. Improved safety in advanced control complexes, without side effects

    International Nuclear Information System (INIS)

    Harmon, D.L.

    1997-01-01

    If we only look for a moment at the world around us, it is obvious that advances in digital electronic equipment and Human-System Interface (HSI) technology are occurring at a phenomenal pace. This is evidenced from our home entertainment systems to the dashboard and computer-based operation of our new cars. Though the nuclear industry has less vigorously embraced these advances, their application is being implemented through individual upgrades to current generation nuclear plants and as plant-wide control complexes for advanced plants. In both venues modem technology possesses widely touted advantages for improving plant availability as well as safety. The well-documented safety benefits of digital Instrumentation and Controls (I ampersand C) include higher reliability resulting from redundancy and fault tolerance, inherent self-test and self-diagnostic capabilities which have replaced error-prone human tasks, resistance to setpoint drift increasing available operating margins, and the ability to run complex, real-time, computer-based algorithms directly supporting an operator's monitoring and control task requirements. 22 refs., 3 figs., 5 tabs

  9. Improving Quality and Occupational Safety on Automated Casting Lines

    Directory of Open Access Journals (Sweden)

    Kukla S.

    2017-09-01

    Full Text Available The paper presents a practical example of improving quality and occupational safety on automated casting lines. Working conditions on the line of box moulding with horizontal mould split were analysed due to low degree of automation at the stage of cores or filters installation as well as spheroidizing mortar dosing. A simulation analysis was carried out, which was related to the grounds of introducing an automatic mortar dispenser to the mould. To carry out the research, a simulation model of a line in universal Arena software for modelling and simulation of manufacturing systems by Rockwell Software Inc. was created. A simulation experiment was carried out on a model in order to determine basic parameters of the working system. Organization and working conditions in other sections of the line were also analysed, paying particular attention to quality, ergonomics and occupational safety. Ergonomics analysis was carried out on manual cores installation workplace and filters installation workplace, and changes to these workplaces were suggested in order to eliminate actions being unnecessary and onerous for employees.

  10. Using a Training Video to Improve Agricultural Workers' Knowledge of On-Farm Food Safety

    Science.gov (United States)

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

    2012-01-01

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

  11. Improvement of driving safety in road traffic system

    Science.gov (United States)

    Li, Ke-Ping; Gao, Zi-You

    2005-05-01

    A road traffic system is a complex system in which humans participate directly. In this system, human factors play a very important role. In this paper, a kind of control signal is designated at a given site (i.e., signal point) of the road. Under the effect of the control signal, the drivers will decrease their velocities when their vehicles pass the signal point. Our aim is to transit the traffic flow states from disorder to order and then improve the traffic safety. We have tested this technique for the two-lane traffic model that is based on the deterministic Nagel-Schreckenberg (NaSch) traffic model. The simulation results indicate that the traffic flow states can be transited from disorder to order. Different order states can be observed in the system and these states are safer.

  12. Evolution of strategies to improve preclinical cardiac safety testing.

    Science.gov (United States)

    Gintant, Gary; Sager, Philip T; Stockbridge, Norman

    2016-07-01

    The early and efficient assessment of cardiac safety liabilities is essential to confidently advance novel drug candidates. This article discusses evolving mechanistically based preclinical strategies for detecting drug-induced electrophysiological and structural cardiotoxicity using in vitro human ion channel assays, human-based in silico reconstructions and human stem cell-derived cardiomyocytes. These strategies represent a paradigm shift from current approaches, which rely on simplistic in vitro assays that measure blockade of the Kv11.1 current (also known as the hERG current or IKr) and on the use of non-human cells or tissues. These new strategies have the potential to improve sensitivity and specificity in the early detection of genuine cardiotoxicity risks, thereby reducing the likelihood of mistakenly discarding viable drug candidates and speeding the progression of worthy drugs into clinical trials.

  13. Organising a manuscript reporting quality improvement or patient safety research.

    Science.gov (United States)

    Holzmueller, Christine G; Pronovost, Peter J

    2013-09-01

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

  14. Flooding Experiments and Modeling for Improved Reactor Safety

    International Nuclear Information System (INIS)

    Solmos, M.; Hogan, K.J.; VIerow, K.

    2008-01-01

    Countercurrent two-phase flow and 'flooding' phenomena in light water reactor systems are being investigated experimentally and analytically to improve reactor safety of current and future reactors. The aspects that will be better clarified are the effects of condensation and tube inclination on flooding in large diameter tubes. The current project aims to improve the level of understanding of flooding mechanisms and to develop an analysis model for more accurate evaluations of flooding in the pressurizer surge line of a Pressurized Water Reactor (PWR). Interest in flooding has recently increased because Countercurrent Flow Limitation (CCFL) in the AP600 pressurizer surge line can affect the vessel refill rate following a small break LOCA and because analysis of hypothetical severe accidents with the current flooding models in reactor safety codes shows that these models represent the largest uncertainty in analysis of steam generator tube creep rupture. During a hypothetical station blackout without auxiliary feedwater recovery, should the hot leg become voided, the pressurizer liquid will drain to the hot leg and flooding may occur in the surge line. The flooding model heavily influences the pressurizer emptying rate and the potential for surge line structural failure due to overheating and creep rupture. The air-water test results in vertical tubes are presented in this paper along with a semi-empirical correlation for the onset of flooding. The unique aspects of the study include careful experimentation on large-diameter tubes and an integrated program in which air-water testing provides benchmark knowledge and visualization data from which to conduct steam-water testing

  15. Evaluating the Effectiveness of Two Teaching Strategies to Improve Nursing Students' Knowledge, Skills, and Attitudes About Quality Improvement and Patient Safety.

    Science.gov (United States)

    Maxwell, Karen L; Wright, Vivian H

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

  16. Representing the Fuzzy improved risk graph for determination of optimized safety integrity level in industrial setting

    Directory of Open Access Journals (Sweden)

    Z. Qorbali

    2013-12-01

    .Conclusion: as a result of establishing the presented method, identical levels in conventional risk graph table are replaced with different sublevels that not only increases the accuracy in determining the SIL, but also elucidates the effective factor in improving the safety level and consequently saves time and cost significantly. The proposed technique has been employed to develop the SIL of Tehran Refinery ISOMAX Center. IRG and FIRG results have been compared to clarify the efficacy and importance of the proposed method

  17. The SHIELD (Safety & Health Improvement: Enhancing Law Enforcement Departments Study: Feasibility and Findings

    Directory of Open Access Journals (Sweden)

    Kerry Stephen Kuehl

    2014-05-01

    Full Text Available This randomized prospective trial aimed to assess the feasibility and efficacy of a team-based worksite health and safety intervention for law enforcement personnel. Four-hundred and eight subjects were enrolled and half were randomized to meet participants met for weekly, peer-led sessions delivered from a scripted team-based health and safety curriculum. Curriculum addressed: exercise, nutrition, stress, sleep, body weight, injury, and other unhealthy lifestyle behaviours such as smoking and heavy alcohol use. Health and safety questionnaires administered before and after the intervention found significant improvements for increased fruit and vegetable consumption, overall healthy eating, increased sleep quantity and sleep quality, and reduced personal stress.

  18. Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety.

    Science.gov (United States)

    Kim, Julia M; Suarez-Cuervo, Catalina; Berger, Zackary; Lee, Joy; Gayleard, Jessica; Rosenberg, Carol; Nagy, Natalia; Weeks, Kristina; Dy, Sydney

    2018-04-01

    Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5). We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity. Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining

  19. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

    Science.gov (United States)

    Goeschel, Christine A; Wachter, Robert M; Pronovost, Peter J

    2010-07-01

    Concern about the quality and safety of health care persists, 10 years after the 1999 Institute of Medicine report To Err is Human. Despite growing awareness of quality and safety risks, and significant efforts to improve, progress is difficult to measure. Hospital leaders, including boards and medical staffs, are accountable to improve care, yet they often address this duty independently. Shared responsibility for quality and patient safety improvement presents unique challenges and unprecedented opportunities for boards and medical staffs. To capitalize on the pressure to improve, both groups may benefit from a better understanding of their synergistic potential. Boards should be educated about the quality of care provided in their institutions and about the challenges of valid measurement and accurate reporting. Boards strengthen their quality oversight capacity by recruiting physicians for vacant board seats. Medical staff members strengthen their role as hospital leaders when they understand the unique duties of the governing board. A quality improvement strategy rooted in synergistic efforts by the board and the medical staff may offer the greatest potential for safer care. Such a mutually advantageous approach requires a clear appreciation of roles and responsibilities and respect for differences. In this article, we review these responsibilities, describe opportunities for boards and medical staffs to collaborate as leaders, and offer recommendations for how boards and medical staff members can address the challenges of shared responsibility for quality of care.

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

    International Nuclear Information System (INIS)

    Lipar, M.

    1998-01-01

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

  1. Discussion on establishment and improvement of the nuclear safety culture system

    International Nuclear Information System (INIS)

    Lu Weiqiang; Na Fuli

    2010-01-01

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

  2. Investigating and improving pedestrian safety in an urban environment.

    Science.gov (United States)

    Pollack, Keshia M; Gielen, Andrea C; Mohd Ismail, Mohd Nasir; Mitzner, Molly; Wu, Michael; Links, Jonathan M

    2014-12-01

    Prompted by a series of fatal and nonfatal pedestrian-vehicle collisions, university leadership from one urban institution collaborated with its academic injury research center to investigate traffic-related hazards facing pedestrians. This descriptive epidemiologic study used multiple data collection strategies to determine the burden of pedestrian injury in the target area. Data were collected in 2011 through a review of university crash reports from campus police; a systematic environmental audit and direct observations using a validated instrument and trained raters; and focus groups with faculty, students, and staff. Study findings were synthesized and evidence-informed recommendations were developed and disseminated to university leadership. Crash reports provided some indication of the risks on the streets adjacent to the campus. The environmental audit identified a lack of signage posting the speed limit, faded crosswalks, issues with traffic light and walk sign synchronization, and limited formal pedestrian crossings, which led to jaywalking. Focus groups participants described dangerous locations and times, signal controls and signage, enforcement of traffic laws, use of cell phones and iPods, and awareness of pedestrian safety. Recommendations to improve pedestrian safety were developed in accordance with the three E's of injury prevention (education, enforcement, and engineering), and along with plans for implementation and evaluation, were presented to university leadership. These results underscore the importance of using multiple methods to understand fully the problem, developing pragmatic recommendations that align with the three E's of injury prevention, and collaborating with leadership who have the authority to implement recommended injury countermeasures. These lessons are relevant for the many colleges and universities in urban settings where a majority of travel to offices, classrooms, and surrounding amenities are by foot.

  3. New Improved Nuclear Data for Nuclear Criticality and Safety

    International Nuclear Information System (INIS)

    Guber, Klaus H.; Leal, Luiz C.; Lampoudis, C.; Kopecky, S.; Schillebeeckx, P.; Emiliani, F.; Wynants, R.; Siegler, P.

    2011-01-01

    The Geel Electron Linear Accelerator (GELINA) was used to measure neutron total and capture cross sections of 182,183,184,186 W and 63,65 Cu in the energy range from 100 eV to ∼200 keV using the time-of-flight method. GELINA is the only high-power white neutron source with excellent timing resolution and ideally suited for these experiments. Concerns about the use of existing cross-section data in nuclear criticality calculations using Monte Carlo codes and benchmarks were a prime motivator for the new cross-section measurements. To support the Nuclear Criticality Safety Program, neutron cross-section measurements were initiated using GELINA at the EC-JRC-IRMM. Concerns about data deficiencies in some existing cross-section evaluations from libraries such as ENDF/B, JEFF, or JENDL for nuclear criticality calculations were the prime motivator for new cross-section measurements. Over the past years many troubles with existing nuclear data have emerged, such as problems related to proper normalization, neutron sensitivity backgrounds, poorly characterized samples, and use of improper pulse-height weighting functions. These deficiencies may occur in the resolved- and unresolved-resonance region and may lead to erroneous nuclear criticality calculations. An example is the use of the evaluated neutron cross-section data for tungsten in nuclear criticality safety calculations, which exhibit discrepancies in benchmark calculations and show the need for reliable covariance data. We measured the neutron total and capture cross sections of 182,183,184,186 W and 63,65 Cu in the neutron energy range from 100 eV to several hundred keV. This will help to improve the representation of the cross sections since most of the available evaluated data rely only on old measurements. Usually these measurements were done with poor experimental resolution or only over a very limited energy range, which is insufficient for the current application.

  4. Improving nuclear power plant safety through operator aids

    International Nuclear Information System (INIS)

    1987-12-01

    In October 1986, the IAEA convened a one-week Technical Committee Meeting on Improving Nuclear Power Plant Safety Through Operator Aids. The term ''operator aid'' or more formally ''operator support system'' refers to a class of devices designed to be added to a nuclear power plant control station to assist an operator in performing his job and thereby decrease the probability of operator error. The addition of a carefully planned and designed operator aid should result in an increase in nuclear power plant safety and reliability. Operator aids encompass a wide range of devices from the very simple, such as color coding a display to distinguish it out of a group of similar displays, to the very complex, such as a computer-generated video display which concentrates a number of scattered indicator readings located around a control room into a concise display in front of the operator. This report provides guidelines and information to help make a decision as to whether an operator aid is needed, what kinds of operator aids are available and whether it should be purchased or developed by the utility. In addition, a discussion is presented on advanced operator aids to provide information on what may become available in the future. The broad scope of these guidelines makes it most suitable for use by a multi-disciplinary team. The document consists of two parts. The recommendations and results of the meeting discussions are given in the first part. The second part is the annex where the papers presented at the Technical Committee Meeting are printed. A separate abstract was prepared for each of the 10 papers. Refs, figs and tabs

  5. An electronic intervention to improve safety for pain patients co-prescribed chronic opioids and benzodiazepines.

    Science.gov (United States)

    Zaman, Tauheed; Rife, Tessa L; Batki, Steven L; Pennington, David L

    2018-03-29

    Co-prescribing opioids and benzodiazepines increases overdose risk. A paucity of literature exists evaluating strategies to improve safety of co-prescribing. This study evaluated an electronic intervention to improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines at 3 and 6 months. A prospective cohort study was conducted from December 2015 through May 2016 at San Francisco Veterans Affairs Health Care System. A clinical dashboard identified 145 eligible patients prescribed chronic opioids and benzodiazepines. Individualized taper and safety recommendations were communicated to prescribers via electronic medical record progress note and encrypted e-mail at baseline. Primary outcome was number of patients co-prescribed chronic opioids and benzodiazepines. Secondary outcomes included daily dose of opioids and benzodiazepines and number prescribed ≥100 mg morphine equivalent daily dose. Safety outcomes included number with opioid overdose education and naloxone distribution, annual urine drug screening, annual prescription drug monitoring program review, and signed opioid informed consent. Linear mixed models and generalized estimating equations were used to examine within-group change in outcomes between baseline and 3 and 6 months. Among the 145 patients, mean (standard deviation) age was 62 (11) years and 91.7% (133/145) were male. Number co-prescribed significantly decreased from 145/145 (100%) at baseline to 93/139 (67%) at 6-month follow-up (odds ratio [OR] = 0.53, 95% confidence interval [CI]: 0.34-0.81, P = .003). Mean opioid and benzodiazepine doses significantly decreased from 84.61 to 65.63 mg (95% CI: 8.32-27.86, P improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines.

  6. Significance of impurities in the safety evaluation of crop protection products - (IUPAC technical report)

    NARCIS (Netherlands)

    Ambrus, A.; Hamilton, D.J.; Kuiper, H.A.; Racke, K.D.

    2003-01-01

    There may be substantial differences in the chemical composition of technical-grade products of the same active ingredient manufactured under different conditions, from different raw materials, or by different routes of synthesis. Resulting differences in impurity content may significantly affect

  7. Significance of iodine radioactive isotopes in the problem of radiation safety of nuclear fuel cycle

    International Nuclear Information System (INIS)

    Malenchenko, A.F.; Mironov, V.P.

    1979-01-01

    The data on actual wastes of nuclear-power plants, environmental distribution and biological effects of iodine radioactive isotopes have been analyzed. Dose-response relationship is estimated as well as its significance for struma maligna development under ionizing radiation and the contribution of iodine radionuclides resulted from nuclear power engineering to this process

  8. Temporary blinding from bright light sources as a significant impact on occupational safety and health

    International Nuclear Information System (INIS)

    Reidenbach, Hans-Dieter

    2008-01-01

    Low power laser and high-brightness LEDs (HB-LEDs) have been applied in specially developed and computer assisted test setups in order to determine the duration and progression of colours in afterimages, the disturbance of visual acuity as well as the impairment of colour and contrast vision. Interrelationships between wavelength, exposure duration, optical power and energy have been investigated. Afterimage durations up to 300 seconds were found if the fovea of the human retina is irradiated from a laser beam at less than 30 μW, whereas lower values are valid in the Parafoveal region and in the periphery. The visual acuity was strongly reduced during about 30 % of the afterimage time. The time-dependent progression of the afterimage colours was determined for 4 different dominant wavelengths of HB-LEDs, i.e. 455 nm, 530 nm, 590 nm and 625 nm, in the power range between 0.05 m W and 0.5 m W for exposure durations between 0.5 s and 5 s. The flight of colours obtained with 5 test persons is given as 8-bit RGB-values and illustrated as a function of the applied optical energy in the CIE chromaticity diagram together with the respective total afterimage durations. The colour contrast capability was investigated for 3 volunteers with specially developed test charts in 7 colours, namely without and after glare from 4 coloured high-brightness LEDs. Each subject completed 56 time-consuming tests since adequate adaptation was necessary between the respective tests. Glare increases the identification times about 14 s and 16 s and even stronger impairment is observable especially at low colour contrast. Tests with 40 subjects and 4 different pseudoisochromatic colour plates have shown that colour vision was impaired for periods between 27 s and 186 s depending on the applied colour plate and respective LED colour. Such relatively long lasting visual disturbances could be of particular concern connected with performing safety critical operations such as working with machines

  9. 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

  10. Neuro-Linguistic Programming: Improving Rapport between Track/Cross Country Coaches and Significant Others

    Science.gov (United States)

    Helm, David Jay

    2017-01-01

    This study examines the background information and the components of N.L.P., being eye movements, use of predicates, and posturing, as they apply to improving rapport and empathy between track/cross country coaches and their significant others in the arena of competition to help alleviate the inherent stressors.

  11. Multi-physics Modeling for Improving Li-Ion Battery Safety; NREL (National Renewable Energy Laboratory)

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-04-21

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

  12. Obtaining Valid Safety Data for Software Safety Measurement and Process Improvement

    Science.gov (United States)

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

    2010-01-01

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

  13. Rehearsal significantly improves immediate and delayed recall on the Rey Auditory Verbal Learning Test.

    Science.gov (United States)

    Hessen, Erik

    2011-10-01

    A repeated observation during memory assessment with the Rey Auditory Verbal Learning Test (RAVLT) is that patients who spontaneously employ a memory rehearsal strategy by repeating the word list more than once achieve better scores than patients who only repeat the word list once. This observation led to concern about the ability of the standard test procedure of RAVLT and similar tests in eliciting the best possible recall scores. The purpose of the present study was to test the hypothesis that a rehearsal recall strategy of repeating the word list more than once would result in improved scores of recall on the RAVLT. We report on differences in outcome after standard administration and after experimental administration on Immediate and Delayed Recall measures from the RAVLT of 50 patients. The experimental administration resulted in significantly improved scores for all the variables employed. Additionally, it was found that patients who failed effort screening showed significantly poorer improvement on Delayed Recall compared with those who passed the effort screening. The general clear improvement both in raw scores and T-scores demonstrates that recall performance can be significantly influenced by the strategy of the patient or by small variations in instructions by the examiner.

  14. Advancing rig design: latest rig technologies improving efficiency and safety

    Energy Technology Data Exchange (ETDEWEB)

    Greenaway, R.

    1997-12-01

    Recent advances in drilling rig technologies that improve the ways for finding oil and natural gas, and are also solving some safety and transportation problems, have been reviewed. The coiled tubing drilling rig developed by joint venture TransOcean Ensign Drilling Technology was one of the innovations described. It is able to run a three-and-a-quarter inch coiled tubing, the only system capable of doing this in a land-based application. Tesco Corporation`s new casing drilling rig, which is expected to lower the cost of moving the rig, and Brinkerhoff Drilling`s new generation modular (NGM)-rig, claimed to be the most mobile rig in North America, are other new developments worthy of note. Tesco`s casing drilling rig has the potential to reduce drilling costs by as much as 30 to 40 per cent, while the NGM-rig could reduce rig mobilization time by 50 to 80 per cent, and the number of wells drilled by the same rig could increase by 20 per cent, due to the NGM-rig`s versatility and flexibility.

  15. COUNTERCURRENT FLOW LIMITATION EXPERIMENTS AND MODELING FOR IMPROVED REACTOR SAFETY

    International Nuclear Information System (INIS)

    Vierow, Karen

    2008-01-01

    This project is investigating countercurrent flow and 'flooding' phenomena in light water reactor systems to improve reactor safety of current and future reactors. To better understand the occurrence of flooding in the surge line geometry of a PWR, two experimental programs were performed. In the first, a test facility with an acrylic test section provided visual data on flooding for air-water systems in large diameter tubes. This test section also allowed for development of techniques to form an annular liquid film along the inner surface of the 'surge line' and other techniques which would be difficult to verify in an opaque test section. Based on experiences in the air-water testing and the improved understanding of flooding phenomena, two series of tests were conducted in a large-diameter, stainless steel test section. Air-water test results and steam-water test results were directly compared to note the effect of condensation. Results indicate that, as for smaller diameter tubes, the flooding phenomena is predominantly driven by the hydrodynamics. Tests with the test sections inclined were attempted but the annular film was easily disrupted. A theoretical model for steam venting from inclined tubes is proposed herein and validated against air-water data. Empirical correlations were proposed for air-water and steam-water data. Methods for developing analytical models of the air-water and steam-water systems are discussed, as is the applicability of the current data to the surge line conditions. This report documents the project results from July 1, 2005 through June 30, 2008

  16. Costello Syndrome with Severe Nodulocystic Acne: Unexpected Significant Improvement of Acanthosis Nigricans after Oral Isotretinoin Treatment

    Directory of Open Access Journals (Sweden)

    Leelawadee Sriboonnark

    2015-01-01

    Full Text Available We report the case of 17-year-old female diagnosed with Costello syndrome. Genetic testing provided a proof with G12S mutation in the HRAS gene since 3 years of age with a presentation of severe nodulocystic acne on her face. After 2 months of oral isotretinoin treatment, improvement in her acne was observed. Interestingly, an unexpected significant improvement of acanthosis nigricans on her neck and dorsum of her hands was found as well. We present this case as a successful treatment option by using oral isotretinoin for the treatment of acanthosis nigricans in Costello syndrome patients.

