Sample records for improve process safety
-
Process safety improvement--quality and target zero.
Van Scyoc, Karl
2008-11-15
Process safety practitioners have adopted quality management principles in design of process safety management systems with positive effect, yet achieving safety objectives sometimes remain a distant target. Companies regularly apply tools and methods which have roots in quality and productivity improvement. The "plan, do, check, act" improvement loop, statistical analysis of incidents (non-conformities), and performance trending popularized by Dr. Deming are now commonly used in the context of process safety. Significant advancements in HSE performance are reported after applying methods viewed as fundamental for quality management. In pursuit of continual process safety improvement, the paper examines various quality improvement methods, and explores how methods intended for product quality can be additionally applied to continual improvement of process safety. Methods such as Kaizen, Poke yoke, and TRIZ, while long established for quality improvement, are quite unfamiliar in the process safety arena. These methods are discussed for application in improving both process safety leadership and field work team performance. Practical ways to advance process safety, based on the methods, are given.
-
McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R
2014-10-01
Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.
-
McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R
2015-01-01
Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.
-
Donnelly, Lane F; Dickerson, Julie M; Lehkamp, Todd W; Gessner, Kevin E; Moskovitz, Jay; Hutchinson, Sally
2008-11-01
As part of a patient safety program in the authors' department of radiology, operational rounds have been instituted. This process consists of radiology leaders' visiting imaging divisions at the site of imaging and discussing frontline employees' concerns about patient safety, the quality of care, and patient and family satisfaction. Operational rounds are executed at a time to optimize the number of attendees. Minutes that describe the issues identified, persons responsible for improvement, and updated improvement plan status are available to employees online. Via this process, multiple patient safety and other issues have been identified and remedied. The authors believe that the process has improved patient safety, the quality of care, and the efficiency of operations. Since the inception of the safety program, the mean number of days between serious safety events involving radiology has doubled. The authors review the background around such walk rounds, describe their particular program, and give multiple illustrative examples of issues identified and improvement plans put in place.
-
DOT National Transportation Integrated Search
2009-09-01
Changing At-Risk Behavior (CAB) is a safety process that is being conducted at Union Pacifics San Antonio Service Unit (SASU) with the aim of improving road and yard safety. CAB is an example of a proactive safety risk-reduction method called Clea...
-
Improving safety culture through the health and safety organization: a case study.
Nielsen, Kent J
2014-02-01
International research indicates that internal health and safety organizations (HSO) and health and safety committees (HSC) do not have the intended impact on companies' safety performance. The aim of this case study at an industrial plant was to test whether the HSO can improve company safety culture by creating more and better safety-related interactions both within the HSO and between HSO members and the shop-floor. A quasi-experimental single case study design based on action research with both quantitative and qualitative measures was used. Based on baseline mapping of safety culture and the efficiency of the HSO three developmental processes were started aimed at the HSC, the whole HSO, and the safety representatives, respectively. Results at follow-up indicated a marked improvement in HSO performance, interaction patterns concerning safety, safety culture indicators, and a changed trend in injury rates. These improvements are interpreted as cultural change because an organizational double-loop learning process leading to modification of the basic assumptions could be identified. The study provides evidence that the HSO can improve company safety culture by focusing on safety-related interactions. © 2013. Published by Elsevier Ltd and National Safety Council.
-
[Process management in the hospital pharmacy for the improvement of the patient safety].
Govindarajan, R; Perelló-Juncá, A; Parès-Marimòn, R M; Serrais-Benavente, J; Ferrandez-Martí, D; Sala-Robinat, R; Camacho-Calvente, A; Campabanal-Prats, C; Solà-Anderiu, I; Sanchez-Caparrós, S; Gonzalez-Estrada, J; Martinez-Olalla, P; Colomer-Palomo, J; Perez-Mañosas, R; Rodríguez-Gallego, D
2013-01-01
To define a process management model for a hospital pharmacy in order to measure, analyse and make continuous improvements in patient safety and healthcare quality. In order to implement process management, Igualada Hospital was divided into different processes, one of which was the Hospital Pharmacy. A multidisciplinary management team was given responsibility for each process. For each sub-process one person was identified to be responsible, and a working group was formed under his/her leadership. With the help of each working group, a risk analysis using failure modes and effects analysis (FMEA) was performed, and the corresponding improvement actions were implemented. Sub-process indicators were also identified, and different process management mechanisms were introduced. The first risk analysis with FMEA produced more than thirty preventive actions to improve patient safety. Later, the weekly analysis of errors, as well as the monthly analysis of key process indicators, permitted us to monitor process results and, as each sub-process manager participated in these meetings, also to assume accountability and responsibility, thus consolidating the culture of excellence. The introduction of different process management mechanisms, with the participation of people responsible for each sub-process, introduces a participative management tool for the continuous improvement of patient safety and healthcare quality. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.
-
System Safety in an IT Service Organization
NASA Astrophysics Data System (ADS)
Parsons, Mike; Scutt, Simon
Within Logica UK, over 30 IT service projects are considered safetyrelated. These include operational IT services for airports, railway infrastructure asset management, nationwide radiation monitoring and hospital medical records services. A recent internal audit examined the processes and documents used to manage system safety on these services and made a series of recommendations for improvement. This paper looks at the changes and the challenges to introducing them, especially where the service is provided by multiple units supporting both safety and non-safety related services from multiple locations around the world. The recommendations include improvements to service agreements, improved process definitions, routine safety assessment of changes, enhanced call logging, improved staff competency and training, and increased safety awareness. Progress is reported as of today, together with a road map for implementation of the improvements to the service safety management system. A proposal for service assurance levels (SALs) is discussed as a way forward to cover the wide variety of services and associated safety risks.
-
The potential application of behavior-based safety in the trucking industry
DOT National Transportation Integrated Search
2000-04-01
Behavior-based safety (BBS) is a set of methods to improve safety performance in the workplace by engaging workers in the improvement process, identifying critical safety behaviors, performing observations to gather data, providing feedback to encour...
-
Safety culture and care: a program to prevent surgical errors.
Hemingway, Maureen White; O'Malley, Catherine; Silvestri, Sandra
2015-04-01
Surgical errors are under scrutiny in health care as part of ensuring a culture of safety in which patients receive quality care. Hospitals use safety measures to compare their performance against industry benchmarks. To understand patient safety issues, health care providers must have processes in place to analyze and evaluate the quality of the care they provide. At one facility, efforts made to improve its quality and safety led to the development of a robust safety program with resources devoted to enhancing the culture of safety in the Perioperative Services department. Improvement initiatives included changing processes for safety reporting and performance improvement plans, adding resources and nurse roles, and creating communication strategies around adverse safety events and how to improve care. One key outcome included a 54% increase in the percentage of personnel who indicated in a survey that they would speak up if they saw something negatively affecting patient care. Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.
-
Motor Carrier Safety Fitness Determination: An Improved Process
DOT National Transportation Integrated Search
1996-12-01
PREFACE This report was undertaken to define an improved process for motor carrier safety fitness determination. It was produced by the Research and Special Program Administration's (RSPA} John A. Volpe National Transportation Systems Center (the Vol...
-
Health IT for Patient Safety and Improving the Safety of Health IT.
Magrabi, Farah; Ong, Mei-Sing; Coiera, Enrico
2016-01-01
Alongside their benefits health IT applications can pose new risks to patient safety. Problems with IT have been linked to many different types of clinical errors including prescribing and administration of medications; as well as wrong-patient, wrong-site errors, and delays in procedures. There is also growing concern about the risks of data breach and cyber-security. IT-related clinical errors have their origins in processes undertaken to design, build, implement and use software systems in a broader sociotechnical context. Safety can be improved with greater standardization of clinical software and by improving the quality of processes at different points in the technology life cycle, spanning design, build, implementation and use in clinical settings. Oversight processes can be set up at a regional or national level to ensure that clinical software systems meet specific standards. Certification and regulation are two mechanisms to improve oversight. In the absence of clear standards, guidelines are useful to promote safe design and implementation practices. Processes to identify and mitigate hazards can be formalised via a safety management system. Minimizing new patient safety risks is critical to realizing the benefits of IT.
-
Improving health care quality and safety: the role of collective learning.
Singer, Sara J; Benzer, Justin K; Hamdan, Sami U
2015-01-01
Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes.
-
Improving health care quality and safety: the role of collective learning
Singer, Sara J; Benzer, Justin K; Hamdan, Sami U
2015-01-01
Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes. PMID:29355197
-
Improving safety on rural local and tribal roads site safety analysis - user guide #1.
DOT National Transportation Integrated Search
2014-08-01
This User Guide presents an example of how rural local and Tribal practitioners can study conditions at a preselected site. It demonstrates the step-by-step safety analysis process presented in Improving Safety on Rural Local and Tribal Roads Saf...
-
[Innovative technology and blood safety].
Begue, S; Morel, P; Djoudi, R
2016-11-01
If technological innovations are not enough alone to improve blood safety, their contributions for several decades in blood transfusion are major. The improvement of blood donation (new apheresis devices, RFID) or blood components (additive solutions, pathogen reduction technology, automated processing of platelets concentrates) or manufacturing process of these products (by automated processing of whole blood), all these steps where technological innovations were implemented, lead us to better traceability, more efficient processes, quality improvement of blood products and therefore increased blood safety for blood donors and patients. If we are on the threshold of a great change with the progress of pathogen reduction technology (for whole blood and red blood cells), we hope to see production of ex vivo red blood cells or platelets who are real and who open new conceptual paths on blood safety. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
-
ERIC Educational Resources Information Center
Westfall, John M.; Fernald, Douglas H.; Staton, Elizabeth W.; VanVorst, Rebecca; West, David; Pace, Wilson D.
2004-01-01
Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. Applied Strategies for Improving…
-
Software Design Improvements. Part 2; Software Quality and the Design and Inspection Process
NASA Technical Reports Server (NTRS)
Lalli, Vincent R.; Packard, Michael H.; Ziemianski, Tom
1997-01-01
The application of assurance engineering techniques improves the duration of failure-free performance of software. The totality of features and characteristics of a software product are what determine its ability to satisfy customer needs. Software in safety-critical systems is very important to NASA. We follow the System Safety Working Groups definition for system safety software as: 'The optimization of system safety in the design, development, use and maintenance of software and its integration with safety-critical systems in an operational environment. 'If it is not safe, say so' has become our motto. This paper goes over methods that have been used by NASA to make software design improvements by focusing on software quality and the design and inspection process.
-
Deckard, Gloria J; Borkowski, Nancy; Diaz, Deisell; Sanchez, Carlos; Boisette, Serge A
2010-01-01
Designated primary care clinics largely serve low-income and uninsured patients who present a disproportionate number of chronic illnesses and face great difficulty in obtaining the medical care they need, particularly the access to specialty physicians. With limited capacity for providing specialty care, these primary care clinics generally refer patients to safety net hospitals' specialty ambulatory care clinics. A large public safety net health system successfully improved the effectiveness and efficiency of the specialty clinic referral process through application of Lean Six Sigma, an advanced process-improvement methodology and set of tools driven by statistics and engineering concepts.
-
Fong, Allan; Harriott, Nicole; Walters, Donna M; Foley, Hanan; Morrissey, Richard; Ratwani, Raj R
2017-08-01
Many healthcare providers have implemented patient safety event reporting systems to better understand and improve patient safety. Reviewing and analyzing these reports is often time consuming and resource intensive because of both the quantity of reports and length of free-text descriptions in the reports. Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication related patient safety events. Different NLP algorithmic approaches were developed to identify four types of medication related patient safety events and the models were compared. Well performing NLP models were generated to categorize medication related events into pharmacy delivery delays, dispensing errors, Pyxis discrepancies, and prescriber errors with receiver operating characteristic areas under the curve of 0.96, 0.87, 0.96, and 0.81 respectively. We also found that modeling the brief without the resolution text generally improved model performance. These models were integrated into a dashboard visualization to support the patient safety committee review process. We demonstrate the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication related patient safety events. The NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis. Copyright © 2017 Elsevier B.V. All rights reserved.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lower, Mark D; Christopher, Timothy W; Oland, C Barry
The Facilities and Operations (F&O) Directorate is sponsoring a continuous process improvement (CPI) program. Its purpose is to stimulate, promote, and sustain a culture of improvement throughout all levels of the organization. The CPI program ensures that a scientific and repeatable process exists for improving the delivery of F&O products and services in support of Oak Ridge National Laboratory (ORNL) Management Systems. Strategic objectives of the CPI program include achieving excellence in laboratory operations in the areas of safety, health, and the environment. Identifying and promoting opportunities for achieving the following critical outcomes are important business goals of the CPImore » program: improved safety performance; process focused on consumer needs; modern and secure campus; flexibility to respond to changing laboratory needs; bench strength for the future; and elimination of legacy issues. The Steam Pressure-Reducing Station (SPRS) Safety and Energy Efficiency Improvement Project, which is under the CPI program, focuses on maintaining and upgrading SPRSs that are part of the ORNL steam distribution network. This steam pipe network transports steam produced at the ORNL steam plant to many buildings in the main campus site. The SPRS Safety and Energy Efficiency Improvement Project promotes excellence in laboratory operations by (1) improving personnel safety, (2) decreasing fuel consumption through improved steam system energy efficiency, and (3) achieving compliance with applicable worker health and safety requirements. The SPRS Safety and Energy Efficiency Improvement Project being performed by F&O is helping ORNL improve both energy efficiency and worker safety by modifying, maintaining, and repairing SPRSs. Since work began in 2006, numerous energy-wasting steam leaks have been eliminated, heat losses from uninsulated steam pipe surfaces have been reduced, and deficient pressure retaining components have been replaced. These improvements helped ORNL reduce its overall utility costs by decreasing the amount of fuel used to generate steam. Reduced fuel consumption also decreased air emissions. These improvements also helped lower the risk of burn injuries to workers and helped prevent shrapnel injuries resulting from missiles produced by pressurized component failures. In most cases, the economic benefit and cost effectiveness of the SPRS Safety and Energy Efficiency Improvement Project is reflected in payback periods of 1 year or less.« less
-
Safety Considerations in the Chemical Process Industries
NASA Astrophysics Data System (ADS)
Englund, Stanley M.
There is an increased emphasis on chemical process safety as a result of highly publicized accidents. Public awareness of these accidents has provided a driving force for industry to improve its safety record. There has been an increasing amount of government regulation.
-
Patient safety - the role of human factors and systems engineering.
Carayon, Pascale; Wood, Kenneth E
2010-01-01
Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.
-
Major accident prevention through applying safety knowledge management approach.
Kalatpour, Omid
2016-01-01
Many scattered resources of knowledge are available to use for chemical accident prevention purposes. The common approach to management process safety, including using databases and referring to the available knowledge has some drawbacks. The main goal of this article was to devise a new emerged knowledge base (KB) for the chemical accident prevention domain. The scattered sources of safety knowledge were identified and scanned. Then, the collected knowledge was formalized through a computerized program. The Protégé software was used to formalize and represent the stored safety knowledge. The domain knowledge retrieved as well as data and information. This optimized approach improved safety and health knowledge management (KM) process and resolved some typical problems in the KM process. Upgrading the traditional resources of safety databases into the KBs can improve the interaction between the users and knowledge repository.
-
Microbial bioinformatics for food safety and production
Alkema, Wynand; Boekhorst, Jos; Wels, Michiel
2016-01-01
In the production of fermented foods, microbes play an important role. Optimization of fermentation processes or starter culture production traditionally was a trial-and-error approach inspired by expert knowledge of the fermentation process. Current developments in high-throughput ‘omics’ technologies allow developing more rational approaches to improve fermentation processes both from the food functionality as well as from the food safety perspective. Here, the authors thematically review typical bioinformatics techniques and approaches to improve various aspects of the microbial production of fermented food products and food safety. PMID:26082168
-
Ackerman, Sara L; Gourley, Gato; Le, Gem; Williams, Pamela; Yazdany, Jinoos; Sarkar, Urmimala
2018-03-14
The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized. Surveys and transcripts from the meetings were analyzed to understand the decision-making process. The Delphi process included eight panelists. Consensus was reached to adopt 9 of 13 proposed measures. All 9 measures were unanimously considered valid, but concern was expressed about the feasibility of implementing several of the measures. Although safety net health systems face high barriers to standardized measurement, our study demonstrates that consensus can be reached on acceptable and feasible methods for tracking patient safety gaps in safety net health systems. If accompanied by the active participation key stakeholder groups, including patients, clinicians, staff, data system professionals, and health system leaders, the consensus measures reported here represent one step toward improving ambulatory patient safety in safety net health systems.
-
ERIC Educational Resources Information Center
Bonometti, Patrizia
2012-01-01
Purpose: The aim of this contribution is to describe a new complexity-science-based approach for improving safety, quality and efficiency and the way it was implemented by TenarisDalmine. Design/methodology/approach: This methodology is called "a safety-building community". It consists of a safety-behaviour social self-construction…
-
Enhanced Time Out: An Improved Communication Process.
Nelson, Patricia E
2017-06-01
An enhanced time out is an improved communication process initiated to prevent such surgical errors as wrong-site, wrong-procedure, or wrong-patient surgery. The enhanced time out at my facility mandates participation from all members of the surgical team and requires designated members to respond to specified time out elements on the surgical safety checklist. The enhanced time out incorporated at my facility expands upon the safety measures from the World Health Organization's surgical safety checklist and ensures that all personnel involved in a surgical intervention perform a final check of relevant information. Initiating the enhanced time out at my facility was intended to improve communication and teamwork among surgical team members and provide a highly reliable safety process to prevent wrong-site, wrong-procedure, and wrong-patient surgery. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
-
Rizal, Datu; Tani, Shinichi; Nishiyama, Kimitoshi; Suzuki, Kazuhiko
2006-10-11
In this paper, a novel methodology in batch plant safety and reliability analysis is proposed using a dynamic simulator. A batch process involving several safety objects (e.g. sensors, controller, valves, etc.) is activated during the operational stage. The performance of the safety objects is evaluated by the dynamic simulation and a fault propagation model is generated. By using the fault propagation model, an improved fault tree analysis (FTA) method using switching signal mode (SSM) is developed for estimating the probability of failures. The timely dependent failures can be considered as unavailability of safety objects that can cause the accidents in a plant. Finally, the rank of safety object is formulated as performance index (PI) and can be estimated using the importance measures. PI shows the prioritization of safety objects that should be investigated for safety improvement program in the plants. The output of this method can be used for optimal policy in safety object improvement and maintenance. The dynamic simulator was constructed using Visual Modeler (VM, the plant simulator, developed by Omega Simulation Corp., Japan). A case study is focused on the loss of containment (LOC) incident at polyvinyl chloride (PVC) batch process which is consumed the hazardous material, vinyl chloride monomer (VCM).
-
Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust.
Scholefield, Helen
2007-08-01
The provision of safe high-quality care in obstetrics and gynaecology is a key target in the UK National Health Service (NHS), in part because of the high cost of litigation in this area. Good risk management processes should improve safety and reduce the cost of litigation to the NHS. This chapter looks at structures and processes for improving quality and patient safety, using the stepwise approach described by the National Patient Safety Authority (NPSA). This encompasses building a safety culture, leading and supporting staff, integrating risk management activity, promoting reporting, involving and communicating with patients and the public, learning and sharing safety lessons, and implementing solutions to prevent harm. Examples from the Liverpool Women's NHS Foundation Trust are used to illustrate these steps, including how they were developed, what obstacles had to be overcome, ongoing challenges, and whether good risk management has translated into better, safer health care.
-
Advancing perinatal patient safety through application of safety science principles using health IT.
Webb, Jennifer; Sorensen, Asta; Sommerness, Samantha; Lasater, Beth; Mistry, Kamila; Kahwati, Leila
2017-12-19
The use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety. Semi-structured interviews were conducted with L&D units participating in the Agency for Healthcare Research and Quality's (AHRQ's) Safety Program for Perinatal Care (SPPC) to assess units' experience with program implementation. Analysis of interview transcripts was used to characterize the process and experience of using health IT for applying safety science principles to L&D unit processes. Forty-six L&D units from 10 states completed participation in SPPC program implementation; thirty-two (70%) reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects. L&D units standardized care processes through use of electronic health record (EHR)-based order sets and use of smart pumps and other technology to improve medication safety. Units also standardized EHR documentation, particularly related to electronic fetal monitoring (EFM) and shoulder dystocia. Cognitive aids and tools were integrated into EHR and care workflows to create independent checks such as checklists, risk assessments, and communication handoff tools. Units also used data from EHRs to monitor processes of care to learn from defects. Units experienced several challenges incorporating health IT, including obtaining organization approval, working with their busy IT departments, and retrieving standardized data from health IT systems. Use of health IT played an integral part in the planning and implementation of SPPC for participating L&D units. Use of health IT is an encouraging approach for incorporating safety science principles into care to improve perinatal safety and should be incorporated into materials to facilitate the implementation of perinatal safety initiatives.
-
Use of a Surgical Safety Checklist to Improve Team Communication.
Cabral, Richard A; Eggenberger, Terry; Keller, Kathryn; Gallison, Barry S; Newman, David
2016-09-01
To improve surgical team communication, a team at Broward Health Imperial Point Hospital, Ft Lauderdale, Florida, implemented a program for process improvement using a locally adapted World Health Organization Surgical Safety Checklist. This program included a standardized, comprehensive time out and a briefing/debriefing process. Postimplementation responses to the Safety Attitudes Questionnaire revealed a significant increase in the surgical team's perception of communication compared with that reported on the pretest (6% improvement resulting in t79 = -1.72, P < .05, d = 0.39). Perceptions of communication increased significantly for nurses (12% increase, P = .002), although the increase for surgeons and surgical technologists was lower (4% for surgeons, P = .15 and 2.3% for surgical technologists, P = .06). As a result of this program, we have observed improved surgical teamwork behaviors and an enhanced culture of safety in the OR. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
-
Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A
2006-11-01
Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.
-
Analysis of vehicle's safety envelope under car-following model
NASA Astrophysics Data System (ADS)
Tang, Tie-Qiao; Zhang, Jian; Chen, Liang; Shang, Hua-Yan
2017-05-01
In this paper, we propose an improved car-following model to explore the impacts of vehicle's two safety distances (i.e., the front safety distance and back safety distance) on the traffic safety during the starting process. The numerical results show that our model is prominently safer than the FVD (full velocity difference) model, i.e., our model is better than the FVD model from the perspective of the traffic safety, which shows that each driver should consider his two safety distances during his driving process.
-
Patient Safety: The Role of Human Factors and Systems Engineering
Carayon, Pascale; Wood, Kenneth E.
2011-01-01
Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety. PMID:20543237
-
DOT National Transportation Integrated Search
2014-03-01
Recent research in highway safety has focused on the more advanced and statistically proven techniques of highway : safety analysis. This project focuses on the two most recent safety analysis tools, the Highway Safety Manual (HSM) : and SafetyAnalys...
-
A Process-Centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement
2005-01-01
next patient safety steps in individual health care organizations. The low priority given to Category 3 (Focus on patients , other customers , and...presents a patient safety applicator tool for implementing and assessing patient safety systems in health care institutions. The applicator tool consists...the survey rounds. The study addressed three research questions: 1. What critical processes should be included in health care patient safety systems
-
NASA Technical Reports Server (NTRS)
Helms, William R.; Starr, Stanley O.
1997-01-01
Priorities and achievements of the Kennedy Space Center (KSF) Instrumentation Laboratories in improving operational safety and decreasing processing costs associated with the Shuttle vehicle are addressed. Technologies that have been or are in the process of technology transfer are reviewed, and routes by which commercial concerns can obtain licenses to other KSF Instrumentation Laboratory technologies are discussed.
-
Enhancing patient safety: improving the patient handoff process through appreciative inquiry.
Shendell-Falik, Nancy; Feinson, Michael; Mohr, Bernard J
2007-02-01
Patient transfers from one care giver to another are an area of high safety consequence, as is evident by many studies and the Joint Commission on Accreditation of Healthcare Organization's Patient Safety Goals. The authors describe how one hospital made measurable improvements in a patient handoff process by using an unconventional approach to change called appreciative inquiry. Rather than identifying the root causes of ineffective handoffs, appreciative inquiry was used to engage staff in identifying and building on their most effective handoff experiences.
-
Risikko, Tanja; Remes, Jouko; Hassi, Juhani
2008-01-01
Cold is a typical environmental risk factor in outdoor work in northern regions. It should be taken into account in a company's occupational safety, health and quality systems. A development process for improving cold risk management at the Finnish Maritime Administration (FMA) was carried out by FMA and external experts. FMA was to implement it. Three years after the development phase, the outcomes and implementation were evaluated. The study shows increased awareness about cold work and few concrete improvements. Concrete improvements in occupational safety and health practices could be seen in the pilot group. However, organization-wide implementation was insufficient, the main reasons being no organization-wide practices, unclear process ownership, no resources and a major reorganization process. The study shows a clear need for expertise supporting implementation. The study also presents a matrix for analyzing the process.
-
DOT National Transportation Integrated Search
2009-09-01
Changing At-Risk Behavior (CAB) is a safety process that is being conducted at Union Pacifics San Antonio Service Unit (SASU) with the aim of improving road and yard safety. CAB is an example of a proactive safety risk-reduction method, called Cle...
-
Promising evidence of impact on road safety by changing at-risk behavior process at Union Pacific
DOT National Transportation Integrated Search
2008-06-01
Changing At-risk Behavior (CAB) is a safety process that is being conducted at Union Pacifics San Antonio Service Unit with the aim of improving locomotive cab safety related to constraining signals. CAB is an example of a risk reduction method th...
-
Herzer, Kurt R.; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A.; Mark, Lynette J.
2014-01-01
Background Since 1999, hospitals have made substantial commitments to healthcare quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. Cohesive quality and safety approaches have become comprehensive programs to identify and mitigate hazards that could harm patients. This article moves to the next level with an intense refocusing of attention on one of the individual components of a comprehensive program--the patient safety reporting system—with a goal of maximized usefulness of the reports and long-term sustainability of quality improvements arising from them. Methods A six-phase framework was developed to deal with patient safety hazards: identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with “Good Catch” awards, and follow up to determine if quality improvements were sustained over time. Results To date, 29 patient safety hazards have gone through this process with “Good Catch” awards being granted at our institution. These awards were presented at various times over the past 4 years since the process began in 2008. Follow-up revealed that 86% of the associated quality improvements have been sustained over time since the awards were given. We present the details of two of these “Good Catch” awards: vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control. Conclusion A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting system, positive recognition with a “Good Catch” award, education of practitioners, and long-term follow-up resulted in an outcome of sustained quality improvement initiatives. PMID:22946251
-
Xie, Anping; Carayon, Pascale
2014-01-01
Healthcare systems need to be redesigned to provide care that is safe, effective and efficient, and meets the multiple needs of patients. This systematic review examines how Human Factors and Ergonomics (HFE) is applied to redesign healthcare work systems and processes and improve quality and safety of care. We identified twelve projects representing 23 studies and addressing different physical, cognitive and organizational HFE issues in a variety of healthcare systems and care settings. Some evidence exists for the effectiveness of HFE-based healthcare system redesign in improving process and outcome measures of quality and safety of care. We assessed risk of bias in 16 studies reporting the impact of HFE-based healthcare system redesign and found varying quality across studies. Future research should further assess the impact of HFE on quality and safety of care, and clearly define the mechanisms by which HFE-based system redesign can improve quality and safety of care. Practitioner Summary Existing evidence shows that HFE-based healthcare system redesign has the potential to improve quality of care and patient safety. Healthcare organizations need to recognize the importance of HFE-based healthcare system redesign to quality of care and patient safety, and invest resources to integrate HFE in healthcare improvement activities. PMID:25323570
-
Herzer, Kurt R; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A; Mark, Lynette J
2012-08-01
Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them. A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time. Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail. A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.
-
Medication room madness: calming the chaos.
Conrad, Carole; Fields, Willa; McNamara, Tracey; Cone, Maryann; Atkins, Patricia
2010-01-01
Nurses work in stressful environments, encountering interruptions and distractions at almost every turn. The aim of this medication safety project was to improve the physical design and organizational layout of the medication room, reduce nurse interruptions and distractions, and create a standard medication process for enhanced patient safety and efficiency. This successful change improved the medication administration process, decreased medication errors, and enhanced nursing satisfaction.
-
Using a safety forecast model to calculate future safety metrics.
DOT National Transportation Integrated Search
2017-05-01
This research sought to identify a process to improve long-range planning prioritization by using forecasted : safety metrics in place of the existing Utah Department of Transportation Safety Indexa metric based on historical : crash data. The res...
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lacey, D.; Bacon, M.L.
The UK fully supports the objective of the Joint Convention on the Safety of Spent Fuel Management and on the Safety of Radioactive Waste Management to achieve and maintain a high level of safety worldwide in spent fuel and radioactive waste management, through the enhancement of national measures and international co-operation, including where appropriate, safety-related co-operation. The UK's Health and Safety Executive, through its Nuclear Safety Directorate (NSD), has been committed to the Convention since the initial negotiations to set up the Convention and provided the president of the first review meeting in 2003. It would be wrong of anymore » nation to believe that they have all the best solutions to managing spent fuel and radioactive waste. The process of compiling reports for the Convention review meetings provides a structured process through which every contracting party can review its provisions against a common set of standards and identify for itself possible areas of improvements. The sharing of reports and the asking and answering of questions then provides a further opportunity for both sharing of experience and learning. The UK was encouraged by the spirit of constructive discussion rather than negative criticism that pervaded the first review meeting that provided an incentive for all to learn and improve. While, as could be expected of the first meeting of such a group, not everything worked as well as could be hoped for, all parties seemed committed to learn from mistakes and to make the process more effective. Lessons were learned from the Nuclear Safety Convention on the process of submitting reports electronically and the UK actively supported aims to use IAEA requirements documents as an additional focus for reports. This should, we hope, provide for even better benchmarking of achievements and provide feedback for improvements of the IAEA requirements where appropriate. In summary, the UK finds the Joint Convention process to be a very positive one that can only improve the worldwide standards of safety in spent fuel and radioactive waste management. (authors)« less
-
Development of an evaluation framework for African-European hospital patient safety partnerships.
Rutter, Paul; Syed, Shamsuzzoha B; Storr, Julie; Hightower, Joyce D; Bagheri-Nejad, Sepideh; Kelley, Edward; Pittet, Didier
2014-04-01
Patient safety is recognised as a significant healthcare problem worldwide, and healthcare-associated infections are an important aspect. African Partnerships for Patient Safety is a WHO programme that pairs hospitals in Africa with hospitals in Europe with the objective to work together to improve patient safety. To describe the development of an evaluation framework for hospital-to-hospital partnerships participating in the programme. The framework was structured around the programme's three core objectives: facilitate strong interhospital partnerships, improve in-hospital patient safety and spread best practices nationally. Africa-based clinicians, their European partners and experts in patient safety were closely involved in developing the evaluation framework in an iterative process. The process defined six domains of partnership strength, each with measurable subdomains. We developed a questionnaire to measure these subdomains. Participants selected six indicators of hospital patient safety improvement from a short-list of 22 based on their relevance, sensitivity to intervention and measurement feasibility. Participants proposed 20 measures of spread, which were refined into a two-part conceptual framework, and a data capture tool created. Taking a highly participatory approach that closely involved its end users, we developed an evaluation framework and tools to measure partnership strength, patient safety improvements and the spread of best practice.
-
Obtaining Valid Safety Data for Software Safety Measurement and Process Improvement
NASA Technical Reports Server (NTRS)
Basili, Victor r.; Zelkowitz, Marvin V.; Layman, Lucas; Dangle, Kathleen; Diep, Madeline
2010-01-01
We report on a preliminary case study to examine software safety risk in the early design phase of the NASA Constellation spaceflight program. Our goal is to provide NASA quality assurance managers with information regarding the ongoing state of software safety across the program. We examined 154 hazard reports created during the preliminary design phase of three major flight hardware systems within the Constellation program. Our purpose was two-fold: 1) to quantify the relative importance of software with respect to system safety; and 2) to identify potential risks due to incorrect application of the safety process, deficiencies in the safety process, or the lack of a defined process. One early outcome of this work was to show that there are structural deficiencies in collecting valid safety data that make software safety different from hardware safety. In our conclusions we present some of these deficiencies.
-
Effects of auditing patient safety in hospital care: design of a mixed-method evaluation
2013-01-01
Background Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects. Methods and design Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011–July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects. Discussion We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to early detect unsafe care and improve patient safety continuously. Trial registration Netherlands Trial Register (NTR): NTR3343 PMID:23800253
-
Effects of auditing patient safety in hospital care: design of a mixed-method evaluation.
Hanskamp-Sebregts, Mirelle; Zegers, Marieke; Boeijen, Wilma; Westert, Gert P; van Gurp, Petra J; Wollersheim, Hub
2013-06-22
Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects. Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011-July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects. We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to early detect unsafe care and improve patient safety continuously. Netherlands Trial Register (NTR): NTR3343.
-
77 FR 76075 - Whistleblower Protection Advisory Committee (WPAC)
Federal Register 2010, 2011, 2012, 2013, 2014
2012-12-26
... workers and employers, improving the investigative and enforcement process, improvements of regulations..., 49 U.S.C. 42121; the Sarbanes-Oxley Act, 18 U.S.C. 1514A; the Pipeline Safety Improvement Act, 49 U.S... Act, 6 U.S.C. 1142; the Consumer Product Safety Improvement Act, 15 U.S.C. 2087; Section 1558 of the...
-
Safe Handling of Snakes in an ED Setting.
Cockrell, Melanie; Swanson, Kristofer; Sanders, April; Prater, Samuel; von Wenckstern, Toni; Mick, JoAnn
2017-01-01
Efforts to improve consistency in management of snakes and venomous snake bites in the emergency department (ED) can improve patient and staff safety and outcomes, as well as improve surveillance data accuracy. The emergency department at a large academic medical center identified an opportunity to implement a standardized process for snake disposal and identification to reduce staff risk exposure to snake venom from snakes patients brought with them to the ED. A local snake consultation vendor and zoo Herpetologist assisted with development of a process for snake identification and disposal. All snakes have been identified and securely disposed of using the newly implemented process and no safety incidents have been reported. Other emergency department settings may consider developing a standardized process for snake disposal using listed specialized consultants combined with local resources and suppliers to promote employee and patient safety. Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
-
Application of the SEIPS Model to Analyze Medication Safety in a Crisis Residential Center.
Steele, Maria L; Talley, Brenda; Frith, Karen H
2018-02-01
Medication safety and error reduction has been studied in acute and long-term care settings, but little research is found in the literature regarding mental health settings. Because mental health settings are complex, medication administration is vulnerable to a variety of errors from transcription to administration. The purpose of this study was to analyze critical factors related to a mental health work system structure and processes that threaten safe medication administration practices. The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework to analyze factors affecting medication safety. The model approach analyzes the work system concepts of technology, tasks, persons, environment, and organization to guide the collection of data. In the study, the Lean methodology tools were used to identify vulnerabilities in the system that could be targeted later for improvement activities. The project director completed face-to-face interviews, asked nurses to record disruptions in a log, and administered a questionnaire to nursing staff. The project director also conducted medication chart reviews and recorded medication errors using a standardized taxonomy for errors that allowed categorization of the prevalent types of medication errors. Results of the study revealed disruptions during the medication process, pharmacology training needs, and documentation processes as the primary opportunities for improvement. The project engaged nurses to identify sustainable quality improvement strategies to improve patient safety. The mental health setting carries challenges for safe medication administration practices. Through analysis of the structure, process, and outcomes of medication administration, opportunities for quality improvement and sustainable interventions were identified, including minimizing the number of distractions during medication administration, training nurses on psychotropic medications, and improving the documentation system. A task force was created to analyze the descriptive data and to establish objectives aimed at improving efficiency of the work system and care process involved in medication administration at the end of the project. Copyright © 2017 Elsevier Inc. All rights reserved.
-
Ward, Marie; McDonald, Nick; Morrison, Rabea; Gaynor, Des; Nugent, Tony
2010-02-01
Aircraft maintenance is a highly regulated, safety critical, complex and competitive industry. There is a need to develop innovative solutions to address process efficiency without compromising safety and quality. This paper presents the case that in order to improve a highly complex system such as aircraft maintenance, it is necessary to develop a comprehensive and ecologically valid model of the operational system, which represents not just what is meant to happen, but what normally happens. This model then provides the backdrop against which to change or improve the system. A performance report, the Blocker Report, specific to aircraft maintenance and related to the model was developed gathering data on anything that 'blocks' task or check performance. A Blocker Resolution Process was designed to resolve blockers and improve the current check system. Significant results were obtained for the company in the first trial and implications for safety management systems and hazard identification are discussed. Statement of Relevance: Aircraft maintenance is a safety critical, complex, competitive industry with a need to develop innovative solutions to address process and safety efficiency. This research addresses this through the development of a comprehensive and ecologically valid model of the system linked with a performance reporting and resolution system.
-
NASA Technical Reports Server (NTRS)
Dhooge, P. M.; Nimitz, J. S.
2001-01-01
Process analysis can identify opportunities for efficiency improvement including cost reduction, increased safety, improved quality, and decreased environmental impact. A thorough, systematic approach to materials and process selection is valuable in any analysis. New operations and facilities design offer the best opportunities for proactive cost reduction and environmental improvement, but existing operations and facilities can also benefit greatly. Materials and processes that have been used for many years may be sources of excessive resource use, waste generation, pollution, and cost burden that should be replaced. Operational and purchasing personnel may not recognize some materials and processes as problems. Reasons for materials or process replacement may include quality and efficiency improvements, excessive resource use and waste generation, materials and operational costs, safety (flammability or toxicity), pollution prevention, compatibility with new processes or materials, and new or anticipated regulations.
-
Kussaga, Jamal B; Jacxsens, Liesbeth; Tiisekwa, Bendantunguka Pm; Luning, Pieternel A
2014-08-01
This study seeks to provide insight into current deficiencies in food safety management systems (FSMS) in African food-processing companies and to identify possible strategies for improvement so as to contribute to African countries' efforts to provide safe food to both local and international markets. This study found that most African food products had high microbiological and chemical contamination levels exceeding the set (legal) limits. Relative to industrialized countries, the study identified various deficiencies at government, sector/branch, retail and company levels which affect performance of FSMS in Africa. For instance, very few companies (except exporting and large companies) have implemented HACCP and ISO 22000:2005. Various measures were proposed to be taken at government (e.g. construction of risk-based legislative frameworks, strengthening of food safety authorities, recommend use of ISO 22000:2005, and consumers' food safety training), branch/sector (e.g. sector-specific guidelines and third-party certification), retail (develop stringent certification standards and impose product specifications) and company levels (improving hygiene, strict raw material control, production process efficacy, and enhancing monitoring systems, assurance activities and supportive administrative structures). By working on those four levels, FSMS of African food-processing companies could be better designed and tailored towards their production processes and specific needs to ensure food safety. © 2014 Society of Chemical Industry.
-
Changes in Efficiency and Safety Culture After Integration of an I-PASS-Supported Handoff Process.
Sheth, Shreya; McCarthy, Elisa; Kipps, Alaina K; Wood, Matthew; Roth, Stephen J; Sharek, Paul J; Shin, Andrew Y
2016-02-01
Recent publications have shown improved outcomes associated with resident-to-resident handoff processes. However, the implementation of similar handoff processes for patients moving between units and teams with expansive responsibilities presents unique challenges. We sought to determine the impact of a multidisciplinary standardized handoff process on efficiency, safety culture, and satisfaction. A prospective improvement initiative to standardize handoffs during patient transitions from the cardiovascular ICU to the acute care unit was implemented in a university-affiliated children's hospital. Time between verbal handoff and patient transfer decreased from baseline (397 ± 167 minutes) to the postintervention period (24 ± 21 minutes) (P < .01). Percentage positive scores for the handoff/transitions domain of a national culture of safety survey improved (39.8% vs 15.2% and 38.8% vs 19.6%; P = .005 and 0.03, respectively). Provider satisfaction improved related to the information conveyed (34% to 41%; P = .03), time to transfer (5% to 34%; P < .01), and overall experience (3% to 24%; P < .01). Family satisfaction improved for several questions, including: "satisfaction with the information conveyed" (42% to 70%; P = .02), "opportunities to ask questions" (46% to 74%; P < .01), and "Acute Care team's knowledgeabout my child's issues" (50% to 73%; P = .04). No differences in rates of readmission, rapid response team calls, or mortality were observed. Implementation of a multidisciplinary I-PASS-supported handoff process for patients transferring from the cardiovascular ICU to the acute care unit resulted in improved transfer efficiency, safety culture scores, and satisfaction of providers and families. Copyright © 2016 by the American Academy of Pediatrics.
-
NASA's post-Challenger safety program - Themes and thrusts
NASA Technical Reports Server (NTRS)
Rodney, G. A.
1988-01-01
The range of managerial, technical, and procedural initiatives implemented by NASA's post-Challenger safety program is reviewed. The recommendations made by the Rogers Commission, the NASA post-Challenger review of Shuttle design, the Congressional investigation of the accident, the National Research Council, the Aerospace Safety Advisory Panel, and NASA internal advisory panels and studies are summarized. NASA safety initiatives regarding improved organizational accountability for safety, upgraded analytical techniques and methodologies for risk assessment and management, procedural initiatives in problem reporting and corrective-action tracking, ground processing, maintenance documentation, and improved technologies are discussed. Safety issues relevant to the planned Space Station are examined.
-
Tracking data in the office environment.
Erickson, Ty B
2010-09-01
Data tracking in the office setting focuses on a narrow spectrum of the entire patient safety arena; however, when properly executed, data tracking increases staff members' awareness of the importance of patient safety. Data tracking is also a high-volume event and thereby continues to loop back on the consciousness of providers in all aspects of their practice. Improvement in date tracking will improve the collateral areas of patient safety such as proper medication usage, legibility of written communication, effective delegation of patient safety initiatives, and a collegial effort at developing teams for safety design processes.
-
Impact of the time-out process on safety attitude in a tertiary neurosurgical department.
McLaughlin, Nancy; Winograd, Deborah; Chung, Hallie R; Van de Wiele, Barbara; Martin, Neil A
2014-11-01
In July 2011, the UCLA Health System released its current time-out process protocol used across the Health System. Numerous interventions were performed to improve checklist completion and time-out process observance. This study assessed the impact of the current protocol for the time-out on healthcare providers' safety attitude and operating room safety climate. All members involved in neurosurgical procedures in the main operating room of the Ronald Reagan UCLA Medical Center were asked to anonymously complete an online survey on their overall perception of the time-out process. The survey was completed by 93 of 128 members of the surgical team. Overall, 98.9% felt that performing a pre-incision time-out improves patient safety. The majority of respondents (97.8%) felt that the team member introductions helped to promote a team spirit during the case. In addition, 93.5% felt that performing a time-out helped to ensure all team members were comfortable to voice safety concerns throughout the case. All respondents felt that the attending surgeon should be present during the time-out and 76.3% felt that he/she should lead the time-out. Unanimously, it was felt that the review of anticipated critical elements by the attending surgeon was helpful to respondents' role during the case. Responses revealed that although the time-out brings the team together physically, it does not necessarily reinforce teamwork. The time-out process favorably impacted team members' safety attitudes and perception as well as overall safety climate in neurosurgical ORs. Survey responses identified leadership training and teamwork training as two avenues for future improvement. Copyright © 2014 Elsevier Inc. All rights reserved.
-
Improving patient safety and optimizing nursing teamwork using crew resource management techniques.
West, Priscilla; Sculli, Gary; Fore, Amanda; Okam, Nwoha; Dunlap, Cleveland; Neily, Julia; Mills, Peter
2012-01-01
This project describes the application of the "sterile cockpit rule," a crew resource management (CRM) technique, targeted to improve efficacy and safety for nursing assistants in the performance of patient care duties. Crew resource management techniques have been successfully implemented in the aviation industry to improve flight safety. Application of these techniques can improve patient safety in medical settings. The Veterans Affairs (VA) National Center for Patient Safety conducted a CRM training program in select VA nursing units. One unit developed a novel application of the sterile cockpit rule to create protected time for certified nursing assistants (CNAs) while they collected vital signs and blood glucose data at the beginning of each shift. The typical nursing authority structure was reversed, with senior nurses protecting CNAs from distractions. This process led to improvements in efficiency and communication among nurses, with the added benefit of increased staff morale. Crew resource management techniques can be used to improve efficiency, morale, and patient safety in the healthcare setting.
-
EHR Safety: The Way Forward to Safe and Effective Systems
Walker, James M.; Carayon, Pascale; Leveson, Nancy; Paulus, Ronald A.; Tooker, John; Chin, Homer; Bothe, Albert; Stewart, Walter F.
2008-01-01
Diverse stakeholders—clinicians, researchers, business leaders, policy makers, and the public—have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents. PMID:18308981
-
Xie, Anping; Carayon, Pascale
2015-01-01
Healthcare systems need to be redesigned to provide care that is safe, effective and efficient, and meets the multiple needs of patients. This systematic review examines how human factors and ergonomics (HFE) is applied to redesign healthcare work systems and processes and improve quality and safety of care. We identified 12 projects representing 23 studies and addressing different physical, cognitive and organisational HFE issues in a variety of healthcare systems and care settings. Some evidence exists for the effectiveness of HFE-based healthcare system redesign in improving process and outcome measures of quality and safety of care. We assessed risk of bias in 16 studies reporting the impact of HFE-based healthcare system redesign and found varying quality across studies. Future research should further assess the impact of HFE on quality and safety of care, and clearly define the mechanisms by which HFE-based system redesign can improve quality and safety of care.
-
Management of local economic and ecological system of coal processing company
NASA Astrophysics Data System (ADS)
Kiseleva, T. V.; Mikhailov, V. G.; Karasev, V. A.
2016-10-01
The management issues of local ecological and economic system of coal processing company - coal processing plant - are considered in the article. The objectives of the research are the identification and the analysis of local ecological and economic system (coal processing company) performance and the proposals for improving the mechanism to support the management decision aimed at improving its environmental safety. The data on the structure of run-of-mine coal processing products are shown. The analysis of main ecological and economic indicators of coal processing enterprises, characterizing the state of its environmental safety, is done. The main result of the study is the development of proposals to improve the efficiency of local enterprise ecological and economic system management, including technical, technological and business measures. The results of the study can be recommended to industrial enterprises to improve their ecological and economic efficiency.
