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Sample records for incident reporting system

  1. 49 CFR 191.9 - Distribution system: Incident report.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 3 2010-10-01 2010-10-01 false Distribution system: Incident report. 191.9... CONDITION REPORTS § 191.9 Distribution system: Incident report. (a) Except as provided in paragraph (c) of this section, each operator of a distribution pipeline system shall submit Department of...

  2. 49 CFR 191.9 - Distribution system: Incident report.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 3 2011-10-01 2011-10-01 false Distribution system: Incident report. 191.9... CONDITION REPORTS § 191.9 Distribution system: Incident report. (a) Except as provided in paragraph (c) of this section, each operator of a distribution pipeline system shall submit Department of...

  3. Early Warning: Development of Confidential Incident Reporting Systems

    NASA Technical Reports Server (NTRS)

    OLeary, Mike J.; Chappell, Sheryl L.; Connell, Linda (Technical Monitor)

    1996-01-01

    Accidents hardly ever happen without warning. The combination, or sequence, of failures and mistakes that cause an accident may indeed be unique but the individual failures and mistakes rarely are. In the USA in 1974 the crews on two different aircraft misunderstood the same aeronautical chart and descended towards their destination dangerously early towards a mountain. The first crew were in good weather conditions and could see the mountain and resolved their misinterpretation of the chart. The second crew six weeks later were not so lucky. In cloud they had no clues to point out their mistake nor the presence of the mountain. The resulting crash and the ensuing inquiry, which brought to light the previous incident, shocked the country but gave it the impetus to instigate a safety reporting system. This system eventually became the NASA's Aviation Safety Reporting System (ASRS). The programme collects incident reports from pilots, controllers, mechanics, cabin attendants and many others involved in aviation operations. By disseminating this safety information the ASRS has helped enormously to give US airlines and airspace the highest safety standards. Accident prevention is a goal sought by everyone in the aviation industry and establishing effective incident reporting programmes can go a long way toward achieving that goal. This article will describe the steps and issues required to establish an incident reporting system. The authors summarize the lessons learned from the ASRS, now in its twentieth year of operation and from the Confidential Human Factors Reporting (HER) Programme run by British Airways, an airline that is a recognized world leader in safety reporting and analysis. The differences between government and airline operation of confidential safety reporting systems will be addressed.

  4. What to do With Healthcare Incident Reporting Systems

    PubMed Central

    Pham, Julius Cuong; Girard, Thierry; Pronovost, Peter J.

    2013-01-01

    Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems. These limitations include: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don’t generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. IRS do offer significant value; their value is found in the following: i) IRS can be used to identify local system hazards; ii) IRS can be used to aggregate experiences for uncommon conditions; iii) IRS can be used to share lessons within and across organizations; iv) IRS can be used to increase patient safety culture. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, report and investigate them well; v) convene with diverse stakeholders to enhance the value of IRS. Significance for public health Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. However, they are not the panacea that many believe them to be. They have several limitations that should be considered when utilizing them or interpreting their output: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS

  5. Establishing national medical imaging incident reporting systems: issues and challenges.

    PubMed

    Jones, D Neil; Benveniste, Klee A; Schultz, Timothy J; Mandel, Catherine J; Runciman, William B

    2010-08-01

    Radiology incident reporting systems provide one source of invaluable patient safety data that, when combined with appropriate analysis and action, can result in significantly safer health care, which is now an urgent priority for governments worldwide. Such systems require integration into a wider safety, quality, and risk management framework because many issues have global implications, and they also require an international classification scheme, which is now being developed. These systems can be used to inform global research activities as identified by the World Health Organization, many of which intersect with the activities of and issues seen in medical imaging departments. How to ensure that radiologists (and doctors in general) report incidents, and are engaged in the process, is a challenge. However, as demonstrated with the example of the Australian Radiology Events Register, this can be achieved when the reporting system is integrated with their professional organization and its other related activities (such as training and education) and administered by a patient safety organization. PMID:20678728

  6. [Incident-reporting electronic-based system in internal medicine].

    PubMed

    Servet, J; Bart, P-A; Wasserfallen, J-B; Castioni, J

    2015-11-01

    How to recognize, announce and analyze incidents in internal medicine units is a daily challenge that is taught to all hospital staff. It allows suggesting useful improvements for patients, as well as for the medical department and the institution. Here is presented the assessment made in the CHUV internal medicine department one year after the beginning of the institutional procedure which promotes an open process regarding communication and risk management. The department of internal medicine underlines the importance of feedback to the reporters, ensures the staff of regular follow-up concerning the measures being taken and offers to external reporters such as general practioners the possibility of using this reporting system too. PMID:26685652

  7. EMS helicopter incidents reported to the NASA Aviation Safety Reporting System

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.; Reynard, William D.

    1993-01-01

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

  8. 49 CFR 191.15 - Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations... OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE...; gathering systems; and liquefied natural gas facilities: Incident report. (a) Transmission or...

  9. 49 CFR 191.15 - Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations... OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE...; gathering systems; and liquefied natural gas facilities: Incident report. (a) Transmission or...

  10. 49 CFR 191.15 - Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations... OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE...; gathering systems; and liquefied natural gas facilities: Incident report. (a) Transmission or...

  11. 49 CFR 191.15 - Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations... OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE...; gathering systems; and liquefied natural gas facilities: Incident report. (a) Transmission or...

  12. The development of an incident event reporting system for nursing students.

    PubMed

    Chiou, Shwu-Fen; Huang, Ean-Wen; Chuang, Jen-Hsiang

    2009-01-01

    Incident events may occur when nursing students are present in the clinical setting. Their inexperience and unfamiliarity with clinical practice put them at risk for making mistakes that could potentially harm patients and themselves. However, there are deficiencies with incident event reporting systems, including incomplete data and delayed reports. The purpose of this study was to develop an incident event reporting system for nursing students in clinical settings and evaluate its effectiveness. This study was undertaken in three phases. In the first phase, a literature review and focus groups were used to develop the architecture of the reporting system. In the second phase, the reporting system was implemented. Data from incident events that involved nursing students were collected for a 12-month period. In the third phase, a pre-post trial was undertaken to evaluate the performance of the reporting system. The ASP.NET software and Microsoft Access 2003 were used to create an interactive web-based interface and design a database for the reporting system. Email notifications alerted the nursing student's teacher when an incident event was reported. One year after installing the reporting system, the number of reported incident events increased tenfold. However, the time to report the incident event and the time required to complete the reporting procedures were shorter than before implementation of the reporting system. The incident event reporting system appeared to be effective in more comprehensively reporting the number of incident events and shorten the time required for reporting them compared to traditional written reports. PMID:19592912

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

    NASA Technical Reports Server (NTRS)

    McGreevy, Michael W.

    1996-01-01

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

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

    SciTech Connect

    Kakinohana, Y; Toita, T; Heianna, J; Murayama, S

    2015-06-15

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

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

    PubMed Central

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

    2014-01-01

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

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

    SciTech Connect

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

    2013-03-15

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

  17. Learning from defects using a comprehensive management system for incident reports in critical care.

    PubMed

    Arabi, Y M; Al Owais, S M; Al-Attas, K; Alamry, A; AlZahrani, K; Baig, B; White, D; Deeb, A M; Al-Dozri, H D; Haddad, S; Tamim, H M; Taher, S

    2016-03-01

    Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety. PMID:27029653

  18. 49 CFR 191.15 - Transmission and gathering systems: Incident report.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 3 2010-10-01 2010-10-01 false Transmission and gathering systems: Incident...-RELATED CONDITION REPORTS § 191.15 Transmission and gathering systems: Incident report. (a) Except as provided in paragraph (c) of this section, each operator of a transmission or a gathering pipeline...

  19. Surface Movement Incidents Reported to the NASA Aviation Safety Reporting System

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.; Hubener, Simone

    1997-01-01

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

  20. Do we need a national incident reporting system for medical imaging?

    PubMed

    Itri, Jason N; Krishnaraj, Arun

    2012-05-01

    The essential role of an incident reporting system as a tool to improve safety and reliability has been described in high-risk industries such as aviation and nuclear power, with anesthesia being the first medical specialty to successfully integrate incident reporting into a comprehensive quality improvement strategy. Establishing an incident reporting system for medical imaging that effectively captures system errors and drives improvement in the delivery of imaging services is a key component of developing and evaluating national quality improvement initiatives in radiology. Such a national incident reporting system would be most effective if implemented as one piece of a comprehensive quality improvement strategy designed to enhance knowledge about safety, identify and learn from errors, raise standards and expectations for improvement, and create safer systems through implementation of safe practices. The potential benefits of a national incident reporting system for medical imaging include reduced morbidity and mortality, improved patient and referring physician satisfaction, reduced health care expenses and medical liability costs, and improved radiologist satisfaction. The purposes of this article are to highlight the positive impact of external reporting systems, discuss how similar advancements in quality and safety can be achieved with an incident reporting system for medical imaging in the United States, and describe current efforts within the imaging community toward achieving this goal. PMID:22554630

  1. [The critical incident reporting system as an instrument of risk management for better patient safety].

    PubMed

    Panzica, M; Krettek, C; Cartes, M

    2011-09-01

    The probability that an inpatient will be harmed by a medical procedure is at least 3% of all patients. As a consequence, hospital risk management has become a central management task in the health care sector. The critical incident reporting system (CIRS) as a voluntary instrument for reporting (near) incidents plays a key role in the implementation of a risk management system. The goal of the CIRS is to register system errors without assigning guilt or meting out punishment and at the same time increasing the number of voluntary reports. PMID:21877221

  2. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system

    PubMed Central

    Westbrook, Johanna I.; Li, Ling; Lehnbom, Elin C.; Baysari, Melissa T.; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O.

    2015-01-01

    Objectives To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Design Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’. Setting Two major academic teaching hospitals in Sydney, Australia. Main Outcome Measures Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. Results A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Conclusions Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and

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

    SciTech Connect

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

    2014-06-01

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

  4. Adult Perpetrator Gender Asymmetries in Child Sexual Assault Victim Selection: Results from the 2000 National Incident-Based Reporting System

    ERIC Educational Resources Information Center

    McCloskey, Kathy A.; Raphael, Desreen N.

    2005-01-01

    Data from the 2000 National Incident-Based Reporting System (NIBRS) show that while males make up about nine out of every 10 adult sexual assault perpetrators, totaling about 26,878 incidents within the reporting period, females account for about one out of 10 perpetrators, totaling about 1,162 incidents. Male sexual assault perpetrators offend…

  5. The implementation and utility of fire incident reporting systems: the Delaware experience.

    PubMed

    Bergen, Gwendolyn; Frattaroli, Shannon; Ballesteros, Michael F; Ta, Van M; Beach, Crystal; Gielen, Andrea C

    2008-04-01

    Fires and burns are the fifth most common cause of unintentional injury deaths in the United States. To address fires and fire deaths, the National Fire Data Center (NFDC) established the National Fire Incident Reporting System (NFIRS) as a surveillance system for fires. Delaware implemented NFIRS as the Delaware Fire Incident Reporting System (DFIRS), and is currently capturing all fires reported in the system. The objectives of this study are to: 1) understand the implementation of DFIRS; 2) analyze data from DFIRS to describe fire incidents; and 3) inform other states' fire surveillance efforts. We interviewed Delaware State Fire Marshal's Office personnel to understand the implementation of DFIRS and analyzed DFIRS data from May 2003 to December 2004 to examine data completeness, and characteristics of fires, smoke alarms, and fire injuries and deaths. DFIRS captures 100% of Delaware fires reported to fire departments. Data completeness for the fields examined ranged from 33% to 100%. Fires in which smoke alarms alerted occupants were significantly less likely to result in injury or death than fires in which smoke alarms did not. DFIRS has the potential to serve as a valuable fire prevention and fire analysis tool. For DFIRS to reach its full potential as a surveillance system, increased attention to data completeness is necessary. PMID:18074209

  6. Improving patient safety incident reporting systems by focusing upon feedback - lessons from English and Welsh trusts.

    PubMed

    Wallace, Louise M; Spurgeon, Peter; Benn, Jonathan; Koutantji, Maria; Vincent, Charles

    2009-08-01

    This paper describes practical implications and learning from a multi-method study of feedback from patient safety incident reporting systems. The study was performed using the Safety Action and Information Feedback from Incident Reporting model, a model of the requirements of the feedback element of a patient safety incident reporting and learning system, derived from a scoping review of research and expert advice from world leaders in safety in high-risk industries. We present the key findings of the studies conducted in the National Health Services (NHS) trusts in England and Wales in 2006. These were a survey completed by risk managers for 351 trusts in England and Wales, three case studies including interviews with staff concerning an example of good practice feedback and an audit of 90 trusts clinical risk staff newsletters. We draw on an Expert Workshop that included 71 experts from the NHS, from regulatory bodies in health care, Royal Colleges, Health and Safety Executive and safety agencies in health care and high-risk industries (commercial aviation, rail and maritime industries). We draw recommendations of enduring relevance to the UK NHS that can be used by trust staff to improve their systems. The recommendations will be of relevance in general terms to health services worldwide. PMID:19633181

  7. Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study

    PubMed Central

    Şalvız, Emine Aysu; Edipoğlu, Saadet İpek; Sungur, Mukadder Orhan; Altun, Demet; Büget, Mehmet İlke; Seyhan, Tülay Özkan

    2016-01-01

    Objective Critical incident reporting systems (CIRS) and morbidity–mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents. Methods One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists’ knowledge, experience and attitudes regarding CIs. Results Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as “an unexpected /accidental event” was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in 60.5% of hospitals. Nevertheless, 96% of anaesthetists believe that CIRS and MMMs decrease the incidence of CI occurring. CI occurrence was attributed to human error as 4 [1–5]/10 and 3 [1–5]/10 in UHs and TRHs, respectively (p=0.005). In both hospital types, technical errors were evaluated as 3 [1–5]/10 (p=0.498). Conclusion This first study regarding CIRS in the Turkish anaesthesia departments/hospitals highlights the lack of CI knowledge and CIRS awareness and use in anaesthesia departments/teaching hospitals in Turkey despite a safety reporting system set up by the Turkish Ministry of Health. PMID:27366560

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

    PubMed Central

    2011-01-01

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

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

    NASA Technical Reports Server (NTRS)

    Withrow, Colleen A.; Reveley, Mary S.

    2014-01-01

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

  10. Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

    PubMed Central

    Pham, Julius Cuong; Williams, Tamara L; Sparnon, Erin M; Cillie, Tam K; Scharen, Hilda F; Marella, William M

    2016-01-01

    BACKGROUND: In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. METHODS: We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. RESULTS: A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. CONCLUSIONS: Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of

  11. Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

    PubMed Central

    2014-01-01

    Objective A few cases of adverse reactions linked to erroneous use of transdermal opioid patches have been reported in the literature. The aim of this study was to describe and characterize medication errors (MEs) associated with use of transdermal fentanyl and buprenorphine. Methods All events concerning transdermal opioid patches reported between 2004 and 2011 to a regional incident reporting system and assessed as MEs were scrutinized and characterized. MEs were defined as “a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient”. Results In the study 151 MEs were identified. The three most common error types were wrong administration time 67 (44%), wrong dose 34 (23%), and omission of dose 20 (13%). Of all MEs, 118 (78%) occurred in the administration stage of the medication process. Harm was reported in 26 (17%) of the included cases, of which 2 (1%) were regarded as serious harm (nausea/vomiting and respiratory depression). Pain was the most common adverse reaction reported. Conclusions Of the reported MEs related to transdermal fentanyl and buprenorphine, most occurred during administration. Improved routines to ascertain correct and timely administration and educational interventions to reduce MEs for these drugs are warranted. PMID:24912424

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

    SciTech Connect

    Briscoe, G.J.

    1993-06-07

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

  13. Cyber Incidents Involving Control Systems

    SciTech Connect

    Robert J. Turk

    2005-10-01

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

  14. Enhancing the National Incident-Based Reporting System: A Policy Proposal.

    PubMed

    Bierie, David M

    2015-09-01

    The National Incident-Based Reporting System (NIBRS) is an important data set serving social scientists, policy makers, the business community, and the press. However, it is hampered by low participation rates among the nation's police agencies. This article outlines a strategy for enhancing NIBRS by (a) providing police agencies free and supported software to extract and transmit an agency's Record Management System (RMS) data in NIBRS format (or a data-entry system if an RMS does not exist), (b) including personal identifiers of arrestees, and (c) allowing police agencies to access the national data for routine police work. The article describes how taking these steps would decrease the costs of implementing and maintaining NIBRS, encourage widespread adoption, and increase data quality. These enhancements could foster substantial improvements in policing as well as other aspects of the criminal justice system. These changes would also open up new and exciting areas for academics and analysts, including the ability to study criminal careers over time as well as criminal networks within NIBRS. PMID:24618875

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

    NASA Technical Reports Server (NTRS)

    Withrow, Colleen A.; Reveley, Mary S.

    2014-01-01

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

  16. Adverse incident reporting in intensive care.

    PubMed

    Hart, G K; Baldwin, I; Gutteridge, G; Ford, J

    1994-10-01

    This prospective, observational, anonymous incident reporting study aimed to identify and correct factors leading to reduced patient safety in intensive care. An incident was any event which caused or had the potential to cause harm to the patient, but included problems in policy or procedure. Reports were discussed at monthly meetings. Of 390 incidents, 106 occasioned "actual" harm and 284 "potential" harm. There was one death, 86 severe complications and 88 complications of minor severity. Most were transient but the effects of 24 lasted up to a week. Most incidents affected cardiovascular and respiratory systems. Incident categories involved drugs, equipment, management or procedures. Incident causes were knowledge-based, rule-based, technical, slip/lapse, no error or unclassifiable. The study has identified some human and equipment performance problems in our intensive care unit. Correction of these should lead to a reduction in the future incidence of those events and hence an increased level of patient safety. PMID:7818059

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

    PubMed Central

    2015-01-01

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

  18. A safety incident reporting system for primary care. A systematic literature review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

    PubMed Central

    Klemp, Kerstin; Zwart, Dorien; Hansen, Jørgen; Hellebek, Torben; Luettel, Dagmar; Verstappen, Wim; Beyer, Martin; Gerlach, Ferdin M.; Hoffmann, Barbara; Esmail, Aneez

    2015-01-01

    Background: Incident reporting is widely used in both patient safety improvement programmes, and in research on patient safety. Objective: To identify the key requirements for incident reporting systems in primary care; to develop an Internet-based incident reporting and learning system for primary care. Methods: A literature review looking at the purpose, design and requirements of an incident reporting system (IRS) was used to update an existing incident reporting system, widely used in Germany. Then, an international expert panel with knowledge on IRS developed the criteria for the design of a new web-based incident reporting system for European primary care. A small demonstration project was used to create a web-based reporting system, to be made freely available for practitioners and researchers. The expert group compiled recommendations regarding the desirable features of an incident reporting system for European primary care. These features covered the purpose of reporting, who should be involved in reporting, the mode of reporting, design considerations, feedback mechanisms and preconditions necessary for the implementation of an IRS. Results: A freely available web-based reporting form was developed, based on these criteria. It can be modified for local contexts. Practitioners and researchers can use this system as a means of recording patient safety incidents in their locality and use it as a basis for learning from errors. Conclusion: The LINNEAUS collaboration has provided a freely available incident reporting system that can be modified for a local context and used throughout Europe. PMID:26339835

  19. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

    PubMed Central

    Cousins, David H; Gerrett, David; Warner, Bruce

    2012-01-01

    A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1 January 2005 and 31 December 2010 was undertaken. The 526 186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394 951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44 952) from primary care, representing 8.5% of the total. Of 86 821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263 228; 50%) and prescribing (97 097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82 028; 16%) and wrong dose (80 170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance. PMID:22188210

  20. Medication incidents in primary care medicine: protocol of a study by the Swiss Federal Sentinel Reporting System

    PubMed Central

    Gnädinger, Markus; Ceschi, Alessandro; Conen, Dieter; Herzig, Lilli; Puhan, Milo; Staehelin, Alfred; Zoller, Marco

    2015-01-01

    Background/rationale Patient safety is a major concern in healthcare systems worldwide. Although most safety research has been conducted in the inpatient setting, evidence indicates that medical errors and adverse events are a threat to patients in the primary care setting as well. Since information about the frequency and outcomes of safety incidents in primary care is required, the goals of this study are to describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Methods and analysis Study design and setting: We will conduct a prospective surveillance study to identify cases of medication incidents among primary care patients in Switzerland over the course of the year 2015. Participants: Patients undergoing drug treatment by 167 general practitioners or paediatricians reporting to the Swiss Federal Sentinel Reporting System. Inclusion criteria: Any erroneous event, as defined by the physician, related to the medication process and interfering with normal treatment course. Exclusion criteria: Lack of treatment effect, adverse drug reactions or drug–drug or drug–disease interactions without detectable treatment error. Primary outcome: Medication incidents. Risk factors: Age, gender, polymedication, morbidity, care dependency, hospitalisation. Statistical Analysis: Descriptive statistics to assess type, frequency, seasonal and regional distribution of medication incidents and logistic regression to assess their association with potential risk factors. Estimated sample size: 500 medication incidents. Limitations: We will take into account under-reporting and selective reporting among others as potential sources of bias or imprecision when interpreting the results. Ethics and dissemination No formal request was necessary because of fully anonymised data. The results will be published in a peer-reviewed journal. Trial registration number

  1. National Incident Management System (NIMS) Standards Review Panel Workshop Summary Report

    SciTech Connect

    Stenner, Robert D.; Kirk, Jennifer L.; Stanton, James R.; Shebell, Peter; Schwartz, Deborah S.; Judd, Kathleen S.; Gelston, Gariann M.