  17. Determination of significance in Ecological Impact Assessment: Past change, current practice and future improvements

    Energy Technology Data Exchange (ETDEWEB)

    Briggs, Sam; Hudson, Malcolm D., E-mail: mdh@soton.ac.uk

    2013-01-15

    Ecological Impact Assessment (EcIA) is an important tool for conservation and achieving sustainable development. 'Significant' impacts are those which disturb or alter the environment to a measurable degree. Significance is a crucial part of EcIA, our understanding of the concept in practice is vital if it is to be effective as a tool. This study employed three methods to assess how the determination of significance has changed through time, what current practice is, and what would lead to future improvements. Three data streams were collected: interviews with expert stakeholders, a review of 30 Environmental Statements and a broad-scale survey of the United Kingdom Institute of Ecology and Environmental Management (IEEM) members. The approach taken in the determination of significance has become more standardised and subjectivity has become constrained through a transparent framework. This has largely been driven by a set of guidelines produced by IEEM in 2006. The significance of impacts is now more clearly justified and the accuracy with which it is determined has improved. However, there are limitations to accuracy and effectiveness of the determination of significance. These are the quality of baseline survey data, our scientific understanding of ecological processes and the lack of monitoring and feedback of results. These in turn are restricted by the limited resources available in consultancies. The most notable recommendations for future practice are the implementation of monitoring and the publication of feedback, the creation of a central database for baseline survey data and the streamlining of guidance. - Highlights: Black-Right-Pointing-Pointer The assessment of significance has changed markedly through time. Black-Right-Pointing-Pointer The IEEM guidelines have driven a standardisation of practice. Black-Right-Pointing-Pointer Currently limited by quality of baseline data and scientific understanding. Black-Right-Pointing-Pointer Monitoring

  18. Significance of Alkali-Silica reaction in nuclear safety-related concrete structures

    International Nuclear Information System (INIS)

    Le Pape, Y.; Field, K.G.; Mattus, C.H.; Naus, D.J.; Busby, J.T.; Saouma, V.; Ma, Z.J.; Cabage, J.V.; Guimaraes, M.

    2015-01-01

    Nuclear Power Plant license renewal up to 60 years and possible life extension beyond has established a renewed focus on long-term aging of nuclear generating stations materials, and particularly, on concrete. Large irreplaceable sections of most nuclear generating stations include concrete components. The Expanded Materials Degradation Analysis, jointly performed by the Department of Energy, the U.S. Nuclear Regulatory Commission, the Academia and the Power Generation Industry, identified the need to develop a consistent knowledge base of alkali-silica reaction (ASR) within concrete as an urgent priority (Graves et al., 2014). ASR results in an expansion of Concrete produced by the reaction between alkali (generally from cement), reactive aggregate (like amorphous silica) and water absorption. ASR causes expansion, cracking and loss of mechanical properties. Considering that US commercial reactors in operation enter the age when ASR distress can be potentially observed and that numerous non-nuclear infrastructures (transportation, energy production) in a majority of the States have already experienced ASR-related concrete degradation, the susceptibility and significance of ASR for nuclear concrete structures must be addressed. This paper outlines an on-going research program including the investigation of the possibility of ASR in nuclear power plants, and the assessment of the residual shear bearing capacity of ASR-subjected nuclear structures. (authors)

  19. Histone deacetylase inhibitor significantly improved the cloning efficiency of porcine somatic cell nuclear transfer embryos.

    Science.gov (United States)

    Huang, Yongye; Tang, Xiaochun; Xie, Wanhua; Zhou, Yan; Li, Dong; Yao, Chaogang; Zhou, Yang; Zhu, Jianguo; Lai, Liangxue; Ouyang, Hongsheng; Pang, Daxin

    2011-12-01

    Valproic acid (VPA), a histone deacetylase inbibitor, has been shown to generate inducible pluripotent stem (iPS) cells from mouse and human fibroblasts with a significant higher efficiency. Because successful cloning by somatic cell nuclear transfer (SCNT) undergoes a full reprogramming process in which the epigenetic state of a differentiated donor nuclear is converted into an embryonic totipotent state, we speculated that VPA would be useful in promoting cloning efficiency. Therefore, in the present study, we examined whether VPA can promote the developmental competence of SCNT embryos by improving the reprogramming state of donor nucleus. Here we report that 1 mM VPA for 14 to 16 h following activation significantly increased the rate of blastocyst formation of porcine SCNT embryos constructed from Landrace fetal fibroblast cells compared to the control (31.8 vs. 11.4%). However, we found that the acetylation level of Histone H3 lysine 14 and Histone H4 lysine 5 and expression level of Oct4, Sox2, and Klf4 was not significantly changed between VPA-treated and -untreated groups at the blastocyst stage. The SCNT embryos were transferred to 38 surrogates, and the cloning efficiency in the treated group was significantly improved compared with the control group. Taken together, we have demonstrated that VPA can improve both in vitro and in vivo development competence of porcine SCNT embryos.

  20. Improved technical specifications and related improvements to safety in commercial Nuclear power plants

    Energy Technology Data Exchange (ETDEWEB)

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

    2004-07-01

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

  1. Improved technical specifications and related improvements to safety in commercial Nuclear power plants

    International Nuclear Information System (INIS)

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

    2004-01-01

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

  2. [Improving patient safety: Usefulness of safety checklists in a neonatal unit].

    Science.gov (United States)

    Arriaga Redondo, María; Sanz López, Ester; Rodríguez Sánchez de la Blanca, Ana; Marsinyach Ros, Itziar; Collados Gómez, Laura; Díaz Redondo, Alicia; Sánchez Luna, Manuel

    2017-10-01

    Due to the complexity and characteristics of their patients, neonatal units are risk areas for the development of adverse events (AE). For this reason, there is a need to introduce and implement some tools and strategies that will help to improve the safety of the neonatal patient. Safety check-lists have shown to be a useful tool in other health areas but they are not sufficiently developed in Neonatal Units. A quasi-experimental prospective study was conducted on the design and implementation of the use of a checklist and evaluation of its usefulness for detecting incidents. The satisfaction of the health professionals on using the checklist tool was also assessed. The compliance rate in the neonatal intensive care unit (NICU) was 56.5%, with 4.03 incidents per patient being detected. One incident was detected for every 5.3 checklists used. The most frequent detected incidents were those related to medication, followed by inadequate alarm thresholds, adjustments of the monitors, and medication pumps. The large majority (75%) of the NICU health professionals considered the checklist useful or very useful, and 68.75% considered that its use had managed to avoid an AE. The overall satisfaction was 83.33% for the professionals with less than 5 years working experience, and 44.4% of the professionals with more than 5 years of experience were pleased or very pleased. The checklists have shown to be a useful tool for the detection of incidents, especially in NICU, with a positive assessment from the health professionals of the unit. Copyright © 2016 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

  3. A Novel Cast Removal Training Simulation to Improve Patient Safety.

    Science.gov (United States)

    Brubacher, Jacob W; Karg, Jeffrey; Weinstock, Peter; Bae, Donald S

    2016-01-01

    Cast application and removal are essential to orthopedics and performed by providers of variable training. Simulation training and practice of proper cast application and removal may reduce injury, optimize outcomes, and reduce health care costs. The purpose of this educational initiative was to develop, validate, and implement a novel simulation trainer and curriculum to improve safety during cast removal. In all, 30 thermocouples (Omega, Stamford, CT) were applied to a radius fracture model (Sawbones, Vashon, WA). After reduction and cast application, a saw (Stryker, Kalamazoo, MI) was used to cut the cast with temperature recording. Both "good" and "poor" techniques-as established by consensus best practices-were used. Maximal temperatures were compared to known thresholds for thermal injury; humans experience pain at temperatures exceeding 47°C and contact temperatures exceeding 60°C may lead to epidermal necrosis. Construct validity was evaluated by assessing novice (postgraduate year 1), intermediate (postgraduate year 3), and expert (pediatric orthopedic attending) performance. With the "good" technique, mean peak temperatures were 43°C + 4.3°C. The highest recorded was 51.9°C. With the "poor" technique, mean peak temperature was 75.2°C + 17.3°C. The maximum temperature recorded with the "poor" technique was 112.4°C. Construct validity testing showed that novices had the highest increases in temperatures (12.9°C). There was a decline in heat generation as experience increased with the intermediate group (9.7°C), and the lowest heat generation was seen in the expert group (5.0°C). A novel task simulator and curriculum have been developed to assess competency and enhance performance in the application and removal of casts. There was a 32.2°C temperature decrease when the proper cast saw technique was used. Furthermore, the "poor" technique consistently achieved temperatures that would cause epidermal necrosis in patients. Clinical experience was a

  4. Designing continuous safety improvement within chemical industrial areas

    NARCIS (Netherlands)

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

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

  5. Applying the behaviour grid for improving safety in industrial environments

    NARCIS (Netherlands)

    Boer, de J. (Johannes); Heylen, D. (Dirk); Teeuw, W.B. (Wouter)

    2013-01-01

    The Saxion University of Applied Sciences recently started its “Safety at Work” project. Its objective is to increase safety in the workplace by combining and applying state-of-the-art factors from Ambient Intelligence, Industrial & Product Design and Smart Materials [1].The human

  6. Improved safety for drivers and couriers of coaches

    NARCIS (Netherlands)

    Coo, P.J.A. de; Hazelebach, R.; Oorschot, E. van; Wessels, J.

    2001-01-01

    According to general accidents statistics a coach is the safest means of transportation with respect to fatalities per billion traveller kilometers. Reasons for this include the existing regulations related to coach safety and the self regulation of the coach building industry. Most passive safety

  7. ALWR - regulatory stabilization through simplicity, margin, and improved safety

    International Nuclear Information System (INIS)

    Vine, G.; Gray, S.

    1989-01-01

    The Electric Power Research Institute Advanced Light Water Reactor (ALWR) program is discussed with respect to the following topics: fundamental acceptance criteria for the ALWR; program approach; utility steering committee technical guidance; safety principles; utility requirements document; design bases; generic safety issue resolution; reactor accidents prevention and mitigation; and programmatic plans

  8. Martin Marietta Energy Systems Nuclear Criticality Safety Improvement Program

    International Nuclear Information System (INIS)

    Speas, I.G.

    1987-01-01

    This report addresses questions raised by criticality safety violation at several DOE plants. Two charts are included that define the severity and reporting requirements for the six levels of accidents. A summary is given of all reported criticality incident at the DOE plants involved. The report concludes with Martin Marietta's Nuclear Criticality Safety Policy Statement

  9. Improvement of the regulatory system by implementation new safety demands

    International Nuclear Information System (INIS)

    Iglesias, R.; Alfonso, C.

    1996-01-01

    The work describes in broad terms, the analysis that is being performed aiming at the adoption of a regulatory system that could meet the current safety demands, but which, at the same time, could be a general system that might allow different safety assessments to be done by making use of more specific technical standards of the technology supplier

  10. Communication: Proper treatment of classically forbidden electronic transitions significantly improves detailed balance in surface hopping

    Energy Technology Data Exchange (ETDEWEB)

    Sifain, Andrew E. [Department of Physics and Astronomy, University of Southern California, Los Angeles, California 90089-0485 (United States); Wang, Linjun [Department of Chemistry, Zhejiang University, Hangzhou 310027 (China); Prezhdo, Oleg V. [Department of Physics and Astronomy, University of Southern California, Los Angeles, California 90089-0485 (United States); Department of Chemistry, University of Southern California, Los Angeles, California 90089-1062 (United States)

    2016-06-07

    Surface hopping is the most popular method for nonadiabatic molecular dynamics. Many have reported that it does not rigorously attain detailed balance at thermal equilibrium, but does so approximately. We show that convergence to the Boltzmann populations is significantly improved when the nuclear velocity is reversed after a classically forbidden hop. The proposed prescription significantly reduces the total number of classically forbidden hops encountered along a trajectory, suggesting that some randomization in nuclear velocity is needed when classically forbidden hops constitute a large fraction of attempted hops. Our results are verified computationally using two- and three-level quantum subsystems, coupled to a classical bath undergoing Langevin dynamics.

  11. Applying Sensor-Based Technology to Improve Construction Safety Management.

    Science.gov (United States)

    Zhang, Mingyuan; Cao, Tianzhuo; Zhao, Xuefeng

    2017-08-11

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

  12. Use of the Home Safety Self-Assessment Tool (HSSAT) within Community Health Education to Improve Home Safety.

    Science.gov (United States)

    Horowitz, Beverly P; Almonte, Tiffany; Vasil, Andrea

    2016-10-01

    This exploratory research examined the benefits of a health education program utilizing the Home Safety Self-Assessment Tool (HSSAT) to increase perceived knowledge of home safety, recognition of unsafe activities, ability to safely perform activities, and develop home safety plans of 47 older adults. Focus groups in two senior centers explored social workers' perspectives on use of the HSSAT in community practice. Results for the health education program found significant differences between reported knowledge of home safety (p = .02), ability to recognize unsafe activities (p = .01), safely perform activities (p = .04), and develop a safety plan (p = .002). Social workers identified home safety as a major concern and the HSSAT a promising assessment tool. Research has implications for reducing environmental fall risks.

  13. Improved Flow Modeling in Transient Reactor Safety Analysis Computer Codes

    International Nuclear Information System (INIS)

    Holowach, M.J.; Hochreiter, L.E.; Cheung, F.B.

    2002-01-01

    A method of accounting for fluid-to-fluid shear in between calculational cells over a wide range of flow conditions envisioned in reactor safety studies has been developed such that it may be easily implemented into a computer code such as COBRA-TF for more detailed subchannel analysis. At a given nodal height in the calculational model, equivalent hydraulic diameters are determined for each specific calculational cell using either laminar or turbulent velocity profiles. The velocity profile may be determined from a separate CFD (Computational Fluid Dynamics) analysis, experimental data, or existing semi-empirical relationships. The equivalent hydraulic diameter is then applied to the wall drag force calculation so as to determine the appropriate equivalent fluid-to-fluid shear caused by the wall for each cell based on the input velocity profile. This means of assigning the shear to a specific cell is independent of the actual wetted perimeter and flow area for the calculational cell. The use of this equivalent hydraulic diameter for each cell within a calculational subchannel results in a representative velocity profile which can further increase the accuracy and detail of heat transfer and fluid flow modeling within the subchannel when utilizing a thermal hydraulics systems analysis computer code such as COBRA-TF. Utilizing COBRA-TF with the flow modeling enhancement results in increased accuracy for a coarse-mesh model without the significantly greater computational and time requirements of a full-scale 3D (three-dimensional) transient CFD calculation. (authors)

  14. SAFETY IMPROVES DRAMATICALLY IN FLUOR HANFORD SOIL AND GROUNDWATER REMEDIATION PROJECT

    International Nuclear Information System (INIS)

    GERBER MS

    2007-01-01

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

  15. The basic discussion on nuclear power safety improvement based on nuclear equipment design

    International Nuclear Information System (INIS)

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

    2013-01-01

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

  16. SAFETY IMPROVES DRAMATICALLY IN FLUOR HANFORD SOIL AND GROUNDWATER REMEDIATION PROJECT

    Energy Technology Data Exchange (ETDEWEB)

    GERBER MS

    2007-12-05

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

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

    Science.gov (United States)

    Bonometti, Patrizia

    2012-01-01

    Purpose: The aim of this contribution is to describe a new complexity-science-based approach for improving safety, quality and efficiency and the way it was implemented by TenarisDalmine. Design/methodology/approach: This methodology is called "a safety-building community". It consists of a safety-behaviour social self-construction…

  18. The challenges of ESRD care in developing economies: sub-Saharan African opportunities for significant improvement.

    Science.gov (United States)

    Bamgboye, Ebun Ladipo

    Chronic kidney disease (CKD) is a significant cause of morbidity and mortality in sub-Saharan Africa. This, along with other noncommunicable diseases like hypertension, diabetes, and heart diseases, poses a double burden on a region that is still struggling to cope with the scourge of communicable diseases like malaria, tuberculosis, HIV, and more recently Ebola. Causes of CKD in the region are predominantly glomerulonephritis and hypertension, although type 2 diabetes is also becoming a significant cause as is the retroviral disease. Patients are generally younger than in the developed world, and there is a significant male preponderance. Most patients are managed by hemodialysis, with peritoneal dialysis and kidney transplantation being available in only few countries in the region. Government funding and support for dialysis is often unavailable, and when available, often with restrictions. There is a dearth of trained manpower to treat the disease, and many countries have a limited number of units, which are often ill-equipped to deal adequately with the number of patients who require end-stage renal disease (ESRD) care in the region. Although there has been a significant improvement when compared with the situation, even as recently as 10 years ago, there is also the potential for further improvement, which would significantly improve the outcomes in patients with ESRD in the region. The information in this review was obtained from a combination of renal registry reports (published and unpublished), published articles, responses to a questionnaire sent to nephrologists prior to the World Congress of Nephrology (WCN) in Cape Town, and from nephrologists attending the WCN in Cape Town (March 13 - 17, 2015).

  19. Survival prediction algorithms miss significant opportunities for improvement if used for case selection in trauma quality improvement programs.

    Science.gov (United States)

    Heim, Catherine; Cole, Elaine; West, Anita; Tai, Nigel; Brohi, Karim

    2016-09-01

    Quality improvement (QI) programs have shown to reduce preventable mortality in trauma care. Detailed review of all trauma deaths is a time and resource consuming process and calculated probability of survival (Ps) has been proposed as audit filter. Review is limited on deaths that were 'expected to survive'. However no Ps-based algorithm has been validated and no study has examined elements of preventability associated with deaths classified as 'expected'. The objective of this study was to examine whether trauma performance review can be streamlined using existing mortality prediction tools without missing important areas for improvement. We conducted a retrospective study of all trauma deaths reviewed by our trauma QI program. Deaths were classified into non-preventable, possibly preventable, probably preventable or preventable. Opportunities for improvement (OPIs) involve failure in the process of care and were classified into clinical and system deviations from standards of care. TRISS and PS were used for calculation of probability of survival. Peer-review charts were reviewed by a single investigator. Over 8 years, 626 patients were included. One third showed elements of preventability and 4% were preventable. Preventability occurred across the entire range of the calculated Ps band. Limiting review to unexpected deaths would have missed over 50% of all preventability issues and a third of preventable deaths. 37% of patients showed opportunities for improvement (OPIs). Neither TRISS nor PS allowed for reliable identification of OPIs and limiting peer-review to patients with unexpected deaths would have missed close to 60% of all issues in care. TRISS and PS fail to identify a significant proportion of avoidable deaths and miss important opportunities for process and system improvement. Based on this, all trauma deaths should be subjected to expert panel review in order to aim at a maximal output of performance improvement programs. Copyright © 2016 Elsevier

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

    Science.gov (United States)

    Kuy, SreyRam; Romero, Ramon A L

    2017-06-01

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

  1. Improving radiopharmaceutical supply chain safety by implementing bar code technology.

    Science.gov (United States)

    Matanza, David; Hallouard, François; Rioufol, Catherine; Fessi, Hatem; Fraysse, Marc

    2014-11-01

    The aim of this study was to describe and evaluate an approach for improving radiopharmaceutical supply chain safety by implementing bar code technology. We first evaluated the current situation of our radiopharmaceutical supply chain and, by means of the ALARM protocol, analysed two dispensing errors that occurred in our department. Thereafter, we implemented a bar code system to secure selected key stages of the radiopharmaceutical supply chain. Finally, we evaluated the cost of this implementation, from overtime, to overheads, to additional radiation exposure to workers. An analysis of the events that occurred revealed a lack of identification of prepared or dispensed drugs. Moreover, the evaluation of the current radiopharmaceutical supply chain showed that the dispensation and injection steps needed to be further secured. The bar code system was used to reinforce product identification at three selected key stages: at usable stock entry; at preparation-dispensation; and during administration, allowing to check conformity between the labelling of the delivered product (identity and activity) and the prescription. The extra time needed for all these steps had no impact on the number and successful conduct of examinations. The investment cost was reduced (2600 euros for new material and 30 euros a year for additional supplies) because of pre-existing computing equipment. With regard to the radiation exposure to workers there was an insignificant overexposure for hands with this new organization because of the labelling and scanning processes of radiolabelled preparation vials. Implementation of bar code technology is now an essential part of a global securing approach towards optimum patient management.

  2. Learning from errors in radiology to improve patient safety.

    Science.gov (United States)

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

    2013-10-01

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

  3. A participatory model for improving occupational health and safety: improving informal sector working conditions in Thailand.

    Science.gov (United States)

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

    2009-01-01

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

  4. Interface management: Effective communication to improve process safety

    International Nuclear Information System (INIS)

    Kelly, Brian; Berger, Scott

    2006-01-01

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

  5. Safety Computer Vision Rules for Improved Sensor Certification

    DEFF Research Database (Denmark)

    Mogensen, Johann Thor Ingibergsson; Kraft, Dirk; Schultz, Ulrik Pagh

    2017-01-01

    Mobile robots are used across many domains from personal care to agriculture. Working in dynamic open-ended environments puts high constraints on the robot perception system, which is critical for the safety of the system as a whole. To achieve the required safety levels the perception system needs...... to be certified, but no specific standards exist for computer vision systems, and the concept of safe vision systems remains largely unexplored. In this paper we present a novel domain-specific language that allows the programmer to express image quality detection rules for enforcing safety constraints...

  6. SCALE Graphical Developments for Improved Criticality Safety Analyses

    International Nuclear Information System (INIS)

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

    1999-01-01

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

  7. Improving plant state information for better operational safety

    International Nuclear Information System (INIS)

    Girard, C.; Olivier, E.; Grimaldi, X.