-
Code of Federal Regulations, 2014 CFR
2014-04-01
... evaluation process to analyze and assess results achieved by the HSIP and uses this information, where... program of projects, technologies, or strategies to reduce or eliminate highway safety hazards; (G) Adopts... elements to develop highway safety improvement projects. (5) A process for establishing priorities for...
-
Code of Federal Regulations, 2012 CFR
2012-04-01
... evaluation process to analyze and assess results achieved by the HSIP and uses this information, where... program of projects, technologies, or strategies to reduce or eliminate highway safety hazards; (G) Adopts... elements to develop highway safety improvement projects. (5) A process for establishing priorities for...
-
Code of Federal Regulations, 2013 CFR
2013-04-01
... evaluation process to analyze and assess results achieved by the HSIP and uses this information, where... program of projects, technologies, or strategies to reduce or eliminate highway safety hazards; (G) Adopts... elements to develop highway safety improvement projects. (5) A process for establishing priorities for...
-
Station Blackout: A case study in the interaction of mechanistic and probabilistic safety analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
Curtis Smith; Diego Mandelli; Cristian Rabiti
2013-11-01
The ability to better characterize and quantify safety margins is important to improved decision making about nuclear power plant design, operation, and plant life extension. As research and development (R&D) in the light-water reactor (LWR) Sustainability (LWRS) Program and other collaborative efforts yield new data, sensors, and improved scientific understanding of physical processes that govern the aging and degradation of plant SSCs needs and opportunities to better optimize plant safety and performance will become known. The purpose of the Risk Informed Safety Margin Characterization (RISMC) Pathway R&D is to support plant decisions for risk-informed margin management with the aim tomore » improve economics, reliability, and sustain safety of current NPPs. In this paper, we describe the RISMC analysis process illustrating how mechanistic and probabilistic approaches are combined in order to estimate a safety margin. We use the scenario of a “station blackout” wherein offsite power and onsite power is lost, thereby causing a challenge to plant safety systems. We describe the RISMC approach, illustrate the station blackout modeling, and contrast this with traditional risk analysis modeling for this type of accident scenario.« less
-
Improving food safety within the dairy chain: an application of conjoint analysis.
Valeeva, N I; Meuwissen, M P M; Lansink, A G J M Oude; Huirne, R B M
2005-04-01
This study determined the relative importance of attributes of food safety improvement in the production chain of fluid pasteurized milk. The chain was divided into 4 blocks: "feed" (compound feed production and its transport), "farm" (dairy farm), "dairy processing" (transport and processing of raw milk, delivery of pasteurized milk), and "consumer" (retailer/catering establishment and pasteurized milk consumption). The concept of food safety improvement focused on 2 main groups of hazards: chemical (antibiotics and dioxin) and microbiological (Salmonella, Escherichia coli, Mycobacterium paratuberculosis, and Staphylococcus aureus). Adaptive conjoint analysis was used to investigate food safety experts' perceptions of the attributes' importance. Preference data from individual experts (n = 24) on 101 attributes along the chain were collected in a computer-interactive mode. Experts perceived the attributes from the "feed" and "farm" blocks as being more vital for controlling the chemical hazards; whereas the attributes from the "farm" and "dairy processing" were considered more vital for controlling the microbiological hazards. For the chemical hazards, "identification of treated cows" and "quality assurance system of compound feed manufacturers" were considered the most important attributes. For the microbiological hazards, these were "manure supply source" and "action in salmonellosis and M. paratuberculosis cases". The rather high importance of attributes relating to quality assurance and traceability systems of the chain participants indicates that participants look for food safety assurance from the preceding participants. This information has substantial decision-making implications for private businesses along the chain and for the government regarding the food safety improvement of fluid pasteurized milk.
-
Najjar, Peter; Kachalia, Allen; Sutherland, Tori; Beloff, Jennifer; David-Kasdan, Jo Ann; Bates, David W; Urman, Richard D
2015-01-01
The AHRQ Patient Safety Indicators (PSIs) are used for calculation of risk-adjusted postoperative rates for adverse events. The payers and quality consortiums are increasingly requiring public reporting of hospital performance on these metrics. We discuss processes designed to improve the accuracy and clinical utility of PSI reporting in practice. The study was conducted at a 793-bed tertiary care academic medical center where PSI processes have been aggressively implemented to track patient safety events at discharge. A three-phased approach to improving administrative data quality was implemented. The initiative consisted of clinical review of all PSIs, documentation improvement, and provider outreach including active querying for patient safety events. This multidisciplinary effort to develop a streamlined process for PSI calculation reduced the reporting of miscoded PSIs and increased the clinical utility of PSI monitoring. Over 4 quarters, 4 of 41 (10%) PSI-11 and 9 of 138 (7%) PSI-15 errors were identified on review of clinical documentation and appropriate adjustments were made. A multidisciplinary, phased approach leveraging existing billing infrastructure for robust metric coding, ongoing clinical review, and frontline provider outreach is a novel and effective way to reduce the reporting of false-positive outcomes and improve the clinical utility of PSIs.
-
Patient handover in orthopaedics, improving safety using Information Technology.
Pearkes, Tim
2015-01-01
Good inpatient handover ensures patient safety and continuity of care. An adjunct to this is the patient list which is routinely managed by junior doctors. These lists are routinely created and managed within Microsoft Excel or Word. Following the merger of two orthopaedic departments into a single service in a new hospital, it was felt that a number of safety issues within the handover process needed to be addressed. This quality improvement project addressed these issues through the creation and implementation of a new patient database which spanned the department, allowing trouble free, safe, and comprehensive handover. Feedback demonstrated an improved user experience, greater reliability, continuity within the lists and a subsequent improvement in patient safety.
-
Patient Safety and the Malpractice System.
Swift, James Q
2017-05-01
The cost of health care in the United States and malpractice insurance has escalated greatly over the past 30 years. In an ideal world, the goals of the tort system would be aligned with efforts at improving safety. In fact, there is little evidence that the tort system and the processes of risk management and informed consent have improved patient safety. This article explores the disunion between patient safety and the malpractice system. Copyright © 2016 Elsevier Inc. All rights reserved.
-
Improving staff perception of a safety climate with crew resource management training.
Kuy, SreyRam; Romero, Ramon A L
2017-06-01
Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate. Published by Elsevier Inc.
-
Sibal, Anupam; Dewan, Shaveta; Uberoi, R S; Kar, Sujoy; Loria, Gaurav; Fernandes, Clive; Yatheesh, G; Sharma, Karan
2012-01-01
Ensuring patient safety is a vital step for any hospital in achieving the best clinical outcomes. The Apollo Quality Program aimed at standardization of processes for clinical handovers, medication safety, surgical safety, patient identification, verbal orders, hand washing compliance and falls prevention across the hospitals in the Group. Thirty-two hospitals across the Group in settings varying from rural to semi urban, urban and metropolitan implemented the program and over a period of one year demonstrated a visible improvement in the compliance to processes for patient safety translating into better patient safety statistics.
-
Evolution of International Space Station Program Safety Review Processes and Tools
NASA Technical Reports Server (NTRS)
Ratterman, Christian D.; Green, Collin; Guibert, Matt R.; McCracken, Kristle I.; Sang, Anthony C.; Sharpe, Matthew D.; Tollinger, Irene V.
2013-01-01
The International Space Station Program at NASA is constantly seeking to improve the processes and systems that support safe space operations. To that end, the ISS Program decided to upgrade their Safety and Hazard data systems with 3 goals: make safety and hazard data more accessible; better support the interconnection of different types of safety data; and increase the efficiency (and compliance) of safety-related processes. These goals are accomplished by moving data into a web-based structured data system that includes strong process support and supports integration with other information systems. Along with the data systems, ISS is evolving its submission requirements and safety process requirements to support the improved model. In contrast to existing operations (where paper processes and electronic file repositories are used for safety data management) the web-based solution provides the program with dramatically faster access to records, the ability to search for and reference specific data within records, reduced workload for hazard updates and approval, and process support including digital signatures and controlled record workflow. In addition, integration with other key data systems provides assistance with assessments of flight readiness, more efficient review and approval of operational controls and better tracking of international safety certifications. This approach will also provide new opportunities to streamline the sharing of data with ISS international partners while maintaining compliance with applicable laws and respecting restrictions on proprietary data. One goal of this paper is to outline the approach taken by the ISS Progrm to determine requirements for the new system and to devise a practical and efficient implementation strategy. From conception through implementation, ISS and NASA partners utilized a user-centered software development approach focused on user research and iterative design methods. The user-centered approach used on the new ISS hazard system utilized focused user research and iterative design methods employed by the Human Computer Interaction Group at NASA Ames Research Center. Particularly, the approach emphasized the reduction of workload associated with document and data management activities so more resources can be allocated to the operational use of data in problem solving, safety analysis, and recurrence control. The methods and techniques used to understand existing processes and systems, to recognize opportunities for improvement, and to design and review improvements are described with the intent that similar techniques can be employed elsewhere in safety operations. A second goal of this paper is to provide and overview of the web-based data system implemented by ISS. The software selected for the ISS hazard systemMission Assurance System (MAS)is a NASA-customized vairant of the open source software project Bugzilla. The origin and history of MAS as a NASA software project and the rationale for (and advantages of) using open-source software are documented elsewhere (Green, et al., 2009).
-
Computerized Aid Improves Safety Decision Process for Survivors of Intimate Partner Violence
ERIC Educational Resources Information Center
Glass, Nancy; Eden, Karen B.; Bloom, Tina; Perrin, Nancy
2010-01-01
A computerized safety decision aid was developed and tested with Spanish or English-speaking abused women in shelters or domestic violence (DV) support groups (n = 90). The decision aid provides feedback about risk for lethal violence, options for safety, assistance with setting priorities for safety, and a safety plan personalized to the user.…
-
Harnessing hospital purchase power to design safe care delivery.
Ebben, Steven F; Gieras, Izabella A; Gosbee, Laura Lin
2008-01-01
Since the Institute of Medicine's well-publicized 1999 report To Err is Human, the healthcare patient safety movement has grown at an exponential pace. However, much more can be done to advance patient safety from a care process design vantage point-improving safety through effective care processes and technology integration. While progress is being made, the chasm between technology developers and caregivers remains a profound void. Why hasn't more been done to expand our view of patient safety to include technology design? Healthcare organizations have not consolidated their purchasing power to expect improved designs. This article will (1) provide an assessment of the present state of healthcare technology management and (2) provide recommendations for collaborative design of safe healthcare delivery systems.
-
[Improving patient safety through voluntary peer review].
Kluge, S; Bause, H
2015-01-01
The intensive care unit (ICU) is one area of the hospital in which processes and communication are of primary importance. Errors in intensive care units can lead to serious adverse events with significant consequences for patients. Therefore quality and risk-management are important measures when treating critically ill patients. A pragmatic approach to support quality and safety in intensive care is peer review. This approach has gained significant acceptance over the past years. It consists of mutual visits by colleagues who conduct standardised peer reviews. These reviews focus on the systematic evaluation of the quality of an ICU's structure, its processes and outcome. Together with different associations, the State Chambers of Physicians and the German Medical Association have developed peer review as a standardized tool for quality improvement. The common goal of all stakeholders is the continuous and sustainable improvement in intensive care with peer reviews significantly increasing and improving communication between professions and disciplines. Peer reviews secure the sustainability of planned change processes and consequently lead the way to an improved culture of quality and safety.
-
Simons, Pascale A M; Houben, Ruud; Benders, Jos; Pijls-Johannesma, Madelon; Vandijck, Dominique; Marneffe, Wim; Backes, Huub; Groothuis, Siebren
2014-10-01
To realize safe radiotherapy treatment, processes must be stabilized. Standard operating procedures (SOP's) were expected to stabilize the treatment process and perceived task importance would increase sustainability in compliance. This paper presents the effects on compliance to safety related tasks of a process redesign based on lean principles. Compliance to patient safety tasks was measured by video recording of actual radiation treatment, before (T0), directly after (T1) and 1.5 years after (T2) a process redesign. Additionally, technologists were surveyed on perceived task importance and reported incidents were collected for three half-year periods between 2007 and 2009. Compliance to four out of eleven tasks increased at T1, of which improvements on three sustained (T2). Perceived importance of tasks strongly correlated (0.82) to compliance rates at T2. The two tasks, perceived as least important, presented low base-line compliance, improved (T1), but relapsed at T2. The reported near misses (patient-level not reached) on accelerators increased (P < 0.001) from 144 (2007) to 535 (2009), while the reported misses (patient-level reached) remained constant. Compliance to specific tasks increased after introducing SOP's and improvements sustained after 1.5 years, indicating increased stability. Perceived importance of tasks correlated positively to compliance and sustainability. Raising the perception of task importance is thus crucial to increase compliance. The redesign resulted in increased willingness to report incidents, creating opportunities for patient safety improvement in radiotherapy treatment. Copyright © 2014 Elsevier Ltd. All rights reserved.
-
Transforming primary care in the New Orleans safety-net: the patient experience.
Schmidt, Laura A; Rittenhouse, Diane R; Wu, Kevin J; Wiley, James A
2013-02-01
The patient-centered medical home (PCMH) is a key service delivery innovation in health reform. However, there are growing questions about whether the changes in clinics promoted by the PCMH model lead to improvements in the patient experience. To test the hypothesis that PCMH improvements in safety-net primary care clinics are associated with a more positive patient experience. Multilevel cross-sectional analysis of patients nested within the primary care clinics that serve them. Primary care clinic leaders and patients throughout the City of New Orleans health care safety-net. Dependent variables included patient ratings of accessibility, coordination, and confidence in the quality/safety of care. The key independent variable was a score measuring PCMH structural and process improvements at the clinic level. Approximately two thirds of patients in New Orleans gave positive ratings to their clinics on access and quality/safety, but only one third did for care coordination. In all but the largest clinics, patient experiences of care coordination were positively associated with the clinic's use of PCMH structural and process changes. Results for patient ratings of access and quality/safety were mixed. Among primary care clinics in the New Orleans safety-net, use of more PCMH improvements at the clinic level led to more positive patient rating of care coordination, but not of accessibility or confidence in quality/safety. Ongoing efforts to pilot, demonstrate, implement, and evaluate the PCMH should consider how the impact of medical practice transformation could vary across different aspects of the patient experience.
-
Hoffmann, B; Müller, V; Rochon, J; Gondan, M; Müller, B; Albay, Z; Weppler, K; Leifermann, M; Mießner, C; Güthlin, C; Parker, D; Hofinger, G; Gerlach, F M
2014-01-01
The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations. In this study we assessed the effects of FraTrix on safety culture in general practice. We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12 months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. During the team sessions, practice teams reflected on their safety culture and decided on about 10 actions per practice to improve it. After 12 months, no significant differences were found between intervention and control groups in terms of error management (competing probability=0.48, 95% CI 0.34 to 0.63, p=0.823), 11 further patient safety culture indicators and safety climate scales. Intervention practices showed better reporting of patient safety incidents, reflected in a higher number of incident reports (mean (SD) 4.85 (4.94) vs 3.10 (5.42), p=0.045) and incident reports of higher quality (scoring 2.27 (1.93) vs 1.49 (1.67), p=0.038) than control practices. Applied as a team-based instrument to assess safety culture, FraTrix did not lead to measurable improvements in error management. Comparable studies with more positive results had less robust study designs. In future research, validated combined methods to measure safety culture will be required. In addition, more attention should be paid to evaluation of process parameters. Implemented actions and incident reporting may be more appropriate target endpoints. German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) No. DRKS00000145.
-
Evaluating Amtrak's S2S: Are Recorded Injury Rates Showing Actual Injury Rates?
DOT National Transportation Integrated Search
2017-08-01
Since 2009, Amtrak has been engaged in unprecedented efforts to advance its safety processes and improve the safety culture of the entire corporation, including establishing a peer-to-peer feedback process, known as the Safe-2-Safer program. FRA is c...
-
Settle, Margaret Doyle; Coakley, Amanda Bulette; Annese, Christine Donahue
2017-02-01
Human milk provides superior nutritional value for infants in the neonatal intensive care unit and is the enteral feeding of choice. Our hospital used the system engineering initiative for patient safety model to evaluate the human milk management system in our neonatal intensive care unit. Nurses described the previous process in a negative way, fraught with opportunities for error, increased stress for nurses, and the need to be away from the bedside and their patients. The redesigned process improved the quality and safety of human milk management and created time for the nurses to spend with their patients.
-
Database management systems for process safety.
Early, William F
2006-03-17
Several elements of the process safety management regulation (PSM) require tracking and documentation of actions; process hazard analyses, management of change, process safety information, operating procedures, training, contractor safety programs, pre-startup safety reviews, incident investigations, emergency planning, and compliance audits. These elements can result in hundreds of actions annually that require actions. This tracking and documentation commonly is a failing identified in compliance audits, and is difficult to manage through action lists, spreadsheets, or other tools that are comfortably manipulated by plant personnel. This paper discusses the recent implementation of a database management system at a chemical plant and chronicles the improvements accomplished through the introduction of a customized system. The system as implemented modeled the normal plant workflows, and provided simple, recognizable user interfaces for ease of use.
-
Worker participation in change processes in a Danish industrial setting.
Rasmussen, Kurt; Glasscock, David J; Hansen, Ole N; Carstensen, Ole; Jepsen, Jette F; Nielsen, Kent J
2006-09-01
Improving the design, management and organization of work may be an important step in improving occupational health. An intervention, guided by the principles of participatory action research (PAR), is directed at traditional work environment problems in the epoxy plastic industry, that is, eczema and accident-related injuries. The study population consisted of employees at two wind turbine- manufacturing plants. A quasi-experimental design was employed with before and after measurements and a comparison group with a 3(1/2) year follow-up period. The role of employee elected safety representatives was changed from one of controlling and "policing" to that of safety advisors. The attitudes of employees also changed, from an individualistic understanding of safety as the responsibility of the single employee, to a more collective understanding of safety as being everyone's shared responsibility. Structural changes led to a less hierarchical management system. This process led eventually to the establishment of self-governing work groups in which each member had a well-defined area of responsibility. The change process was associated with improvements in the psychosocial work environment and safety climate, a 66% reduction in the incidence of eczema, and a 48.6% reduction in the incidence of occupational accidents. In the comparison population, a twin factory under the same company, similar but delayed and less dramatic changes also occurred. Implementation of a comprehensive intervention was followed by improved employee perceptions of the company's safety standards and the psychosocial work environment, as well as by substantial reductions in the incidence of eczema and occupational accidents.
-
Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families.
Thornton, Kevin C; Schwarz, Jennifer J; Gross, A Kendall; Anderson, Wendy G; Liu, Kathleen D; Romig, Mark C; Schell-Chaple, Hildy; Pronovost, Peter J; Sapirstein, Adam; Gropper, Michael A; Lipshutz, Angela K M
2017-09-01
Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. Our group determined by consensus which resources would best inform this review. A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.
-
Code of Federal Regulations, 2011 CFR
2011-04-01
...) Ensure the accuracy and currency of the safety data; (ii) Identify factors that affect the priority of... HIGHWAY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION HIGHWAY SAFETY HIGHWAY SAFETY IMPROVEMENT PROGRAM... reaching the performance goals identified in § 924.9(a)(3)(ii)(G). (2) Include a process to evaluate the...
-
The effects of a lean transition on process times, patients and employees.
Simons, Pascale; Backes, Huub; Bergs, Jochen; Emans, Davy; Johannesma, Madelon; Jacobs, Maria; Marneffe, Wim; Vandijck, Dominique
2017-03-13
Purpose Treatment delays must be avoided, especially in oncology, to assure sustainable high-quality health care and increase the odds of survival. The purpose of this paper is to hypothesize that waiting times would decrease and patients and employees would benefit, when specific lean interventions are incorporated in an organizational improvement approach. Design/methodology/approach In 2013, 15 lean interventions were initiated to improve flow in a single radiotherapy institute. Process/waiting times, patient satisfaction, safety, employee satisfaction, and absenteeism were evaluated using a mixed methods methodology (2010-2014). Data from databases, surveys, and interviews were analyzed by time series analysis, χ 2 , multi-level regression, and t-tests. Findings Median waiting/process times improved from 20.2 days in 2012 to 16.3 days in 2014 ( p<0.001). The percentage of palliative patients for which waiting times had exceeded Dutch national norms (ten days) improved from 35 (six months in 2012: pre-intervention) to 16 percent (six months in 2013-2014: post-intervention; p<0.01), and the percentage exceeding national objectives (seven days) from 22 to 17 percent ( p=0.44). For curative patients, exceeding of norms (28 days) improved from 17 (2012) to 8 percent (2013-2014: p=0.05), and for the objectives (21 days) from 18 to 10 percent ( p<0.01). Reported safety incidents decreased 47 percent from 2009 to 2014, whereas safety culture, awareness, and intention to solve problems improved. Employee satisfaction improved slightly, and absenteeism decreased from 4.6 (2010) to 2.7 percent (2014; p<0.001). Originality/value Combining specific lean interventions with an organizational improvement approach improved waiting times, patient safety, employee satisfaction, and absenteeism on the short term. Continuing evaluation of effects should study the improvements sustainability.
-
NASA Astrophysics Data System (ADS)
Rolita, Lisa; Surarso, Bayu; Gernowo, Rahmat
2018-02-01
In order to improve airport safety management system (SMS) performance, an evaluation system is required to improve on current shortcomings and maximize safety. This study suggests the integration of the DEMATEL and ANP methods in decision making processes by analyzing causal relations between the relevant criteria and taking effective analysis-based decision. The DEMATEL method builds on the ANP method in identifying the interdependencies between criteria. The input data consists of questionnaire data obtained online and then stored in an online database. Furthermore, the questionnaire data is processed using DEMATEL and ANP methods to obtain the results of determining the relationship between criteria and criteria that need to be evaluated. The study cases on this evaluation system were Adi Sutjipto International Airport, Yogyakarta (JOG); Ahmad Yani International Airport, Semarang (SRG); and Adi Sumarmo International Airport, Surakarta (SOC). The integration grades SMS performance criterion weights in a descending order as follow: safety and destination policy, safety risk management, healthcare, and safety awareness. Sturges' formula classified the results into nine grades. JOG and SMG airports were in grade 8, while SOG airport was in grade 7.
-
An organizational process for promoting home fire safety in two community settings.
Lehna, Carlee; Twyman, Stephanie; Fahey, Erin; Coty, Mary-Beth; Williams, Joe; Scrivener, Drane; Wishnia, Gracie; Myers, John
2017-02-01
The purpose of this study was to describe the home fire safety quality improvement model designed to aid organizations in achieving institutional program goals. The home fire safety model was developed from community-based participatory research (CBPR) applying training-the-trainer methods and is illustrated by an institutional case study. The model is applicable to other types of organizations to improve home fire safety in vulnerable populations. Utilizing the education model leaves trained employees with guided experience to build upon, adapt, and modify the home fire safety intervention to more effectively serve their clientele, promote safety, and meet organizational objectives. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.
-
Effects of patient safety auditing in hospital care: results of a mixed-method evaluation (part 1).
Hanskamp-Sebregts, Mirelle; Zegers, Marieke; Westert, Gert P; Boeijen, Wilma; Teerenstra, Steven; van Gurp, Petra J; Wollersheim, Hub
2018-06-15
To evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety. A before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands. Internal auditing and feedback focussed on improving patient safety. The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety. The AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P < 0.001). The SMR, patient safety culture and team climate remained unchanged after the internal audit. The SWRs showed that medication safety and information security were improved (P < 0.05). Internal auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.
-
Brouard, Agnes; Fagon, Jean Yves; Daniels, Charles E
2011-01-01
This project was designed to underline any actions relative to medication error prevention and patient safety improvement setting up in North American hospitals which could be implemented in French Parisian hospitals. A literature research and analysis of medication-use process in the North American hospitals and a validation survey of hospital pharmacist managers in the San Diego area was performed to assess main points of hospital medication-use process. Literature analysis, survey analysis of respondents highlighted main differences between the two countries at three levels: nationwide, hospital level and pharmaceutical service level. According to this, proposal development to optimize medication-use process in the French system includes the following topics: implementation of an expanded use of information technology and robotics; increase pharmaceutical human resources allowing expansion of clinical pharmacy activities; focus on high-risk medications and high-risk patient populations; develop a collective sense of responsibility for medication error prevention in hospital settings, involving medical, pharmaceutical and administrative teams. Along with a strong emphasis that should be put on the identified topics to improve the quality and safety of hospital care in France, consideration of patient safety as a priority at a nationwide level needs to be reinforced.
-
Human factors systems approach to healthcare quality and patient safety
Carayon, Pascale; Wetterneck, Tosha B.; Rivera-Rodriguez, A. Joy; Hundt, Ann Schoofs; Hoonakker, Peter; Holden, Richard; Gurses, Ayse P.
2013-01-01
Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety. PMID:23845724
-
Laboratory safety and the WHO World Alliance for Patient Safety.
McCay, Layla; Lemer, Claire; Wu, Albert W
2009-06-01
Laboratory medicine has been a pioneer in the field of patient safety; indeed, the College of American Pathology first called attention to the issue in 1946. Delivering reliable laboratory results has long been considered a priority, as the data produced in laboratory medicine have the potential to critically influence individual patients' diagnosis and management. Until recently, most attention on laboratory safety has focused on the analytic stage of laboratory medicine. Addressing this stage has led to significant and impressive improvements in the areas over which laboratories have direct control. However, recent data demonstrate that pre- and post-analytical phases are at least as vulnerable to errors; to further improve patient safety in laboratory medicine, attention must now be focused on the pre- and post-analytic phases, and the concept of patient safety as a multi-disciplinary, multi-stage and multi-system concept better understood. The World Alliance for Patient Safety (WAPS) supports improvement of patient safety globally and provides a potential framework for considering the total testing process.
-
Mahan, Bruce; Maclin, Reggie; Ruttenberg, Ruth; Mundy, Keith; Frazee, Tom; Schwartzkopf, Randy; Morawetz, John
2018-01-01
This study of Afton Chemical Corporation's Sauget facility and its International Chemical Workers Union Council (ICWUC) Local 871C demonstrates how significant safety improvements can be made when committed leadership from both management and union work together, build trust, train the entire work force in U.S. Occupational Safety and Health Administration 10-hour classes, and communicate with their work force, both salaried and hourly. A key finding is that listening to the workers closest to production can lead to solutions, many of them more cost-efficient than top-down decision-making. Another is that making safety and health an authentic value is hard work, requiring time, money, and commitment. Third, union and management must both have leadership willing to take chances and learn to trust one another. Fourth, training must be for everyone and ongoing. Finally, health and safety improvements require dedicated funding. The result was resolution of more than one hundred safety concerns and an ongoing institutionalized process for continuing improvement.
-
Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes.
Sorrentino, Patricia
2016-01-01
The purpose of this article is to describe a quality improvement process using failure mode and effects analysis (FMEA) to evaluate systems handoff communication processes, improve emergency department (ED) throughput and reduce crowding through development of a standardized handoff, and, ultimately, improve patient safety. Risk of patient harm through ineffective communication during handoff transitions is a major reason for breakdown of systems. Complexities of ED processes put patient safety at risk. An increased incidence of submitted patient safety event reports for handoff communication failures between the ED and inpatient units solidified a decision to implement the use of FMEA to identify handoff failures to mitigate patient harm through redesign. The clinical nurse specialist implemented an FMEA. Handoff failure themes were created from deidentified retrospective reviews. Weekly meetings were held over a 3-month period to identify failure modes and determine cause and effect on the process. A functional block diagram process map tool was used to illustrate handoff processes. An FMEA grid was used to list failure modes and assign a risk priority number to quantify results. Multiple areas with actionable failures were identified. A majority of causes for high-priority failure modes were specific to communications. Findings demonstrate the complexity of transition and handoff processes. The FMEA served to identify and evaluate risk of handoff failures and provide a framework for process improvement. A focus on mentoring nurses to quality handoff processes so that it becomes habitual practice is crucial to safe patient transitions. Standardizing content and hardwiring within the system are best practice. The clinical nurse specialist is prepared to provide strong leadership to drive and implement system-wide quality projects.
-
Newell, Terry L; Steinmetz-Malato, Laura L; Van Dyke, Deborah L
2011-01-01
The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital. © 2010 National Association for Healthcare Quality.
-
USDA-ARS?s Scientific Manuscript database
Stapylococcus saprophyticus is a common contaminant in foods and causes urinary tract infections in humans. Three nonthermal food safety intervention technologies used to improve the safety foods include high pressure processing (HPP), ionizing (gamma) radiation (GR), and ultraviolet light (UV-C). A...
-
Gleich, Stephen J; Nemergut, Michael E; Stans, Anthony A; Haile, Dawit T; Feigal, Scott A; Heinrich, Angela L; Bosley, Christopher L; Tripathi, Sandeep
2016-08-01
Ineffective and inefficient patient transfer processes can increase the chance of medical errors. Improvements in such processes are high-priority local institutional and national patient safety goals. At our institution, nonintubated postoperative pediatric patients are first admitted to the postanesthesia care unit before transfer to the PICU. This quality improvement project was designed to improve the patient transfer process from the operating room (OR) to the PICU. After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of the process to determine error-prone and inefficient areas. We evaluated primary outcome measures of handoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction was evaluated as a counterbalance measure. With the introduction of the new direct OR-PICU patient transfer process, the handoff communication error rate improved from 1.9 to 0.3 errors per patient handoff (P = .002). Inefficiency (patient wait time and non-value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved with fewer information omissions (P < .001). Staff satisfaction significantly improved among nearly all PICU providers. By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustained improvements in patient safety and efficiency. Handoff communication was enhanced, with fewer errors and content omissions. The new process improved efficiency, with high staff satisfaction. Copyright © 2016 by the American Academy of Pediatrics.
-
Plan for Quality to Improve Patient Safety at the Point of Care
Ehrmeyer, Sharon S.
2011-01-01
The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety. PMID:21808107
-
Glenn, Kevin C
2008-01-01
During the last two decades, the public and private sectors have made substantial research progress internationally toward improving the nutritional value of a wide range of food and feed crops. Nevertheless, significant numbers of people still suffer from the effects of undernutrition. As newly developed crops with nutritionally improved traits come closer to being available to producers and consumers, scientifically sound and efficient processes are needed to assess the safety and nutritional quality of these crops. In 2004, a Task Force of international scientific experts, convened by the International Food Biotechnology Committee (IFBiC) of ILSI, published recommendations for the safety and nutritional assessment of foods and feeds nutritionally improved through modern biotechnology (J. Food Science, 2004, 69:CRH62-CRH68). The comparative safety assessment process is a basic principle in this publication and is the starting point, not the conclusion, of the analysis. Significant differences in composition are expected to be observed in the case of nutritionally enhanced crops and must be assessed on a case-by-case basis. The Golden Rice 2 case study will be presented as an example of a food crop nutritionally enhanced through the application of modern biotechnology (i.e., recombinant DNA techniques) to illustrate how the 2004 recommendations provide a robust paradigm for the safety assessment of "real world" examples of improved nutrition crops.
-
Increasing patient safety and efficiency in transfusion therapy using formal process definitions.
Henneman, Elizabeth A; Avrunin, George S; Clarke, Lori A; Osterweil, Leon J; Andrzejewski, Chester; Merrigan, Karen; Cobleigh, Rachel; Frederick, Kimberly; Katz-Bassett, Ethan; Henneman, Philip L
2007-01-01
The administration of blood products is a common, resource-intensive, and potentially problem-prone area that may place patients at elevated risk in the clinical setting. Much of the emphasis in transfusion safety has been targeted toward quality control measures in laboratory settings where blood products are prepared for administration as well as in automation of certain laboratory processes. In contrast, the process of transfusing blood in the clinical setting (ie, at the point of care) has essentially remained unchanged over the past several decades. Many of the currently available methods for improving the quality and safety of blood transfusions in the clinical setting rely on informal process descriptions, such as flow charts and medical algorithms, to describe medical processes. These informal descriptions, although useful in presenting an overview of standard processes, can be ambiguous or incomplete. For example, they often describe only the standard process and leave out how to handle possible failures or exceptions. One alternative to these informal descriptions is to use formal process definitions, which can serve as the basis for a variety of analyses because these formal definitions offer precision in the representation of all possible ways that a process can be carried out in both standard and exceptional situations. Formal process definitions have not previously been used to describe and improve medical processes. The use of such formal definitions to prospectively identify potential error and improve the transfusion process has not previously been reported. The purpose of this article is to introduce the concept of formally defining processes and to describe how formal definitions of blood transfusion processes can be used to detect and correct transfusion process errors in ways not currently possible using existing quality improvement methods.
-
Colligan, Lacey; Anderson, Janet E; Potts, Henry W W; Berman, Jonathan
2010-01-07
Many quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners' judgments. A sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams. Quality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants' preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted. The results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured.
-
Mutic, Sasa; Brame, R Scott; Oddiraju, Swetha; Parikh, Parag; Westfall, Melisa A; Hopkins, Merilee L; Medina, Angel D; Danieley, Jonathan C; Michalski, Jeff M; El Naqa, Issam M; Low, Daniel A; Wu, Bin
2010-09-01
The value of near-miss and error reporting processes in many industries is well appreciated and typically can be supported with data that have been collected over time. While it is generally accepted that such processes are important in the radiation therapy (RT) setting, studies analyzing the effects of organized reporting and process improvement systems on operation and patient safety in individual clinics remain scarce. The purpose of this work is to report on the design and long-term use of an electronic reporting system in a RT department and compare it to the paper-based reporting system it replaced. A specifically designed web-based system was designed for reporting of individual events in RT and clinically implemented in 2007. An event was defined as any occurrence that could have, or had, resulted in a deviation in the delivery of patient care. The aim of the system was to support process improvement in patient care and safety. The reporting tool was designed so individual events could be quickly and easily reported without disrupting clinical work. This was very important because the system use was voluntary. The spectrum of reported deviations extended from minor workflow issues (e.g., scheduling) to errors in treatment delivery. Reports were categorized based on functional area, type, and severity of an event. The events were processed and analyzed by a formal process improvement group that used the data and the statistics collected through the web-based tool for guidance in reengineering clinical processes. The reporting trends for the first 24 months with the electronic system were compared to the events that were reported in the same clinic with a paper-based system over a seven-year period. The reporting system and the process improvement structure resulted in increased event reporting, improved event communication, and improved identification of clinical areas which needed process and safety improvements. The reported data were also useful for the evaluation of corrective measures and recognition of ineffective measures and efforts. The electronic system was relatively well accepted by personnel and resulted in minimal disruption of clinical work. Event reporting in the quarters with the fewest number of reported events, though voluntary, was almost four times greater than the most events reported in any one quarter with the paper-based system and remained consistent from the inception of the process through the date of this report. However, the acceptance was not universal, validating the need for improved education regarding reporting processes and systematic approaches to reporting culture development. Specially designed electronic event reporting systems in a radiotherapy setting can provide valuable data for process and patient safety improvement and are more effective reporting mechanisms than paper-based systems. Additional work is needed to develop methods that can more effectively utilize reported data for process improvement, including the development of standardized event taxonomy and a classification system for RT.
-
The complexity of patient safety reporting systems in UK dentistry.
Renton, T; Master, S
2016-10-21
Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.
-
Wang, Panfeng; Zhang, Hongjun; Li, Baohua; Lin, Keke
2016-01-01
The aims of this study were to develop a nursing information system (NIS), enhance the visibility of patient risk, and identify challenges and facilitators to adoption of the NIS risk assessment system for nurse leaders. This article describes the function of a nursing risk assessment information system, and the results of a survey on the risk assessment system. The results suggested that quality of information processing in nursing significantly improved patient safety. Nurses surveyed demonstrated a high degree of satisfaction, with saving time and improving safety. The nursing document information system described was introduced to improve patient safety and decrease risk. The application of the system has greatly enhanced the efficiency of nursing work, and guides the nurses to make an accurate, comprehensive and objective assessment of patient information, contributing significantly to further improvement in care standards and care decisions.
-
Lee, Jin; Huang, Yueng-Hsiang; Cheung, Janelle H; Chen, Zhuo; Shaw, William S
2018-04-26
Safety climate represents the meaningfulness of safety and how safety is valued in an organization. The contributions of safety climate to organizational safety have been well documented. There is a dearth of empirical research, however, on specific safety climate interventions and their effectiveness. The present study aims at examining the trend of safety climate interventions and offering compiled information for designing and implementing evidence-based safety climate interventions. Our literature search yielded 384 titles that were inspected by three examiners. Using a stepwise process that allowed for assessment of interobserver agreement, 19 full articles were selected and reviewed. Results showed that 10 out of the 19 articles (52.6%) were based on a quasi-experimental pre- and postintervention design, whereas 42.1% (n = 8) studies were based on a mixed-design approach (including both between- and within-subject design). All interventions in these 19 studies involved either safety-/health-related communication or education/training. Improvement of safety leadership was also a common component of safety climate interventions. According to the socio-technical systems classification of intervention strategies, all studies were categorized as interventions focusing on improving organizational and managerial structure as well as the personnel subsystem; four of them also aimed at improving technological aspects of work, and five of them aimed at improving the physical work subsystem. In general, a vast majority of the studies (89.5%, n = 17) showed a statistically significant improvement in safety climate across their organizations postintervention. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
-
Improving the safety of vaccine delivery.
Evans, Huw P; Cooper, Alison; Williams, Huw; Carson-Stevens, Andrew
2016-05-03
Vaccines save millions of lives per annum as an integral part of community primary care provision worldwide. Adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and adverse drug event surveillance offer a rich opportunity for understanding the underlying causes of those errors. Reducing harm relies on the identification and implementation of changes to improve vaccine safety at multiple levels: from patient interventions through to organizational actions at local, national and international levels. Here we highlight the potential for maximizing learning from patient safety incident reports to improve the quality and safety of vaccine delivery.
-
Singh, Ranjit; Hickner, John; Mold, Jim; Singh, Gurdev
2014-03-01
Testing plays a vital role in primary care. Failures in the process are common and can be harmful. As the great 19th century microbiologist Louis Pasteur put it "chance favors only the prepared mind." Our objective is to prepare minds in primary care practices to improve safety in the testing process. Various principles from safety science can be applied. A prospective methodology that uses an anonymous practice survey based on concepts from failure modes and effects analysis is proposed. Responses are used to rank perceived hazards in the testing process, leading to prioritization of areas for intervention. Secondary data analysis (using data from a study of medication safety) was used to explore the value of this approach in the context of assessing the testing process. At 3 primary care practice sites, a total of 61 staff members completed 4 survey items examining the testing process. Comparison across practices shows that each has a distinct profile of hazards, which would lead each on a different path toward improvement. The proposed approach treats each practice as a unique complex adaptive system aiming to help it thrive by inculcating trust, mutual respect, and collaboration. Implications for patient safety research and practice are discussed.
-
RFID in the blood supply chain--increasing productivity, quality and patient safety.
Briggs, Lynne; Davis, Rodeina; Gutierrez, Alfonso; Kopetsky, Matthew; Young, Kassandra; Veeramani, Raj
2009-01-01
As part of an overall design of a new, standardized RFID-enabled blood transfusion medicine supply chain, an assessment was conducted for two hospitals: the University of Iowa Hospital and Clinics (UIHC) and Mississippi Baptist Health System (MBHS). The main objectives of the study were to assess RFID technological and economic feasibility, along with possible impacts to productivity, quality and patient safety. A step-by-step process analysis focused on the factors contributing to process "pain points" (errors, inefficiency, product losses). A process re-engineering exercise produced blueprints of RFID-enabled processes to alleviate or eliminate those pain-points. In addition, an innovative model quantifying the potential reduction in adverse patient effects as a result of RFID implementation was created, allowing improvement initiatives to focus on process areas with the greatest potential impact to patient safety. The study concluded that it is feasible to implement RFID-enabled processes, with tangible improvements to productivity and safety expected. Based on a comprehensive cost/benefit model, it is estimated for a large hospital (UIHC) to recover investment from implementation within two to three years, while smaller hospitals may need longer to realize ROI. More importantly, the study estimated that RFID technology could reduce morbidity and mortality effects substantially among patients receiving transfusions.
-
Sobottka, Stephan B; Töpfer, Armin; Eberlein-Gonska, Maria; Schackert, Gabriele; Albrecht, D Michael
2010-01-01
Six Sigma is an innovative management- approach to reach practicable zero- defect quality in medical service processes. The Six Sigma principle utilizes strategies, which are based on quantitative measurements and which seek to optimize processes, limit deviations or dispersion from the target process. Hence, Six Sigma aims to eliminate errors or quality problems of all kinds. A pilot project to optimize the preparation for neurosurgery could now show that the Six Sigma method enhanced patient safety in medical care, while at the same time disturbances in the hospital processes and failure costs could be avoided. All six defined safety relevant quality indicators were significantly improved by changes in the workflow by using a standardized process- and patient- oriented approach. Certain defined quality standards such as a 100% complete surgical preparation at start of surgery and the required initial contact of the surgeon with the patient/ surgical record on the eve of surgery could be fulfilled within the range of practical zero- defect quality. Likewise, the degree of completion of the surgical record by 4 p.m. on the eve of surgery and their quality could be improved by a factor of 170 and 16, respectively, at sigma values of 4.43 and 4.38. The other two safety quality indicators "non-communicated changes in the OR- schedule" and the "completeness of the OR- schedule by 12:30 a.m. on the day before surgery" also show an impressive improvement by a factor of 2.8 and 7.7, respectively, corresponding with sigma values of 3.34 and 3.51. The results of this pilot project demonstrate that the Six Sigma method is eminently suitable for improving quality of medical processes. In our experience this methodology is suitable, even for complex clinical processes with a variety of stakeholders. In particular, in processes in which patient safety plays a key role, the objective of achieving a zero- defect quality is reasonable and should definitely be aspirated. Copyright © 2010. Published by Elsevier GmbH.
-
NASA Astrophysics Data System (ADS)
Shi, J. T.; Han, X. T.; Xie, J. F.; Yao, L.; Huang, L. T.; Li, L.
2013-03-01
A Pulsed High Magnetic Field Facility (PHMFF) has been established in Wuhan National High Magnetic Field Center (WHMFC) and various protection measures are applied in its control system. In order to improve the reliability and robustness of the control system, the safety analysis of the PHMFF is carried out based on Fault Tree Analysis (FTA) technique. The function and realization of 5 protection systems, which include sequence experiment operation system, safety assistant system, emergency stop system, fault detecting and processing system and accident isolating protection system, are given. The tests and operation indicate that these measures improve the safety of the facility and ensure the safety of people.
-
Yurko, Joseph P.; Buongiorno, Jacopo; Youngblood, Robert
2015-05-28
System codes for simulation of safety performance of nuclear plants may contain parameters whose values are not known very accurately. New information from tests or operating experience is incorporated into safety codes by a process known as calibration, which reduces uncertainty in the output of the code and thereby improves its support for decision-making. The work reported here implements several improvements on classic calibration techniques afforded by modern analysis techniques. The key innovation has come from development of code surrogate model (or code emulator) construction and prediction algorithms. Use of a fast emulator makes the calibration processes used here withmore » Markov Chain Monte Carlo (MCMC) sampling feasible. This study uses Gaussian Process (GP) based emulators, which have been used previously to emulate computer codes in the nuclear field. The present work describes the formulation of an emulator that incorporates GPs into a factor analysis-type or pattern recognition-type model. This “function factorization” Gaussian Process (FFGP) model allows overcoming limitations present in standard GP emulators, thereby improving both accuracy and speed of the emulator-based calibration process. Calibration of a friction-factor example using a Method of Manufactured Solution is performed to illustrate key properties of the FFGP based process.« less
-
Spreading a medication administration intervention organizationwide in six hospitals.
Kliger, Julie; Singer, Sara; Hoffman, Frank; O'Neil, Edward
2012-02-01
Six hospitals from the San Francisco Bay Area participated in a 12-month quality improvement project conducted by the Integrated Nurse Leadership Program (INLP). A quality improvement intervention that focused on improving medication administration accuracy was spread from two pilot units to all inpatient units in the hospitals. INLP developed a 12-month curriculum, presented in a combination of off-site training sessions and hospital-based training and consultant-led meetings, to teach clinicians the key skills needed to drive organizationwide change. Each hospital established a nurse-led project team, as well as unit teams to address six safety processes designed to improve medication administration accuracy: compare medication to the medication administration record; keep medication labeled throughout; check two patient identifications; explain drug to patient (if applicable); chart immediately after administration; and protect process from distractions and interruptions. From baseline until one year after project completion, the six hospitals improved their medication accuracy rates, on average, from 83.4% to 98.0% in the spread units. The spread units also improved safety processes overall from 83.1% to 97.2%. During the same time, the initial pilot units also continued to improve accuracy from 94.0% to 96.8% and safety processes overall from 95.3% to 97.2%. With thoughtful planning, engaging those doing the work early and focusing on the "human side of change" along with technical knowledge of improvement methodologies, organizations can spread initiatives enterprisewide. This program required significant training of frontline workers in problem-solving skills, leading change, team management, data tracking, and communication.
-
In-Class Simulation of Pooling Safety Stock
ERIC Educational Resources Information Center
Bandy, D. Brent
2005-01-01
In managing business process flows, safety stock can be used to protect against stockouts due to demand variability. When more than one location is involved, the concept of aggregation enables the pooling of demands and associated inventories, resulting in improved service levels without increasing the total level of safety stock. This pooling of…
-
Federal Register 2010, 2011, 2012, 2013, 2014
2010-11-30
... cause review, a Safety Culture Implications Review, organizational and process changes in response to... of the assessment. d. NFS agrees to develop and implement an appropriate safety culture improvement plan to address the findings identified in the second Safety Culture Assessment report that was...
-
DOT National Transportation Integrated Search
2014-03-01
Similar to an ill patient, road safety issues can : also be diagnosed, if the right tools are available. : Statistics on roadway incidents can locate areas : that have a high rate of incidents and require : a solution, such as better signage, lightin...