    2006-02-07

    The importance and need for full compliant implementation of NIMS nationwide was clearly demonstrated during the Hurricane Katrina event, which was clearly expressed in Secretary Chertoff's October 4, 2005 letter addressed to the State's governors. It states, ''Hurricane Katrina was a stark reminder of how critical it is for our nation to approach incident management in a coordinated, consistent, and efficient manner. We must be able to come together, at all levels of government, to prevent, prepare for, respond to, and recover from any emergency or disaster. Our operations must be seamless and based on common incident management doctrine, because the challenges we face as a nation are far greater than capabilities of any one jurisdiction.'' The NIMS is a system/architecture for organizing response on a ''national'' level. It incorporations ICS as a main component of that structure (i.e., it institutionalizes ICS in NIMS). In a paper published on the NIMS Website, the following statements were made: ''NIMS represents a core set of doctrine, principles, terminology, and organizational processes to enable effective, efficient and collaborative incident management at all levels. To provide the framework for interoperability and compatibility, the NIMS is based on a balance between flexibility and standardization.'' Thus the NIC is challenged with the need to adopt quality SDO generated standards to support NIMS compliance, but in doing so maintain the flexibility necessary so that response operations can be tailored for the specific jurisdictional and geographical needs across the nation. In support of this large and complex challenge facing the NIC, the Pacific Northwest National Laboratory (PNNL) was asked to provide technical support to the NIC, through their DHS Science and Technology ? Standards Portfolio Contract, to help identify, review, and develop key standards for NIMS compliance. Upon examining the challenge, the following general process appears to be a

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

    NASA Technical Reports Server (NTRS)

    Bergeron, H. P.

    1983-01-01

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

  3. Analysis of general aviation single-pilot IFR incident data obtained from the NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    Bergeron, H. P.

    1980-01-01

    Data obtained from the NASA Aviation Safety Reporting System (ASRS) data base were used to determine problems in general aviation single pilot IFR operations. The data examined consisted of incident reports involving flight safety in the National Aviation System. Only those incidents involving general aviation fixed wing aircraft flying under IFR in instrument meteorological conditions were analyzed. The data were cataloged into one of five major problem areas: (1) controller judgement and response problems; (2) pilot judgement and response problems; (3) air traffic control intrafacility and interfacility conflicts; (4) ATC and pilot communications problems; and (5) IFR-VFR conflicts. The significance of the related problems, and the various underlying elements associated with each are discussed. Previous ASRS reports covering several areas of analysis are reviewed.

  4. Major incident in Kent: a case report.

    PubMed

    Hardy, Sophie Elizabeth Jap

    2015-01-01

    A major incident was declared after a road traffic accident involving 150 cars and 200 people in Kent, England. The emergency services oversaw coordination of the scene, recovery and triage of casualties and transfer of patients to hospital. The crash was one of the worst seen on British roads and it has been hailed as a miracle that there were no deaths and very few serious injuries.This case report is a retrospective analysis of the regional health system's response to the crash. The structure is based on the content of a report submitted using an online open access template for major incident reporting (Scand J Trauma Resusc Emerg Med 22: 5, 2014; http://www.majorincidentreporting.org ). A more comprehensive analysis of the incident has also been the theme of a Masters thesis (Hardy S. Reporting Major Incidents in England: Putting Theory into Practice. England: Queen Mary's University of London; 2014). PMID:26391879

  5. Adult perpetrator gender asymmetries in child sexual assault victim selection: results from the 2000 National Incident-Based Report System.

    PubMed

    McCloskey, Kathy A; Raphael, Desreen N

    2005-01-01

    Data from the 2000 National Incident-Based Reporting System (NIBRS) show that while males make up about nine out of every 10 adult sexual assault perpetrators, totaling about 26,878 incidents within the reporting period, females account for about one out of 10 perpetrators, totaling about 1,162 incidents. Male sexual assault perpetrators offend against child victims about 25% of the time and predominantly choose female child victims, whereas female perpetrators offend against child victims about 40% of the time and choose child victims of both genders equally. Male perpetrators offend against adolescent victims about 40% of the time, and once again tend to choose female adolescent victims. Female perpetrators offend against adolescent victims a comparable amount of time (about 45%), and for forcible offenses (rape, sodomy, sexual assault with an object, and forcible fondling) choose adolescent victims of both genders equally, while for non-forcible offenses (non-forcible incest and statutory rape) they tend to choose predominantly male victims. Finally, adult male sexual assault perpetrators choose adult victims about 36% of the time while female perpetrators choose adult victims only 16% of the time. Implications for professionals are discussed, including recommendations to aid in correct identification of adult perpetrators and child/adolescent victims of sexual assault. PMID:16354646

  6. Care Staff Perceptions of Choking Incidents: What Details Are Reported?

    ERIC Educational Resources Information Center

    Guthrie, Susan; Lecko, Caroline; Roddam, Hazel

    2015-01-01

    Background: Following a series of fatal choking incidents in one UK specialist service, this study evaluated the detail included in incident reporting. This study compared the enhanced reporting system in the specialist service with the national reporting and learning system. Methods: Eligible reports were selected from a national organization and…

  7. German critical incident reporting system database of prehospital emergency medicine: Analysis of reported communication and medication errors between 2005–2015

    PubMed Central

    Hohenstein, Christian; Fleischmann, Thomas; Rupp, Peter; Hempel, Dorothea; Wilk, Sophia; Winning, Johannes

    2016-01-01

    BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors. METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all. RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classification resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure. CONCLUSION: Communication deficits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety. PMID:27313802

  8. Semantic Theme Analysis of Pilot Incident Reports

    NASA Technical Reports Server (NTRS)

    Thirumalainambi, Rajkumar

    2009-01-01

    Pilots report accidents or incidents during take-off, on flight and landing to airline authorities and Federal aviation authority as well. The description of pilot reports for an incident contains technical terms related to Flight instruments and operations. Normal text mining approaches collect keywords from text documents and relate them among documents that are stored in database. Present approach will extract specific theme analysis of incident reports and semantically relate hierarchy of terms assigning weights of themes. Once the theme extraction has been performed for a given document, a unique key can be assigned to that document to cross linking the documents. Semantic linking will be used to categorize the documents based on specific rules that can help an end-user to analyze certain types of accidents. This presentation outlines the architecture of text mining for pilot incident reports for autonomous categorization of pilot incident reports using semantic theme analysis.

  9. Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents

    PubMed Central

    2011-01-01

    Background Even though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. Through the study of specific incidents related to the processes involved in the administration of medication, we sought to find out if the prescribing system had unintended consequences in creating new errors. The focus of this study was a large acute hospital in the Midlands in the United Kingdom, which implemented a Prescribing, Information and Communication System (PICS). Methods This exploratory study was based on a survey of routinely collected medication incidents over five months. Data were independently reviewed by two of the investigators with a clinical pharmacology and nursing background respectively, and grouped into broad types: sociotechnical incidents (related to human interactions with the system) and non-sociotechnical incidents. Sociotechnical incidents were distinguished from the others because they occurred at the point where the system and the professional intersected and would not have occurred in the absence of the system. The day of the week and time of day that an incident occurred were tested using univariable and multivariable analyses. We acknowledge the limitations of conducting analyses of data extracted from incident reports as it is widely recognised that most medication errors are not reported and may contain inaccurate data. Interpretation of results must therefore be tentative. Results Out of a total of 485 incidents, a modest 15% (n = 73) were distinguished as sociotechnical issues and thus may be unique to hospitals that have such systems in place. These incidents were further analysed and subdivided into categories in order to identify aspects of the context which gave rise to adverse situations and possible risks to patient safety. The analysis of sociotechnical incidents by time of day and day of week indicated a trend

  10. What Would You Like? Identifying the Required Characteristics of an Industry-Wide Incident Reporting and Learning System for the Led Outdoor Activity Sector

    ERIC Educational Resources Information Center

    Goode, Natassia; Finch, Caroline F.; Cassell, Erin; Lenne, Michael G.; Salmon, Paul M.

    2014-01-01

    The aim of this study was to identify the characteristics that led outdoor activity providers agree are necessary for the development of a new industry-wide incident reporting and learning system (UPLOADS). The study involved: 1) a literature review to identify a set of characteristics that are considered to be hallmarks of successful reporting…

  11. Automatic Analysis of Critical Incident Reports: Requirements and Use Cases.

    PubMed

    Denecke, Kerstin

    2016-01-01

    Increasingly, critical incident reports are used as a means to increase patient safety and quality of care. The entire potential of these sources of experiential knowledge remains often unconsidered since retrieval and analysis is difficult and time-consuming, and the reporting systems often do not provide support for these tasks. The objective of this paper is to identify potential use cases for automatic methods that analyse critical incident reports. In more detail, we will describe how faceted search could offer an intuitive retrieval of critical incident reports and how text mining could support in analysing relations among events. To realise an automated analysis, natural language processing needs to be applied. Therefore, we analyse the language of critical incident reports and derive requirements towards automatic processing methods. We learned that there is a huge potential for an automatic analysis of incident reports, but there are still challenges to be solved. PMID:27139389

  12. C2-Related Incidents Reported by UAS Pilots

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

    2016-01-01

    It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. This presentation focuses on incidents that involved the management of the command and control (C2) link. The identified issues include loss of link, interference from undesired transmissions, voice latency, accidental control transfer, and the use of the lost link timer, or lost link OK features.

  13. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids

    PubMed Central

    Franklin, Bryony Dean; Panesar, Sukhmeet S; Vincent, Charles; Donaldson, Liam J

    2014-01-01

    Background Catastrophic errors in healthcare are rare, yet the consequences are so serious that where possible, special procedures are put in place to prevent them. As systems become safer, it becomes progressively more difficult to detect the remaining vulnerabilities. Using inadvertent intrathecal administration of vinca alkaloids as an example, we investigated whether analysis of incident report data describing low-harm events could bridge this gap. Methods We studied nine million patient safety incidents reported from England and Wales between November 2003 and May 2013. We searched for reports relating to administration of vinca alkaloids in patients also receiving intrathecal medication, and classified the failures identified against steps in the relevant national protocol. Results Of 38 reports that met our inclusion criteria, none resulted in actual harm. The stage of the medication process most commonly involved was ‘supply, transport and storage’ (15 cases). Seven cases related to dispensing, six to documentation, and four each to prescribing and administration. Defences most commonly breached related to separation of intravenous vinca alkaloids and intrathecal medication in timing (n=16) and location (n=8); potential for confusion due to inadequate separation of these drugs therefore remains. Problems involved in six cases did not align with the procedural defences in place, some of which represented major hazards. Conclusions We identified areas of concern even within the context of a highly controlled standardised national process. If incident reporting systems include and encourage reports of no-harm incidents in addition to actual patient harm, they can facilitate monitoring the resilience of healthcare processes. Patient safety incidents that produce the most serious harm are often rare, and it is difficult to know whether patients are adequately protected. Our approach provides a potential solution. PMID:24643293

  14. Development of Incident Report Database for Organizational Learning

    NASA Astrophysics Data System (ADS)

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

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

  15. Visually Exploring Worldwide Incidents Tracking System Data

    SciTech Connect

    Chhatwal, Shree D.; Rose, Stuart J.

    2008-01-27

    This paper presents refinements of an existing analytic tool, Juxter, which was developed for the visualization of multi-dimensional categorical data, and explores its application to support exploration and interaction with open source Worldwide Incidents Tracking System (WITS) data. The volume and complexity of data available on terrorism makes it hard to analyze. Information systems that can efficiently and effectively collect, access, analyze, and report terrorist incidents can help in further studies focused on preventing, detecting, and responding to terrorist attacks. Existing interfaces to the WITS data support advanced search capabilities, and geolocation but lack functionality for identifying patterns and trends. To better support efficient browsing we have refined Juxter’s existing capabilities for filtering, selecting, and sorting elements and categories within the visualization.

  16. Incidents/accidents classification and reporting in Statoil.

    PubMed

    Berentsen, Rune; Holmboe, Rolf H

    2004-07-26

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

  17. Incident reporting in one UK accident and emergency department.

    PubMed

    Tighe, Catherine M; Woloshynowych, Maria; Brown, Ruth; Wears, Bob; Vincent, Charles

    2006-01-01

    Greater focus is needed on improving patient safety in modern healthcare systems and the first step to achieving this is to reliably identify the safety issues arising in healthcare. Research has shown the accident and emergency (A&E) department to be a particularly problematic environment where safety is a concern due to various factors, such as the range, nature and urgency of presenting conditions and the high turnover of patients. As in all healthcare environments clinical incident reporting in A&E is an important tool for detecting safety issues which can result in identifying solutions, learning from error and enhancing patient safety. This tool must be responsive and flexible to the local circumstances and work for the department to support the clinical governance agenda. In this paper, we describe the local processes for reporting and reviewing clinical incidents in one A&E department in a London teaching hospital and report recent changes to the system within the department. We used the historical data recorded on the Trust incident database as a representation of the information that would be available to the department in order to identify the high risk areas. In this paper, we evaluate the internal processes, the information available on the database and make recommendations to assist the emergency department in their internal processes. These will strengthen the internal review and staff feedback system so that the department can learn from incidents in a consistent manner. The process was reviewed by detailed examination of the centrally held electronic record (Datix database) of all incidents reported in a one year period. The nature of the incident and the level and accuracy of information provided in the incident reports was evaluated. There were positive aspects to the established system including evidence of positive changes made as a result of the reporting process, new initiatives to feedback to staff, and evolution of the programme for

  18. Estimating the Size of the HCV Infection Prevalence: A Modeling Approach Using the Incidence of Cases Reported to an Official Notification System.

    PubMed

    Amaku, Marcos; Burattini, Marcelo Nascimento; Coutinho, Francisco Antonio Bezerra; Lopez, Luis Fernandez; Mesquita, Fabio; Naveira, Marcelo Contardo Moscoso; Pereira, Gerson Fernando Mendes; Santos, Melina Érica; Massad, Eduardo

    2016-05-01

    In this paper we propose two methods to give a first rough estimate of the actual number of hepatitis C virus (HCV)-infected individuals (prevalence) taking into account the notification rate of newly diagnosed infections (incidence of notification) and the size of the liver transplantation waiting list (LTWL) of patients with liver failure due to chronic HCV infection. Both approaches, when applied to the Brazilian HCV situation converge to the same results, that is, the methods proposed reproduce both the prevalence of reported cases and the LTWL with reasonable accuracy. We use two methods to calculate the prevalence of HCV that, as a first, and very crude approximation, assumes that the actual prevalence of HCV in Brazil is proportional to the reported incidence to the official notification system with a constant denoted [Formula: see text]. In the paper we discuss the limitations and advantages of this assumption. With the two methods we calculated [Formula: see text], which reproduces both the reported incidence and the size of the LTWL. With the value of [Formula: see text] we calculated the prevalence I(a) (the integral of which resulted in 1.6 million people living with the infection in Brazil, most of whom unidentified). Other variables related to HCV infection (e.g., the distribution of the proportion of people aged a who got infected n years ago) can be easily calculated from this model. These new variables can then be measured and the model can be recursively updated, improving its accuracy. PMID:27160282

  19. [jeder-fehler-zaehlt.de: Content of and prospective benefits from a critical incident reporting and learning system (CIRS) for primary care].

    PubMed

    Beyer, Martin; Blazejewski, Tatjana; Güthlin, Corina; Klemp, Kerstin; Wunder, Armin; Hoffmann, Barbara; Müller, Hardy; Verheyen, Frank; Gerlach, Ferdinand M

    2015-01-01

    Critical incident reporting and learning systems (CIRS) have been recommended as an instrument to promote patient safety for a long time. However, both their scientific value and their actual impact have been disputed. The nationwide German CIRS for primary care has been in operation since September 2004. Incident reports are available online, and the question is how to make use of this large database to promote patient safety. A descriptive analysis of the content was performed, classifying, in particular, types of error and contributing factors. Its usage is presented for the period from 2004 to 2013 where a total of 483 complete reports have been recorded. Their severity ranges from 35.6 % with no tangible harm to patients to 14.6 % with important harm (or errors contributing to mortality). The majority of them (74.2 %) were process errors, compared to 25.8 % knowledge/skills errors. The main areas involved were treatment/medication (54.2 %) and diagnosis/tests (16.4 %). The results of the analysis of the CIRS cannot be used as an epidemiological data source. And yet they will generate hypotheses for further research in the field of patient safety. Moreover, they will enable practice teams to make themselves familiar with and learn from critical incident analysis. In spite of the specific difficulties in ambulatory care, CIRS should be promoted in this sector to enable learning. Participation in CIRS can be increased by enhanced feedback. PMID:25839371

  20. Elderly in America: a descriptive study of elder abuse examining National Incident-Based Reporting System (NIBRS) data, 2000-2005.

    PubMed

    Krienert, Jessie L; Walsh, Jeffrey A; Turner, Moriah

    2009-10-01

    Elder abuse is the newest form of intrafamilial violence to garner the attention of the public, policy makers, health officials, researchers, and the criminal justice system. Despite evidence that elder abuse is a growing problem, there is little known about the phenomenon because of persistent limitations in the extant empirical work. The present study examined a large cross-national sample of reported incidents (n = 87,422) collected as part of the National Incident-Based Reporting System (NIBRS), 2000-2005. Addressing limitations in prior works, this research employed a criminal justice oriented definition of elder abuse examining victim, offender, and incident characteristics using chi-square tests and logistic regression to establish baseline findings from a more comprehensive sample of data than previously existed. Results render a baseline profile of victims and abusers and suggest that gender differences prevail throughout elder abuse. This work both corroborates and contrasts past findings of elder abuse research, providing new insights and much needed baseline data. PMID:20183138

  1. Acute incident rapid response at a mass-gathering event through comprehensive planning systems: a case report from the 2013 Shamrock Shuffle.

    PubMed

    Başdere, Mehmet; Ross, Colleen; Chan, Jennifer L; Mehrotra, Sanjay; Smilowitz, Karen; Chiampas, George

    2014-06-01

    Planning and execution of mass-gathering events involves various challenges. In this case report, the Chicago Model (CM), which was designed to organize and operate such events and to maintain the health and wellbeing of both runners and the public in a more effective way, is described. The Chicago Model also was designed to prepare for unexpected incidents, including disasters, during the marathon event. The model has been used successfully in the planning and execution stages of the Bank of America Shamrock Shuffle and the Bank of America Chicago Marathon since 2008. The key components of the CM are organizational structure, information systems, and communication. This case report describes how the organizers at the 2013 Shamrock Shuffle used the key components of the CM approach in order to respond to an acute incident caused by a man who was threatening to jump off the State Street Bridge. The course route was changed to accommodate this unexpected event, while maintaining access to key health care facilities. The lessons learned from the incident are presented and further improvements to the existing model are proposed. PMID:24820906

  2. Patterns of Error in Confidential Maintenance Incident Reports

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Kanki, Barbara G.

    2008-01-01

    Confidential reports of maintenance incidents are a valuable source of information on maintenance errors and the contexts within which they occur. NASA's Aviation Safety Reporting System (ASRS) has been receiving an increasing number of maintenance incident reports since a specialized maintenance reporting form was introduced in 1996. In a series of studies, the database of ASRS maintenance incidents was examined using correspondence analysis, a statistical technique that converts complex data tables into a visual form. The analyses revealed patterns within the ASRS data set that would have otherwise been difficult to detect. The results have implications for a range of purposes including human factors training, the design of procedures, and the identification of improvements in aircraft design.

  3. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 4 2011-10-01 2011-10-01 false Reporting of accidents/incidents. 225.11 Section... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.11 Reporting of accidents/incidents. (a) Each railroad subject to this part shall submit...

  4. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  5. Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department

    PubMed Central

    Okafor, Nnaemeka G.; Doshi, Pratik B.; Miller, Sara K.; McCarthy, James J.; Hoot, Nathan R.; Darger, Bryan F.; Benitez, Roberto C.; Chathampally, Yashwant G.

    2015-01-01

    Introduction Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. Methods A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. Results The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. Conclusion Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system. PMID:26759657

  6. 78 FR 38803 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ... Incident Report--Natural and Other Gas Transmission and Gathering Pipeline Systems; PHMSA F 7100.2-1 Annual Report for Calendar Year 20-- Natural and Other Gas Transmission and Gathering Pipeline Systems; PHMSA F... Incident Report-- Natural and Other Gas Transmission and Gathering Pipeline Systems Form (GTG...

  7. Improving reporting of critical incidents through education and involvement.

    PubMed

    Donnelly, Peter

    2015-01-01

    Critical incident reporting involves highlighting events and near-misses which have a potential impact on patient care and patient safety. Reporting of critical incidents is a recognised tool in improving patient safety. Within the community paediatric setting in the Belfast Health & Social Care Trust (BHSCT) there is a paucity of incident report forms. The purpose of this quality improvement project was to establish the barriers to reporting critical incidents and to implement plan-do-study-act (PDSA) cycles to create a climate for change. The methodology for this project was to firstly perform a baseline audit to review all submitted critical incident reports for the Community Paediatric team in the BHSCT for a six month period. A questionnaire was distributed to staff within the multidisciplinary team to establish examples of barriers to reporting. Interventions performed included introducing an agreed definition of a critical incident, distributing/presenting questionnaire findings to senior members of the various management teams and providing feedback to healthcare workers after presentation of a critical incident presentation. A review of incident reports was performed over the subsequent six month period to assess how the interventions impacted on incident reporting. Over 12 questionnaires 28 barriers to reporting critical incidents were reported which fell into five separate categories. Staff members were twice as likely to report negativity after reporting a critical incident. Overall critical incident reporting within the BHSCT Community Paediatric team improved from 11 incident reports (1.8 per month) to 22 incident reports (3.7 per month) after completion of the quality improvement project. This represents an increase of 100%. PMID:26734409

  8. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 33 Navigation and Navigable Waters 2 2013-07-01 2013-07-01 false Reporting a pollution incident. 150.830 Section 150.830 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY... pollution incident. Oil pollution incidents involving a deepwater port are reported according to §§...