    1994-01-01

    Nuclear Power Plant (NPP) safety is strongly dependent on components' reliability and particularly on plant state information reliability. This information, used by the plant operators in order to produce appropriate actions, have to be of a high degree of confidence, especially in accidental conditions where safety is threatened. In this perspective, FRAMATOME, EDF and CEA have started a joint research program to prospect different solutions aiming at a better reliability for critical information needed to safety operate the plant. This paper gives the main results of this program and describes the developments that have been made in order to assess reliability of different information systems used in a Nuclear Power Plant. (Author)

  8. The Role of the Master in Improving Safety Culture Onboard Ships

    Directory of Open Access Journals (Sweden)

    T. Bielic

    2017-03-01

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

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

    OpenAIRE

    T. Karkoszka; M. Andraczke

    2011-01-01

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

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

    International Nuclear Information System (INIS)

    Huizenga, David; Newton, Douglas; Connery, Joyce

    2002-01-01

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

  11. PXD101 significantly improves nuclear reprogramming and the in vitro developmental competence of porcine SCNT embryos

    Energy Technology Data Exchange (ETDEWEB)

    Jin, Jun-Xue; Kang, Jin-Dan; Li, Suo; Jin, Long; Zhu, Hai-Ying; Guo, Qing; Gao, Qing-Shan; Yan, Chang-Guo; Yin, Xi-Jun, E-mail: yinxj33@msn.com

    2015-01-02

    Highlights: • First explored that the effects of PXD101 on the development of SCNT embryos in vitro. • 0.5 μM PXD101 treated for 24 h improved the development of porcine SCNT embryos. • Level of AcH3K9 was significantly higher than control group at early stages. - Abstract: In this study, we investigated the effects of the histone deacetylase inhibitor PXD101 (belinostat) on the preimplantation development of porcine somatic cell nuclear transfer (SCNT) embryos and their expression of the epigenetic markers histone H3 acetylated at lysine 9 (AcH3K9). We compared the in vitro developmental competence of SCNT embryos treated with various concentrations of PXD101 for 24 h. Treatment with 0.5 μM PXD101 significantly increased the proportion of SCNT embryos that reached the blastocyst stage, in comparison to the control group (23.3% vs. 11.5%, P < 0.05). We tested the in vitro developmental competence of SCNT embryos treated with 0.5 μM PXD101 for various amounts of times following activation. Treatment for 24 h significantly improved the development of porcine SCNT embryos, with a significantly higher proportion of embryos reaching the blastocyst stage in comparison to the control group (25.7% vs. 10.6%, P < 0.05). PXD101-treated SCNT embryos were transferred into two surrogate sows, one of whom became pregnant and four fetuses developed. PXD101 treatment significantly increased the fluorescence intensity of immunostaining for AcH3K9 in embryos at the pseudo-pronuclear and 2-cell stages. At these stages, the fluorescence intensities of immunostaining for AcH3K9 were significantly higher in PXD101-treated embryos than in control untreated embryos. In conclusion, this study demonstrates that PXD101 can significantly improve the in vitro and in vivo developmental competence of porcine SCNT embryos and can enhance their nuclear reprogramming.

  12. Editorial: Advances in healthcare provider and patient training to improve the quality and safety of patient care

    Directory of Open Access Journals (Sweden)

    Elizabeth M. Borycki

    2015-09-01

    Full Text Available This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic health records and mobile health applications. Such technologies can be harnessed to improve patient safety; however, if not used properly they can negatively impact on patient safety. In this issue we focus on advances in training that can improve patient safety and the optimal use of new technologies in healthcare. For example, use of clinical simulations and online computer based training can be employed both to facilitate learning about new clinical discoveries as well as to integrate technology into day to day healthcare practices. In this issue we are publishing papers that describe advances in healthcare provider and patient training to improve patient safety as it relates to the use of educational technologies, health information technology and on-line health resources. In addition, in the special issue we describe new approaches to training and patient safety including, online communities, clinical simulations, on-the-job training, computer based training and health information systems that educate about and support safer patient care in real-time (i.e. when health professionals are providing care to patients. These educational and technological initiatives can be aimed at health professionals (i.e. students and those who are currently working in the field. The outcomes of this work are significant as they lead to safer care for patients and their family members. The issue has both theoretical and applied papers that describe advances in patient

  13. Reliability Improved Design for a Safety System Channel

    International Nuclear Information System (INIS)

    Oh, Eung Se; Kim, Yun Goo

    2016-01-01

    Nowadays, these systems are implemented with a same platform type, such as a qualified programmable logic controller (PLC). The platform intensively uses digital communication with fiber-optic links to reduce cabling costs and to achieve effective signal isolation. These communication interface and redundancies within a channel increase the complexness of an overall system design. This paper proposes a simpler channel architecture design to reduce the complexity and to enhance overall channel reliability. Simplified safety channel configuration is proposed and the failure probabilities are compared with baseline safety channel configuration using an estimated generic value. The simplified channel configuration achieves 40 percent failure reduction compare to baseline safety channel configuration. If this configuration can be implemented within a processor module, overall safety channel reliability is increase and costs of fabrication and maintenance will be greatly reduced

  14. Reliability Improved Design for a Safety System Channel

    Energy Technology Data Exchange (ETDEWEB)

    Oh, Eung Se; Kim, Yun Goo [KHNP, Daejeon (Korea, Republic of)

    2016-05-15

    Nowadays, these systems are implemented with a same platform type, such as a qualified programmable logic controller (PLC). The platform intensively uses digital communication with fiber-optic links to reduce cabling costs and to achieve effective signal isolation. These communication interface and redundancies within a channel increase the complexness of an overall system design. This paper proposes a simpler channel architecture design to reduce the complexity and to enhance overall channel reliability. Simplified safety channel configuration is proposed and the failure probabilities are compared with baseline safety channel configuration using an estimated generic value. The simplified channel configuration achieves 40 percent failure reduction compare to baseline safety channel configuration. If this configuration can be implemented within a processor module, overall safety channel reliability is increase and costs of fabrication and maintenance will be greatly reduced.

  15. Toward improved construction health, safety, and ergonomics in ...

    African Journals Online (AJOL)

    involved in architectural CPD programmes take 'upstream design ownership' and use the model as a ... health and safety (H&S), inclusive of construction ergonomics, the responsibility for ...... Santiago, Chile, 18-20 January. Rotterdam: CIB ...

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

    Science.gov (United States)

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

    2016-05-01

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

  17. Taking up national safety alerts to improve patient safety in hospitals: The perspective of healthcare quality and risk managers.

    Science.gov (United States)

    Pfeiffer, Yvonne; Schwappach, David

    2016-01-01

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

  18. Packaging Evaluation Approach to Improve Cosmetic Product Safety

    OpenAIRE

    Benedetta Briasco; Priscilla Capra; Arianna Cecilia Cozzi; Barbara Mannucci; Paola Perugini

    2016-01-01

    In the Regulation 1223/2009, evaluation of packaging has become mandatory to assure cosmetic product safety. In fact, the safety assessment of a cosmetic product can be successfully carried out only if the hazard deriving from the use of the designed packaging for the specific product is correctly evaluated. Despite the law requirement, there is too little information about the chemical-physical characteristics of finished packaging and the possible interactions between formulation and packag...

  19. The effect of Health, Safety and Environment Management System (HSE-MS on the improvement of safety performance indices in Urea and Ammonia Kermanshah Petrochemical Company

    Directory of Open Access Journals (Sweden)

    M. S. Poursoleiman

    2015-09-01

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

  20. Unified Health Gamification can significantly improve well-being in corporate environments.

    Science.gov (United States)

    Shahrestani, Arash; Van Gorp, Pieter; Le Blanc, Pascale; Greidanus, Fabrizio; de Groot, Kristel; Leermakers, Jelle

    2017-07-01

    There is a multitude of mHealth applications that aim to solve societal health problems by stimulating specific types of physical activities via gamification. However, physical health activities cover just one of the three World Health Organization (WHO) dimensions of health. This paper introduces the novel notion of Unified Health Gamification (UHG), which covers besides physical health also social and cognitive health and well-being. Instead of rewarding activities in the three WHO dimensions using different mHealth competitions, UHG combines the scores for such activities on unified leaderboards and lets people interact in social circles beyond personal interests. This approach is promising in corporate environments since UHG can connect the employees with intrinsic motivation for physical health with those who have quite different interests. In order to evaluate this approach, we realized an app prototype and we evaluated it in two corporate pilot studies. In total, eighteen pilot users participated voluntarily for six weeks. Half of the participants were recruited from an occupational health setting and the other half from a treatment setting. Our results suggest that the UHG principles are worth more investigation: various positive health effects were found based on a validated survey. The mean mental health improved significantly at one pilot location and at the level of individual pilot participants, multiple other effects were found to be significant: among others, significant mental health improvements were found for 28% of the participants. Most participants intended to use the app beyond the pilot, especially if it would be further developed.

  1. Risk-based configuration control: Application of PSA in improving technical specifications and operational safety

    International Nuclear Information System (INIS)

    Samanta, P.K.; Kim, I.S.; Vesely, W.E.

    1992-01-01

    Risk-based configuration control is the management of component configurations using a risk perspective to control risk and assure safety. A configuration, as used here, is a set of component operability statuses that define the state of a nuclear power plant. If the component configurations that have high risk implications do not occur, then the risk from the operation of nuclear power plants would be minimal. The control of component configurations, i.e., the management of component statuses, to minimize the risk from components being unavailable, becomes difficult, because the status of a standby safety system component is often not apparent unless it is tested. Controlling plant configuration from a risk-perspective can provide more direct risk control and also more operational flexibility by allowing looser controls in areas unimportant to risk. Risk-based configuration control approaches can be used to replace parts of nuclear power plant Technical Specifications. With the advances in probabilistic safety assessment (PSA) technology, such approaches to improve Technical Specifications and operational safety are feasible. In this paper, we present an analysis of configuration risks, and a framework for risk-based configuration control to achieve the desired control of risk-significant configurations during plant operation

  2. 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.

  3. Utilization of a risk matrix based on Probabilistic Safety Analysis to improve nuclear safety in NPP

    International Nuclear Information System (INIS)

    Stubbe, Gerald

    2010-01-01

    PSA models. Those asymmetries are characterized by the fact that, for instance, a LOCA is considered to occur only on a certain primary loop. So, to take that weakness into account, we have decided to group the different redundant equipments of a function as one. This leads to some conservatism. For instance, if you have 3 LPSI pumps, you group those and consider as one. Uncertainties are also a threat for the PSA models. You must be sure that the model you use do not have 'cliff edge' effects. A complete sensitivity study can be enough to demonstrate that the uncertainties are bounded and understood. By use of the PSA models, we can give an importance factor to each equipment. This qualitative approach of quantitative data is expressed by two quantities: The Fussel Vessely (FV) and the Risk Increased Factor (RIF). The combination of those 2 factors can lead to the ranking of the equipment in three categories: Highly Safety Significant (HSS), Medium Safety Significant (MSS), Low Safety Significant (LSS). This ranking can be done globally, for all sequences, or initiator by initiator. The latter one is used to construct our matrix. It permits a larger comprehension of the phenomena following an initiator. And this is the goal of our risk matrix. A frequency of occurrence is assigned to each initiators, depending on generic data, or plant specific data for the more frequent ones. As an initiator occurs, you have a conditional probability to go to core damage. We call it the severity. We will assign a set of colour, representing the importance of the severity and the frequency of occurrence. This permits us to have a clear overview of what could happen to the plant. One of the main advantages of this matrix is to link, with a risk approach, equipments that are not linked together within the technical specifications of the plant. As example, in the NPP of GDF-Suez, we have a second level for the safeguards systems. In the design phase, it was to provide a protection

  4. An evaluation of The Great Escape: can an interactive computer game improve young children's fire safety knowledge and behaviors?

    Science.gov (United States)

    Morrongiello, Barbara A; Schwebel, David C; Bell, Melissa; Stewart, Julia; Davis, Aaron L

    2012-07-01

    Fire is a leading cause of unintentional injury and, although young children are at particularly increased risk, there are very few evidence-based resources available to teach them fire safety knowledge and behaviors. Using a pre-post randomized design, the current study evaluated the effectiveness of a computer game (The Great Escape) for teaching fire safety information to young children (3.5-6 years). Using behavioral enactment procedures, children's knowledge and behaviors related to fire safety were compared to a control group of children before and after receiving the intervention. The results indicated significant improvements in knowledge and fire safety behaviors in the intervention group but not the control. Using computer games can be an effective way to promote young children's understanding of safety and how to react in different hazardous situations.

  5. The use of probabilistic safety assessments for improving nuclear safety in Europe

    International Nuclear Information System (INIS)

    Birkhofer, A.

    1992-01-01

    The political changes in Europe broadened the scope of international nuclear safety matters considerably. The Western world started to receive reliable and increasingly detailed information on Eastern European nuclear technology and took note of a broad range of technical and administrative problems relevant for nuclear safety in these countries. Reunification made Germany a focus of information exchange on these matters. Here, cooperation with the former German Democratic Republic and with other Eastern European countries as well as safety analyses of Soviet-built nuclear power plants started rather early. Meanwhile, these activities are progressing toward all-European cooperation in the nuclear safety sector. This cooperation includes the use of probabilistic safety assessments (PSAs) addressing applications in both Western and Eastern Europe as well as the further development of this methodology in a converging Europe

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

    Science.gov (United States)

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

    2015-10-01

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

  7. Thermosensitive Hydrogel Mask Significantly Improves Skin Moisture and Skin Tone; Bilateral Clinical Trial

    Directory of Open Access Journals (Sweden)

    Anna Quattrone

    2017-06-01

    Full Text Available Objective: A temperature-sensitive state-changing hydrogel mask was used in this study. Once it comes into contact with the skin and reaches the body temperature, it uniformly and quickly releases the active compounds, which possess moisturizing, anti-oxidant, anti-inflammatory and regenerative properties. Methods: An open label clinical trial was conducted to evaluate the effects of the test product on skin hydration, skin tone and skin ageing. Subjects applied the product to one side of their face and underwent Corneometer® and Chromameter measurements, Visual assessment of facial skin ageing and facial photography. All assessments and Self-Perception Questionnaires (SPQ were performed at baseline, after the first application of the test product and after four applications. Results: After a single treatment we observed an increase in skin moisturisation, an improvement of skin tone/luminosity and a reduction in signs of ageing, all statistically significant. After four applications a further improvement in all measured parameters was recorded. These results were confirmed by the subjects’ own perceptions, as reported in the SPQ both after one and four applications. Conclusion: The hydrogel mask tested in this study is very effective in improving skin hydration, skin radiance and luminosity, in encouraging an even skin tone and in reducing skin pigmentation.

  8. E2F5 status significantly improves malignancy diagnosis of epithelial ovarian cancer

    KAUST Repository

    Kothandaraman, Narasimhan

    2010-02-24

    Background: Ovarian epithelial cancer (OEC) usually presents in the later stages of the disease. Factors, especially those associated with cell-cycle genes, affecting the genesis and tumour progression for ovarian cancer are largely unknown. We hypothesized that over-expressed transcription factors (TFs), as well as those that are driving the expression of the OEC over-expressed genes, could be the key for OEC genesis and potentially useful tissue and serum markers for malignancy associated with OEC.Methods: Using a combination of computational (selection of candidate TF markers and malignancy prediction) and experimental approaches (tissue microarray and western blotting on patient samples) we identified and evaluated E2F5 transcription factor involved in cell proliferation, as a promising candidate regulatory target in early stage disease. Our hypothesis was supported by our tissue array experiments that showed E2F5 expression only in OEC samples but not in normal and benign tissues, and by significantly positively biased expression in serum samples done using western blotting studies.Results: Analysis of clinical cases shows that of the E2F5 status is characteristic for a different population group than one covered by CA125, a conventional OEC biomarker. E2F5 used in different combinations with CA125 for distinguishing malignant cyst from benign cyst shows that the presence of CA125 or E2F5 increases sensitivity of OEC detection to 97.9% (an increase from 87.5% if only CA125 is used) and, more importantly, the presence of both CA125 and E2F5 increases specificity of OEC to 72.5% (an increase from 55% if only CA125 is used). This significantly improved accuracy suggests possibility of an improved diagnostics of OEC. Furthermore, detection of malignancy status in 86 cases (38 benign, 48 early and late OEC) shows that the use of E2F5 status in combination with other clinical characteristics allows for an improved detection of malignant cases with sensitivity

  9. Significance of MPEG-7 textural features for improved mass detection in mammography.

    Science.gov (United States)

    Eltonsy, Nevine H; Tourassi, Georgia D; Fadeev, Aleksey; Elmaghraby, Adel S

    2006-01-01

    The purpose of the study is to investigate the significance of MPEG-7 textural features for improving the detection of masses in screening mammograms. The detection scheme was originally based on morphological directional neighborhood features extracted from mammographic regions of interest (ROIs). Receiver Operating Characteristics (ROC) was performed to evaluate the performance of each set of features independently and merged into a back-propagation artificial neural network (BPANN) using the leave-one-out sampling scheme (LOOSS). The study was based on a database of 668 mammographic ROIs (340 depicting cancer regions and 328 depicting normal parenchyma). Overall, the ROC area index of the BPANN using the directional morphological features was Az=0.85+/-0.01. The MPEG-7 edge histogram descriptor-based BPNN showed an ROC area index of Az=0.71+/-0.01 while homogeneous textural descriptors using 30 and 120 channels helped the BPNN achieve similar ROC area indexes of Az=0.882+/-0.02 and Az=0.877+/-0.01 respectively. After merging the MPEG-7 homogeneous textural features with the directional neighborhood features the performance of the BPANN increased providing an ROC area index of Az=0.91+/-0.01. MPEG-7 homogeneous textural descriptor significantly improved the morphology-based detection scheme.

  10. The experiences of research reactor accident to safety improvement

    International Nuclear Information System (INIS)

    Wiranto, S.

    1999-01-01

    The safety of reactor operation is the main factor in order that the nuclear technology development program can be held according the expected target. Several experience with research reactor incidents must be learned and understood by the nuclear program personnel, especially for operators and supervisors of RSG-GA. Siwabessy. From the incident experience of research reactor in the world, which mentioned in the book 'Experience with research reactor incidents' by IAEA, 1995, was concluded that the main cause of research reactor accidents is understandless about the safety culture by the nuclear installation personnel. With learn, understand and compare between this experiences and the condition of RSG GA Siwabessy is expended the operators and supervisors more attention about the safety culture, so that RSG GA Siwabessy can be operated successfull, safely according the expected target

  11. Carfilzomib significantly improves the progression-free survival of high-risk patients in multiple myeloma.

    Science.gov (United States)

    Avet-Loiseau, Hervé; Fonseca, Rafael; Siegel, David; Dimopoulos, Meletios A; Špička, Ivan; Masszi, Tamás; Hájek, Roman; Rosiñol, Laura; Goranova-Marinova, Vesselina; Mihaylov, Georgi; Maisnar, Vladimír; Mateos, Maria-Victoria; Wang, Michael; Niesvizky, Ruben; Oriol, Albert; Jakubowiak, Andrzej; Minarik, Jiri; Palumbo, Antonio; Bensinger, William; Kukreti, Vishal; Ben-Yehuda, Dina; Stewart, A Keith; Obreja, Mihaela; Moreau, Philippe

    2016-09-01

    The presence of certain high-risk cytogenetic abnormalities, such as translocations (4;14) and (14;16) and deletion (17p), are known to have a negative impact on survival in multiple myeloma (MM). The phase 3 study ASPIRE (N = 792) demonstrated that progression-free survival (PFS) was significantly improved with carfilzomib, lenalidomide, and dexamethasone (KRd), compared with lenalidomide and dexamethasone (Rd) in relapsed MM. This preplanned subgroup analysis of ASPIRE was conducted to evaluate KRd vs Rd by baseline cytogenetics according to fluorescence in situ hybridization. Of 417 patients with known cytogenetic risk status, 100 patients (24%) were categorized with high-risk cytogenetics (KRd, n = 48; Rd, n = 52) and 317 (76%) were categorized with standard-risk cytogenetics (KRd, n = 147; Rd, n = 170). For patients with high-risk cytogenetics, treatment with KRd resulted in a median PFS of 23.1 months, a 9-month improvement relative to treatment with Rd. For patients with standard-risk cytogenetics, treatment with KRd led to a 10-month improvement in median PFS vs Rd. The overall response rates for KRd vs Rd were 79.2% vs 59.6% (high-risk cytogenetics) and 91.2% vs 73.5% (standard-risk cytogenetics); approximately fivefold as many patients with high- or standard-risk cytogenetics achieved a complete response or better with KRd vs Rd (29.2% vs 5.8% and 38.1% vs 6.5%, respectively). KRd improved but did not abrogate the poor prognosis associated with high-risk cytogenetics. This regimen had a favorable benefit-risk profile in patients with relapsed MM, irrespective of cytogenetic risk status, and should be considered a standard of care in these patients. This trial was registered at www.clinicaltrials.gov as #NCT01080391. © 2016 by The American Society of Hematology.

  12. Leveraging Safety Programs to Improve and Support Security Programs

    Energy Technology Data Exchange (ETDEWEB)

    Leach, Janice [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Snell, Mark K. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Pratt, R. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Sandoval, S. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States)

    2015-10-01

    There has been a long history of considering Safety, Security, and Safeguards (3S) as three functions of nuclear security design and operations that need to be properly and collectively integrated with operations. This paper specifically considers how safety programmes can be extended directly to benefit security as part of an integrated facility management programme. The discussion will draw on experiences implementing such a programme at Sandia National Laboratories’ Annular Research Reactor Facility. While the paper focuses on nuclear facilities, similar ideas could be used to support security programmes at other types of high-consequence facilities and transportation activities.