-
Teaching Laboratory Renovation
DOE Office of Scientific and Technical Information (OSTI.GOV)
Al-Zuhairi, Ali Jassim; Al-Dahhan, Wedad; Hussein, Falah
Scientists at universities across Iraq are actively working to report actual incidents and accidents occurring in their laboratories, as well as structural improvements made to improve safety and security, to raise awareness and encourage openness, leading to widespread adoption of robust Chemical Safety and Security (CSS) practices. The improvement of students’ understanding of concepts in science and its applications, practical scientific skills and understanding of how science and scientists work in laboratory experiences have been considered key aspects of education in science for over 100 years. Facility requirements for the necessary level of safety and security combined with specific requirementsmore » relevant to the course to be conducted dictate the structural design of a particular laboratory, and the design process must address both. This manuscript is the second in a series of five case studies describing laboratory incidents, accidents, and laboratory improvements. We summarize the process used to guide a major renovation of the chemistry instructional laboratory facilities at Al-Nahrain University and discuss lessons learned from the project.« less
-
Processes of technology assessment: The National Transportation Safety Board
NASA Technical Reports Server (NTRS)
Weiss, E.
1972-01-01
The functions and operations of the Safety Board as related to technology assessment are described, and a brief history of the Safety Board is given. Recommendations made for safety in all areas of transportation and the actions taken are listed. Although accident investigation is an important aspect of NTSB's activity, it is felt that the greatest contribution is in pressing for development of better accident prevention programs. Efforts of the Safety Board in changing transportation technology to improve safety and prevent accidents are illustrated.
-
Research on Taxiway Path Optimization Based on Conflict Detection
Zhou, Hang; Jiang, Xinxin
2015-01-01
Taxiway path planning is one of the effective measures to make full use of the airport resources, and the optimized paths can ensure the safety of the aircraft during the sliding process. In this paper, the taxiway path planning based on conflict detection is considered. Specific steps are shown as follows: firstly, make an improvement on A * algorithm, the conflict detection strategy is added to search for the shortest and safe path in the static taxiway network. Then, according to the sliding speed of aircraft, a time table for each node is determined and the safety interval is treated as the constraint to judge whether there is a conflict or not. The intelligent initial path planning model is established based on the results. Finally, make an example in an airport simulation environment, detect and relieve the conflict to ensure the safety. The results indicate that the model established in this paper is effective and feasible. Meanwhile, make comparison with the improved A*algorithm and other intelligent algorithms, conclude that the improved A*algorithm has great advantages. It could not only optimize taxiway path, but also ensure the safety of the sliding process and improve the operational efficiency. PMID:26226485
-
Research on Taxiway Path Optimization Based on Conflict Detection.
Zhou, Hang; Jiang, Xinxin
2015-01-01
Taxiway path planning is one of the effective measures to make full use of the airport resources, and the optimized paths can ensure the safety of the aircraft during the sliding process. In this paper, the taxiway path planning based on conflict detection is considered. Specific steps are shown as follows: firstly, make an improvement on A * algorithm, the conflict detection strategy is added to search for the shortest and safe path in the static taxiway network. Then, according to the sliding speed of aircraft, a time table for each node is determined and the safety interval is treated as the constraint to judge whether there is a conflict or not. The intelligent initial path planning model is established based on the results. Finally, make an example in an airport simulation environment, detect and relieve the conflict to ensure the safety. The results indicate that the model established in this paper is effective and feasible. Meanwhile, make comparison with the improved A*algorithm and other intelligent algorithms, conclude that the improved A*algorithm has great advantages. It could not only optimize taxiway path, but also ensure the safety of the sliding process and improve the operational efficiency.
-
NASA Technical Reports Server (NTRS)
Safie, Fayssal M.; Daniel, Charles; Kalia, Prince; Smith, Charles A. (Technical Monitor)
2002-01-01
The United States National Aeronautics and Space Administration (NASA) is in the midst of a 10-year Second Generation Reusable Launch Vehicle (RLV) program to improve its space transportation capabilities for both cargo and crewed missions. The objectives of the program are to: significantly increase safety and reliability, reduce the cost of accessing low-earth orbit, attempt to leverage commercial launch capabilities, and provide a growth path for manned space exploration. The safety, reliability and life cycle cost of the next generation vehicles are major concerns, and NASA aims to achieve orders of magnitude improvement in these areas. To get these significant improvements, requires a rigorous process that addresses Reliability, Maintainability and Supportability (RMS) and safety through all the phases of the life cycle of the program. This paper discusses the RMS process being implemented for the Second Generation RLV program.
-
An interprofessional training course in crises and human factors for perioperative teams.
Stephens, Tim; Hunningher, Annie; Mills, Helen; Freeth, Della
2016-09-01
Improving patient safety and the culture of care are health service priorities that coexist with financial pressures on organisations. Research suggests team training and better team processes can improve team culture, safety, performance, and clinical outcomes, yet opportunities for interprofessional learning remain scarce. Perioperative practitioners work in a high pressure, high-risk environment without the benefits of stable team membership: this limits opportunities and momentum for team-initiated collaborative improvements. This article describes an interprofessional course focused on crises and human factors which comprised a 1-day event and a multifaceted sustainment programme for perioperative practitioners, grouped by surgical specialty. Participants reported increased understanding and confidence to enact processes and behaviours that support patient safety, including: team behaviours (communication, coordination, cooperation and back-up, leadership, situational awareness); recognising different perspectives and expectations within the team; briefing and debriefing; after action review; and using specialty-specific incident reports to generate specialty-specific interprofessional improvement plans. Participants valued working with specialty colleagues away from normal work pressures. In the high-pressure arena of front-line healthcare delivery, improving patient safety and theatre efficiency can often be erroneously considered conflicting agendas. Interprofessional collaboration amongst staff participating in this initiative enabled general and specialty-specific interprofessional learning that transcended this conflict.
-
A multicenter collaborative approach to reducing pediatric codes outside the ICU.
Hayes, Leslie W; Dobyns, Emily L; DiGiovine, Bruno; Brown, Ann-Marie; Jacobson, Sharon; Randall, Kelly H; Wathen, Beth; Richard, Heather; Schwab, Carolyn; Duncan, Kathy D; Thrasher, Jodi; Logsdon, Tina R; Hall, Matthew; Markovitz, Barry
2012-03-01
The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points. A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores. Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%. A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.
-
The Use of Crow-AMSAA Plots to Assess Mishap Trends
NASA Technical Reports Server (NTRS)
Dawson, Jeffrey W.
2011-01-01
Crow-AMSAA (CA) plots are used to model reliability growth. Use of CA plots has expanded into other areas, such as tracking events of interest to management, maintenance problems, and safety mishaps. Safety mishaps can often be successfully modeled using a Poisson probability distribution. CA plots show a Poisson process in log-log space. If the safety mishaps are a stable homogenous Poisson process, a linear fit to the points in a CA plot will have a slope of one. Slopes of greater than one indicate a nonhomogenous Poisson process, with increasing occurrence. Slopes of less than one indicate a nonhomogenous Poisson process, with decreasing occurrence. Changes in slope, known as "cusps," indicate a change in process, which could be an improvement or a degradation. After presenting the CA conceptual framework, examples are given of trending slips, trips and falls, and ergonomic incidents at NASA (from Agency-level data). Crow-AMSAA plotting is a robust tool for trending safety mishaps that can provide insight into safety performance over time.
-
Establishing a culture for patient safety - the role of education.
Milligan, Frank J
2007-02-01
This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).
-
Sanchez-Izquierdo-Riera, Jose Angel; Molano-Alvarez, Esteban; Saez-de la Fuente, Ignacio; Maynar-Moliner, Javier; Marín-Mateos, Helena; Chacón-Alves, Silvia
2016-01-01
The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients [46.3%] vs. 16 patients [22.2%]; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.
-
Lichte, Thomas; Klement, Andreas; Herrmann, Markus
2009-01-01
The development of a medical safety culture is spreading beyond the hospital into the ambulatory setting. Patient safety defined as "absence of unwanted events" (primum non nocere) can serve as a starting point for the advancement of our ambulatory medical care system. Error analyses conducted in GP and specialist practices will identify gaps and traps in the system and provide ideas for the development and implementation of new safety strategies in ambulatory patient care. In the light of the structures and processes of GP medical care aspects of patient safety will be correlated to the outcome quality and examples will be discussed. Possible strategies for the improvement of patient safety in GP practice will be presented from the perspective of both patient- and practice individuality.
-
Simpson, Kathleen Rice; Knox, G Eric; Martin, Morgan; George, Chris; Watson, Sam R
2011-12-01
Preventable harm to mothers and infants during labor and birth is a significant patient safety and professional liability issue. A Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Obstetric Collaborative Project involved perinatal teams from 15 Michigan hospitals during an 11-month period in 2009. The purpose of the project was to promote safe care practices during labor and birth using the Comprehensive Unit-based Safety Program (CUSP). Consistent with the CUSP model, this project's components included assessing and promoting a culture of safety; interdisciplinary team building; case review; learning from defects through multiple methods of education; team and individual coaching and peer encouragement; administrative support for the establishment of a fundamental safety infrastructure; and ongoing evaluation of care processes and outcomes. Study measures included 32 components of a perinatal patient infrastructure, 6 care processes during labor and birth, and 4 neonatal outcomes. Significant improvements were found in the safety culture (Safety Attitudes Questionnaire), the perinatal patient safety infrastructure components, and all care processes. Although the project was successful, getting buy-in from all members of the clinical team in each hospital for all of the measures was challenging at times. There was initial resistance to some of the measures and their various expected aspects of care. For example, some of the clinicians were initially reluctant to adopt the recommended standardized oxytocin protocol. Peer encouragement and unit-based feedback on progress in minimizing early elective births proved useful in many hospitals. A CUSP in obstetrics can be beneficial in improving the care of mothers and infants during labor and birth.
-
USDA-ARS?s Scientific Manuscript database
Uropathogenic Escherichia coli (UPEC) are common contaminants in meat and poultry. Nonthermal food safety intervention technologies used to improve safety and shelf-life of both human and pet foods can include high pressure processing (HPP), ionizing (gamma) radiation (GR), and ultraviolet light (UV...
-
Implementation of a Surgical Safety Checklist: Impact on Surgical Team Perspectives
Papaconstantinou, Harry T.; Jo, ChanHee; Reznik, Scott I.; Smythe, W. Roy; Wehbe-Janek, Hania
2013-01-01
Background The World Health Organization (WHO) surgical safety checklist has been shown to decrease mortality and complications and has been adopted worldwide. However, system flaws and human errors persist. Identifying provider perspectives of patient safety initiatives may identify strategies for improvement. The purpose of this study was to determine provider perspectives of surgical safety checklist implementation in an effort to improve initiatives that enhance surgical patients' safety. Methods In September 2010, a WHO-adapted surgical safety checklist was implemented at our institution. Surgical teams were invited to complete a checklist-focused questionnaire 1 month before and 1 year after implementation. Baseline and follow-up results were compared. Results A total of 437 surgical care providers responded to the survey: 45% of providers responded at baseline and 64% of providers responded at follow-up. Of the total respondents, 153 (35%) were nurses, 104 (24%) were anesthesia providers, and 180 (41%) were surgeons. Overall, we found an improvement in the awareness of patient safety and quality of care, with significant improvements in the perception of the value of and participation in the time-out process, in surgical team communication, and in the establishment and clarity of patient care needs. Some discordance was noted between surgeons and other surgical team members, indicating that barriers in communication still exist. Overall, approximately 65% of respondents perceived that the checklist improved patient safety and patient care; however, we found a strong negative perception of operating room efficiency. Conclusion Implementation of a surgical safety checklist improves perceptions of surgical safety. Barriers to implementation exist, but staff feedback may be used to enhance the sustainability and success of patient safety initiatives. PMID:24052757
-
Transformation of safety culture on the San Antonio service unit of Union Pacific Railroad
DOT National Transportation Integrated Search
2012-10-31
The Federal Railroad Administration conducted a pilot demonstration of Clear Signal for Action (CSA), a risk reduction process : that combines peer-to-peer feedback, continuous improvement, and safety leadership development. An independent formative ...
-
DOT National Transportation Integrated Search
2017-01-01
Researchers completed the following activities: - Reviewed the literature, state HSIP processes and practices, and HSIP tools used by various agencies. - Evaluated the applicability of safety assessment methods and tools used by other states and loca...
-
Update from C3RS lessons learned team : safety culture and trend analysis.
DOT National Transportation Integrated Search
2014-07-01
The Federal Railroad Administration (FRA) believes that, in addition to process and technology innovations, human-factors-based solutions can significantly contribute to improving safety in the railroad industry. To test this assumption, FRA implemen...
-
Anderson, Janet E; Kodate, Naonori; Walters, Rhiannon; Dodds, Anneliese
2013-04-01
Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. Qualitative research design using documentary analysis and semi-structured interviews. Two large teaching hospitals in London; one providing acute and the other mental healthcare. Sixty-two healthcare practitioners with experience of reporting and analysing incidents. Incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals. Incident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
-
Forrester, Jared A; Koritsanszky, Luca A; Amenu, Demisew; Haynes, Alex B; Berry, William R; Alemu, Seifu; Jiru, Fekadu; Weiser, Thomas G
2018-06-01
Surgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety. We introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements. Process mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals. Enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
-
Arcury, Thomas A; Grzywacz, Joseph G; Anderson, Andrea M; Mora, Dana C; Carrillo, Lourdes; Chen, Haiying; Quandt, Sara A
2013-02-01
This analysis describes the work safety climate of Latino poultry processing workers and notes differences by worker personal characteristics and employer; describes the use of common personal protective equipment (PPE) among workers; and examines the associations of work safety climate with use of common PPE. Data are from a cross-sectional study of 403 Latino poultry processing workers in western North Carolina. Work safety climate differed little by personal characteristics, but it did differ consistently by employer. Provision of PPE varied; for example, 27.2% of participants were provide with eye protection at no cost, 57.0% were provided with hand protection at no cost, and 84.7% were provided with protective clothing at no cost. PPE use varied by type. Provision of PPE at no cost was associated with lower work safety climate; this result was counter-intuitive. Consistent use of PPE was associated with higher work safety climate. Work safety climate is important for improving workplace safety for immigrant workers. Research among immigrant workers should document work safety climate for different employers and industries, and delineate how work safety climate affects safety behavior and injuries. Copyright © 2012 Wiley Periodicals, Inc.
-
Final Report of the NASA Office of Safety and Mission Assurance Agile Benchmarking Team
NASA Technical Reports Server (NTRS)
Wetherholt, Martha
2016-01-01
To ensure that the NASA Safety and Mission Assurance (SMA) community remains in a position to perform reliable Software Assurance (SA) on NASAs critical software (SW) systems with the software industry rapidly transitioning from waterfall to Agile processes, Terry Wilcutt, Chief, Safety and Mission Assurance, Office of Safety and Mission Assurance (OSMA) established the Agile Benchmarking Team (ABT). The Team's tasks were: 1. Research background literature on current Agile processes, 2. Perform benchmark activities with other organizations that are involved in software Agile processes to determine best practices, 3. Collect information on Agile-developed systems to enable improvements to the current NASA standards and processes to enhance their ability to perform reliable software assurance on NASA Agile-developed systems, 4. Suggest additional guidance and recommendations for updates to those standards and processes, as needed. The ABT's findings and recommendations for software management, engineering and software assurance are addressed herein.
-
Department of the Navy Explosives Safety Site Approval Process Improvement Initiative
2010-07-01
All applicable existing land-use restrictions, such as explosives safety quantity distance (ESQD) arcs, Hazards of Electromagnetic Radiation to... Ordnance ( HERO ) zones, air field safety zones, and munitions response program sites are noted in the ESAR. PWO will have in place a written...N547) Naval Ordnance Safety and Security Activity Farragut Hall, 3817 Strauss Ave, Suite 108 Indian Head, MD 20640-5151 (301) 744-6059
-
42 CFR 3.102 - Process and requirements for initial and continued listing of PSOs.
Code of Federal Regulations, 2014 CFR
2014-10-01
... improve patient safety and the quality of health care delivery. (B) The PSO must have appropriately... patient safety reporting system to which health care providers (other than members of the entity's... activities, defined in § 3.20. With respect to paragraphs (5) and (6) in the definition of patient safety...
-
42 CFR 3.102 - Process and requirements for initial and continued listing of PSOs.
Code of Federal Regulations, 2013 CFR
2013-10-01
... improve patient safety and the quality of health care delivery. (B) The PSO must have appropriately... patient safety reporting system to which health care providers (other than members of the entity's... activities, defined in § 3.20. With respect to paragraphs (5) and (6) in the definition of patient safety...
-
42 CFR 3.102 - Process and requirements for initial and continued listing of PSOs.
Code of Federal Regulations, 2012 CFR
2012-10-01
... improve patient safety and the quality of health care delivery. (B) The PSO must have appropriately... patient safety reporting system to which health care providers (other than members of the entity's... activities, defined in § 3.20. With respect to paragraphs (5) and (6) in the definition of patient safety...
-
An Organizational Learning Framework for Patient Safety.
Edwards, Marc T
Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.
-
Mutungi, C; Irungu, F G; Nduko, J; Mutua, F; Affognon, H; Nakimbugwe, D; Ekesi, S; Fiaboe, K K M
2017-08-30
In many African cultures, insects are part of the diet of humans and domesticated animals. Compared to conventional food and feed sources, insects have been associated with a low ecological foot print because fewer natural resources are required for their production. To this end, the Food and Agriculture Organization of the United Nations recognized the role that edible insects can play in improving global food and nutrition security; processing technologies, as well as packaging and storage techniques that improve shelf-life were identified as being crucial. However, knowledge of these aspects in light of nutritional value, safety, and functionality is fragmentary and needs to be consolidated. This review attempts to contribute to this effort by evaluating the available evidence on postharvest processes for edible insects in Africa, with the aim of identifying areas that need research impetus. It further draws attention to potential postharvest technology options for overcoming hurdles associated with utilization of insects for food and feed. A greater research thrust is needed in processing and this can build on traditional knowledge. The focus should be to establish optimal techniques that improve presentation, quality and safety of products, and open possibilities to diversify use of edible insects for other benefits.
-
Relationships between Climate, Process, and Performance in Continuous Quality Improvement Groups
ERIC Educational Resources Information Center
Wilkens, Roxanne; London, Manuel
2006-01-01
This study examined relationships between group climate (participants' learning orientation, feelings of psychological safety, and self-disclosure), process (feedback and conflict), and performance in continuous quality improvement groups. Forty-nine participants in eight hospital groups were surveyed as the groups neared completion. Groups were…
-
Technologies and Trends to Improve Table Olive Quality and Safety
Campus, Marco; Değirmencioğlu, Nurcan; Comunian, Roberta
2018-01-01
Table olives are the most widely consumed fermented food in the Mediterranean countries. Peculiar processing technologies are used to process olives, which are aimed at the debittering of the fruits and improvement of their sensory characteristics, ensuring safety of consumption at the same time. Processors demand for novel techniques to improve industrial performances, while consumers' attention for natural and healthy foods has increased in recent years. From field to table, new techniques have been developed to decrease microbial load of potential spoilage microorganisms, improve fermentation kinetics and ensure safety of consumption of the packed products. This review article depicts current technologies and recent advances in the processing technology of table olives. Attention has been paid on pre processing technologies, some of which are still under-researched, expecially physical techniques, such ad ionizing radiations, ultrasounds and electrolyzed water solutions, which are interesting also to ensure pesticide decontamination. The selections and use of starter cultures have been extensively reviewed, particularly the characterization of Lactic Acid Bacteria and Yeasts to fasten and safely drive the fermentation process. The selection and use of probiotic strains to address the request for functional foods has been reported, along with salt reduction strategies to address health concerns, associated with table olives consumption. In this respect, probiotics enriched table olives and strategies to reduce sodium intake are the main topics discussed. New processing technologies and post packaging interventions to extend the shelf life are illustrated, and main findings in modified atmosphere packaging, high pressure processing and biopreservaton applied to table olive, are reported and discussed. PMID:29670593
-
Lotfi, Zahra; Atashzadeh-Shoorideh, Foroozan; Mohtashami, Jamileh; Nasiri, Maliheh
2018-03-12
To determine the relationship between ethical leadership, organisational commitment of nurses and their perception of patient safety culture. Patient safety, organisational commitment and ethical leadership styles are very important for improving the quality of nursing care. In this descriptive-correlational study, 340 nurses were selected using random sampling from the hospitals in Tehran in 2016. Data were analysed using descriptive and inferential statistics in SPSS v.20. There was a significant positive relationship between the ethical leadership of nursing managers, perception of patient safety culture and organisational commitment. The regression analysis showed that nursing managers' ethical leadership and nurses' organisational commitment is a predictor of patient safety culture and confirms the relationship between the variables. Regarding the relationship between the nurses' safety performance, ethical leadership and organisational commitment, it seems that the optimisation of the organisational commitment and adherence to ethical leadership by administrators and managers in hospitals could improve the nurses' performance in terms of patient safety. Implementing ethical leadership seems to be one feasible strategy to improve nurses' organisational commitment and perception of patient safety culture. Efforts by nurse managers to develop ethical leadership reinforce organisational commitment to improve patient outcomes. Nurse managers' engagement and performance in this process is vital for a successful result. © 2018 John Wiley & Sons Ltd.
-
Parker, David L; Brosseau, Lisa M; Samant, Yogindra; Xi, Min; Pan, Wei; Haugan, David
2009-01-01
Metal fabrication employs an estimated 3.1 million workers in the United States. The absence of machine guarding and related programs such as lockout/tagout may result in serious injury or death. The purpose of this study was to improve machine-related safety in small metal-fabrication businesses. We used a randomized trial with two groups: management only and management-employee. We evaluated businesses for the adequacy of machine guarding (machine scorecard) and related safety programs (safety audit). We provided all businesses with a report outlining deficiencies and prioritizing their remediation. In addition, the management-employee group received four one-hour interactive training sessions from a peer educator. We evaluated 40 metal-fabrication businesses at baseline and 37 (93%) one year later. Of the three nonparticipants, two had gone out of business. More than 40% of devices required for adequate guarding were missing or inadequate, and 35% of required safety programs and practices were absent at baseline. Both measures improved significantly during the course of the intervention. No significant differences in changes occurred between the two intervention groups. Machine-guarding practices and programs improved by up to 13% and safety audit scores by up to 23%. Businesses that added safety committees or those that started with the lowest baseline measures showed the greatest improvements. Simple and easy-to-use assessment tools allowed businesses to significantly improve their safety practices, and safety committees facilitated this process.
-
A study of 6S workplace improvement in Ergonomic Laboratory
NASA Astrophysics Data System (ADS)
Sari, AD; Suryoputro, MR; Rahmillah, FI
2017-12-01
This article discusses 6S implementation in Ergonomic Laboratory, Department of Industrial Engineering, Islamic University of Indonesia. This research is improvement project of 5S implementation in Ergonomic laboratory. Referring to the 5S implementation of the previous year, there have been improvements from environmental conditions or a more organized workplace however there is still a lack of safety aspects. There are several safeties problems such as equipment arrangement, potential hazards of room dividers that cause injury several times, placement of fire extinguisher, no evacuation path and assembly point in case of fire, as well as expired hydrant condition and lack of awareness of stakeholders related to safety. Therefore, this study aims to apply the 6S kaizen method to the Ergonomic laboratory to facilitate the work process, reduce waste, improve work safety and improve staff performance. Based on the score 6S assessment increased audit results by 32 points, before implementation is 75 point while after implementation is 107 point. This has implications for better use for mitigate people in laboratory area, save time when looking for tools and materials, safe workplace, as well as improving the culture and spirit of ‘6S’ on staff due to better and safetier working environment.
-
Measurement, Standards, and Peer Benchmarking: One Hospital's Journey.
Martin, Brian S; Arbore, Mark
2016-04-01
Peer-to-peer benchmarking is an important component of rapid-cycle performance improvement in patient safety and quality-improvement efforts. Institutions should carefully examine critical success factors before engagement in peer-to-peer benchmarking in order to maximize growth and change opportunities. Solutions for Patient Safety has proven to be a high-yield engagement for Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, with measureable improvement in both organizational process and culture. Copyright © 2016 Elsevier Inc. All rights reserved.
-
Putting the ‘patient’ in patient safety: a qualitative study of consumer experiences
Rathert, Cheryl; Brandt, Julie; Williams, Eric S.
2011-01-01
Abstract Background Although patient safety has been studied extensively, little research has directly examined patient and family (consumer) perceptions. Evidence suggests that clinicians define safety differently from consumers, e.g. clinicians focus more on outcomes, whereas consumers may focus more on processes. Consumer perceptions of patient safety are important for several reasons. First, health‐care policy leaders have been encouraging patients and families to take a proactive role in ensuring patient safety; therefore, an understanding of how patients define safety is needed. Second, consumer perceptions of safety could influence outcomes such as trust and satisfaction or compliance with treatment protocols. Finally, consumer perspectives could be an additional lens for viewing complex systems and processes for quality improvement efforts. Objectives To qualitatively explore acute care consumer perceptions of patient safety. Design and methods Thirty‐nine individuals with a recent overnight hospital visit participated in one of four group interviews. Analysis followed an interpretive analytical approach. Results Three basic themes were identified: Communication, staffing issues and medication administration. Consumers associated care process problems, such as delays or lack of information, with safety rather than as service quality problems. Participants agreed that patients need family caregivers as advocates. Conclusions Consumers seem acutely aware of care processes they believe pose risks to safety. Perceptual measures of patient safety and quality may help to identify areas where there are higher risks of preventable adverse events. PMID:21624026
-
[High-quality nursing health care environment: the patient safety perspective].
Tu, Yu-Ching; Wang, Ruey-Hsia
2011-06-01
Patient safety is regarded as an important indicator of nursing care quality, and nurses hold frontline responsibility to maintain patient safety. Many countries now face healthcare provider shortfalls, and recognize a close correlation between adequate manpower and patient safety. Many healthcare organizations work to foster positive work environments in order to improve health service quality. The active participation and "buy in" of nurses, patients and policymakers are critical to maximize healthcare environment quality and improve patient safety. This article adopts Donabedian's theoretical "Structure-Process-Outcome" model of quality (Donabedian, 1988) and presumes all high-quality healthcare environment indicators to be linked to patient safety. In addition to raising public awareness regarding the influence of healthcare environment quality on patient safety, this research suggests certain indicators for tracking and assessing healthcare environment quality. Future research may design an empirical study based on these indicators to help further enhance healthcare environment quality and the professional development of nurses.
-
2016-09-01
an instituted safety program that utilizes a generic risk assessment method involving the 5-M (Mission, Man, Machine , Medium and Management) factor...the Safety core value is hinged upon three key principles—(1) each soldier has a crucial part to play, by adopting safety as a core value and making...it a way of life in his unit; (2) safety is an integral part of training, operations and mission success, and (3) safety is an individual, team and
-
NASA Aviation Safety Reporting System (ASRS)
NASA Technical Reports Server (NTRS)
Connell, Linda
2011-01-01
The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 900,000 reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 5,500 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides de-identified report information through the online ASRS Database at http://asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation \\vill discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.
-
NASA Aviation Safety Reporting System (ASRS)
NASA Technical Reports Server (NTRS)
Connell, Linda J.
2017-01-01
The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.
-
Singh, Hardeep
2016-01-01
Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety benefits of health IT in real-world clinical settings. PMID:26369894
-
HEFNER, KATHRYN R.; VERONA, EDELYN; CURTIN, JOHN. J.
2017-01-01
Improved understanding of fear inhibition processes can inform the etiology and treatment of anxiety disorders. Safety signals can reduce fear to threat, but precise mechanisms remain unclear. Safety signals may acquire attentional salience and affective properties (e.g., relief) independent of the threat; alternatively, safety signals may only hold affective value in the presence of simultaneous threat. To clarify such mechanisms, an experimental paradigm assessed independent processing of threat and safety cues. Participants viewed a series of red and green words from two semantic categories. Shocks were administered following red words (cue+). No shocks followed green words (cue−). Words from one category were defined as safety signals (SS); no shocks were administered on cue+ trials. Words from the other (control) category did not provide information regarding shock administration. Threat (cue+ vs. cue−) and safety (SS+ vs. SS−) were fully crossed. Startle response and ERPs were recorded. Startle response was increased during cue+ versus cue−. Safety signals reduced startle response during cue+, but had no effect on startle response during cue−. ERP analyses (PD130 and P3) suggested that participants parsed threat and safety signal information in parallel. Motivated attention was not associated with safety signals in the absence of threat. Overall, these results confirm that fear can be reduced by safety signals. Furthermore, safety signals do not appear to hold inherent hedonic salience independent of their effect during threat. Instead, safety signals appear to enable participants to engage in effective top-down emotion regulatory processes. PMID:27088643
-
Post-Challenger evaluation of space shuttle risk assessment and management
NASA Technical Reports Server (NTRS)
1988-01-01
As the shock of the Space Shuttle Challenger accident began to subside, NASA initiated a wide range of actions designed to ensure greater safety in various aspects of the Shuttle system and an improved focus on safety throughout the National Space Transportation System (NSTS) Program. Certain specific features of the NASA safety process are examined: the Critical Items List (CIL) and the NASA review of the Shuttle primary and backup units whose failure might result in the loss of life, the Shuttle vehicle, or the mission; the failure modes and effects analyses (FMEA); and the hazard analysis and their review. The conception of modern risk management, including the essential element of objective risk assessment is described and it is contrasted with NASA's safety process in general terms. The discussion, findings, and recommendations regarding particular aspects of the NASA STS safety assurance process are reported. The 11 subsections each deal with a different aspect of the process. The main lessons learned by SCRHAAC in the course of the audit are summarized.
-
Development of safety performance functions for North Carolina.
DOT National Transportation Integrated Search
2011-12-06
"The objective of this effort is to develop safety performance functions (SPFs) for different types of facilities in North Carolina : and illustrate how they can be used to improve the decision making process. The prediction models in Part C of the H...
-
Hallock, M L; Alper, S J; Karsh, B
The diagnosis of illness is important for quality patient care and patient safety and is greatly aided by diagnostic testing. For diagnostic tests, such as pathology and radiology, to positively impact patient care, the tests must be processed and the physician and patient must be notified of the results in a timely fashion. There are many steps in the diagnostic testing process, from ordering to result dissemination, where the process can break down and therefore delay patient care and reduce patient safety. This study was carried out to examine the diagnostic testing process (i.e. from ordering to result notification) and used a macro-ergonomic work system analysis to uncover system design flaws that contributed to delayed physician and patient notification of results. The study was carried out in a large urban outpatient health-care facility made up of 30 outpatient clinics. Results indicated a number of variances that contributed to delays, the majority of which occurred across the boundaries of different systems and were related to poor or absent feedback structures. Recommendations for improvements are discussed.
-
IEC 61511 and the capital project process--a protective management system approach.
Summers, Angela E
2006-03-17
This year, the process industry has reached an important milestone in process safety-the acceptance of an internationally recognized standard for safety instrumented systems (SIS). This standard, IEC 61511, documents good engineering practice for the assessment, design, operation, maintenance, and management of SISs. The foundation of the standard is established by several requirements in Part 1, Clauses 5-7, which cover the development of a management system aimed at ensuring that functional safety is achieved. The management system includes a quality assurance process for the entire SIS lifecycle, requiring the development of procedures, identification of resources and acquisition of tools. For maximum benefit, the deliverables and quality control checks required by the standard should be integrated into the capital project process, addressing safety, environmental, plant productivity, and asset protection. Industry has become inundated with a multitude of programs focusing on safety, quality, and cost performance. This paper introduces a protective management system, which builds upon the work process identified in IEC 61511. Typical capital project phases are integrated with the management system to yield one comprehensive program to efficiently manage process risk. Finally, the paper highlights areas where internal practices or guidelines should be developed to improve program performance and cost effectiveness.
-
Gu, Jun-Fei; Feng, Liang; Zhang, Ming-Hua; Wu, Chan; Jia, Xiao-Bin
2013-11-01
Safety is an important component of the quality control of traditional Chinese medicine (TCM) preparation products, as well as an important guarantee for clinical application. Currently, the quality control of TCMs in Chinese Pharmacopoeia mostly focuses on indicative compounds for TCM efficacy. TCM preparations are associated with multiple links, from raw materials to products, and each procedure may have impacts on the safety of preparation. We make a summary and analysis on the factors impacting safety during the preparation of TCM products, and then expound the important role of the "multi-dimensional structure and process dynamic quality control technology system" in the quality safety of TCM preparations. Because the product quality of TCM preparation is closely related to the safety, the control over safety-related material basis is an important component of the product quality control of TCM preparations. The implementation of the quality control over the dynamic process of TCM preparations from raw materials to products, and the improvement of the TCM quality safety control at the microcosmic level help lay a firm foundation for the development of the modernization process of TCM preparations.
-
The role of the PIRT process in identifying code improvements and executing code development
DOE Office of Scientific and Technical Information (OSTI.GOV)
Wilson, G.E.; Boyack, B.E.
1997-07-01
In September 1988, the USNRC issued a revised ECCS rule for light water reactors that allows, as an option, the use of best estimate (BE) plus uncertainty methods in safety analysis. The key feature of this licensing option relates to quantification of the uncertainty in the determination that an NPP has a {open_quotes}low{close_quotes} probability of violating the safety criteria specified in 10 CFR 50. To support the 1988 licensing revision, the USNRC and its contractors developed the CSAU evaluation methodology to demonstrate the feasibility of the BE plus uncertainty approach. The PIRT process, Step 3 in the CSAU methodology, wasmore » originally formulated to support the BE plus uncertainty licensing option as executed in the CSAU approach to safety analysis. Subsequent work has shown the PIRT process to be a much more powerful tool than conceived in its original form. Through further development and application, the PIRT process has shown itself to be a robust means to establish safety analysis computer code phenomenological requirements in their order of importance to such analyses. Used early in research directed toward these objectives, PIRT results also provide the technical basis and cost effective organization for new experimental programs needed to improve the safety analysis codes for new applications. The primary purpose of this paper is to describe the generic PIRT process, including typical and common illustrations from prior applications. The secondary objective is to provide guidance to future applications of the process to help them focus, in a graded approach, on systems, components, processes and phenomena that have been common in several prior applications.« less
-
[B-BS and occupational health and safety management systems].
Bacchetta, Adriano Paolo
2010-01-01
The objective of a SGSL is the "prevention" agreement as approach of "pro-active" toward the safety at work through the construction of an integrated managerial system in synergic an dynamic way with the business organization, according to continuous improvement principles. Nevertheless the adoption of a SGSL, not could guarantee by itself the obtainment of the full effectiveness than projected and every individual's adhesion to it, must guarantee it's personal involvement in proactive way, so that to succeed to actual really how much hypothesized to systemic level to increase the safety in firm. The objective of a behavioral safety process that comes to be integrated in a SGSL, it has the purpose to succeed in implementing in firm a process of cultural change that raises the workers social group fundamental safety value, producing an ample and full involvement of all in the activities of safety at work development. SGSL = Occupational Health and Safety Management System.
-
Flightdeck Automation Problems (FLAP) Model for Safety Technology Portfolio Assessment
NASA Technical Reports Server (NTRS)
Ancel, Ersin; Shih, Ann T.
2014-01-01
NASA's Aviation Safety Program (AvSP) develops and advances methodologies and technologies to improve air transportation safety. The Safety Analysis and Integration Team (SAIT) conducts a safety technology portfolio assessment (PA) to analyze the program content, to examine the benefits and risks of products with respect to program goals, and to support programmatic decision making. The PA process includes systematic identification of current and future safety risks as well as tracking several quantitative and qualitative metrics to ensure the program goals are addressing prominent safety risks accurately and effectively. One of the metrics within the PA process involves using quantitative aviation safety models to gauge the impact of the safety products. This paper demonstrates the role of aviation safety modeling by providing model outputs and evaluating a sample of portfolio elements using the Flightdeck Automation Problems (FLAP) model. The model enables not only ranking of the quantitative relative risk reduction impact of all portfolio elements, but also highlighting the areas with high potential impact via sensitivity and gap analyses in support of the program office. Although the model outputs are preliminary and products are notional, the process shown in this paper is essential to a comprehensive PA of NASA's safety products in the current program and future programs/projects.
-
Sutherland, Tori; Beloff, Jennifer; Lightowler, Marie; Liu, Xiaoxia; Nascimben, Luigino; Urman, Richard D
2014-01-01
The Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created because of recognition of the impact of proper perioperative prophylaxis on an estimated annual 1 million inpatient days and $1.6 billion in excess health care costs that are secondary to preventable surgical site infections. There is a need to create low-cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration. The impact of interventions on provider compliance with SCIP inpatient antibiotic guidelines and net financial gain or loss to a large tertiary center were assessed. A single hospital was able to significantly improve their SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for reinvestment in patient safety initiatives. Low-cost interventions aimed at educating providers that utilize existing infrastructure result in improved SCIP compliance and patient safety. As a secondary gain, there were hundreds of thousands of dollars in annual cost savings. The impact of compliance on infection rates is inferred but requires further study.
-
Tarrago, Rod; Nowak, Jeffrey E; Leonard, Christopher S; Payne, Nathaniel R
2014-06-01
In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events. The PICU Safety Checklist was implemented in the pediatric ICU (PICU) at Children's Hospitals and Clinics of Minnesota. During a 21-month period, the checklist was used to prompt the care team to address quality and safety items during rounds. The initial checklist was paper, with two subsequent versions being incorporated into the electronic medical record (EMR). The daily safety checklist was successfully implemented in the PICU. Work-flow improvements based on regular multidisciplinary feedback led to more consistent use of the checklist. Improvements on all quality and safety metrics were identified, including invasive device use, medication costs, antibiotic and laboratory test use, and compliance with standards of care. Staff satisfaction rates were > 80% for safety, communication, and collaboration. By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.
-
Improving Patient Safety in Hospitals through Usage of Cloud Supported Video Surveillance.
Dašić, Predrag; Dašić, Jovan; Crvenković, Bojan
2017-04-15
Patient safety in hospitals is of equal importance as providing treatments and urgent healthcare. With the development of Cloud technologies and Big Data analytics, it is possible to employ VSaaS technology virtually anywhere, for any given security purpose. For the listed benefits, in this paper, we give an overview of the existing cloud surveillance technologies which can be implemented for improving patient safety. Modern VSaaS systems provide higher elasticity and project scalability in dealing with real-time information processing. Modern surveillance technologies can prove to be an effective tool for prevention of patient falls, undesired movement and tempering with attached life supporting devices. Given a large number of patients who require constant supervision, a cloud-based monitoring system can dramatically reduce the occurring costs. It provides continuous real-time monitoring, increased overall security and safety, improved staff productivity, prevention of dishonest claims and long-term digital archiving. Patient safety is a growing issue which can be improved with the usage of high-end centralised surveillance systems allowing the staff to focus more on treating health issues rather that keeping a watchful eye on potential incidents.
-
NASA Technical Reports Server (NTRS)
Barrientos, Francesca; Castle, Joseph; McIntosh, Dawn; Srivastava, Ashok
2007-01-01
This document presents a preliminary evaluation the utility of the FAA Safety Analytics Thesaurus (SAT) utility in enhancing automated document processing applications under development at NASA Ames Research Center (ARC). Current development efforts at ARC are described, including overviews of the statistical machine learning techniques that have been investigated. An analysis of opportunities for applying thesaurus knowledge to improving algorithm performance is then presented.
-
Magill, Stephen T; Wang, Doris D; Rutledge, W Caleb; Lau, Darryl; Berger, Mitchel S; Sankaran, Sujatha; Lau, Catherine Y; Imershein, Sarah G
2017-11-01
Patient safety is foundational to neurosurgical care. Postprocedural "debrief" checklists have been proposed to improve patient safety, but data about their use in neurosurgery are limited. Here, we implemented an initiative to routinely perform postoperative debriefs and evaluated the impact of debriefing on operating room (OR) safety culture. A 10-question safety attitude questionnaire (SAQ) was sent to neurosurgical OR staff at a major academic medical center before and 18 months after the implementation of a postoperative debriefing initiative. Rates of debrief compliance and changes in attitudes before and after the survey were evaluated. The survey used a Likert scale and analyzed with standard statistical methods. After the debrief initiative, the rate of debriefing increased from 51% to 86% of cases for the neurosurgery service. Baseline SAQ responses found that neurosurgeons had a more favorable perception of OR safety than did anesthesiologists and nurses. After implementation of the postoperative debriefing process, perceptions of OR safety significantly improved for neurosurgeons, anesthesiologists, and nurses. Furthermore, the disparity between nurses and surgeons was no longer significant. After debrief implementation, neurosurgical OR staff had improved perceptions of patient safety compared with surgical services that did not commonly perform debriefing. Debriefing identified OR efficiency concerns in 26.9% of cases, and prevention of potential adverse events/near misses was reported in 8% of cases. Postoperative debriefing can be effectively introduced into the OR and improves the safety culture after implementation. Debriefing is an effective tool to identify OR inefficiencies and potential adverse events. Copyright © 2017 Elsevier Inc. All rights reserved.
-
Changing conversations: teaching safety and quality in residency training.
Voss, John D; May, Natalie B; Schorling, John B; Lyman, Jason A; Schectman, Joel M; Wolf, Andrew M D; Nadkarni, Mohan M; Plews-Ogan, Margaret
2008-11-01
Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.
-
Modernizing bridge safety inspection with process improvement and digital assistance.
DOT National Transportation Integrated Search
2004-01-01
This research effort was developed to record and analyze the Virginia Department of Transportation (VDOT) bridge/structure inspection processes as an aid to modernizing and automating these inspection processes through the use of mobile personal comp...
-
Improving animal research facility operations through the application of lean principles.
Khan, Nabeel; Umrysh, Brian M
2008-06-01
Animal research is a vital component of US research and well-functioning animal research facilities are critical both to the research itself and to the housing and feeding of the animals. The Office of Animal Care (OAC) at Seattle Children's Hospital Research Institute realized it had to improve the efficiency and safety of its animal research facility (ARF) to prepare for expansion and to advance the Institute's mission. The main areas for improvement concerned excessive turnaround time to process animal housing and feeding equipment; the movement and flow of equipment and inventory; and personnel safety. To address these problems, management held two process improvement workshops to educate employees about lean principles. In this article we discuss the application of these principles and corresponding methods to advance Children's Research Institute's mission of preventing, treating, and eliminating childhood diseases.
-
Cutter, Catherine Nettles
2006-09-01
It has been well documented that vacuum or modified atmosphere packaging materials, made from polyethylene- or other plastic-based materials, have been found to improve the stability and safety of raw or further processed muscle foods. However, recent research developments have demonstrated the feasibility, utilization, and commercial application of a variety of bio-based polymers or bio-polymers made from a variety of materials, including renewable/sustainable agricultural commodities, and applied to muscle foods. A variety of these bio-based materials have been shown to prevent moisture loss, drip, reduce lipid oxidation and improve flavor attributes, as well as enhancing the handling properties, color retention, and microbial stability of foods. With consumers demanding more environmentally friendly packaging and a desire for more natural products, bio-based films or bio-polymers will continue to play an important role in the food industry by improving the quality of many products, including fresh or further processed muscle foods.
-
Smith, Maxwell L; Wilkerson, Trent; Grzybicki, Dana M; Raab, Stephen S
2012-09-01
Few reports have documented the effectiveness of Lean quality improvement in changing anatomic pathology patient safety. We used Lean methods of education; hoshin kanri goal setting and culture change; kaizen events; observation of work activities, hand-offs, and pathways; A3-problem solving, metric development, and measurement; and frontline work redesign in the accessioning and gross examination areas of an anatomic pathology laboratory. We compared the pre- and post-Lean implementation proportion of near-miss events and changes made in specific work processes. In the implementation phase, we documented 29 individual A3-root cause analyses. The pre- and postimplementation proportions of process- and operator-dependent near-miss events were 5.5 and 1.8 (P < .002) and 0.6 and 0.6, respectively. We conclude that through culture change and implementation of specific work process changes, Lean implementation may improve pathology patient safety.
-
Leonardo, Jennifer B; Spicer, Rebecca S; Katradis, Maria; Allison, Jennifer; Thomas, Rebekah
2018-06-01
This study investigated whether the Child Safety Collaborative Innovation and Improvement Network (CS CoIIN) framework could be applied in the field of injury and violence prevention to reduce fatalities, hospitalizations and emergency department visits among 0-19 year olds. Twenty-one states/jurisdictions were accepted into cohort 1 of the CS CoIIN, and 14 were engaged from March 2016 through April 2017. A quality improvement framework was used to test, implement and spread evidence-based change ideas (strategies and programs) in child passenger safety, falls prevention, interpersonal violence prevention, suicide and self-harm prevention and teen driver safety. Outcome and process measure data were analyzed using run chart rules. Descriptive data were analyzed for participation measures and descriptive statistics were produced. Qualitative data were analyzed to identify key themes. Seventy-six percent of CS CoIIN states/jurisdictions were engaged in activities and used data to inform decision making. Within a year, states/jurisdictions were able to test and implement evidence-based change ideas in pilot sites. A small group showed improvement in process measures and were ready to spread change ideas. Improvement in outcome measures was not achieved; however, 25% of states/jurisdictions identified data sources and reported on real-time outcome measures. Evidence indicates the CS CoIIN framework can be applied to make progress on process measures, but more time is needed to determine if this will result in progress on long-term outcome measures of fatalities, hospitalizations and emergency department visits. Seventeen states/jurisdictions will participate in cohort 2. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
-
Risk Informed Margins Management as part of Risk Informed Safety Margin Characterization
DOE Office of Scientific and Technical Information (OSTI.GOV)
Curtis Smith
2014-06-01
The ability to better characterize and quantify safety margin is important to improved decision making about Light Water Reactor (LWR) design, operation, and plant life extension. A systematic approach to characterization of safety margins and the subsequent margin management options represents a vital input to the licensee and regulatory analysis and decision making that will be involved. In addition, as research and development in the LWR Sustainability (LWRS) Program and other collaborative efforts yield new data, sensors, and improved scientific understanding of physical processes that govern the aging and degradation of plant SSCs needs and opportunities to better optimize plantmore » safety and performance will become known. To support decision making related to economics, readability, and safety, the Risk Informed Safety Margin Characterization (RISMC) Pathway provides methods and tools that enable mitigation options known as risk informed margins management (RIMM) strategies.« less
-
The OSHA standard setting process: role of the occupational health nurse.
Klinger, C S; Jones, M L
1994-08-01
1. Occupational health nurses are the health professionals most often involved with the worker who suffers as a result of ineffective or non-existent safety and health standards. 2. Occupational health nurses are familiar with health and safety standards, but may not understand or participate in the rulemaking process used to develop them. 3. Knowing the eight basic steps of rulemaking and actively participating in the process empowers occupational health nurses to influence national policy decisions affecting the safety and health of millions of workers. 4. By actively participating in rulemaking activities, occupational health nurses also improve the quality of occupational health nursing practice and enhance the image of the nursing profession.