  9. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 33 Navigation and Navigable Waters 2 2012-07-01 2012-07-01 false Reporting a pollution incident. 150.830 Section 150.830 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY... pollution incident. Oil pollution incidents involving a deepwater port are reported according to §§...

  10. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 33 Navigation and Navigable Waters 2 2014-07-01 2014-07-01 false Reporting a pollution incident. 150.830 Section 150.830 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY... pollution incident. Oil pollution incidents involving a deepwater port are reported according to §§...

  11. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 33 Navigation and Navigable Waters 2 2010-07-01 2010-07-01 false Reporting a pollution incident. 150.830 Section 150.830 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY... pollution incident. Oil pollution incidents involving a deepwater port are reported according to §§...

  12. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 33 Navigation and Navigable Waters 2 2011-07-01 2011-07-01 false Reporting a pollution incident. 150.830 Section 150.830 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY... pollution incident. Oil pollution incidents involving a deepwater port are reported according to §§...

  13. Development of the Space Operations Incident Reporting Tool (SOIRT)

    NASA Technical Reports Server (NTRS)

    Minton, Jacquie

    1997-01-01

    The space operations incident reporting tool (SOIRT) is an instrument used to record information about an anomaly occurring during flight which may have been due to insufficient and/or inappropriate application of human factors knowledge. We originally developed the SOIRT form after researching other incident reporting systems of this type. We modified the form after performing several in-house reviews and a pilot test to access usability. Finally, crew members from Space Shuttle flights participated in a usability test of the tool after their missions. Since the National Aeronautics and Space Administration (NASA) currently has no system for continuous collection of this type of information, the SOIRT was developed to report issues such as reach envelope constraints, control operation difficulties, and vision impairments. However, if the SOIRT were to become a formal NASA process, information from crew members could be collected in a database and made available to individuals responsible for improving in-flight safety and productivity. Potential benefits include documentation to justify the redesign or development of new equipment/systems, provide the mission planners with a method for identifying past incidents, justify the development of timelines and mission scenarios, and require the creation of more appropriate work/rest cycles.

  14. Prospective risk analysis prior to retrospective incident reporting and analysis as a means to enhance incident reporting behaviour: a quasi-experimental field study.

    PubMed

    Kessels-Habraken, Marieke; De Jonge, Jan; Van der Schaaf, Tjerk; Rutte, Christel

    2010-05-01

    Hospitals can apply prospective and retrospective methods to reduce the large number of medical errors. Retrospective methods are used to identify errors after they occur and to facilitate learning. Prospective methods aim to determine, assess and minimise risks before incidents happen. This paper questions whether the order of implementation of those two methods influences the resultant impact on incident reporting behaviour. From November 2007 until June 2008, twelve wards of two Dutch general hospitals participated in a quasi-experimental reversed-treatment non-equivalent control group design. The six units of Hospital 1 first conducted a prospective analysis, after which a sophisticated incident reporting and analysis system was implemented. On the six units of Hospital 2 the two methods were implemented in reverse order. Data from the incident reporting and analysis system and from a questionnaire were used to assess between-hospital differences regarding the number of reported incidents, the spectrum of reported incident types, and the profession of reporters. The results show that carrying out a prospective analysis first can improve incident reporting behaviour in terms of a wider spectrum of reported incident types and a larger proportion of incidents reported by doctors. However, the proposed order does not necessarily yield a larger number of reported incidents. This study fills an important gap in safety management research regarding the order of the implementation of prospective and retrospective methods, and contributes to literature on incident reporting. This research also builds on the network theory of social contagion. The results might indicate that health care employees can disseminate their risk perceptions through communication with their direct colleagues. PMID:20202731

  15. 78 FR 71033 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-27

    ... intent to revise six forms under OMB Control Number 2137-0522. These forms include: PHMSA F 7100.1 Incident Report--Gas Distribution System; PHMSA F 7100.1-2 Mechanical Fitting Failure Report Form for Calendar Year 20xx for Distribution Operators; PHMSA F 7100.2 Incident Report-- Natural and Other...

  16. Redefining critical incidents: a preliminary report.

    PubMed

    Burns, C; Rosenberg, L

    2001-01-01

    This pilot study was conducted to describe how some traumatic events become "critical incidents" and to generate a new understanding of the term critical incident. The qualitative research design utilized content analysis of structured interviews of six emergency nurses. The nurses were interviewed regarding the ways they think about certain patient care events, the reasons that specific events are remembered and the changes that occurred following the experience of an event they considered to be critical. The definitions of a critical incident as described in the literature--as an event, as a professional's reaction and as a professional's performance--are included in the nurses' comments. None of them, however, offers a comprehensive way of describing a critical incident. The results of this pilot study suggest one, two or all three elements may be present when a traumatic event is experienced. The interaction of these elements helps to produce a fourth "critical" component, the meaning a nurse gives to an event, which can trigger cognitive, affective and/or behavioral changes. This study acknowledges the importance of all the definitions of a critical incident and proposes a more comprehensive definition that results from the interaction among the other components and the generation of personal meaning and change. PMID:11351507

  17. Wrong intraocular lens events-what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010-2014 versus 2003-2010.

    PubMed

    Steeples, L R; Hingorani, M; Flanagan, D; Kelly, S P

    2016-08-01

    PurposeTo identify the causal factors in wrong intraocular lens (IOL) events from a national data set and to compare with similar historical data (2003-2010) prior to mandatory checklist use, for the purpose of developing strategies to prevent never events.MethodsData from wrong IOL patient safety incidents (PSIs) submitted to the National Reporting and Learning System (2010-2014) were reviewed by thematic analysis and compared with the data previously collected by the group using the same methodology.ResultsOne hundred and seventy eight wrong IOL PSIs were identified. The contributory factors included: transcription errors (n=26); wrong patient biometry (n=21); wrong IOL selection (n=16); changes in planned procedure (n=16); incorrect IOL brought into theatre (n=11); left/right eye selection errors (n=9); communication errors (n=9); and positive/negative IOL power errors (n=9). In 44 PSIs, no causal factor was reported, limiting the learning value of such reports. Compared with the data from previous years, biometry errors were much reduced but IOL transcription and documentation errors were greater, particularly if further checks did not refer to the original source documentation. IOL exchange surgery was reported in 45 cases.ConclusionsThe selection and implantation of the correct IOL is a complex process which is not adequately addressed by existing checking procedures. Despite the introduction of surgical checklists, wrong IOL incidents continue to occur and are probably under-reported. Human or behavioural factors are heavily implicated in these errors and need to be addressed by novel approaches, including simulation training. There is also scope to further improve the quality and detail of incident reporting and analysis to enhance patient safety. PMID:27174380

  18. Listening to victims: use of a Critical Incident Reporting System to enable adult victims of childhood sexual abuse to participate in a political reappraisal process in Germany.

    PubMed

    Rassenhofer, Miriam; Spröber, Nina; Schneider, Thekla; Fegert, Jörg M

    2013-09-01

    Recent revelations about the scope and severity of past child sexual abuse in German institutions set off a broad public debate on this issue, and led to the establishment of a politically appointed Round Table committee and an Independent Commissioner whose mandates were to reappraise the issue and develop recommendations for future policies. A media campaign was launched to publicize the establishment of a Critical Incident Reporting System (CIRS) whereby now-adult victims of past abuse could anonymously provide testimonials and let policy makers know what issues were important to them. Respondents could either call a hotline number or communicate by mail or email. The information collected was documented and analyzed by a research team, and the results of interim reports were included in the recommendations of the Independent Commissioner and the Round Table committee. Most of the respondents described severe and repeated occurrences of childhood sexual abuse. For many, priorities were improvements in therapy and counseling services, the abolishment of the statute of limitations on prosecuting offenders, and financial compensation. Based on the recommendations of the Round Table and the Independent Commissioner, two new laws were adopted as well as an action plan and some guidelines. In addition to rules for recompensation of victims in an institutional context a fund for victims of sexual abuse in intrafamilial context was established by the Federal Government. Another effect of this process was raising societal sensitivity to the problem of child sexual abuse. The use of a CIRS enabled those directly affected by childhood sexual abuse to have some input into a political process designed to address this issue. Such an approach could have applicability in other countries or in other domains of public health and other forms of societal conflict as well. PMID:23796600

  19. Detecting medication errors: analysis based on a hospital's incident reports.

    PubMed

    Härkänen, Marja; Turunen, Hannele; Saano, Susanna; Vehviläinen-Julkunen, Katri

    2015-04-01

    The aim of this paper is to analyse how medication incidents are detected in different phases of the medication process. The study design is a retrospective register study. The material was collected from one university hospital's web-based incident reporting database in Finland. In 2010, 1617 incident reports were made, 671 of those were medication incidents and analysed in this study. Statistical methods were used to analyse the material. Results were reported using frequencies and percentages. Twenty-one percent of all medication incidents were detected during documenting or reading the documents. One-sixth of medication incidents were detected during medicating the patients, and approximately one-tenth were detected during verifying of the medicines. It is important to learn how to break the chain of medication errors as early as possible. Findings showed that for nurses, the ability to concentrate on documenting and medicating the patient is essential. PMID:24256158

  20. Incident investigation team report: K-reactor D20 spill

    SciTech Connect

    Enis, E.

    1990-12-31

    This report discusses a spill of approximately 20 gallons of D2O (moderator) which occurred on February 7, 1990, at 0008 hours. The spill occurred while construction was removing process water lines from the 5B heat exchanger at a location referred to as a Rams Horn to allow the heat exchanger to be realigned. The heat exchangers in the other systems (loops) had been successfully disconnected (lines broken) during the previous two months and had been realigned without incident under the control of job plans similar to the System 5 job plan. Construction personnel reacted positively at the time the spill and successfully rebolted and tightened the leaking flanges on 5B and later on the 5A heat exchangers. This initial reaction stopped the leak and prevented a more severe incident. The spill incident resulted in a Site Alert declaration by the Shift Manager at 0220 hours when the Stack Tritium Monitor indicated a tritium release which exceeded the limits specified. After the event it was determined that a Temporary Procedure Change (TPC) to this DPSOL, had been approved and issued in April 1989. Had this TPC been available to the Shift Manager, the alert would not have been declared. Although the environmental impact of this event was negligible with no real radiological consequences minimal, the causal factors and programmatic deficiencies identified by this investigation show significant weakness in some critical areas.

  1. Incident investigation team report: K-reactor D20 spill

    SciTech Connect

    Enis, E.

    1990-01-01

    This report discusses a spill of approximately 20 gallons of D2O (moderator) which occurred on February 7, 1990, at 0008 hours. The spill occurred while construction was removing process water lines from the 5B heat exchanger at a location referred to as a Rams Horn to allow the heat exchanger to be realigned. The heat exchangers in the other systems (loops) had been successfully disconnected (lines broken) during the previous two months and had been realigned without incident under the control of job plans similar to the System 5 job plan. Construction personnel reacted positively at the time the spill and successfully rebolted and tightened the leaking flanges on 5B and later on the 5A heat exchangers. This initial reaction stopped the leak and prevented a more severe incident. The spill incident resulted in a Site Alert declaration by the Shift Manager at 0220 hours when the Stack Tritium Monitor indicated a tritium release which exceeded the limits specified. After the event it was determined that a Temporary Procedure Change (TPC) to this DPSOL, had been approved and issued in April 1989. Had this TPC been available to the Shift Manager, the alert would not have been declared. Although the environmental impact of this event was negligible with no real radiological consequences minimal, the causal factors and programmatic deficiencies identified by this investigation show significant weakness in some critical areas.

  2. Unit-based incident reporting and root cause analysis: variation at three hospital unit types

    PubMed Central

    Wagner, Cordula; Merten, Hanneke; Zwaan, Laura; Lubberding, Sanne; Timmermans, Danielle; Smits, Marleen

    2016-01-01

    Objectives To minimise adverse events in healthcare, various large-scale incident reporting and learning systems have been developed worldwide. Nevertheless, learning from patient safety incidents is going slowly. Local, unit-based reporting systems can help to get faster and more detailed insight into unit-specific safety issues. The aim of our study was to gain insight into types and causes of patient safety incidents in hospital units and to explore differences between unit types. Design Prospective observational study. Setting 10 emergency medicine units, 10 internal medicine units and 10 general surgery units in 20 hospitals in the Netherlands participated. Patient safety incidents were reported by healthcare providers. Reports were analysed with root cause analysis. The results were compared between the 3 unit types. Results A total of 2028 incidents were reported in an average reporting period of 8 weeks per unit. More than half had some consequences for patients, such as a prolonged hospital stay or longer waiting time, and a small number resulted in patient harm. Significant differences in incident types and causes were found between unit types. Emergency units reported more incidents related to collaboration, whereas surgical and internal medicine units reported more incidents related to medication use. The distribution of root causes of surgical and emergency medicine units showed more mutual similarities than those of internal medicine units. Conclusions Comparable incidents and causes have been found in all units, but there were also differences between units and unit types. Unit-based incident reporting gives specific information and therefore makes improvements easier. We conclude that unit-based incident reporting has an added value besides hospital-wide or national reporting systems that already exist in various countries. PMID:27329443

  3. Developing a departmental culture for reporting adverse incidents.

    PubMed

    Bhatia, R; Blackshaw, G; Rogers, A; Grant, A; Kulkarni, R

    2003-01-01

    A simple, reproducible model for reporting adverse events was developed in order to promote cultural awareness and acceptance of risk management within the authors' department. A departmental proforma was created and prospective reporting of adverse events was encouraged. In the six months prior to commencing this study only four adverse incidents were reported. Following the introduction of the proforma 64 critical incidents and near-misses were reported in the one-year period. In conclusion a simple model for reporting critical incidents and near-misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer patients continuous improvement in care. PMID:12870255

  4. Loss of Situation Awareness in Pilots: Analysis of Incident Reports

    NASA Technical Reports Server (NTRS)

    Villeda, Eric B.

    1996-01-01

    Introduction Approximately 75% of all aviation accidents and incidents are attributable to human failures in monitoring, managing, and operating system. Tactical decision errors were found to be a factor in 25 of 37 major US air transport accidents between 1978 and 1990. These two facts demonstrate the inability of some pilots to maintain situation awareness. Situation awareness (SA) is defined as 'the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future". Thus, when a pilot loses SA, he or she is unable to ether perceive, comprehend, or project the status of the aircraft. In pilots terms, he or she has 'fallen behind the airplane'. Our study this summer involved an analysis of 190 NASA Aviation Safety Reporting System (ASRS) reports.

  5. Sexual Assault of Young Children as Reported to Law Enforcement: Victim, Incident, and Offender Characteristics. A NIBRS Statistical Report.

    ERIC Educational Resources Information Center

    Snyder, Howard N.

    Until recently, law enforcement and policymakers had few hard data on the child victims of sexual abuse, offenders, and other characteristics of these crimes on which to base a response. The National Incident-Based Reporting System (NIBRS), capturing a wide range of information on each sexual assault incident reported to law enforcement, can…

  6. Incident reporting in post-operative patients managed by acute pain service

    PubMed Central

    Hasan, Syeda Fauzia; Hamid, Mohammad

    2015-01-01

    Background and Aims: Incident reporting is a reliable and inexpensive tool used in anaesthesia to identify errors in patient management. A hospital incident reporting system was already present in our hospital, but we were unable to find any incident related to acute pain management. Hence, acute pain service (APS) was started for voluntary incident reporting in post-operative patients to identify critical incidents, review the root cause and suggest remedial measures. Methods: All post-operative patients managed by APS were included in this observational study. A proforma was developed by APS, which included information about the type of incident (equipment and patient-related, human errors), severity of incident, person responsible and suggestions to prevent the same incident in the future. Patients and medical staff were informed about the reporting system. Whenever an incident was identified, a proforma was filled out by APS resident and data entered in SPSS programme. Results: Total of 98 (1.80%) incidents were reported in 5432 patients managed by APS during 3 years period. Average age of the patients was 46 ± 17 years. Majority of incidents were related to epidural care (71%) and occurred in surgical wards (87%). Most of the incidents occurred due to human error and infusion delivery set-related defects. Conclusion: Incident reporting proved to be a feasible method of improving quality care in developing countries. It not only provides valuable information about areas which needed improvement, but also helped in developing strategies to improve care. Knowledge and attitudes of medical and paramedical staff are identified as the targeted area for improvement. PMID:26903672

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

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

    2016-01-01

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

  8. Spatial Distribution of Black Bear Incident Reports in Michigan

    PubMed Central

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

    2016-01-01

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

  9. Spatial Distribution of Black Bear Incident Reports in Michigan.

    PubMed

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

    2016-01-01

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

  10. The reported incidence of man-machine interface issues in Army aviators using the Aviator's Night Vision System (ANVIS) in a combat theatre

    NASA Astrophysics Data System (ADS)

    Hiatt, Keith L.; Rash, Clarence E.

    2011-06-01

    Background: Army Aviators rely on the ANVIS for night operations. Human factors literature notes that the ANVIS man-machine interface results in reports of visual and spinal complaints. This is the first study that has looked at these issues in the much harsher combat environment. Last year, the authors reported on the statistically significant (p<0.01) increased complaints of visual discomfort, degraded visual cues, and incidence of static and dynamic visual illusions in the combat environment [Proc. SPIE, Vol. 7688, 76880G (2010)]. In this paper we present the findings regarding increased spinal complaints and other man-machine interface issues found in the combat environment. Methods: A survey was administered to Aircrew deployed in support of Operation Enduring Freedom (OEF). Results: 82 Aircrew (representing an aggregate of >89,000 flight hours of which >22,000 were with ANVIS) participated. Analysis demonstrated high complaints of almost all levels of back and neck pain. Additionally, the use of body armor and other Aviation Life Support Equipment (ALSE) caused significant ergonomic complaints when used with ANVIS. Conclusions: ANVIS use in a combat environment resulted in higher and different types of reports of spinal symptoms and other man-machine interface issues over what was previously reported. Data from this study may be more operationally relevant than that of the peacetime literature as it is derived from actual combat and not from training flights, and it may have important implications about making combat predictions based on performance in training scenarios. Notably, Aircrew remarked that they could not execute the mission without ANVIS and ALSE and accepted the degraded ergonomic environment.

  11. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 18 Conservation of Power and Water Resources 1 2011-04-01 2011-04-01 false Reporting safety-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS AND PROJECT WORKS Reports and Records §...

  12. 28 CFR 541.14 - Incident report and investigation.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... the investigation, and staff may not question the inmate until the Federal Bureau of Investigation or... report and investigation. (a) Incident report. The Bureau of Prisons encourages informal resolution... Section 541.14 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL...

  13. Incident reporting: Its role in aviation safety and the acquisition of human error data

    NASA Technical Reports Server (NTRS)

    Reynard, W. D.

    1983-01-01

    The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

  14. 49 CFR 171.16 - Detailed hazardous materials incident reports.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 2 2013-10-01 2013-10-01 false Detailed hazardous materials incident reports. 171.16 Section 171.16 Transportation Other Regulations Relating to Transportation PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION HAZARDOUS MATERIALS REGULATIONS GENERAL INFORMATION, REGULATIONS, AND...

  15. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 18 Conservation of Power and Water Resources 1 2014-04-01 2014-04-01 false Reporting safety-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS...

  16. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 18 Conservation of Power and Water Resources 1 2010-04-01 2010-04-01 false Reporting safety-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS...

  17. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 18 Conservation of Power and Water Resources 1 2012-04-01 2012-04-01 false Reporting safety-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS...

  18. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 18 Conservation of Power and Water Resources 1 2013-04-01 2013-04-01 false Reporting safety-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS...

  19. 36 CFR 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 36 Parks, Forests, and Public Property 3 2011-07-01 2011-07-01 false How do agencies report incidents? 1230.14 Section 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT UNLAWFUL OR ACCIDENTAL REMOVAL, DEFACING, ALTERATION, OR DESTRUCTION OF...

  20. 36 CFR 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 36 Parks, Forests, and Public Property 3 2010-07-01 2010-07-01 false How do agencies report incidents? 1230.14 Section 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT UNLAWFUL OR ACCIDENTAL REMOVAL, DEFACING, ALTERATION, OR DESTRUCTION OF...

  1. Identification of Human Factors in Unmanned Aviation Via Pilot Incident Reports

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

    2015-01-01

    There is a need for incident data relevant to the operation of civilian unmanned aircraft systems (UAS) in the National Air Space (NAS). Currently, very limited incident and accident data are available from military sources, and the tightly-restricted civilian UAS industry has produced very few incident reports that could shed light on design issues relevant to human factors. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from UAS pilots, and using the information to identify areas where human factors guidelines will be of assistance. Experienced UAS pilots are participating in small focus groups in which they are prompted to describe critical incidents that either reveal a system flaw, or highlight a case where the human operator contributed to system resilience or mission success. The de-identified incidents are being analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot in dealing with the incident. Preliminary findings will be described.