  13. Research on the improvement of nuclear safety -Improvement of level 1 PSA computer code package-

    International Nuclear Information System (INIS)

    Park, Chang Kyoo; Kim, Tae Woon; Kim, Kil Yoo; Han, Sang Hoon; Jung, Won Dae; Jang, Seung Chul; Yang, Joon Un; Choi, Yung; Sung, Tae Yong; Son, Yung Suk; Park, Won Suk; Jung, Kwang Sub; Kang Dae Il; Park, Jin Heui; Hwang, Mi Jung; Hah, Jae Joo

    1995-07-01

    This year is the third year of the Government-sponsored mid- and long-term nuclear power technology development project. The scope of this sub project titled on 'The improvement of level-1 PSA computer codes' is divided into three main activities : (1) Methodology development on the underdeveloped fields such as risk assessment technology for plant shutdown and low power situations, (2) Computer code package development for level-1 PSA, (3) Applications of new technologies to reactor safety assessment. At first, in this area of shutdown risk assessment technology development, plant outage experiences of domestic plants are reviewed and plant operating states (POS) are decided. A sample core damage frequency is estimated for over draining event in RCS low water inventory i.e. mid-loop operation. Human reliability analysis and thermal hydraulic support analysis are identified to be needed to reduce uncertainty. Two design improvement alternatives are evaluated using PSA technique for mid-loop operation situation: one is use of containment spray system as backup of shutdown cooling system and the other is installation of two independent level indication system. Procedure change is identified more preferable option to hardware modification in the core damage frequency point of view. Next, level-1 PSA code KIRAP is converted to PC-windows environment. For the improvement of efficiency in performing PSA, the fast cutest generation algorithm and an analytical technique for handling logical loop in fault tree modeling are developed. 48 figs, 15 tabs, 59 refs. (Author)

  14. Research on the improvement of nuclear safety -Improvement of level 1 PSA computer code package-

    Energy Technology Data Exchange (ETDEWEB)

    Park, Chang Kyoo; Kim, Tae Woon; Kim, Kil Yoo; Han, Sang Hoon; Jung, Won Dae; Jang, Seung Chul; Yang, Joon Un; Choi, Yung; Sung, Tae Yong; Son, Yung Suk; Park, Won Suk; Jung, Kwang Sub; Kang Dae Il; Park, Jin Heui; Hwang, Mi Jung; Hah, Jae Joo [Korea Atomic Energy Research Institute, Taejon (Korea, Republic of)

    1995-07-01

    This year is the third year of the Government-sponsored mid- and long-term nuclear power technology development project. The scope of this sub project titled on `The improvement of level-1 PSA computer codes` is divided into three main activities : (1) Methodology development on the underdeveloped fields such as risk assessment technology for plant shutdown and low power situations, (2) Computer code package development for level-1 PSA, (3) Applications of new technologies to reactor safety assessment. At first, in this area of shutdown risk assessment technology development, plant outage experiences of domestic plants are reviewed and plant operating states (POS) are decided. A sample core damage frequency is estimated for over draining event in RCS low water inventory i.e. mid-loop operation. Human reliability analysis and thermal hydraulic support analysis are identified to be needed to reduce uncertainty. Two design improvement alternatives are evaluated using PSA technique for mid-loop operation situation: one is use of containment spray system as backup of shutdown cooling system and the other is installation of two independent level indication system. Procedure change is identified more preferable option to hardware modification in the core damage frequency point of view. Next, level-1 PSA code KIRAP is converted to PC-windows environment. For the improvement of efficiency in performing PSA, the fast cutest generation algorithm and an analytical technique for handling logical loop in fault tree modeling are developed. 48 figs, 15 tabs, 59 refs. (Author).

  15. Bone Mass and Strength are Significantly Improved in Mice Overexpressing Human WNT16 in Osteocytes.

    Science.gov (United States)

    Alam, Imranul; Reilly, Austin M; Alkhouli, Mohammed; Gerard-O'Riley, Rita L; Kasipathi, Charishma; Oakes, Dana K; Wright, Weston B; Acton, Dena; McQueen, Amie K; Patel, Bhavmik; Lim, Kyung-Eun; Robling, Alexander G; Econs, Michael J

    2017-04-01

    Recently, we demonstrated that osteoblast-specific overexpression of human WNT16 increased both cortical and trabecular bone mass and structure in mice. To further identify the cell-specific role of Wnt16 in bone homeostasis, we created transgenic (TG) mice overexpressing human WNT16 in osteocytes using Dmp1 promoter (Dmp1-hWNT16 TG) on C57BL/6 (B6) background. We analyzed bone phenotypes and serum bone biomarkers, performed gene expression analysis and measured dynamic bone histomorphometry in Dmp1-hWNT16 TG and wild-type (WT) mice. Compared to WT mice, Dmp1-hWNT16 TG mice exhibited significantly higher whole-body, spine and femoral aBMD, BMC and trabecular (BV/TV, Tb.N, and Tb.Th) and cortical (bone area and thickness) parameters in both male and female at 12 weeks of age. Femur stiffness and ultimate force were also significantly improved in the Dmp1-hWNT16 TG female mice, compared to sex-matched WT littermates. In addition, female Dmp1-hWNT16 TG mice displayed significantly higher MS/BS, MAR and BFR/BS compared to the WT mice. Gene expression analysis demonstrated significantly higher mRNA level of Alp in both male and female Dmp1-hWNT16 TG mice and significantly higher levels of Osteocalcin, Opg and Rankl in the male Dmp1-hWNT16 TG mice in bone tissue compared to sex-matched WT mice. These results indicate that WNT16 plays a critical role for acquisition of both cortical and trabecular bone mass and strength. Strategies designed to use WNT16 as a target for therapeutic interventions will be valuable to treat osteoporosis and other low bone mass conditions.

  16. Radiotherapy is associated with significant improvement in local and regional control in Merkel cell carcinoma

    International Nuclear Information System (INIS)

    Kang, Susan H; Haydu, Lauren E; Goh, Robin Yeong Hong; Fogarty, Gerald B

    2012-01-01

    Merkel cell carcinoma (MCC) is a rare tumour of skin. This study is a retrospective audit of patients with MCC from St Vincent’s and Mater Hospital, Sydney, Australia. The aim of this study was to investigate the influence of radiotherapy (RT) on the local and regional control of MCC lesions and survival of patients with MCC. The data bases in anatomical pathology, RT and surgery. We searched for patients having a diagnosis of MCC between 1996 and 2007. Patient, tumour and treatment characteristics were collected and analysed. Univariate survival analysis of categorical variables was conducted with the Kaplan-Meier method together with the Log-Rank test for statistical significance. Continuous variables were assessed using the Cox regression method. Multivariate analysis was performed for significant univariate results. Sixty seven patients were found. Sixty two who were stage I-III and were treated with radical intent were analysed. 68% were male. The median age was 74 years. Forty-two cases (68%) were stage I or II, and 20 cases (32%) were stage III. For the subset of 42 stage I and II patients, those that had RT to their primary site had a 2-year local recurrence free survival of 89% compared with 36% for patients not receiving RT (p<0.001). The cumulative 2-year regional recurrence free survival for patients having adjuvant regional RT was 84% compared with 43% for patients not receiving this treatment (p<0.001). Immune status at initial surgery was a significant predictor for OS and MCCSS. In a multivariate analysis combining macroscopic size (mm) and immune status at initial surgery, only immune status remained a significant predictor of overall survival (HR=2.096, 95% CI: 1.002-4.385, p=0.049). RT is associated with significant improvement in local and regional control in Merkel cell carcinoma. Immunosuppression is an important factor in overall survival

  17. Track 2: business outlook and the significance of safety - safety of nuclear power reactor installations in a deregulated environment. Panel Discussion

    International Nuclear Information System (INIS)

    Schultz, Stephen P.; Floyd, Stephen; Berkow, Herbert N.; Quinn, Edward L.; Hagen, Ronald E.; Esselman, Thomas C.

    2001-01-01

    Full text of publication follows: Deregulation in the nuclear industry sets the stage for a new production environment with cost and profit-based competition. This not only affects the commercial reactor sector but also is a key element of the U.S. Department of Energy's (DoE's) strategy for facility deployment and commercialization. This panel is designed to explore how these transitions are being made with the assurance of the principle of safety in operations. Panelists have been assembled from industry, the U.S. Nuclear Regulatory Commission (NRC), and DOE to explore these challenges and opportunities in the deregulated operational environment from a variety of perspectives. Presentations by each panelist will be followed by a panel session that will explore both technical and process elements of these major transitions. Success in a deregulated environment requires both safety and economic operation of facilities. With respect to each of these attributes, competition may be expected to result in substantially higher levels of performance. This panel will examine how these expectations are likely to be set, how they will be measured, and what will constitute success. The baseline for evaluation begins with assessment of past performance. The panelists have examined this for both the commercial nuclear reactor sector, as well as for the DOE complex. The Nuclear Energy Institute and the NRC have been working over the past few years on a program to establish new performance indicators for monitoring safety of reactor operation. The session participants will first examine the effectiveness of this system as it is designed to measure performance in today's environment. Second, the panelists will project the capabilities and attributes of this system in monitoring safety in transition to a deregulated, consolidated market. Will these systems have the capability to identify trends that will be significant in this new environment? Will today's system and metrics be

  18. Thermal hydraulic tests for reactor safety system -Research on the improvement of nuclear safety-

    International Nuclear Information System (INIS)

    Chung, Moon Ki; Park, Chun Kyeong; Yang, Seon Kyu; Chung, Chang Hwan; Chun, Shee Yeong; Song, Cheol Hwa; Chun, Hyeong Gil; Chang, Seok Kyu; Chung, Heung Joon; Won, Soon Yeon; Cho, Yeong Ro; Kim, Bok Deuk; Min, Kyeong Ho

    1994-07-01

    The present research aims at the development of the thermal hydraulic verification test technology for the reactor safety system of the conventional and advanced nuclear power plant and the development of the advanced thermal hydraulic measuring techniques. (Author)

  19. Integration of biomimicry and nanotechnology for significantly improved detection of circulating tumor cells (CTCs).

    Science.gov (United States)

    Myung, Ja Hye; Park, Sin-Jung; Wang, Andrew Z; Hong, Seungpyo

    2017-12-13

    Circulating tumor cells (CTCs) have received a great deal of scientific and clinical attention as a biomarker for diagnosis and prognosis of many types of cancer. Given their potential significance in clinics, a variety of detection methods, utilizing the recent advances in nanotechnology and microfluidics, have been introduced in an effort of achieving clinically significant detection of CTCs. However, effective detection and isolation of CTCs still remain a tremendous challenge due to their extreme rarity and phenotypic heterogeneity. Among many approaches that are currently under development, this review paper focuses on a unique, promising approach that takes advantages of naturally occurring processes achievable through application of nanotechnology to realize significant improvement in sensitivity and specificity of CTC capture. We provide an overview of successful outcome of this biomimetic CTC capture system in detection of tumor cells from in vitro, in vivo, and clinical pilot studies. We also emphasize the clinical impact of CTCs as biomarkers in cancer diagnosis and predictive prognosis, which provides a cost-effective, minimally invasive method that potentially replaces or supplements existing methods such as imaging technologies and solid tissue biopsy. In addition, their potential prognostic values as treatment guidelines and that ultimately help to realize personalized therapy are discussed. Copyright © 2017. Published by Elsevier B.V.

  20. Research on the improvement of nuclear safety -Thermal hydraulic tests for reactor safety system-

    Energy Technology Data Exchange (ETDEWEB)

    Jung, Moon Kee; Park, Choon Kyung; Yang, Sun Kyoo; Chun, Se Yung; Song, Chul Hwa; Jun, Hyung Kil; Jung, Heung Joon; Won, Soon Yun; Cho, Yung Roh; Min, Kyung Hoh; Jung, Jang Hwan; Jang, Suk Kyoo; Kim, Bok Deuk; Kim, Wooi Kyung; Huh, Jin; Kim, Sook Kwan; Moon, Sang Kee; Lee, Sang Il [Korea Atomic Energy Research Institute, Taejon (Korea, Republic of)

    1995-06-01

    The present research aims at the development of the thermal hydraulic verification test technology for the safety system of the conventional and advanced nuclear power plant and the development of the advanced thermal hydraulic measuring techniques. In this research, test facilities simulating the primary coolant system and safety system are being constructed for the design verification tests of the existing and advanced nuclear power plant. 97 figs, 14 tabs, 65 refs. (Author).

  1. Alberta Environment's weir safety program : options for rehabilitation to improve public safety : a case study of the Calgary weir

    Energy Technology Data Exchange (ETDEWEB)

    Blakely, D [Alberta Environment, Edmonton, AB (Canada)

    2009-07-01

    Alberta Environment Water Management Operations (WMO) owns and operates 46 dams and 800 kilometres of canals in Alberta. The WMO consists of 120 staff and several contract operators to take care of this infrastructure. Most of the infrastructure supplies water for irrigation use, which adds 5 billion dollars to the provincial economy annually. Other water uses include stock watering, domestic use, municipal use, recreational use and habitat. Alberta Environment's weir safety program was also discussed along with options for rehabilitation to improve public safety. A case study of Calgary's Weir Dam on the Bow River was highlighted. A brief history of the dam was offered and safety programs around provincially-owned weirs were discussed. Photographs were included to illustrate some of the additional safety measures at the Calgary weir, such as suspended safety buoys upstream of the boom directing paddlers to the portage trail, and signage on the river that can be activated when the boom is out. Typical river users on the Calgary Bow River and safety history at the Calgary Weir were discussed along with other topics such as the Calgary Bow River weir project criteria; project design progress; pre-feasibility options; scale modelling; final design analysis; construction funding; and proposed changes to the safety program for the new weir configuration. figs.

  2. International cooperation - a way to improve reliability and safety

    International Nuclear Information System (INIS)

    John, A.

    1998-01-01

    The mission of the World Association of Nuclear Operators (WANO) is highlighted, and WANO's Peer Review programme is described. At the Dukovany nuclear power plant, a Peer Review was undertaken in December 1997. The results gave evidence of a good level of safety, reliability and culture of operation of the plant. (P.A.)

  3. Montana Highway Safety Improvement Program : an RSPCB Peer Exchange

    Science.gov (United States)

    2011-05-01

    This report provides a summary of a peer-to-peer (P2P) videoconference sponsored by the : Montana Department of Transportation (MDT) and the Federal Highway Administration : (FHWA) Office of Safety. The videoconference format provided a low-cost oppo...

  4. Can traceability improve consumers' confidence in food quality and safety?

    NARCIS (Netherlands)

    Rijswijk, van W.; Cornelisse-Vermaat, J.R.; Frewer, L.J.

    2006-01-01

    Abstract This paper investigates whether the implementation of traceability systems in line with the European General Food Law as well as food labelling laws related to allergens can impact on consumer confidence in food quality and safety. It aims to give insight into consumer demands regarding

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

    Science.gov (United States)

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

    2016-05-01

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

  6. Packaging Evaluation Approach to Improve Cosmetic Product Safety

    Directory of Open Access Journals (Sweden)

    Benedetta Briasco

    2016-09-01

    Full Text Available In the Regulation 1223/2009, evaluation of packaging has become mandatory to assure cosmetic product safety. In fact, the safety assessment of a cosmetic product can be successfully carried out only if the hazard deriving from the use of the designed packaging for the specific product is correctly evaluated. Despite the law requirement, there is too little information about the chemical-physical characteristics of finished packaging and the possible interactions between formulation and packaging; furthermore, different from food packaging, the cosmetic packaging is not regulated and, to date, appropriate guidelines are still missing. The aim of this work was to propose a practical approach to investigate commercial polymeric containers used in cosmetic field, especially through mechanical properties’ evaluation, from a safety point of view. First of all, it is essential to obtain complete information about raw materials. Subsequently, using an appropriate full factorial experimental design, it is possible to investigate the variables, like polymeric density, treatment, or type of formulation involved in changes to packaging properties or in formulation-packaging interaction. The variation of these properties can greatly affect cosmetic safety. In particular, mechanical properties can be used as an indicator of pack performances and safety. As an example, containers made of two types of polyethylene with different density, low-density polyethylene (LDPE and high-density polyethylene (HDPE, are investigated. Regarding the substances potentially extractable from the packaging, in this work the headspace solid-phase microextraction method (HSSPME was used because this technique was reported in the literature as suitable to detect extractables from the polymeric material here employed.

  7. 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

  8. Proceedings of the CSNI WGOE/SEGHOF workshop on modifications at nuclear power plants - Operating experience, safety significance and the role of human factors and organisation

    International Nuclear Information System (INIS)

    2004-01-01

    recognised as safety significant. Similar kinds of challenges may be born during plant maintenance, when changes in the design or materials may be made without anyone recognising that the maintenance work has modified the function of plant equipment. A modification process in which possible safety influences are assessed early can improve nuclear safety and, at the same time, reduce the overall costs. Screening of intended changes can be used to estimate design and analysis efforts required in the modification process. It should be observed that systems complexity sometimes may have unexpected impacts. Screening criteria should address both the safety significance of the systems and components modified and the impact of the changes on tasks performed by operators and maintainers. Major modification projects should always involve a comprehensive review, which includes both technical and human contributions to plant operability and maintainability. It is important to create awareness and understanding of the potential safety impact of large and small modifications in NPPs. This awareness may be improved by collecting and disseminating information about modification-related events. There is evidence that good results can be achieved by integrating technical and human factors considerations in the safety assessment process for plant modifications. Regulators have an important role in ensuring that modification processes are acceptable and documented, and that the processes are followed. International agencies have a role in informing regulators and industry about the importance of using appropriate processes when modifications are planned, reviewed, designed, and implemented. During the first day of the workshop, all participants attended eight paper presentations. On the following two days, participants were separated into four groups with three focusing on human factors in modifications and the other focusing on minor and non-identified modifications. There were three

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

    International Nuclear Information System (INIS)

    Gantchev, T.

    1998-01-01

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

  10. 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

  11. Significant Improvement of Organic Thin-Film Transistor Mobility Utilizing an Organic Heterojunction Buffer Layer

    International Nuclear Information System (INIS)

    Pan Feng; Qian Xian-Rui; Huang Li-Zhen; Wang Hai-Bo; Yan Dong-Hang

    2011-01-01

    High-mobility vanadyl phthalocyanine (VOPc)/5,5‴-bis(4-fluorophenyl)-2,2':5',2″:5″,2‴-quaterthiophene (F2-P4T) thin-film transistors are demonstrated by employing a copper hexadecafluorophthalocyanine (F 16 CuPc)/copper phthalocyanine (CuPc) heterojunction unit, which are fabricated at different substrate temperatures, as a buffer layer. The highest mobility of 4.08cm 2 /Vs is achieved using a F 16 CuPc/CuPc organic heterojunction buffer layer fabricated at high substrate temperature. Compared with the random small grain-like morphology of the room-temperature buffer layer, the high-temperature organic heterojunction presents a large-sized fiber-like film morphology, resulting in an enhanced conductivity. Thus the contact resistance of the transistor is significantly reduced and an obvious improvement in device mobility is obtained. (cross-disciplinary physics and related areas of science and technology)

  12. Significant improvement of optical traps by tuning standard water immersion objectives

    International Nuclear Information System (INIS)

    Reihani, S Nader S; Mir, Shahid A; Richardson, Andrew C; Oddershede, Lene B

    2011-01-01

    Focused infrared lasers are widely used for micromanipulation and visualization of biological specimens. An inherent practical problem is that off-the-shelf commercial microscope objectives are designed for use with visible and not infrared wavelengths. Less aberration is introduced by water immersion objectives than by oil immersion ones, however, even water immersion objectives induce significant aberration. We present a simple method to reduce the spherical aberration induced by water immersion objectives, namely by tuning the correction collar of the objective to a value that is ∼ 10% lower than the physical thickness of the coverslip. This results in marked improvements in optical trapping strengths of up to 100% laterally and 600% axially from a standard microscope objective designed for use in the visible range. The results are generally valid for any water immersion objective with any numerical aperture

  13. Safety cases for the co-ordinated research project on improvement of safety assessment methodologies for near surface radioactive waste disposal facilities (ISAM)

    International Nuclear Information System (INIS)

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

    2002-01-01

    A Co-ordinated Research Project (CRP) has recently been completed on the Improvement of Safety Assessment Methodologies for Near-Surface Radioactive Waste Disposal Facilities (ISAM). A major aspect of the project was the use of safety cases for the practical application of safety assessment. An overview of the ISAM safety cases is given in this paper. (author)

  14. Significant improvement in the electrical characteristics of Schottky barrier diodes on molecularly modified Gallium Nitride surfaces

    Science.gov (United States)

    Garg, Manjari; Naik, Tejas R.; Pathak, C. S.; Nagarajan, S.; Rao, V. Ramgopal; Singh, R.

    2018-04-01

    III-Nitride semiconductors face the issue of localized surface states, which causes fermi level pinning and large leakage current at the metal semiconductor interface, thereby degrading the device performance. In this work, we have demonstrated the use of a Self-Assembled Monolayer (SAM) of organic molecules to improve the electrical characteristics of Schottky barrier diodes (SBDs) on n-type Gallium Nitride (n-GaN) epitaxial films. The electrical characteristics of diodes were improved by adsorption of SAM of hydroxyl-phenyl metallated porphyrin organic molecules (Zn-TPPOH) onto the surface of n-GaN. SAM-semiconductor bonding via native oxide on the n-GaN surface was confirmed using X-ray photoelectron spectroscopy measurements. Surface morphology and surface electronic properties were characterized using atomic force microscopy and Kelvin probe force microscopy. Current-voltage characteristics of different metal (Cu, Ni) SBDs on bare n-GaN were compared with those of Cu/Zn-TPPOH/n-GaN and Ni/Zn-TPPOH/n-GaN SBDs. It was found that due to the molecular monolayer, the surface potential of n-GaN was decreased by ˜350 mV. This caused an increase in the Schottky barrier height of Cu and Ni SBDs from 1.13 eV to 1.38 eV and 1.07 eV to 1.22 eV, respectively. In addition to this, the reverse bias leakage current was reduced by 3-4 orders of magnitude for both Cu and Ni SBDs. Such a significant improvement in the electrical performance of the diodes can be very useful for better device functioning.

  15. pEPito: a significantly improved non-viral episomal expression vector for mammalian cells

    Directory of Open Access Journals (Sweden)

    Ogris Manfred

    2010-03-01

    Full Text Available Abstract Background The episomal replication of the prototype vector pEPI-1 depends on a transcription unit starting from the constitutively expressed Cytomegalovirus immediate early promoter (CMV-IEP and directed into a 2000 bp long matrix attachment region sequence (MARS derived from the human β-interferon gene. The original pEPI-1 vector contains two mammalian transcription units and a total of 305 CpG islands, which are located predominantly within the vector elements necessary for bacterial propagation and known to be counterproductive for persistent long-term transgene expression. Results Here, we report the development of a novel vector pEPito, which is derived from the pEPI-1 plasmid replicon but has considerably improved efficacy both in vitro and in vivo. The pEPito vector is significantly reduced in size, contains only one transcription unit and 60% less CpG motives in comparison to pEPI-1. It exhibits major advantages compared to the original pEPI-1 plasmid, including higher transgene expression levels and increased colony-forming efficiencies in vitro, as well as more persistent transgene expression profiles in vivo. The performance of pEPito-based vectors was further improved by replacing the CMV-IEP with the human CMV enhancer/human elongation factor 1 alpha promoter (hCMV/EF1P element that is known to be less affected by epigenetic silencing events. Conclusions The novel vector pEPito can be considered suitable as an improved vector for biotechnological applications in vitro and for non-viral gene delivery in vivo.