-
Continuous quality improvement using intelligent infusion pump data analysis.
Breland, Burnis D
2010-09-01
The use of continuous quality-improvement (CQI) processes in the implementation of intelligent infusion pumps in a community teaching hospital is described. After the decision was made to implement intelligent i.v. infusion pumps in a 413-bed, community teaching hospital, drug libraries for use in the safety software had to be created. Before drug libraries could be created, it was necessary to determine the epidemiology of medication use in various clinical care areas. Standardization of medication administration was performed through the CQI process, using practical knowledge of clinicians at the bedside and evidence-based drug safety parameters in the scientific literature. Post-implementation, CQI allowed refinement of clinically important safety limits while minimizing inappropriate, meaningless soft limit alerts on a few select agents. Assigning individual clinical care areas (CCAs) to individual patient care units facilitated customization of drug libraries and identification of specific CCA compliance concerns. Between June 2007 and June 2008, there were seven library updates. These involved drug additions and deletions, customization of individual CCAs, and alterations of limits. Overall compliance with safety software use rose over time, from 33% in November 2006 to over 98% in December 2009. Many potentially clinically significant dosing errors were intercepted by the safety software, prompting edits by end users. Only 4-6% of soft limit alerts resulted in edits. Compliance rates for use of infusion pump safety software varied among CCAs over time. Education, auditing, and refinement of drug libraries led to improved compliance in most CCAs.
-
NASA Technical Reports Server (NTRS)
Zernic, Michael J.
2002-01-01
Broadband satellite communications for aeronautics marries communication and network technologies to address NASA's goals in information technology base research and development, thereby serving the safety and capacity needs of the National Airspace System. This marriage of technology increases the interactivity between airborne vehicles and ground systems. It improves decision-making and efficiency, reduces operation costs, and improves the safety and capacity of the National Airspace System. To this end, a collaborative project called the Aeronautical Satellite Assisted Process for Information Exchange through Network Technologies, or Aero-SAPIENT, was conducted out of Tinker AFB, Oklahoma, during November and December 2000.
-
Toffel, Michael W; Birkner, Lawrence R
2002-07-01
The protection of people and physical assets is the objective of health and safety professionals and is accomplished through the paradigm of anticipation, recognition, evaluation, and control of risks in the occupational environment. Risk assessment concepts are not only used by health and safety professionals, but also by business and financial planners. Since meeting health and safety objectives requires financial resources provided by business and governmental managers, the hypothesis addressed here is that health and safety risk decisions should be made with probabilistic processes used in financial decision-making and which are familiar and recognizable to business and government planners and managers. This article develops the processes and demonstrates the use of incident probabilities, historic outcome information, and incremental impact analysis to estimate risk of multiple alternatives in the chemical process industry. It also analyzes how the ethical aspects of decision-making can be addressed in formulating health and safety risk management plans. It is concluded that certain, easily understood, and applied probabilistic risk assessment methods used by business and government to assess financial and outcome risk have applicability to improving workplace health and safety in three ways: 1) by linking the business and health and safety risk assessment processes to securing resources, 2) by providing an additional set of tools for health and safety risk assessment, and 3) by requiring the risk assessor to consider multiple risk management alternatives.
-
Demystifying process mapping: a key step in neurosurgical quality improvement initiatives.
McLaughlin, Nancy; Rodstein, Jennifer; Burke, Michael A; Martin, Neil A
2014-08-01
Reliable delivery of optimal care can be challenging for care providers. Health care leaders have integrated various business tools to assist them and their teams in ensuring consistent delivery of safe and top-quality care. The cornerstone to all quality improvement strategies is the detailed understanding of the current state of a process, captured by process mapping. Process mapping empowers caregivers to audit how they are currently delivering care to subsequently strategically plan improvement initiatives. As a community, neurosurgery has clearly shown dedication to enhancing patient safety and delivering quality care. A care redesign strategy named NERVS (Neurosurgery Enhanced Recovery after surgery, Value, and Safety) is currently being developed and piloted within our department. Through this initiative, a multidisciplinary team led by a clinician neurosurgeon has process mapped the way care is currently being delivered throughout the entire episode of care. Neurosurgeons are becoming leaders in quality programs, and their education on the quality improvement strategies and tools is essential. The authors present a comprehensive review of process mapping, demystifying its planning, its building, and its analysis. The particularities of using process maps, initially a business tool, in the health care arena are discussed, and their specific use in an academic neurosurgical department is presented.
-
Safety leadership: application in construction site.
Cooper, Dominic
2010-01-01
The extant safety literature suggests that managerial Safety Leadership is vital to the success and maintenance of a behavioral safety process. The current paper explores the role of Managerial Safety Leadership behaviors in the success of a behavioral safety intervention in the Middle-East with 47,000 workers from multiple nationalities employed by fourteen sub-contractors and one main contractor. A quasi-experimental repeating ABABAB, within groups design was used. Measurement focused on managerial Safety Leadership and employee safety behaviors as well as Corrective Actions. Data was collected over 104 weeks. During this time, results show safety behavior improved by 30 percentage points from an average of 65% during baseline to an average of 95%. The site achieved 121 million man-hours free of lost-time injuries on the longest run. Stepwise multiple regression analyses indicated 86% of the variation in employee safety behavior was associated with senior, middle and front-line manager's Safety Leadership behaviors and the Corrective Action Rate. Approximately 38% of the variation in the Total Recordable Incident Rate (TRIR) was associated with the Observation rate, Corrective Action Rate and Observers Records of managerial safety leaders (Visible Ongoing Support). The results strongly suggest manager's Safety Leadership influences the success of Behavioral Safety processes.
-
[Concept analysis of a participatory approach to occupational safety and health].
Yoshikawa, Etsuko
2013-01-01
The purpose of this study was to analyze a participatory approach to occupational safety and health, and to examine the possibility of applying the concept to the practice and research of occupational safety and health. According to Rodger's method, descriptive data concerning antecedents, attributes and consequences were qualitatively analyzed. A total of 39 articles were selected for analysis. Attributes with a participatory approach were: "active involvement of both workers and employers", "focusing on action-oriented low-cost and multiple area improvements based on good practices", "the process of emphasis on consensus building", and "utilization of a local network". Antecedents of the participatory approach were classified as: "existing risks at the workplace", "difficulty of occupational safety and health activities", "characteristics of the workplace and workers", and "needs for the workplace". The derived consequences were: "promoting occupational safety and health activities", "emphasis of self-management", "creation of safety and healthy workplace", and "contributing to promotion of quality of life and productivity". A participatory approach in occupational safety and health is defined as, the process of emphasis on consensus building to promote occupational safety and health activities with emphasis on self-management, which focuses on action-oriented low-cost and multiple area improvements based on good practices with active involvement of both workers and employers through utilization of local networks. We recommend that the role of the occupational health professional be clarified and an evaluation framework be established for the participatory approach to promote occupational safety and health activities by involving both workers and employers.
-
Improving cardiac surgical care: a work systems approach.
Wiegmann, Douglas A; Eggman, Ashley A; Elbardissi, Andrew W; Parker, Sarah Henrickson; Sundt, Thoralf M
2010-09-01
Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper. 2010 Elsevier Ltd. All rights reserved.
-
The use of in-situ simulation to improve safety in the plastic surgery office: a feasibility study.
Shapiro, Fred E; Pawlowski, John B; Rosenberg, Noah M; Liu, Xiaoxia; Feinstein, David M; Urman, Richard D
2014-01-01
Simulation-based interventions and education can potentially contribute to safer and more effective systems of care. We utilized in-situ simulation to highlight safety issues, regulatory requirements, and assess perceptions of safety processes by the plastic surgery office staff. A high-fidelity human patient simulator was brought to an office-based plastic surgery setting to enact a half-day full-scale, multidisciplinary medical emergency. Facilitated group debriefings were conducted after each scenario with special consideration of the principles of team training, communication, crisis management, and adherence to evidence-based protocols and regulatory standards. Abbreviated AHRQ Medical Office Safety Culture Survey was completed by the participants before and after the session. The in-situ simulations had a high degree of acceptance and face validity according to the participants. Areas highlighted by the simulation sessions included rapid communication, delegation of tasks, location of emergency materials, scope of practice, and logistics of transport. The participant survey indicated greater awareness of patient safety issues following participation in simulation and debriefing exercises in 3 areas (P < 0.05): the need to change processes if there is a recognized patient safety issue (100% vs 75%), openness to ideas about improving office processes (100% vs 88%), and the need to discuss ways to prevent errors from recurring (88% vs 62%). Issues of safety and regulatory compliance can be assessed in an office-based setting through the short-term (half-day) use of in-situ simulation with facilitated debriefing and the review of audiovisual recordings by trained facilities inspectors.
-
The Use of In-Situ Simulation to Improve Safety in the Plastic Surgery Office: A Feasibility Study
Shapiro, Fred E.; Pawlowski, John B.; Rosenberg, Noah M.; Liu, Xiaoxia; Feinstein, David M.; Urman, Richard D.
2014-01-01
Objective: Simulation-based interventions and education can potentially contribute to safer and more effective systems of care. We utilized in-situ simulation to highlight safety issues, regulatory requirements, and assess perceptions of safety processes by the plastic surgery office staff. Methods: A high-fidelity human patient simulator was brought to an office-based plastic surgery setting to enact a half-day full-scale, multidisciplinary medical emergency. Facilitated group debriefings were conducted after each scenario with special consideration of the principles of team training, communication, crisis management, and adherence to evidence-based protocols and regulatory standards. Abbreviated AHRQ Medical Office Safety Culture Survey was completed by the participants before and after the session. Results: The in-situ simulations had a high degree of acceptance and face validity according to the participants. Areas highlighted by the simulation sessions included rapid communication, delegation of tasks, location of emergency materials, scope of practice, and logistics of transport. The participant survey indicated greater awareness of patient safety issues following participation in simulation and debriefing exercises in 3 areas (P < 0.05): the need to change processes if there is a recognized patient safety issue (100% vs 75%), openness to ideas about improving office processes (100% vs 88%), and the need to discuss ways to prevent errors from recurring (88% vs 62%). Conclusions: Issues of safety and regulatory compliance can be assessed in an office-based setting through the short-term (half-day) use of in-situ simulation with facilitated debriefing and the review of audiovisual recordings by trained facilities inspectors. PMID:24501616
-
NASA Technical Reports Server (NTRS)
Askew, John C.
1994-01-01
An alternative to the immersion process for the electrodeposition of chromium from aqueous solutions on the inside diameter (ID) of long tubes is described. The Vessel Plating Process eliminates the need for deep processing tanks, large volumes of solutions, and associated safety and environmental concerns. Vessel Plating allows the process to be monitored and controlled by computer thus increasing reliability, flexibility and quality. Elimination of the trivalent chromium accumulation normally associated with ID plating is intrinsic to the Vessel Plating Process. The construction and operation of a prototype Vessel Plating Facility with emphasis on materials of construction, engineered and operational safety and a unique system for rinse water recovery are described.
-
Patient safety and health policy: a history and review.
Small, Stephen D; Barach, Paul
2002-12-01
Policy initiatives on many fronts have converged to improve patient safety. A major tension that characterizes this process is the attempt to achieve a balance between learning and control in complex systems with technical, social, and organizational components. Efforts to improve learning are marked by better information flow, discovery, flexibility in thinking, embracing of failures as learning opportunities, and core incentives to promote voluntary participation of all stakeholders in the process. Efforts to improve accountability are traditionally marked by public disclosure, meeting of certain widely disseminated standards, availability of performance measures, exposure to legal liability, and compliance with mandated directives (statutes, regulations, accreditation requirements). In some sense, these directions are mutually exclusive. Although a more collaborative regulatory-improvement model would be helpful in creating an industrywide safety culture, it is likely that learning and accountability functions will follow separate tracks. An exception would be policy that stimulates organizations to comply with regulation by showing how well and by what methods they are learning and how others can profit from these experiences. Any approach to improving patient safety should, at a minimum, include a nonpunitive in-depth mechanism for reporting incidents, postincident evaluations for identification of system changes to prevent subsequent occurrences, and state-guaranteed legislative protection from discovery for all aspects of information gathered to improve patient safety. Nonpunitive approaches have yielded useful results in other industries [43]. State and federal courts, state licensing boards, and accrediting bodies such as JCAHO all function to maintain accountability and standards; however, the very fear of existing legal liability or its misapplication are the greatest hurdles to pioneering patient-safety efforts. The health care system needs to transform the existing culture of blame and punishment that suppresses information about errors and adverse events into a culture of safety that focuses on openness and information sharing to improve health care and prevent adverse outcomes. Education and leadership will be most important to creating and sustaining a strong safety culture and arguably the most important defense against preventable harms. Safety culture cannot be legislated, just as the old adage states that it is easier to pull rather than push a piece of spaghetti. Given the imbalances and inefficiencies of market forces in health care, perverse incentives that have strengthened resistance to change, and secrecy when it comes to adverse event information, however, it is likely that policy initiatives will continue to play an important role in the transformation of the industry to more highly reliable, safer levels of care.
-
Effect of pavement resurfacing on traffic safety.
DOT National Transportation Integrated Search
2004-02-01
The objectives of this study were to analyze the before and after crash history and speeds on routes which have been resurfaced , inspect resurfacing projects, make recommendations to improve the resurfacing process, and determine improvements which ...
-
... Progress, June 2016 issue, explores The Joint Commission’s internal Robust Process Improvement ® program. Read the ... cry for improving our services. It has provided a pulpit from which we structure quality and safety activities and get buy-in from ...
-
Continued improvements at one C3RS site
DOT National Transportation Integrated Search
2015-06-01
Human-factors-based solutions, along with process and technology innovations, can make significant contributions to improving safety in the railroad industry. As part of ongoing efforts to address human-factors, FRA implemented the Confidential Close...
-
Staying Well in a Sea of Harm.
Deutsch, Ellen S
2018-03-01
Physician psychological wellness is an emergent outcome resulting from dynamic interactions among complex conditions. We may enhance opportunities for physician wellness by applying principles developed to improve another emergent outcome: patient safety. The Safety I approach to patient safety focuses on "what went wrong" and considers humans a liability. Safety II is a powerful complementary approach that focuses on "what went right" and values human creativity. These contrasting perspectives are described in the context of patient safety, but the underlying principles have relevance for physician psychological wellness. We can create conditions that interfere with wellness and conditions that support wellness. We can learn from exploring and reinforcing successes and improving routine processes; together, these approaches may have a greater cumulative positive impact than just addressing problems. In addition to learning from failures, there is much we can learn from success.
-
Margin of Safety Definition and Examples Used in Safety Basis Documents and the USQ Process
DOE Office of Scientific and Technical Information (OSTI.GOV)
Beaulieu, R. A.
The Nuclear Safety Management final rule, 10 CFR 830, provides an undefined term, margin of safety (MOS). Safe harbors listed in 10 CFR 830, Table 2, such as DOE-STD-3009 use but do not define the term. This lack of definition has created the need for the definition. This paper provides a definition of MOS and documents examples of MOS as applied in a U.S. Department of Energy (DOE) approved safety basis for an existing nuclear facility. If we understand what MOS looks like regarding Technical Safety Requirements (TSR) parameters, then it helps us compare against other parameters that do notmore » involve a MOS. This paper also documents parameters that are not MOS. These criteria could be used to determine if an MOS exists in safety basis documents. This paper helps DOE, including the National Nuclear Security Administration (NNSA) and its contractors responsible for the safety basis improve safety basis documents and the unreviewed safety question (USQ) process with respect to MOS.« less
-
DOT National Transportation Integrated Search
2008-12-01
After the success of the Federal Railroad Administration (FRA) Human Factors Program demonstration project at Union Pacific (UP) Railroads San Antonio Service Unit (SASU), which focused on managers and road crews with a proactive safety risk reductio...
-
Using game technologies to improve the safety of construction plant operations.
Guo, Hongling; Li, Heng; Chan, Greg; Skitmore, Martin
2012-09-01
Many accidents occur world-wide in the use of construction plant and equipment, and safety training is considered by many to be one of the best approaches to their prevention. However, current safety training methods/tools are unable to provide trainees with the hands-on practice needed. Game technology-based safety training platforms have the potential to overcome this problem in a virtual environment. One such platform is described in this paper - its characteristics are analysed and its possible contribution to safety training identified. This is developed and tested by means of a case study involving three major pieces of construction plant, which successfully demonstrates that the platform can improve the process and performance of the safety training involved in their operation. This research not only presents a new and useful solution to the safety training of construction operations, but illustrates the potential use of advanced technologies in solving construction industry problems in general. Copyright © 2011 Elsevier Ltd. All rights reserved.
-
Hagerman, Nancy S; Varughese, Anna M; Kurth, C Dean
2014-06-01
Cognitive aids are tangible or intangible instruments that guide users in decision-making and in the completion of a complex series of tasks. Common examples include mnemonics, checklists, and algorithms. Cognitive aids constitute very effective approaches to achieve well tolerated, high quality healthcare because they promote highly reliable processes that reduce the likelihood of failure. This review describes recent advances in quality improvement for pediatric anesthesiology with emphasis on application of cognitive aids to impact patient safety and outcomes. Quality improvement encourages the examination of systems to create stable processes and ultimately high-value care. Quality improvement initiatives in pediatric anesthesiology have been shown to improve outcomes and the delivery of efficient and effective care at many institutions. The use of checklists, in particular, improves adherence to evidence-based care in crisis situations, decreases catheter-associated bloodstream infections, reduces blood product utilization, and improves communication during the patient handoff process. Use of this simple tool has been associated with decreased morbidity, fewer medical errors, improved provider satisfaction, and decreased mortality in nonanesthesia disciplines as well. Successful quality improvement initiatives utilize cognitive aids such as checklists and have been shown to optimize pediatric patient experience and anesthesia outcomes and reduce perioperative complications.
-
Singh, Hardeep; Sittig, Dean F
2016-04-01
Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety benefits of health IT in real-world clinical settings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
-
Use the Bar Code System to Improve Accuracy of the Patient and Sample Identification.
Chuang, Shu-Hsia; Yeh, Huy-Pzu; Chi, Kun-Hung; Ku, Hsueh-Chen
2018-01-01
In time and correct sample collection were highly related to patient's safety. The sample error rate was 11.1%, because misbranded patient information and wrong sample containers during January to April, 2016. We developed a barcode system of "Specimens Identify System" through process of reengineering of TRM, used bar code scanners, add sample container instructions, and mobile APP. Conclusion, the bar code systems improved the patient safety and created green environment.
-
Improving patient safety through quality assurance.
Raab, Stephen S
2006-05-01
Anatomic pathology laboratories use several quality assurance tools to detect errors and to improve patient safety. To review some of the anatomic pathology laboratory patient safety quality assurance practices. Different standards and measures in anatomic pathology quality assurance and patient safety were reviewed. Frequency of anatomic pathology laboratory error, variability in the use of specific quality assurance practices, and use of data for error reduction initiatives. Anatomic pathology error frequencies vary according to the detection method used. Based on secondary review, a College of American Pathologists Q-Probes study showed that the mean laboratory error frequency was 6.7%. A College of American Pathologists Q-Tracks study measuring frozen section discrepancy found that laboratories improved the longer they monitored and shared data. There is a lack of standardization across laboratories even for governmentally mandated quality assurance practices, such as cytologic-histologic correlation. The National Institutes of Health funded a consortium of laboratories to benchmark laboratory error frequencies, perform root cause analysis, and design error reduction initiatives, using quality assurance data. Based on the cytologic-histologic correlation process, these laboratories found an aggregate nongynecologic error frequency of 10.8%. Based on gynecologic error data, the laboratory at my institution used Toyota production system processes to lower gynecologic error frequencies and to improve Papanicolaou test metrics. Laboratory quality assurance practices have been used to track error rates, and laboratories are starting to use these data for error reduction initiatives.
-
Rosenberg, Amy F
2016-10-01
UF Health's participation in a mentored quality-improvement impact program for health professionals as part of an ASHP initiative-"Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital"-is described. ASHP invited hospitals to participate in its initiative at a time when UF Health was evaluating the risks and benefits of insulin pen use due to external reports of safety concerns and making a commitment to continue insulin pen use and optimize safeguards. Improvement opportunities in insulin pen best practices and staff education on insulin pen preparation and injection technique were identified and implemented. The storage of insulin pens for patients with contact isolation precautions was identified as a problem in certain patient care areas, and a practical solution was devised. Other process improvements included implementation of barcode medication administration, with scanning of insulin pens designated for specific patients to avoid inadvertent and intentional sharing of pens among multiple patients. Mentored calls with teams at other hospitals conducted as part of the program provided the opportunity to share experiences and solutions to improve insulin pen use. Participating with a knowledgeable mentor and other hospital teams struggling with the same issues and concerns related to safe insulin pen use facilitated problem solving. Discussing challenges and sharing ideas for solutions to safety concerns with other hospitals identified new process enhancements, which have the potential to improve the safety of insulin pen use at UF Health. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
-
Patient safety problem identification and solution sharing among rural community pharmacists.
Galt, Kimberly A; Fuji, Kevin T; Faber, Jennifer
2013-01-01
To implement a communication network for safety problem identification and solution sharing among rural community pharmacists and to report participating pharmacists' perceived value and impact of the network on patient safety after 1 year of implementation. Action research study. Rural community pharmacies in Nebraska from January 2010 to April 2011. Rural community pharmacists who voluntarily agreed to join the Pharmacists for Patient Safety Network in Nebraska. Pharmacists reported errors, near misses, and safety concerns through Web-based event reporting. A rapid feedback process was used to provide patient safety solutions to consider implementing across the network. Qualitative interviews were conducted 1 year after program implementation with participating pharmacists to assess use of the reporting system, value of the disseminated safety solutions, and perceived impact on patient safety in pharmacies. 30 of 38 pharmacists participating in the project completed the interviews. The communication network improved pharmacist awareness, promoted open discussion and knowledge sharing, contributed to practice vigilance, and led to incorporation of proactive safety prevention practices. Despite low participation in error and near-miss reporting, a dynamic communication network designed to rapidly disseminate evidence-based patient safety strategies to reduce risk was valued and effective at improving patient safety practices in rural community pharmacies.
-
Burnett, Susan; Benn, Jonathan; Pinto, Anna; Parand, Anam; Iskander, Sandra; Vincent, Charles
2010-08-01
Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding 'readiness' at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.
-
Flame and acid resistant polymide fibers
NASA Technical Reports Server (NTRS)
Stringham, R. S.; Toy, M. S.
1977-01-01
Economical process improves flame resistance and resistance to acids of polyamide fibers, without modifying colors of mechanical properties. Process improves general safety of garments and other items made from polyamide fibers and makes them suitable for applications requiring exposure to oxygen-rich atmosphere or corrosive acids. Halo-olefins are added to surface of fibers by photoadditon in sealed chamber. Process could be used with films and other forms of polyamide.
-
Richter, Jason; Mazurenko, Olena; Kazley, Abby Swanson; Ford, Eric W
2017-11-04
Evidenced-based processes of care improve patient outcomes, yet universal compliance is lacking, and perceptions of the quality of care are highly variable. The purpose of this study is to examine how differences in clinician and management perceptions on teamwork and communication relate to adherence to hospital processes of care. Hospitals submitted identifiable data for the 2012 Hospital Survey on Patient Safety Culture and the Centers for Medicare and Medicaid Services' Hospital Compare. The dependent variable was a composite, developed from the scores on adherence to acute myocardial infarction, heart failure, and pneumonia process of care measures. The primary independent variables reflected 4 safety culture domains: communication openness, feedback about errors, teamwork within units, and teamwork between units. We assigned each hospital into one of 4 groups based on agreement between managers and clinicians on each domain. Each hospital was categorized as "high" (above the median) or "low" (below) for clinicians and managers in communication and teamwork. We found a positive relationship between perceived teamwork and communication climate and processes of care measures. If managers and clinicians perceived the communication openness as high, the hospital was more likely to adhere with processes of care. Similarly, if clinicians perceived teamwork across units as high, the hospital was more likely to adhere to processes of care. Manager and staff perceptions about teamwork and communications impact adherence to processes of care. Policies should recognize the importance of perceptions of both clinicians and managers on teamwork and communication and seek to improve organizational climate and practices. Clinician perceptions of teamwork across units are more closely linked to processes of care, so managers should be cognizant and try to improve their perceptions.
-
Rostami, Paryaneh; Ashcroft, Darren M; Tully, Mary P
2018-01-01
Reducing medication-related harm is a global priority; however, impetus for improvement is impeded as routine medication safety data are seldom available. Therefore, the Medication Safety Thermometer was developed within England's National Health Service. This study aimed to explore the implementation of the tool into routine practice from users' perspectives. Fifteen semi-structured interviews were conducted with purposely sampled National Health Service staff from primary and secondary care settings. Interview data were analysed using an initial thematic analysis, and subsequent analysis using Normalisation Process Theory. Secondary care staff understood that the Medication Safety Thermometer's purpose was to measure medication safety and improvement. However, other uses were reported, such as pinpointing poor practice. Confusion about its purpose existed in primary care, despite further training, suggesting unsuitability of the tool. Decreased engagement was displayed by staff less involved with medication use, who displayed less ownership. Nonetheless, these advocates often lacked support from management and frontline levels, leading to an overall lack of engagement. Many participants reported efforts to drive scale-up of the use of the tool, for example, by securing funding, despite uncertainty around how to use data. Successful improvement was often at ward-level and went unrecognised within the wider organisation. There was mixed feedback regarding the value of the tool, often due to a perceived lack of "capacity". However, participants demonstrated interest in learning how to use their data and unexpected applications of data were reported. Routine medication safety data collection is complex, but achievable and facilitates improvements. However, collected data must be analysed, understood and used for further work to achieve improvement, which often does not happen. The national roll-out of the tool has accelerated shared learning; however, a number of difficulties still exist, particularly in primary care settings, where a different approach is likely to be required.
-
Ashcroft, Darren M.; Tully, Mary P.
2018-01-01
Background Reducing medication-related harm is a global priority; however, impetus for improvement is impeded as routine medication safety data are seldom available. Therefore, the Medication Safety Thermometer was developed within England’s National Health Service. This study aimed to explore the implementation of the tool into routine practice from users’ perspectives. Method Fifteen semi-structured interviews were conducted with purposely sampled National Health Service staff from primary and secondary care settings. Interview data were analysed using an initial thematic analysis, and subsequent analysis using Normalisation Process Theory. Results Secondary care staff understood that the Medication Safety Thermometer’s purpose was to measure medication safety and improvement. However, other uses were reported, such as pinpointing poor practice. Confusion about its purpose existed in primary care, despite further training, suggesting unsuitability of the tool. Decreased engagement was displayed by staff less involved with medication use, who displayed less ownership. Nonetheless, these advocates often lacked support from management and frontline levels, leading to an overall lack of engagement. Many participants reported efforts to drive scale-up of the use of the tool, for example, by securing funding, despite uncertainty around how to use data. Successful improvement was often at ward-level and went unrecognised within the wider organisation. There was mixed feedback regarding the value of the tool, often due to a perceived lack of “capacity”. However, participants demonstrated interest in learning how to use their data and unexpected applications of data were reported. Conclusion Routine medication safety data collection is complex, but achievable and facilitates improvements. However, collected data must be analysed, understood and used for further work to achieve improvement, which often does not happen. The national roll-out of the tool has accelerated shared learning; however, a number of difficulties still exist, particularly in primary care settings, where a different approach is likely to be required. PMID:29489842
-
Weinstock, Deborah; Failey, Tara
2014-11-01
In the United States, unions sometimes joined by worker advocacy groups (e.g., Public Citizen and the American Public Health Association) have played a critical role in strengthening worker safety and health protections. They have sought to improve standards that protect workers by participating in the rulemaking process, through written comments and involvement in hearings; lobbying decision-makers; petitioning the Department of Labor; and defending improved standards in court. Their efforts have culminated in more stringent exposure standards, access to information about the presence of potentially hazardous toxic chemicals, and improved access to personal protective equipment-further improving working conditions in the United States.
-
23 CFR 630.1008 - State-level processes and procedures.
Code of Federal Regulations, 2010 CFR
2010-04-01
... review are intended to lead to improvements in work zone processes and procedures, data and information... 23 Highways 1 2010-04-01 2010-04-01 false State-level processes and procedures. 630.1008 Section... OPERATIONS PRECONSTRUCTION PROCEDURES Work Zone Safety and Mobility § 630.1008 State-level processes and...
-
Usage of information safety requirements in improving tube bending process
NASA Astrophysics Data System (ADS)
Livshitz, I. I.; Kunakov, E.; Lontsikh, P. A.
2018-05-01
This article is devoted to an improvement of the technological process's analysis with the information security requirements implementation. The aim of this research is the competition increase analysis in aircraft industry enterprises due to the information technology implementation by the example of the tube bending technological process. The article analyzes tube bending kinds and current technique. In addition, a potential risks analysis in a tube bending technological process is carried out in terms of information security.
-
Quality improvement in pediatrics: past, present, and future.
Schwartz, Stephanie P; Rehder, Kyle J
2017-01-01
Almost two decades ago, the landmark report "To Err is Human" compelled healthcare to address the large numbers of hospitalized patients experiencing preventable harm. Concurrently, it became clear that the rapidly rising cost of healthcare would be unsustainable in the long-term. As a result, quality improvement methodologies initially rooted in other high-reliability industries have become a primary focus of healthcare. Multiple pediatric studies demonstrate remarkable quality and safety improvements in several domains including handoffs, catheter-associated blood stream infections, and other serious safety events. While both quality improvement and research are data-driven processes, significant differences exist between the two. Research utilizes a hypothesis driven approach to obtain new knowledge while quality improvement often incorporates a cyclic approach to translate existing knowledge into clinical practice. Recent publications have provided guidelines and methods for effectively reporting quality and safety work and improvement implementations. This review examines not only how quality improvement in pediatrics has led to improved outcomes, but also looks to the future of quality improvement in healthcare with focus on education and collaboration to ensure best practice approaches to caring for children.
-
Baumann, Andrea; Holness, D Linn; Norman, Patrica; Idriss-Wheeler, Dina; Boucher, Patricia
2012-07-01
This article presents a health and safety intervention model and the use of process evaluation to assess a participatory ergonomic intervention. The effectiveness of the Ergonomic Program Implementation Continuum (EPIC) was assessed at six healthcare pilot sites in Ontario, Canada. The model provided a framework to demonstrate evaluation findings. Participants reported that EPIC was thorough and identified improvements related to its use. Participants believed the program contributed to advancing an organizational culture of safety (COS). Main barriers to program uptake included resistance to change and need for adequate funding and resources. The dedication of organizational leaders and consultant coaches was identified as essential to the program's success. In terms of impact on industry, findings contribute to the evidence-based knowledge of health and safety interventions and support use of the framework for creating a robust infrastructure to advance organizational COS and link staff safety and wellness with patient safety in healthcare. Copyright © 2012 National Safety Council and Elsevier Ltd. All rights reserved.
-
Improving Patient Safety in Hospitals through Usage of Cloud Supported Video Surveillance
Dašić, Predrag; Dašić, Jovan; Crvenković, Bojan
2017-01-01
BACKGROUND: Patient safety in hospitals is of equal importance as providing treatments and urgent healthcare. With the development of Cloud technologies and Big Data analytics, it is possible to employ VSaaS technology virtually anywhere, for any given security purpose. AIM: For the listed benefits, in this paper, we give an overview of the existing cloud surveillance technologies which can be implemented for improving patient safety. MATERIAL AND METHODS: Modern VSaaS systems provide higher elasticity and project scalability in dealing with real-time information processing. Modern surveillance technologies can prove to be an effective tool for prevention of patient falls, undesired movement and tempering with attached life supporting devices. Given a large number of patients who require constant supervision, a cloud-based monitoring system can dramatically reduce the occurring costs. It provides continuous real-time monitoring, increased overall security and safety, improved staff productivity, prevention of dishonest claims and long-term digital archiving. CONCLUSION: Patient safety is a growing issue which can be improved with the usage of high-end centralised surveillance systems allowing the staff to focus more on treating health issues rather that keeping a watchful eye on potential incidents. PMID:28507610
-
Bonnabry, P; Cingria, L; Sadeghipour, F; Ing, H; Fonzo-Christe, C; Pfister, R
2005-01-01
Background: Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. Methods: A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. Results: The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Conclusions: Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities. PMID:15805453
-
Bonnabry, P; Cingria, L; Sadeghipour, F; Ing, H; Fonzo-Christe, C; Pfister, R E
2005-04-01
Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities.
-
Mort, Elizabeth A; Demehin, Akinluwa A; Marple, Keith B; McCullough, Kathryn Y; Meyer, Gregg S
2013-08-01
Hospitals are continually challenged to provide safer and higher-quality patient care despite resource constraints. With an ever-increasing range of quality and safety targets at the national, state, and local levels, prioritization is crucial in effective institutional quality goal setting and resource allocation.Organizational goal-setting theory is a performance improvement methodology with strong results across many industries. The authors describe a structured goal-setting process they have established at Massachusetts General Hospital for setting annual institutional quality and safety goals. Begun in 2008, this process has been conducted on an annual basis. Quality and safety data are gathered from many sources, both internal and external to the hospital. These data are collated and classified, and multiple approaches are used to identify the most pressing quality issues facing the institution. The conclusions are subject to stringent internal review, and then the top quality goals of the institution are chosen. Specific tactical initiatives and executive owners are assigned to each goal, and metrics are selected to track performance. A reporting tool based on these tactics and metrics is used to deliver progress updates to senior hospital leadership.The hospital has experienced excellent results and strong organizational buy-in using this effective, low-cost, and replicable goal-setting process. It has led to improvements in structural, process, and outcomes aspects of quality.
-
Beyond Texas City: the state of process safety in the unionized U.S. oil refining industry.
McQuiston, Thomas H; Lippin, Tobi Mae; Bradley-Bull, Kristin; Anderson, Joseph; Beach, Josie; Beevers, Gary; Frederick, Randy J; Frederick, James; Greene, Tammy; Hoffman, Thomas; Lefton, James; Nibarger, Kim; Renner, Paul; Ricks, Brian; Seymour, Thomas; Taylor, Ren; Wright, Mike
2009-01-01
The March 2005 British Petroleum (BP) Texas City Refinery disaster provided a stimulus to examine the state of process safety in the U.S. refining industry. Participatory action researchers conducted a nation-wide mail-back survey of United Steelworkers local unions and collected data from 51 unionized refineries. The study examined the prevalence of highly hazardous conditions key to the Texas City disaster, refinery actions to address those conditions, emergency preparedness and response, process safety systems, and worker training. Findings indicate that the key highly hazardous conditions were pervasive and often resulted in incidents or near-misses. Respondents reported worker training was insufficient and less than a third characterized their refineries as very prepared to respond safely to a hazardous materials emergency. The authors conclude that the potential for future disasters plagues the refining industry. In response, they call for effective proactive OSHA regulation and outline ten urgent and critical actions to improve refinery process safety.
-
Guo, Xin-E; Zhao, Yu-Bin; Xie, Yan-Ming; Zhao, Li-Cai; Li, Yan-Feng; Hao, Zhe
2013-09-01
To establish a nurse based post-marketing safety surveillance model for traditional Chinese medicine injections (TCMIs). A TCMIs safety monitoring team and a research hospital team engaged in the research, monitoring processes, and quality control processes were established, in order to achieve comprehensive, timely, accurate and real-time access to research data, to eliminate errors in data collection. A triage system involving a study nurse, as the first point of contact, clinicians and clinical pharmacists was set up in a TCM hospital. Following the specified workflow involving labeling of TCM injections and using improved monitoring forms it was found that there were no missing reports at the ratio of error was zero. A research nurse as the first and main point of contact in post-marketing safety monitoring of TCM as part of a triage model, ensures that research data collected has the characteristics of authenticity, accuracy, timeliness, integrity, and eliminate errors during the process of data collection. Hospital based monitoring is a robust and operable process.
-
John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital.
Uhlig, Paul N; Brown, Jeffrey; Nason, Anne K; Camelio, Addie; Kendall, Elise
2002-12-01
The Cardiac Surgery Program at Concord Hospital (Concord, NH) restructured clinical teamwork for improved safety and effectiveness on the basis of theory and practice from human factors science, aviation safety, and high-reliability organization theory. A team-based, collaborative rounds process--the Concord Collaborative Care Model--that involved use of a structured communications protocol was conducted daily at each patient's bedside. The entire care team agreed to meet at the same time each day (8:45 AM to 9:30 AM) to share information and develop a plan of care for each patient, with patient and family members as active participants. The cardiac surgery team developed a structured communications protocol adapted from human factors science. To provide a forum for discussion of team goals and progress and to address system-level concerns, a biweekly system rounds process was established. Following implementation of collaborative rounds, mortality of Concord Hospital's cardiac surgery patients declined significantly from expected rates. Satisfaction rates of open heart patients scores were consistently in the 97th-99th percentile nationally. A quality of work life survey indicated that in every category, providers expressed greater satisfaction with the collaborative care process than with the traditional rounds process. Practice patterns in the Cardiac Surgery Program at Concord Hospital have changed to a much more collaborative and participatory process, with improved outcomes, happier patients, and more satisfied practitioners. A culture of continuous program improvement has been implemented that continues to evolve and produce benefits.
-
Development a Comprehensive Food Safety System in Serbia- A Narrative Review Article
RADOVIĆ, Vesela; KEKOVIĆ, Zoran; AGIĆ, Samir
2014-01-01
Abstract Background Food safety issues are not a new issue in science, but due to the dynamic changes in the modern world it is as equally important as decades ago. The aim of the study was to address the efforts in the development of a comprehensive food safety system in Serbia, and make specific recommendations regarding the improvement of epidemiological investigation capacity as a useful tool which contributes to improving the public health by joint efforts of epidemiologists and law enforcement. Methods We used the methodology appropriate for social sciences. Results The findings show the current state-of-affairs in the area of food safety and health care system and present some most important weaknesses which have to be overcome. Policy makers need timely and reliable information so that they can make informed decisions to improve the population health in an ongoing process of seeking full membership in the European Union. Conclusion Serbia has to apply significant changes in practice because the current state-of-affairs in the area of food safety and health care system is not so favourable due to numerous both objective and subjective factors. Hence, the policy-makers must work on the development of epidemiological investigation capacities as a firm basis for greater efficiency and effectiveness. Epidemiologists would not stay alone in their work. Law enforcement as well as many other stakeholders should recognize their new role in the process of the development of epidemiological investigation capacity as a tool for the development of a comprehensive food safety system in Serbia. PMID:25909057
-
Effects of genetic, processing, or product formulation changes on efficacy and safety of probiotics.
Sanders, Mary Ellen; Klaenhammer, Todd R; Ouwehand, Arthur C; Pot, Bruno; Johansen, Eric; Heimbach, James T; Marco, Maria L; Tennilä, Julia; Ross, R Paul; Franz, Charles; Pagé, Nicolas; Pridmore, R David; Leyer, Greg; Salminen, Seppo; Charbonneau, Duane; Call, Emma; Lenoir-Wijnkoop, Irene
2014-02-01
Commercial probiotic strains for food or supplement use can be altered in different ways for a variety of purposes. Production conditions for the strain or final product may be changed to address probiotic yield, functionality, or stability. Final food products may be modified to improve flavor and other sensory properties, provide new product formats, or respond to market opportunities. Such changes can alter the expression of physiological traits owing to the live nature of probiotics. In addition, genetic approaches may be used to improve strain attributes. This review explores whether genetic or phenotypic changes, by accident or design, might affect the efficacy or safety of commercial probiotics. We highlight key issues important to determining the need to re-confirm efficacy or safety after strain improvement, process optimization, or product formulation changes. Research pinpointing the mechanisms of action for probiotic function and the development of assays to measure them are greatly needed to better understand if such changes have a substantive impact on probiotic efficacy. © 2014 New York Academy of Sciences.
-
Embedding technology into inter-professional best practices in home safety evaluation.
Burns, Suzanne Perea; Pickens, Noralyn Davel
2017-08-01
To explore inter-professional home evaluators' perspectives and needs for building useful and acceptable decision-support tools for the field of home modifications. Twenty semi-structured interviews were conducted with a range of home modification professionals from different regions of the United States. The interview transcripts were analyzed with a qualitative, descriptive, perspective approach. Technology supports current best practice and has potential to inform decision making through features that could enhance home evaluation processes, quality, efficiency and inter-professional communication. Technological advances with app design have created numerous opportunities for the field of home modifications. Integrating technology and inter-professional best practices will improve home safety evaluation and intervention development to meet client-centred and societal needs. Implications for rehabilitation Understanding home evaluators technology needs for home safety evaluations contributes to the development of app-based assessments. Integrating inter-professional perspectives of best practice and technological needs in an app for home assessments improves processes. Novice and expert home evaluators would benefit from decision support systems embedded in app-based assessments. Adoption of app-based assessment would improve efficiency while remaining client-centred.
-
Development of a Mapped Diabetes Community Program Guide for a Safety Net Population
Zallman, Leah; Ibekwe, Lynn; Thompson, Jennifer W.; Ross-Degnan, Dennis; Oken, Emily
2014-01-01
Purpose Enhancing linkages between patients and community programs is increasingly recognized as a method for improving physical activity, nutrition and weight management. Although interactive mapped community program guides may be beneficial, there remains a dearth of articles that describe the processes and practicalities of creating such guides. This article describes the development of an interactive, web-based mapped community program guide at a safety net institution and the lessons learned from that process. Conclusions This project demonstrated the feasibility of creating two maps – a program guide and a population health map. It also revealed some key challenges and lessons for future work in this area, particularly within safety-net institutions. Our work underscores the need for developing partnerships outside of the health care system and the importance of employing community-based participatory methods. In addition to facilitating improvements in individual wellness, mapping community programs also has the potential to improve population health management by healthcare delivery systems such as hospitals, health centers, or public health systems, including city and state departments of health. PMID:24752180
-
Quality and Safety in Health Care, Part XXI: PSOs and the Vascular Quality Initiative.
Harolds, Jay A
2017-04-01
Congress provided for the formation of patient safety organizations (PSOs) so that physicians and other providers would come forward to improve the safety and quality of health care. Important legal safeguards for the providers and patients were put in place for PSOs. The Society for Vascular Surgery (SVS) PSO operates the Vascular Quality Initiative. The latter gathers information from certain commonly done vascular procedures. First, information is collected so a risk adjustment determination of each individual patient can be done. Then the details of every procedure are recorded for later analysis of the processes of the patient's care. In addition, outcome analysis from all procedures is carried out. This registry is an important source of data for research improving health care safety and quality.
-
A toolbox for safety instrumented system evaluation based on improved continuous-time Markov chain
NASA Astrophysics Data System (ADS)
Wardana, Awang N. I.; Kurniady, Rahman; Pambudi, Galih; Purnama, Jaka; Suryopratomo, Kutut
2017-08-01
Safety instrumented system (SIS) is designed to restore a plant into a safe condition when pre-hazardous event is occur. It has a vital role especially in process industries. A SIS shall be meet with safety requirement specifications. To confirm it, SIS shall be evaluated. Typically, the evaluation is calculated by hand. This paper presents a toolbox for SIS evaluation. It is developed based on improved continuous-time Markov chain. The toolbox supports to detailed approach of evaluation. This paper also illustrates an industrial application of the toolbox to evaluate arch burner safety system of primary reformer. The results of the case study demonstrates that the toolbox can be used to evaluate industrial SIS in detail and to plan the maintenance strategy.
-
Lydon, Sinéad; Cupples, Margaret E; Hart, Nigel; Murphy, Andrew W; Faherty, Aileen; O'Connor, Paul
2016-01-01
Research on patient safety has focused largely on secondary care settings, and there is a dearth of knowledge relating to safety culture or climate, and safety climate improvement strategies, in the context of primary care. This is problematic given the high rates of usage of primary care services and the myriad of opportunities for clinical errors daily. The current research programme aimed to assess the effectiveness of an intervention derived from the Scottish Patient Safety Programme in Primary Care. The intervention consists of safety climate measurement and feedback and patient chart audit using the trigger review method. The purpose of this paper is to describe the background to this research and to present the methodology of this feasibility study in preparation for a future definitive RCT. The SAP-C study is a feasibility study employing a randomised controlled pretest-posttest design that will be conducted in 10 general practices in the Republic of Ireland and Northern Ireland. Five practices will receive the safety climate intervention over a 9-month period. The five practices in the control group will continue care as usual but will complete the GP-SafeQuest safety climate questionnaire at baseline (month 1) and at the terminus of the intervention (month 9). The outcomes of the study include process evaluation metrics (i.e. rates of participant recruitment and retention, rates of completion of safety climate measures, qualitative data regarding participants' perceptions of the intervention's potential efficacy, acceptability, and sustainability), patient safety culture in intervention and control group practices at posttest, and instances of undetected patient harm identified through patient chart audit using the trigger review method. The planned study investigates an intervention to improve safety climate in Irish primary care settings. The resulting data may inform our knowledge of the frequency of undetected patient safety incidents in primary care, may contribute to improved patient safety practices in primary care settings, and may inform future research on patient safety improvement initiatives.
-
Edwards, Brian; Hugman, Bruce; Tobin, Mary; Whalen, Matthew
2012-04-01
Robust, active cooperation, and effective, open communication between all stakeholders is essential for ensuring regulatory compliance and healthcare product safety; avoiding the necessity for whistle-blowing; and, most essentially, meeting the transparency requirements of public trust.The focus here is on what can be done within a healthcare product organization (HPO) to achieve actionable, sustainable policies and practices such as leadership, management, and supervision role-modelling of best practice; ongoing process review and improvements in every department; protection of those who report concerns through robust policies endorsed at Board level throughout an organization to eliminate the fear of retaliation; training in open, non-defensive team-working principles; and mediation structure and process for resolution of differences of opinion or interpretation of contradictory and volatile data.Based on analyses of other safety systems, workplace silence and interpersonal breakdowns are warning signs of defective systems underlying poor compliance and compromising safety. Remedying the situation requires attention to the root causes underlying such symptoms of dysfunction, especially the human factor, i.e. those factors that influence human performance. It is essential that leadership and management listen to employees' concerns about systems and processes, assess them impartially and reward contributions that improve safety.Fundamentally, the safety, transparency, and trustworthiness of HPOs, both commercial and regulatory, can be judged by the extent of the freedom of their staff to 'speak up' when the time is right. This, in turn, consolidates the trust of external stakeholders in the safety of a system and its products. The promotion of 'speaking up' in an organization provides an important safeguard against the risk of poor compliance and the undermining of societal confidence in the safety of healthcare products.