  2. Feedback from reporting patient safety incidents--are NHS trusts learning lessons?

    PubMed

    Wallace, Louise

    2010-01-01

    For the study, first published in 2006, the researchers examined how well NHS organisations had attempted to use the information they gathered from adverse clinical incidents and whether they were learning from it. By looking at existing relevant research worldwide, interviewing experts, surveying NHS organizations (acute, community and ambulance), consulting health care and other high-risk industry safety experts and NHS risk managers, and investigating case studies of good practice, they developed a model to assess how ready NHS systems were to learn from incidents. This is known as Safety Action and Information Feedback from Incident Reporting (SAIFIR). PMID:20075136

  3. Patient safety in primary care: incident reporting and significant event reviews in British general practice.

    PubMed

    Rea, David; Griffiths, Sarah

    2016-07-01

    Over the past 20 years, healthcare has adapted to the 'quality revolution' by moving away from direct provision and hierarchical control mechanisms. In their place, new structures based on contractual relationships are being developed coupled with attempts to create an organisational culture that shares learning and that scrutinises existing practice so that it can be improved. The issue here is that contractual arrangements require surveillance, monitoring, regulation and governance systems that can be perceived as antipathetic to the examination of practice and subsequent learning. Historically, reporting levels from general practice have remained low; little information is shared and consequently lessons are not shared across the general practice community. Given large-scale under-engagement of general practitioners (GPs) in incident reporting systems, significant event analysis is advocated to encourage sharing of information about incidents to inform the patient safety agenda at a local and national level. Previous research has concentrated on the secondary care environment and little is known about the situation in primary care, where the majority of patient contacts with healthcare occur. To explore attitudes to incident reporting, the study adopted a qualitative approach to GPs working in a mixture of urban and rural practices reporting to a Welsh Local Health Board. The study found that GPs used significant event analysis methodology to report incidents within their practice, but acknowledged under-reporting. They were less enthusiastic about reporting externally. A number of barriers exist to reporting, including insufficient time to report, lack of feedback, fear of blame, and damage to reputations and patient confidence in a competitive environment. If incident reporting processes are perceived as supportive and formative, and where protected time is allocated to discuss incidents, then GPs are willing to participate. They also need to know how the

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

    PubMed

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

    2010-01-01

    Incident reporting offers insight into a variety of intricate processes in healthcare. However, it has been found that medication incidents are under reported in the community pharmacy setting. The Community Pharmacy Incident Reporting (CPhIR) program was created by the Institute for Safe Medication Practices Canada specifically for incident reporting in the community pharmacy setting in Canada. The initial development of key elements for CPhIR included several focus-group teleconferences with pharmacists from Ontario and Nova Scotia. Throughout the development and release of the CPhIR pilot, feedback from pharmacists and pharmacy technicians was constantly incorporated into the reporting program. After several rounds of iterative feedback, testing and consultation with community pharmacy practitioners, a final version of the CPhIR program, together with self-directed training materials, is now ready to launch. The CPhIR program provides users with a one-stop platform to report and record medication incidents, export data for customized analysis and view comparisons of individual and aggregate data. These unique functions allow for a detailed analysis of underlying contributing factors in medication incidents. A communication piece for pharmacies to share their experiences is in the process of development. To ensure the success of the CPhIR program, a patient safety culture must be established. By gaining a deeper understanding of possible causes of medication incidents, community pharmacies can implement system-based strategies for quality improvement and to prevent potential errors from occurring again in the future. This article highlights key features of the CPhIR program that will assist community pharmacies to improve their drug distribution system and, ultimately, enhance patient safety. PMID:20959726

  5. Brief report: The bystander effect in cyberbullying incidents.

    PubMed

    Machackova, Hana; Dedkova, Lenka; Mezulanikova, Katerina

    2015-08-01

    This study examined the bystander effect in cyberbullying. Using self-reported data from 257 Czech respondents who had witnessed a cyberbullying attack, we tested whether provided help decreased with increased number of other bystanders. We controlled for several individual and contextual factors, including empathy, social self-efficacy, empathic response to victimization, and relationship to the victim. Results showed that participants tend to help the victims more in incidents with only one or two other bystanders. We also found that, as in the "offline" realm, bystander effect is not linear: no significant differences were found between incidents with a moderate number (3-10) and a larger number of total bystanders. Our findings, thus, provide support for the presence of the bystander effect in cyberbullying. PMID:26070168

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

    PubMed

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

    2016-02-01

    One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget. PMID:26217037

  7. Report of cancer incidence and mortality in China, 2010

    PubMed Central

    Zheng, Rongshou; Zhang, Siwei; Zhao, Ping; Zeng, Hongmei; Zou, Xiaonong

    2014-01-01

    Purpose To estimate the cancer incidences and mortalities in China in 2010. Methods On basis of the evaluation procedures and data quality criteria described in the National Central Cancer Registry (NCCR), data from 219 cancer registries were evaluated. Data from 145 registries were identified as qualified and then accepted for the 2010 cancer registry report. The incidences and mortalities of major cancers and the overall incidence and mortality were stratified by residency (urban or rural), areas (eastern, middle, and western), gender, and age. The cancer cases and deaths were estimated based on age-specific rate and national population in 2010. The China 2010 Population Census data and Segi’s world population data were used for calculating the age-standardized cancer incidence/mortality rates. Results Data were obtained from a total of 145 cancer registries (63 in urban areas and 82 in rural areas) covering 158,403,248 people (92,433,739 in urban areas and 65,969,509 in rural areas). The percentage of morphologically verified cases (MV%) were 67.11%; 2.99% of incident cases were identified through proportion of death certification only (DCO%), with the mortality to incidence ratio of (M/I) 0.61. The estimates of new cancer cases and cancer deaths were 3,093,039 and 1,956,622 in 2010, respectively. The crude incidence was 235.23/105 (268.65/105 in males and 200.21/105 in females), the age-standardized rates by Chinese standard population (ASR China) and by world standard population (ASR world) were 184.58/105 and 181.49/105, and the cumulative incidence rate (0-74 age years old) was 21.11%. The cancer incidence and ASR China were 256.41/105 and 187.53/105 in urban areas and 213.71/105 and 181.10/105 in rural areas. The crude cancer mortality in China was 148.81/105 (186.37/105 in males and 109.42/105 in females), the age-standardized mortalities by Chinese standard population and by world standard population were 113.92/105 and 112.86/105, and the cumulative

  8. Incident Command Systems: Because Life Happens

    ERIC Educational Resources Information Center

    Isaac, Gayle; Moore, Brian

    2011-01-01

    Preparing for every possible contingency seems daunting, but with teamwork and some help from the government, it's almost do-able. There is a great system out there that will help business professionals and educators develop a strong, effective emergency preparedness plan. If they haven't done a good job of implementing a solid emergency response…

  9. 41 CFR 102-33.450 - How must we report accident and incident data?

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 41 Public Contracts and Property Management 3 2011-01-01 2011-01-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION PERSONAL PROPERTY 33-MANAGEMENT OF GOVERNMENT AIRCRAFT...

  10. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 41 Public Contracts and Property Management 3 2013-07-01 2013-07-01 false What accident and incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION PERSONAL PROPERTY 33-MANAGEMENT OF GOVERNMENT AIRCRAFT...

  11. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 41 Public Contracts and Property Management 3 2011-01-01 2011-01-01 false What accident and incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION PERSONAL PROPERTY 33-MANAGEMENT OF GOVERNMENT AIRCRAFT...

  12. 41 CFR 102-33.450 - How must we report accident and incident data?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 41 Public Contracts and Property Management 3 2013-07-01 2013-07-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION PERSONAL PROPERTY 33-MANAGEMENT OF GOVERNMENT AIRCRAFT...

  13. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false What accident and incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION PERSONAL...

  14. 49 CFR 225.15 - Accidents/incidents not to be reported.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

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

    PubMed

    Miles, Elizabeth N

    2006-03-17

    In 1996, Health & Safety introduced an incident investigation process called Learning to Look to Johnson & Johnson. This process provides a systematic way of analyzing work-related injuries and illness, uncovers root cause that leads to system defects, and points to viable solutions. The process analyzed involves three steps: investigation and reporting of the incident, determination of root cause, and development and implementation of a corrective action plan. The process requires the investigators to provide an initial communication for work-related serious injuries and illness as well as lost workday cases to Corporate Headquarters within 72 h of the incident with a full investigative report to follow within 10 days. A full investigation requires a written report, a cause-result logic diagram (CRLD), a corrective action plan (CAP) and a report of incident costs (SafeCost) all due to be filed electronically. It is incumbent on the principal investigator and his or her investigative teams to assemble the various parts of the investigation and to follow up with the relevant parties to ensure corrective actions are implemented, and a full report submitted to Corporate executives. Initial review of the system revealed that the process was not working as designed. A number of reports were late, not signed by the business leaders, and in some instances, all cause were not identified. Process excellence was the process used to study the issue. The team used six sigma DMAI2C methodologies to identify and implement system improvements. The project examined the breakdown of the critical aspects of the reporting and investigation process that lead to system errors. This report will discuss the study findings, recommended improvements, and methods used to monitor the new improved process. PMID:16225990

  16. MO-G-BRE-06: Metrics of Success: Measuring Participation and Attitudes Related to Near-Miss Incident Learning Systems

    SciTech Connect

    Nyflot, MJ; Kusano, AS; Zeng, J; Carlson, JC; Novak, A; Sponseller, P; Jordan, L; Kane, G; Ford, EC

    2014-06-15

    Purpose: Interest in incident learning systems (ILS) for improving safety and quality in radiation oncology is growing, as evidenced by the upcoming release of the national ILS. However, an institution implementing such a system would benefit from quantitative metrics to evaluate performance and impact. We developed metrics to measure volume of reporting, severity of reported incidents, and changes in staff attitudes over time from implementation of our institutional ILS. Methods: We analyzed 2023 incidents from our departmental ILS from 2/2012–2/2014. Incidents were prospectively assigned a near-miss severity index (NMSI) at multidisciplinary review to evaluate the potential for error ranging from 0 to 4 (no harm to critical). Total incidents reported, unique users reporting, and average NMSI were evaluated over time. Additionally, departmental safety attitudes were assessed through a 26 point survey adapted from the AHRQ Hospital Survey on Patient Safety Culture before, 12 months, and 24 months after implementation of the incident learning system. Results: Participation in the ILS increased as demonstrated by total reports (approximately 2.12 additional reports/month) and unique users reporting (0.51 additional users reporting/month). Also, the average NMSI of reports trended lower over time, significantly decreasing after 12 months of reporting (p<0.001) but with no significant change at months 18 or 24. In survey data significant improvements were noted in many dimensions, including perceived barriers to reporting incidents such as concern of embarrassment (37% to 18%; p=0.02) as well as knowledge of what incidents to report, how to report them, and confidence that these reports were used to improve safety processes. Conclusion: Over a two-year period, our departmental ILS was used more frequently, incidents became less severe, and staff confidence in the system improved. The metrics used here may be useful for other institutions seeking to create or evaluate

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

    PubMed

    Goodman-Delahunty, Jane; Crehan, Anna Corbo

    2016-07-01

    In an online survey about experiences with the police complaint system, 239 client advocates described a recent incident in which a client with grounds to lodge a complaint declined to do so. Almost one third of those incidents involved domestic violence. Thematic analysis of case descriptions revealed that many police did not take domestic violence reports seriously. A typology of problematic police conduct was developed. Many officers failed to observe current procedures and appeared to lack knowledge of relevant laws. Citizens feared retaliatory victimization by police and/or perceived that complaining was futile. Implications of these findings are reviewed in light of procedural justice theory. PMID:26567295

  18. Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012

    PubMed Central

    Donaldson, Liam J.; Panesar, Sukhmeet S.; Darzi, Ara

    2014-01-01

    Background Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced. Methods and Findings The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement. Conclusions Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives. Please see later in the article for the Editors' Summary PMID:24959751

  19. School Crisis Teams within an Incident Command System

    ERIC Educational Resources Information Center

    Nickerson, Amanda B.; Brock, Stephen E.; Reeves, Melissa A.

    2006-01-01

    Despite the increasing attention given to the need for schools to be prepared to respond in a variety of crisis situations, there is a lack of information about how to coordinate with multiple agencies following a crisis. This article describes the U. S. Department of Homeland Security's (2004) National Incident Management System and its Incident…

  20. Reporting of Violent and Disruptive Incidents by Public Schools. Report 2005-S-38

    ERIC Educational Resources Information Center

    New York State Education Department, 2006

    2006-01-01

    The objective of this report was to determine whether the State Education Department (SED) has developed effective processes for (1) ensuring that school districts report violent and disruptive incidents to SED in accordance with State law and regulations, (2) identifying schools that should be designated as persistently dangerous because of their…

  1. 30 CFR 585.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 30 Mineral Resources 2 2012-07-01 2012-07-01 false What incidents must I report, and when must I report them? 585.831 Section 585.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY AND ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER CONTINENTAL SHELF Environmental and Safety...

  2. 30 CFR 285.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What incidents must I report, and when must I report them? 285.831 Section 285.831 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER CONTINENTAL SHELF Environmental and Safety...

  3. 30 CFR 585.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 30 Mineral Resources 2 2014-07-01 2014-07-01 false What incidents must I report, and when must I report them? 585.831 Section 585.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY AND ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER CONTINENTAL SHELF Environmental and Safety...

  4. 30 CFR 285.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What incidents must I report, and when must I report them? 285.831 Section 285.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, REGULATION, AND ENFORCEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER CONTINENTAL...

  5. 30 CFR 585.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 30 Mineral Resources 2 2013-07-01 2013-07-01 false What incidents must I report, and when must I report them? 585.831 Section 585.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY AND ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER CONTINENTAL SHELF Environmental and Safety...

  6. NATIONAL FIRE INCIDENT REPORTING SYSTEM (NFIRS)

    EPA Science Inventory

    The Federal Fire Prevention and Control Act of 1974 (P.L. 93-498) authorizes the National Fire Data Center in the U.S. Fire Administration (USFA) to gather and analyze information on the magnitude of the Nation's fire problem, as well as its detailed characteristics and trends. T...

  7. Analysis of FEL optical systems with grazing incidence mirrors

    SciTech Connect

    Knapp, C.E.; Viswanathan, V.K.; Bender, S.C.; Appert, Q.D.; Lawrence, G.; Barnard, C.

    1986-01-01

    The use of grazing incidence optics in resonators alleviates the problem of damage to the optical elements and permits higher powers in cavities of reasonable dimensions for a free electron laser (FEL). The design and manufacture of a grazing incidence beam expander for the Los Alamos FEL mock-up has been completed. In this paper, we describe the analysis of a bare cavity, grazing incidence optical beam expander for an FEL system. Since the existing geometrical and physical optics codes were inadequate for such an analysis, the GLAD code was modified to include global coordinates, exact conic representation, raytracing, and exact aberration features to determine the alignment sensitivities of laser resonators. A resonator cavity has been manufactured and experimentally setup in the Optical Evaluation Laboratory at Los Alamos. Calculated performance is compared with the laboratory measurements obtained so far.

  8. What Can Hospitalized Patients Tell Us About Adverse Events? Learning from Patient-Reported Incidents

    PubMed Central

    Weingart, Saul N; Pagovich, Odelya; Sands, Daniel Z; Li, Joseph M; Aronson, Mark D; Davis, Roger B; Bates, David W; Phillips, Russell S

    2005-01-01

    Purpose Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors. Subjects We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital. Methods Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about “problems,”“mistakes,” and “injuries” that occurred. Physician investigators classified patients' reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events. Results Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4). Conclusion Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety. PMID:16117751

  9. 12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 12 Banks and Banking 3 2011-01-01 2011-01-01 false Reports of change in control of bank management incident to a merger. 250.181 Section 250.181 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM MISCELLANEOUS INTERPRETATIONS Interpretations § 250.181 Reports of change in control of...

  10. Incidence and pattern of 12 years of reported transfusion adverse events in Zimbabwe: a retrospective analysis

    PubMed Central

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

    2014-01-01

    Background Haemovigilance hinges on a systematically structured reporting system, which unfortunately does not always exist in resource-limited settings. We determined the incidence and pattern of transfusion-related adverse events reported to the National Blood Service Zimbabwe. Materials and methods A retrospective review of the transfusion-event records of the National Blood Service Zimbabwe was conducted covering the period from 1 January 1999 to 31 December 2011. All transfusion-related event reports received during the period were analysed. Results A total of 308 transfusion adverse events (0.046%) were reported for 670,625 blood components distributed. The majority (61.6%) of the patients who experienced an adverse event were female. The median age was 36 years (range, 1–89 years). The majority (68.8%) of the adverse events were acute transfusion reactions consisting of febrile non-haemolytic transfusion reactions (58.5%), minor allergies (31.6%), haemolytic reactions (5.2%), severe allergic reactions (2.4%), anaphylaxis (1.4%) and hypotension (0.9%). Two-thirds (66.6%) of the adverse events occurred following administration of whole blood, although only 10.6% of the blood was distributed as whole blood. Packed cells, which accounted for 75% of blood components distributed, were associated with 20.1% of the events. Discussion The incidence of suspected transfusion adverse events was generally lower than the incidences reported globally in countries with well-established haemovigilance systems. The administration of whole blood was disproportionately associated with transfusion adverse events. The pattern of the transfusion adverse events reported here highlights the probable differences in practice between different settings. Under-reporting of transfusion events is rife in passive reporting systems. PMID:24887217

  11. Implementing a template for major incident reporting: experiences from the first year.

    PubMed

    Fattah, Sabina; Rehn, Marius; Wisborg, Torben

    2015-01-01

    Major incidents are resource-demanding situations that require urgent and effective medical management. The possibility to extract learning from them is therefore important. Comparative analysis of information based on uniform data collection from previous incidents may facilitate learning. The Major Incident Reporting Collaborators have developed a template for reporting of the medical pre-hospital response to major incidents. The template is accompanied by an open access webpage ( www.majorincidentreporting.org ) for online reporting and access to published reports. This commentary presents the experiences from the first year of implementing the template including a presentation of the five published reports. PMID:26242290

  12. Wavefront Sensing Analysis of Grazing Incidence Optical Systems

    NASA Technical Reports Server (NTRS)

    Rohrbach, Scott; Saha, Timo

    2012-01-01

    Wavefront sensing is a process by which optical system errors are deduced from the aberrations in the image of an ideal source. The method has been used successfully in near-normal incidence, but not for grazing incidence systems. This innovation highlights the ability to examine out-of-focus images from grazing incidence telescopes (typically operating in the x-ray wavelengths, but integrated using optical wavelengths) and determine the lower-order deformations. This is important because as a metrology tool, this method would allow the integration of high angular resolution optics without the use of normal incidence interferometry, which requires direct access to the front surface of each mirror. Measuring the surface figure of mirror segments in a highly nested x-ray telescope mirror assembly is difficult due to the tight packing of elements and blockage of all but the innermost elements to normal incidence light. While this can be done on an individual basis in a metrology mount, once the element is installed and permanently bonded into the assembly, it is impossible to verify the figure of each element and ensure that the necessary imaging quality will be maintained. By examining on-axis images of an ideal point source, one can gauge the low-order figure errors of individual elements, even when integrated into an assembly. This technique is known as wavefront sensing (WFS). By shining collimated light down the optical axis of the telescope and looking at out-of-focus images, the blur due to low-order figure errors of individual elements can be seen, and the figure error necessary to produce that blur can be calculated. The method avoids the problem of requiring normal incidence access to the surface of each mirror segment. Mirror figure errors span a wide range of spatial frequencies, from the lowest-order bending to the highest order micro-roughness. While all of these can be measured in normal incidence, only the lowest-order contributors can be determined

  13. A system concept for wide swath constant incident angle coverage

    NASA Technical Reports Server (NTRS)

    Claassen, J. P.; Eckerman, J.

    1978-01-01

    Multiple beam approach readily overcomes radar ambiguity constraints associated with orbital systems and therefore permits imagery over swaths much wider than 100 kilometers. Furthermore, the antenna technique permits imagery at nearly constant incident angles. When frequency scanning is employed, the center angle may be programmed. The redundant use of the antenna aperture during reception results in lower transmitted power and in shorter antenna lengths in comparison to conventional designs. Compatibility of the approach with passive imagery is also considered.

  14. The etiology and incidence of anaphylaxis in Rochester, Minnesota: A report from the Rochester Epidemiology Project

    PubMed Central

    Decker, Wyatt W.; Campbell, Ronna L.; Manivannan, Veena; Luke, Anuradha; St. Sauver, Jennifer L.; Weaver, Amy; Bellolio, M. Fernanda; Bergstralh, Eric J.; Stead, Latha G.; Li, James T. C.

    2009-01-01

    Background Reported incidences of anaphylaxis range from 3.2 to 20 per 100,000 population. The incidence and trend over time has meaningful public health implications but has not been well characterized because of a lack of a standard definition and deficiencies in reporting of events. Objective We sought to determine the incidence and cause of anaphylaxis over a 10-year period. Methods We performed a population-based incidence study that was conducted in Rochester, Minnesota, from 1990 through 2000. Anaphylaxis episodes were identified on the basis of symptoms and signs of mast cell and basophil mediator release plus mucocutaneous, gastrointestinal tract, respiratory tract, or cardiovascular system involvement. Results Two hundred eleven cases of anaphylaxis were identified (55.9% in female subjects). The mean age was 29.3 years (SD, 18.2 years; range, 0.8–78.2 years). The overall age-and sex-adjusted incidence rate was 49.8 (95% CI, 45.0–54.5) per 100,000 person-years. Age-specific rates were highest for ages 0 to 19 years (70 per 100,000 person-years). Ingested foods accounted for 33.2% (70 cases), insect stings accounted for 18.5% (39 cases), medication accounted for 13.7% (29 cases), radiologic contrast agent accounted for 0.5% (1 case), “other” causes accounted for 9% (19 cases), and “unknown” causes accounted for 25.1% (53 cases). The “other” group included cats, latex, cleaning agents, environmental allergens, and exercise. There was an increase in the annual incidence rate during the study period from 46.9 per 100,000 persons in 1990 to 58.9 per 100,000 persons in 2000 (P = .03). Conclusion The overall incidence rate is 49.8 per 100,000 person-years, which is higher than previously reported. The annual incidence rate is also increasing. Food and insect stings continue to be major inciting agents for anaphylaxis. PMID:18992928

  15. 40 CFR 159.184 - Toxic or adverse effect incident reports.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 40 Protection of Environment 24 2014-07-01 2014-07-01 false Toxic or adverse effect incident... Information § 159.184 Toxic or adverse effect incident reports. (a) General. Information about incidents... organism suffered a toxic or adverse effect, or may suffer a delayed or chronic adverse effect in...