  16. Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance.

    Science.gov (United States)

    Boyce, John M

    2017-05-01

    Monitoring hand hygiene compliance among health care personnel (HCP) is an essential element of hand hygiene promotion programs. Observation by trained auditors is considered the gold standard method for establishing hand hygiene compliance rates. Advantages of observational surveys include the unique ability to establish compliance with all of the World Health Organization "My 5 Moments for Hand Hygiene" initiative Moments and to provide just-in-time coaching. Disadvantages include the resources required for observational surveys, insufficient sample sizes, and nonstandardized methods of conducting observations. Electronic and camera-based systems can monitor hand hygiene performance on all work shifts without a Hawthorne effect and provide significantly more data regarding hand hygiene performance. Disadvantages include the cost of installation, variable accuracy in estimating compliance rates, issues related to acceptance by HCP, insufficient data regarding their cost-effectiveness and influence on health care-related infection rates, and the ability of most systems to monitor only surrogates for Moments 1, 4, and 5. Increasing evidence suggests that monitoring only Moments 1, 4, and 5 provides reasonable estimates of compliance with all 5 Moments. With continued improvement of electronic monitoring systems, combining electronic monitoring with observational methods may provide the best information as part of a multimodal strategy to improve and sustain hand hygiene compliance rates among HCP. Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

  17. An On-Chip RBC Deformability Checker Significantly Improves Velocity-Deformation Correlation

    Directory of Open Access Journals (Sweden)

    Chia-Hung Dylan Tsai

    2016-10-01

    Full Text Available An on-chip deformability checker is proposed to improve the velocity–deformation correlation for red blood cell (RBC evaluation. RBC deformability has been found related to human diseases, and can be evaluated based on RBC velocity through a microfluidic constriction as in conventional approaches. The correlation between transit velocity and amount of deformation provides statistical information of RBC deformability. However, such correlations are usually only moderate, or even weak, in practical evaluations due to limited range of RBC deformation. To solve this issue, we implemented three constrictions of different width in the proposed checker, so that three different deformation regions can be applied to RBCs. By considering cell responses from the three regions as a whole, we practically extend the range of cell deformation in the evaluation, and could resolve the issue about the limited range of RBC deformation. RBCs from five volunteer subjects were tested using the proposed checker. The results show that the correlation between cell deformation and transit velocity is significantly improved by the proposed deformability checker. The absolute values of the correlation coefficients are increased from an average of 0.54 to 0.92. The effects of cell size, shape and orientation to the evaluation are discussed according to the experimental results. The proposed checker is expected to be useful for RBC evaluation in medical practices.

  18. Patient safety climate profiles across time: Strength and level of safety climate associated with a quality improvement program in Switzerland—A cross-sectional survey study

    Science.gov (United States)

    Mascherek, Anna C.

    2017-01-01

    Safety Climate has been acknowledged as an unspecific factor influencing patient safety. However, studies rarely provide in-depth analysis of climate data. As a helpful approach, the concept of “climate strength” has been proposed. In the present study we tested the hypotheses that even if safety climate remains stable on mean-level across time, differences might be evident in strength or shape. The data of two hospitals participating in a large national quality improvement program were analysed for differences in climate profiles at two measurement occasions. We analysed differences on mean-level, differences in percent problematic response, agreement within groups, and frequency histograms in two large hospitals in Switzerland at two measurement occasions (2013 and 2015) applying the Safety Climate Survey. In total, survey responses of 1193 individuals were included in the analyses. Overall, small but significant differences on mean-level of safety climate emerged for some subgroups. Also, although agreement was strong at both time-points within groups, tendencies of divergence or consensus were present in both hospitals. Depending on subgroup and analyses chosen, differences were more or less pronounced. The present study illustrated that taking several measures into account and describing safety climate from different perspectives is necessary in order to fully understand differences and trends within groups and to develop interventions addressing the needs of different groups more precisely. PMID:28753633

  19. Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

    Science.gov (United States)

    Kuo, Calvin C; Robb, William J

    2013-06-01

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

  20. Fabrication of CoZn alloy nanowire arrays: Significant improvement in magnetic properties by annealing process

    International Nuclear Information System (INIS)

    Koohbor, M.; Soltanian, S.; Najafi, M.; Servati, P.

    2012-01-01

    Highlights: ► Increasing the Zn concentration changes the structure of NWs from hcp to amorphous. ► Increasing the Zn concentration significantly reduces the Hc value of NWs. ► Magnetic properties of CoZn NWs can be significantly enhanced by appropriate annealing. ► The pH of electrolyte has no significant effect on the properties of the NW arrays. ► Deposition frequency has considerable effects on the magnetic properties of NWs. - Abstract: Highly ordered arrays of Co 1−x Zn x (0 ≤ x ≤ 0.74) nanowires (NWs) with diameters of ∼35 nm and high length-to-diameter ratios (up to 150) were fabricated by co-electrodeposition of Co and Zn into pores of anodized aluminum oxide (AAO) templates. The Co and Zn contents of the NWs were adjusted by varying the ratio of Zn and Co ion concentrations in the electrolyte. The effect of the Zn content, electrodeposition conditions (frequency and pH) and annealing on the structural and magnetic properties (e.g., coercivity (Hc) and squareness (Sq)) of NW arrays were investigated using X-ray diffraction (XRD), scanning electron microscopy, electron diffraction, and alternating gradient force magnetometer (AGFM). XRD patterns reveal that an increase in the concentration of Zn ions of the electrolyte forces the hcp crystal structure of Co NWs to change into an amorphous phase, resulting in a significant reduction in Hc. It was found that the magnetic properties of NWs can be significantly improved by appropriate annealing process. The highest values for Hc (2050 Oe) and Sq (0.98) were obtained for NWs electrodeposited using 0.95/0.05 Co:Zn concentrations at 200 Hz and annealed at 575 °C. While the pH of electrolyte is found to have no significant effect on the structural and magnetic properties of the NW arrays, the electrodeposition frequency has considerable effects on the magnetic properties of the NW arrays. The changes in magnetic property of NWs are rooted in a competition between shape anisotropy and

  1. Fabrication of CoZn alloy nanowire arrays: Significant improvement in magnetic properties by annealing process

    Energy Technology Data Exchange (ETDEWEB)

    Koohbor, M. [Department of Physics, University of Kurdistan, Sanandaj (Iran, Islamic Republic of); Soltanian, S., E-mail: s.soltanian@gmail.com [Department of Physics, University of Kurdistan, Sanandaj (Iran, Islamic Republic of); Department of Electrical and Computer Engineering, University of British Columbia, Vancouver (Canada); Najafi, M. [Department of Physics, University of Kurdistan, Sanandaj (Iran, Islamic Republic of); Department of Physics, Hamadan University of Technology, Hamadan (Iran, Islamic Republic of); Servati, P. [Department of Electrical and Computer Engineering, University of British Columbia, Vancouver (Canada)

    2012-01-05

    Highlights: Black-Right-Pointing-Pointer Increasing the Zn concentration changes the structure of NWs from hcp to amorphous. Black-Right-Pointing-Pointer Increasing the Zn concentration significantly reduces the Hc value of NWs. Black-Right-Pointing-Pointer Magnetic properties of CoZn NWs can be significantly enhanced by appropriate annealing. Black-Right-Pointing-Pointer The pH of electrolyte has no significant effect on the properties of the NW arrays. Black-Right-Pointing-Pointer Deposition frequency has considerable effects on the magnetic properties of NWs. - Abstract: Highly ordered arrays of Co{sub 1-x}Zn{sub x} (0 {<=} x {<=} 0.74) nanowires (NWs) with diameters of {approx}35 nm and high length-to-diameter ratios (up to 150) were fabricated by co-electrodeposition of Co and Zn into pores of anodized aluminum oxide (AAO) templates. The Co and Zn contents of the NWs were adjusted by varying the ratio of Zn and Co ion concentrations in the electrolyte. The effect of the Zn content, electrodeposition conditions (frequency and pH) and annealing on the structural and magnetic properties (e.g., coercivity (Hc) and squareness (Sq)) of NW arrays were investigated using X-ray diffraction (XRD), scanning electron microscopy, electron diffraction, and alternating gradient force magnetometer (AGFM). XRD patterns reveal that an increase in the concentration of Zn ions of the electrolyte forces the hcp crystal structure of Co NWs to change into an amorphous phase, resulting in a significant reduction in Hc. It was found that the magnetic properties of NWs can be significantly improved by appropriate annealing process. The highest values for Hc (2050 Oe) and Sq (0.98) were obtained for NWs electrodeposited using 0.95/0.05 Co:Zn concentrations at 200 Hz and annealed at 575 Degree-Sign C. While the pH of electrolyte is found to have no significant effect on the structural and magnetic properties of the NW arrays, the electrodeposition frequency has considerable effects on

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

    International Nuclear Information System (INIS)

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

    2017-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2017-07-01

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

  4. Compression stockings significantly improve hemodynamic performance in post-thrombotic syndrome irrespective of class or length.

    Science.gov (United States)

    Lattimer, Christopher R; Azzam, Mustapha; Kalodiki, Evi; Makris, Gregory C; Geroulakos, George

    2013-07-01

    Graduated elastic compression (GEC) stockings have been demonstrated to reduce the morbidity associated with post-thrombotic syndrome. The ideal length or compression strength required to achieve this is speculative and related to physician preference and patient compliance. The aim of this study was to evaluate the hemodynamic performance of four different stockings and determine the patient's preference. Thirty-four consecutive patients (40 legs, 34 male) with post-thrombotic syndrome were tested with four different stockings (Mediven plus open toe, Bayreuth, Germany) of their size in random order: class 1 (18-21 mm Hg) and class II (23-32 mm Hg), below-knee (BK) and above-knee thigh-length (AK). The median age, Venous Clinical Severity Score, Venous Segmental Disease Score, and Villalta scale were 62 years (range, 31-81 years), 8 (range, 1-21), 5 (range, 2-10), and 10 (range, 2-22), respectively. The C of C0-6EsAs,d,pPr,o was C0 = 2, C2 = 1, C3 = 3, C4a = 12, C4b = 7, C5 = 12, C6 = 3. Obstruction and reflux was observed on duplex in 47.5% legs, with deep venous reflux alone in 45%. Air plethysmography was used to measure the venous filling index (VFI), venous volume, and time to fill 90% of the venous volume. Direct pressure measurements were obtained while lying and standing using the PicoPress device (Microlab Elettronica, Nicolò, Italy). The pressure sensor was placed underneath the test stocking 5 cm above and 2 cm posterior to the medial malleolus. At the end of the study session, patients stated their preferred stocking based on comfort. The VFI, venous volume, and time to fill 90% of the venous volume improved significantly with all types of stocking versus no compression. In class I, the VFI (mL/s) improved from a median of 4.9 (range, 1.7-16.3) without compression to 3.7 (range, 0-14) BK (24.5%) and 3.6 (range, 0.6-14.5) AK (26.5%). With class II, the corresponding improvement was to 4.0 (range, 0.3-16.2) BK (18.8%) and 3.7 (range, 0.5-14.2) AK (24

  5. Significant improvement of intestinal microbiota of gibel carp (Carassius auratus gibelio) after traditional Chinese medicine feeding.

    Science.gov (United States)

    Wu, Z B; Gatesoupe, F-J; Li, T T; Wang, X H; Zhang, Q Q; Feng, D Y; Feng, Y Q; Chen, H; Li, A H

    2018-03-01

    Increasing attention has been attracted to intestinal microbiota, due to interactions with nutrition, metabolism and immune defence of the host. Traditional Chinese medicine (TCM) feed additives have been applied in aquaculture to improve fish health, but the interaction with fish gut microbiota is still poorly understood. This study aimed to explore the effect of adding TCM in feed on the intestinal microbiota of gibel carp (Carassius auratus gibelio). Bacterial communities of 16 fish intestinal contents and one water sample were characterized by high-throughput sequencing and analysis of the V4-V5 region of the 16S rRNA gene. The results showed that the composition and structure of the bacterial community were significantly altered by the TCM feeding. Some phyla increased markedly (Proteobacteria, Actinobacteria, Acidobacteria, etc.), while Fusobacteria were significantly reduced. Concurrently, the richness and diversity of the taxonomic units increased, and the microbiota composition of TCM-treated fish was more homogeneous among individuals. At the genus level, the addition of TCM tended to reduce the incidence of potential pathogens (Aeromonas, Acinetobacter and Shewanella), while stimulating the emergence of some potential probiotics (Lactobacillus, Lactococcus, Bacillus and Pseudomonas). These data suggested that the feed additive could regulate the fish intestinal microbiota by reinforcing the microbial balance. This study may provide useful information for further application of TCM for diseases prevention and stress management in aquaculture. © 2017 The Society for Applied Microbiology.

  6. Significant improvement in one-dimensional cursor control using Laplacian electroencephalography over electroencephalography

    Science.gov (United States)

    Boudria, Yacine; Feltane, Amal; Besio, Walter

    2014-06-01

    Objective. Brain-computer interfaces (BCIs) based on electroencephalography (EEG) have been shown to accurately detect mental activities, but the acquisition of high levels of control require extensive user training. Furthermore, EEG has low signal-to-noise ratio and low spatial resolution. The objective of the present study was to compare the accuracy between two types of BCIs during the first recording session. EEG and tripolar concentric ring electrode (TCRE) EEG (tEEG) brain signals were recorded and used to control one-dimensional cursor movements. Approach. Eight human subjects were asked to imagine either ‘left’ or ‘right’ hand movement during one recording session to control the computer cursor using TCRE and disc electrodes. Main results. The obtained results show a significant improvement in accuracies using TCREs (44%-100%) compared to disc electrodes (30%-86%). Significance. This study developed the first tEEG-based BCI system for real-time one-dimensional cursor movements and showed high accuracies with little training.

  7. Induction-heating MOCVD reactor with significantly improved heating efficiency and reduced harmful magnetic coupling

    KAUST Repository

    Li, Kuang-Hui; Alotaibi, Hamad S.; Sun, Haiding; Lin, Ronghui; Guo, Wenzhe; Torres-Castanedo, Carlos G.; Liu, Kaikai; Galan, Sergio V.; Li, Xiaohang

    2018-01-01

    In a conventional induction-heating III-nitride metalorganic chemical vapor deposition (MOCVD) reactor, the induction coil is outside the chamber. Therefore, the magnetic field does not couple with the susceptor well, leading to compromised heating efficiency and harmful coupling with the gas inlet and thus possible overheating. Hence, the gas inlet has to be at a minimum distance away from the susceptor. Because of the elongated flow path, premature reactions can be more severe, particularly between Al- and B-containing precursors and NH3. Here, we propose a structure that can significantly improve the heating efficiency and allow the gas inlet to be closer to the susceptor. Specifically, the induction coil is designed to surround the vertical cylinder of a T-shaped susceptor comprising the cylinder and a top horizontal plate holding the wafer substrate within the reactor. Therefore, the cylinder coupled most magnetic field to serve as the thermal source for the plate. Furthermore, the plate can block and thus significantly reduce the uncoupled magnetic field above the susceptor, thereby allowing the gas inlet to be closer. The results show approximately 140% and 2.6 times increase in the heating and susceptor coupling efficiencies, respectively, as well as a 90% reduction in the harmful magnetic flux on the gas inlet.

  8. Induction-heating MOCVD reactor with significantly improved heating efficiency and reduced harmful magnetic coupling

    KAUST Repository

    Li, Kuang-Hui

    2018-02-23

    In a conventional induction-heating III-nitride metalorganic chemical vapor deposition (MOCVD) reactor, the induction coil is outside the chamber. Therefore, the magnetic field does not couple with the susceptor well, leading to compromised heating efficiency and harmful coupling with the gas inlet and thus possible overheating. Hence, the gas inlet has to be at a minimum distance away from the susceptor. Because of the elongated flow path, premature reactions can be more severe, particularly between Al- and B-containing precursors and NH3. Here, we propose a structure that can significantly improve the heating efficiency and allow the gas inlet to be closer to the susceptor. Specifically, the induction coil is designed to surround the vertical cylinder of a T-shaped susceptor comprising the cylinder and a top horizontal plate holding the wafer substrate within the reactor. Therefore, the cylinder coupled most magnetic field to serve as the thermal source for the plate. Furthermore, the plate can block and thus significantly reduce the uncoupled magnetic field above the susceptor, thereby allowing the gas inlet to be closer. The results show approximately 140% and 2.6 times increase in the heating and susceptor coupling efficiencies, respectively, as well as a 90% reduction in the harmful magnetic flux on the gas inlet.

  9. [Improvement of local lymph node assay for cosmetics safety evaluation].

    Science.gov (United States)

    Liu, Zhen; Liu, Junping; Wang, Fei; Xu, Guifeng; Hou, Juan; Wan, Xuying; Zhang, Tianbao

    2009-09-01

    To improve the local lymph node assay (LLNA) as an alternative method to detect chemicals for both sensitization and irritation. The following chemicals: one negative control: 4-Aminobenzoic Acid, three sensitizers: 2,4-dinitrochlorobenzene (DNCB), Hexyl cinnamic aldehyde (HCA), 2-Aminophenol (2-APC) and two irritations: potassium hydroxide (KOH), sodium lauryl sulphate (SLS) were selected. According to the normal LLNA, groups of female Balb/c mice were treated with test solutions. The thickness of each ear was measured and each auricle was weighed. On the sixth day, the bilateral draining auricular lymph nodes were excised and weighed. The single cell suspensions were prepared, the lymphocyte were counted and the proliferations of lymph cells were detected by cell counting kit-8 (CCK-8). Significant increase in ear thickness and weight were found in groups of KOH, SLS and DNCB (above 0.5%) (P LLNA using auricle thickness and weighing as observed markers for irritation, and using lymph nodes weighing and proliferation of lymphocyte as observed markers for sensitization, could evaluate both sensitization and irritation at the same time.

  10. Improving the safety of room air pneumoperitoneum for diagnostic laparoscopy.

    Science.gov (United States)

    Ikechebelu, J I; Okeke, C A F

    2008-06-01

    Laparoscopic examination is a useful investigation in the evaluation of infertile women. To perform this test, pneumoperitoneum is required to distend the abdomen, improve visibility and displace the intestines out of the pelvis. Several gases have been used to achieve this purpose including Nitrous Oxide (N2O), Carbondioxide (CO2), Helium, Xenon andAir. This was a prospective study in a private fertility centre in Nnewi, Nigeria aimed at reducing the morbidities inherent in the use Room Air pneumoperitoneum for diagnostic laparoscopy. This was sequel to an earlier study, which revealed that women who had Room Air pneumoperitoneum had a higher port wound infection rate, abdominal discomfort (feeling of retained gas in the abdomen) and shoulder pain with resultant delayed return to normal activity than women who had Co2 pneumoperitoneum. This study demonstrated that the use of soda lime to purify the Room Air and a low pressure suction pump to evacuate the air after the procedure significantly reduced the wound infection rate and virtually eliminated the abdominal discomfort and shoulder pain associated with Room Air pneumoperitoneum. This was followed by early return to normal activity. Therefore, use of Room Air for pneumoperitoneum is safe and affordable. It is recommended for low resource settings.

  11. Safety improvement plant modifications at Forsmark 3, 1986-1995

    Energy Technology Data Exchange (ETDEWEB)

    Kjellander, M. [Kaernkraftsaekerhet och utbildning, Nykoeping (Sweden)

    1998-10-01

    All important plant modifications implemented in safety-related equipment or software at Forsmark 3 are compiled in this report. The report covers the period from the start of commercial operation in 1985 up to and including 1995. The plant modifications, which were carried out by different suppliers during the guarantee period, are not included in the report since they have not been administered by the Forsmark organisation. The report contains references to relevant modification notices and to files and file divider numbers. These data refer to the Safety Department central archives. The report is based on Forsmark 3 Technical Specifications (STF) which means that Chapter 3 is divided into the same sections as in the STF. Modifications, which cannot be directly attributed to any specific STF chapter, and major modifications are described separately

  12. Safety and improvement of movement function after stroke with atomoxetine: A pilot randomized trial

    Science.gov (United States)

    Ward, Andrea; Carrico, Cheryl; Powell, Elizabeth; Westgate, Philip M.; Nichols, Laurie; Fleischer, Anne; Sawaki, Lumy

    2016-01-01

    Background: Intensive, task-oriented motor training has been associated with neuroplastic reorganization and improved upper extremity movement function after stroke. However, to optimize such training for people with moderate-to-severe movement impairment, pharmacological modulation of neuroplasticity may be needed as an adjuvant intervention. Objective: Evaluate safety, as well as improvement in movement function, associated with motor training paired with a drug to upregulate neuroplasticity after stroke. Methods: In this double-blind, randomized, placebo-controlled study, 12 subjects with chronic stroke received either atomoxetine or placebo paired with motor training. Safety was assessed using vital signs. Upper extremity movement function was assessed using Fugl-Meyer Assessment, Wolf Motor Function Test, and Action Research Arm Test at baseline, post-intervention, and 1-month follow-up. Results: No significant between-groups differences were found in mean heart rate (95% CI, –12.4–22.6; p = 0.23), mean systolic blood pressure (95% CI, –1.7–29.6; p = 0.21), or mean diastolic blood pressure (95% CI, –10.4–13.3; p = 0.08). A statistically significant between-groups difference on Fugl-Meyer at post-intervention favored the atomoxetine group (95% CI, 1.6–12.7; p = 0.016). Conclusion: Atomoxetine combined with motor training appears safe and may optimize motor training outcomes after stroke. PMID:27858723

  13. Virtual reality by mobile smartphone: improving child pedestrian safety.

    Science.gov (United States)

    Schwebel, David C; Severson, Joan; He, Yefei; McClure, Leslie A

    2017-10-01

    Pedestrian injuries are a leading cause of paediatric injury. Effective, practical and cost-efficient behavioural interventions to teach young children street crossing skills are needed. They must be empirically supported and theoretically based. Virtual reality (VR) offers promise to fill this need and teach child pedestrian safety skills for several reasons, including: (A) repeated unsupervised practice without risk of injury, (B) automated feedback on crossing success or failure, (C) tailoring to child skill levels: (D) appealing and fun training environment, and (E) most recently given technological advances, potential for broad dissemination using mobile smartphone technology. Extending previous work, we will evaluate delivery of an immersive pedestrian VR using mobile smartphones and the Google Cardboard platform, technology enabling standard smartphones to function as immersive VR delivery systems. We will overcome limitations of previous research suggesting children learnt some pedestrian skills after six VR training sessions but did not master adult-level pedestrian skills by implementing a randomised non-inferiority trial with two equal-sized groups of children ages 7-8 years (total N=498). All children will complete baseline, postintervention and 6-month follow-up assessments of pedestrian safety and up to 25 30-min pedestrian safety training trials until they reach adult levels of functioning. Half the children will be randomly assigned to train in Google Cardboard and the other half in a semi-immersive kiosk VR. Analysis of Covariance (ANCOVA) models will assess primary outcomes. If results are as hypothesised, mobile smartphones offer substantial potential to overcome barriers of dissemination and implementation and deliver pedestrian safety training to children worldwide. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  14. Improving Chemical Plant Safety Training Using Virtual Reality

    OpenAIRE

    Nasios, Konstantinos

    2002-01-01

    The chemical engineering industry often requires people to work in hazardous environments and to operate complicated equipment which often limits the type of training that be carried out on site. The daily job of chemical plant operators is becoming more demanding due to the increasing plant complexity together with increasing requirements on plant safety, production capacity, product quality and cost effectiveness. The importance of designing systems and environments that are as safe as poss...