-
Dahm, Maria R; Georgiou, Andrew; Westbrook, Johanna I; Greenfield, David; Horvath, Andrea R; Wakefield, Denis; Li, Ling; Hillman, Ken; Bolton, Patrick; Brown, Anthony; Jones, Graham; Herkes, Robert; Lindeman, Robert; Legg, Michael; Makeham, Meredith; Moses, Daniel; Badmus, Dauda; Campbell, Craig; Hardie, Rae-Anne; Li, Julie; McCaughey, Euan; Sezgin, Gorkem; Thomas, Judith; Wabe, Nasir
2018-02-15
The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems. This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings. Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
-
Assessing the relationship between patient safety culture and EHR strategy.
Ford, Eric W; Silvera, Geoffrey A; Kazley, Abby S; Diana, Mark L; Huerta, Timothy R
2016-07-11
Purpose - The purpose of this paper is to explore the relationship between hospitals' electronic health record (EHR) adoption characteristics and their patient safety cultures. The "Meaningful Use" (MU) program is designed to increase hospitals' adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated. Design/methodology/approach - Providers' perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality's surveys on patient safety culture (level 1) and the American Hospital Association's survey and healthcare information technology supplement (level 2). Findings - The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers' perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research. Originality/value - Relating EHR MU and providers' care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.
-
[Failure mode and effects analysis to improve quality in clinical trials].
Mañes-Sevilla, M; Marzal-Alfaro, M B; Romero Jiménez, R; Herranz-Alonso, A; Sanchez Fresneda, M N; Benedi Gonzalez, J; Sanjurjo-Sáez, M
The failure mode and effects analysis (FMEA) has been used as a tool in risk management and quality improvement. The objective of this study is to identify the weaknesses in processes in the clinical trials area, of a Pharmacy Department (PD) with great research activity, in order to improve the safety of the usual procedures. A multidisciplinary team was created to analyse each of the critical points, identified as possible failure modes, in the development of clinical trial in the PD. For each failure mode, the possible cause and effect were identified, criticality was calculated using the risk priority number and the possible corrective actions were discussed. Six sub-processes were defined in the development of the clinical trials in PD. The FMEA identified 67 failure modes, being the dispensing and prescription/validation sub-processes the most likely to generate errors. All the improvement actions established in the AMFE were implemented in the Clinical Trials area. The FMEA is a useful tool in proactive risk management because it allows us to identify where we are making mistakes and analyze the causes that originate them, to prioritize and to adopt solutions to risk reduction. The FMEA improves process safety and quality in PD. Copyright © 2018 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.
-
Kapur, Ajay; Adair, Nilda; O'Brien, Mildred; Naparstek, Nikoleta; Cangelosi, Thomas; Zuvic, Petrina; Joseph, Sherin; Meier, Jason; Bloom, Beatrice; Potters, Louis
Modern external beam radiation therapy treatment delivery processes potentially increase the number of tasks to be performed by therapists and thus opportunities for errors, yet the need to treat a large number of patients daily requires a balanced allocation of time per treatment slot. The goal of this work was to streamline the underlying workflow in such time-interval constrained processes to enhance both execution efficiency and active safety surveillance using a Kaizen approach. A Kaizen project was initiated by mapping the workflow within each treatment slot for 3 Varian TrueBeam linear accelerators. More than 90 steps were identified, and average execution times for each were measured. The time-consuming steps were stratified into a 2 × 2 matrix arranged by potential workflow improvement versus the level of corrective effort required. A work plan was created to launch initiatives with high potential for workflow improvement but modest effort to implement. Time spent on safety surveillance and average durations of treatment slots were used to assess corresponding workflow improvements. Three initiatives were implemented to mitigate unnecessary therapist motion, overprocessing of data, and wait time for data transfer defects, respectively. A fourth initiative was implemented to make the division of labor by treating therapists as well as peer review more explicit. The average duration of treatment slots reduced by 6.7% in the 9 months following implementation of the initiatives (P = .001). A reduction of 21% in duration of treatment slots was observed on 1 of the machines (P < .001). Time spent on safety reviews remained the same (20% of the allocated interval), but the peer review component increased. The Kaizen approach has the potential to improve operational efficiency and safety with quick turnaround in radiation therapy practice by addressing non-value-adding steps characteristic of individual department workflows. Higher effort opportunities are identified to guide continual downstream quality improvements. Copyright © 2017 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
-
Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm.
Lyren, Anne; Brilli, Richard J; Zieker, Karen; Marino, Miguel; Muething, Stephen; Sharek, Paul J
2017-09-01
To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs). A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions. Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; P < .005 for all). The mean monthly SSE rate decreased 32% (from 0.77 to 0.52; P < .001). The 12-month rolling average SSE rate decreased 50% (from 0.82 to 0.41; P < .001). Participation in a structured collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm. Copyright © 2017 by the American Academy of Pediatrics.
-
Chera, Bhishamjit S; Mazur, Lukasz; Jackson, Marianne; Taylor, Kinely; Mosaly, Prithima; Chang, Sha; Deschesne, Kathy; LaChapelle, Dana; Hoyle, Lesley; Saponaro, Patricia; Rockwell, John; Adams, Robert; Marks, Lawrence B
2014-01-01
We have systematically been incorporating several operational efficiency and safety initiatives into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful, metrics. The data from 5 quality improvement initiatives, each focused on a specific safety/process concern in our clinic, are presented. Data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using statistical analysis. Results from the Agency for Health Care Research and Quality (AHRQ) patient safety culture surveys administered during and after many of these initiatives were similarly compared. (1) Workload levels for nurses assisting with brachytherapy were high (National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores >55-60, suggesting, "overwork"). Changes in work flow and procedure room layout reduced workload to more acceptable levels (NASA-TLX <55; P < .01). (2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range, 1-11) times per patient treatment to a mean <1 (range, 0-3; P < .001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (ie, delayed, on time). (3) The rates of replans by dosimetrists was reduced from 11% to 6% (P < .01) through a more systematic pretreatment peer review process. (4) Standardizing nursing and resident functions reduced patient wait times by ≈ 45% (14 min; P < .01). (5) Standardizing presimulation instructions from the physician reduced the number of patients experiencing delays on the simulator (>50% to <10%; P < .01). To assess the overall changes in "patient safety culture," we conducted a pre- and postanalysis using the AHRQ survey. Improvements in all measured dimensions were noted. Quality improvement initiatives can be successfully implemented in an academic radiation oncology department to yield measurable improvements in operations resulting in improvement in patient safety culture. Copyright © 2014 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
-
Barcode identification for transfusion safety.
Murphy, M F; Kay, J D S
2004-09-01
Errors related to blood transfusion in hospitals may produce catastrophic consequences. This review addresses potential solutions to prevent patient misidentification including the use of new technology, such as barcoding. A small number of studies using new technology for the transfusion process in hospitals have shown promising results in preventing errors. The studies demonstrated improved transfusion safety and staff preference for new technology such as bedside handheld scanners to carry out pretransfusion bedside checking. They also highlighted the need for considerable efforts in the training of staff in the new procedures before their successful implementation. Improvements in hospital transfusion safety are a top priority for transfusion medicine, and will depend on a combined approach including a better understanding of the causes of errors, a reduction in the complexity of routine procedures taking advantage of new technology, improved staff training, and regular monitoring of practice. The use of new technology to improve the safety of transfusion is very promising. Further development of the systems is needed to enable staff to carry out bedside transfusion procedures quickly and accurately, and to increase their functionality to justify the cost of their wider implementation.
-
Linguistic analysis of large-scale medical incident reports for patient safety.
Fujita, Katsuhide; Akiyama, Masanori; Park, Keunsik; Yamaguchi, Etsuko Nakagami; Furukawa, Hiroyuki
2012-01-01
The analysis of medical incident reports is indispensable for patient safety. The cycles between analysis of incident reports and proposals to medical staffs are a key point for improving the patient safety in the hospital. Most incident reports are composed from freely written descriptions, but an analysis of such free descriptions is not sufficient in the medical field. In this study, we aim to accumulate and reinterpret findings using structured incident information, to clarify improvements that should be made to solve the root cause of the accident, and to ensure safe medical treatment through such improvements. We employ natural language processing (NLP) and network analysis to identify effective categories of medical incident reports. Network analysis can find various relationships that are not only direct but also indirect. In addition, we compare bottom-up results obtained by NLP with existing categories based on experts' judgment. By the bottom-up analysis, the class of patient managements regarding patients' fallings and medicines in top-down analysis is created clearly. Finally, we present new perspectives on ways of improving patient safety.
-
Robert, Glenn B; Anderson, Janet E; Burnett, Susan J; Aase, Karina; Andersson-Gare, Boel; Bal, Roland; Calltorp, Johan; Nunes, Francisco; Weggelaar, Anne-Marie; Vincent, Charles A; Fulop, Naomi J
2011-10-26
although there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The 'Quality and Safety in Europe by Research' (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them. The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients. in-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features: • a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience • a conceptualisation of quality as a human, social, technical and organisational accomplishment • an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union. Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims). the protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the 'organisational and cultural characteristics associated with better quality of care' in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.
-
Airline Safety Improvement Through Experience with Near-Misses: A Cautionary Tale.
Madsen, Peter; Dillon, Robin L; Tinsley, Catherine H
2016-05-01
In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes. Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry. Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses-those where the possible dangers are salient. Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses. © 2015 Society for Risk Analysis.
-
Creating a Highly Reliable Neonatal Intensive Care Unit Through Safer Systems of Care.
Panagos, Patoula G; Pearlman, Stephen A
2017-09-01
Neonates requiring intensive care are at high risk for medical errors due to their unique characteristics and high acuity. Designing a safer work environment begins with safe processes. Creating a culture of safety demands the involvement of all organizational levels and an interdisciplinary approach. Adverse events can result from suboptimal communication and lack of a shared mental model. This chapter describes tools to promote better patient safety in the NICU through monitoring adverse events, improving communication and using information technology. Unplanned extubation is an example of a neonatal safety concern that can be reduced by employing quality improvement methodology. Copyright © 2017 Elsevier Inc. All rights reserved.
-
Bohmer, Richard M J; Bloom, Jonathan D; Mort, Elizabeth A; Demehin, Akinluwa A; Meyer, Gregg S
2009-12-01
Recent focus on the need to improve the quality and safety of health care has created new challenges for academic health centers (AHCs). Whereas previously quality was largely assumed, today it is increasingly quantifiable and requires organized systems for improvement. Traditional structures and cultures within AHCs, although well suited to the tripartite missions of teaching, research, and clinical care, are not easily adaptable to the tasks of measuring, reporting, and improving quality. Here, the authors use a case study of Massachusetts General Hospital's efforts to restructure quality and safety to illustrate the value of beginning with a focus on organizational culture, using a systematic process of engaging clinical leadership, developing an organizational framework dependent on proven business principles, leveraging focus events, and maintaining executive dedication to execution of the initiative. The case provides a generalizable example for AHCs of how applying explicit management design can foster robust organizational change with relatively modest incremental financial resources.
-
ERIC Educational Resources Information Center
General Accounting Office, Washington, DC.
This report presents information on the status of the safety and use of polio vaccines in the United States. Topics discussed include: (1) the role of the Food and Drug Administration (FDA) in processing an inactivated polio vaccine license application; (2) the steps the federal government has taken to improve the safety of the vaccine; (3) the…
-
Inactivation of Salmonella spp. in ground chicken using High Pressure Processing
USDA-ARS?s Scientific Manuscript database
High pressure processing (HPP) is a safe and effective process for improving the microbial safety and shelf-life of foods. Salmonella is a common contaminant in poultry meat and is frequently responsible for foodborne illness associated with contaminated poultry meat. In this study the inactivation...
-
Cold plasma processing to improve food safety
USDA-ARS?s Scientific Manuscript database
Cold plasma is an antimicrobial process being developed for application as a food processing technology. This novel intervention is the subject of an expanding research effort by groups around the world. A variety of devices can be used to generate cold plasma and apply it to the food commodity bein...
-
Using continuous process improvement methodology to standardize nursing handoff communication.
Klee, Kristi; Latta, Linda; Davis-Kirsch, Sallie; Pecchia, Maria
2012-04-01
The purpose of this article was to describe the use of continuous performance improvement (CPI) methodology to standardize nurse shift-to-shift handoff communication. The goals of the process were to standardize the content and process of shift handoff, improve patient safety, increase patient and family involvement in the handoff process, and decrease end-of-shift overtime. This article will describe process changes made over a 4-year period as result of application of the plan-do-check-act procedure, which is an integral part of the CPI methodology, and discuss further work needed to continue to refine this critical nursing care process. Copyright © 2012 Elsevier Inc. All rights reserved.
-
Certified safe farm: identifying and removing hazards on the farm.
Rautiainen, R H; Grafft, L J; Kline, A K; Madsen, M D; Lange, J L; Donham, K J
2010-04-01
This article describes the development of the Certified Safe Farm (CSF) on-farm safety review tools, characterizes the safety improvements among participating farms during the study period, and evaluates differences in background variables between low and high scoring farms. Average farm review scores on 185 study farms improved from 82 to 96 during the five-year study (0-100 scale, 85 required for CSF certification). A total of 1292 safety improvements were reported at an estimated cost of $650 per farm. A wide range of improvements were made, including adding 9 rollover protective structures (ROPS), 59 power take-off (PTO) master shields, and 207 slow-moving vehicle (SMV) emblems; improving lighting on 72 machines: placing 171 warning decals on machinery; shielding 77 moving parts; locking up 17 chemical storage areas, adding 83 lockout/tagout improvements; and making general housekeeping upgrades in 62 farm buildings. The local, trained farm reviewers and the CSF review process overall were well received by participating farmers. In addition to our earlier findings where higher farm review scores were associated with lower self-reported health outcome costs, we found that those with higher farm work hours, younger age, pork production in confinement, beef production, poultry production, and reported exposure to agrichemicals had higher farm review scores than those who did not have these characteristics. Overall, the farm review process functioned as expected. encouraging physical improvements in the farm environment, and contributing to the multi-faceted CSF intervention program.
-
Opportunities to Apply the 3Rs in Safety Assessment Programs
Sewell, Fiona; Edwards, Joanna; Prior, Helen; Robinson, Sally
2016-01-01
Abstract Before a potential new medicine can be administered to humans it is essential that its safety is adequately assessed. Safety assessment in animals forms an integral part of this process, from early drug discovery and initial candidate selection to the program of recommended regulatory tests in animals. The 3Rs (replacement, reduction, and refinement of animals in research) are integrated in the current regulatory requirements and expectations and, in the EU, provide a legal and ethical framework for in vivo research to ensure the scientific objectives are met whilst minimizing animal use and maintaining high animal welfare standards. Though the regulations are designed to uncover potential risks, they are intended to be flexible, so that the most appropriate approach can be taken for an individual product. This article outlines current and future opportunities to apply the 3Rs in safety assessment programs for pharmaceuticals, and the potential (scientific, financial, and ethical) benefits to the industry, across the drug discovery and development process. For example, improvements to, or the development of, novel, early screens (e.g., in vitro, in silico, or nonmammalian screens) designed to identify compounds with undesirable characteristics earlier in development have the potential to reduce late-stage attrition by improving the selection of compounds that require regulatory testing in animals. Opportunities also exist within the current regulatory framework to simultaneously reduce and/or refine animal use and improve scientific outcomes through improvements to technical procedures and/or adjustments to study designs. It is important that approaches to safety assessment are continuously reviewed and challenged to ensure they are science-driven and predictive of relevant effects in humans. PMID:28053076
-
Federal Register 2010, 2011, 2012, 2013, 2014
2010-02-25
... Technology Program is a newly authorized program under the Rail Safety Improvement Act of 2008 (RSIA) (Pub. L. 110-432; October 16, 2008). The program was directed by Congress and passed into law in the aftermath... the Nation's attention to rail safety and the possibility that new technologies, such as PTC, could...
-
USDA-ARS?s Scientific Manuscript database
High pressure processing (HPP) is a safe and effective technology for improving food safety while maintaining food quality attributes. Non-O157:H7 Shiga Toxin-producing Escherichia coli (STEC) have been increasingly implicated in foodborne illness outbreaks and recalls, and the USDA Food Safety Ins...
-
Electronic clinical safety reporting system: a benefits evaluation.
Elliott, Pamela; Martin, Desmond; Neville, Doreen
2014-06-11
Eastern Health, a large health care organization in Newfoundland and Labrador (NL), started a staged implementation of an electronic occurrence reporting system (used interchangeably with "clinical safety reporting system") in 2008, completing Phase One in 2009. The electronic clinical safety reporting system (CSRS) was designed to replace a paper-based system. The CSRS involves reporting on occurrences such as falls, safety/security issues, medication errors, treatment and procedural mishaps, medical equipment malfunctions, and close calls. The electronic system was purchased from a vendor in the United Kingdom that had implemented the system in the United Kingdom and other places, such as British Columbia. The main objective of the new system was to improve the reporting process with the goal of improving clinical safety. The project was funded jointly by Eastern Health and Canada Health Infoway. The objectives of the evaluation were to: (1) assess the CSRS on achieving its stated objectives (particularly, the benefits realized and lessons learned), and (2) identify contributions, if any, that can be made to the emerging field of electronic clinical safety reporting. The evaluation involved mixed methods, including extensive stakeholder participation, pre/post comparative study design, and triangulation of data where possible. The data were collected from several sources, such as project documentation, occurrence reporting records, stakeholder workshops, surveys, focus groups, and key informant interviews. The findings provided evidence that frontline staff and managers support the CSRS, identifying both benefits and areas for improvement. Many benefits were realized, such as increases in the number of occurrences reported, in occurrences reported within 48 hours, in occurrences reported by staff other than registered nurses, in close calls reported, and improved timelines for notification. There was also user satisfaction with the tool regarding ease of use, accessibility, and consistency. The implementation process encountered challenges related to customizing the software and the development of the classification system for coding occurrences. This impacted on the ability of the managers to close-out files in a timely fashion. The issues that were identified, and suggestions for improvements to the form itself, were shared with the Project Team as soon as they were noted. Changes were made to the system before the rollout. There were many benefits realized from the new system that can contribute to improved clinical safety. The participants preferred the electronic system over the paper-based system. The lessons learned during the implementation process resulted in recommendations that informed the rollout of the system in Eastern Health, and in other health care organizations in the province of Newfoundland and Labrador. This study also informed the evaluation of other health organizations in the province, which was completed in 2013.
-
Sindhwani, Geetika; Gupta, Monica; Arora, Sweta; Mishra, Arpita; Bhatt, Jayesh; Arora, Manali; Gehani, Anisha
2017-01-01
Introduction An organization’s transformation from imple-mentation of small, distinct Quality Improvement (QI) efforts to complete incorporation of Quality Improvement Program (QIP) into its culture occurs through a process of churning the foundational elements over time. Aim To develop a quality culture across the employees, identify measurable indicators and various tools to impart effective quality care and develop a learning culture for continuous quality improvement in the field of imaging services. Materials and Methods To establish a QIP, the bare minimum requirement started with forming a quality committee. The committee identified the areas of improvement and ascertaining the core principle of Quality Management System (QMS) by having a Quality Manual, Standard Operating Procedures (SOP’s), work-instructions, identification and monitoring of quality indicators and a training calendar. Appropriate tools like formatted daily registers, periodic check lists, run charts etc., were developed to collect the data followed by multiple PDSA cycles (Plan, Do, Study and Act) which helped identify the process bottlenecks, followed by implementing solutions and reanalysis. Results A total of 17 measurable key performance indicators were identified from the four major quality tasks namely Safety, Process Improvement, Professional Outcome and Satisfaction, to assess the performance measures and targets of QIP. Conclusion Diagnostic services should evaluate how to choose the most appropriate method and develop a comprehensive QIP to meet the needs of the staff and the end users, thus, creating a working environment, where people constitutes the intrinsic value in attaining the ultimate quality and safety. PMID:28969238
-
Clarke, Christina M; Persaud, Drepaul David
2011-03-01
Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.
-
Robertson, Eleanor; Morgan, Lauren; New, Steve; Pickering, Sharon; Hadi, Mohammed; Collins, Gary; Rivero Arias, Oliver; Griffin, Damian; McCulloch, Peter
2015-01-01
Background To investigate the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. We conducted a controlled interrupted time series study in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control. Study Design We used a 3 month intervention with 3 months data collection period before and after it. A combined teamwork training and lean process improvement intervention was delivered by an experienced specialist team. Before and after the intervention we evaluated team non-technical skills using NOTECHS II, technical performance using the glitch rate and WHO checklist compliance using a simple 3 point scale. We recorded complication rate, readmission rate and length of hospital stay data for 6 months before and after the intervention. Results In the active group, but not the control group, full compliance with WHO Time Out (T/O) increased from 14 to 71% (p = 0.032), Sign Out attempt rate (S/O) increased from 0% to 50% (p<0.001) and Oxford NOTECHS II scores increased after the intervention (P = 0.058). Glitch rate decreased in the active group and increased in the control group (p = 0.001). Complications and length of stay appeared to rise in the control group and fall in the active group. Conclusions Combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. We suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients. PMID:26381643
-
Nozawa, Takayuki; Taki, Yasuyuki; Kanno, Akitake; Akimoto, Yoritaka; Ihara, Mizuki; Yokoyama, Ryoichi; Kotozaki, Yuka; Nouchi, Rui; Sekiguchi, Atsushi; Takeuchi, Hikaru; Miyauchi, Carlos Makoto; Ogawa, Takeshi; Goto, Takakuni; Sunda, Takashi; Shimizu, Toshiyuki; Tozuka, Eiji; Hirose, Satoru; Nanbu, Tatsuyoshi; Kawashima, Ryuta
2015-01-01
Increasing proportion of the elderly in the driving population raises the importance of assuring their safety. We explored the effects of three different types of cognitive training on the cognitive function, brain structure, and driving safety of the elderly. Thirty-seven healthy elderly daily drivers were randomly assigned to one of three training groups: Group V trained in a vehicle with a newly developed onboard cognitive training program, Group P trained with a similar program but on a personal computer, and Group C trained to solve a crossword puzzle. Before and after the 8-week training period, they underwent neuropsychological tests, structural brain magnetic resonance imaging, and driving safety tests. For cognitive function, only Group V showed significant improvements in processing speed and working memory. For driving safety, Group V showed significant improvements both in the driving aptitude test and in the on-road evaluations. Group P showed no significant improvements in either test, and Group C showed significant improvements in the driving aptitude but not in the on-road evaluations. The results support the effectiveness of the onboard training program in enhancing the elderly's abilities to drive safely and the potential advantages of a multimodal training approach.
-
Taki, Yasuyuki; Kanno, Akitake; Akimoto, Yoritaka; Ihara, Mizuki; Yokoyama, Ryoichi; Kotozaki, Yuka; Sekiguchi, Atsushi; Takeuchi, Hikaru; Miyauchi, Carlos Makoto; Ogawa, Takeshi; Goto, Takakuni; Sunda, Takashi; Shimizu, Toshiyuki; Tozuka, Eiji; Hirose, Satoru; Nanbu, Tatsuyoshi; Kawashima, Ryuta
2015-01-01
Background. Increasing proportion of the elderly in the driving population raises the importance of assuring their safety. We explored the effects of three different types of cognitive training on the cognitive function, brain structure, and driving safety of the elderly. Methods. Thirty-seven healthy elderly daily drivers were randomly assigned to one of three training groups: Group V trained in a vehicle with a newly developed onboard cognitive training program, Group P trained with a similar program but on a personal computer, and Group C trained to solve a crossword puzzle. Before and after the 8-week training period, they underwent neuropsychological tests, structural brain magnetic resonance imaging, and driving safety tests. Results. For cognitive function, only Group V showed significant improvements in processing speed and working memory. For driving safety, Group V showed significant improvements both in the driving aptitude test and in the on-road evaluations. Group P showed no significant improvements in either test, and Group C showed significant improvements in the driving aptitude but not in the on-road evaluations. Conclusion. The results support the effectiveness of the onboard training program in enhancing the elderly's abilities to drive safely and the potential advantages of a multimodal training approach. PMID:26161000
-
[Sustainable process improvement with application of 'lean philosophy'].
Rouppe van der Voort, Marc B V; van Merode, G G Frits; Veraart, Henricus G N
2013-01-01
Process improvement is increasingly being implemented, particularly with the aid of 'lean philosophy'. This management philosophy aims to improve quality by reducing 'wastage'. Local improvements can produce negative effects elsewhere due to interdependence of processes. An 'integrated system approach' is required to prevent this. Some hospitals claim that this has been successful. Research into process improvement with the application of lean philosophy has reported many positive effects, defined as improved safety, quality and efficiency. Due to methodological shortcomings and lack of rigorous evaluations it is, however, not yet possible to determine the impact of this approach. It is, however, obvious that the investigated applications are fragmentary, with a dominant focus on the instrumental aspect of the philosophy and a lack of integration in a total system, and with insufficient attention to human aspects. Process improvement is required to achieve better and more goal-oriented healthcare. To achieve this, hospitals must develop integrated system approaches that combine methods for process design with continuous improvement of processes and with personnel management. It is crucial that doctors take the initiative to guide and improve processes in an integral manner.
-
Tupper, Judith B; Gray, Carolyn E; Pearson, Karen B; Coburn, Andrew F
2015-01-01
The "siloed" approach to healthcare delivery contributes to communication challenges and to potential patient harm when patients transfer between settings. This article reports on the evaluation of a demonstration in 10 rural communities to improve the safety of nursing facility (NF) transfers to hospital emergency departments by forming interprofessional teams of hospital, emergency medical service, and NF staff to develop and implement tools and protocols for standardizing critical interfacility communication pathways and information sharing. We worked with each of the 10 teams to document current communication processes and information sharing tools and to design, implement, and evaluate strategies/tools to increase effective communication and sharing of patient information across settings. A mixed methods approach was used to evaluate changes from baseline in documentation of patient information shared across settings during the transfer process. Study findings showed significant improvement in key areas across the three settings, including infection status and baseline mental functioning. Improvement strategies and performance varied across settings; however, accurate and consistent information sharing of advance directives and medication lists remains a challenge. Study results demonstrate that with neutral facilitation and technical support, collaborative interfacility teams can assess and effectively address communication and information sharing problems that threaten patient safety.
-
What motivates professionals to engage in the accreditation of healthcare organizations?
Greenfield, David; Pawsey, Marjorie; Braithwaite, Jeffrey
2011-02-01
Motivated staff are needed to improve quality and safety in healthcare organizations. Stimulating and engaging staff to participate in accreditation processes is a considerable challenge. The purpose of this study was to explore the experiences of health executives, managers and frontline clinicians who participated in organizational accreditation processes: what motivated them to engage, and what benefits accrued? The setting was a large public teaching hospital undergoing a planned review of its accreditation status. A research protocol was employed to conduct semi-structured interviews with a purposive sample of 30 staff with varied organizational roles, from different professions, to discuss their involvement in accreditation. Thematic analysis of the data was undertaken. The analysis identified three categories, each with sub-themes: accreditation response (reactions to accreditation and the value of surveys); survey issues (participation in the survey, learning through interactions and constraints) and documentation issues (self-assessment report, survey report and recommendations). Participants' occupational role focuses their attention to prioritize aspects of the accreditation process. Their motivations to participate and the benefits that accrue to them can be positively self-reinforcing. Participants have a desire to engage collaboratively with colleagues to learn and validate their efforts to improve. Participation in the accreditation process promoted a quality and safety culture that crossed organizational boundaries. The insights into worker motivation can be applied to engage staff to promote learning, overcome organizational boundaries and improve services. The findings can be applied to enhance involvement with accreditation and, more broadly, to other quality and safety activities.
-
Projecting effects of improvements in passive safety of the New Zealand light vehicle fleet.
Keall, Michael; Newstead, Stuart; Jones, Wayne
2007-09-01
In the year 2000, as part of the process for setting New Zealand road safety targets, a projection was made for a reduction in social cost of 15.5 percent associated with improvements in crashworthiness, which is a measure of the occupant protection of the light passenger vehicle fleet. Since that document was produced, new estimates of crashworthiness have become available, allowing for a more accurate projection. The objective of this paper is to describe a methodology for projecting changes in casualty rates associated with passive safety features and to apply this methodology to produce a new prediction. The shape of the age distribution of the New Zealand light passenger vehicle fleet was projected to 2010. Projected improvements in crashworthiness and associated reductions in social cost were also modeled based on historical trends. These projections of changes in the vehicle fleet age distribution and of improvements in crashworthiness together provided a basis for estimating the future performance of the fleet in terms of secondary safety. A large social cost reduction of about 22 percent for 2010 compared to the year 2000 was predicted due to the expected huge impact of improvements in passive vehicle features on road trauma in New Zealand. Countries experiencing improvements in their vehicle fleets can also expect significant reductions in road injury compared to a less crashworthy passenger fleet. Such road safety gains can be analyzed using some of the methodology described here.
-
Development of a Comprehensive Database System for Safety Analyst
Paz, Alexander; Veeramisti, Naveen; Khanal, Indira; Baker, Justin
2015-01-01
This study addressed barriers associated with the use of Safety Analyst, a state-of-the-art tool that has been developed to assist during the entire Traffic Safety Management process but that is not widely used due to a number of challenges as described in this paper. As part of this study, a comprehensive database system and tools to provide data to multiple traffic safety applications, with a focus on Safety Analyst, were developed. A number of data management tools were developed to extract, collect, transform, integrate, and load the data. The system includes consistency-checking capabilities to ensure the adequate insertion and update of data into the database. This system focused on data from roadways, ramps, intersections, and traffic characteristics for Safety Analyst. To test the proposed system and tools, data from Clark County, which is the largest county in Nevada and includes the cities of Las Vegas, Henderson, Boulder City, and North Las Vegas, was used. The database and Safety Analyst together help identify the sites with the potential for safety improvements. Specifically, this study examined the results from two case studies. The first case study, which identified sites having a potential for safety improvements with respect to fatal and all injury crashes, included all roadway elements and used default and calibrated Safety Performance Functions (SPFs). The second case study identified sites having a potential for safety improvements with respect to fatal and all injury crashes, specifically regarding intersections; it used default and calibrated SPFs as well. Conclusions were developed for the calibration of safety performance functions and the classification of site subtypes. Guidelines were provided about the selection of a particular network screening type or performance measure for network screening. PMID:26167531
-
NASA Technical Reports Server (NTRS)
Xu, Xidong; Ulrey, Mike L.; Brown, John A.; Mast, James; Lapis, Mary B.
2013-01-01
NextGen is a complex socio-technical system and, in many ways, it is expected to be more complex than the current system. It is vital to assess the safety impact of the NextGen elements (technologies, systems, and procedures) in a rigorous and systematic way and to ensure that they do not compromise safety. In this study, the NextGen elements in the form of Operational Improvements (OIs), Enablers, Research Activities, Development Activities, and Policy Issues were identified. The overall hazard situation in NextGen was outlined; a high-level hazard analysis was conducted with respect to multiple elements in a representative NextGen OI known as OI-0349 (Automation Support for Separation Management); and the hazards resulting from the highly dynamic complexity involved in an OI-0349 scenario were illustrated. A selected but representative set of the existing safety methods, tools, processes, and regulations was then reviewed and analyzed regarding whether they are sufficient to assess safety in the elements of that OI and ensure that safety will not be compromised and whether they might incur intolerably high costs.
-
Safe and effective nursing shift handover with NURSEPASS: An interrupted time series.
Smeulers, Marian; Dolman, Christine D; Atema, Danielle; van Dieren, Susan; Maaskant, Jolanda M; Vermeulen, Hester
2016-11-01
Implementation of a locally developed evidence based nursing shift handover blueprint with a bedside-safety-check to determine the effect size on quality of handover. A mixed methods design with: (1) an interrupted time series analysis to determine the effect on handover quality in six domains; (2) descriptive statistics to analyze the intercepted discrepancies by the bedside-safety-check; (3) evaluation sessions to gather experiences with the new handover process. We observed a continued trend of improvement in handover quality and a significant improvement in two domains of handover: organization/efficiency and contents. The bedside-safety-check successfully identified discrepancies on drains, intravenous medications, bandages or general condition and was highly appreciated. Use of the nursing shift handover blueprint showed promising results on effectiveness as well as on feasibility and acceptability. However, to enable long term measurement on effectiveness, evaluation with large scale interrupted times series or statistical process control is needed. Copyright © 2016 Elsevier Inc. All rights reserved.
-
Participatory design of a preliminary safety checklist for general practice
Bowie, Paul; Ferguson, Julie; MacLeod, Marion; Kennedy, Susan; de Wet, Carl; McNab, Duncan; Kelly, Moya; McKay, John; Atkinson, Sarah
2015-01-01
Background The use of checklists to minimise errors is well established in high reliability, safety-critical industries. In health care there is growing interest in checklists to standardise checking processes and ensure task completion, and so provide further systemic defences against error and patient harm. However, in UK general practice there is limited experience of safety checklist use. Aim To identify workplace hazards that impact on safety, health and wellbeing, and performance, and codesign a standardised checklist process. Design and setting Application of mixed methods to identify system hazards in Scottish general practices and develop a safety checklist based on human factors design principles. Method A multiprofessional ‘expert’ group (n = 7) and experienced front-line GPs, nurses, and practice managers (n = 18) identified system hazards and developed and validated a preliminary checklist using a combination of literature review, documentation review, consensus building workshops using a mini-Delphi process, and completion of content validity index exercise. Results A prototype safety checklist was developed and validated consisting of six safety domains (for example, medicines management), 22 sub-categories (for example, emergency drug supplies) and 78 related items (for example, stock balancing, secure drug storage, and cold chain temperature recording). Conclusion Hazards in the general practice work system were prioritised that can potentially impact on the safety, health and wellbeing of patients, GP team members, and practice performance, and a necessary safety checklist prototype was designed. However, checklist efficacy in improving safety processes and outcomes is dependent on user commitment, and support from leaders and promotional champions. Although further usability development and testing is necessary, the concept should be of interest in the UK and internationally. PMID:25918338
-
Collaborating with nurse leaders to develop patient safety practices.
Kanerva, Anne; Kivinen, Tuula; Lammintakanen, Johanna
2017-07-03
Purpose The organisational level and leadership development are crucial elements in advancing patient safety, because patient safety weaknesses are often caused by system failures. However, little is known about how frontline leader and director teams can be supported to develop patient safety practices. The purpose of this study is to describe the patient safety development process carried out by nursing leaders and directors. The research questions were: how the chosen development areas progressed in six months' time and how nursing leaders view the participatory development process. Design/methodology/approach Participatory action research was used to engage frontline nursing leaders and directors into developing patient safety practices. Semi-structured group interviews ( N = 10) were used in data collection at the end of a six-month action cycle, and data were analysed using content analysis. Findings The participatory development process enhanced collaboration and gave leaders insights into patient safety as a part of the hospital system and their role in advancing it. The chosen development areas advanced to different extents, with the greatest improvements in those areas with simple guidelines to follow and in which the leaders were most participative. The features of high-reliability organisation were moderately identified in the nursing leaders' actions and views. For example, acting as a change agent to implement patient safety practices was challenging. Participatory methods can be used to support leaders into advancing patient safety. However, it is important that the participants are familiar with the method, and there are enough facilitators to steer development processes. Originality/value Research brings more knowledge of how leaders can increase their effectiveness in advancing patient safety and promoting high-reliability organisation features in the healthcare organisation.
-
Near-miss incident management in the chemical process industry.
Phimister, James R; Oktem, Ulku; Kleindorfer, Paul R; Kunreuther, Howard
2003-06-01
This article provides a systematic framework for the analysis and improvement of near-miss programs in the chemical process industries. Near-miss programs improve corporate environmental, health, and safety (EHS) performance through the identification and management of near misses. Based on more than 100 interviews at 20 chemical and pharmaceutical facilities, a seven-stage framework has been developed and is presented herein. The framework enables sites to analyze their own near-miss programs, identify weak management links, and implement systemwide improvements.
-
Manothum, Aniruth; Rukijkanpanich, Jittra; Thawesaengskulthai, Damrong; Thampitakkul, Boonwa; Chaikittiporn, Chalermchai; Arphorn, Sara
2009-01-01
The purpose of this study was to evaluate the implementation of an Occupational Health and Safety Management Model for informal sector workers in Thailand. The studied model was characterized by participatory approaches to preliminary assessment, observation of informal business practices, group discussion and participation, and the use of environmental measurements and samples. This model consisted of four processes: capacity building, risk analysis, problem solving, and monitoring and control. The participants consisted of four local labor groups from different regions, including wood carving, hand-weaving, artificial flower making, and batik processing workers. The results demonstrated that, as a result of applying the model, the working conditions of the informal sector workers had improved to meet necessary standards. This model encouraged the use of local networks, which led to cooperation within the groups to create appropriate technologies to solve their problems. The authors suggest that this model could effectively be applied elsewhere to improve informal sector working conditions on a broader scale.
-
Bin, Wong Saw; Richardson, Stanley; Yeow, Paul H P
2010-01-01
The study aimed to conduct an ergonomic intervention on a conventional line (CL) in a semiconductor factory in Malaysia, an industrially developing country (IDC), to improve workers' occupational health and safety (OHS). Low-cost and simple (LCS) ergonomics methods were used (suitable for IDCs), e.g., subjective assessment, direct observation, use of archival data and assessment of noise. It was found that workers were facing noise irritation, neck and back pains and headache in the various processes in the CL. LCS ergonomic interventions to rectify the problems included installing noise insulating covers, providing earplugs, installing elevated platforms, slanting visual display terminals and installing extra exhaust fans. The interventions cost less than 3 000 USD but they significantly improved workers' OHS, which directly correlated with an improvement in working conditions and job satisfaction. The findings are useful in solving OHS problems in electronics industries in IDCs as they share similar manufacturing processes, problems and limitations.
-
Bepko, Robert J; Moore, John R; Coleman, John R
2009-01-01
This article reports an intervention to improve the quality and safety of hospital patient care by introducing the use of pharmacy robotics into the medication distribution process. Medication safety is vitally important. The integration of pharmacy robotics with computerized practitioner order entry and bedside medication bar coding produces a significant reduction in medication errors. The creation of a safe medication-from initial ordering to bedside administration-provides enormous benefits to patients, to health care providers, and to the organization as well.
-
Multi-Robot Systems in Military Domains (Les Systemes Multi-Robots Dans les Domaines Militaires)
2008-12-01
to allow him to react quickly to improve his personal safety , it is mandatory to shorten the current very long delay needed for the human operator to...Hard RT tasks 2 OS / API Process monitoring 3 H / API Flexible communication medium 4 H / API Networking capabilities 5 H / API Safety 6 API...also be considered between high level services and legacy systems. 4) This is the one of the basic requirement for CoRoDe. 5) Safety : CRC, Timeouts
-
Development of a Medication Safety and Quality Survey for Small Rural Hospitals.
Winterstein, Almut G; Johns, Thomas E; Campbell, Kyle N; Libby, Joel; Pannell, Bob
2017-12-01
We summarize the development and initial implementation of a survey tool to assess medication safety in small rural hospitals. As part of an ongoing rural hospital medication safety improvement program, we developed a survey tool in all 13 critical access hospitals (CAHs) in Florida. The survey was compiled from existing medication safety assessments and standards, clinical practice guidelines, and published literature. Survey items were selected based on considerations regarding practicality and relevance to the CAH setting.The final survey instrument included 134 items representing 17 medication safety domains. Overall hospital scores ranged from 41% to 95%, with a median of 59%. Most hospitals showed large variation in scores across domains, with 5 hospitals having at least 1 domain with scores less than 10%. Highest scores across all facilities were seen for safety procedures concerning high-alert or look-alike medications and the assembly of emergency carts. The lowest median scores included availability and consistent use of standardized order sets and the effective implementation of medication safety committees. Most hospitals used the survey results to identify and prioritize quality improvement activities. The survey can be used to conduct a short medication safety assessment specific to a limited number of areas and services in CAHs. It showed good ability to discriminate medication safety levels across participating sites and highlighted opportunities for improvement. It may need modification if case mix or services differ in other states or if the status quo of medication safety in CAHs or related standards advance. The described process of survey development might be helpful to support such modifications.
-
Alolah, Turki; Stewart, Rodney A; Panuwatwanich, Kriengsak; Mohamed, Sherif
2014-07-01
In the public schools of many developing countries, numerous accidents and incidents occur because of poor safety regulations and management systems. To improve the educational environment in Saudi Arabia, the Ministry of Education seeks novel approaches to measure school safety performance in order to decrease incidents and accidents. The main objective of this research was to develop a systematic approach for measuring Saudi school safety performance using the balanced scorecard framework philosophy. The evolved third generation balanced scorecard framework is considered to be a suitable and robust framework that captures the system-wide leading and lagging indicators of business performance. The balanced scorecard architecture is ideal for adaptation to complex areas such as safety management where a holistic system evaluation is more effective than traditional compartmentalised approaches. In developing the safety performance balanced scorecard for Saudi schools, the conceptual framework was first developed and peer-reviewed by eighteen Saudi education experts. Next, 200 participants, including teachers, school executives, and Ministry of Education officers, were recruited to rate both the importance and the performance of 79 measurement items used in the framework. Exploratory factor analysis, followed by the confirmatory partial least squares method, was then conducted in order to operationalise the safety performance balanced scorecard, which encapsulates the following five salient perspectives: safety management and leadership; safety learning and training; safety policy, procedures and processes; workforce safety culture; and safety performance. Partial least squares based structural equation modelling was then conducted to reveal five significant relationships between perspectives, namely, safety management and leadership had a significant effect on safety learning and training and safety policy, procedures and processes, both safety learning and training and safety policy, procedures and processes had significant effects on workforce safety culture, and workforce safety culture had a significant effect on safety performance. Copyright © 2014 Elsevier Ltd. All rights reserved.
-
ATV Engineering Support Team Safety Console Preparation for the Johannes Kepler Mission
NASA Astrophysics Data System (ADS)
Chase, R.; Oliefka, L.
2010-09-01
This paper describes the improvements to be implemented in the Safety console position of the Engineering Support Team(EST) at the Automated Transfer Vehicle(ATV) Control Centre(ATV-CC) for the upcoming ATV Johannes Kepler mission. The ATV missions to the International Space Station are monitored and controlled from the ATV-CC in Toulouse, France. The commanding of ATV is performed by the Vehicle Engineering Team(VET) in the main control room under authority of the Flight Director. The EST performs a monitoring function in a room beside the main control room. One of the EST positions is the Safety console, which is staffed by safety engineers from ESA and the industrial prime contractor, Astrium. The function of the Safety console is to check whether the hazard controls are available throughout the mission as required by the Hazard Reports approved by the ISS Safety Review Panel. Safety console preparation activities were limited prior to the first ATV mission due to schedule constraints, and the safety engineers involved have been working to improve the readiness for ATV 2. The following steps have been taken or are in process, and will be described in this paper: • review of the implementation of Operations Control Agreement Documents(OCADs) that record the way operational hazard controls are performed to meet the needs of the Hazard Reports(typically in Flight Rules and Crew Procedures), • crosscheck of operational control needs and implementations with respect to ATV's first flight observations and post flight evaluations, with a view to identifying additional, obsolete or revised operational hazard controls, • participation in the Flight Rule review and update process carried out between missions, • participation in the assessment of anomalies observed during the first ATV mission, to ensure that any impacts are addressed in the ATV 2 safety documentation, • preparation of a Safety console handbook to provide lists of important safety aspects to be monitored at various stages of the mission, including links to relevant Hazard Reports, Flight Rules, and supporting documentation, • participation to training courses conducted in the frame of the ATV Training Academy(ATAC), and provision of courses related to safety for the other members of the VET and EST, • participation to simulations conducted at ATV-CC, including off-nominal cases. The result of these activities will be an improved level of readiness for the ATV 2 mission.
-
Hsu, Ya-Chi; Jerng, Jih-Shuin; Chang, Ching-Wen; Chen, Li-Chin; Hsieh, Ming-Yuan; Huang, Szu-Fen; Liu, Yueh-Ping; Hung, Kuan-Yu
2014-08-11
The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.
-
2014-01-01
Background The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. Methods We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. Results During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Conclusion Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation. PMID:25115403
-
Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio
2012-01-01
Objective Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and setting Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcome To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. Results In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. Conclusions FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children. PMID:23253870
-
Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio
2012-01-01
Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.
-
Implementation of a "No Fly" safety culture in a multicenter radiation medicine department.
Potters, Louis; Kapur, Ajay
2012-01-01
The safe delivery of radiation therapy requires multiple disciplines and interactions to perform flawlessly for each patient. Because treatment is individualized and every aspect of the patient's care is unique, it is difficult to regiment a delivery process that works flawlessly. The purpose of this study is to describe one safety-directed component of our quality program called the "No Fly Policy" (NFP). Our quality assurance program for radiation therapy reviewed the entire process of care prior, during, and after a patient's treatment course. Each component of care was broken down and rebuilt within a matrix of multidisciplinary safety quality checklists (QCL). The QCL process map was subsequently streamlined with revised task due dates and stopping rules. The NFP was introduced to place a holding pattern on treatment initiation pending reconciliation of associated stopping events. The NFP was introduced in a pilot phase using a Six-Sigma process improvement approach. Quantitative analysis on the performance of the new QCLs was performed using crystal reports in the Oncology Information Systems. Root cause analysis was conducted. Notable improvements in QCL performance were observed. The variances among staff in completing tasks reduced by a factor of at least 3, suggesting better process control. Steady improvements over time indicated an increasingly compliant and controlled adoption of the new safety-oriented process map. Stopping events led to rescheduling treatments with average and maximum delays of 2 and 4 days, respectively, with no reported adverse effects. The majority of stopping events were due to incomplete plan approvals stemming from treatment planning delays. Whereas these may have previously solicited last-minute interventions, including intensity modulated radiation therapy quality assurance, the NFP enabled nonpunitive, reasonable schedule adjustments to mitigate compromises in safe delivery. Implementation of the NFP has helped to mitigate risk from expedited care, convert reactive to proactive delays, and created a checklist, process driven, and variance-reducing culture in a large, multicenter department. Copyright © 2012 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
-
Biotechnology in Food Production and Processing
NASA Astrophysics Data System (ADS)
Knorr, Dietrich; Sinskey, Anthony J.