  16. 30 CFR 250.190 - Reporting requirements for incidents requiring written notification.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... written notification. 250.190 Section 250.190 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT... for incidents requiring written notification. (a) For any incident covered under § 250.188, you must submit a written report within 15 calendar days after the incident to the District Manager. The...

  17. 77 FR 71354 - Adjustment of Monetary Threshold for Reporting Rail Equipment Accidents/Incidents for Calendar...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-30

    ...This rule increases the rail equipment accident/incident reporting threshold from $9,500 to $9,900 for certain railroad accidents/incidents involving property damage that occur during calendar year 2013. This action is needed to ensure that FRA's reporting requirements reflect cost increases that have occurred since the reporting threshold was last published in November of...

  18. Automating patient safety incident reporting to improve healthcare quality in the defence medical services.

    PubMed

    Lamb, Di; Piper, N

    2015-12-01

    There are many reasons for poor compliance with patient safety incident reporting in the UK. The Defence Medical Services has made a significant investment to address the culture and process by which risk to patient safety is managed within its organisation. This paper describes the decision process and technical considerations in the design of an automated reporting system together with the implementation procedure aimed to maximise compliance. The elimination of inherent weaknesses in feedback mechanisms from the three Armed Forces, which had been uniquely different, ensured the quality of data improved, which enabled resources to be prioritised that would also have a direct impact upon the quality of patient care. PMID:26400974

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

    PubMed

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

    2015-07-01

    Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care. PMID:25526960

  20. Brief Report: Incidence of Ophthalmologic Disorders in Children with Autism

    ERIC Educational Resources Information Center

    Ikeda, Jamie; Davitt, Bradley V.; Ultmann, Monica; Maxim, Rolanda; Cruz, Oscar A.

    2013-01-01

    Purpose: To determine the incidence of ophthalmologic disorders in children with autism and related disorders. Design: Retrospective chart review. Four hundred and seven children diagnosed with autism or a related disorder between 1998 and 2006. One hundred and fifty-four of these children completed a comprehensive ophthalmology exam by a…

  1. Adaptive Dispatching of Incidences Based on Reputation for SCADA Systems

    NASA Astrophysics Data System (ADS)

    Alcaraz, Cristina; Agudo, Isaac; Fernandez-Gago, Carmen; Roman, Rodrigo; Fernandez, Gerardo; Lopez, Javier

    SCADA systems represent a challenging scenario where the management of critical alarms is crucial. Their response to these alarms should be efficient and fast in order to mitigate or contain undesired effects. This work presents a mechanism, the Adaptive Assignment Manager (AAM) that will aid to react to incidences in a more efficient way by dynamically assigning alarms to the most suitable human operator. The mechanism uses various inputs for identifying the operators such as their availability, workload and reputation. In fact, we also define a reputation component that stores the reputation of the human operators and uses feedback from past experiences.

  2. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 2 2014-01-01 2014-01-01 false Internal safety reporting and incident... RULES Fractional Ownership Operations Program Management § 91.1021 Internal safety reporting and incident/accident response. (a) Each program manager must establish an internal anonymous safety...

  3. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 14 Aeronautics and Space 2 2012-01-01 2012-01-01 false Internal safety reporting and incident... RULES Fractional Ownership Operations Program Management § 91.1021 Internal safety reporting and incident/accident response. (a) Each program manager must establish an internal anonymous safety...

  4. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 2 2013-01-01 2013-01-01 false Internal safety reporting and incident... RULES Fractional Ownership Operations Program Management § 91.1021 Internal safety reporting and incident/accident response. (a) Each program manager must establish an internal anonymous safety...

  5. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 2 2010-01-01 2010-01-01 false Internal safety reporting and incident... RULES Fractional Ownership Operations Program Management § 91.1021 Internal safety reporting and incident/accident response. (a) Each program manager must establish an internal anonymous safety...

  6. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 14 Aeronautics and Space 2 2011-01-01 2011-01-01 false Internal safety reporting and incident... RULES Fractional Ownership Operations Program Management § 91.1021 Internal safety reporting and incident/accident response. (a) Each program manager must establish an internal anonymous safety...

  7. 77 FR 36008 - Agency Information Collection Activities; Proposed Collection: Cargo Theft Incident Report...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-15

    ... Incident Report, Revision of a Currently Approved Collection, Comments Requested ACTION: 30-Day notice of... Request to the Office of Management and Budget (OMB) for review and clearance in accordance with the...: Cargo Theft Incident Report. (3) The agency form number, if any, and the applicable component of...

  8. 30 CFR 285.832 - How do I report incidents requiring immediate notification?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... notification? 285.832 Section 285.832 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF THE INTERIOR... Environmental and Safety Management, Inspections, and Facility Assessments for Activities Conducted Under SAPs, COPs and GAPs Incident Reporting and Investigation § 285.832 How do I report incidents...

  9. Enhancing the Safety of Children in Foster Care and Family Support Programs: Automated Critical Incident Reporting

    ERIC Educational Resources Information Center

    Brenner, Eliot; Freundlich, Madelyn

    2006-01-01

    The Adoption and Safe Families Act of 1997 has made child safety an explicit focus in child welfare. The authors describe an automated critical incident reporting program designed for use in foster care and family-support programs. The program, which is based in Lotus Notes and uses e-mail to route incident reports from direct service staff to…

  10. 30 CFR 250.190 - Reporting requirements for incidents requiring written notification.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... written notification. 250.190 Section 250.190 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF... notification. (a) For any incident covered under § 250.188, you must submit a written report within 15 calendar days after the incident to the District Manager. The report must contain the following information:...

  11. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system

    SciTech Connect

    Ford, Eric C.; Smith, Koren; Harris, Kendra; Terezakis, Stephanie

    2012-11-15

    Purpose: A series of examples are presented in which potential errors in the delivery of radiation therapy were prevented through use of incident learning. These examples underscore the value of reporting near miss incidents. Methods: Using a departmental incident learning system, eight incidents were noted over a two-year period in which fields were treated 'out-of-sequence,' that is, fields from a boost phase were treated, while the patient was still in the initial phase of treatment. As a result, an error-prevention policy was instituted in which radiation treatment fields are 'hidden' within the oncology information system (OIS) when they are not in current use. In this way, fields are only available to be treated in the intended sequence and, importantly, old fields cannot be activated at the linear accelerator control console. Results: No out-of-sequence treatments have been reported in more than two years since the policy change. Furthermore, at least three near-miss incidents were detected and corrected as a result of the policy change. In the first two, the policy operated as intended to directly prevent an error in field scheduling. In the third near-miss, the policy operated 'off target' to prevent a type of error scenario that it was not directly intended to prevent. In this incident, an incorrect digitally reconstructed radiograph (DRR) was scheduled in the OIS for a patient receiving lung cancer treatment. The incorrect DRR had an isocenter which was misplaced by approximately two centimeters. The error was a result of a field from an old plan being scheduled instead of the intended new plan. As a result of the policy described above, the DRR field could not be activated for treatment however and the error was discovered and corrected. Other quality control barriers in place would have been unlikely to have detected this error. Conclusions: In these examples, a policy was adopted based on incident learning, which prevented several errors, at least one

  12. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice

    PubMed Central

    Carson-Stevens, Andrew; Hibbert, Peter; Avery, Anthony; Butlin, Amy; Carter, Ben; Cooper, Alison; Evans, Huw Prosser; Gibson, Russell; Luff, Donna; Makeham, Meredith; McEnhill, Paul; Panesar, Sukhmeet S; Parry, Gareth; Rees, Philippa; Shiels, Emma; Sheikh, Aziz; Ward, Hope Olivia; Williams, Huw; Wood, Fiona; Donaldson, Liam; Edwards, Adrian

    2015-01-01

    Introduction Incident reports contain descriptions of errors and harms that occurred during clinical care delivery. Few observational studies have characterised incidents from general practice, and none of these have been from the England and Wales National Reporting and Learning System. This study aims to describe incidents reported from a general practice care setting. Methods and analysis A general practice patient safety incident classification will be developed to characterise patient safety incidents. A weighted-random sample of 12 500 incidents describing no harm, low harm and moderate harm of patients, and all incidents describing severe harm and death of patients will be classified. Insights from exploratory descriptive statistics and thematic analysis will be combined to identify priority areas for future interventions. Ethics and dissemination The need for ethical approval was waivered by the Aneurin Bevan University Health Board research risk review committee given the anonymised nature of data (ABHB R&D Ref number: SA/410/13). The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers. PMID:26628526

  13. What Happened, and Why: Toward an Understanding of Human Error Based on Automated Analyses of Incident Reports. Volume 1

    NASA Technical Reports Server (NTRS)

    Maille, Nicolas P.; Statler, Irving C.; Ferryman, Thomas A.; Rosenthal, Loren; Shafto, Michael G.; Statler, Irving C.

    2006-01-01

    The objective of the Aviation System Monitoring and Modeling (ASMM) project of NASA s Aviation Safety and Security Program was to develop technologies that will enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. This presents a particular challenge in the aviation system where people are key components and human error is frequently cited as a major contributing factor or cause of incidents and accidents. In the aviation "world", information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. This report describes a conceptual model and an approach to automated analyses of textual data sources for the subjective perspective of the reporter of the incident to aid in understanding why an incident occurred. It explores a first-generation process for routinely searching large databases of textual reports of aviation incident or accidents, and reliably analyzing them for causal factors of human behavior (the why of an incident). We have defined a generic structure of information that is postulated to be a sound basis for defining similarities between aviation incidents. Based on this structure, we have introduced the simplifying structure, which we call the Scenario as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. We believe that it will be possible to design an automated analysis process guided by the structure of the Scenario that will aid aviation-safety experts to understand the systemic issues that are conducive to human error.

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

    ERIC Educational Resources Information Center

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

    2010-01-01

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

  15. Harms from discharge to primary care: mixed methods analysis of incident reports

    PubMed Central

    Williams, Huw; Edwards, Adrian; Hibbert, Peter; Rees, Philippa; Prosser Evans, Huw; Panesar, Sukhmeet; Carter, Ben; Parry, Gareth; Makeham, Meredith; Jones, Aled; Avery, Anthony; Sheikh, Aziz; Donaldson, Liam; Carson-Stevens, Andrew

    2015-01-01

    Background Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital. Aim To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice. Design and setting A mixed methods analysis of 598 patient safety incident reports in England and Wales related to ‘Discharge’ from the National Reporting and Learning System. Method Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice. Results A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with ‘safe discharge’ checklists, discharge coordinators, and family involvement. Conclusion Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely. PMID:26622036

  16. Rising incidence of early-onset colorectal cancer in Australia over two decades: report and review.

    PubMed

    Young, Joanne P; Win, Aung Ko; Rosty, Christophe; Flight, Ingrid; Roder, David; Young, Graeme P; Frank, Oliver; Suthers, Graeme K; Hewett, Peter J; Ruszkiewicz, Andrew; Hauben, Ehud; Adelstein, Barbara-Ann; Parry, Susan; Townsend, Amanda; Hardingham, Jennifer E; Price, Timothy J

    2015-01-01

    The average age at diagnosis for colorectal cancer (CRC) in Australia is 69, and the age-specific incidence rises rapidly after age 50 years. The incidence has stabilized or is declining in older age groups in Australia during recent decades, possibly related to the increased uptake of screening and high-risk surveillance. In the same time frame, a rising incidence of CRC in younger adults has been well-documented in the United States. This rise in incidence in the young has not been reported from other countries that share long-term exposure to westernised urban lifestyles. Using data from the Australian Institute of Health and Welfare, we examined trends in national incidence rates for CRC under age 50 years and observed that rates in people under age 40 years have been rising for the last two decades. We further performed a review of the literature regarding CRC in young adults to outline the extent of current understanding, explore potential risk factors such as obesity, alcohol, and sedentary lifestyles, and to identify the questions remaining to be addressed. Although absolute numbers might not justify a population screening approach, the dispersal of young adults with CRC across the primary health-care system decreases probability of their recognition. Patient and physician awareness, aided by stool and emerging blood-screening tests and risk profiling tools, have the potential to aid in identification of those young adults who would most benefit from a colonoscopy through early detection of CRCs or by removal of advanced polyps. PMID:25251195

  17. The Canadian Incidence Study of Reported Child Abuse and Neglect: a partnership.

    PubMed

    Tonmyr, L

    2015-01-01

    In the mid-1990s, Health Canada's Family Violence Prevention Unit commissioned a study to assess the possibility of collecting child maltreatment data from child welfare agencies across Canada. A Health Canada group responsible for maternal and child health surveillance built on the results of this study. This group consulted widely with provincial and territorial partners to build a surveillance system, resulting in a truly collaborative effort that led to the implementation of the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS). This was a remarkable accomplishment considering the challenge of working with multiple partners, different legislative frameworks and the stigma that often accompanies the experience of child maltreatment. PMID:26605558

  18. PAIRS, The GIS-Based Incident Response System for Pennsylvania, and NASA

    NASA Technical Reports Server (NTRS)

    Conrad, Eric; Arbegast, Daniel; Maynard, Nancy; Vicente, Gilberto

    2003-01-01

    Over the past several years the Pennsylvania Departments of Environmental Protection (DEP), Health (DOH), and Agriculture (PDA) built the GIs-based Pennsylvania West Nile Surveillance System. That system has become a model for collecting data that has a field component, laboratory component, reporting and mapping component, and a public information component. Given the success of the West Nile Virus System and the events of September 11, 2001, DEP then embarked on the development of the Pennsylvania Incident Response System, or PAIRS. PAIRS is an effective GIs-based approach to providing a system for response to incidents of any kind, including terrorism because it is building upon the existing experience, infrastructure and databases that were successfully developed to respond to the West Nile Virus by DEP, DOH, and PDA. The proposed system can be described as one that supports data acquisition, laboratory forensics, decision making/response, and communications. Decision makers will have tools to view and analyze data from various sources and, at the same time, to communicate with the large numbers of people responding to the same incident. Recent collaborations with NASA partners are creating mechanisms for the PAIRS system to incorporate space-based and other remote sensing geophysical parameters relevant to public health assessment and management, such as surface temperatures, precipitation, land cover/land use change, and humidity. This presentation will describe the PAIRS system and outline the Pennsylvania-NASA collaboration for integration of space-based data into the PAIRS system.

  19. Longitudinal trends in organophosphate incidents reported to the National Pesticide Information Center, 1995–2007

    PubMed Central

    2009-01-01

    Background Regulatory decisions to phase-out the availability and use of common organophosphate pesticides among the general public were announced in 2000 and continued through 2004. Based on revised risk assessments, chlorpyrifos and diazinon were determined to pose unacceptable risks. To determine the impact of these decisions, organophosphate (OP) exposure incidents reported to the National Pesticide Information Center (NPIC) were analyzed for longitudinal trends. Methods Non-occupational human exposure incidents reported to NPIC were grouped into pre- (1995–2000) and post-announcement periods (2001–2007). The number of total OP exposure incidents, as well as reports for chlorpyrifos, diazinon and malathion, were analyzed for significant differences between these two periods. The number of informational inquiries from the general public was analyzed over time as well. Results The number of average annual OP-related exposure incidents reported to NPIC decreased significantly between the pre- and post-announcement periods (p < 0.001). A significant decrease in the number of chlorpyrifos and diazinon reports was observed over time (p < 0.001). No significant difference in the number of incident reports for malathion was observed (p = 0.4), which was not phased-out of residential use. Similar to exposure incidents, the number of informational inquiries received by NPIC declined over time following the phase-out announcement. Conclusion Consistent with other findings, the number of chlorpyrifos and diazinon exposure incidents reported to NPIC significantly decreased following public announcement and targeted regulatory action. PMID:19379510

  20. Understanding patient-to-worker violence in hospitals: a qualitative analysis of documented incident reports

    PubMed Central

    Arnetz, Judith E.; Hamblin, Lydia; Essenmacher, Lynnette; Upfal, Mark J.; Ager, Joel; Luborsky, Mark

    2016-01-01

    Aim To explore catalysts to, and circumstances surrounding, patient-to-worker violent incidents recorded by employees in a hospital system database. Background Violence by patients towards healthcare workers (Type II workplace violence) is a significant occupational hazard in hospitals worldwide. Studies to date have failed to investigate its root causes due to a lack of empirical research based on documented episodes of patient violence. Design Qualitative content analysis. Methods Content analysis was conducted on the total sample of 214 Type II incidents documented in 2011 by employees of an American hospital system with a centralized reporting system. Findings The majority of incidents were reported by nurses (39·8%), security staff (15·9%) and nurse assistants (14·4%). Three distinct themes were identified from the analysis: Patient Behaviour, Patient Care and Situational Events. Specific causes of violence related to Patient Behaviour were cognitive impairment and demanding to leave. Catalysts related to patient care were the use of needles, patient pain/discomfort and physical transfers of patients. Situational factors included the use/presence of restraints; transitions in the care process; intervening to protect patients and/or staff; and redirecting patients. Conclusions Identifying catalysts and situations involved in patient violence in hospitals informs administrators about potential targets for intervention. Hospital staff can be trained to recognize these specific risk factors for patient violence and can be educated in how to best mitigate or prevent the most common forms of violent behaviour. A social–ecological model can be adapted to the hospital setting as a framework for prevention of patient violence towards staff. PMID:25091833

  1. Nervous System and Intracranial Tumour Incidence by Ethnicity in England, 2001–2007: A Descriptive Epidemiological Study

    PubMed Central

    Maile, Edward J.; Barnes, Isobel; Finlayson, Alexander E.; Sayeed, Shameq; Ali, Raghib

    2016-01-01

    Background There is substantial variation in nervous system and intracranial tumour incidence worldwide. UK incidence data have limited utility because they group these diverse tumours together and do not provide data for individual ethnic groups within Blacks and South Asians. Our objective was to determine the incidence of individual tumour types for seven individual ethnic groups. Methods We used data from the National Cancer Intelligence Network on tumour site, age, sex and deprivation to identify 42,207 tumour cases. Self-reported ethnicity was obtained from the Hospital Episode Statistics database. We used mid-year population estimates from the Office for National Statistics. We analysed tumours by site using Poisson regression to estimate incidence rate ratios comparing non-White ethnicities to Whites after adjustment for sex, age and deprivation. Results Our study showed differences in tumour incidence by ethnicity for gliomas, meningiomas, pituitary tumours and cranial and paraspinal nerve tumours. Relative to Whites; South Asians, Blacks and Chinese have a lower incidence of gliomas (p<0.01), with respective incidence rate ratios of 0.68 (confidence interval: 0.60–0.77), 0.62 (0.52–0.73) and 0.58 (0.41–0.83). Blacks have a higher incidence of meningioma (p<0.01) with an incidence rate ratio of 1.29 (1.05–1.59) and there is heterogeneity in meningioma incidence between individual South Asian ethnicities. Blacks have a higher incidence of pituitary tumours relative to Whites (p<0.01) with an incidence rate ratio of 2.95 (2.37–3.67). There is heterogeneity in pituitary tumour incidence between individual South Asian ethnicities. Conclusions We present incidence data of individual tumour types for seven ethnic groups. Current understanding of the aetiology of these tumours cannot explain our results. These findings suggest avenues for further work. PMID:27135830

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

    ERIC Educational Resources Information Center

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

    1999-01-01

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

  3. 30 CFR 285.833 - What are the reporting requirements for incidents requiring written notification?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... incidents requiring written notification? 285.833 Section 285.833 Mineral Resources MINERALS MANAGEMENT... OUTER CONTINENTAL SHELF Environmental and Safety Management, Inspections, and Facility Assessments for Activities Conducted Under SAPs, COPs and GAPs Incident Reporting and Investigation § 285.833 What are...

  4. A consensus based template for reporting of pre-hospital major incident medical management

    PubMed Central

    2014-01-01

    Background Structured reporting of major incidents has been advocated to improve the care provided at future incidents. A systematic review identified ten existing templates for reporting major incident medical management, but these templates are not in widespread use. We aimed to address this challenge by designing an open access template for uniform reporting of data from pre-hospital major incident medical management that will be tested for feasibility. Methods An expert group of thirteen European major incident practitioners, planners or academics participated in a four stage modified nominal group technique consensus process to design a novel reporting template. Initially, each expert proposed 30 variables. Secondly, these proposals were combined and each expert prioritized 45 variables from the total of 270. Thirdly, the expert group met in Norway to develop the template. Lastly, revisions to the final template were agreed via e-mail. Results The consensus process resulted in a template consisting of 48 variables divided into six categories; pre-incident data, Emergency Medical Service (EMS) background, incident characteristics, EMS response, patient characteristics and key lessons. Conclusions The expert group reached consensus on a set of key variables to report the medical management of pre-hospital major incidents and developed a novel reporting template. The template will be freely available for downloading and reporting on http://www.majorincidentreporting.org. This is the first global open access database for pre-hospital major incident reporting. The use of a uniform dataset will allow comparative analysis and has potential to identify areas of improvement for future responses. PMID:24517242

  5. 46 CFR 148.115 - Report of incidents.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... by this part must also be reported as required under 49 CFR 171.15, if applicable. A copy of the written report required under 49 CFR 171.16 must also be sent to the Commandant (CG-ENG-5), Attn: Hazardous Materials Division, U.S. Coast Guard Stop 7509, 2703 Martin Luther King Jr. Avenue SE.,...