  15. Improving economics and safety of water cooled reactors. Proven means and new approaches

    International Nuclear Information System (INIS)

    2002-05-01

    Nuclear power plants (NPPs) with water cooled reactors [either light water reactors (LWRs) or heavy water reactors (HWRs)] constitute the large majority of the currently operating plants. Water cooled reactors can make a significant contribution to meeting future energy needs, to reducing greenhouse gas emissions, and to energy security if they can compete economically with fossil alternatives, while continuing to achieve a very high level of safety. It is generally agreed that the largest commercial barrier to the addition of new nuclear power capacity is the high capital cost of nuclear plants relative to other electricity generating alternatives. If nuclear plants are to form part of the future generating mix in competitive electricity markets, capital cost reduction through simplified designs must be an important focus. Reductions in operating, maintenance and fuel costs should also be pursued. The Department of Nuclear Energy of the IAEA is examining the competitiveness of nuclear power and the means for improving its economics. The objective of this TECDOC is to emphasize the need, and to identify approaches, for new nuclear plants with water cooled reactors to achieve competitiveness while maintaining high levels of safety. The cost reduction methods discussed herein can be implemented into plant designs that are currently under development as well as into designs that may be developed in the longer term. Many of the approaches discussed also generally apply to other reactor types (e.g. gas cooled and liquid metal cooled reactors). To achieve the largest possible cost reductions, proven means for reducing costs must be fully implemented, and new approaches described in this document should be developed and implemented. These new approaches include development of advanced technologies, increased use of risk-informed methods for evaluating the safety benefit of design features, and international consensus regarding commonly acceptable safety requirements that

  16. Improving economics and safety of water cooled reactors. Proven means and new approaches

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2002-05-01

    Nuclear power plants (NPPs) with water cooled reactors [either light water reactors (LWRs) or heavy water reactors (HWRs)] constitute the large majority of the currently operating plants. Water cooled reactors can make a significant contribution to meeting future energy needs, to reducing greenhouse gas emissions, and to energy security if they can compete economically with fossil alternatives, while continuing to achieve a very high level of safety. It is generally agreed that the largest commercial barrier to the addition of new nuclear power capacity is the high capital cost of nuclear plants relative to other electricity generating alternatives. If nuclear plants are to form part of the future generating mix in competitive electricity markets, capital cost reduction through simplified designs must be an important focus. Reductions in operating, maintenance and fuel costs should also be pursued. The Department of Nuclear Energy of the IAEA is examining the competitiveness of nuclear power and the means for improving its economics. The objective of this TECDOC is to emphasize the need, and to identify approaches, for new nuclear plants with water cooled reactors to achieve competitiveness while maintaining high levels of safety. The cost reduction methods discussed herein can be implemented into plant designs that are currently under development as well as into designs that may be developed in the longer term. Many of the approaches discussed also generally apply to other reactor types (e.g. gas cooled and liquid metal cooled reactors). To achieve the largest possible cost reductions, proven means for reducing costs must be fully implemented, and new approaches described in this document should be developed and implemented. These new approaches include development of advanced technologies, increased use of risk-informed methods for evaluating the safety benefit of design features, and international consensus regarding commonly acceptable safety requirements that

  17. A Checklist to Improve Patient Safety in Interventional Radiology

    International Nuclear Information System (INIS)

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

    2013-01-01

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

  18. Improved safety features in the design of Alto Lazio NPP

    International Nuclear Information System (INIS)

    Bava, G.; Cianciolo, T.; Del Nero, G.

    1988-01-01

    The ALTO LAZIO Nuclear Power Plant, two 1000Mwe units, is a BWR 6/MARK III located about 100 km north of Rome, on the Tyrrhenian Sea Coasts. The construction of the plant started in 1978, but it has recently been stopped by a Government decision following a national referendum, when the units were about 70% completed. This paper is mainly intended to illustrate the major safety features which have been implemented as result of specific requirements issued by the safety authority (ENEA DISP) during the construction permit stage or the subsequent licensing process. One of the tools used to identify the need for design modifications has been a comprehensive reliability analysis of safety system: in the paper the methods used and the major results obtained by this study are briefly presented. Also, the approach used in the investigation of severe accidents and major applications in the area of plant design and emergency procedures are briefly discussed; furthermore the trend toward a simpler mitigation concept is described

  19. 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.

  20. Safety Challenges and Improvement Strategies of Ethnic Minority Construction Workers: A Case Study in Hong Kong.

    Science.gov (United States)

    Wu, Chunlin; Luo, Xiaowei; Wang, Tao; Wang, Yue; Sapkota, Bibek

    2018-04-18

    Due to cultural differences, ethnic minority construction workers are more difficult to manage and more vulnerable to accidents. This study aims to identify the major barriers faced by ethnic minority workers from their own perspectives and determine potential strategies to enhance safety climate of construction projects, thus ultimately improve their safety performance. A survey with modified Nordic safety climate questionnaire was conducted in a certain sub-contractor in Hong Kong. In-depth interviews, status quo description, major challenge investigation and safety knowledge tests were carried as well. The top three most important safety challenges identified are improper stereotypes from the whole industry, lack of opportunities for job assignment, and language barriers. To improve the safety performance, employers should allocate sufficient personal protective equipment and governments should organize unannounced site visits more frequently. Besides, the higher-level management should avoid giving contradictory instructions to foremen against to the standards of supervisors.

  1. Significantly improved survival time in pigs with complete liver ischemia treated with a novel bioartificial liver

    NARCIS (Netherlands)

    Flendrig, L. M.; Calise, F.; Di Florio, E.; Mancini, A.; Ceriello, A.; Santaniello, W.; Mezza, E.; Sicoli, F.; Belleza, G.; Bracco, A.; Cozzolino, S.; Scala, D.; Mazzone, M.; Fattore, M.; Gonzales, E.; Chamuleau, R. A.

    1999-01-01

    Aim of the study was to evaluate treatment efficacy and safety of a scaled-up version of our porcine hepatocytes based BAL system in pigs with complete liver ischemia (LIS). Thirty-one pigs underwent total devascularization of the liver (LIS) by termino-lateral porta-caval shunts and sutures around

  2. Knowledge representation in safety assessment: improving transparency and traceability

    Energy Technology Data Exchange (ETDEWEB)

    Lemos, F.L. de [Centro de Desenvolvimento da Tecnologia Nuclear (CDTN/CNEN-MG), Belo Horizonte, MG (Brazil); Sullivan, T. [Brookhaven National Laboratory (BNL), Upton, NY (United States); Ross, T. [University of New Mexico (UNM), Albuquerque, NM (United States); Guimaraes, L.N.F. [Instituto de Estudos Avancados (IEAv/CTA), Sao Jose dos Campos, SP (Brazil)

    2011-07-01

    Transparency and traceability are key factors for confidence building, acceptability, and quality enhancement of the safety assessment, and safety case for a radioactive waste disposal facility. In order to facilitate analysis and promote discussions, all of the information used to make decisions should be readily available to stake holders. The information should convey a good understanding of the intermediate decisions processes, allowing examination of alternatives and 'what if questions'. In an ideal situation all stake holders, including scientists and the public, should be able to follow the path of a certain parameter, from the beginning where it was defined, its assumptions and uncertainties, throughout the calculations until the final results of the safety assessment. One of the main challenges, to achieving such a transparency and traceability, is that stake holders are a very diverse audience, with very different backgrounds. This could require preparation of various versions of the same documentation, which would be impractical. While the linguistic information is of crucial importance to understanding the reasoning, it is very difficult to convey the supporting conditions, and consequent uncertainties for the selection of parameters values. Even scientists involved in the process can become confused due to the overwhelming amount of information that is used to support parameter value selection. The amount of details makes it difficult to track the decisions, which lead to the selection of a certain parameter, throughout the calculations. This paper presents a methodology to represent the linguistic information used in the safety assessment in terms of mathematical expressions by using the fuzzy sets and fuzzy logic tools. This methodology aims to help information to be readily available while keeping, as much as possible, the original meaning of the linguistic expressions and, consequently, to be available at any time as a quick reference

  3. Knowledge representation in safety assessment: improving transparency and traceability

    International Nuclear Information System (INIS)

    Lemos, F.L. de; Sullivan, T.; Ross, T.; Guimaraes, L.N.F.

    2011-01-01

    Transparency and traceability are key factors for confidence building, acceptability, and quality enhancement of the safety assessment, and safety case for a radioactive waste disposal facility. In order to facilitate analysis and promote discussions, all of the information used to make decisions should be readily available to stake holders. The information should convey a good understanding of the intermediate decisions processes, allowing examination of alternatives and 'what if questions'. In an ideal situation all stake holders, including scientists and the public, should be able to follow the path of a certain parameter, from the beginning where it was defined, its assumptions and uncertainties, throughout the calculations until the final results of the safety assessment. One of the main challenges, to achieving such a transparency and traceability, is that stake holders are a very diverse audience, with very different backgrounds. This could require preparation of various versions of the same documentation, which would be impractical. While the linguistic information is of crucial importance to understanding the reasoning, it is very difficult to convey the supporting conditions, and consequent uncertainties for the selection of parameters values. Even scientists involved in the process can become confused due to the overwhelming amount of information that is used to support parameter value selection. The amount of details makes it difficult to track the decisions, which lead to the selection of a certain parameter, throughout the calculations. This paper presents a methodology to represent the linguistic information used in the safety assessment in terms of mathematical expressions by using the fuzzy sets and fuzzy logic tools. This methodology aims to help information to be readily available while keeping, as much as possible, the original meaning of the linguistic expressions and, consequently, to be available at any time as a quick reference. This would

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

    NARCIS (Netherlands)

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

    2003-01-01

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

  5. National Space Agencies vs. Commercial Space: Towards Improved Space Safety

    Science.gov (United States)

    Pelton, J.

    2013-09-01

    Traditional space policies as developed at the national level includes many elements but they are most typically driven by economic and political objectives. Legislatively administered programs apportion limited public funds to achieve "gains" that can involve employment, stimulus to the economy, national defense or other advancements. Yet political advantage is seldom far from the picture.Within the context of traditional space policies, safety issues cannot truly be described as "afterthoughts", but they are usually, at best, a secondary or even tertiary consideration. "Space safety" is often simply assumed to be "in there" somewhere. The current key question is can "safety and risk minimization", within new commercial space programs actually be elevated in importance and effectively be "designed in" at the outset. This has long been the case with commercial aviation and there is at least reasonable hope that this could also be the case for the commercial space industry in coming years. The cooperative role that the insurance industry has now played for centuries in the shipping industry and for decades in aviation can perhaps now play a constructive role in risk minimization in the commercial space domain as well. This paper begins by examining two historical case studies in the context of traditional national space policy development to see how major space policy decisions involving "manned space programs" have given undue primacy to "political considerations" over "safety" and other factors. The specific case histories examined here include first the decision to undertake the Space Shuttle Program (i.e. 1970-1972) and the second is the International Space Station. In both cases the key and overarching decisions were driven by political, schedule and cost considerations, and safety seems absence as a prime consideration. In publicly funded space programs—whether in the United States, Europe, Russia, Japan, China, India or elsewhere—it seems realistic to

  6. Improvement of operational performance and increase of safety of WWER-1000/V-392

    International Nuclear Information System (INIS)

    Kurakov, Y.A.; Dragunov, Y.G.; Podshibiakin, A.K.; Fil, N.S.; Krushelnitsky, V.N.; Berkovich, V.M.

    2001-01-01

    The national programme of nuclear power development approved by the Russian Federation Government in 1998 considers the design of WWER-1000/V-392 power unit as a priority project of the new generation NPP with improved operational performances and increased safety. The pilot unit of this design (NVAES-2) is licensed for construction at the Novovoronezh NPP site. The NVAES-2 design is developed on the basis of standard power unit with reactor plant V-320. Twenty units of this type are in operation at the nuclear power plants in Russia, Ukraine and Bulgaria having totally about 270 reactor-years of operation. Two more V-320 units are being commissioned this year at Rostov NPP and Temelin NPP. So, the WWER-1000/V-392 design is as a whole an evolutionary development of the operating standard unit WWER-1000/V-320. Many technical solutions aimed at increase of safety and improvement of operational performance of the plant are implemented in the NVAES-2 design, such as advanced reactor WWER-1000, passive system of residual power removal, passive system of the core flooding under loss-of-coolant accidents, and others. NVAES-2 design refers to a class of advanced light water reactors and corresponds to the international requirements imposed to the nuclear power plants to be put into operation after the year 2000. New V-392 power unit has a good perspective from the view point of extensive implementation in the framework of the nuclear electricity production in Russia. Design decisions on NVAES-2 power unit with WWER-1000/V-392 reactor plant which assure significantly higher safety level and improve economical performance as compared to the operating WWER-1000 units are briefly considered in the present paper. (author)

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

    Science.gov (United States)

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

    2009-01-01

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

  8. Nicotine Significantly Improves Chronic Stress-Induced Impairments of Cognition and Synaptic Plasticity in Mice.

    Science.gov (United States)

    Shang, Xueliang; Shang, Yingchun; Fu, Jingxuan; Zhang, Tao

    2017-08-01

    The aim of this study was to examine if nicotine was able to improve cognition deficits in a mouse model of chronic mild stress. Twenty-four male C57BL/6 mice were divided into three groups: control, stress, and stress with nicotine treatment. The animal model was established by combining chronic unpredictable mild stress (CUMS) and isolated feeding. Mice were exposed to CUMS continued for 28 days, while nicotine (0.2 mg/kg) was also administrated for 28 days. Weight and sucrose consumption were measured during model establishing period. The anxiety and behavioral despair were analyzed using the forced swim test (FST) and open-field test (OFT). Spatial cognition was evaluated using Morris water maze (MWM) test. Following behavioral assessment, both long-term potentiation (LTP) and depotentiation (DEP) were recorded in the hippocampal dentate gyrus (DG) region. Both synaptic and Notch1 proteins were measured by Western. Nicotine increased stressed mouse's sucrose consumption. The MWM test showed that spatial learning and reversal learning in stressed animals were remarkably affected relative to controls, whereas nicotine partially rescued cognitive functions. Additionally, nicotine considerably alleviated the level of anxiety and the degree of behavioral despair in stressed mice. It effectively mitigated the depression-induced impairment of hippocampal synaptic plasticity, in which both the LTP and DEP were significantly inhibited in stressed mice. Moreover, nicotine enhanced the expression of synaptic and Notch1 proteins in stressed animals. The results suggest that nicotine ameliorates the depression-like symptoms and improves the hippocampal synaptic plasticity closely associated with activating transmembrane ion channel receptors and Notch signaling components. Graphical Abstract ᅟ.

  9. Significant improvements in stability and reproducibility of atomic-scale atomic force microscopy in liquid

    International Nuclear Information System (INIS)

    Akrami, S M R; Nakayachi, H; Fukuma, T; Watanabe-Nakayama, T; Asakawa, H

    2014-01-01

    Recent advancement of dynamic-mode atomic force microscopy (AFM) for liquid-environment applications enabled atomic-scale studies on various interfacial phenomena. However, instabilities and poor reproducibility of the measurements often prevent systematic studies. To solve this problem, we have investigated the effect of various tip treatment methods for atomic-scale imaging and force measurements in liquid. The tested methods include Si coating, Ar plasma, Ar sputtering and UV/O 3 cleaning. We found that all the methods provide significant improvements in both the imaging and force measurements in spite of the tip transfer through the air. Among the methods, we found that the Si coating provides the best stability and reproducibility in the measurements. To understand the origin of the fouling resistance of the cleaned tip surface and the difference between the cleaning methods, we have investigated the tip surface properties by x-ray photoelectron spectroscopy and contact angle measurements. The results show that the contaminations adsorbed on the tip during the tip transfer through the air should desorb from the surface when it is immersed in aqueous solution due to the enhanced hydrophilicity by the tip treatments. The tip surface prepared by the Si coating is oxidized when it is immersed in aqueous solution. This creates local spots where stable hydration structures are formed. For the other methods, there is no active mechanism to create such local hydration sites. Thus, the hydration structure formed under the tip apex is not necessarily stable. These results reveal the desirable tip properties for atomic-scale AFM measurements in liquid, which should serve as a guideline for further improvements of the tip treatment methods. (paper)

  10. Significant improvement of accuracy and precision in the determination of trace rare earths by fluorescence analysis

    International Nuclear Information System (INIS)

    Ozawa, L.; Hersh, H.N.

    1976-01-01

    Most of the rare earths in yttrium, gadolinium and lanthanum oxides emit characteristic fluorescent line spectra under irradiation with photons, electrons and x rays. The sensitivity and selectivity of the rare earth fluorescences are high enough to determine the trace amounts (0.01 to 100 ppM) of rare earths. The absolute fluorescent intensities of solids, however, are markedly affected by the synthesis procedure, level of contamination and crystal perfection, resulting in poor accuracy and low precision for the method (larger than 50 percent error). Special care in preparation of the samples is required to obtain good accuracy and precision. It is found that the accuracy and precision for the determination of trace (less than 10 ppM) rare earths by fluorescence analysis improved significantly, while still maintaining the sensitivity, when the determination is made by comparing the ratio of the fluorescent intensities of the trace rare earths to that of a deliberately added rare earth as reference. The variation in the absolute fluorescent intensity remains, but is compensated for by measuring the fluorescent line intensity ratio. Consequently, the determination of trace rare earths (with less than 3 percent error) is easily made by a photoluminescence technique in which the rare earths are excited directly by photons. Accuracy is still maintained when the absolute fluorescent intensity is reduced by 50 percent through contamination by Ni, Fe, Mn or Pb (about 100 ppM). Determination accuracy is also improved for fluorescence analysis by electron excitation and x-ray excitation. For some rare earths, however, accuracy by these techniques is reduced because indirect excitation mechanisms are involved. The excitation mechanisms and the interferences between rare earths are also reported

  11. Fall prevention and safety communication training for foremen: report of a pilot project designed to improve residential construction safety.

    Science.gov (United States)

    Kaskutas, Vicki; Dale, Ann Marie; Lipscomb, Hester; Evanoff, Brad

    2013-02-01

    Falls from heights account for 64% of residential construction worker fatalities and 20% of missed work days. We hypothesized that worker safety would improve with foremen training in fall prevention and safety communication. Training priorities identified through foreman and apprentice focus groups and surveys were integrated into an 8-hour training. We piloted the training with ten foremen employed by a residential builder. Carpenter trainers contrasted proper methods to protect workers from falls with methods observed at the foremen's worksites. Trainers presented methods to deliver toolbox talks and safety messages. Results from worksite observational audits (n=29) and foremen/crewmember surveys (n=97) administered before and after training were compared. We found that inexperienced workers are exposed to many fall hazards that they are often not prepared to negotiate. Fall protection is used inconsistently and worksite mentorship is often inadequate. Foremen feel pressured to meet productivity demands and some are unsure of the fall protection requirements. After the training, the frequency of daily mentoring and toolbox talks increased, and these talks became more interactive and focused on hazardous daily work tasks. Foremen observed their worksites for fall hazards more often. We observed increased compliance with fall protection and decreased unsafe behaviors during worksite audits. Designing the training to meet both foremen's and crewmembers' needs ensured the training was learner-centered and contextually-relevant. This pilot suggests that training residential foremen can increase use of fall protection, improve safety behaviors, and enhance on-the-job training and safety communication at their worksites. Construction workers' training should target safety communication and mentoring skills with workers who will lead work crews. Interventions at multiple levels are necessary to increase safety compliance in residential construction and decrease falls

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

    Science.gov (United States)

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

    2015-01-01

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

  13. 77 FR 18298 - Improvements to the Compliance, Safety, Accountability (CSA) Motor Carrier Safety Measurement...

    Science.gov (United States)

    2012-03-27

    ... safety performance data available through the public Web site http://ai.fmcsa.dot.gov/SMS . Select... that remain to be implemented in future phases include more comprehensive implementation of the full... of future crashes. As part of this effort, FMCSA has been looking at methods for determining crash...

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

    Science.gov (United States)

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

    2015-09-01

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

  15. Flavonol-rich dark cocoa significantly decreases plasma endothelin-1 and improves cognition in urban children.

    Science.gov (United States)

    Calderón-Garcidueñas, Lilian; Mora-Tiscareño, Antonieta; Franco-Lira, Maricela; Cross, Janet V; Engle, Randall; Aragón-Flores, Mariana; Gómez-Garza, Gilberto; Jewells, Valerie; Medina-Cortina, Humberto; Solorio, Edelmira; Chao, Chih-Kai; Zhu, Hongtu; Mukherjee, Partha S; Ferreira-Azevedo, Lara; Torres-Jardón, Ricardo; D'Angiulli, Amedeo

    2013-01-01

    Air pollution exposures are linked to systemic inflammation, cardiovascular and respiratory morbidity and mortality, neuroinflammation and neuropathology in young urbanites. In particular, most Mexico City Metropolitan Area (MCMA) children exhibit subtle cognitive deficits, and neuropathology studies show 40% of them exhibiting frontal tau hyperphosphorylation and 51% amyloid-β diffuse plaques (compared to 0% in low pollution control children). We assessed whether a short cocoa intervention can be effective in decreasing plasma endothelin 1 (ET-1) and/or inflammatory mediators in MCMA children. Thirty gram of dark cocoa with 680 mg of total flavonols were given daily for 10.11 ± 3.4 days (range 9-24 days) to 18 children (10.55 years, SD = 1.45; 11F/7M). Key metabolite ratios in frontal white matter and in hippocampus pre and during cocoa intervention were quantified by magnetic resonance spectroscopy. ET-1 significantly decreased after cocoa treatment (p = 0.0002). Fifteen children (83%) showed a marginally significant individual improvement in one or both of the applied simple short memory tasks. Endothelial dysfunction is a key feature of exposure to particulate matter (PM) and decreased endothelin-1 bioavailability is likely useful for brain function in the context of air pollution. Our findings suggest that cocoa interventions may be critical for early implementation of neuroprotection of highly exposed urban children. Multi-domain nutraceutical interventions could limit the risk for endothelial dysfunction, cerebral hypoperfusion, neuroinflammation, cognitive deficits, structural volumetric detrimental brain effects, and the early development of the neuropathological hallmarks of Alzheimer's and Parkinson's diseases.