1985-09-01
The food processing industry is the oldest and largest industry using biotechnological processes. Further development of food products and processes based on biotechnology depends upon the improvement of existing processes, such as fermentation, immobilized biocatalyst technology, and production of additives and processing aids, as well as the development of new opportunities for food biotechnology. Improvements are needed in the characterization, safety, and quality control of food materials, in processing methods, in waste conversion and utilization processes, and in currently used food microorganism and tissue culture systems. Also needed are fundamental studies of the structure-function relationship of food materials and of the cell physiology and biochemistry of raw materials.
-
Safety in surgery: is selection the missing link?
Paice, Alistair G; Aggarwal, Rajesh; Darzi, Ara
2010-09-01
Health care providers comprise an example of a "high risk organization." Safety failings within these organizations have the potential to cause significant public harm. Significant safety improvements in other high risk organizations such as the aviation industry have led to the concept of a high reliability organization (HRO)--a high risk organization that has enjoyed a prolonged safety record. A strong organizational culture is common to all successful HROs, encompassing powerful systems of selection and training. Aircrew selection processes provide a good example of this and are examined in detail in this article using the Royal Air Force process as an example. If the lessons of successful HROs are to be applied to health care organizations, candidate selection to specialties such as surgery must become more objective and robust. Other HROs can provide valuable lessons in how this may be approached.
-
Probabilistic Risk Assessment Procedures Guide for NASA Managers and Practitioners (Second Edition)
NASA Technical Reports Server (NTRS)
Stamatelatos,Michael; Dezfuli, Homayoon; Apostolakis, George; Everline, Chester; Guarro, Sergio; Mathias, Donovan; Mosleh, Ali; Paulos, Todd; Riha, David; Smith, Curtis;
2011-01-01
Probabilistic Risk Assessment (PRA) is a comprehensive, structured, and logical analysis method aimed at identifying and assessing risks in complex technological systems for the purpose of cost-effectively improving their safety and performance. NASA's objective is to better understand and effectively manage risk, and thus more effectively ensure mission and programmatic success, and to achieve and maintain high safety standards at NASA. NASA intends to use risk assessment in its programs and projects to support optimal management decision making for the improvement of safety and program performance. In addition to using quantitative/probabilistic risk assessment to improve safety and enhance the safety decision process, NASA has incorporated quantitative risk assessment into its system safety assessment process, which until now has relied primarily on a qualitative representation of risk. Also, NASA has recently adopted the Risk-Informed Decision Making (RIDM) process [1-1] as a valuable addition to supplement existing deterministic and experience-based engineering methods and tools. Over the years, NASA has been a leader in most of the technologies it has employed in its programs. One would think that PRA should be no exception. In fact, it would be natural for NASA to be a leader in PRA because, as a technology pioneer, NASA uses risk assessment and management implicitly or explicitly on a daily basis. NASA has probabilistic safety requirements (thresholds and goals) for crew transportation system missions to the International Space Station (ISS) [1-2]. NASA intends to have probabilistic requirements for any new human spaceflight transportation system acquisition. Methods to perform risk and reliability assessment in the early 1960s originated in U.S. aerospace and missile programs. Fault tree analysis (FTA) is an example. It would have been a reasonable extrapolation to expect that NASA would also become the world leader in the application of PRA. That was, however, not to happen. Early in the Apollo program, estimates of the probability for a successful roundtrip human mission to the moon yielded disappointingly low (and suspect) values and NASA became discouraged from further performing quantitative risk analyses until some two decades later when the methods were more refined, rigorous, and repeatable. Instead, NASA decided to rely primarily on the Hazard Analysis (HA) and Failure Modes and Effects Analysis (FMEA) methods for system safety assessment.
-
USDA-ARS?s Scientific Manuscript database
Infrared (IR) radiation heating has been considered as an alternative to current food and agricultural processing methods for improving product quality and safety, increasing energy and processing efficiency, and reducing water and chemical usage. As part of the electromagnetic spectrum, IR has the ...
-
USDA-ARS?s Scientific Manuscript database
Newly emerging nonthermal and advanced thermal processing technologies are now being adopted by the food processing industry for the purpose of providing safe and high quality food products to consumers. Scientists and engineers at USDA’s Eastern Regional Research Center in Wyndmoor, PA are activel...
-
USDA-ARS?s Scientific Manuscript database
In the past two decades, worldwide demands for meat and seafood products have increased dramatically due to the improved economical condition in many countries. To meet the demand, the producers have increased the production of meat and seafood products as well as applied new processing techniques t...
-
Behavior-based safety on construction sites: a case study.
Choudhry, Rafiq M
2014-09-01
This work presents the results of a case study and describes an important area within the field of construction safety management, namely behavior-based safety (BBS). This paper adopts and develops a management approach for safety improvements in construction site environments. A rigorous behavioral safety system and its intervention program was implemented and deployed on target construction sites. After taking a few weeks of safety behavior measurements, the project management team implemented the designed intervention and measurements were taken. Goal-setting sessions were arranged on-site with workers' participation to set realistic and attainable targets of performance. Safety performance measurements continued and the levels of performance and the targets were presented on feedback charts. Supervisors were asked to give workers recognition and praise when they acted safely or improved critical behaviors. Observers were requested to have discussions with workers, visit the site, distribute training materials to workers, and provide feedback to crews and display charts. They were required to talk to operatives in the presence of line managers. It was necessary to develop awareness and understanding of what was being measured. In the process, operatives learned how to act safely when conducting site tasks using the designed checklists. Current weekly scores were discussed in the weekly safety meetings and other operational site meetings with emphasis on how to achieve set targets. The reliability of the safety performance measures taken by the company's observers was monitored. A clear increase in safety performance level was achieved across all categories: personal protective equipment; housekeeping; access to heights; plant and equipment, and scaffolding. The research reveals that scores of safety performance at one project improved from 86% (at the end of 3rd week) to 92.9% during the 9th week. The results of intervention demonstrated large decreases in unsafe behaviors and significant increases in safe behaviors. The results of this case study showed that an approach based on goal setting, feedback, and an effective measure of safety behavior if properly applied by committed management, can improve safety performance significantly in construction site environments. The results proved that the BBS management technique can be applied to any country's culture, showing that it would be a good approach for improving the safety of front-line workers and that it has industry wide application for ongoing construction projects. Copyright © 2014 Elsevier Ltd. All rights reserved.
-
Wasserman, Melanie; Renfrew, Megan R; Green, Alexander R; Lopez, Lenny; Tan-McGrory, Aswita; Brach, Cindy; Betancourt, Joseph R
2014-01-01
Since the 1999 Institute of Medicine (IOM) report To Err is Human, progress has been made in patient safety, but few efforts have focused on safety in patients with limited English proficiency (LEP). This article describes the development, content, and testing of two new evidence-based Agency for Healthcare Research and Quality (AHRQ) tools for LEP patient safety. In the content development phase, a comprehensive mixed-methods approach was used to identify common causes of errors for LEP patients, high-risk scenarios, and evidence-based strategies to address them. Based on our findings, Improving Patient Safety Systems for Limited English Proficient Patients: A Guide for Hospitals contains recommendations to improve detection and prevention of medical errors across diverse populations, and TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency Module trains staff to improve safety through team communication and incorporating interpreters in the care process. The Hospital Guide was validated with leaders in quality and safety at diverse hospitals, and the TeamSTEPPS LEP module was field-tested in varied settings within three hospitals. Both tools were found to be implementable, acceptable to their audiences, and conducive to learning. Further research on the impact of the combined use of the guide and module would shed light on their value as a multifaceted intervention. © 2014 National Association for Healthcare Quality.
-
The effect of drought and heat stress on reproductive processes in cereals.
Barnabás, Beáta; Jäger, Katalin; Fehér, Attila
2008-01-01
As the result of intensive research and breeding efforts over the last 20 years, the yield potential and yield quality of cereals have been greatly improved. Nowadays, yield safety has gained more importance because of the forecasted climatic changes. Drought and high temperature are especially considered as key stress factors with high potential impact on crop yield. Yield safety can only be improved if future breeding attempts will be based on the valuable new knowledge acquired on the processes determining plant development and its responses to stress. Plant stress responses are very complex. Interactions between plant structure, function and the environment need to be investigated at various phases of plant development at the organismal, cellular as well as molecular levels in order to obtain a full picture. The results achieved so far in this field indicate that various plant organs, in a definite hierarchy and in interaction with each other, are involved in determining crop yield under stress. Here we attempt to summarize the currently available information on cereal reproduction under drought and heat stress and to give an outlook towards potential strategies to improve yield safety in cereals.
-
Harolds, Jay A
2016-09-01
The work system in which diagnosis takes place is affected by the external environment, which includes requirements such as certification, accreditation, and regulations. How errors are reported, malpractice, and the system for payment are some other aspects of the external environment. Improving the external environment is expected to decrease errors in diagnosis. More research on improving the diagnostic process is needed.
-
Laser Peening Effects on Friction Stir Welding
NASA Technical Reports Server (NTRS)
Hatameleh, Omar
2009-01-01
The laser peening process can result in considerable improvement to crack initiation, propagation, and mechanical properties in FSW which equates to longer hardware service life Processed hardware safety is improved by producing higher failure tolerant hardware, and reducing risk. Lowering hardware maintenance cost produces longer hardware service life, and lower hardware down time. Application of this proposed technology will result in substantial benefits and savings throughout the life of the treated components
-
Identifying risk event in Indonesian fresh meat supply chain
NASA Astrophysics Data System (ADS)
Wahyuni, H. C.; Vanany, I.; Ciptomulyono, U.
2018-04-01
The aim of this paper is to identify risk issues in Indonesian fresh meat supply chain from the farm until to the “plate”. The critical points for food safety in physical fresh meat product flow are also identified. The paper employed one case study in the Indonesian fresh meat company by conducting observations and in-depth three stages of interviews. At the first interview, the players, process, and activities in the fresh meat industry were identified. In the second interview, critical points for food safety were recognized. The risk events in each player and process were identified in the last interview. The research will be conducted in three stages, but this article focuses on risk identification process (first stage) only. The second stage is measuring risk and the third stage focuses on determining the value of risk priority. The results showed that there were four players in the fresh meat supply chain: livestock (source), slaughter (make), distributor and retail (deliver). Each player has different activities and identified 16 risk events in the fresh meat supply chain. Some of the strategies that can be used to reduce the occurrence of such risks include improving the ability of laborers on food safety systems, improving cutting equipment and distribution processes
-
Is your electric process heater safe?
DOE Office of Scientific and Technical Information (OSTI.GOV)
Tiras, C.S.
2000-04-01
Over the past 35 years, electric process heaters (EPHs) have been used to heat flowing fluids in different sectors of the energy industry: oil and gas exploration and production, refineries, petrochemical plants, pipeline compression facilities and power-generation plants. EPHs offer several advantages over fired heaters and shell-and-tube exchangers, which have been around for many years, including: smaller size, lighter weight, cleaner operation, lower capital costs, lower maintenance costs, no emissions or leakage, better control and improved safety. However, while many industrial standards have addressed safety concerns of fired heaters and shell-and-tube exchangers (API, TEMA, NFPA, OSHA and NEC), no standardsmore » address EPHs. The paper presents a list of questions that plant operators need to ask about the safety of their electric process heaters. The answers are also given.« less
-
75 FR 69165 - Conductor Certification
Federal Register 2010, 2011, 2012, 2013, 2014
2010-11-10
...FRA proposes to prescribe regulations for certification of conductors, as required by the Rail Safety Improvement Act of 2008. The proposed rule would require railroads to have a formal program for certifying conductors. As part of that program, railroads would be required to have a formal process for training prospective conductors and determining that all persons are competent before permitting them to serve as a conductor. FRA is proposing this regulation to ensure that only those persons who meet minimum Federal safety standards serve as conductors, to reduce the rate and number of accidents and incidents, and to improve railroad safety. Although this NPRM does not propose any specific amendments to the regulation governing locomotive engineer certification, it does highlight areas in that regulation that may require conforming changes.
-
Hughes, K Michael; Benenson, Ronald S; Krichten, Amy E; Clancy, Keith D; Ryan, James Patrick; Hammond, Christopher
2014-09-01
Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program. The initial trauma communication survey was completed by 160 team members (49% response). Twenty-five trauma resuscitations were observed and scored using Communication and Teamwork Skills. Areas of concern were identified and 324 staff completed our 3-hour CRM course during a 3-month period. After CRM training, 132 communication surveys and 38 Communication and Teamwork Skills observations were completed. In the post-CRM survey, respondents indicated improvement in accuracy of field to medical command information (p = 0.029); accuracy of emergency department medical command information to the resuscitation area (p = 0.002); and team leader identity, communication of plan, and role assignment (p = 0.001). After CRM training, staff were more likely to speak up when patient safety was a concern (p = 0.002). Crew Resource Management in the trauma resuscitation area enhances team dynamics, communication, and, ostensibly, patient safety. Philosophy and culture of CRM should be compulsory components of trauma programs and in resuscitation of injured patients. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
-
Evaluation of low-dose irradiation on microbiological quality of white carrots and string beans
NASA Astrophysics Data System (ADS)
Koike, Amanda C. R.; Santillo, Amanda G.; Rodrigues, Flávio T.; Duarte, Renato C.; Villavicencio, Anna Lucia C. H.
2012-08-01
The minimally processed food provided the consumer with a product quality, safety and practicality. However, minimal processing of food does not reduce pathogenic population of microorganisms to safe levels. Ionizing radiation used in low doses is effective to maintain the quality of food, reducing the microbiological load but rather compromising the nutritional values and sensory property. The association of minimal processing with irradiation could improve the quality and safety of product. The purpose of this study was to evaluate the effectiveness of low-doses of ionizing radiation on the reduction of microorganisms in minimally processed foods. The results show that the ionizing radiation of minimally processed vegetables could decontaminate them without several changes in its properties.
-
Exploring the role of emotional intelligence in behavior-based safety coaching.
Wiegand, Douglas M
2007-01-01
Safety coaching is an applied behavior analysis technique that involves interpersonal interaction to understand and manipulate environmental conditions that are directing (i.e., antecedent to) and motivating (i.e., consequences of) safety-related behavior. A safety coach must be skilled in interacting with others so as to understand their perspectives, communicate a point clearly, and be persuasive with behavior-based feedback. This article discusses the evidence-based "ability model" of emotional intelligence and its relevance to the interpersonal aspect of the safety coaching process. Emotional intelligence has potential for improving safety-related efforts and other aspects of individuals' work and personal lives. Safety researchers and practitioners are therefore encouraged to gain an understanding of emotional intelligence and conduct and support research applying this construct toward injury prevention.
-
Advanced Oxidation Process sanitation of hatching eggs reduces Salmonella in broiler chicks
USDA-ARS?s Scientific Manuscript database
Reduction of Salmonella contamination of eggs is important in improving the microbial food safety of poultry and poultry products. Developing interventions to reduce Salmonella contamination of eggs is important to improving the microbial quality of eggs entering the hatchery. Previously, the hydr...
-
DOT National Transportation Integrated Search
1998-01-01
The National Research Council (NRC) was asked to conduct an independent assessment of the safety management process used by the Aircraft Certification Service of the Federal Aviation Administration (FAA) to define how the current process might be imp...
-
Bekker, Sheree; Paliadelis, Penny; Finch, Caroline F
2017-03-28
A recognised research-to-practice gap exists in the health research field of sports injury prevention and safety promotion. There is a need for improved insight into increasing the relevancy, accessibility and legitimacy of injury prevention and safety promotion research knowledge for sport settings. The role of key organisations as intermediaries in the process of health knowledge translation for sports settings remains under-explored, and this paper aims to determine, and describe, the processes of knowledge translation undertaken by a set of key organisations in developing and distributing injury prevention and safety promotion resources. The National Guidance for Australian Football Partnerships and Safety (NoGAPS) project provided the context for this study. Representatives from five key NoGAPS organisations participated in individual face-to-face interviews about organisational processes of knowledge translation. A qualitative descriptive methodology was used to analyse participants' descriptions of knowledge translation activities undertaken at their respective organisations. Several themes emerged around health knowledge translation processes and considerations, including (1) identifying a need for knowledge translation, (2) developing and disseminating resources, and (3) barriers and enablers to knowledge translation. This study provides insight into the processes that key organisations employ when developing and disseminating injury prevention and safety promotion resources within sport settings. The relevancy, accessibility and legitimacy of health research knowledge is foregrounded, with a view to increasing the influence of research on the development of health-related resources suitable for community sport settings.
-
National blueprint for runway safety
DOT National Transportation Integrated Search
2000-10-01
The Blueprint describes the processes : employed to measurably reduce the risks : associated with runway incursions and surface : incidents. It sets expectations, establishes : accountability, communicates information, : and defines new and improved ...
-
Enhancing surgical safety using digital multimedia technology.
Dixon, Jennifer L; Mukhopadhyay, Dhriti; Hunt, Justin; Jupiter, Daniel; Smythe, William R; Papaconstantinou, Harry T
2016-06-01
The purpose of this study was to examine whether incorporating digital and video multimedia components improved surgical time-out performance of a surgical safety checklist. A prospective pilot study was designed for implementation of a multimedia time-out, including a patient video. Perceptions of the staff participants were surveyed before and after intervention (Likert scale: 1, strongly disagree to 5, strongly agree). Employee satisfaction was high for both time-out procedures. However, employees appreciated improved clarity of patient identification (P < .05) and operative laterality (P < .05) with the digital method. About 87% of the respondents preferred the digital version to the standard time-out (75% anesthesia, 89% surgeons, 93% nursing). Although the duration of time-outs increased (49 and 79 seconds for standard and digital time-outs, respectively, P > .001), there was significant improvement in performance of key safety elements. The multimedia time-out allows improved participation by the surgical team and is preferred to a standard time-out process. Copyright © 2015 Elsevier Inc. All rights reserved.
-
Sun, Xinlu; Chong, Heap-Yih; Liao, Pin-Chao
2018-06-25
Navigated inspection seeks to improve hazard identification (HI) accuracy. With tight inspection schedule, HI also requires efficiency. However, lacking quantification of HI efficiency, navigated inspection strategies cannot be comprehensively assessed. This work aims to determine inspection efficiency in navigated safety inspection, controlling for the HI accuracy. Based on a cognitive method of the random search model (RSM), an experiment was conducted to observe the HI efficiency in navigation, for a variety of visual clutter (VC) scenarios, while using eye-tracking devices to record the search process and analyze the search performance. The results show that the RSM is an appropriate instrument, and VC serves as a hazard classifier for navigation inspection in improving inspection efficiency. This suggests a new and effective solution for addressing the low accuracy and efficiency of manual inspection through navigated inspection involving VC and the RSM. It also provides insights into the inspectors' safety inspection ability.
-
Patient safety competencies in undergraduate nursing students: a rapid evidence assessment.
Bianchi, Monica; Bressan, Valentina; Cadorin, Lucia; Pagnucci, Nicola; Tolotti, Angela; Valcarenghi, Dario; Watson, Roger; Bagnasco, Annamaria; Sasso, Loredana
2016-12-01
To identify patient safety competencies, and determine the clinical learning environments that facilitate the development of patient safety competencies in nursing students. Patient safety in nursing education is of key importance for health professional environments, settings and care systems. To be effective, safe nursing practice requires a good integration between increasing knowledge and the different clinical practice settings. Nurse educators have the responsibility to develop effective learning processes and ensure patient safety. Rapid Evidence Assessment. MEDLINE, CINAHL, SCOPUS and ERIC were searched, yielding 500 citations published between 1 January 2004-30 September 2014. Following the Rapid Evidence Assessment process, 17 studies were included in this review. Hawker's (2002) quality assessment tool was used to assess the quality of the selected studies. Undergraduate nursing students need to develop competencies to ensure patient safety. The quality of the pedagogical atmosphere in the clinical setting has an important impact on the students' overall level of competence. Active student engagement in clinical processes stimulates their critical reasoning, improves interpersonal communication and facilitates adequate supervision and feedback. Few studies describe the nursing students' patient safety competencies and exactly what they need to learn. In addition, studies describe only briefly which clinical learning environments facilitate the development of patient safety competencies in nursing students. Further research is needed to identify additional pedagogical strategies and the specific characteristics of the clinical learning environments that encourage the development of nursing students' patient safety competencies. © 2016 John Wiley & Sons Ltd.
-
Design and analysis of automobile components using industrial procedures
NASA Astrophysics Data System (ADS)
Kedar, B.; Ashok, B.; Rastogi, Nisha; Shetty, Siddhanth
2017-11-01
Today’s automobiles depend upon mechanical systems that are crucial for aiding in the movement and safety features of the vehicle. Various safety systems such as Antilock Braking System (ABS) and passenger restraint systems have been developed to ensure that in the event of a collision be it head on or any other type, the safety of the passenger is ensured. On the other side, manufacturers also want their customers to have a good experience while driving and thus aim to improve the handling and the drivability of the vehicle. Electronics systems such as Cruise Control and active suspension systems are designed to ensure passenger comfort. Finally, to ensure optimum and safe driving the various components of a vehicle must be manufactured using the latest state of the art processes and must be tested and inspected with utmost care so that any defective component can be prevented from being sent out right at the beginning of the supply chain. Therefore, processes which can improve the lifetime of their respective components are in high demand and much research and development is done on these processes. With a solid base research conducted, these processes can be used in a much more versatile manner for different components, made up of different materials and under different input conditions. This will help increase the profitability of the process and also upgrade its value to the industry.
-
NASA Astrophysics Data System (ADS)
Goularte, L.; Martins, C. G.; Morales-Aizpurúa, I. C.; Destro, M. T.; Franco, B. D. G. M.; Vizeu, D. M.; Hutzler, B. W.; Landgraf, M.
2004-09-01
The feasibility of gamma radiation in combination with minimal processing (MP) to reduce the number of Salmonella spp. and Escherichia coli O157:H7 in iceberg lettuce ( Lactuca sativa, L.) (shredded) was studied in order to increase the safety of the product. The reduction of the microbial population during the processing, the D10-values for Salmonella spp. and E. coli O157:H7 inoculated on shredded iceberg lettuce as well as the sensory evaluation of the irradiated product were evaluated. The immersion in chlorine (200 ppm) reduced coliform and aerobic mesophilic microorganisms by 0.9 and 2.7 log, respectively. D-values varied from 0.16 to 0.23 kGy for Salmonella spp. and from 0.11 to 0.12 kGy for E. coli O157:H7. Minimally processed iceberg lettuce exposed to 0.9 kGy does not show any change in sensory attributes. However, the texture of the vegetable was affected during the exposition to 1.1 kGy. The exposition of MP iceberg lettuce to 0.7 kGy reduced the population of Salmonella spp. by 4.0 log and E. coli by 6.8 log without impairing the sensory attributes. The combination of minimal process and gamma radiation to improve the safety of iceberg lettuce is feasible if good hygiene practices begins at farm stage.
-
Learning and feedback from the Danish patient safety incident reporting system can be improved.
Moeller, Anders Damgaard; Rasmussen, Kurt; Nielsen, Kent Jacob
2016-06-01
The perceived usefulness of incident reporting systems is an important motivational factor for reporting. The usefulness may be facilitated by well-established feedback mechanisms and by learning processes. The aim of this study was to investigate how feedback mechanisms and learning processes were implemented at four Danish hospital units all located in one of the five Danish regions. Based on the concepts of feedback and learning from incident processes, a questionnaire was developed and distributed to 335 patient safety representatives from 200 departments at four Danish hospital units in one of the five Danish regions. The study showed that external reporters were rarely contacted for dialogue, grouped front-line staff were sparsely involved in the learning process, few evaluated the effectiveness of implemented interventions and personal factors were frequently perceived as a primary contributory factor to these incidents. In contrast, the patient safety representatives perceived their competencies as sufficient for the job, internal reporters were often contacted for dialogue, evaluation was widely used and management supported the work with incident reports. The results of the study identified several shortcomings in the implementation of learning processes and feedback mechanisms. The apparent existence of a person-focused approach stands out as an element of notice. The insufficient implementation we observed indicates that there is room for improvement in the efforts made to maximise learning from incidents in the investigated population. not relevant. not relevant.
-
Effects of using the developing nurses' thinking model on nursing students' diagnostic accuracy.
Tesoro, Mary Gay
2012-08-01
This quasi-experimental study tested the effectiveness of an educational model, Developing Nurses' Thinking (DNT), on nursing students' clinical reasoning to achieve patient safety. Teaching nursing students to develop effective thinking habits that promote positive patient outcomes and patient safety is a challenging endeavor. Positive patient outcomes and safety are achieved when nurses accurately interpret data and subsequently implement appropriate plans of care. This study's pretest-posttest design determined whether use of the DNT model during 2 weeks of clinical postconferences improved nursing students' (N = 83) diagnostic accuracy. The DNT model helps students to integrate four constructs-patient safety, domain knowledge, critical thinking processes, and repeated practice-to guide their thinking when interpreting patient data and developing effective plans of care. The posttest scores of students from the intervention group showed statistically significant improvement in accuracy. Copyright 2012, SLACK Incorporated.
-
Improving patient safety by instructional systems design
Battles, J B
2006-01-01
Education and training are important elements in patient safety, both as a potential contributing factor to risks and hazards of healthcare associated injury or harm and as an intervention to be used in eliminating or preventing such harm. All too often we have relied on training as the only interventions for patient safety without examining other alternatives or realizing that, in some cases, the training systems themselves are part of the problem. One way to ensure safety by design is to apply established design principles to education and training. Instructional systems design (ISD) is a systematic method of development of education and training programs for improved learner performance. The ISD process involves five integrated steps: analysis, development, design, implementation, and evaluation (ADDIE). The application of ISD using the ADDIE approach can eliminate or prevent education and training from being a contributing factor of health associated injury or harm, and can also be effective in preventing injury or harm. PMID:17142604
-
The current status of biomarkers for predicting toxicity
Campion, Sarah; Aubrecht, Jiri; Boekelheide, Kim; Brewster, David W; Vaidya, Vishal S; Anderson, Linnea; Burt, Deborah; Dere, Edward; Hwang, Kathleen; Pacheco, Sara; Saikumar, Janani; Schomaker, Shelli; Sigman, Mark; Goodsaid, Federico
2013-01-01
Introduction There are significant rates of attrition in drug development. A number of compounds fail to progress past preclinical development due to limited tools that accurately monitor toxicity in preclinical studies and in the clinic. Research has focused on improving tools for the detection of organ-specific toxicity through the identification and characterization of biomarkers of toxicity. Areas covered This article reviews what we know about emerging biomarkers in toxicology, with a focus on the 2012 Northeast Society of Toxicology meeting titled ‘Translational Biomarkers in Toxicology.’ The areas covered in this meeting are summarized and include biomarkers of testicular injury and dysfunction, emerging biomarkers of kidney injury and translation of emerging biomarkers from preclinical species to human populations. The authors also provide a discussion about the biomarker qualification process and possible improvements to this process. Expert opinion There is currently a gap between the scientific work in the development and qualification of novel biomarkers for nonclinical drug safety assessment and how these biomarkers are actually used in drug safety assessment. A clear and efficient path to regulatory acceptance is needed so that breakthroughs in the biomarker toolkit for nonclinical drug safety assessment can be utilized to aid in the drug development process. PMID:23961847
-
Patel, Ekta; Muthusamy, Veena; Young, John Q
2018-06-01
Residency programs must provide training in patient safety. Yet, significant gaps exist among published patient safety curricula. The authors developed a rotation designed to be scalable to an entire residency, built on sound pedagogy, aligned with hospital safety processes, and effective in improving educational outcomes. From July 2015 to May 2017, each second-year resident completed the two-week rotation. Residents engaged the foundational science asynchronously via multiple modalities and then practiced applying key concepts during a mock root cause analysis. Next, each resident performed a special review of an actual adverse patient event and presented findings to the hospital's Special Review Committee (SRC). Multiple educational outcomes were assessed, including resident satisfaction and attitudes (postrotation survey), changes in knowledge via pre- and posttest, quality of the residents' written safety analyses and oral presentations (per survey of SRC members), and organizational changes that resulted from the residents' reviews. Twenty-two residents completed the rotation. Most components were rated favorably; 80% (12/15 respondents) indicated interest in future patient safety work. Knowledge improved by 44.3% (P < .0001; pretest mean 23.7, posttest mean 34.2). Compared to faculty, SRC members rated the quality of residents' written reviews as superior and the quality of the rated oral presentations as either comparable or superior. The reviews identified a variety of safety vulnerabilities and led to multiple corrective actions. The authors will evaluate the curriculum in a controlled trial with better measures of change in behavior. Further tests of the curriculum's scalability to other contexts are needed.
-
The European space suit, a design for productivity and crew safety.
Skoog, A I; Berthier, S; Ollivier, Y
1991-01-01
In order to fulfill the two major mission objectives, i.e. support planned and unplanned external servicing of the COLUMBUS FFL and support the HERMES vehicle for safety critical operations and emergencies, the European Space Suit System baseline configuration incorporates a number of design features, which shall enhance the productivity and the crew safety of EVA astronauts. The work in EVA is today--and will be for several years--a manual work. Consequently, to improve productivity, the first challenge is to design a suit enclosure which minimizes movement restrictions and crew fatigue. It is covered by the "ergonomic" aspect of the suit design. Furthermore, it is also necessary to help the EVA crewmember in his work, by giving him the right information at the right time. Many solutions exist in this field of Man-Machine Interface, from a very simple system, based on cuff check lists, up to advanced systems, including Head-Up Displays. The design concept for improved productivity encompasses following features: easy donning/doffing thru rear entry, suit ergonomy optimisation, display of operational information in alpha-numerical and graphical form, and voice processing for operations and safety critical information. Concerning crew safety the major design features are: a lower R-factor for emergency EVA operations thru increased suit pressure, zero prebreath conditions for normal operations, visual and voice processing of all safety critical functions, and an autonomous life support system to permit unrestricted operations around HERMES and the CFFL. The paper analyses crew safety and productivity criteria and describes how these features are being built into the design of the European Space Suit System.
-
Safety of clinical and non-clinical decision makers in telephone triage: a narrative review.
Wheeler, Sheila Q; Greenberg, Mary E; Mahlmeister, Laura; Wolfe, Nicole
2015-09-01
Patient safety is a persistent problem in telephone triage research; however, studies have not differentiated between clinicians' and non-clinicians' respective safety. Currently, four groups of decision makers perform aspects of telephone triage: clinicians (physicians, nurses), and non-clinicians (emergency medical dispatchers (EMD) and clerical staff). Using studies published between 2002-2012, we applied Donabedian's structure-process-outcome model to examine groups' systems for evidence of system completeness (a minimum measure of structure and quality). We defined system completeness as the presence of a decision maker and four additional components: guidelines, documentation, training, and standards. Defining safety as appropriate referrals (AR) - (right time, right place with the right person), we measured each groups' corresponding AR rate percentages (outcomes). We analyzed each group's respective decision-making process as a safe match to the telephone triage task, based on each group's system structure completeness, process and AR rates (outcome). Studies uniformly noted system component presence: nurses (2-4), physicians (1), EMDs (2), clerical staff (1). Nurses had the highest average appropriate referral (AR) rates (91%), physicians' AR (82% average). Clerical staff had no system and did not perform telephone triage by standard definitions; EMDs may represent the use of the wrong system. Telephone triage appears least safe after hours when decision makers with the least complete systems (physicians, clerical staff) typically manage calls. At minimum, telephone triage decision makers should be clinicians; however, clinicians' safety calls for improvement. With improved training, standards and CDSS quality, the 24/7 clinical call center has potential to represent the national standard. © The Author(s) 2015.
-
Seidling, Hanna M; Stützle, Marion; Hoppe-Tichy, Torsten; Allenet, Benoît; Bedouch, Pierrick; Bonnabry, Pascal; Coleman, Jamie J; Fernandez-Llimos, Fernando; Lovis, Christian; Rei, Maria Jose; Störzinger, Dominic; Taylor, Lenka A; Pontefract, Sarah K; van den Bemt, Patricia M L A; van der Sijs, Heleen; Haefeli, Walter E
2016-04-01
While evidence on implementation of medication safety strategies is increasing, reasons for selecting and relinquishing distinct strategies and details on implementation are typically not shared in published literature. We aimed to collect and structure expert information resulting from implementing medication safety strategies to provide advice for decision-makers. Medication safety experts with clinical expertise from thirteen hospitals throughout twelve European and North American countries shared their experience in workshop meetings, on-site-visits and remote structured interviews. We performed an expert-based, in-depth assessment of implementation of best-practice strategies to improve drug prescribing and drug administration. Workflow, variability and recommended medication safety strategies in drug prescribing and drug administration processes. According to the experts, institutions chose strategies that targeted process steps known to be particularly error-prone in the respective setting. Often, the selection was channeled by local constraints such as the e-health equipment and critically modulated by national context factors. In our study, the experts favored electronic prescribing with clinical decision support and medication reconciliation as most promising interventions. They agreed that self-assessment and introduction of medication safety boards were crucial to satisfy the setting-specific differences and foster successful implementation. While general evidence for implementation of strategies to improve medication safety exists, successful selection and adaptation of a distinct strategy requires a thorough knowledge of the institute-specific constraints and an ongoing monitoring and adjustment of the implemented measures.
-
Sittig, Dean F; Ash, Joan S; Singh, Hardeep
2014-05-01
Electronic health records (EHRs) have potential to improve quality and safety of healthcare. However, EHR users have experienced safety concerns from EHR design and usability features that are not optimally adapted for the complex work flow of real-world practice. Few strategies exist to address unintended consequences from implementation of EHRs and other health information technologies. We propose that organizations equipped with EHRs should consider the strategy of "proactive risk assessment" of their EHR-enabled healthcare system to identify and address EHR-related safety concerns. In this paper, we describe the conceptual underpinning of an EHR-related self-assessment strategy to provide institutions a foundation upon which they could build their safety efforts. With support from the Office of the National Coordinator for Health Information Technology (ONC), we used a rigorous, iterative process to develop a set of 9 self-assessment tools to optimize the safety and safe use of EHRs. These tools, referred to as the Safety Assurance Factors for EHR Resilience (SAFER) guides, could be used to self-assess safety and effectiveness of EHR implementations, identify specific areas of vulnerability, and create solutions and culture change to mitigate risks. A variety of audiences could conduct these assessments, including frontline clinicians or care teams in different practices, or clinical, quality, or administrative leaders within larger institutions. The guides use a multifaceted systems-based approach to assess risk and empower organizations to work with internal or external stakeholders (eg, EHR developers) on optimizing EHR functionality and using EHRs to drive improvements in the quality and safety of healthcare.
-
NASA Astrophysics Data System (ADS)
1990-05-01
The Department of Energy (DOE) policy requires that all activities be conducted in a manner that protects the safety of the public and provides a safe and healthful workplace for employees. DOE has also prescribed that all personnel be protected in any explosives operation undertaken. The level of safety provided shall be at least equivalent to that of the best industrial practice. The risk of death or serious injury shall be limited to the lowest practicable minimum. DOE and contractors shall continually review their explosives operations with the aim of achieving further refinements and improvements in safety practices and protective features. This manual describes the Department's explosive safety requirements applicable to operations involving the development, testing, handling, and processing of explosives or assemblies containing explosives. It is intended to reflect the state-of-the-art in explosives safety. In addition, it is essential that applicable criteria and requirements for implementing this policy be readily available and known to those responsible for conducting DOE programs. This document shall be periodically reviewed and updated to establish new requirements as appropriate. Users are requested to submit suggestions for improving the DOE Explosives Safety Manual through their appropriate Operations Office to the Office of Quality Programs.
-
NASA Accident Precursor Analysis Handbook, Version 1.0
NASA Technical Reports Server (NTRS)
Groen, Frank; Everett, Chris; Hall, Anthony; Insley, Scott
2011-01-01
Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.
-
Pulsed electric field processing for fruit and vegetables
USDA-ARS?s Scientific Manuscript database
This month’s column reviews the theory and current applications of pulsed electric field (PEF) processing for fruits and vegetables to improve their safety and quality. This month’s column coauthor, Stefan Toepfl, is advanced research manager at the German Institute of Food Technologies and professo...
-
Certification Strategies using Run-Time Safety Assurance for Part 23 Autopilot Systems
NASA Technical Reports Server (NTRS)
Hook, Loyd R.; Clark, Matthew; Sizoo, David; Skoog, Mark A.; Brady, James
2016-01-01
Part 23 aircraft operation, and in particular general aviation, is relatively unsafe when compared to other common forms of vehicle travel. Currently, there exists technologies that could increase safety statistics for these aircraft; however, the high burden and cost of performing the requisite safety critical certification processes for these systems limits their proliferation. For this reason, many entities, including the Federal Aviation Administration, NASA, and the US Air Force, are considering new options for certification for technologies that will improve aircraft safety. Of particular interest, are low cost autopilot systems for general aviation aircraft, as these systems have the potential to positively and significantly affect safety statistics. This paper proposes new systems and techniques, leveraging run-time verification, for the assurance of general aviation autopilot systems, which would be used to supplement the current certification process and provide a viable path for near-term low-cost implementation. In addition, discussions on preliminary experimentation and building the assurance case for a system, based on these principles, is provided.
-
Bacci, Jennifer L; Berenbrok, Lucas A
2018-06-07
The scope of community pharmacy practice has expanded beyond the provision of drug product to include the provision of patient care services. Likewise, the community pharmacist's approach to patient safety must also expand beyond prevention of errors during medication dispensing to include optimization of medications and prevention of adverse events throughout the entire medication use process. Connectivity to patient data and other healthcare providers has been a longstanding challenge in community pharmacy with implications for the delivery and safety of patient care. Here, we describe three innovative advances in connectivity in community pharmacy practice that enhance patient safety in the provision of community pharmacist patient care services across the entire medication use process. Specifically, we discuss the growing use of immunization information systems, quality improvement platforms, and health information exchanges in community pharmacy practice and their implications for patient safety. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
-
NAVIGATING A QUALITY ROUTE TO A NATIONAL SAFETY AWARD
DOE Office of Scientific and Technical Information (OSTI.GOV)
PREVETTE SS
Deming quality methodologies applied to safety are recognized with the National Safety Council's annual Robert W. Campbell Award. Over the last ten years, the implementation of Statistical Process Control and quality methodologies at the U.S. Department of Energy's Hanford Site have contributed to improved safety. Improvements attributed to Statistical Process Control are evidenced in Occupational Safety and Health records and documented through several articles in Quality Progress and the American Society of Safety Engineers publication, Professional Safety. Statistical trending of safety, quality, and occurrence data continues to playa key role in improving safety and quality at what has been calledmore » the world's largest environmental cleanup project. DOE's Hanford Site played a pivotal role in the nation's defense beginning in the 1940s, when it was established as part of the Manhattan Project. After more than 50 years of producing material for nuclear weapons, Hanford, which covers 586 square miles in southeastern Washington state, is now focused on three outcomes: (1) Restoring the Columbia River corridor for multiple uses; (2) Transitioning the central plateau to support long-term waste management; and (3) Putting DOE assets to work for the future. The current environmental cleanup mission faces challenges of overlapping technical, political, regulatory, environmental, and cultural interests. From Oct. 1, 1996 through Sept. 30, 2008, Fluor Hanford was a prime contractor to the Department of Energy's Richland Operations Office. In this role, Fluor Hanford managed several major cleanup activities that included dismantling former nuclear-processing facilities, cleaning up the Site's contaminated groundwater, retrieving and processing transuranic waste for shipment and disposal off-site, maintaining the Site's infrastructure, providing security and fire protection, and operating the Volpentest HAMMER Training and Education Center. On October 1,2008, a transition occurred that changed Fluor's role at Hanford. Fluor's work at Hanford was split in two with the technical scope being assumed by the CH2M HILL Plateau Remediation Company (CHPRC) CHPRC is now spearheading much of the cleanup work associated with former nuclear-processing facilities, contaminated groundwater, and transuranic waste. Fluor is an integrated subcontractor to CH PRC in this effort. In addition, at the time of this writing, while the final outcome is being determined for the new Mission Support Contract, Fluor Hanford has had its contract extended to provide site-wide services that include security, fire protection, infrastructure, and operating the HAMMER facility. The emphasis has to be on doing work safely, delivering quality work, controlling costs, and meeting deadlines. Statistical support is provided by Fluor to the PRC, within Fluor Hanford, and to a third contractor, Washington Closure Hanford, which is tasked with cleaning up approximately 210 square miles designated as the Columbia River corridor along the outer edge of the Hanford Site. The closing months of Fluor Hanford's 12 year contract were busy, characterized by special events that capped its work as a prime cleanup contractor, transitions of work scope and personnel, and the completion numerous activities. At this time, Fluor's work and approach to safety were featured in state and national forums. A 'Blockbuster' presentation at the Washington State Governor's Industrial Safety Conference in September 2008 featured Fluor Hanford's Chief Operating Officer, a company Safety Representative, and me. Simultaneously, an award ceremony in Anaheim, Calif. recognized Fluor Hanford as the winner of the 2008 Robert W. Campbell Award. The Robert W. Campbell Award is co-sponsored by Exxon Mobil Corporation and the National Safety Council. Named after a pioneer of industrial safety, the Campbell Award recognizes organizations that demonstrate how integration of environmental, health and safety (EHS) management into business operations is a cornerstone of their corporate success. Fluor Hanford received the award for corporations with more than 1,000 employees. Campbell Award winners undergo rigorous assessments that include site visits and comprehensive evaluations of their commitment to, and implementation of, EHS practices. Award winners work with an international partnership of 21 organizations to develop case studies that illustrate their superior EHS programs and best practices, for use by top business and engineering schools worldwide. Quality methodologies in place at Fluor Hanford played a key role in the award process. Fluor Hanford's integrated use of Statistical Process Control and Pareto Charts for analyzing and displaying EHS performance were viewed favorably by the award judges.« less
-
Kapur, Ajay; Potters, Louis
2012-01-01
The purpose of this work was to develop and implement six sigma practices toward the enhancement of patient safety in an electronic, quality checklist-driven, multicenter, paperless radiation medicine department. A quality checklist process map (QPM), stratified into consultation through treatment-completion stages was incorporated into an oncology information systems platform. A cross-functional quality management team conducted quality-function-deployment and define-measure-analyze-improve-control (DMAIC) six sigma exercises with a focus on patient safety. QPM procedures were Pareto-sorted in order of decreasing patient safety risk with failure mode and effects analysis (FMEA). Quantitative metrics for a grouped set of highest risk procedures were established. These included procedural delays, associated standard deviations and six sigma Z scores. Baseline performance of the QPM was established over the previous year of usage. Data-driven analysis led to simplification, standardization, and refinement of the QPM with standard deviation, slip-day reduction, and Z-score enhancement goals. A no-fly policy (NFP) for patient safety was introduced at the improve-control DMAIC phase, with a process map interlock imposed on treatment initiation in the event of FMEA-identified high-risk tasks being delayed or not completed. The NFP was introduced in a pilot phase with specific stopping rules and the same metrics used for performance assessments. A custom root-cause analysis database was deployed to monitor patient safety events. Relative to the baseline period, average slip days and standard deviations for the risk-enhanced QPM procedures improved by over threefold factors in the NFP period. The Z scores improved by approximately 20%. A trend for proactive delays instead of reactive hard stops was observed with no adverse effects of the NFP. The number of computed potential no-fly delays per month dropped from 60 to 20 over a total of 520 cases. The fraction of computed potential no-fly cases that were delayed in NFP compliance rose from 28% to 45%. Proactive delays rose to 80% of all delayed cases. For potential no-fly cases, event reporting rose from 18% to 50%, while for actually delayed cases, event reporting rose from 65% to 100%. With complex technologies, resource-compromised staff, and pressures to hasten treatment initiation, the use of the six sigma driven process interlocks may mitigate potential patient safety risks as demonstrated in this study. Copyright © 2012 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
-
Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events.
Olson, Andrew P J; Graber, Mark L; Singh, Hardeep
2018-01-29
Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying "undesirable diagnostic events" (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.
-
Ausserhofer, Dietmar; Rakic, Severin; Novo, Ahmed; Dropic, Emira; Fisekovic, Eldin; Sredic, Ana; Van Malderen, Greet
2016-06-01
We explored how selected 'positive deviant' healthcare facilities in Bosnia and Herzegovina approach the continuous development, adaptation, implementation, monitoring and evaluation of nursing-related standard operating procedures. Standardized nursing care is internationally recognized as a critical element of safe, high-quality health care; yet very little research has examined one of its key instruments: nursing-related standard operating procedures. Despite variability in Bosnia and Herzegovina's healthcare and nursing care quality, we assumed that some healthcare facilities would have developed effective strategies to elevate nursing quality and safety through the use of standard operating procedures. Guided by the 'positive deviance' approach, we used a multiple-case study design to examine a criterion sample of four facilities (two primary healthcare centres and two hospitals), collecting data via focus groups and individual interviews. In each studied facility, certification/accreditation processes were crucial to the initiation of continuous development, adaptation, implementation, monitoring and evaluation of nursing-related SOPs. In one hospital and one primary healthcare centre, nurses working in advanced roles (i.e. quality coordinators) were responsible for developing and implementing nursing-related standard operating procedures. Across the four studied institutions, we identified a consistent approach to standard operating procedures-related processes. The certification/accreditation process is enabling necessary changes in institutions' organizational cultures, empowering nurses to take on advanced roles in improving the safety and quality of nursing care. Standardizing nursing procedures is key to improve the safety and quality of nursing care. Nursing and Health Policy are needed in Bosnia and Herzegovina to establish a functioning institutional framework, including regulatory bodies, educational systems for developing nurses' capacities or the inclusion of nursing-related standard operating procedures in certification/accreditation standards. © 2016 International Council of Nurses.
-
Safe teleoperation based on flexible intraoperative planning for robot-assisted laser microsurgery.
Mattos, Leonardo S; Caldwell, Darwin G
2012-01-01
This paper describes a new intraoperative planning system created to improve precision and safety in teleoperated laser microsurgeries. It addresses major safety issues related to real-time control of a surgical laser during teleoperated procedures, which are related to the reliability and robustness of the telecommunication channels. Here, a safe solution is presented, consisting in a new planning system architecture that maintains the flexibility and benefits of real-time teleoperation and keeps the surgeon in control of all surgical actions. The developed system is based on our virtual scalpel system for robot-assisted laser microsurgery, and allows the intuitive use of stylus to create surgical plans directly over live video of the surgical field. In this case, surgical plans are defined as graphic objects overlaid on the live video, which can be easily modified or replaced as needed, and which are transmitted to the main surgical system controller for subsequent safe execution. In the process of improving safety, this new planning system also resulted in improved laser aiming precision and improved capability for higher quality laser procedures, both due to the new surgical plan execution module, which allows very fast and precise laser aiming control. Experimental results presented herein show that, in addition to the safety improvements, the new planning system resulted in a 48% improvement in laser aiming precision when compared to the previous virtual scalpel system.