  6. Safety awareness, pilot education, and incident reporting programs

    NASA Technical Reports Server (NTRS)

    Enders, J.

    1984-01-01

    Education in safety awareness, pilot training, and accident reporting is discussed. Safety awareness and risk management are examined. Both quantitative and qualitive risk management are explored. Information dissemination on safety is considered.

  7. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... to report a fatality caused by a heart attack at work? Yes, your local OSHA Area Office director will decide whether to investigate the incident, depending on the circumstances of the heart attack. (6) Do...

  8. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... to report a fatality caused by a heart attack at work? Yes, your local OSHA Area Office director will decide whether to investigate the incident, depending on the circumstances of the heart attack. (6) Do...

  9. 28 CFR 541.7 - Unit Discipline Committee (UDC) review of the incident report.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ..., 28 CFR part 542, subpart B. ... the incident report. 541.7 Section 541.7 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT INMATE DISCIPLINE AND SPECIAL HOUSING UNITS Inmate Discipline...

  10. 30 CFR 250.187 - What are MMS' incident reporting requirements?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... CFR 254.46. ... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What are MMS' incident reporting requirements? 250.187 Section 250.187 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF THE...

  11. 14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... Consumer Protection Division a report on any incidents involving the loss, injury, or death of an animal... of transportation, is being kept as a pet in a family household in the United States....

  12. 14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Consumer Protection Division a report on any incidents involving the loss, injury, or death of an animal... of transportation, is being kept as a pet in a family household in the United States....

  13. Second Workshop on the Investigation and Reporting of Incidents and Accidents, IRIA 2003

    NASA Technical Reports Server (NTRS)

    Hayhurst, Kelly J. (Compiler); Holloway, C. Michael (Compiler)

    2003-01-01

    This publication consists of papers presented at the Second Workshop on the Investigation and Reporting of Incidents and Accidents, IRIA 2003, sponsored by NASA Langley Research Center and the University of Virginia.

  14. Problem Reporting System

    NASA Technical Reports Server (NTRS)

    Potter, Don; Serian, Charles; Sweet, Robert; Sapir, Babak; Gamez, Enrique; Mays, David

    2008-01-01

    The Problem Reporting System (PRS) is a Web application, running on two Web servers (load-balanced) and two database servers (RAID-5), which establishes a system for submission, editing, and sharing of reports to manage risk assessment of anomalies identified in NASA's flight projects. PRS consolidates diverse anomaly-reporting systems, maintains a rich database set, and incorporates a robust engine, which allows tracking of any hardware, software, or paper process by configuring an appropriate life cycle. Global and specific project administration and setup tools allow lifecycle tailoring, along with customizable controls for user, e-mail, notifications, and more. PRS is accessible via the World Wide Web for authorized user at most any location. Upon successful log-in, the user receives a customizable window, which displays time-critical 'To Do' items (anomalies requiring the user s input before the system moves the anomaly to the next phase of the lifecycle), anomalies originated by the user, anomalies the user has addressed, and custom queries that can be saved for future use. Access controls exist depending on a user's role as system administrator, project administrator, user, or developer, and then, further by association with user, project, subsystem, company, or item with provisions for business-to-business exclusions, limitations on access according to the covert or overt nature of a given project, all with multiple layers of filtration, as needed. Reporting of metrics is built in. There is a provision for proxy access (in which the user may choose to grant one or more other users to view screens and perform actions as though they were the user, during any part of a tracking life cycle - especially useful during tight build schedules and vacations to keep things moving). The system also provides users the ability to have an anomaly link to or notify other systems, including QA Inspection Reports, Safety, GIDEP (Government-Industry Data Exchange Program

  15. 77 FR 69925 - Assessment of Hazardous Materials Incident Data Collection, Analysis, Reporting, and Use

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-21

    ... for an assessment to improve the collection, analysis, reporting, and use of data related to accidents... Department to conduct an assessment to improve the collection, analysis, reporting, and use of data related... improving the collection, analysis, reporting, and use of data related to accidents and incidents...

  16. 40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

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

  17. Effectiveness and Sustainability of Education about Incident Reporting at a University Hospital in Japan

    PubMed Central

    Yamashita, Yuichi; Tanihara, Shinichi; Maeda, Chiemi

    2014-01-01

    Objectives The aim of this study was to evaluate the effectiveness and sustainability of educational interventions to encourage incident reporting. Methods This was a quasi-experimental design. The study involved nurses working in two gastroenterology surgical wards at Fukuoka University Hospital, Japan. The number of participants on each ward was 26 nurses at baseline. For the intervention group, we provided 15 minutes of education about patient safety and the importance of incident reporting once per month for six months. After the completion of the intervention, we compared incident reporting in the subsequent 12 months for both groups. Questionnaires about reasons/motives for reporting were administered three times, before the intervention, after the intervention, and six months after the intervention for both the intervention group and the control group. Results For the intervention group, incident reporting during the 6 months after the intervention period increased significantly compared with the baseline. During the same period, the reasons and motives for reporting changed significantly in the intervention group. The increase in reported incidents during the 6- to 12-month period following the intervention was not significant. In the control group, there was no significant difference during follow-up compared with the baseline. Conclusions A brief intervention about patient safety changed the motives for reporting incidents and the frequency of incidents reported by nurses working in surgical wards in a university hospital in Japan. However, the effect of the education decreased after six months following the education. Regular and long-term effort is required to maintain the effect of education. PMID:25152834

  18. 78 FR 14877 - Pipeline Safety: Incident and Accident Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-07

    ... certain circumstances. PHMSA published a Federal Register notice on April 13, 2012, (77 FR 22387) inviting... Systems'' forms. On September 21, 2012, PHMSA published a subsequent Federal Register notice (77 FR 58616) to respond to comments requested by (77 FR 22387), provide the public with an additional 30 days...

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

    PubMed Central

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

    2016-01-01

    Purpose Acquisition of human papillomavirus (HPV) in women occurs predominantly through vaginal sex. However, HPV has been detected in girls reporting no previous sex. We aimed to determine incidence and risk factors for HPV acquisition in girls who report no previous sex in Tanzania, a country with high HPV prevalence and cervical cancer incidence. Methods We followed 503 adolescent girls aged 15–16 years in Mwanza, Tanzania, with face-to-face interviews and self-administered vaginal swabs every 3 months for 18 months; 397 girls reported no sex before enrollment or during follow-up; of whom, 120 were randomly selected. Samples from enrollment, 6-, 12-, and 18-month visits were tested for 37 HPV genotypes. Incidence, clearance, point prevalence, and duration of any HPV and genotype-specific infections were calculated and associated factors were evaluated. Results Of 120 girls who reported no previous sex, 119 were included, contributing 438 samples. HPV was detected in 51 (11.6%) samples. The overall incidence of new HPV infections was 29.4/100 person-years (95% confidence interval: 15.9–54.2). The point prevalence of vaccine types HPV-6,-11,-16, and -18 was .9%, .9%, 2.0%, and 0%, respectively. Spending a night away from home and using the Internet were associated with incident HPV, and reporting having seen a pornographic movie was inversely associated with HPV incidence. Conclusions Incident HPV infections were detected frequently in adolescent girls who reported no previous sex over 18 months. This is likely to reflect under-reporting of sex. A low-point prevalence of HPV genotypes in licensed vaccines was seen, indicating that vaccination of these girls might still be effective. PMID:26725717

  20. Incident reporting by acute pain service at a tertiary care university hospital

    PubMed Central

    Ahmed, Aliya; Yasir, Muhammad

    2015-01-01

    Background and Aims: Provision of effective and safe postoperative pain management is the principal responsibility of acute pain services (APSs). Continuous quality assurance is essential for high-quality patient care. We initiated anonymous reporting of critical incidents by APS to ensure continuous quality improvement and here present prospectively collected data on the reported incidents. Our objective was to analyze the frequency and nature of incidents and to see if any harm was caused to patients. Material and Methods: Data were collected from January 1, 2012 to September 30, 2013. An incident related to pain management was defined as An incident that occurs in a patient receiving pain management supervised by APS, and causes or has the potential to cause harm or affects patient safety. A form was filled including incident type, personnel involved, any harm caused, and steps taken to rectify it. Frequencies and percentages were computed for categorical variables. Results: A total of 2042 patients were seen and 442 (21.64%) incidents reported during the study period, including documentation errors (136/31%), noncompliance with protocols (113/25.56%), wrong combination of drugs (56/12.66%), premature discontinuation (74/16.72%), prolonged delays in change of syringes (27/6.10%), loss to follow-up (19/4.29%), administration of contraindicated drugs (9/2.03%), catheter pull-outs (6/1.35%), and faulty equipment (2/0.45%). Steps were taken to rectify the errors accordingly. No harm was caused to any patient. Conclusion: Reporting of untoward incidents and their regular analysis by APS is recommended to ensure high-quality patient care and to provide guidance in making teaching strategies and guidelines to improve patient safety. PMID:26702208

  1. 30 CFR 250.188 - What incidents must I report to MMS and when must I report them?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What incidents must I report to MMS and when must I report them? 250.188 Section 250.188 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT... surface equipment or procedures. (4) All fires and explosions. (5) All reportable releases of...

  2. Conceptualisation of socio-technical integrated information technology solutions to improve incident reporting through Maslow's hierarchy of needs: a qualitative study of junior doctors.

    PubMed

    Yee, Kwang Chien

    2007-01-01

    Medical errors are common, especially within the acute healthcare delivery. The identification of systemic factors associated with adverse events and the construction of models to improve the safety of the healthcare system seems straightforward, this process has been proven to be much more difficult in the realism of medical practice due to the failure of the incident reporting system to capture the essential information, especially from the perspective of junior doctors. The failure of incidence reporting system has been related to the lack of socio-technical consideration for both system designs and system implementations. The main reason of non-reporting can be conceptualised through the motivation psychology model: Maslow's hierarchy of needs; in order to achieve a change in the socio-cultural domain for incident reporting. This paper presents a qualitative research methodology approach to generate contextual-rich insights into the socio-cultural and technological factors of incident reporting among junior doctors. The research illuminates the guiding principles for future socio-technical integrated information communication technology designs and implementations. Using Maslow's hierarchy of needs as the conceptual framework, the guiding principles aim to design electronic incident reporting systems which will motivate junior doctors to participate in the process. This research paper aims to make a significant contribution to the fields of socio-technical systems and medical errors management. The design and implementation of the new incident reporting system has great potential to motivate junior doctors to change the culture of incident reporting and to work towards a safer future healthcare system. PMID:17917200

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

    ERIC Educational Resources Information Center

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

    2016-01-01

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

  4. Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial

    PubMed Central

    Verbakel, Natasha J; Langelaan, Maaike; Verheij, Theo JM; Wagner, Cordula; Zwart, Dorien LM

    2015-01-01

    Background A constructive safety culture is essential for the successful implementation of patient safety improvements. Aim To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture. Design and setting A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands. Method The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires. Results The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups. Conclusion Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety. PMID:25918337

  5. Reported fatal and non-fatal incidents involving tourists in Thailand, July 1997-June 1999.

    PubMed

    Leggat, Peter A; Leggat, Frances W

    2003-05-01

    Objectives. To examine fatal and non-fatal incidents involving tourists in Thailand. Methods. Press records from a major English language newspaper for the period from July 1997 to June 1999 were examined for reports of fatal and non-fatal incidents involving tourists. Results. From July 1997 to June 1999, up to 233 deaths were reported and up to a further 216 were reported injured in incidents involving tourists. One hundred and one deaths and 45 injured were reported following one major domestic jet aircraft crash in southern Thailand, however, it was not stated what proportion of casualties were tourists. Approximately 90 people perished in a single hotel fire in southeast Thailand. Most of the victims were local travellers attending meetings of two Thai companies. Sixteen deaths and 86 injured resulted from five road accidents. The majority of deaths and injuries involved foreigners. Twelve deaths and at least 33 injured resulted from three ferry and tour boat accidents. Most victims were reported to be foreigners. Three deaths and 35 injured resulted from a single cable car accident in northern Thailand. Most of these were Thai tourists, however, four of the injured were foreigners. Eight deaths and six injured resulted from 11 muggings and other violent incidents. All were foreigners. Six deaths were reportedly connected to a scam at the airport in Bangkok involving unlicensed airport taxis. Three deaths and four injured were due to other reported incidents. Conclusions. Newspaper reports of fatal and non-fatal incidents involving tourists in Thailand were probably uncommon, particularly given the volume of tourists entering the Kingdom, although better reporting mechanisms are needed. With the exception of the unusual major incidents, most reported fatal and non-fatal incidents involving tourists were due to road trauma and other transportation accidents, muggings, and occasional water sports and other accidents, which could occur at any major tourist

  6. 75 FR 33760 - Information Collection; Virtual Incident Procurement (VIPR) System Existing Vendor Survey

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-15

    ... Forest Service Information Collection; Virtual Incident Procurement (VIPR) System Existing Vendor Survey... organizations on the new information collection, Virtual Incident Procurement (VIPR) System Existing Vendor User... Acquisition Management Systems; 2150 Centre Ave., Bldg. A, Suite 317; Fort Collins, CO 80526. The public...

  7. Hospital incident command system: tool for a TJC accreditation survey.

    PubMed

    Shaw, Kenneth A; Wilson, Karen D; Brown, Judy E

    2016-01-01

    The unannounced Joint Commission (TJC) accreditation survey can prove just as unpredictable and challenging as any other incident. In this article, the authors describe a plan developed by a hospital emergency response team that has proven successful in dealing with TJC and other surveys. PMID:26978959

  8. Problem of small numbers in reporting of cancer incidence and mortality rates in Indian cancer registries.

    PubMed

    Takiar, Ramnath; Nadayil, Deenu; Nandakumar, A

    2009-01-01

    The present paper examines the problem of small numbers (<20 cases) associated with many sites of cancers in Indian cancer registries. The cancer incidence data of 14 Population Based Cancer Registries for the periods of 2001-03 and 2004-05 were utilized for the analysis. Nine out of 14 registries had more than 50% of their sites being associated with small numbers while seven registries had 50% of their sites having as low as 5 cases. Sites associated with small numbers showed a lot of variation and significant differences in their incidence rates within two years duration which are not feasible. The percentage age distribution was also found to vary with different periods. The paper has effectively shown the effect of population size on incidence rates. For a registry of population size 300,000, the incidence rate of 6 can very well be unstable. There are many registries in the world with their population size less than 200,000. Even in the case of registries with high population (>or= 500,000) the practice is to report the cancer incidence by different ethnic groups with populations less than 200,000 and thereby introduce the problem of small numbers in reporting the incidences of various cancer sites. To overcome this problem, pooling of data over broad age groups or ten years age groups or 3 to 5 years periods is one immediate solution. PMID:19827889

  9. Rating and Classification of Incident Reporting in Radiology in a Large Academic Medical Center.

    PubMed

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

    2016-01-01

    The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs. PMID:27020256

  10. Multi-media authoring - Instruction and training of air traffic controllers based on ASRS incident reports

    NASA Technical Reports Server (NTRS)

    Armstrong, Herbert B.; Roske-Hofstrand, Renate J.

    1989-01-01

    This paper discusses the use of computer-assisted instructions and flight simulations to enhance procedural and perceptual motor task training. Attention is called to the fact that incorporating the accident and incident data contained in reports filed with the Aviation Safety Reporting System (ASRS) would be a valuable training tool which the learner could apply for other situations. The need to segment the events is emphasized; this would make it possible to modify events in order to suit the needs of the training environment. Methods were developed for designing meaningful scenario development on runway incursions on the basis of analysis of ASRS reports. It is noted that, while the development of interactive training tools using the ASRS and other data bases holds much promise, the design and production of interactive video programs and laser disks are very expensive. It is suggested that this problem may be overcome by sharing the costs of production to develop a library of materials available to a broad range of users.

  11. EP&R Standards Project Report: Technical Review of National Incident Management Standards

    SciTech Connect

    Stenner, Robert D.

    2007-04-24

    The importance and necessity for a fully developed and implemented National Incident Management System (NIMS) has been demonstrated in recent years by the impact of national events such as Hurricane Katrina in 2005. Throughout the history of emergency response to major disasters, especially when multiple response organizations are involved, there have been systemic problems in the consistency and uniformity of response operations. Identifying national standards that support the development and implementation of NIMS is key to helping solve these systemic problems. The NIMS seeks to provide uniformity and consistency for incident management by using common terminology and protocols that will enable responders to coordinate their efforts to ensure an efficient response.

  12. A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward.

    PubMed

    Webster, Craig S; Anderson, David J

    2002-08-01

    This paper discusses an anonymous incident reporting scheme to reduce drug administration error on the hospital ward, as part of an effective, non-punitive, systems-focused approach to safety. Drug error is costly in terms of increased hospital stay, resources consumed, patient harm, lives lost and careers ruined. Safety initiatives that focus, not on blaming individuals, but on improving the wider system in which personnel work have been adopted in a number of branches of health care. However, in nursing, blame remains the predominant approach for dealing with error, and the ward has seen little application of the systems approach to safety. Safety interventions founded on an effective incident scheme typically pay for themselves in terms of dollar savings arising from averted harm. Recent calls for greater health-care safety require finding new ways to make drug administration safer throughout the hospital, and the scope for such safety gains on the hospital ward remains considerable. PMID:12100674

  13. Incidence and severity of reported acute sports injuries in 35 sports using insurance registry data.

    PubMed

    Åman, M; Forssblad, M; Henriksson-Larsén, K

    2016-04-01

    Acute injuries in sport are still a problem where limited knowledge of incidence and severity in different sports at national level exists. In Sweden, 80% of the sports federations have their mandatory injury insurance for all athletes in the same insurance company and injury data are systematically kept in a national database. The aim of the study was to identify high-risk sports with respect to incidence of acute and severe injuries in 35 sports reported to the database. The number and incidences of injuries as well as injuries leading to permanent medical impairment (PMI) were calculated during 2008-2011. Each year approximately 12,000 injuries and 1,162,660 licensed athletes were eligible for analysis. Eighty-five percent of the injuries were reported in football, ice hockey, floorball, and handball. The highest injury incidence as well as PMI was in motorcycle, handball, skating, and ice hockey. Females had higher risk of a PMI compared with males in automobile sport, handball, floorball, and football. High-risk sports with numerous injuries and high incidence of PMI injuries were motorcycle, handball, ice hockey, football, floorball, and automobile sports. Thus, these sports ought to be the target of preventive actions at national level. PMID:25850826

  14. 76 FR 34812 - Proposed Information Collection (Report of Medical, Legal, and Other Expenses Incident to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-14

    ... for Injury or Death) Activity; Comment Request AGENCY: Department of Veterans Affairs, Veterans... Expenses Incident to Recovery for Injury or Death, VA Form 21-8416b. OMB Control Number: 2900-0545. Type of... report compensation awarded by another entity or government agency for personal injury or death....

  15. Reported and Actual Incidence of Asthma in Teenage Athletes: A Dangerous Discrepancy

    ERIC Educational Resources Information Center

    Swenson, Ruth; Stewart, Craig

    2004-01-01

    Asthma in athletes is a serious concern for coaches, trainers and athletic directors because of its threat to general health and its apparent continued increase in individuals of all ages. Of special concern is the discrepancy between the reported incidence and the actual occurrence of asthma in athletes. The purpose of this study was to continue…

  16. 41 CFR 102-33.450 - How must we report accident and incident data?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ...-MANAGEMENT OF GOVERNMENT AIRCRAFT Reporting Information on Government Aircraft Accident and Incident Data... Street, NW., Washington, DC 20405. Common Aviation Management Information Standard (C-AMIS) ... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false How must we...

  17. Major Findings from the Canadian Incidence Study of Reported Child Abuse and Neglect

    ERIC Educational Resources Information Center

    Trocme, Nico M.; Tourigny, Marc; MacLaurin, Bruce; Fallon, Barbara

    2003-01-01

    Objective: To present key findings from the Canadian Incidence Study of Reported Child Maltreatment (CIS) in sufficient detail to provide a basis for international comparisons in terms of forms and severity of maltreatment and the age and sex of victims. Method: A survey conducted in a random sample of 51 child welfare service areas across Canada…

  18. Preparation of Personnel for Service to Low-Incidence Disability Populations: Final Report.

    ERIC Educational Resources Information Center

    Engleman, Melissa Darrow; Maddox, June I.

    This final report describes the federally-funded Transition Challenge-North Carolina Project (TRAC-NC), a project that prepared 45 newly qualified individuals to serve students with low-incidence disabilities over the last four years. The project provides: (1) add-on certification and/or master's degree training to persons preparing to teach…

  19. 30 CFR 250.187 - What are MMS' incident reporting requirements?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... liquid pollutants in accordance with 30 CFR 254.46. ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What are MMS' incident reporting requirements? 250.187 Section 250.187 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, REGULATION,...

  20. 30 CFR 285.830 - What are my incident reporting requirements?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... liquid pollutants in accordance with 30 CFR 254.46. ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What are my incident reporting requirements? 285.830 Section 285.830 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, REGULATION,...