  16. Model training across multiple breeding cycles significantly improves genomic prediction accuracy in rye (Secale cereale L.).

    Science.gov (United States)

    Auinger, Hans-Jürgen; Schönleben, Manfred; Lehermeier, Christina; Schmidt, Malthe; Korzun, Viktor; Geiger, Hartwig H; Piepho, Hans-Peter; Gordillo, Andres; Wilde, Peer; Bauer, Eva; Schön, Chris-Carolin

    2016-11-01

    Genomic prediction accuracy can be significantly increased by model calibration across multiple breeding cycles as long as selection cycles are connected by common ancestors. In hybrid rye breeding, application of genome-based prediction is expected to increase selection gain because of long selection cycles in population improvement and development of hybrid components. Essentially two prediction scenarios arise: (1) prediction of the genetic value of lines from the same breeding cycle in which model training is performed and (2) prediction of lines from subsequent cycles. It is the latter from which a reduction in cycle length and consequently the strongest impact on selection gain is expected. We empirically investigated genome-based prediction of grain yield, plant height and thousand kernel weight within and across four selection cycles of a hybrid rye breeding program. Prediction performance was assessed using genomic and pedigree-based best linear unbiased prediction (GBLUP and PBLUP). A total of 1040 S 2 lines were genotyped with 16 k SNPs and each year testcrosses of 260 S 2 lines were phenotyped in seven or eight locations. The performance gap between GBLUP and PBLUP increased significantly for all traits when model calibration was performed on aggregated data from several cycles. Prediction accuracies obtained from cross-validation were in the order of 0.70 for all traits when data from all cycles (N CS  = 832) were used for model training and exceeded within-cycle accuracies in all cases. As long as selection cycles are connected by a sufficient number of common ancestors and prediction accuracy has not reached a plateau when increasing sample size, aggregating data from several preceding cycles is recommended for predicting genetic values in subsequent cycles despite decreasing relatedness over time.

  17. Significantly improving trace thallium removal from surface waters during coagulation enhanced by nanosized manganese dioxide.

    Science.gov (United States)

    Huangfu, Xiaoliu; Ma, Chengxue; Ma, Jun; He, Qiang; Yang, Chun; Jiang, Jin; Wang, Yaan; Wu, Zhengsong

    2017-02-01

    Thallium (Tl) is an element of high toxicity and significant accumulation in human body. There is an urgent need for the development of appropriate strategies for trace Tl removal in drinking water treatment plants. In this study, the efficiency and mechanism of trace Tl (0.5 μg/L) removal by conventional coagulation enhanced by nanosized manganese dioxide (nMnO 2 ) were explored in simulated water and two representative surface waters (a river water and a reservoir water obtained from Northeast China). Experimental results showed that nMnO 2 significantly improve Tl(I) removal from selected waters. The removal efficiency was dramatically higher in the simulated water, demonstrating by less than 0.1 μg/L Tl residual. The enhancement of trace Tl removal in the surface waters decreased to a certain extent. Both adjusting water pH to alkaline condition and preoxidation of Tl(I) to Tl(III) benefit trace Tl removal from surface waters. Data also indicated that competitive cation of Ca 2+ decreased the efficiency of trace Tl removal, resulting from the reduction of Tl adsorption on nMnO 2 . Humic acid could largely low Tl removal efficiency during nMnO 2 enhanced coagulation processes. Trace elemental Tl firstly adsorbed on nMnO 2 and then removed accompanying with nMnO 2 settling. The information obtained in the present study may provide a potential strategy for drinking water treatment plants threatened by trace Tl. Copyright © 2016 Elsevier Ltd. All rights reserved.

  18. Approach to improving safety for TEPCO's nuclear power plants

    International Nuclear Information System (INIS)

    Watanabe, Kunimichi

    2008-01-01

    TEPCO (Tokyo Electric Power Company) has still continued implementing countermeasures to guard against a reoccurrence of incidents in 2002, such as promoting disclosure of information and ensuring transparency of nuclear operations, creating a work environment where proper operations can be carried out, strengthening internal surveillance and reforming the corporate culture and promoting observance of corporate ethics. It is essential to give top priority to safety in nuclear operations and actualize the above properly. Discrepancy resolution management and human errors preventive measures were discussed. Lacks of communications, risk prediction and management will result in human errors related issues to be solved. (T. Tanaka)

  19. Evaluating a smartphone application to improve child passenger safety and fire safety knowledge and behaviour.

    Science.gov (United States)

    Omaki, Elise; Shields, Wendy C; McDonald, Eileen; Aitken, Mary E; Bishai, David; Case, James; Gielen, Andrea

    2017-02-01

    Although proven measures for reducing injury due to motor vehicle collision and residential fires exist, the number of families properly and consistently using child passenger restraints and smoke alarms remains low. This paper describes the design of the Safety In Seconds (SIS) 2.0 study, which aims to evaluate the impact of a smartphone app on parents' use of child restraints and smoke alarms. SIS is a multisite randomised controlled trial. Participants are parents of children aged 4-7 years who are visiting the Pediatric Emergency Department or Pediatric Trauma Service. Parents are randomised to receive tailored education about child passenger safety or about fire safety via the SIS smartphone app. A baseline and two follow-up surveys at 3 months and 6 months are conducted. Primary outcomes are: (1) having the correct child restraint for the child's age and size; (2) restraining the child in the back seat of the car; (3) buckling the child up for every ride; (4) having the restraint inspected by a child passenger safety technician; (5) having a working smoke alarm on every level of the home; (6) having hard-wired or lithium battery smoke alarms; (7) having and (8) practising a fire escape plan. Finding ways to communicate with parents about child passenger and fire safety continues to be a research priority. This study will contribute to the evidence about how to promote benefits of proper and consistent child restraint and smoke alarm use. NCT02345941; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  20. Legacy data sharing to improve drug safety assessment: the eTOX project

    DEFF Research Database (Denmark)

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

    2017-01-01

    The sharing of legacy preclinical safety data among pharmaceutical companies and its integration with other information sources offers unprecedented opportunities to improve the early assessment of drug safety. Here, we discuss the experience of the eTOX project, which was established through...

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

    Science.gov (United States)

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

    2018-04-16

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

  2. 78 FR 55257 - Patient Safety and Quality Improvement: Civil Money Penalty Inflation Adjustment

    Science.gov (United States)

    2013-09-10

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

  3. Significant effect of Ca2+ on improving the heat resistance of lactic acid bacteria.

    Science.gov (United States)

    Huang, Song; Chen, Xiao Dong

    2013-07-01

    The heat resistance of lactic acid bacteria (LAB) has been extensively investigated due to its highly practical significance. Reconstituted skim milk (RSM) has been found to be one of the most effective protectant wall materials for microencapsulating microorganisms during convective drying, such as spray drying. In addition to proteins and carbohydrate, RSM is rich in calcium. It is not clear which component is critical in the RSM protection mechanism. This study investigated the independent effect of calcium. Ca(2+) was added to lactose solution to examine its influence on the heat resistance of Lactobacillus rhamnosus ZY, Lactobacillus casei Zhang, Lactobacillus plantarum P8 and Streptococcus thermophilus ND03. The results showed that certain Ca(2+) concentrations enhanced the heat resistance of the LAB strains to different extents, that is produced higher survival and shorter regrowth lag times of the bacterial cells. In some cases, the improvements were dramatic. More scientifically insightful and more intensive instrumental study of the Ca(2+) behavior around and in the cells should be carried out in the near future. In the meantime, this work may lead to the development of more cost-effective wall materials with Ca(2+) added as a prime factor. © 2013 Federation of European Microbiological Societies. Published by John Wiley & Sons Ltd. All rights reserved.

  4. Targeting Heparin to Collagen within Extracellular Matrix Significantly Reduces Thrombogenicity and Improves Endothelialization of Decellularized Tissues.

    Science.gov (United States)

    Jiang, Bin; Suen, Rachel; Wertheim, Jason A; Ameer, Guillermo A

    2016-12-12

    Thrombosis within small-diameter vascular grafts limits the development of bioartificial, engineered vascular conduits, especially those derived from extracellular matrix (ECM). Here we describe an easy-to-implement strategy to chemically modify vascular ECM by covalently linking a collagen binding peptide (CBP) to heparin to form a heparin derivative (CBP-heparin) that selectively binds a subset of collagens. Modification of ECM with CBP-heparin leads to increased deposition of functional heparin (by ∼7.2-fold measured by glycosaminoglycan composition) and a corresponding reduction in platelet binding (>70%) and whole blood clotting (>80%) onto the ECM. Furthermore, addition of CBP-heparin to the ECM stabilizes long-term endothelial cell attachment to the lumen of ECM-derived vascular conduits, potentially through recruitment of heparin-binding growth factors that ultimately improve the durability of endothelialization in vitro. Overall, our findings provide a simple yet effective method to increase deposition of functional heparin on the surface of ECM-based vascular grafts and thereby minimize thrombogenicity of decellularized tissue, overcoming a significant challenge in tissue engineering of bioartificial vessels and vascularized organs.

  5. Do daily ward interviews improve measurement of hospital quality and safety indicators? A prospective observational study.

    Science.gov (United States)

    Sarkies, Mitchell N; Bowles, Kelly-Ann; Skinner, Elizabeth H; Haas, Romi; Mitchell, Deb; O'Brien, Lisa; May, Kerry; Ghaly, Marcelle; Ho, Melissa; Haines, Terry P

    2016-10-01

    The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems. A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit. An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01). Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety

  6. Significant Improvement in Chronic Persistent Headaches Caused by Small Rathke Cleft Cysts After Transsphenoidal Surgery

    OpenAIRE

    Fukui, Issei; Hayashi, Yasuhiko; Kita, Daisuke; Sasagawa, Yasuo; Oishi, Masahiro; Tachibana, Osamu; Nakada, Mitsutoshi

    2017-01-01

    Purpose Rathke cleft cysts (RCC) usually are asymptomatic and can be observed via the use of conservative methods. Some patients with RCCs, however, have severe headaches even if they are small enough to be confined to the sella, and these small RCCs seldom have been discussed. This study presents an investigation into clinical characteristics of small RCCs associated with severe headaches, demonstrating efficacy and safety of endoscopic transsphenoidal surgery (ETSS) to relieve headaches. Me...

  7. Successful percutaneous coronary intervention significantly improves coronary sinus blood flow as assessed by transthoracic echocardiography.

    Science.gov (United States)

    Lyubarova, Radmila; Boden, William E; Fein, Steven A; Schulman-Marcus, Joshua; Torosoff, Mikhail

    2018-06-01

    Transthoracic echocardiography (TTE) has been used to assess coronary sinus blood flow (CSBF), which reflects total coronary arterial blood flow. Successful angioplasty is expected to improve coronary arterial blood flow. Changes in CSBF after percutaneous coronary intervention (PCI), as assessed by TTE, have not been systematically evaluated. TTE can be utilized to reflect increased CSBF after a successful, clinically indicated PCI. The study cohort included 31 patients (18 females, 62 ± 11 years old) referred for diagnostic cardiac catheterization for suspected coronary artery disease and possible PCI, when clinically indicated. All performed PCIs were successful, with good angiographic outcome. CSBF per cardiac cycle (mL/beat) was measured using transthoracic two-dimensional and Doppler flow imaging as the product of coronary sinus (CS) area and CS flow time-velocity integral. CSBF per minute (mL/min) was calculated as the product of heart rate and CSBF per cardiac cycle. In each patient, CSBF was assessed prospectively, before and after cardiac catheterization with and without clinically indicated PCI. Within- and between-group differences in CSBF before and after PCI were assessed using repeated measures analysis of variance. Technically adequate CSBF measurements were obtained in 24 patients (77%). In patients who did not undergo PCI, there was no significant change in CSBF (278.1 ± 344.1 versus 342.7 ± 248.5, p = 0.36). By contrast, among patients who underwent PCI, CSBF increased significantly (254.3 ± 194.7 versus 618.3 ± 358.5 mL/min, p < 0.01, p-interaction = 0.03). Other hemodynamic and echocardiographic parameters did not change significantly before and after cardiac catheterization in either treatment group. Transthoracic echocardiographic assessment can be employed to document CSBF changes after angioplasty. Future studies are needed to explore the clinical utility of this noninvasive metric.

  8. Efficacy and safety of a novel, soluble microneedle patch for the improvement of facial wrinkle.

    Science.gov (United States)

    Hong, Ji Yeon; Ko, Eun Jung; Choi, Sun Young; Li, Kapsok; Kim, A Reum; Park, Jin O; Kim, Beom Joon

    2018-04-01

    Various kinds of functional cosmetics are on the market, although there are a variety of opinions concerning the actual effect. Transdermal microneedle patch has been introduced as a newly developed device for drug delivery through the skin. This study was conducted to verify the face skin improvement effect and safety of a novel cosmetic microneedle patch. A total of 84 Korean females finished this prospective clinical trial. The subjects were divided into 3 groups: (1) soluble hyaluronic acid (HA) microneedle patch alone, (2) soluble HA microneedle patch plus adenosine wrinkle cream, and (3) adenosine wrinkle cream alone. The treatments were applied to the crow's feet and nasolabial fold wrinkle for 12 weeks. The test areas were measured before treatment and at 4, 8, and 12 weeks after use of the test product. At the completion of the testing period of the trial, the global assessment of efficacy and product preferences were surveyed from the subjects. Combination treatment with wrinkle cream and microneedle patch significantly improved Merz scale for crow's feet and nasolabial folds, compared to the sole application of wrinkle cream or patch. Measurement on the crow's feet showed an overall improvement in all 3 groups, yielding no significant differences among the groups. No serious adverse effects were observed during the follow-up period. Combination application of a soluble microneedle patch and wrinkle cream was an effective treatment in improving facial wrinkles, thus enhancing skin rejuvenation. © 2017 Wiley Periodicals, Inc.

  9. Empirical estimation of school siting parameter towards improving children's safety

    Science.gov (United States)

    Aziz, I. S.; Yusoff, Z. M.; Rasam, A. R. A.; Rahman, A. N. N. A.; Omar, D.

    2014-02-01

    Distance from school to home is a key determination in ensuring the safety of hildren. School siting parameters are made to make sure that a particular school is located in a safe environment. School siting parameters are made by Department of Town and Country Planning Malaysia (DTCP) and latest review was on June 2012. These school siting parameters are crucially important as they can affect the safety, school reputation, and not to mention the perception of the pupil and parents of the school. There have been many studies to review school siting parameters since these change in conjunction with this ever-changing world. In this study, the focus is the impact of school siting parameter on people with low income that live in the urban area, specifically in Johor Bahru, Malaysia. In achieving that, this study will use two methods which are on site and off site. The on site method is to give questionnaires to people and off site is to use Geographic Information System (GIS) and Statistical Product and Service Solutions (SPSS), to analyse the results obtained from the questionnaire. The output is a maps of suitable safe distance from school to house. The results of this study will be useful to people with low income as their children tend to walk to school rather than use transportation.

  10. Applied gis software for improving pedestrian & bicycle safety

    Directory of Open Access Journals (Sweden)

    H. Ziari

    2005-08-01

    Full Text Available People are important in towns. They are the foundation of the social and economic processes that drive the urban system and sustain the urban fabric. While people spend much of their time inside buildings – at home, at work, and at play – it is the movement of people, whether in vehicles or on foot, that is indicative of the vibrancy of the town. Comfort and safety are important for people movement. The crash data in cities, provinces started with the Traffic Organization of Inner Ministry looking at access management controls on functionally classified streets. Safety is a driving factor in access management and the crash reports are the best indicator of the lack of safe roads. This paper presents the development and findings of crash data from police reports and how they are being used in Geographic Information System (GIS. This tool generates a contour map identifying areas of high crash occurrence determined by crash density and clusters of crashes involving pedestrians or bicyclists. Summary statistics of the selected zones can be generated and displayed in a table or chart form.

  11. Improving E-Bike Safety on Urban Highways in China

    Directory of Open Access Journals (Sweden)

    Linjun Lu

    2015-01-01

    Full Text Available This paper aims to examine characteristics of e-bike fatal crashes on urban highways in China. Crash data were retrieved from the three-year crash reports (2010–2012 of Taixing City. Descriptive analysis was conducted to examine characteristics of e-bike riders, drivers, and crashes. The important findings include the following: (1 most fatal crashes were related to e-bike riders’ aberrant driving behaviors, including driving in motorized lanes, red-light running, driving against the direction of traffic, inattentive driving, and drunk driving; (2 e-bike riders with lower educational background tended to perform illegal or inattentive driving behaviors in fatal crashes; (3 most drivers were not found to commit any faults and very few drivers were found to commit drunk driving offences; (4 most nighttime fatal crashes were related to absence of street lightings; (5 heavy good vehicles (HGVs and small passenger cars were the two vehicle types that were mostly involved in the e-bike fatal crashes. This study provides useful information that can help traffic engineers better understand e-bike safety in China and develop safety countermeasures.

  12. Improvement of Level-1 PSA computer code package -A study for nuclear safety improvement-

    International Nuclear Information System (INIS)

    Park, Chang Kyu; Kim, Tae Woon; Ha, Jae Joo; Han, Sang Hoon; Cho, Yeong Kyun; Jeong, Won Dae; Jang, Seung Cheol; Choi, Young; Seong, Tae Yong; Kang, Dae Il; Hwang, Mi Jeong; Choi, Seon Yeong; An, Kwang Il

    1994-07-01

    This year is the second year of the Government-sponsored Mid- and Long-Term Nuclear Power Technology Development Project. The scope of this subproject titled on 'The Improvement of Level-1 PSA Computer Codes' is divided into three main activities : (1) Methodology development on the under-developed fields such as risk assessment technology for plant shutdown and external events, (2) Computer code package development for Level-1 PSA, (3) Applications of new technologies to reactor safety assessment. At first, in the area of PSA methodology development, foreign PSA reports on shutdown and external events have been reviewed and various PSA methodologies have been compared. Level-1 PSA code KIRAP and CCF analysis code COCOA are converted from KOS to Windows. Human reliability database has been also established in this year. In the area of new technology applications, fuzzy set theory and entropy theory are used to estimate component life and to develop a new measure of uncertainty importance. Finally, in the field of application study of PSA technique to reactor regulation, a strategic study to develop a dynamic risk management tool PEPSI and the determination of inspection and test priority of motor operated valves based on risk importance worths have been studied. (Author)

  13. Safety margins in older adults increase with improved control of a dynamic object

    Science.gov (United States)

    Hasson, Christopher J.; Sternad, Dagmar

    2014-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Christopher James Hasson

    2014-07-01

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

  15. Formal testing and utilization of streaming media to improve flight crew safety knowledge.

    Science.gov (United States)

    Bellazzini, Marc A; Rankin, Peter M; Quisling, Jason; Gangnon, Ronald; Kohrs, Mike

    2008-01-01

    Increased concerns over the safety of air medical transport have prompted development of novel ways to increase safety. The objective of our study was to determine if an Internet streaming media safety video increased crew safety knowledge. 23 out of 40 crew members took an online safety pre-test, watched a safety video specific to our program and completed immediate and long-term post-testing 6 months later. Mean pre-test, post-test and 6 month follow up test scores were 84.9%, 92.3% and 88.4% respectively. There was a statistically significant difference in all scores (p Streaming media proved to be an accessible and effective supplement to safety training in our study.

  16. Improving Patient Safety in Hospitals through Usage of Cloud Supported Video Surveillance

    Directory of Open Access Journals (Sweden)

    Predrag Dašić

    2017-03-01

    CONCLUSION: Patient safety is a growing issue which can be improved with the usage of high-end centralised surveillance systems allowing the staff to focus more on treating health issues rather that keeping a watchful eye on potential incidents.

  17. West Virginia Peer Exchange : Streamlining Highway Safety Improvement Program Project Delivery - An RSPCB Peer Exchange

    Science.gov (United States)

    2014-09-01

    The West Virginia Division of Highways (WV DOH) hosted a Peer Exchange to share information and experiences for streamlining Highway Safety Improvement Program (HSIP) project delivery. The event was held September 23 to 24, 2014 in Charleston, West V...

  18. The NPPR Trnava participation in the NPP V-2 modernisation and safety improvement project

    International Nuclear Information System (INIS)

    Michal, V.; Losonsky, B.; Magdolen, J.

    1999-01-01

    The presented contribution deals with form, present state and results of Nuclear Power Plants Research Inst.e participation in the NPP V-2 Jaslovske Bohunice Modernization and Safety Improvement Project.(author)

  19. Application of visualization and simulation program to improve work zone safety and mobility.

    Science.gov (United States)

    2010-01-01

    "A previous study sponsored by the Smart Work Zone Deployment Initiative, Feasibility of Visualization and Simulation Applications to Improve Work Zone Safety and Mobility, demonstrated the feasibility of combining readily available, inexpensiv...

  20. West Virginia peer exchange : streamlining highway safety improvement program project delivery.

    Science.gov (United States)

    2015-01-01

    The West Virginia Division of Highways (WV DOH) hosted a Peer Exchange to share information and experiences : for streamlining Highway Safety Improvement Program (HSIP) project delivery. The event was held September : 22 to 23, 2014 in Charleston, We...

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

    International Nuclear Information System (INIS)

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

    2001-01-01

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

  2. How immediate and significant is the outcome of training on diversified diets, hygiene and food safety? An effort to mitigate child undernutrition in rural Malawi.