-
USDA-ARS?s Scientific Manuscript database
Infrared (IR) radiation heating has been considered as an alternative to current food and agricultural processing methods for improving product quality and safety, increasing energy and processing efficiency, and reducing water and chemical usage. As part of the electromagnetic spectrum, IR has the ...
-
USDA-ARS?s Scientific Manuscript database
High pressure processing (HPP) is a non-thermal post-packaging process with the potential to improve cheese safety and shelf life because of its lethality to bacteria (spoilage and pathogens) and ability to inactivate many enzymes. Queso Fresco (QF), a high moisture Hispanic-style cheese popular in ...
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Garrett, Richard L.; Niemi, Belinda J.; Paik, Ingle K.
2013-11-07
A Comparative Evaluation was conducted for One System Integrated Project Team to compare the safety bases for the Hanford Waste Treatment and Immobilization Plant Project (WTP) and Tank Operations Contract (TOC) (i.e., Tank Farms) by an Expert Review Team. The evaluation had an overarching purpose to facilitate effective integration between WTP and TOC safety bases. It was to provide One System management with an objective evaluation of identified differences in safety basis process requirements, guidance, direction, procedures, and products (including safety controls, key safety basis inputs and assumptions, and consequence calculation methodologies) between WTP and TOC. The evaluation identified 25more » recommendations (Opportunities for Integration). The resolution of these recommendations resulted in 16 implementation plans. The completion of these implementation plans will help ensure consistent safety bases for WTP and TOC along with consistent safety basis processes. procedures, and analyses. and should increase the likelihood of a successful startup of the WTP. This early integration will result in long-term cost savings and significant operational improvements. In addition, the implementation plans lead to the development of eight new safety analysis methodologies that can be used at other U.S. Department of Energy (US DOE) complex sites where URS Corporation is involved.« less
-
Evaluation of aviation-based safety team training in a hospital in The Netherlands.
De Korne, Dirk F; Van Wijngaarden, Jeroen D H; Van Dyck, Cathy; Hiddema, U Francis; Klazinga, Niek S
2014-01-01
The purpose of this paper is to evaluate the implementation of a broad-scale team resource management (TRM) program on safety culture in a Dutch eye hospital, detailing the program's content and procedures. Aviation-based TRM training is recognized as a useful approach to increase patient safety, but little is known about how it affects safety culture. Pre- and post-assessments of the hospitals' safety culture was based on interviews with ophthalmologists, anesthesiologists, residents, nurses, and support staff. Interim observations were made at training sessions and in daily hospital practice. The program consisted of safety audits of processes and (team) activities, interactive classroom training sessions by aviation experts, a flight simulator session, and video recording of team activities with subsequent feedback. Medical professionals considered aviation experts inspiring role models and respected their non-hierarchical external perspective and focus on medical-technical issues. The post-assessment showed that ophthalmologists and other hospital staff had become increasingly aware of safety issues. The multidisciplinary approach promoted social (team) orientation that replaced the former functionally-oriented culture. The number of reported near-incidents greatly increased; the number of wrong-side surgeries stabilized to a minimum after an initial substantial reduction. The study was observational and the hospital's variety of efforts to improve safety culture prevented us from establishing a causal relation between improvement and any one specific intervention. Aviation-based TRM training can be a useful to stimulate safety culture in hospitals. Safety and quality improvements are not single treatment interventions but complex socio-technical interventions. A multidisciplinary system approach and focus on "team" instead of "profession" seems both necessary and difficult in hospital care.
-
NASA Post-Columbia Safety & Mission Assurance, Review and Assessment Initiatives
NASA Astrophysics Data System (ADS)
Newman, J. Steven; Wander, Stephen M.; Vecellio, Don; Miller, Andrew J.
2005-12-01
On February 1, 2003, NASA again experienced a tragic accident as the Space Shuttle Columbia broke apart upon reentry, resulting in the loss of seven astronauts. Several of the findings and observations of the Columbia Accident Investigation Board addressed the need to strengthen the safety and mission assurance function at NASA. This paper highlights key steps undertaken by the NASA Office of Safety and Mission Assurance (OSMA) to establish a stronger and more- robust safety and mission assurance function for NASA programs, projects, facilities and operations. This paper provides an overview of the interlocking OSMA Review and Assessment Division (RAD) institutional and programmatic processes designed to 1) educate, inform, and prepare for audits, 2) verify requirements flow-down, 3) verify process capability, 4) verify compliance with requirements, 5) support risk management decision making, 6) facilitate secure web- based collaboration, and 7) foster continual improvement and the use of lessons learned.
-
Tele-ICU and Patient Safety Considerations.
Hassan, Erkan
The tele-ICU is designed to leverage, not replace, the need for bedside clinical expertise in the diagnosis, treatment, and assessment of various critical illnesses. Tele-ICUs are primarily decentralized or centralized models with differing advantages and disadvantages. The centralized model has sufficiently powered published data to be associated with improved mortality and ICU length of stay in a cost-effective manner. Factors associated with improved clinical outcomes include improved compliance with best practices; providing off-hours implementation of the bedside physician's care plan; and identification of and rapid response to physiological instability (initial clinical review within 1 hour) and rapid response to alerts, alarms, or direct notification by bedside clinicians. With improved communication and frequent review of patients between the tele-ICU and the bedside clinicians, the bedside clinician can provide the care that only they can provide. Although technology continues to evolve at a rapid pace, technology alone will most likely not improve clinical outcomes. Technology will enable us to process real or near real-time data into complex and powerful predictive algorithms. However, the remote and bedside teams must work collaboratively to develop care processes to better monitor, prioritize, standardize, and expedite care to drive greater efficiencies and improve patient safety.
-
Young, John Q; Wachter, Robert M
2009-09-01
Health care organizations have increasingly embraced industrial methods, such as the Toyota Production System (TPS), to improve quality, safety, timeliness, and efficiency. However, the use of such methods in psychiatric hospitals has been limited. A psychiatric hospital applied TPS principles to patient transfers to the outpatient medication management clinics (MMCs) from all other inpatient and outpatient services within the hospital's system. Sources of error and delay were identified, and a new process was designed to improve timely access (measured by elapsed time from request for transfer to scheduling of an appointment and to the actual visit) and patient safety by decreasing communication errors (measured by number of failed transfers). Complexity was substantially reduced, with one streamlined pathway replacing five distinct and more complicated pathways. To assess sustainability, the postintervention period was divided into Period 1 (first 12 months) and Period 2 (next 24 months). Time required to process the transfer and schedule the first appointment was reduced by 74.1% in Period 1 (p < .001) and by an additional 52.7% in Period 2 (p < .0001) for an overall reduction of 87% (p < .0001). Similarly, time to the actual appointment was reduced 31.2% in Period 1 (p < .0001), but was stable in Period 2 (p = .48). The number of transfers per month successfully processed and scheduled increased 95% in the postintervention period compared with the pre-implementation period (p = .015). Finally, data for failed transfers were only available for the postintervention period, and the rate decreased 89% in Period 2 compared with Period 1 (p = .017). The application of TPS principles enhanced access and safety through marked and sustained improvements in the transfer process's timeliness and reliability. Almost all transfer processes have now been standardized.
-
[Intraprofessional communication during shift change].
Martín Pérez, Sonsoles; Vázquez Calatayud, Mónica; Lizarraga Ursúa, Yolanta; Oroviogoicoechea Ortega, Cristina
2013-05-01
Effective communication between professionals is crucial to ensure patient safety. 1) Explore the intraprofessional communication process during nurse shift change; 2) identify improvement strategies to facilitate optimal communication process. Exploratory study conducted from January to May 2011 in an intermediate unit. There were performed 16 structured observations of the communication process and 4 semistructured interviews and 16 anonymous surveys (designed by the evidence, interviews and observations) to the nurses who agreed to participate in the study. Strengths: complete process and the usefulness of the computer record. lack of common structure, repetition and forgetfulness of information, numerous interruptions during the process and noise. The 68.75% of nurses said that part of the transmitted information was irrelevant and too long. All of them perceived the need for changes in the existing process. Some strategies were identified to improve the development of a guide based on the mnemonic SBAR. It was adapted to the structure of the software as well as a change in location for the transmission of information. We propose to have an effective intraprofessional communication in order to ensure patient safety. In addition the transmission of information during the shift change should be done through a systematic process in a quiet place without interruptions.
-
Ensuring Food Security Through Enhancing Microbiological Food Safety
NASA Astrophysics Data System (ADS)
Mikš-Krajnik, Marta; Yuk, Hyun-Gyun; Kumar, Amit; Yang, Yishan; Zheng, Qianwang; Kim, Min-Jeong; Ghate, Vinayak; Yuan, Wenqian; Pang, Xinyi
2015-10-01
Food safety and food security are interrelated concepts with a profound impact on the quality of human life. Food security describes the overall availability of food at different levels from global to individual household. While, food safety focuses on handling, preparation and storage of foods in order to prevent foodborne illnesses. This review focuses on innovative thermal and non-thermal technologies in the area of food processing as the means to ensure food security through improving food safety with emphasis on the reduction and control of microbiological risks. The antimicrobial efficiency and mechanism of new technologies to extend the shelf life of food product were also discussed.
-
Improving safety in CT through the use of educational media.
Mattingly, Melisa
2011-01-01
With a grant from the AHRA and Toshiba Putting Patients First program, Community Hospital in Indianapolis, IN set out to reduce the need for patient sedation, mechanical restraint, additional radiation dosage,and repeat procedures for pediatric patients. An online video was produced to educate pediatric patients and their caregivers about the diagnostic imaging process enabling them to be more comfortable and compliant during the procedure. Early information and results indicate a safer experience for the patient.The goal is for the video to become a new best practice tool for improving patient care and safety in diagnostic imaging.
-
NASA Astrophysics Data System (ADS)
Machfudiyanto, Rossy Armyn; Latief, Yusuf; Yogiswara, Yoko; Setiawan, R. Mahendra Fitra
2017-06-01
In facing the ASEAN Economic Community, the level of prevailing working accidents becomes one of the competitiveness factors among the companies. A construction industry is one of the industries prone to high level of accidents. Improving the safety record will not be completely effective unless the occupational safety and healthy culture is enhanced. The aim of this research was to develop a model and to conduct empirical investigation on the relationships among the dimensions of construction occupational safety culture. This research used the structural equation model as a means to examine the hypothesis of positive relationships between dimensions and objectives. The method used in this research was questionnaire survey which was distributed to the respondents from construction companies in a state-owned enterprise in Indonesia. Moreover, there were dimensions of occupational safety culture that was established, such as leadership, behavior, value, strategy, policy, process, employee, safety cost, and contract system. The results of this study indicated that all dimensions were significant and inter-related in forming the safety culture. The result of R2 yielded the safety performance was 54%, which means it was in low category and evaluation of policies on construction companies was required in addressing the issue of working accidents.
-
Capability maturity models for offshore organisational management.
Strutt, J E; Sharp, J V; Terry, E; Miles, R
2006-12-01
The goal setting regime imposed by the UK safety regulator has important implications for an organisation's ability to manage health and safety related risks. Existing approaches to safety assurance based on risk analysis and formal safety assessments are increasingly considered unlikely to create the step change improvement in safety to which the offshore industry aspires and alternative approaches are being considered. One approach, which addresses the important issue of organisational behaviour and which can be applied at a very early stage of design, is the capability maturity model (CMM). The paper describes the development of a design safety capability maturity model, outlining the key processes considered necessary to safety achievement, definition of maturity levels and scoring methods. The paper discusses how CMM is related to regulatory mechanisms and risk based decision making together with the potential of CMM to environmental risk management.
-
ERIC Educational Resources Information Center
Resnikoff, Marvin
1975-01-01
This article presents an economic analysis of the nuclear fuel reprocessing industry. It indicates that while environmental safety devices have improved the working conditions, they have also added ever-increasing costs to this necessary process. (MA)
-
Sobottka, Stephan B; Eberlein-Gonska, Maria; Schackert, Gabriele; Töpfer, Armin
2009-01-01
Due to the knowledge gap that exists between patients and health care staff the quality of medical treatment usually cannot be assessed securely by patients. For an optimization of safety in treatment-related processes of medical care, the medical staff needs to be actively involved in preventive and proactive quality management. Using voluntary, confidential and non-punitive systematic employee surveys, vulnerable topics and areas in patient care revealing preventable risks can be identified at an early stage. Preventive measures to continuously optimize treatment quality can be defined by creating a risk portfolio and a priority list of vulnerable topics. Whereas critical incident reporting systems are suitable for continuous risk assessment by detecting safety-relevant single events, employee surveys permit to conduct a systematic risk analysis of all treatment-related processes of patient care at any given point in time.
-
Sensor fault diagnosis of aero-engine based on divided flight status.
Zhao, Zhen; Zhang, Jun; Sun, Yigang; Liu, Zhexu
2017-11-01
Fault diagnosis and safety analysis of an aero-engine have attracted more and more attention in modern society, whose safety directly affects the flight safety of an aircraft. In this paper, the problem concerning sensor fault diagnosis is investigated for an aero-engine during the whole flight process. Considering that the aero-engine is always working in different status through the whole flight process, a flight status division-based sensor fault diagnosis method is presented to improve fault diagnosis precision for the aero-engine. First, aero-engine status is partitioned according to normal sensor data during the whole flight process through the clustering algorithm. Based on that, a diagnosis model is built for each status using the principal component analysis algorithm. Finally, the sensors are monitored using the built diagnosis models by identifying the aero-engine status. The simulation result illustrates the effectiveness of the proposed method.
-
Sensor fault diagnosis of aero-engine based on divided flight status
NASA Astrophysics Data System (ADS)
Zhao, Zhen; Zhang, Jun; Sun, Yigang; Liu, Zhexu
2017-11-01
Fault diagnosis and safety analysis of an aero-engine have attracted more and more attention in modern society, whose safety directly affects the flight safety of an aircraft. In this paper, the problem concerning sensor fault diagnosis is investigated for an aero-engine during the whole flight process. Considering that the aero-engine is always working in different status through the whole flight process, a flight status division-based sensor fault diagnosis method is presented to improve fault diagnosis precision for the aero-engine. First, aero-engine status is partitioned according to normal sensor data during the whole flight process through the clustering algorithm. Based on that, a diagnosis model is built for each status using the principal component analysis algorithm. Finally, the sensors are monitored using the built diagnosis models by identifying the aero-engine status. The simulation result illustrates the effectiveness of the proposed method.
-
Memorial Hermann: high reliability from board to bedside.
Shabot, M Michael; Monroe, Douglas; Inurria, Juan; Garbade, Debbi; France, Anne-Claire
2013-06-01
In 2006 the Memorial Hermann Health System (MHHS), which includes 12 hospitals, began applying principles embraced by high reliability organizations (HROs). Three factors support its HRO journey: (1) aligned organizational structure with transparent management systems and compressed reporting processes; (2) Robust Process Improvement (RPI) with high-reliability interventions; and (3) cultural establishment, sustainment, and evolution. The Quality and Safety strategic plan contains three domains, each with a specific set of measures that provide goals for performance: (1) "Clinical Excellence;" (2) "Do No Harm;" and (3) "Saving Lives," as measured by the Serious Safety Event rate. MHHS uses a uniform approach to performance improvement--RPI, which includes Six Sigma, Lean, and change management, to solve difficult safety and quality problems. The 9 acute care hospitals provide multiple opportunities to integrate high-reliability interventions and best practices across MHHS. For example, MHHS partnered with the Joint Commission Center for Transforming Healthcare in its inaugural project to establish reliable hand hygiene behaviors, which improved MHHS's average hand hygiene compliance rate from 44% to 92% currently. Soon after compliance exceeded 85% at all 12 hospitals, the average rate of central line-associated bloodstream and ventilator-associated pneumonias decreased to essentially zero. MHHS's size and diversity require a disciplined approach to performance improvement and systemwide achievement of measurable success. The most significant cultural change at MHHS has been the expectation for 100% compliance with evidence-based quality measures and 0% incidence of patient harm.
-
Safety systems in gamma irradiation facilities.
Drndarevic, V
1997-08-01
A new electronic device has been developed to guard against individuals gaining entry through the product entry and exit ports into our irradiation facility for industrial sterilization. This device uses the output from electronic sensors and pressure mats to assure that only the transport cabins may pass through these ports. Any intention of personnel trespassing is detected, the process is stopped by the safety system, and the source is placed in safe position. Owing to a simple construction, the new device enables reliable operation, is inexpensive, easy to implement, and improves the existing safety systems.
-
New technologies and worker safety in western agriculture.
Fenske, Richard A
2009-01-01
The New Paths: Health and Safety in Western Agriculture conference, November 11-13, 2008, highlighted the role of technological innovation in agricultural production. The tree fruit industry in the Pacific Northwest has adopted a "technology road map" to reduce production costs and improve efficiency. An agricultural tour provided field demonstrations and discussions on such topics as mobile work platforms in orchards, traumatic and musculoskeletal injuries, and new pest control technologies. Occupational safety and health research will need to adapt to and keep pace with rapid changes in agricultural production processes.
-
The objective impact of clinical peer review on hospital quality and safety.
Edwards, Marc T
2011-01-01
Despite its importance, the objective impact of clinical peer review on the quality and safety of care has not been studied. Data from 296 acute care hospitals show that peer review program and related organizational factors can explain up to 18% of the variation in standardized measures of quality and patient safety. The majority of programs rely on an outmoded and dysfunctional process model. Adoption of best practices informed by the continuing study of peer review program effectiveness has the potential to significantly improve patient outcomes.
-
Bain, Kevin T.; Holmes, Holly M.; Beers, Mark H.; Maio, Vittorio; Handler, Steven M.; Pauker, Stephen G.
2009-01-01
Thousands of Americans are injured or die each year from adverse drug reactions, many of which are preventable. The burden of harm conveyed by the use of medications is a significant public health problem and, therefore, improving the medication-use process is a priority. Recent and ongoing efforts to improve the medication-use process focus primarily on improving medication prescribing, and not much emphasis has been put on improving medication discontinuation. A formalized approach for rationally discontinuing medications is a necessary antecedent to improving medication safety and improving the nation’s quality of care. This paper proposes a conceptual framework for revising the prescribing stage of the medication-use process to include discontinuing medications. This framework has substantial practice and research implications, especially for the clinical care of older persons, who are particularly susceptible to the adverse effects of medications. PMID:18771457
-
Optimizing Web-Based Instruction: A Case Study Using Poultry Processing Unit Operations
ERIC Educational Resources Information Center
O' Bryan, Corliss A.; Crandall, Philip G.; Shores-Ellis, Katrina; Johnson, Donald M.; Ricke, Steven C.; Marcy, John
2009-01-01
Food companies and supporting industries need inexpensive, revisable training methods for large numbers of hourly employees due to continuing improvements in Hazard Analysis Critical Control Point (HACCP) programs, new processing equipment, and high employee turnover. HACCP-based food safety programs have demonstrated their value by reducing the…
-
A Safety Index and Method for Flightdeck Evaluation
NASA Technical Reports Server (NTRS)
Latorella, Kara A.
2000-01-01
If our goal is to improve safety through machine, interface, and training design, then we must define a metric of flightdeck safety that is usable in the design process. Current measures associated with our notions of "good" pilot performance and ultimate safety of flightdeck performance fail to provide an adequate index of safe flightdeck performance for design evaluation purposes. The goal of this research effort is to devise a safety index and method that allows us to evaluate flightdeck performance holistically and in a naturalistic experiment. This paper uses Reason's model of accident causation (1990) as a basis for measuring safety, and proposes a relational database system and method for 1) defining a safety index of flightdeck performance, and 2) evaluating the "safety" afforded by flightdeck performance for the purpose of design iteration. Methodological considerations, limitations, and benefits are discussed as well as extensions to this work.
-
The Union RAP: Industry-Wide Research-Action Projects to Win Health and Safety Improvements
McQuiston, Thomas H.; Lippin, Tobi Mae; Anderson, Leeann G.; Beach, M. Josie; Frederick, James; Seymour, Thomas A.
2009-01-01
Unions are ripe to engage in community-based participatory research (CBPR). We briefly profile 3 United Steelworker CBPR projects aimed at uncovering often-undocumented, industry-wide health and safety conditions in which US industrial workers toil. The results are to be used to advocate improvements at workplace, industry, and national policy levels. We offer details of our CBPR approach (Research-Action Project [RAP]) that engages workers and others in all research stages. Elements of RAPs include strategically constructed teams with knowledge of the industry and health and safety and with skills in research, participatory facilitation, and training; reciprocal training on these knowledge and skill areas; iterative processes of large and small group work; use of technology; and facilitator-developed tools and intermediate products. PMID:19890145
-
MO-F-CAMPUS-T-02: An Electronic Whiteboard Platform to Manage Treatment Planning Process
DOE Office of Scientific and Technical Information (OSTI.GOV)
DiCostanzo, D; Woollard, J; Gupta, N
2015-06-15
Purpose: In an effort to improve patient safety and streamline the radiotherapy treatment planning (TP) process, a software based whiteboard had been developed and put in use in our facility Methods: The electronic whiteboard developed using SQL database (DB) and PHP/JavaScript based web interface, is published via department intranet and login credentials. The DB stores data for each TP process such as patient information, plan type, simulation/start dates, physician, dosimetrist, QA and the current status in planning process. Users interact with the DB per plan and perform status updates in real time as the planning process progresses. All user interactionsmore » with the DB are recorded with timestamps so as to calculate statistical information for TP process management such as contouring times, planning and review times, dosimetry, physics and therapist QA times. External beam and brachytherapy plans are categorized according to complexity (ex: IMRT, 3D, HDR, LDR etc) and treatment types and applicators. Each plan category is assigned specific timelines for each planning process. When a plan approaches or passes the predetermined timeline, users are alerted via color coded graphical cues. When certain process items are not completed in time, pre-determined actions are triggered such as a delay in treatment start date. Results: Our institution has been using the electronic whiteboard for two years. Implementation of pre-determined actions based on the statistical information collected by the whiteboard improved our TP process. For example, the average time for normal tissue contouring decreased from 0.73±1.37 to 0.24±0.33 days. The average time for target volume contouring decreased from 3.2±2.84 to 2.37±2.54 days. This increase in efficiency allows more time for quality assurance processes, improving patient safety. Conclusion: The electronic whiteboard has been an invaluable tool for streamlining our TP processes. It facilitates timely and accurate communication between all parties involved in the TP process increasing patient safety.« less
-
Ratanawongsa, Neda; Handley, Margaret A.; Sarkar, Urmimala; Quan, Judy; Pfeifer, Kelly; Soria, Catalina; Schillinger, Dean
2014-01-01
Safety net systems need innovative diabetes self-management programs for linguistically diverse patients. A low-income government-sponsored managed care plan implemented a 27-week automated telephone self-management support (ATSM) / health coaching intervention for English, Spanish-, and Cantonese-speaking members from four publicly-funded clinics in a practice-based research network. Compared to waitlist, immediate intervention participants had greater 6-month improvements in overall diabetes self-care behaviors (standardized effect size [ES] 0.29, p<0.01) and SF-12 physical scores (ES 0.25, p=0.03); changes in patient-centered processes of care and cardiometabolic outcomes did not differ. ATSM is a strategy for improving patient-reported self-management and may also improve some outcomes. PMID:24594561
-
Tamuz, Michal; Harrison, Michael I
2006-01-01
Objective To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices. Data Sources/Study Setting We reviewed and drew examples from studies of organization theory and health services research. Study Design After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA). Principal Findings HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors. Conclusions Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures. PMID:16898984
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Hoover, Mark D.; Myers, David S.; Cash, Leigh J.
The National Council on Radiation Protection and Measurements (NCRP) has established NCRP Scientific Committee 2-6 to develop a report on the current state of knowledge and guidance for radiation safety programs involved with nanotechnology. Nanotechnology is the understanding and control of matter at the nanoscale, at dimensions between approximately 1 and 100 nanometers, where unique phenomena enable novel applications. While the full report is in preparation, this article presents and applies an informatics-based decision-making framework and process through which the radiation protection community can anticipate that nano-enabled applications, processes, nanomaterials, and nanoparticles are likely to become present or are alreadymore » present in radiation-related activities; recognize specific situations where environmental and worker safety, health, well-being, and productivity may be affected by nano-related activities; evaluate how radiation protection practices may need to be altered to improve protection; control information, interpretations, assumptions, and conclusions to implement scientifically sound decisions and actions; and confirm that desired protection outcomes have been achieved. This generally applicable framework and supporting process can be continuously applied to achieve health and safety at the convergence of nanotechnology and radiation-related activities.« less
-
Hoover, Mark D; Myers, David S; Cash, Leigh J; Guilmette, Raymond A; Kreyling, Wolfgang G; Oberdörster, Günter; Smith, Rachel; Cassata, James R; Boecker, Bruce B; Grissom, Michael P
2015-02-01
The National Council on Radiation Protection and Measurements (NCRP) established NCRP Scientific Committee 2-6 to develop a report on the current state of knowledge and guidance for radiation safety programs involved with nanotechnology. Nanotechnology is the understanding and control of matter at the nanoscale, at dimensions between ∼1 and 100 nm, where unique phenomena enable novel applications. While the full report is in preparation, this paper presents and applies an informatics-based decision-making framework and process through which the radiation protection community can anticipate that nano-enabled applications, processes, nanomaterials, and nanoparticles are likely to become present or are already present in radiation-related activities; recognize specific situations where environmental and worker safety, health, well-being, and productivity may be affected by nano-related activities; evaluate how radiation protection practices may need to be altered to improve protection; control information, interpretations, assumptions, and conclusions to implement scientifically sound decisions and actions; and confirm that desired protection outcomes have been achieved. This generally applicable framework and supporting process can be continuously applied to achieve health and safety at the convergence of nanotechnology and radiation-related activities.
-
Ares Project Overview - Quality in Design
NASA Technical Reports Server (NTRS)
Cianciola, Chris; Crane, Kenneth
2008-01-01
This presentation introduces the audience to the overall goals of the Ares Project, which include providing human access to low-Earth orbit, the Moon, and beyond. The presentation also provides an overview of with the vehicles that will execute those goals and progress made on the vehicles to date. The briefing will provide an introduction to Lean, Six Sigma, and Kaizen practices Ares will use to improve the overall effectiveness and quality of its efforts. Finally, the briefing includes a summary of Safety and Mission Assurance practices being implemented within[Ares to ensure safety and quality early in the design process. Integrating Safety and Mission Assurance in Design: This presentation describes how the Ares Projects are learning from the successes and failures of previous launch systems in order to maximize safety and reliability while maintaining fiscal responsibility. The Ares Projects are integrating Safer T and Mission Assurance into design activities and embracing independent assessments by Quality experts in thorough reviews of designs and processes. Incorporating Lean thinking into the design process, Ares is also streamlining existing processes and future manufacturing flows which will yield savings during production. Understanding the value of early involvement of Quality experts, the Ares Projects are leading launch vehicle development into the 21st century.
-
Hoover, Mark D.; Myers, David S.; Cash, Leigh J.; ...
2015-01-01
The National Council on Radiation Protection and Measurements (NCRP) has established NCRP Scientific Committee 2-6 to develop a report on the current state of knowledge and guidance for radiation safety programs involved with nanotechnology. Nanotechnology is the understanding and control of matter at the nanoscale, at dimensions between approximately 1 and 100 nanometers, where unique phenomena enable novel applications. While the full report is in preparation, this article presents and applies an informatics-based decision-making framework and process through which the radiation protection community can anticipate that nano-enabled applications, processes, nanomaterials, and nanoparticles are likely to become present or are alreadymore » present in radiation-related activities; recognize specific situations where environmental and worker safety, health, well-being, and productivity may be affected by nano-related activities; evaluate how radiation protection practices may need to be altered to improve protection; control information, interpretations, assumptions, and conclusions to implement scientifically sound decisions and actions; and confirm that desired protection outcomes have been achieved. This generally applicable framework and supporting process can be continuously applied to achieve health and safety at the convergence of nanotechnology and radiation-related activities.« less
-
Miller, Robert H; Bovbjerg, Randall R
2002-06-01
Medical care should be safer. Inpatient problems and solutions have received the most attention; this outpatient qualitative case study addresses a gap in knowledge. We describe safety improvements among large physician groups, model the key influences on their behavior, and identify beneficial public and private policies. All groups were trying to reduce medical injury, which was part of the sample design. The most commonly targeted problems are those that are similar across groups: shortcomings in diagnosis, abnormal tests follow-up, scope of practice and referral patterns, and continuity of care. Medical group innovators vary greatly, however, in implementation of improvements, that is, in the extent to which they implement process changes that identify events/problems, analyze and track incidents, decide how to change clinical and administrative practices, and monitor impacts of the changes. Our conceptual model identifies key determinants: (1) demand for safety comes from external factors: legal, market, and professional; (2) organizational responses depend on internal factors: group size, scope, and integration; leadership and governance; professional culture; information-system assets; and financial and intellectual capital. Further, safety is an aspect of quality (the same tools, decision making, interventions, and monitoring apply), and safety management benefits from prior efficiency management (similar skills and culture of innovation). Observed variation in even simple safeguards shows that existing safety incentives are too weak. Our model suggests that the biggest improvement would come from boosting the demand for quality and safety from both private and public larger group purchasers. Current policy relies too much on litigation and discipline, which have sometimes helped, but not solved, problems because they are inefficient, tend to drive needed information underground, and complicate needed cultural change. Patients' safety demand is also weak for want of information and market power. Big purchasers' demands, however, quickly influence the internal environment of medical groups, helping managers advance quality safety toward the top of groups' congested decision-making "queues."
-
Yu, Xiaochu; Jiang, Jingmei; Liu, Changwei; Shen, Keng; Wang, Zixing; Han, Wei; Liu, Xingrong; Lin, Guole; Zhang, Ye; Zhang, Ying; Ma, Yufen; Bo, Haixin; Zhao, Yupei
2017-06-15
Surgical safety has emerged as a crucial global health issue in the past two decades. Although several safety-enhancing tools are available, the pace of large-scale improvement remains slow, especially in developing countries such as China. The present project (Modern Surgery and Anesthesia Safety Management System Construction and Promotion) aims to develop and validate system-based integrated approaches for reducing perioperative deaths and complications using a multicentre, multistage design. The project involves collection of clinical and outcome information for 1 20 000 surgical inpatients at four regionally representative academic/teaching general hospitals in China during three sequential stages: preparation and development, effectiveness validation and improvement of implementation for promotion. These big data will provide the evidence base for the formulation, validation and improvement processes of a system-based stratified safety intervention package covering the entire surgical pathway. Attention will be directed to managing inherent patient risks and regulating medical safety behaviour. Information technology will facilitate data collection and intervention implementation, provide supervision mechanisms and guarantee transfer of key patient safety messages between departments and personnel. Changes in rates of deaths, surgical complications during hospitalisation, length of stay, system adoption and implementation rates will be analysed to evaluate effectiveness and efficiency. This study was approved by the institutional review boards of Peking Union Medical College Hospital, First Hospital of China Medical University, Qinghai Provincial People's Hospital, Xiangya Hospital Central South University and the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences. Study findings will be disseminated via peer-reviewed journals, conference presentations and patent papers. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
-
Yu, Xiaochu; Jiang, Jingmei; Liu, Changwei; Shen, Keng; Wang, Zixing; Han, Wei; Liu, Xingrong; Lin, Guole; Zhang, Ye; Zhang, Ying; Ma, Yufen; Bo, Haixin; Zhao, Yupei
2017-01-01
Introduction Surgical safety has emerged as a crucial global health issue in the past two decades. Although several safety-enhancing tools are available, the pace of large-scale improvement remains slow, especially in developing countries such as China. The present project (Modern Surgery and Anesthesia Safety Management System Construction and Promotion) aims to develop and validate system-based integrated approaches for reducing perioperative deaths and complications using a multicentre, multistage design. Methods and analysis The project involves collection of clinical and outcome information for 1 20 000 surgical inpatients at four regionally representative academic/teaching general hospitals in China during three sequential stages: preparation and development, effectiveness validation and improvement of implementation for promotion. These big data will provide the evidence base for the formulation, validation and improvement processes of a system-based stratified safety intervention package covering the entire surgical pathway. Attention will be directed to managing inherent patient risks and regulating medical safety behaviour. Information technology will facilitate data collection and intervention implementation, provide supervision mechanisms and guarantee transfer of key patient safety messages between departments and personnel. Changes in rates of deaths, surgical complications during hospitalisation, length of stay, system adoption and implementation rates will be analysed to evaluate effectiveness and efficiency. Ethics and dissemination This study was approved by the institutional review boards of Peking Union Medical College Hospital, First Hospital of China Medical University, Qinghai Provincial People’s Hospital, Xiangya Hospital Central South University and the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences. Study findings will be disseminated via peer-reviewed journals, conference presentations and patent papers. PMID:28619774
-
Godycki-Cwirko, Maciek; Esmail, Aneez; Dovey, Susan; Wensing, Michel; Parker, Dianne; Kowalczyk, Anna; Błaszczyk, Honorata; Kosiek, Katarzyna
2015-01-01
ABSTRACT Background: Despite patient safety being recognized as an important healthcare issue in the European Union, there has been variable implementation of patient safety initiatives in Central and Eastern Europe (CEE). Objective: To assess the status of patient safety initiatives in countries in CEE; to describe a process of engagement in Poland, which can serve as a template for the implementation of patient safety initiatives in primary care. Methods: A mixed methods design was used. We conducted a review of literature focusing on publications from CEE, an inventory of patient safety initiatives in CEE countries, interviews with key informants, international survey, review of national reporting systems, and pilot demonstrator project in Poland with implementation of patient safety toolkits assessment. Results: There was no published patient safety research from Albania, Belarus, Greece, Latvia, Lithuania, Romania, or Russia. Nine papers were found from Bulgaria, Croatia, the Czech Republic, Poland, Serbia, and Slovenia. In most of the CEE countries, patient safety had been addressed at the policy level although the focus was mainly in hospital care. There was a dearth of activity in primary care. The use of patient improvement strategies was low. Conclusion: International cooperation as exemplified in the demonstrator project can help in the development and implementation of patient safety initiatives in primary care in changing the emphasis away from a blame culture to one where greater emphasis is placed on improvement and learning. PMID:26339839
-
Open wide: looking into the safety culture of dental school clinics.
Ramoni, Rachel; Walji, Muhammad F; Tavares, Anamaria; White, Joel; Tokede, Oluwabunmi; Vaderhobli, Ram; Kalenderian, Elsbeth
2014-05-01
Although dentists perform highly technical procedures in complex environments, patient safety has not received the same focus in dentistry as in medicine. Cultivating a robust patient safety culture is foundational to minimizing patient harm, but little is known about how dental teams view patient safety or the patient safety culture within their practice. As a step toward rectifying that omission, the goals of this study were to benchmark the patient safety culture in three U.S. dental schools, identifying areas for improvement. The extensively validated Medical Office Survey on Patient Safety Culture (MOSOPS), developed by the Agency for Healthcare Research and Quality, was administered to dental faculty, dental hygienists, dental students, and staff at the three schools. Forty-seven percent of the 328 invited individuals completed the survey. The "Teamwork" category received the highest marks and "Patient Care Tracking and Follow-Up" and "Leadership Support for Patient Safety" the lowest. Only 48 percent of the respondents rated systems and processes in place to prevent/catch patient problems as good/excellent. All patient safety dimensions received lower marks than in medical practices. These findings and the inherent risk associated with dental procedures lead to the conclusion that dentistry in general, and academic dental clinics in particular, stands to benefit from an increased focus on patient safety. This first published use of the MOSOPS in a dental clinic setting highlights both clinical and educational priorities for improving the safety of care in dental school clinics.
-
[Improving inpatient pharmacoterapeutic process by Lean Six Sigma methodology].
Font Noguera, I; Fernández Megía, M J; Ferrer Riquelme, A J; Balasch I Parisi, S; Edo Solsona, M D; Poveda Andres, J L
2013-01-01
Lean Six Sigma methodology has been used to improve care processes, eliminate waste, reduce costs, and increase patient satisfaction. To analyse the results obtained with Lean Six Sigma methodology in the diagnosis and improvement of the inpatient pharmacotherapy process during structural and organisational changes in a tertiary hospital. 1.000 beds tertiary hospital. prospective observational study. The define, measure, analyse, improve and control (DMAIC), were deployed from March to September 2011. An Initial Project Charter was updated as results were obtained. 131 patients with treatments prescribed within 24h after admission and with 4 drugs. safety indicators (medication errors), and efficiency indicators (complaints and time delays). Proportion of patients with a medication error was reduced from 61.0% (25/41 patients) to 55.7% (39/70 patients) in four months. Percentage of errors (regarding the opportunities for error) decreased in the different phases of the process: Prescription: from 5.1% (19/372 opportunities) to 3.3% (19/572 opportunities); Preparation: from 2.7% (14/525 opportunities) to 1.3% (11/847 opportunities); and administration: from 4.9% (16/329 opportunities) to 3.0% (13/433 opportunities). Nursing complaints decreased from 10.0% (2119/21038 patients) to 5.7% (1779/31097 patients). The estimated economic impact was 76,800 euros saved. An improvement in the pharmacotherapeutic process and a positive economic impact was observed, as well as enhancing patient safety and efficiency of the organization. Standardisation and professional training are future Lean Six Sigma candidate projects. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.
-
Schneider, Erika; Ruggieri, Paul; Fromwiller, Lauren; Underwood, Reginald; Gurland, Brooke; Yurkschatt, Cynthia; Kubiak, Kevin; Obuchowski, Nancy A
2013-12-01
Delays between order and magnetic resonance (MR) exam often result when using the conventional paper-based MR safety screening process. The impact of an electronic MR safety screening process imbedded in a computerized physician order entry (CPOE) system was evaluated. Retrospective chart review of 4 months of inpatient MR exam orders and reports was performed before and after implementation of electronic MR safety documentation. Time from order to MR exam completion, time from MR exam completion to final radiology report, and time from first order to final report were analyzed by exam anatomy. Length of stay (LOS) and date of service within the admission were also analyzed. We evaluated 1947 individual MR orders in 1549 patients under an institutional review board exemption and a waiver of informed consent. Implementation of the electronic safety screening process resulted in a significant decrease of 1.1 hours (95% confidence interval 1.0-1.3 hours) in the mean time between first order to final report and a nonsignificant decrease of 0.8 hour in the median time from first order to exam end. There was a 1-day reduction (P = .697) in the time from admission to the MR exam compared to the paper process. No significant change in LOS was found except in neurological intensive care patients imaged within the first 24 hours of their admission, where a mean 0.9-day decrease was found. Benefits of an electronic process for MR safety screening include enabling inpatients to have decreased time to MR exams, thus enabling earlier diagnosis and treatment and reduced LOS. Copyright © 2013 AUR. Published by Elsevier Inc. All rights reserved.
-
Strayer, Reuben J; Shy, Bradley D; Shearer, Peter L
2014-12-01
Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error. To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the month's case reviews are presented, learning points discussed, and corrective actions are proposed. By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome. Copyright © 2014 Elsevier Inc. All rights reserved.
-
Retrofit concept for small safety related stationary machines
NASA Astrophysics Data System (ADS)
Epple, S.; Jalba, C. K.; Muminovic, A.; Jung, R.
2017-05-01
More and more old machines have the problem that their control electronics’ lifecycle comes to its intended end of life, whilst the mechanics itself and process capability is still in very good condition. This article shows an example of a reactive ion etcher originally built in 1988, which was refitted with a new control concept. The original control unit was repaired several times based on manufacturer’s obsolescence management. At start of the retrofit project the integrated circuits were no longer available for further repair of the original control unit. Safety, repeatability and stability of the process were greatly improved.
-
Tvedt, Christine; Sjetne, Ingeborg Strømseng; Helgeland, Jon; Bukholm, Geir
2012-01-01
Objectives The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing. Design This is an observational cross-sectional study using survey methods. Setting Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey. Participants All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses' practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture. Outcome measures Nurses' assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures. Results Quality system, nurse–physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses’ affiliations to medical department and hospital type. Conclusions Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care. PMID:23263021
-
The European space suit, a design for productivity and crew safety
NASA Astrophysics Data System (ADS)
Skoog, A. Ingemar; Berthier, S.; Ollivier, Y.
In order to fulfil the two major mission objectives, i.e. support planned and unplanned external servicing of the COLUMBUS FFL and support the HERMES vehicle for safety critical operations and emergencies, the European Space Suit System baseline configuration incorporates a number of design features, which shall enhance the productivity and the crew safety of EVA astronauts. The work in EVA is today - and will be for several years - a manual work. Consequently, to improve productivity, the first challenge is to design a suit enclosure which minimizes movement restrictions and crew fatigue. It is covered by the "ergonomic" aspect of the suit design. Furthermore, it is also necessary to help the EVA crewmember in his work, by giving him the right information at the right time. Many solutions exist in this field of Man-Machine Interface, from a very simple system, based on cuff check lists, up to advanced systems, including Head-Up Displays. The design concept for improved productivity encompasses following features: • easy donning/doffing thru rear entry, • suit ergonomy optimisation, • display of operational information in alpha-numerical and graphical from, and • voice processing for operations and safety critical information. Concerning crew safety the major design features are: • a lower R-factor for emergency EVA operations thru incressed suit pressure, • zero prebreath conditions for normal operations, • visual and voice processing of all safety critical functions, and • an autonomous life support system to permit unrestricted operations around HERMES and the CFFL. The paper analyses crew safety and productivity criteria and describes how these features are being built into the design of the European Space Suit System.
-
FHWA White Paper on Mobile Ad Hoc Networks
DOT National Transportation Integrated Search
2018-01-01
Advanced next generation communications technologies offer the potential to greatly improve safety, system efficiency, and mobility across our Nations roadways. These new technologies and processes can address both traditionally difficult as well ...
-
Framework for the Intelligent Transportation System (ITS) Evaluation : ITS Integration Activities
DOT National Transportation Integrated Search
2006-08-01
Intelligent Transportation Systems (ITS) represent a significant opportunity to improve the efficiency and safety of the surface transportation system. ITS includes technologies to support information processing, communications, surveillance and cont...
-
Material Gradients in Oxygen System Components Improve Safety
NASA Technical Reports Server (NTRS)
Forsyth, Bradley S.
2011-01-01
Oxygen system components fabricated by Laser Engineered Net Shaping (TradeMark) (LENS(TradeMark)) could result in improved safety and performance. LENS(TradeMark) is a near-net shape manufacturing process fusing powdered materials injected into a laser beam. Parts can be fabricated with a variety of elemental metals, alloys, and nonmetallic materials without the use of a mold. The LENS(TradeMark) process allows the injected materials to be varied throughout a single workpiece. Hence, surfaces exposed to oxygen could be constructed of an oxygen-compatible material while the remainder of the part could be one chosen for strength or reduced weight. Unlike conventional coating applications, a compositional gradient would exist between the two materials, so no abrupt material boundary exists. Without an interface between dissimilar materials, there is less tendency for chipping or cracking associated with thermal-expansion mismatches.
-
Zhu, Ling-Ling; Lv, Na; Zhou, Quan
2016-12-01
We read, with great interest, the study by Baldwin and Rodriguez (2016), which described the role of the verification nurse and details the verification process in identifying errors related to chemotherapy orders. We strongly agree with their findings that a verification nurse, collaborating closely with the prescribing physician, pharmacist, and treating nurse, can better identify errors and maintain safety during chemotherapy administration.
-
USDA-ARS?s Scientific Manuscript database
Queso Fresco (QF), a popular high-moisture, high-pH Hispanic-style cheese sold in the U.S., underwent high-pressure processing (HPP), which has the potential to improve the safety of cheese, to determine the effects of this process on quality traits of the cheese. Starter-free rennet-set QF (manufa...
-
Practice of Regulatory Science (Development of Medical Devices).
Niimi, Shingo
2017-01-01
Prototypes of medical devices are made in accordance with the needs of clinical practice, and for systems required during the initial process of medical device development for new surgical practices. Verification of whether these prototypes produce the intended performance specifications is conducted using basic tests such as mechanical and animal tests. The prototypes are then improved and modified until satisfactory results are obtained. After a prototype passes through a clinical trial process similar to that for new drugs, application for approval is made. In the approval application process, medical devices are divided into new, improved, and generic types. Reviewers judge the validity of intended use, indications, operation procedures, and precautions, and in addition evaluate the balance between risk and benefit in terms of efficacy and safety. Other characteristics of medical devices are the need for the user to attain proficiency in usage techniques to ensure efficacy and safety, and the existence of a variety of medical devices for which assessment strategies differ, including differences in impact on the body in cases in which a physical burden to the body or failure of a medical device develops. Regulatory science of medical devices involves prediction, judgment, and evaluation of efficacy, safety, and quality, from which data result which can become indices in the development stages from design to application for approval. A reduction in the number of animals used for testing, improvement in efficiency, reduction of the necessity for clinical trials, etc. are expected through rational setting of evaluation items.
-
John, Susan D; Moore, Quentin T; Herrmann, Tracy; Don, Steven; Powers, Kevin; Smith, Susan N; Morrison, Greg; Charkot, Ellen; Mills, Thalia T; Rutz, Lois; Goske, Marilyn J
2013-10-01
Transition from film-screen to digital radiography requires changes in radiographic technique and workflow processes to ensure that the minimum radiation exposure is used while maintaining diagnostic image quality. Checklists have been demonstrated to be useful tools for decreasing errors and improving safety in several areas, including commercial aviation and surgical procedures. The Image Gently campaign, through a competitive grant from the FDA, developed a checklist for technologists to use during the performance of digital radiography in pediatric patients. The checklist outlines the critical steps in digital radiography workflow, with an emphasis on steps that affect radiation exposure and image quality. The checklist and its accompanying implementation manual and practice quality improvement project are open source and downloadable at www.imagegently.org. The authors describe the process of developing and testing the checklist and offer suggestions for using the checklist to minimize radiation exposure to children during radiography. Copyright © 2013 American College of Radiology. All rights reserved.