  1. 30 CFR 285.832 - How do I report incidents requiring immediate notification?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... notification? 285.832 Section 285.832 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, REGULATION, AND... OUTER CONTINENTAL SHELF Environmental and Safety Management, Inspections, and Facility Assessments for Activities Conducted Under SAPs, COPs and GAPs Incident Reporting and Investigation § 285.832 How do I...

  2. 30 CFR 285.830 - What are my incident reporting requirements?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... accordance with 30 CFR 254.46. ... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What are my incident reporting requirements? 285.830 Section 285.830 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF THE...

  3. Reported incidence of occupational asthma in the United Kingdom, 1989-90.

    PubMed Central

    Meredith, S

    1993-01-01

    STUDY OBJECTIVE--To estimate the incidence of occupational asthma seen by respiratory and occupational physicians in the UK in 1989 and 1990. DESIGN--New cases of occupational asthma were taken from a national reporting scheme, the Surveillance of Work-related and Occupational Respiratory Disease Project (SWORD). Estimates of the working population from the Labour Force Survey were used to calculate reported incidence by age group, sex, occupation, and region. SETTING--The SWORD project is a scheme for the reporting of new cases of work-related respiratory disease by thoracic and occupational physicians from throughout the UK which began in 1989. PATIENTS--In 1989 and 1990, of 4229 cases reported, 1085 (26%) were in patients with occupational asthma. MAIN RESULTS--Only half the reported cases were attributed to agents prescribed under the Industrial Injuries Scheme. There was considerable diversity in risk by occupation, with highest annual rates in welders, solderers, and electronic assemblers (175/million), laboratory workers (188/million), metal treaters (267/million), bakers (334/million), plastics workers (337/million), chemical processors (364/million), and spray painters (658/million). Crude rates in men were higher than in women, but rates within occupations were similar in both sexes. Rates of disease rose with age; adjustment for occupation increased the gradient. Regional differences were only partly explained by diversity of industry and were probably mainly due to variation in levels of ascertainment and reporting. CONCLUSIONS--Asthma is the most commonly reported occupational lung disease in the UK. The incidence in the general population is unknown, but it was estimated that the incidence of new cases seen by respiratory and occupational physicians was about three times that reported. High relative risks were found in a number of occupations in which effective control of the work environment is urgently required. PMID:8120500

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

    PubMed Central

    2011-01-01

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

  5. Analysis of the sex ratio of reported gonorrhoea incidence in Shenzhen, China

    PubMed Central

    Xiong, Mingzhou; Lan, Lina; Feng, Tiejian; Zhao, Guanglu; Wang, Feng; Hong, Fuchang; Wu, Xiaobing; Zhang, Chunlai; Wen, Lizhang; Liu, Aizhong; Best, John McCulloch; Tang, Weiming

    2016-01-01

    Objective To assess the clinical process of gonorrhoea diagnosis and report in China, and to determine the difference of sex ratio between reported incidence based on reporting data and true diagnosis rate based on reference tests of gonorrhoea. Setting A total of 26 dermatology and sexually transmitted disease (STD) departments, 34 obstetrics-gynaecology clinics and 28 urology outpatient clinics selected from 34 hospitals of Shenzhen regarded as our study sites. Participants A total of 2754 participants were recruited in this study, and 2534 participants completed the questionnaire survey and provided genital tract secretion specimens. There were 1106 male and 1428 female participants. Eligible participants were patients who presented for outpatient STD care at the selected clinics for the first time in October 2012 were at least 18 years old, and were able to give informed consent. Outcome measures Untested rate, true-positive rate, false-negative rate and unreported rate of gonorrhoea, as well as reported gonorrhoea incidence sex ratio and true diagnosis sex ratio were calculated and used to describe the results. Results 2534 participants were enrolled in the study. The untested rate of gonorrhoea among females was significantly higher than that among males (female 88.1%, male 68.3%, p=0.001). The male-to-female sex ratios of untested rate, true-positive rate, false-negative rate and unreported rate were 1:1.3, 1.2:1, 1:1.6 and 1:1.4, respectively. The reported gonorrhoea incidence sex ratio of new diagnosed gonorrhoea was 19.8:1 (male vs female: 87/1106 vs 5/1420), while the true diagnosis sex ratio was 2.5:1 (male vs female: 161/1106 vs 84/1420). These data indicate that the sex ratio of reported gonorrhoea incidence has been overestimated by a factor of 7.9 (19.8/2.5). Conclusions We found the current reported gonorrhoea incidence and sex ratios to be inaccurate due to underestimations of gonorrhoea incidence, especially among women. PMID:26975933

  6. Systematic literature review of templates for reporting prehospital major incident medical management

    PubMed Central

    Fattah, Sabina; Rehn, Marius; Reierth, Eirik; Wisborg, Torben

    2013-01-01

    Objective To identify and describe the content of templates for reporting prehospital major incident medical management. Design Systematic literature review according to PRISMA guidelines. Data sources PubMed/MEDLINE, EMBASE, CINAHL, Scopus and Web of Knowledge. Grey literature was also searched. Eligibility criteria for selected studies Templates published after 1 January 1990 and up to 19 March 2012. Non-English language literature, except Scandinavian; literature without an available abstract; and literature reporting only psychological aspects were excluded. Results The main database search identified 8497 articles, among which 8389 were excluded based on title and abstract. An additional 96 were excluded based on the full-text. The remaining 12 articles were included in the analysis. A total of 107 articles were identified in the grey literature and excluded. The reference lists for the included articles identified five additional articles. A relevant article published after completing the search was also included. In the 18 articles included in the study, 10 different templates or sets of data are described: 2 methodologies for assessing major incident responses, 3 templates intended for reporting from exercises, 2 guidelines for reporting in medical journals, 2 analyses of previous disasters and 1 Utstein-style template. Conclusions More than one template exists for generating reports. The limitations of the existing templates involve internal and external validity, and none of them have been tested for feasibility in real-life incidents. Trial registration The review is registered in PROSPERO (registration number: CRD42012002051). PMID:23906946

  7. Reported fatal and non-fatal incidents involving tourists in Hawaii Volcanoes National Park, 1992-2002.

    PubMed

    Heggie, Travis W

    2005-08-01

    Objectives. To examine fatal and non-fatal incidents involving tourists in Hawaii Volcanoes National Park. Methods. Official press releases from the public relations office at Hawaii Volcanoes National Park were examined for reports of fatal and non-fatal incidents involving tourists. Results. Between 1992 and 2002 there were 65 press releases reporting 40 fatalities, 45 serious injuries, 53 minor injuries, and 25 no injury events. Severity information was unavailable for four additional tourists. Aircraft and backcountry incidents each accounted for 30% of all incidents followed by road incidents (22%) and frontcountry incidents (17%). Aircraft incidents reported 17 fatalities, backcountry incidents accounted for 10 fatalities, frontcountry incidents reported seven fatalities, and road incidents totaled six fatalities. One fatality was classified as a suicide. Backcountry (23) and road (10) incidents had the highest number of serious incidents. Male tourists (62) were more frequently involved in incidents than female tourists (41) and tourists aged 20-29 years and 40-49 years accounted for the highest number of fatalities and total incidents. Conclusions. Helicopter tours, hiking in areas with active lava flows, falls into steam vents and earthcracks, and driving unfamiliar rental cars in unfamiliar locations are the major activities resulting in death and serious injury. Additional factors such as tourists ignoring warning signs, wandering off-trail or hiking at night, tourists misinformed by guidebooks and other tourists, and tourists with pre-existing heart and asthma conditions are contributing causes in many incidents. The findings of this study provide information that allows prospective tourists, tourism managers, and travel health providers make informed decisions that promote safe tourism and can aid future efforts in developing preventative strategies at tourist destinations with similar environments and activities. However, in order for preventative

  8. High-reliability teams and situation awareness: implementing a hospital emergency incident command system.

    PubMed

    Autrey, Pamela; Moss, Jacqueline

    2006-02-01

    To enhance disaster preparedness, hospitals are beginning to implement the Hospital Emergency Incident Command System. Although Hospital Emergency Incident Command System provides a template for disaster preparation, its successful implementation requires an understanding of situation awareness (SA) and high-reliability teams. The authors present the concept of SA and how this concept relates to team reliability in dynamic environments. Then strategies for increasing SA and team reliability through education, training, and improved communication systems are discussed. PMID:16528147

  9. What Happened, and Why: Toward an Understanding of Human Error Based on Automated Analyses of Incident Reports. Volume 2

    NASA Technical Reports Server (NTRS)

    Ferryman, Thomas A.; Posse, Christian; Rosenthal, Loren J.; Srivastava, Ashok N.; Statler, Irving C.

    2006-01-01

    The objective of the Aviation System Monitoring and Modeling project of NASA's Aviation Safety and Security Program was to develop technologies to enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. Information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. In Volume I, the concept of the Scenario was introduced as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. In this Volume II, that study continues into the analyses of the free narratives to gain understanding as to why the incident occurred from the reporter s perspective. While this is just the first experiment, the results of our approach are encouraging and indicate that it will be possible to design an automated analysis process guided by the structure of the Scenario that can achieve the level of consistency and reliability of human analysis of narrative reports.

  10. The NASA Aviation Safety Reporting System

    NASA Technical Reports Server (NTRS)

    1983-01-01

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

  11. Rapid changes in the incidence of urinary system cancers in Turkey

    PubMed Central

    Aydın, Sabahattin; Boz, Mustafa Yücel

    2015-01-01

    Estimation of national cancer incidence for major cancer sites in Turkey has been carried out by analyzing the data obtained from active cancer registry, and published regularly by Institute of Public Health of Ministry of Health. In the light of these statistics, the incidence of urinary cancers in both sexes and their age related distributions have been discussed, paying special attention to prostate, kidney and bladder cancers. The annual incidence of all cancer cases increased gradually, reaching to 221.5 per 100,000 population in 2009, the latest confirmed figure available at present. Among males the most frequent cancers were those of the lung, prostate and bladder. The incidence rates of urinary cancers among males were 36.1, 21.4 and 6.3 per 100,000 for prostate, bladder and kidney respectively. The reliability of current data concerning the incidence of cancer has been discussed by comparing them with the previously reported national cancer data. PMID:26623151

  12. Comparing Electronic News Media Reports of Potential Bioterrorism-Related Incidents Involving Unknown White Powder to Reports Received by the United States Centers for Disease Control and Prevention and the Federal Bureau of Investigation: USA, 2009–2011

    PubMed Central

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

    2015-01-01

    There have been periodic electronic news media reports of potential bioterrorism-related incidents involving unknown substances (often referred to as “white powder”) since the 2001 intentional dissemination of Bacillus anthracis through the US Postal System. This study reviewed the number of unknown “white powder” incidents reported online by the electronic news media and compared them with unknown “white powder” incidents reported to the US Centers for Disease Control and Prevention (CDC) and the US Federal Bureau of Investigation (FBI) during a two-year period from June 1, 2009 and May 31, 2011. Results identified 297 electronic news media reports, 538 CDC reports, and 384 FBI reports of unknown “white powder.” This study showed different unknown “white powder” incidents captured by each of the three sources. However, the authors could not determine the public health implications of this discordance. PMID:25420771

  13. Harassment and Intimidation (Bullying) in Maryland Public Schools. A Report to the Maryland General Assembly on Incidents Reported under the Safe Schools Reporting Act of 2005

    ERIC Educational Resources Information Center

    Maryland State Department of Education, 2008

    2008-01-01

    The Safe Schools Reporting Act of 2005 requires that county boards of education and the Baltimore City Board of School Commissioners report incidents of harassment or intimidation against students in public schools under the county board's and commission's jurisdiction. The reporting period for the third report encompasses the 2006-2007 school…

  14. The incidence of thyroid cancer is affected by the characteristics of a healthcare system.

    PubMed

    Lee, Tae-Jin; Kim, Sun; Cho, Hong-Jun; Lee, Jae-Ho

    2012-12-01

    The aim of this study was to investigate the associations between the incidence of thyroid cancer and the characteristics of healthcare systems in OECD countries and to demonstrate that the increasing incidence of thyroid cancer is mainly due to overdiagnosis. We used a random effects panel model to regress the incidence of thyroid cancer on the characteristics of healthcare systems (i.e., share of public expenditure on health, mode of health financing, existence of referral system to secondary care, mode of payment to primary care physicians), controlling for macro context variables (i.e., GDP per capita, educational level) on a country level. Data were derived from 34 OECD countries for 2002 and 2008. The share of public expenditure on health was negatively associated with the incidence of thyroid cancer. However, it had no statistically significant effect on the mortality of thyroid cancer and on the incidence of stomach and lung cancer. In the case of colorectal cancer, it had a positive effect on the incidence rate. The upward trend of the incidence of thyroid cancer is closely related to the healthcare system that permits overdiagnosis. Increases in the proportion of public financing may help reduce the overdiagnosis of thyroid cancer. PMID:23255848

  15. 77 FR 53779 - Reports by Air Carriers on Incidents Involving Animals During Air Transport

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-04

    ...This action extends the comment period of an NPRM on the reporting of incidents involving animals during air transport that was published in the Federal Register on June 29, 2012. See 77 FR 38747. The Department of Transportation is extending the period for interested persons to submit comments on this rulemaking from August 28, 2012, to September 27, 2012. This extension is a result of a......

  16. Implementation of the National Incident Management System (NIMS)/Incident Command System (ICS) in the Federal Radiological Monitoring and Assessment Center(FRMAC) - Emergency Phase

    SciTech Connect

    NSTec Environmental Restoration

    2007-04-01

    Homeland Security Presidential Directive HSPD-5 requires all federal departments and agencies to adopt a National Incident Management System (NIMS)/Incident Command System (ICS) and use it in their individual domestic incident management and emergency prevention, preparedness, response, recovery, and mitigation programs and activities, as well as in support of those actions taken to assist state and local entities. This system provides a consistent nationwide template to enable federal, state, local, and tribal governments, private-sector, and nongovernmental organizations to work together effectively and efficiently to prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity, including acts of catastrophic terrorism. This document identifies the operational concepts of the Federal Radiological Monitoring and Assessment Center's (FRMAC) implementation of the NIMS/ICS response structure under the National Response Plan (NRP). The construct identified here defines the basic response template to be tailored to the incident-specific response requirements. FRMAC's mission to facilitate interagency environmental data management, monitoring, sampling, analysis, and assessment and link this information to the planning and decision staff clearly places the FRMAC in the Planning Section. FRMAC is not a mitigating resource for radiological contamination but is present to conduct radiological impact assessment for public dose avoidance. Field monitoring is a fact-finding mission to support this effort directly. Decisions based on the assessed data will drive public protection and operational requirements. This organizational structure under NIMS is focused by the mission responsibilities and interface requirements following the premise to provide emergency responders with a flexible yet standardized structure for incident response activities. The coordination responsibilities outlined in the NRP are based on the NIMS

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

    PubMed Central

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

    2016-01-01

    Background Law enforcement depends on cooperation from the public and crime victims to protect citizens and maintain public safety; however, many crimes are not reported to police because of fear of repercussions or because the crime is considered trivial. It is unclear how police reporting affects the incidence of future victimization. Objective To evaluate the association between reporting victimization to police and incident future victimization. Methods We conducted a retrospective cohort study using National Crime Victimization Survey 2008–2012 data. Participants were 12+ years old household members who may or may not be victimized, were followed biannually for 3 years, and who completed at least one follow-up survey after their first reported victimization between 2008 and 2012. Crude and adjusted generalized linear mixed regression for survey data with Poisson link were used to compare rates of future victimization. Results Out of 18,657 eligible participants, 41% participants reported to their initial victimization to police and had a future victimization rate of 42.8/100 person-years (PY) (95% CI: 40.7, 44.8). The future victimization rate of those who did not report to the police (59%) was 55.0/100 PY (95% CI: 53.0, 57.0). The adjusted rate ratio comparing police reporting to not reporting was 0.78 (95%CI: 0.72, 0.84) for all future victimizations, 0.80 (95% CI: 0.72, 0.90) for interpersonal violence, 0.73 (95% CI: 0.68, 0.78) for thefts, and 0.95 (95% CI: 0.84, 1.07) for burglaries. Conclusions Reporting victimization to police is associated with fewer future victimization, underscoring the importance of police reporting in crime prevention. This association may be attributed to police action and victim services provisions resulting from reporting. PMID:27466811

  18. BIENNIAL REPORTING SYSTEM (BRS)

    EPA Science Inventory

    The Biennial Reporting System (BRS) database contains biennial reports submitted by generators of hazardous wastes and facilities that treat, store or dispose of hazardous wastes. The reports are required by the Resource Conservation and Recovery Act (RCRA) under Title 40 of the ...

  19. Unemployment and lung cancer incidence in the Province of Opole. Brief report.

    PubMed

    Chawińska, Ewa; Tukiendorf, Andrzej; Miszczyk, Leszek

    2013-06-01

    In this geostatistical analysis we present the results of interrelation between unemployment rate and lung cancer incidence ratios in the Province of Opole, Poland. In the study, unemployment statistics and population data were analyzed together with the registered (histopathologically confirmed) lung cancer cases (C34, ICD10) in sex-stratified working age population (18-65 years). The data were collected in the years 2006-2008 in the Statistical Office in Opole and Opole Cancer Registry, Poland. The statistically significant positive correlation/interrelation between unemployment rate and lung cancer incidence ratios in male population was established; in females, this effect was statistically insignificant. The obtained results are consistent with the most up-to-date reports supporting the thesis that a higher burden of disease is observed in more deprived areas. The statistics may have practical relevance in terms of improving health status of the local population following economic reforms. PMID:24053069

  20. The social dimensions of safety incident reporting in maternity care: the influence of working relationships and group processes.

    PubMed

    Lindsay, Patricia; Sandall, Jane; Humphrey, Charlotte

    2012-11-01

    Over the past twenty years there has been a growing awareness of the scale and cost of adverse events in health care. In this paper we discuss findings from a study, undertaken in 2008, investigating social and cultural influences on incident reporting in maternity care in one U.K. National Health Service hospital. Maternity claims account for 50% of NHS compensation expenditure, with claims arising from poor fetal heart monitoring alone amounting to £85.8 million in 2010. Earlier studies on incident reporting used case note review and staff self-reports. We used ethnographic methods to highlight the social nature of, and social processes around, incident reporting, and the use of the collegial work group as an aid to decision-making. Incident reporting was rarely an isolated, private event, but the result of a process involving group deliberation. We suggest that incident reporting in health care should be regarded as a process rather than an event and reporting policies adjusted to accommodate group processes in order to improve reporting rates. While the paper presents findings from a single site we suggest these may add to the understanding of reporting in other care areas of health care. The key contribution this paper makes is to report the existence of a process of worker peer conferral as a decision-making aid prior to incident reporting. PMID:22884941

  1. Incidence of Type II CRISPR1-Cas Systems in Enterococcus Is Species-Dependent

    PubMed Central

    Lyons, Casandra; Raustad, Nicole; Bustos, Mario A.; Shiaris, Michael

    2015-01-01

    CRISPR-Cas systems, which obstruct both viral infection and incorporation of mobile genetic elements by horizontal transfer, are a specific immune response common to prokaryotes. Antiviral protection by CRISPR-Cas comes at a cost, as horizontally-acquired genes may increase fitness and provide rapid adaptation to habitat change. To date, investigations into the prevalence of CRISPR have primarily focused on pathogenic and clinical bacteria, while less is known about CRISPR dynamics in commensal and environmental species. We designed PCR primers and coupled these with DNA sequencing of products to detect and characterize the presence of cas1, a universal CRISPR-associated gene and proxy for the Type II CRISPR1-Cas system, in environmental and non-clinical Enterococcus isolates. CRISPR1-cas1 was detected in approximately 33% of the 275 strains examined, and differences in CRISPR1 carriage between species was significant. Incidence of cas1 in E. hirae was 73%, nearly three times that of E. faecalis (23.6%) and 10 times more frequent than in E. durans (7.1%). Also, this is the first report of CRISPR1 presence in E. durans, as well as in the plant-associated species E. casseliflavus and E. sulfureus. Significant differences in CRISPR1-cas1 incidence among Enterococcus species support the hypothesis that there is a tradeoff between protection and adaptability. The differences in the habitats of enterococcal species may exert varying selective pressure that results in a species-dependent distribution of CRISPR-Cas systems. PMID:26600384

  2. Pesticide Exposure and Self-Reported Incident Depression among Wives in the Agricultural Health Study

    PubMed Central

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

    2013-01-01

    Background Depression in women is a public health problem. Studies have reported positive associations between pesticides and depression, but few studies were prospective or presented results for women separately. Objectives We evaluated associations between pesticide exposure and incident depression among farmers’ wives in the Agricultural Health Study, a prospective cohort study in Iowa and North Carolina. Methods We used data on 16,893 wives who did not report physician-diagnosed depression at enrollment (1993-1997) and who completed a follow-up telephone interview (2005-2010). Among these wives, 1,054 reported physician diagnoses of depression at follow-up. We collected information on potential confounders and on ever use of any pesticide, 11 functional and chemical classes of pesticides, and 50 specific pesticides by wives and their husbands via self-administered questionnaires at enrollment. We used inverse probability weighting to adjust for potential confounders and to account for possible selection bias induced by the death or loss of 10,639 wives during follow-up. We used log-binomial regression models to estimate risk ratios and 95% confidence intervals. Results After weighting for age at enrollment, state of residence, education level, diabetes diagnosis, and not dropping out of the cohort, wives’ incident depression was positively associated with diagnosed pesticide poisoning, but was not associated with ever using any pesticide. Use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives’ depression. Among wives who never used pesticides, husbands’ ever use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives’ incident depression. Conclusions Our study adds further evidence that high level pesticide exposure, such as pesticide poisoning, is associated with increased risk of depression and sets a lower bound on the level of

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

    SciTech Connect

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

    2010-12-01

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

  4. Enhancing the Relevance of Incident Management Systems in Public Health Emergency Preparedness: A Novel Conceptual Framework.