    Science.gov (United States)

    Seetha, Anitha; Tsusaka, Takuji W; Munthali, Timalizge W; Musukwa, Maggie; Mwangwela, Agnes; Kalumikiza, Zione; Manani, Tinna; Kachulu, Lizzie; Kumwenda, Nelson; Musoke, Mike; Okori, Patrick

    2018-04-01

    The present study examined the impacts of training on nutrition, hygiene and food safety designed by the Nutrition Working Group, Child Survival Collaborations and Resources Group (CORE). Adapted from the 21d Positive Deviance/Hearth model, mothers were trained on the subjects of appropriate complementary feeding, water, sanitation and hygiene (WASH) practices, and aflatoxin contamination in food. To assess the impacts on child undernutrition, a randomised controlled trial was implemented on a sample of 179 mothers and their children (<2 years old) in two districts of Malawi, namely Mzimba and Balaka. Settings A 21d intensive learning-by-doing process using the positive deviance approach. Malawian children and mothers. Difference-in-difference panel regression analysis revealed that the impacts of the comprehensive training were positive and statistically significant on the Z-scores for wasting and underweight, where the effects increased constantly over time within the 21d time frame. As for stunting, the coefficients were not statistically significant during the 21d programme, although the level of significance started increasing in 2 weeks, indicating that stunting should also be alleviated in a slightly longer time horizon. The study clearly suggests that comprehensive training immediately guides mothers into improved dietary and hygiene practices, and that improved practices take immediate and progressive effects in ameliorating children's undernutrition.

  3. Improving operational safety management through probabilistic safety assessment on personal computers

    International Nuclear Information System (INIS)

    1988-10-01

    The Technical Committee Meeting considered the current effort in the implementation and use of PSA information for day-to-day operational safety management on Personal Computers. Due to the very recent development of the necessary hardware and software for Personal Computers, the application of PSA information for day-to-day operational safety management on PCs is essentially still in a pioneering stage. There is at present only one such system for end users existing, the PRISIM (Plant Risk Status Information Management) program for which a limited practical application experience is available. Others are still in the development stage. The main aim of the Technical Committee Meeting was to discuss the present status of PSA based systems for operational safety management support on small computers, to consider practical aspects when implementing these systems into a nuclear installation and to address problems related to the further work in the area. A separate abstract was prepared for the summary of the Technical Committee Meeting and for the 8 papers presented by the participants. Refs, figs and tabs

  4. Heat storage in forest biomass significantly improves energy balance closure particularly during stable conditions

    Science.gov (United States)

    Lindroth, A.; Mölder, M.; Lagergren, F.

    2009-08-01

    Temperature measurements in trunks and branches in a mature ca. 100 years-old mixed pine and spruce forest in central Sweden were used to estimate the heat storage in the tree biomass. The estimated heat flux in the sample trees and data on biomass distributions were used to scale up to stand level biomass heat fluxes. The rate of change of sensible and latent heat storage in the air layer below the level of the flux measurements was estimated from air temperature and humidity profile measurements and soil heat flux was estimated from heat flux plates and soil temperature measurements. The fluxes of sensible and latent heat from the forest were measured with an eddy covariance system in a tower. The analysis was made for a two-month period in summer of 1995. The tree biomass heat flux was the largest of the estimated storage components and varied between 40 and -35 W m-2 on summer days with nice weather. Averaged over two months the diurnal maximum of total heat storage was 45 W m-2 and the minimum was -35 W m-2. The soil heat flux and the sensible heat storage in air were out of phase with the biomass flux and they reached maximum values that were about 75% of the maximum of the tree biomass heat storage. The energy balance closure improved significantly when the total heat storage was added to the turbulent fluxes. The slope of a regression line with sum of fluxes and storage as independent and net radiation as dependent variable, increased from 0.86 to 0.95 for half-hourly data and the scatter was also reduced. The most significant finding was, however, that during nights with strongly stable conditions when the sensible heat flux dropped to nearly zero, the total storage matched the net radiation nearly perfectly. Another interesting result was that the mean energy imbalance started to increase when the Richardson number became more negative than ca. -0.1. In fact, the largest energy deficit occurred at maximum instability. Our conclusion is that eddy

  5. Structural equation model to investigate the dimensions influencing safety culture improvement in construction sector: A case in Indonesia

    Science.gov (United States)

    Machfudiyanto, Rossy Armyn; Latief, Yusuf; Yogiswara, Yoko; Setiawan, R. Mahendra Fitra

    2017-06-01

    In facing the ASEAN Economic Community, the level of prevailing working accidents becomes one of the competitiveness factors among the companies. A construction industry is one of the industries prone to high level of accidents. Improving the safety record will not be completely effective unless the occupational safety and healthy culture is enhanced. The aim of this research was to develop a model and to conduct empirical investigation on the relationships among the dimensions of construction occupational safety culture. This research used the structural equation model as a means to examine the hypothesis of positive relationships between dimensions and objectives. The method used in this research was questionnaire survey which was distributed to the respondents from construction companies in a state-owned enterprise in Indonesia. Moreover, there were dimensions of occupational safety culture that was established, such as leadership, behavior, value, strategy, policy, process, employee, safety cost, and contract system. The results of this study indicated that all dimensions were significant and inter-related in forming the safety culture. The result of R2 yielded the safety performance was 54%, which means it was in low category and evaluation of policies on construction companies was required in addressing the issue of working accidents.

  6. Safety Performance Improvement for Nuclear Power Plants Utilizing THOMAS

    International Nuclear Information System (INIS)

    Kim, Won June; Ryu, Jung Uk; Suh, Kune Y.

    2005-01-01

    THOMAS (Thermal Hydraulics Online Monitoring Advisory System) is equipped with a couple of salient features compared with existing monitoring systems. The first has to do with the three-dimensional (3D) visualization technique to support the nuclear power plant (NPP) operators and personnel using the virtual reality (VR) technology. VR depicts an environment simulated by a computer. Most of the VR environments primarily include visual experiences, displayed either on a monitor or though special stereoscopic goggles. Users can often interactively manipulate a VR environment, either through standard input devices like a keyboard, or through specially designed devices like a cybergloves. Additional devices were not applied the in THOMAS. The visualized model file is brought to the VR space from the computer-aided design (CAD) tool. In the VR space, using mapping, the component color is changed with linked value of the safety variables. Operators thus can easily recognize the plant condition. This is related with the human factor engineering. The second is the function of decision making using the influence diagram logic. The influence diagram logic is based on the total probability and Bayesian theory. The accident modeling is rooted in the emergency operating procedure (EOP). The final goal of this system is, in the accident situation, to present a success path to the operator for the recovery of the NPP system. At the current developing level, the database signals THOMAS. In other words, a spectrum of system analysis codes provides the safety parameter values to the database, which are subsequently supplied to THOMAS through the network

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-10-15

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

  8. Significant improvement of eczema with skin care and food elimination in small children.

    Science.gov (United States)

    Norrman, Gunilla; Tomicić, Sara; Böttcher, Malin Fagerås; Oldaeus, Göran; Strömberg, Leif; Fälth-magnusson, Karin

    2005-10-01

    To evaluate common methods of investigation and treatment in children younger than 2 y of age with eczema, with or without sensitization to food allergens. One hundred and twenty-three children younger than 2 y of age with eczema and suspected food allergy were included in this prospective study. The children underwent skin-prick test with cow's milk, fresh hen's egg white and wheat. Specific IgE to milk and egg white was analysed. The eczema extent and severity was estimated with SCORAD before and after treatment. Children with a positive skin-prick test were instructed to exclude that food item from their diet. All children were treated with emollients and topical steroids when needed. Sixty-two of the children were skin-prick positive to at least one of the allergens; 62% had mild, 30% moderate and 8% severe eczema at their first visit. After treatment, 90% had mild, 10% moderate and 0% severe eczema. Forty-six per cent of the children had circulating IgE antibodies to milk or egg white. Ten per cent had specific IgE but negative skin-prick test to the same allergen. This subgroup improved their eczema significantly without elimination diet. The conventional treatments for children with eczema, i.e. skin care and food elimination, are effective. The beneficial effect of skin care as the first step should not be neglected, and it may not be necessary to eliminate food allergens to relieve skin symptoms in all food-sensitized children with eczema.

  9. Introduction of e-learning in dental radiology reveals significantly improved results in final examination.

    Science.gov (United States)

    Meckfessel, Sandra; Stühmer, Constantin; Bormann, Kai-Hendrik; Kupka, Thomas; Behrends, Marianne; Matthies, Herbert; Vaske, Bernhard; Stiesch, Meike; Gellrich, Nils-Claudius; Rücker, Martin

    2011-01-01

    Because a traditionally instructed dental radiology lecture course is very time-consuming and labour-intensive, online courseware, including an interactive-learning module, was implemented to support the lectures. The purpose of this study was to evaluate the perceptions of students who have worked with web-based courseware as well as the effect on their results in final examinations. Users (n(3+4)=138) had access to the e-program from any networked computer at any time. Two groups (n(3)=71, n(4)=67) had to pass a final exam after using the e-course. Results were compared with two groups (n(1)=42, n(2)=48) who had studied the same content by attending traditional lectures. In addition a survey of the students was statistically evaluated. Most of the respondents reported a positive attitude towards e-learning and would have appreciated more access to computer-assisted instruction. Two years after initiating the e-course the failure rate in the final examination dropped significantly, from 40% to less than 2%. The very positive response to the e-program and improved test scores demonstrated the effectiveness of our e-course as a learning aid. Interactive modules in step with clinical practice provided learning that is not achieved by traditional teaching methods alone. To what extent staff savings are possible is part of a further study. Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

  10. Mapping Soil Properties of Africa at 250 m Resolution: Random Forests Significantly Improve Current Predictions.

    Directory of Open Access Journals (Sweden)

    Tomislav Hengl

    Full Text Available 80% of arable land in Africa has low soil fertility and suffers from physical soil problems. Additionally, significant amounts of nutrients are lost every year due to unsustainable soil management practices. This is partially the result of insufficient use of soil management knowledge. To help bridge the soil information gap in Africa, the Africa Soil Information Service (AfSIS project was established in 2008. Over the period 2008-2014, the AfSIS project compiled two point data sets: the Africa Soil Profiles (legacy database and the AfSIS Sentinel Site database. These data sets contain over 28 thousand sampling locations and represent the most comprehensive soil sample data sets of the African continent to date. Utilizing these point data sets in combination with a large number of covariates, we have generated a series of spatial predictions of soil properties relevant to the agricultural management--organic carbon, pH, sand, silt and clay fractions, bulk density, cation-exchange capacity, total nitrogen, exchangeable acidity, Al content and exchangeable bases (Ca, K, Mg, Na. We specifically investigate differences between two predictive approaches: random forests and linear regression. Results of 5-fold cross-validation demonstrate that the random forests algorithm consistently outperforms the linear regression algorithm, with average decreases of 15-75% in Root Mean Squared Error (RMSE across soil properties and depths. Fitting and running random forests models takes an order of magnitude more time and the modelling success is sensitive to artifacts in the input data, but as long as quality-controlled point data are provided, an increase in soil mapping accuracy can be expected. Results also indicate that globally predicted soil classes (USDA Soil Taxonomy, especially Alfisols and Mollisols help improve continental scale soil property mapping, and are among the most important predictors. This indicates a promising potential for transferring

  11. Optimized distributed systems achieve significant performance improvement on sorted merging of massive VCF files.

    Science.gov (United States)

    Sun, Xiaobo; Gao, Jingjing; Jin, Peng; Eng, Celeste; Burchard, Esteban G; Beaty, Terri H; Ruczinski, Ingo; Mathias, Rasika A; Barnes, Kathleen; Wang, Fusheng; Qin, Zhaohui S

    2018-06-01

    Sorted merging of genomic data is a common data operation necessary in many sequencing-based studies. It involves sorting and merging genomic data from different subjects by their genomic locations. In particular, merging a large number of variant call format (VCF) files is frequently required in large-scale whole-genome sequencing or whole-exome sequencing projects. Traditional single-machine based methods become increasingly inefficient when processing large numbers of files due to the excessive computation time and Input/Output bottleneck. Distributed systems and more recent cloud-based systems offer an attractive solution. However, carefully designed and optimized workflow patterns and execution plans (schemas) are required to take full advantage of the increased computing power while overcoming bottlenecks to achieve high performance. In this study, we custom-design optimized schemas for three Apache big data platforms, Hadoop (MapReduce), HBase, and Spark, to perform sorted merging of a large number of VCF files. These schemas all adopt the divide-and-conquer strategy to split the merging job into sequential phases/stages consisting of subtasks that are conquered in an ordered, parallel, and bottleneck-free way. In two illustrating examples, we test the performance of our schemas on merging multiple VCF files into either a single TPED or a single VCF file, which are benchmarked with the traditional single/parallel multiway-merge methods, message passing interface (MPI)-based high-performance computing (HPC) implementation, and the popular VCFTools. Our experiments suggest all three schemas either deliver a significant improvement in efficiency or render much better strong and weak scalabilities over traditional methods. Our findings provide generalized scalable schemas for performing sorted merging on genetics and genomics data using these Apache distributed systems.

  12. Cyclosporin A significantly improves preeclampsia signs and suppresses inflammation in a rat model.

    Science.gov (United States)

    Hu, Bihui; Yang, Jinying; Huang, Qian; Bao, Junjie; Brennecke, Shaun Patrick; Liu, Huishu

    2016-05-01

    Preeclampsia is associated with an increased inflammatory response. Immune suppression might be an effective treatment. The aim of this study was to examine whether Cyclosporin A (CsA), an immunosuppressant, improves clinical characteristics of preeclampsia and suppresses inflammation in a lipopolysaccharide (LPS) induced preeclampsia rat model. Pregnant rats were randomly divided into 4 groups: group 1 (PE) rats each received LPS via tail vein on gestational day (GD) 14; group 2 (PE+CsA5) rats were pretreated with LPS (1.0 μg/kg) on GD 14 and were then treated with CsA (5mg/kg, ip) on GDs 16, 17 and 18; group 3 (PE+CsA10) rats were pretreated with LPS (1.0 μg/kg) on GD 14 and were then treated with CsA (10mg/kg, ip) on GDs 16, 17 and 18; group 4 (pregnant control, PC) rats were treated with the vehicle (saline) used for groups 1, 2 and 3. Systolic blood pressure, urinary albumin, biometric parameters and the levels of serum cytokines were measured on day 20. CsA treatment significantly reduced LPS-induced systolic blood pressure and the mean 24-h urinary albumin excretion. Pro-inflammatory cytokines IL-6, IL-17, IFN-γ and TNF-α were increased in the LPS treatment group but were reduced in (LPS+CsA) group (Ppreeclampsia signs and attenuated inflammatory responses in the LPS induced preeclampsia rat model which suggests that immunosuppressant might be an alternative management option for preeclampsia. Copyright © 2016 Elsevier Ltd. All rights reserved.

  13. Parameter definition using vibration prediction software leads to significant drilling performance improvements

    Energy Technology Data Exchange (ETDEWEB)

    Amorim, Dalmo; Hanley, Chris Hanley; Fonseca, Isaac; Santos, Juliana [National Oilwell Varco, Houston TX (United States); Leite, Daltro J.; Borella, Augusto; Gozzi, Danilo [Petroleo Brasileiro S.A. (PETROBRAS), Rio de Janeiro, RJ (Brazil)

    2012-07-01

    The understanding and mitigation of downhole vibration has been a heavily researched subject in the oil industry as it results in more expensive drilling operations, as vibrations significantly diminish the amount of effective drilling energy available to the bit and generate forces that can push the bit or the Bottom Hole Assembly (BHA) off its concentric axis of rotation, producing high magnitude impacts with the borehole wall. In order to drill ahead, a sufficient amount of energy must be supplied by the rig to overcome the resistance of the drilling system, including the reactive torque of the system, drag forces, fluid pressure losses and energy dissipated by downhole vibrations, then providing the bit with the energy required to fail the rock. If the drill string enters resonant modes of vibration, not only does it decreases the amount of available energy to drill, but increases the potential for catastrophic downhole equipment and drilling bit failures. In this sense, the mitigation of downhole vibrations will result in faster, smoother, and cheaper drilling operations. A software tool using Finite Element Analysis (FEA) has been developed to provide better understanding of downhole vibration phenomena in drilling environments. The software tool calculates the response of the drilling system at various input conditions, based on the design of the wellbore along with the geometry of the Bottom Hole Assembly (BHA) and the drill string. It identifies where undesired levels of resonant vibration will be driven by certain combinations of specific drilling parameters, and also which combinations of drilling parameters will result in lower levels of vibration, so the least shocks, the highest penetration rate and the lowest cost per foot can be achieved. With the growing performance of personal computers, complex software systems modeling the drilling vibrations using FEA has been accessible to a wider audience of field users, further complimenting with real time

  14. The state of quality improvement and patient safety teaching in health professional education in New Zealand.

    Science.gov (United States)

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

    2017-10-27

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

  15. Evidence-Based Quality Improvement: A recipe for improving medication safety and handover of care

    NARCIS (Netherlands)

    Smeulers, M.

    2016-01-01

    In healthcare we strive to provide the highest possible quality of care. Even though healthcare professionals work together with the intention to provide safe care, medical errors still threaten patient safety. Patient safety has received considerable attention since the beginning of this century,

  16. Improvement of Safety Features in Standard Operation Procedure of Tc-99m Generator

    International Nuclear Information System (INIS)

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

    2011-01-01

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

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

    International Nuclear Information System (INIS)

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

    2013-01-01

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

  18. Establishing female-only areas in psychiatry wards to improve safety and quality of care for women.

    Science.gov (United States)

    Kulkarni, Jayashri; Gavrilidis, Emmy; Lee, Stuart; Van Rheenen, Tamsyn E; Grigg, Jasmin; Hayes, Emily; Lee, Adeline; Ong, Roy; Seeary, Amy; Andersen, Shelley; Worsley, Rosie; Keppich-Arnold, Sandra; Stafrace, Simon

    2014-12-01

    Our aim was to assess the impact of creating a female-only area within a mixed-gender inpatient psychiatry service, on female patient safety and experience of care. The Alfred hospital reconfigured one of its two psychiatry wards to include a female-only area. Documented incidents compromising the safety of women on each ward in the 6 months following the refurbishment were compared. Further, a questionnaire assessing perceived safety and experience of care was administered to female inpatients on both wards, and staff feedback was also obtained. The occurrence of documented incidents compromising females' safety was found to be significantly lower on the ward containing a female-only area. Women staying on this ward rated their perceived safety and experience of care significantly more positively than women staying where no such gender segregation was available. Further, the female-only area was identified by the majority of surveyed staff to provide a safer environment for female patients. Establishing female-only areas in psychiatry wards is an effective way to improve the safety and experience of care for female patients. © The Royal Australian and New Zealand College of Psychiatrists 2014.

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

    Science.gov (United States)

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

    2017-01-01

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

  20. Waste Minimization Improvements Achieved Through Six Sigma Analysis Result In Significant Cost Savings

    International Nuclear Information System (INIS)

    Mousseau, Jeffrey D.; Jansen, John R.; Janke, David H.; Plowman, Catherine M.

    2003-01-01

    Improved waste minimization practices at the Department of Energy's (DOE) Idaho National Engineering and Environmental Laboratory (INEEL) are leading to a 15% reduction in the generation of hazardous and radioactive waste. Bechtel, BWXT Idaho, LLC (BBWI), the prime management and operations contractor at the INEEL, applied the Six Sigma improvement process to the INEEL Waste Minimization Program to review existing processes and define opportunities for improvement. Our Six Sigma analysis team: composed of an executive champion, process owner, a black belt and yellow belt, and technical and business team members used this statistical based process approach to analyze work processes and produced ten recommendations for improvement. Recommendations ranged from waste generator financial accountability for newly generated waste to enhanced employee recognition programs for waste minimization efforts. These improvements have now been implemented to reduce waste generation rates and are producing positive results

  1. 16 CFR 1500.88 - Exemptions from lead limits under section 101 of the Consumer Product Safety Improvement Act for...

    Science.gov (United States)

    2010-01-01

    ... 101 of the Consumer Product Safety Improvement Act for certain electronic devices. 1500.88 Section... from lead limits under section 101 of the Consumer Product Safety Improvement Act for certain electronic devices. (a) The Consumer Product Safety Improvement Act (CPSIA) provides for specific lead limits...

  2. Evaluation of intestinal phosphate binding to improve the safety profile of oral sodium phosphate bowel cleansing.

    Directory of Open Access Journals (Sweden)

    Stef Robijn

    Full Text Available Prior to colonoscopy, bowel cleansing is performed for which frequently oral sodium phosphate (OSP is used. OSP results in significant hyperphosphatemia and cases of acute kidney injury (AKI referred to as acute phosphate nephropathy (APN; characterized by nephrocalcinosis are reported after OSP use, which led to a US-FDA warning. To improve the safety profile of OSP, it was evaluated whether the side-effects of OSP could be prevented with intestinal phosphate binders. Hereto a Wistar rat model of APN was developed. OSP administration (2 times 1.2 g phosphate by gavage with a 12h time interval induced bowel cleansing (severe diarrhea and significant hyperphosphatemia (21.79 ± 5.07 mg/dl 6h after the second OSP dose versus 8.44 ± 0.97 mg/dl at baseline. Concomitantly, serum PTH levels increased fivefold and FGF-23 levels showed a threefold increase, while serum calcium levels significantly decreased from 11.29 ± 0.53 mg/dl at baseline to 8.68 ± 0.79 mg/dl after OSP. OSP administration induced weaker NaPi-2a staining along the apical proximal tubular membrane. APN was induced: serum creatinine increased (1.5 times baseline and nephrocalcinosis developed (increased renal calcium and phosphate content and calcium phosphate deposits on Von Kossa stained kidney sections. Intestinal phosphate binding (lanthanum carbonate or aluminum hydroxide was not able to attenuate the OSP induced side-effects. In conclusion, a clinically relevant rat model of APN was developed. Animals showed increased serum phosphate levels similar to those reported in humans and developed APN. No evidence was found for an improved safety profile of OSP by using intestinal phosphate binders.

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

    Science.gov (United States)

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

    2015-01-01

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

  4. A simple intervention to improve patient safety, save time and improve staff experience in the AMU procedure room.

    Science.gov (United States)

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

    2016-01-01

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

  5. Steam Pressure-Reducing Station Safety and Energy Efficiency Improvement Project

    Energy Technology Data Exchange (ETDEWEB)

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

    2011-06-01

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