    PubMed

    Bochenek, Richard; Grant, Moira; Schwartz, Brian

    2015-08-01

    We outline a conceptual framework developed to meet the needs of public health professionals in the province of Ontario for incident management system-related education and training. By using visual models, this framework applies a public health lens to emergency management, introducing concepts relevant to public health and thereby shifting the focus of emergency preparedness from a strict "doctrine" to a more dynamic and flexible approach grounded in the traditional principles of incident management systems. These models provide a foundation for further exploration of the theoretical foundations for public health emergency preparedness in practice. PMID:25991506

  5. HASCAL -- A system for estimating contamination and doses from incidents at worldwide nuclear facilities

    SciTech Connect

    Sjoreen, A.L.; Sykes, R.I.

    1995-04-01

    The Hazard Assessment System for Consequence Analysis (HASCAL) is being developed to support the analysis of radiological incidents anywhere in the world for the Defense Nuclear Agency (DNA). HASCAL is a component of the Hazard Prediction and Assessment Capability (HPAC), which is a comprehensive nuclear, biological, and chemical hazard effects planning and forecasting modeling system that is being developed by DNA. HASCAL computes best-guess estimates of the consequences of radiological incidents. HASCAL estimates the amount of radioactivity released, its atmospheric transport and deposition, and the resulting radiological doses.

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

    PubMed Central

    2011-01-01

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

  7. Cancer incidence and trihalomethane concentrations in a public drinking water system

    SciTech Connect

    Carlo, G.L.; Mettlin, C.L.

    1980-05-01

    Four thousand two hundred fifty-five cases of esophageal, stomach, colon, rectal, bladder, and pancreatic cancer reported from Erie County, NY between 1973 and 1976 were analyzed in terms of their relationship to type of water source, level of trihalomethane (THM) and various social and economic parameters. Among white males, a significant positive correlation existed between pancreatic cancer incidence rates and THM level. No other significant correlations were observed. This research lends little or no support to the hypothesis that THM levels which meet present standards are related to the incidence of human cancer.

  8. 12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 4 2014-01-01 2014-01-01 false Reports of change in control of bank management... Reports of change in control of bank management incident to a merger. (a) A State member bank has inquired whether Pub. L. 88-593 (78 Stat. 940) requires reports of change in control of bank management...

  9. 12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 4 2012-01-01 2012-01-01 false Reports of change in control of bank management... Reports of change in control of bank management incident to a merger. (a) A State member bank has inquired whether Pub. L. 88-593 (78 Stat. 940) requires reports of change in control of bank management...

  10. 12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 4 2013-01-01 2013-01-01 false Reports of change in control of bank management... Reports of change in control of bank management incident to a merger. (a) A State member bank has inquired whether Pub. L. 88-593 (78 Stat. 940) requires reports of change in control of bank management...

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

    PubMed

    Seidel, Robin; Stößlein, Ekkehard; Lauer, Wolfgang

    2016-04-01

    Medical devices are manifold and one of the most innovative fields of technology. As technologies advance, former limits cease to exist and complex devices become reality. Medical devices represent a very dynamic field with high economic relevance. The manufacturer of a medical device is obliged to minimize product-related risks as well as to demonstrate compliance with the so-called "essential requirements" regarding safety and performance before placing the device on the market. Any critical incident in relation to the application of a medical device has to be reported to the competent authority for risk assessment, which in Germany is either the Federal Institute for Drugs and Medical Devices (BfArM) or the Paul Ehrlich Institute (PEI) depending on the type of device. In this article, the German regulatory framework for medical devices and the resulting tasks for BfArM are described as well as the topics of its recently installed research and development group on prospective risk identification and application safety for medical devices. Results of failure mode and root cause analyses of incident data are presented as well as further data on cases with the result "root-cause analysis not possible". Finally an outlook is given on future challenges regarding risk assessment for medical devices. PMID:27028733

  12. A Decade of Child-Initiated Family Violence: Comparative Analysis of Child-Parent Violence and Parricide Examining Offender, Victim, and Event Characteristics in a National Sample of Reported Incidents, 1995-2005

    ERIC Educational Resources Information Center

    Walsh, Jeffrey A.; Krienert, Jessie L.

    2009-01-01

    This article examines 11 years (1995-2005) of National Incident Based Reporting System data comparing victim, offender, and incident characteristics for two types of child-initiated family violence: child-parent violence (CPV) and parricide. The objective is to better understand the victim-offender relationship for CPV and parricide and to…

  13. Reported tailings dam failures. A review of the European incidents in the worldwide context.

    PubMed

    Rico, M; Benito, G; Salgueiro, A R; Díez-Herrero, A; Pereira, H G

    2008-04-01

    A detailed search and re-evaluation of the known historical cases of tailings dam failure was carried out. A corpus of 147 cases of worldwide tailings dam disasters, from which 26 located in Europe, was compiled in a database. This contains six sections, including dam location, its physical and constructive characteristics, actual and putative failure cause, sludge hydrodynamics, socio-economical consequences and environmental impacts. Europe ranks in second place in reported accidents (18%), more than one third of them in dams 10-20 m high. In Europe, the most common cause of failure is related to unusual rain, whereas there is a lack of occurrences associated with seismic liquefaction, which is the second cause of tailings dam breakage elsewhere in the world. Moreover, over 90% of incidents occurred in active mines, and only 10% refer to abandoned ponds. The results reached by this preliminary analysis show an urgent need for EU regulations regarding technical standards of tailings disposal. PMID:17854989

  14. Deep cognitive imaging systems enable estimation of continental-scale fire incidence from climate data.

    PubMed

    Dutta, Ritaban; Aryal, Jagannath; Das, Aruneema; Kirkpatrick, Jamie B

    2013-01-01

    Unplanned fire is a major control on the nature of terrestrial ecosystems and causes substantial losses of life and property. Given the substantial influence of climatic conditions on fire incidence, climate change is expected to substantially change fire regimes in many parts of the world. We wished to determine whether it was possible to develop a deep neural network process for accurately estimating continental fire incidence from publicly available climate data. We show that deep recurrent Elman neural network was the best performed out of ten artificial neural networks (ANN) based cognitive imaging systems for determining the relationship between fire incidence and climate. In a decennium data experiment using this ANN we show that it is possible to develop highly accurate estimations of fire incidence from monthly climatic data surfaces. Our estimations for the continent of Australia had over 90% global accuracy and a very low level of false negatives. The technique is thus appropriate for use in estimating the spatial consequences of climate scenarios on the monthly incidence of wildfire at the landscape scale. PMID:24220174

  15. 30 CFR 250.189 - Reporting requirements for incidents requiring immediate notification.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... immediate notification. 250.189 Section 250.189 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT... for incidents requiring immediate notification. For an incident requiring immediate notification under... incident or injury/fatality); (d) Lease number, OCS area, and block; (e) Platform/facility name and...

  16. A system concept for wide swath constant incident angle coverage. [for SAR environmental monitoring from space

    NASA Technical Reports Server (NTRS)

    Claassen, J. P.; Eckerman, J.

    1978-01-01

    The multiple beam SAR system concept is developed and shown to readily overcome the radar ambiguity constraints associated with orbital systems, thus permitting imagery over swaths much wider than 100 km. The antenna technique permits imagery at nearly constant incidence angles. When frequency scanning is used, the center angle may be programmed. The redundant use of the antenna aperture during reception results in lower transmitted power and in shorter antenna lengths in comparison with conventional designs.

  17. First Annual Report: NASA-ONERA Collaboration on Human Factors in Aviation Accidents and Incidents

    NASA Technical Reports Server (NTRS)

    Srivastava, Ashok; Fabiani, Patrick

    2012-01-01

    This is the first annual report jointly prepared by NASA and ONERA on the work performed under the agreement to collaborate on a study of the human factors entailed in aviation accidents and incidents particularly focused on consequences of decreases in human performance associated with fatigue. The objective of this Agreement is to generate reliable, automated procedures that improve understanding of the levels and characteristics of flight-crew fatigue factors whose confluence will likely result in unacceptable crew performance. This study entails the analyses of numerical and textual data collected during operational flights. NASA and ONERA are collaborating on the development and assessment of automated capabilities for extracting operationally significant information from very large, diverse (textual and numerical) databases much larger than can be handled practically by human experts. This report presents the approach that is currently expected to be used in processing and analyzing the data for identifying decrements in aircraft performance and examining their relationships to decrements in crewmember performance due to fatigue. The decisions on the approach were based on samples of both the numerical and textual data that will be collected during the four studies planned under the Human Factors Monitoring Program (HFMP). Results of preliminary analyses of these sample data are presented in this report.

  18. A review of patient safety incidents reported as 'severe' or 'death' from critical care units in England and Wales between 2004 and 2014.

    PubMed

    Thomas, A N; MacDonald, J J

    2016-09-01

    We analysed 1743 patient safety incidents reported between 2004 and 2014 from critical care units in England and Wales where the harm had been classified as 'severe' (1346, 77%) or 'death' (397, 23%). We classified 593 (34%) of these incidents as resulting in temporary harm, and 782 (45%) as more than temporary harm, of which 389 (22%) may have contributed to the patient's death. We found no described harm in 368 (21%) incidents. We classified 1555 (89%) of the incidents as being avoidable or potentially avoidable. There were changes over time for some incident types (pressure sores: 10 incidents in 2007, 64 in 2012; infections: 60 incidents in 2007, 10 in 2012) and some changes in response to national guidance. We made a comparison with a dataset of all incidents reported from units in North-West England, and this confirmed that the search strategy identified more severe incidents, but did not identify all incidents that contributed to mortality. PMID:27456207

  19. Performance analysis of grazing incidence imaging systems. [X ray telescope aberrations

    NASA Technical Reports Server (NTRS)

    Winkler, C. E.; Korsch, D.

    1977-01-01

    An exact expression relating the coordinates of a point on the incident ray, a point of reflection from an arbitrary surface, and a point on the reflected ray is derived. The exact relation is then specialized for the case of grazing incidence, and first order and third order systematic analyses are carried out for a single reflective surface and then for a combination of two surfaces. The third order treatment yields a complete set of primary aberrations for single element and two element systems. The importance of a judicious choice for a coordinate system in showing field curvature to clearly be the predominant aberration for a two element system is discussed. The validity of the theory is verified through comparisons with the exact ray trace results for the case of the telescope.

  20. Benzene Monitor System report

    SciTech Connect

    Livingston, R.R.

    1992-10-12

    Two systems for monitoring benzene in aqueous streams have been designed and assembled by the Savannah River Technology Center, Analytical Development Section (ADS). These systems were used at TNX to support sampling studies of the full-scale {open_quotes}SRAT/SME/PR{close_quotes} and to provide real-time measurements of benzene in Precipitate Hydrolysis Aqueous (PHA) simulant. This report describes the two ADS Benzene Monitor System (BMS) configurations, provides data on system operation, and reviews the results of scoping tests conducted at TNX. These scoping tests will allow comparison with other benzene measurement options being considered for use in the Defense Waste Processing Facility (DWPF) laboratory. A report detailing the preferred BMS configuration statistical performance during recent tests has been issued under separate title: Statistical Analyses of the At-line Benzene Monitor Study, SCS-ASG-92-066. The current BMS design, called the At-line Benzene Monitor (ALBM), allows remote measurement of benzene in PHA solutions. The authors have demonstrated the ability to calibrate and operate this system using peanut vials from a standard Hydragard{trademark} sampler. The equipment and materials used to construct the ALBM are similar to those already used in other applications by the DWPF lab. The precision of this system ({+-}0.5% Relative Standard Deviation (RSD) at 1 sigma) is better than the purge & trap-gas chromatograpy reference method currently in use. Both BMSs provide a direct measurement of the benzene that can be purged from a solution with no sample pretreatment. Each analysis requires about five minutes per sample, and the system operation requires no special skills or training. The analyzer`s computer software can be tailored to provide desired outputs. Use of this system produces no waste stream other than the samples themselves (i.e. no organic extractants).

  1. Integrated system design report

    SciTech Connect

    Not Available

    1989-07-01

    The primary objective of the integrated system test phase is to demonstrate the commercial potential of a coal fueled diesel engine in its actual operating environment. The integrated system in this project is defined as a coal fueled diesel locomotive. This locomotive, shown on drawing 41D715542, is described in the separate Concept Design Report. The test locomotive will be converted from an existing oil fueled diesel locomotive in three stages, until it nearly emulates the concept locomotive. Design drawings of locomotive components (diesel engine, locomotive, flatcar, etc.) are included.

  2. 12 CFR 250.181 - Reports of change in control of bank management incident to a merger.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

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

  3. Incidence of Self-Reported Interpersonal Violence Related Physical Injury in Iran

    PubMed Central

    Salamati, Payman; Rahimi-Movaghar, Afarin; Motevalian, Seyed Abbas; Amin-Esmaeili, Masoumeh; Sharifi, Vandad; Hajebi, Ahmad; Rad Goodarzi, Reza; Hefazi, Mitra; Naji, Zohrehsadat; Saadat, Soheil; Rahimi-Movaghar, Vafa

    2015-01-01

    Background: Violence is the cause of death for 1.5 million people in a year. Objectives: Our study aimed to estimate the incidence rate of self-reported interpersonal violence related physical injury (VRPI) and its associated factors in Iran. Patients and Methods: The sample included people ranged from 15 to 64 years old who were residing in Iran. A total of 1525 clusters were selected from the whole country. Six families were selected from each cluster via a systematic random sampling method. Then, the residential units were identified and the interviewers contacted the inhabitants. In the next step, one of the family members was selected by using Kish grid method. The instrument was a researcher-made questionnaire and consisted of two sections; demographics and project related data. Face validity and content validity of our questionnaire were investigated based on expert opinions and the reliability was confirmed by a pilot study, as well. The inclusion criteria were considered for choosing the interviewers. An interviewer was assigned for each 42 participants (7 clusters). An educational seminar was held for the administrative managers (54 persons) and interviewers (230 persons) for a week. The field work was distributed among all 46 Medical Sciences universities in Iran. In each university, administrative issues were related to an executive director. Mann-Whitney U test and odds ratio were used to analyze the data with 95% confidence interval. α value was considered less than 5%. Results: The frequency of VRPI among 7886 participants was 24 during the last three months. The incidence rate of interpersonal VRPI was estimated at 3.04 per 1000 population (95% CI: 2.66-3.42) during a three-month interval in Iran. The incidence was 4.72 per 1000 population (95% CI: 4.01-5.43) for males and 1.78 per 1000 population (95% CI: 1.39-2.17) for females during a three-month interval. The mean (SD) of age of the participants with and without a history of VRPI were 26.5 (7

  4. Falling-incident detection and throughput enhancement in a multi-camera video-surveillance system.

    PubMed

    Shieh, Wann-Yun; Huang, Ju-Chin

    2012-09-01

    For most elderly, unpredictable falling incidents may occur at the corner of stairs or a long corridor due to body frailty. If we delay to rescue a falling elder who is likely fainting, more serious consequent injury may occur. Traditional secure or video surveillance systems need caregivers to monitor a centralized screen continuously, or need an elder to wear sensors to detect falling incidents, which explicitly waste much human power or cause inconvenience for elders. In this paper, we propose an automatic falling-detection algorithm and implement this algorithm in a multi-camera video surveillance system. The algorithm uses each camera to fetch the images from the regions required to be monitored. It then uses a falling-pattern recognition algorithm to determine if a falling incident has occurred. If yes, system will send short messages to someone needs to be noticed. The algorithm has been implemented in a DSP-based hardware acceleration board for functionality proof. Simulation results show that the accuracy of falling detection can achieve at least 90% and the throughput of a four-camera surveillance system can be improved by about 2.1 times. PMID:22154761

  5. Discrepancy Reporting Management System

    NASA Technical Reports Server (NTRS)

    Cooper, Tonja M.; Lin, James C.; Chatillon, Mark L.

    2004-01-01

    Discrepancy Reporting Management System (DRMS) is a computer program designed for use in the stations of NASA's Deep Space Network (DSN) to help establish the operational history of equipment items; acquire data on the quality of service provided to DSN customers; enable measurement of service performance; provide early insight into the need to improve processes, procedures, and interfaces; and enable the tracing of a data outage to a change in software or hardware. DRMS is a Web-based software system designed to include a distributed database and replication feature to achieve location-specific autonomy while maintaining a consistent high quality of data. DRMS incorporates commercial Web and database software. DRMS collects, processes, replicates, communicates, and manages information on spacecraft data discrepancies, equipment resets, and physical equipment status, and maintains an internal station log. All discrepancy reports (DRs), Master discrepancy reports (MDRs), and Reset data are replicated to a master server at NASA's Jet Propulsion Laboratory; Master DR data are replicated to all the DSN sites; and Station Logs are internal to each of the DSN sites and are not replicated. Data are validated according to several logical mathematical criteria. Queries can be performed on any combination of data.

  6. The evolution of shortcomings in Incident Command System: Revisions have allowed critical management functions to atrophy.

    PubMed

    Stambler, Kimberly S; Barbera, Joseph A

    2015-01-01

    The original Incident Command System (ICS) was created through the federally funded Firefighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE) program. Initially developed as one element of multiagency coordination for managing severe wildfires, the FIRESCOPE ICS guidance was adopted and evolved through increasingly routine wildl and firefighting. It then was modified for all hazards for the fire service. Only later, through the National Incident Management System (NIMS), was ICS officially adopted for all hazards and all responders. Over this multidecade evolution, the current NIMS ICS version became simplified in several key areas compared to the original, robust FIRESCOPE ICS. NIMS ICS is now promulgated as guidance for managing today's novel, complex, and lengthy disasters involving multidisciplinary response but experiences recurrent problems in key functions. This article examines the history of the subtle, yet critical differences in current ICS compared to the original system design, and focuses on information dissemination and intermediate, long-range and contingency planning. ICS transitions resulted in simplification and consolidation of positions and functions, without recognizing and maintaining critical position tasks necessary for managing complex, extended incidents. PMID:26750813

  7. The Boston Marathon Bombings Mass Casualty Incident: One Emergency Department's Information Systems Challenges and Opportunities.

    PubMed

    Landman, Adam; Teich, Jonathan M; Pruitt, Peter; Moore, Samantha E; Theriault, Jennifer; Dorisca, Elizabeth; Harris, Sheila; Crim, Heidi; Lurie, Nicole; Goralnick, Eric

    2015-07-01

    Emergency department (ED) information systems are designed to support efficient and safe emergency care. These same systems often play a critical role in disasters to facilitate real-time situation awareness, information management, and communication. In this article, we describe one ED's experiences with ED information systems during the April 2013 Boston Marathon bombings. During postevent debriefings, staff shared that our ED information systems and workflow did not optimally support this incident; we found challenges with our unidentified patient naming convention, real-time situational awareness of patient location, and documentation of assessments, orders, and procedures. As a result, before our next mass gathering event, we changed our unidentified patient naming convention to more clearly distinguish multiple, simultaneous, unidentified patients. We also made changes to the disaster registration workflow and enhanced roles and responsibilities for updating electronic systems. Health systems should conduct disaster drills using their ED information systems to identify inefficiencies before an actual incident. ED information systems may require enhancements to better support disasters. Newer technologies, such as radiofrequency identification, could further improve disaster information management and communication but require careful evaluation and implementation into daily ED workflow. PMID:24997562

  8. Racial differences in primary central nervous system lymphoma incidence and survival rates.

    PubMed

    Pulido, Jose S; Vierkant, Robert A; Olson, Janet E; Abrey, Lauren; Schiff, David; O'Neill, Brian Patrick

    2009-06-01

    To determine racial and ethnic differences in incidence and survival in patients with primary central nervous system lymphoma (PCNSL), NCI Surveillance, Epidemiology, and End Results (SEER) program data from 1992 to 2002 were queried. Data were substratified by age (20-49 years vs. 50 or above) and race (White, Black, Asian/Pacific Islander [A/PI], American Indian/Alaskan Native [AI/AN]). Incidence of PCNSL and survival were calculated by SEER(*)Stat software. The incidence rates were 0.94 per 100,000 per year (95% confidence interval [CI] 0.90-0.98) for Whites, 1.10 (95% CI 0.98-1.22) for Blacks, 0.51 (95% CI 0.28-0.74) for AI/AN, and 0.64 (95% CI 0.56-0.72) for A/PI. In patients aged 20-49 years the rates were 0.72 (95% CI 0.68-0.76) for Whites, 1.43 (95% CI 1.27-1.59) for Blacks, 0.58 (95% CI 0.30-0.86) for AI/AN, and 0.21 (CI 0.15-0.27) for A/PI. In patients over 49 years, the rates were 1.30 (95% CI 1.22-1.38) for Whites, 0.56 (95% CI 0.40-0.72) for Blacks, 0.34 (95% CI 0-0.70) for AI/AN, and 1.31 (95% CI 1.00-1.53) for A/PI. PCNSL incidence for ages 20-49 years for Black patients was twice that for Whites. Incidence for ages over 49 years for Whites was twice that for Blacks. Survival at 12 months, 24 months, and 60 months was higher among Whites than Blacks. Research is needed to determine the origin of these differences. PMID:19273630

  9. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... machine, faxing the area office, or sending an e-mail? No, if you can't talk to a person at the Area... incident. (7) What if I don't learn about an incident right away? If you do not learn of a...

  10. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... machine, faxing the area office, or sending an e-mail? No, if you can't talk to a person at the Area... incident. (7) What if I don't learn about an incident right away? If you do not learn of a...