-
Banks, Peter; Brown, Richard; Laslowski, Alex; Daniels, Yvonne; Branton, Phil; Carpenter, John; Zarbo, Richard; Forsyth, Ramses; Liu, Yan-hui; Kohl, Shane; Diebold, Joachim; Masuda, Shinobu; Plummer, Tim
2017-01-01
Background: Anatomic pathology laboratory workflow consists of 3 major specimen handling processes. Among the workflow are preanalytic, analytic, and postanalytic phases that contain multistep subprocesses with great impact on patient care. A worldwide representation of experts came together to create a system of metrics, as a basis for laboratories worldwide, to help them evaluate and improve specimen handling to reduce patient safety risk. Method: Members of the Initiative for Anatomic Pathology Laboratory Patient Safety (IAPLPS) pooled their extensive expertise to generate a list of metrics highlighting processes with high and low risk for adverse patient outcomes. Results: Our group developed a universal, comprehensive list of 47 metrics for patient specimen handling in the anatomic pathology laboratory. Steps within the specimen workflow sequence are categorized as high or low risk. In general, steps associated with the potential for specimen misidentification correspond to the high-risk grouping and merit greater focus within quality management systems. Primarily workflow measures related to operational efficiency can be considered low risk. Conclusion: Our group intends to advance the widespread use of these metrics in anatomic pathology laboratories to reduce patient safety risk and improve patient care with development of best practices and interlaboratory error reporting programs. PMID:28340232
-
Banks, Peter; Brown, Richard; Laslowski, Alex; Daniels, Yvonne; Branton, Phil; Carpenter, John; Zarbo, Richard; Forsyth, Ramses; Liu, Yan-Hui; Kohl, Shane; Diebold, Joachim; Masuda, Shinobu; Plummer, Tim; Dennis, Eslie
2017-05-01
Anatomic pathology laboratory workflow consists of 3 major specimen handling processes. Among the workflow are preanalytic, analytic, and postanalytic phases that contain multistep subprocesses with great impact on patient care. A worldwide representation of experts came together to create a system of metrics, as a basis for laboratories worldwide, to help them evaluate and improve specimen handling to reduce patient safety risk. Members of the Initiative for Anatomic Pathology Laboratory Patient Safety (IAPLPS) pooled their extensive expertise to generate a list of metrics highlighting processes with high and low risk for adverse patient outcomes. : Our group developed a universal, comprehensive list of 47 metrics for patient specimen handling in the anatomic pathology laboratory. Steps within the specimen workflow sequence are categorized as high or low risk. In general, steps associated with the potential for specimen misidentification correspond to the high-risk grouping and merit greater focus within quality management systems. Primarily workflow measures related to operational efficiency can be considered low risk. Our group intends to advance the widespread use of these metrics in anatomic pathology laboratories to reduce patient safety risk and improve patient care with development of best practices and interlaboratory error reporting programs. © American Society for Clinical Pathology 2017.
-
Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong
2016-01-01
Background Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. Objective To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. Methods A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. Results The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of “staff training and skills” were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. Conclusion The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety. PMID:27524887
-
Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong
2016-01-01
Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of "staff training and skills" were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety.
-
Haase, Rocco; Wunderlich, Maria; Dillenseger, Anja; Kern, Raimar; Akgün, Katja; Ziemssen, Tjalf
2018-04-01
For safety evaluation, randomized controlled trials (RCTs) are not fully able to identify rare adverse events. The richest source of safety data lies in the post-marketing phase. Real-world evidence (RWE) and observational studies are becoming increasingly popular because they reflect usefulness of drugs in real life and have the ability to discover uncommon or rare adverse drug reactions. Areas covered: Adding the documentation of psychological symptoms and other medical disciplines, the necessity for a complex documentation becomes apparent. The collection of high-quality data sets in clinical practice requires the use of special documentation software as the quality of data in RWE studies can be an issue in contrast to the data obtained from RCTs. The MSDS3D software combines documentation of patient data with patient management of patients with multiple sclerosis. Following a continuous development over several treatment-specific modules, we improved and expanded the realization of safety management in MSDS3D with regard to the characteristics of different treatments and populations. Expert opinion: eHealth-enhanced post-authorisation safety study may complete the fundamental quest of RWE for individually improved treatment decisions and balanced therapeutic risk assessment. MSDS3D is carefully designed to contribute to every single objective in this process.
-
Feedback from incident reporting: information and action to improve patient safety.
Benn, J; Koutantji, M; Wallace, L; Spurgeon, P; Rejman, M; Healey, A; Vincent, C
2009-02-01
Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. The research comprised a mixed methods review to investigate mechanisms of effective feedback for healthcare, drawing upon experience within established reporting programmes in high-risk industry and transport domains. Systematic searches of published literature were undertaken, and 23 case studies describing incident reporting programmes with feedback were identified for analysis from the international healthcare literature. Semistructured interviews were undertaken with 19 subject matter experts across a range of domains, including: civil aviation, maritime, energy, rail, offshore production and healthcare. In analysis, qualitative information from several sources was synthesised into practical requirements for developing effective feedback in healthcare. Both action and information feedback mechanisms were identified, serving safety awareness, improvement and motivational functions. The provision of actionable feedback that visibly improved systems was highlighted as important in promoting future reporting. Fifteen requirements for the design of effective feedback systems were identified, concerning: the role of leadership, the credibility and content of information, effective dissemination channels, the capacity for rapid action and the need for feedback at all levels of the organisation, among others. Above all, the safety-feedback cycle must be closed by ensuring that reporting, analysis and investigation result in timely corrective actions that effectively address vulnerabilities in existing work systems. Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.
-
Edwards, Eric S; Edwards, Evan T; Simons, F Estelle R; North, Robert
2015-05-01
The systematic application of human factors engineering (HFE) principles to the development of drug-device combination products, including epinephrine auto-injectors (EAIs), has the potential to improve the effectiveness and safety of drug administration. A PubMed search was performed to assess the role of HFE in the development of drug-device combination products. The following keywords were used in different combinations: 'human factors engineering,' 'human factors,' 'medical products,' 'epinephrine/adrenaline auto-injector,' 'healthcare' and 'patient safety.' This review provides a summary of HFE principles and their application to the development of drug-device combination products as advised by the US FDA. It also describes the HFE process that was applied to the development of Auvi-Q, a novel EAI, highlighting specific steps that occurred during the product-development program. For drug-device combination products, device labeling and usability are critical and have the potential to impact clinical outcomes. Application of HFE principles to the development of drug-delivery devices has the potential to improve product quality and reliability, reduce risk and improve patient safety when applied early in the development process. Additional clinical and real-world studies will confirm whether the application of HFE has helped to develop an EAI that better meets the needs of patients at risk of anaphylaxis.
-
Sens, Brigitte
2010-01-01
The concept of general process orientation as an instrument of organisation development is the core principle of quality management philosophy, i.e. the learning organisation. Accordingly, prestigious quality awards and certification systems focus on process configuration and continual improvement. In German health care organisations, particularly in hospitals, this general process orientation has not been widely implemented yet - despite enormous change dynamics and the requirements of both quality and economic efficiency of health care processes. But based on a consistent process architecture that considers key processes as well as management and support processes, the strategy of excellent health service provision including quality, safety and transparency can be realised in daily operative work. The core elements of quality (e.g., evidence-based medicine), patient safety and risk management, environmental management, health and safety at work can be embedded in daily health care processes as an integrated management system (the "all in one system" principle). Sustainable advantages and benefits for patients, staff, and the organisation will result: stable, high-quality, efficient, and indicator-based health care processes. Hospitals with their broad variety of complex health care procedures should now exploit the full potential of total process orientation. Copyright © 2010. Published by Elsevier GmbH.
-
Mills, Pamela Ruth; Weidmann, Anita Elaine; Stewart, Derek
2017-12-01
Background Electronic prescribing system implementation is recommended to improve patient safety and general practitioner's discharge information communication. There is a paucity of information about hospital staff perspectives before and after system implementation. Objective To explore hospital staff views regarding prescribing and discharge communication systems before and after hospital electronic prescribing and medicines administration (HEPMA) system implementation. Setting A 560 bed United Kingdom district general hospital. Methods Semi-structured face-to-face qualitative interviews with a purposive sample of hospital staff involved in the prescribing and discharge communication process. Interviews transcribed verbatim and coded using the Framework Approach. Behavioural aspects mapped to Theoretical Domains Framework (TDF) to highlight associated behavioural change determinants. Main outcome measure Staff perceptions before and after implementation. Results Nineteen hospital staff (consultant doctors, junior doctors, pharmacists and advanced nurse practitioners) participated before and after implementation. Pre-implementation main themes were inpatient chart and discharge letter design and discharge communication process with issues of illegible and inaccurate information. Improved safety was anticipated after implementation. Post-implementation themes were improved inpatient chart clarity and discharge letter quality. TDF domains relevant to staff behavioural determinants preimplementation were knowledge (task or environment); skills (competence); social/professional roles and identity; beliefs about capabilities; environmental context and resources (including incidents). An additional two were relevant post-implementation: social influences and behavioural regulation (including self-monitoring). Participants described challenges and patient safety concerns pre-implementation which were mostly resolved post-implementation. Conclusion HEPMA implementation produced perceptions of patient safety improvement. TDF use enabled behaviour change analysis due to implementation, for example, staff adoption of behaviours to ensure general practitioners receive good quality discharge information.
-
The role of individual diligence in improving safety.
Corbett, Angus; Travaglia, Jo; Braithwaite, Jeffrey
2011-01-01
This paper aims to be a theoretical examination of the role of individuals in sponsoring and facilitating effective, systemic change in organisations. Using reports of a number of high-profile initiatives to improve patient safety, it seeks to analyse the role of individual health care professionals in developing and facilitating new systems of care that improve safety and quality. The paper uses recent work in sociology that is concerned with the phenomenon of "sociological citizenship". The authors test whether successful initiators of change in health care can be described as sociological citizens. This notion of sociological citizens is applied to a number of highly successful initiatives to improve safety and quality to extrapolate the factors associated with individual clinician leadership, which may have affected the success of such endeavours. In each of the examples analysed the initiators of change can be characterised as sociological citizens. In reviewing the roles of these charismatic individuals it is evident that they see the relational interdependence between the individuals and organisations and that they use this information to achieve both professional and organisational objectives. The paper uses a case study method to investigate the usefulness of the role of sociological citizenship in interventions that aim to improve patient safety. The paper reviews the key concepts and uses of the concept of sociological citizenship to produce a framework against which the case studies were assessed. The authors suggest that a goal of policy for improving patient safety should be directed to the problem of how hospitals and health care organisations can create the conditions for encouraging the individual diligence and care that is needed to support reliable, safe health care practices. Improving the safety and quality of health care is an important public health initiative. It has also proven to be difficult to achieve sustained reductions in the harm caused by the occurrence of adverse events in health care. The process of linking individual diligence with service outcomes may help to overcome one of the enduring struggles of health care systems around the world: the policy-practice divide. The paper directs attention towards the role of sociological citizenship in health care systems and organisations.
-
Quick Response codes for surgical safety: a prospective pilot study.
Dixon, Jennifer L; Smythe, William Roy; Momsen, Lara S; Jupiter, Daniel; Papaconstantinou, Harry T
2013-09-01
Surgical safety programs have been shown to reduce patient harm; however, there is variable compliance. The purpose of this study is to determine if innovative technology such as Quick Response (QR) codes can facilitate surgical safety initiatives. We prospectively evaluated the use of QR codes during the surgical time-out for 40 operations. Feasibility and accuracy were assessed. Perceptions of the current time-out process and the QR code application were evaluated through surveys using a 5-point Likert scale and binomial yes or no questions. At baseline (n = 53), survey results from the surgical team agreed or strongly agreed that the current time-out process was efficient (64%), easy to use (77%), and provided clear information (89%). However, 65% of surgeons felt that process improvements were needed. Thirty-seven of 40 (92.5%) QR codes scanned successfully, of which 100% were accurate. Three scan failures resulted from excessive curvature or wrinkling of the QR code label on the body. Follow-up survey results (n = 33) showed that the surgical team agreed or strongly agreed that the QR program was clearer (70%), easier to use (57%), and more accurate (84%). Seventy-four percent preferred the QR system to the current time-out process. QR codes accurately transmit patient information during the time-out procedure and are preferred to the current process by surgical team members. The novel application of this technology may improve compliance, accuracy, and outcomes. Copyright © 2013 Elsevier Inc. All rights reserved.
-
Giesbrecht, Vanessa; Au, Selena
2016-11-01
The morbidity and mortality conference (MMC) provides a valuable opportunity to review patient care processes and safety concerns, aligning with a growing quality improvement (QI) mandate. Yet the structure, processes, and aims of many MMCs are often ill-defined. This review summarizes strategies employed by medical, surgical, and critical care departments in the development of patient safety-centered MMCs. A structured narrative review of literature was conducted using combinations of the search terms "morbidity and mortality conference(s)," "morbidity and mortality meetings," or "morbidity and mortality round(s)." The titles and abstracts of 250 returned articles were screened; 76 articles were reviewed in full, with 32 meeting the full inclusion criteria. The literature review elicited a number of methods used by medical, surgical, and critical care MMCs to emphasize QI and patient safety outcomes. A list of actionable changes made in each article was compiled. Five themes common to QI-centered MMCs were identified: (1) defining the role of the MMC, (2) involving stakeholders, (3) detecting and selecting appropriate cases for presentation, (4) structuring goal-directed discussion, and (5) forming recommendations and assigning follow-up. Innovative methods to pair adverse event screening with MMCs were superior to nonstructured voluntary reporting and case selection for overall morbidity detection. Structured case review, discussion, and follow-up were more likely to lead to implementing systems-based change, and interdisciplinary MMCs were associated with a greater likelihood of forming an action item. The modern patient safety-centered MMC shares common themes of practices that can be adopted by institutions looking to create a venue for analysis of care processes, a platform to launch QI initiatives, and a culture of safety. Copyright 2016 The Joint Commission.
-
“Health Courts” and Accountability for Patient Safety
Mello, Michelle M; Studdert, David M; Kachalia, Allen B; Brennan, Troyen A
2006-01-01
Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or ‘health courts,’ attract considerable policy interest during malpractice ‘crises,’ including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations. PMID:16953807
-
Wolff, André P; Boermeester, Marja; Janssen, Ingrid; Pols, Margreet; Damen, Johan
2010-01-01
In view of the shortcomings of the organisation of the perioperative process that have been ascertained by the Dutch Health Inspectorate (IGZ), the Inspectorate has requested hospitals and care professionals to implement measures to improve this situation. In response to the IGZ's first report, the Dutch Institute for Healthcare Improvement (CBO) has developed the national, multiprofessional guidelines entitled 'Preoperative Trajectory' which were published in January 2010. Implementation of these guidelines should improve communication between professionals and lead to standardization and transparency of the preoperative patient care process, with uniform handovers and clear responsibilities. These guidelines are the first to provide recommendations at process of care level which are intended to increase patient safety and reduce the risk of damage to patients.
-
Park, Peter Y; Young, Jason
2012-03-01
An important potential benefit of a jurisdiction developing an upper-level traffic safety policy statement, such as a strategic highway safety plan (SHSP) or a traffic safety action plan, is the creation of a manageable number of focus areas, known as emphasis areas. The responsible agencies in the jurisdiction can then direct their finite resources in a systematic and strategic way designed to maximize the effort to reduce the number and severity of roadway collisions. In the United States, the federal government through AASHTO has suggested 22 potential emphasis areas. In Canada, CCMTA's 10 potential emphasis areas have been listed for consideration. This study reviewed the SHSP and traffic safety action plan of 53 jurisdictions in North America, and conducted descriptive data analyses to clarify the issues that currently affect the selection and prioritization process of jurisdiction-specific emphasis areas. We found that the current process relies heavily on high-level collision data analysis and communication among the SHSP stakeholders, but may not be the most efficient and effective way of selecting and prioritizing the emphasis areas and allocating safety improvement resources. This study then formulated a formal collision diagnosis test, known as the beta-binomial test, to clarify and illuminate the selection and the prioritization of jurisdiction-specific emphasis areas. We developed numerical examples to demonstrate how engineers can apply the proposed diagnosis test to improve the selection and prioritization of individual jurisdictions' emphasis areas. Copyright © 2011 Elsevier Ltd. All rights reserved.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Farren Hunt
Idaho National Laboratory (INL) performed an Annual Effectiveness Review of the Integrated Safety Management System (ISMS), per 48 Code of Federal Regulations (CFR) 970.5223 1, “Integration of Environment, Safety and Health into Work Planning and Execution.” The annual review assessed Integrated Safety Management (ISM) effectiveness, provided feedback to maintain system integrity, and identified target areas for focused improvements and assessments for fiscal year (FY) 2013. Results of the FY 2012 annual effectiveness review demonstrated that the INL’s ISMS program was significantly strengthened. Actions implemented by the INL demonstrate that the overall Integrated Safety Management System is sound and ensures safemore » and successful performance of work while protecting workers, the public, and environment. This report also provides several opportunities for improvement that will help further strengthen the ISM Program and the pursuit of safety excellence. Demonstrated leadership and commitment, continued surveillance, and dedicated resources have been instrumental in maturing a sound ISMS program. Based upon interviews with personnel, reviews of assurance activities, and analysis of ISMS process implementation, this effectiveness review concludes that ISM is institutionalized and is “Effective”.« less
-
Reliability enhancement of APR + diverse protection system regarding common cause failures
DOE Office of Scientific and Technical Information (OSTI.GOV)
Oh, Y. G.; Kim, Y. M.; Yim, H. S.
2012-07-01
The Advanced Power Reactor Plus (APR +) nuclear power plant design has been developed on the basis of the APR1400 (Advanced Power Reactor 1400 MWe) to further enhance safety and economics. For the mitigation of Anticipated Transients Without Scram (ATWS) as well as Common Cause Failures (CCF) within the Plant Protection System (PPS) and the Emergency Safety Feature - Component Control System (ESF-CCS), several design improvement features have been implemented for the Diverse Protection System (DPS) of the APR + plant. As compared to the APR1400 DPS design, the APR + DPS has been designed to provide the Safety Injectionmore » Actuation Signal (SIAS) considering a large break LOCA accident concurrent with the CCF. Additionally several design improvement features, such as channel structure with redundant processing modules, and changes of system communication methods and auto-system test methods, are introduced to enhance the functional reliability of the DPS. Therefore, it is expected that the APR + DPS can provide an enhanced safety and reliability regarding possible CCF in the safety-grade I and C systems as well as the DPS itself. (authors)« less
-
Clarke, Sharon; Taylor, Ian
2018-05-15
There is increasing evidence to suggest that leaders need to use a combination of leader behaviors to successfully improve safety, including both transformational and transactional styles, but there has been limited testing of this idea. We developed a leadership intervention, based on supervisor training in both transformational and active transactional behaviors, and implemented it with supervisors at a UK-based chemical processing company. The study found that the supervisory training intervention led to significant improvements in perceived employee safety climate, over an eight-week period, relative to the comparison group. Although we found no change in the frequency of leader behaviors, the intervention was effective in helping supervisors to apply active transactional leader behaviors in a safety-critical context. The results indicated that transformational leader behaviors were already at a high level and effectively linked to safety. Our findings suggest not only that employees may be receptive to safety-related active transactional behaviors within high-risk situations, but furthermore, leaders can be trained to adjust their behaviors to focus more on active transactional behaviors in safety-critical contexts. Copyright © 2018 Elsevier Ltd. All rights reserved.
-
Aligning the 3Rs with new paradigms in the safety assessment of chemicals.
Burden, Natalie; Mahony, Catherine; Müller, Boris P; Terry, Claire; Westmoreland, Carl; Kimber, Ian
2015-04-01
There are currently several factors driving a move away from the reliance on in vivo toxicity testing for the purposes of chemical safety assessment. Progress has started to be made in the development and validation of non-animal methods. However, recent advances in the biosciences provide exciting opportunities to accelerate this process and to ensure that the alternative paradigms for hazard identification and risk assessment deliver lasting 3Rs benefits, whilst improving the quality and relevance of safety assessment. The NC3Rs, a UK-based scientific organisation which supports the development and application of novel 3Rs techniques and approaches, held a workshop recently which brought together over 20 international experts in the field of chemical safety assessment. The aim of this workshop was to review the current scientific, technical and regulatory landscapes, and to identify key opportunities towards reaching these goals. Here, we consider areas where further strategic investment will need to be focused if significant impact on 3Rs is to be matched with improved safety science, and why the timing is right for the field to work together towards an environment where we no longer rely on whole animal data for the accurate safety assessment of chemicals.
-
Patient safety challenges in a case study hospital--of relevance for transfusion processes?
Aase, Karina; Høyland, Sindre; Olsen, Espen; Wiig, Siri; Nilsen, Stein Tore
2008-10-01
The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.
-
Training for an effective health and safety committee in a small business setting.
Crollard, Allison; Neitzel, Richard L; Dominguez, Carlos F; Seixas, Noah S
2013-01-01
Health and safety committees are often heralded as a key element of successful health and safety programs, and are thought to represent a means of engaging workers in health and safety efforts. While the understanding of the factors that make these committees effective is growing, there are few resources for how to assist committees in developing these characteristics. This paper describes one approach to creating and implementing a training intervention aimed at improving health and safety committee function at one multilingual worksite. Short-term impacts were evaluated via questionnaire and qualitative observations of committee function. Results indicated high satisfaction with the training as well as modest increases in participation, cooperation, role clarity, and comfort with health and safety skills among committee members. The committee also made considerable achievements in establishing new processes for effective function. Similar interventions may be useful in other workplaces to increase health and safety committee success.
-
Lin, Yihan; Scott, John W; Yi, Sojung; Taylor, Kathryn K; Ntakiyiruta, Georges; Ntirenganya, Faustin; Banguti, Paulin; Yule, Steven; Riviello, Robert
2017-10-23
A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety. The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety. The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda. Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%). In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, p<0.01). All residents reported that the course would improve their ability to provide safer patient care, and 97.4% believed developing nontechnical skills would improve patient outcomes. Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global surgical safety. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.
-
The science of human factors: separating fact from fiction
Russ, Alissa L; Fairbanks, Rollin J; Karsh, Ben-Tzion; Militello, Laura G; Saleem, Jason J; Wears, Robert L
2013-01-01
Background Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement. Methods The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities. Results The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value. Conclusions The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety. PMID:23592760
-
Using failure mode and effects analysis to improve the safety of neonatal parenteral nutrition.
Arenas Villafranca, Jose Javier; Gómez Sánchez, Araceli; Nieto Guindo, Miriam; Faus Felipe, Vicente
2014-07-15
Failure mode and effects analysis (FMEA) was used to identify potential errors and to enable the implementation of measures to improve the safety of neonatal parenteral nutrition (PN). FMEA was used to analyze the preparation and dispensing of neonatal PN from the perspective of the pharmacy service in a general hospital. A process diagram was drafted, illustrating the different phases of the neonatal PN process. Next, the failures that could occur in each of these phases were compiled and cataloged, and a questionnaire was developed in which respondents were asked to rate the following aspects of each error: incidence, detectability, and severity. The highest scoring failures were considered high risk and identified as priority areas for improvements to be made. The evaluation process detected a total of 82 possible failures. Among the phases with the highest number of possible errors were transcription of the medical order, formulation of the PN, and preparation of material for the formulation. After the classification of these 82 possible failures and of their relative importance, a checklist was developed to achieve greater control in the error-detection process. FMEA demonstrated that use of the checklist reduced the level of risk and improved the detectability of errors. FMEA was useful for detecting medication errors in the PN preparation process and enabling corrective measures to be taken. A checklist was developed to reduce errors in the most critical aspects of the process. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
-
Bowie, Paul; Halley, Lyn; Blamey, Avril; Gillies, Jill; Houston, Neil
2016-01-29
To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting. Qualitative study using semistructured interviews. Data were analysed thematically. Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards. 27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence. The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
-
Bowie, Paul; Halley, Lyn; Blamey, Avril; Gillies, Jill; Houston, Neil
2016-01-01
Objectives To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting. Design Qualitative study using semistructured interviews. Data were analysed thematically. Subjects and setting Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards. Results 27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence. Conclusions The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted. PMID:26826149
-
Towards an International Classification for Patient Safety: key concepts and terms
Runciman, William; Hibbert, Peter; Thomson, Richard; Van Der Schaaf, Tjerk; Sherman, Heather; Lewalle, Pierre
2009-01-01
Background Understanding the patient safety literature has been compromised by the inconsistent use of language. Objectives To identify key concepts of relevance to the International Patient Safety Classification (ICPS) proposed by the World Alliance For Patient Safety of the World Health Organization (WHO), and agree on definitions and preferred terms. Methods Six principles were agreed upon—that the concepts and terms should: be applicable across the full spectrum of healthcare; be consistent with concepts from other WHO Classifications; have meanings as close as possible to those in colloquial use; convey the appropriate meanings with respect to patient safety; be brief and clear, without unnecessary or redundant qualifiers; be fit-for-purpose for the ICPS. Results Definitions and preferred terms were agreed for 48 concepts of relevance to the ICPS; these were described and the relationships between them and the ICPS were outlined. Conclusions The consistent use of key concepts, definitions and preferred terms should pave the way for better understanding, for comparisons between facilities and jurisdictions, and for trends to be tracked over time. Changes and improvements, translation into other languages and alignment with other sets of patient safety definitions will be necessary. This work represents the start of an ongoing process of progressively improving a common international understanding of terms and concepts relevant to patient safety. PMID:19147597
-
[Patient safety culture in Family practice residents of Galicia].
Portela Romero, Manuel; Bugarín González, Rosendo; Rodríguez Calvo, María Sol
To determine the views held by Family practice (FP) residents on the different dimensions of patient safety, in order to identify potential areas for improvement. A cross-sectional study. Seven FP of Galicia teaching units. 182 FP residents who completed the Medical Office Survey on Patient Safety Culture questionnaire. The Medical Office Survey on Patient Safety Culture questionnaire was chosen because it is translated, validated, and adapted to the Spanish model of Primary Care. The results were grouped into 12 composites assessed by the mentioned questionnaire. The study variables were the socio-demographic dimensions of the questionnaire, as well as occupational/professional variables: age, gender, year of residence, and teaching unit of FP of Galicia. The "Organisational learning" and "Teamwork" items were considered strong areas. However, the "Patient safety and quality issues", "Information exchange with other settings", and "Work pressure and pace" items were considered areas with significant potential for improvement. First-year residents obtained the best results and the fourth-year ones the worst. The results may indicate the need to include basic knowledge on patient safety in the teaching process of FP residents in order to increase and consolidate the fragile patient safety culture described in this study. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.
-
Resilient Practices in Maintaining Safety of Health Information Technologies
Ash, Joan S.; Sittig, Dean F.; Singh, Hardeep
2014-01-01
Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management. PMID:25866492
-
Qualitative study to explore stakeholder perceptions related to road safety in Hyderabad, India.
Tetali, Shailaja; Lakshmi, J K; Gupta, Shivam; Gururaj, G; Wadhwaniya, Shirin; Hyder, Adnan A
2013-12-01
The Bloomberg Philanthropies Global Road Safety Programme in India focuses on reduction of drink driving and increase in helmet usage in the city of Hyderabad. During the early stages of implementation, perceptions of stakeholders on road safety were explored as part of the monitoring and evaluation process for a better understanding of areas for improving road safety in Hyderabad. Fifteen in-depth interviews with government officials, subject experts, and road traffic injury victims, and four focus group discussions with trauma surgeons, medical interns, nurses, and taxi drivers were conducted, analysed manually, and presented as themes. Respondents found Hyderabad unsafe for road-users. Factors such as inadequate traffic laws, gaps in enforcement, lack of awareness, lack of political will, poor road engineering, and high-risk road users were identified as threats to road safety. The responsibility for road safety was assigned to both individual road-users and the government, with the former bearing the responsibility for safe traffic behaviour, and the latter for infrastructure provision and enforcement of regulations. The establishment of a lead agency to co-ordinate awareness generation, better road engineering, and stricter enforcement of traffic laws with economic and non-economic penalties for suboptimal traffic behaviour, could facilitate improved road safety in Hyderabad. Copyright © 2013 Elsevier Ltd. All rights reserved.
-
NCRP Program Area Committee 2: Operational Radiation Safety
DOE Office of Scientific and Technical Information (OSTI.GOV)
Pryor, Kathryn H.; Goldin, Eric M.
2016-02-29
Program Area Committee 2 of the National Council on Radiation Protection and Measurements provides guidance for radiation safety in occupational settings in a variety of industries and activities. The committee completed three reports in recent years covering recommendations for the development and administration of radiation safety programs for smaller educational institutions, requirements for self-assessment programs that improve radiation safety and identify and correct deficiencies, and a comprehensive process for effective investigation of radiological incidents. Ongoing work includes a report on sealed radioactive source controls and oversight of a report on radioactive nanomaterials focusing on gaps within current radiation safety programs.more » Future efforts may deal with operational radiation safety programs in fields such as the safe use of handheld and portable X-Ray fluorescence analyzers, occupational airborne radioactive contamination, unsealed radioactive sources, or industrial accelerators.« less
-
NASA Astrophysics Data System (ADS)
Zhu, Wenmin; Jia, Yuanhua
2018-01-01
Based on the risk management theory and the PDCA cycle model, requirements of the railway passenger transport safety production is analyzed, and the establishment of the security risk assessment team is proposed to manage risk by FTA with Delphi from both qualitative and quantitative aspects. The safety production committee is also established to accomplish performance appraisal, which is for further ensuring the correctness of risk management results, optimizing the safety management business processes and improving risk management capabilities. The basic framework and risk information database of risk management information system of railway passenger transport safety are designed by Ajax, Web Services and SQL technologies. The system realizes functions about risk management, performance appraisal and data management, and provides an efficient and convenient information management platform for railway passenger safety manager.
-
Auzoult, Laurent; Gangloff, Bernard
2018-04-20
In this study, we analyse the impact of the organizational culture and introduce a new variable, the integration of safety, which relates to the modalities for the implementation and adoption of safety in the work process, either through the activity or by the operator. One hundred and eighty employees replied to a questionnaire measuring the organizational climate, the safety climate and the integration of safety. We expected that implementation centred on the activity or on the operator would mediate the relationship between the organizational culture and the safety climate. The results support our assumptions. A regression analysis highlights the positive impact on the safety climate of organizational values of the 'rule' and 'support' type, as well as of integration by the operator and activity. Moreover, integration mediates the relation between these variables. The results suggest to take into account organizational culture and to introduce different implementation modalities to improve the safety climate.
-
Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses.
Baldwin, Abigail; Rodriguez, Elizabeth S
2016-02-01
The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. This article will describe the role of the VN and details of the verification process. To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed. A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.
-
Work zone performance monitoring application development.
DOT National Transportation Integrated Search
2016-10-01
The Federal Highway Administration (FHWA) requires state transportation agencies to (a) collect and analyze safety and mobility data to manage the work zone impacts of individual projects during construction and (b) improve overall agency processes a...
-
Mulkerin, Daniel L; Bergsbaken, Jason J; Fischer, Jessica A; Mulkerin, Mary J; Bohler, Aaron M; Mably, Mary S
2016-10-01
Use of oral chemotherapy is expanding and offers advantages while posing unique safety challenges. ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offer a framework for improving oral chemotherapy practice at the University of Wisconsin Carbone Cancer Center. With the goal of improving safety, quality, and uniformity within our oral chemotherapy practice, we conducted a gap analysis comparing our practice against ASCO/Oncology Nursing Society guidelines. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Recommendations and process changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, and standardizing documentation for dose modification. Revised processes allow pharmacists to review all orders for oral chemotherapy, and they support monitoring adherence and toxicity by using a library of scripted materials. Between August 2015 and January 2016, revised processes were implemented across the University of Wisconsin Carbone Cancer Center clinics. The following are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle monitoring of adherence and toxicity was achieved. We closed significant gaps between institutional practice and published standards for our oral chemotherapy practice and experienced steady improvement and sustainable performance in key metrics. We created an electronic definition of oral chemotherapies that allowed us to leverage our electronic health records. We believe our tools are broadly applicable.
-
Bergsbaken, Jason J.; Fischer, Jessica A.; Mulkerin, Mary J.; Bohler, Aaron M.; Mably, Mary S.
2016-01-01
Purpose: Use of oral chemotherapy is expanding and offers advantages while posing unique safety challenges. ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offer a framework for improving oral chemotherapy practice at the University of Wisconsin Carbone Cancer Center. Methods: With the goal of improving safety, quality, and uniformity within our oral chemotherapy practice, we conducted a gap analysis comparing our practice against ASCO/Oncology Nursing Society guidelines. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Recommendations and process changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, and standardizing documentation for dose modification. Revised processes allow pharmacists to review all orders for oral chemotherapy, and they support monitoring adherence and toxicity by using a library of scripted materials. Results: Between August 2015 and January 2016, revised processes were implemented across the University of Wisconsin Carbone Cancer Center clinics. The following are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle monitoring of adherence and toxicity was achieved. Conclusion: We closed significant gaps between institutional practice and published standards for our oral chemotherapy practice and experienced steady improvement and sustainable performance in key metrics. We created an electronic definition of oral chemotherapies that allowed us to leverage our electronic health records. We believe our tools are broadly applicable. PMID:27858570
-
Prisoner reentry: a public health or public safety issue for social work practice?
Patterson, George T
2013-01-01
A significant literature identifies the policy, economic, health, and social challenges that confront released prisoners. This literature also describes the public health and public safety risks associated with prisoner reentry, provides recommendations for improving the reentry process, and describes the effectiveness of prison-based programs on recidivism rates. Public health and public safety risks are particularly significant in communities where large numbers of prisoners are released and few evidence-based services exist. The purpose of this article is to describe the public health and public safety risks that released prisoners experience when they reenter communities, and to discuss the social justice issues relevant for social work practice.
-
[In silico, in vitro, in omic experimental models and drug safety evaluation].
Claude, Nancy; Goldfain-Blanc, Françoise; Guillouzo, André
2009-01-01
Over the last few decades, toxicology has benefited from scientific, technical, and bioinformatic developments relating to patient safety assessment during clinical and drug marketing studies. Based on this knowledge, new in silico, in vitro, and "omic" experimental models are emerging. Although these models cannot currently replace classic safety evaluations performed on laboratory animals, they allow compounds with unacceptable toxicity to be rejected in the early stages of drug development, thereby reducing the number of laboratory animals needed. In addition, because these models are particularly adapted to mechanistic studies, they can help to improve the relevance of the data obtained, thus enabling better prevention and screening of the adverse effects that may occur in humans. Much progress remains to be done, especially in the field of validation. Nevertheless, current efforts by industrial, academic laboratories, and regulatory agencies should, in coming years, significantly improve preclinical drug safety evaluation thanks to the integration of these new methods into the drug research and development process.
-
Relative effectiveness of worker safety and health training methods.
Burke, Michael J; Sarpy, Sue Ann; Smith-Crowe, Kristin; Chan-Serafin, Suzanne; Salvador, Rommel O; Islam, Gazi
2006-02-01
We sought to determine the relative effectiveness of different methods of worker safety and health training aimed at improving safety knowledge and performance and reducing negative outcomes (accidents, illnesses, and injuries). Ninety-five quasi-experimental studies (n=20991) were included in the analysis. Three types of intervention methods were distinguished on the basis of learners' participation in the training process: least engaging (lecture, pamphlets, videos), moderately engaging (programmed instruction, feedback interventions), and most engaging (training in behavioral modeling, hands-on training). As training methods became more engaging (i.e., requiring trainees' active participation), workers demonstrated greater knowledge acquisition, and reductions were seen in accidents, illnesses, and injuries. All methods of training produced meaningful behavioral performance improvements. Training involving behavioral modeling, a substantial amount of practice, and dialogue is generally more effective than other methods of safety and health training. The present findings challenge the current emphasis on more passive computer-based and distance training methods within the public health workforce.
-
Relative Effectiveness of Worker Safety and Health Training Methods
Burke, Michael J.; Sarpy, Sue Ann; Smith-Crowe, Kristin; Chan-Serafin, Suzanne; Salvador, Rommel O.; Islam, Gazi
2006-01-01
Objectives. We sought to determine the relative effectiveness of different methods of worker safety and health training aimed at improving safety knowledge and performance and reducing negative outcomes (accidents, illnesses, and injuries). Methods. Ninety-five quasi-experimental studies (n=20991) were included in the analysis. Three types of intervention methods were distinguished on the basis of learners’ participation in the training process: least engaging (lecture, pamphlets, videos), moderately engaging (programmed instruction, feedback interventions), and most engaging (training in behavioral modeling, hands-on training). Results. As training methods became more engaging (i.e., requiring trainees’ active participation), workers demonstrated greater knowledge acquisition, and reductions were seen in accidents, illnesses, and injuries. All methods of training produced meaningful behavioral performance improvements. Conclusions. Training involving behavioral modeling, a substantial amount of practice, and dialogue is generally more effective than other methods of safety and health training. The present findings challenge the current emphasis on more passive computer-based and distance training methods within the public health workforce. PMID:16380566
-
Stories from the Sharp End: Case Studies in Safety Improvement
McCarthy, Douglas; Blumenthal, David
2006-01-01
Motivated by pressure and a wish to improve, health care organizations are implementing programs to improve patient safety. This article describes six natural experiments in health care safety that show where the safety field is heading and opportunities for and barriers to improvement. All these programs identified organizational culture change as critical to making patients safer, differing chiefly in their methods of creating a patient safety culture. Their goal is a safety culture that promotes continuing innovation and improvement, transcending whatever particular safety methodology is used. Policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring voluntary learning collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education. PMID:16529572
-
A Framework to Guide the Assessment of Human-Machine Systems.
Stowers, Kimberly; Oglesby, James; Sonesh, Shirley; Leyva, Kevin; Iwig, Chelsea; Salas, Eduardo
2017-03-01
We have developed a framework for guiding measurement in human-machine systems. The assessment of safety and performance in human-machine systems often relies on direct measurement, such as tracking reaction time and accidents. However, safety and performance emerge from the combination of several variables. The assessment of precursors to safety and performance are thus an important part of predicting and improving outcomes in human-machine systems. As part of an in-depth literature analysis involving peer-reviewed, empirical articles, we located and classified variables important to human-machine systems, giving a snapshot of the state of science on human-machine system safety and performance. Using this information, we created a framework of safety and performance in human-machine systems. This framework details several inputs and processes that collectively influence safety and performance. Inputs are divided according to human, machine, and environmental inputs. Processes are divided into attitudes, behaviors, and cognitive variables. Each class of inputs influences the processes and, subsequently, outcomes that emerge in human-machine systems. This framework offers a useful starting point for understanding the current state of the science and measuring many of the complex variables relating to safety and performance in human-machine systems. This framework can be applied to the design, development, and implementation of automated machines in spaceflight, military, and health care settings. We present a hypothetical example in our write-up of how it can be used to aid in project success.
-
Diffusing aviation innovations in a hospital in The Netherlands.
de Korne, Dirk F; van Wijngaarden, Jeroen D H; Hiddema, U Frans; Bleeker, Fred G; Pronovost, Peter J; Klazinga, Niek S
2010-08-01
Many authors have advocated the diffusion of innovations from other high-risk industries into health care to improve safety. The aviation industry is comparable to health care because of its similarities in (a) the use of technology, (b) the requirement of highly specialized professional teams, and (c) the existence of risk and uncertainties. For almost 20 years, The Rotterdam Eye Hospital (Rotterdam, the Netherlands) has been engaged in diffusing several innovations adapted from aviation. A case-study methodology was used to assess the application of innovations in the hospital, with a focus on the context and the detailed mechanism for each innovation. Data on hospital performance outcomes were abstracted from the hospital information data management system, quality and safety reports, and the incident reporting system. Information on the innovations was obtained from a document search; observations; and semistructured, face-to-face interviews. Aviation industry-based innovations diffused into patient care processes were as follows: patient planning and booking system, taxi service/valet parking, risk analysis (as applied to wrong-site surgery), time-out procedure (also for wrong-site surgery), Crew Resource Management training, and black box. Observations indicated that the innovations had a positive effect on quality and safety in the hospital: Waiting times were reduced, work processes became more standardized, the number of wrong-site surgeries decreased, and awareness of patient safety was heightened. A near-20-year experience with aviation-based innovation suggests that hospitals start with relatively simple innovations and use a systematic approach toward the goal of improving safety.
-
Culture, communication and safety: lessons from the airline industry.
d'Agincourt-Canning, Lori G; Kissoon, Niranjan; Singal, Mona; Pitfield, Alexander F
2011-06-01
Communication is a critical component of effective teamwork and both are essential elements in providing high quality of care to patients. Yet, communication is not an innate skill but a process influenced by internal (personal/cultural values) as well as external (professional roles and hierarchies) factors. To provide illustrative cases, themes and tools for improving communication. Literature review and consensus opinion based on extensive experience. Professional autonomy should be de-emphasized. Tools such as SBAR and simulation are important in communication and teamwork. Tools designed to improve communication and safety in the aviation industry may have applicability to the pediatric intensive care unit.
-
Suva, Domizio; Poizat, Germain
2015-02-04
For many years hospitals have been implementing crew resource management (CRM) programs, inspired by the aviation industry, in order to improve patient safety. However, while contributing to improved patient care, CRM programs are controversial because of their limited impact, a decrease in effectiveness over time, and the underinvestment by some caregivers. By analyzing the space shuttle Challenger accident, the objective of this article is to show the potential impact of the professional culture in decision-making processes. In addition, to present an approach by cultural factors which are an essential complement to current CRM programs in order to enhance the safety of care.
-
Dialysis Facility Safety: Processes and Opportunities.
Garrick, Renee; Morey, Rishikesh
2015-01-01
Unintentional human errors are the source of most safety breaches in complex, high-risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open-ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access-related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and "good catches." Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety. © 2015 Wiley Periodicals, Inc.
-
Research of improved banker algorithm
NASA Astrophysics Data System (ADS)
Yuan, Xingde; Xu, Hong; Qiao, Shijiao
2013-03-01
In the multi-process operating system, resource management strategy of system is a critical global issue, especially when many processes implicating for the limited resources, since unreasonable scheduling will cause dead lock. The most classical solution for dead lock question is the banker algorithm; however, it has its own deficiency and only can avoid dead lock occurring in a certain extent. This article aims at reducing unnecessary safety checking, and then uses the new allocation strategy to improve the banker algorithm. Through full analysis and example verification of the new allocation strategy, the results show the improved banker algorithm obtains substantial increase in performance.
-
Modern methods of surveyor observations in opencast mining under complex hydrogeological conditions.
NASA Astrophysics Data System (ADS)
Usoltseva, L. A.; Lushpei, V. P.; Mursin, VA
2017-10-01
The article considers the possibility of linking the modern methods of surveying security of open mining works to improve industrial safety in the Primorsky Territory, as well as their use in the educational process. Industrial Safety in the management of Surface Mining depends largely on the applied assessment methods and methods of stability of pit walls and slopes of dumps in the complex mining and hydro-geological conditions.
-
Brief Talk about Lithium-ion Batteries’ Safety and Influencing Factors
NASA Astrophysics Data System (ADS)
Jin, Cheng
2017-12-01
A brief introduction of the development background, the concept, characteristic and advantages of lithium-ion battery was given. The typical fire accidents about lithium-ion battery in production process, the vehicle with new energy, portable electronic products were summarized. Some important factors for lithium-ion batteries’ safety were emphatically analyzed. Several constructive suggestions on improvement direction were given, meanwhile, we have a nice exception on the future of lithium-ion battery industry.
-
Using escaped prescribed fire reviews to improve organizational learning
Anne E. Black; James Saveland; Dave Thomas; Jennifer Ziegler
2012-01-01
The US wildland fire community has been interested in cultivating organizational learning to improve safety and overall performance for a number of years. A key focus has been on understanding the difference between culpability (to be guilty) and accountability (to explain) and on re-orienting review processes towards building a collective account of (as opposed to...
-
Leino, Antti
2002-01-01
In the European Union, Council Directive 96/82/EC requires operators producing, using, or handling significant amounts of dangerous substances to improve their safety management systems in order to better manage the major accident potentials deriving from human error. A new safety management system for the Viikinmäki wastewater treatment plant in Helsinki, Finland, was implemented in this study. The system was designed to comply with both the new safety liabilities and the requirements of OHSAS 18001 (British Standards Institute, 1999). During the implementation phase experiences were gathered from the development processes in this small organisation. The complete documentation was placed in the intranet of the plant. Hyperlinks between documents were created to ensure convenience of use. Documentation was made accessible for all workers from every workstation.
-
Daker-White, Gavin; Hays, Rebecca; McSharry, Jennifer; Giles, Sally; Cheraghi-Sohi, Sudeh; Rhodes, Penny; Sanders, Caroline
2015-01-01
Objective Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model. Method Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies. Results Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system. Conclusion Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation. PMID:26244494
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Curtis Smith; Diego Mandelli
Safety is central to the design, licensing, operation, and economics of nuclear power plants (NPPs). As the current light water reactor (LWR) NPPs age beyond 60 years, there are possibilities for increased frequency of systems, structures, and components (SSC) degradations or failures that initiate safety significant events, reduce existing accident mitigation capabilities, or create new failure modes. Plant designers commonly “over-design” portions of NPPs and provide robustness in the form of redundant and diverse engineered safety features to ensure that, even in the case of well-beyond design basis scenarios, public health and safety will be protected with a very highmore » degree of assurance. This form of defense-in-depth is a reasoned response to uncertainties and is often referred to generically as “safety margin.” Historically, specific safety margin provisions have been formulated primarily based on engineering judgment backed by a set of conservative engineering calculations. The ability to better characterize and quantify safety margin is important to improved decision making about LWR design, operation, and plant life extension. A systematic approach to characterization of safety margins and the subsequent margin management options represents a vital input to the licensee and regulatory analysis and decision making that will be involved. In addition, as research and development (R&D) in the LWR Sustainability (LWRS) Program and other collaborative efforts yield new data, sensors, and improved scientific understanding of physical processes that govern the aging and degradation of plant SSCs needs and opportunities to better optimize plant safety and performance will become known. To support decision making related to economics, readability, and safety, the RISMC Pathway provides methods and tools that enable mitigation options known as margins management strategies. The purpose of the RISMC Pathway R&D is to support plant decisions for risk-informed margin management with the aim to improve economics, reliability, and sustain safety of current NPPs. As the lead Department of Energy (DOE) Laboratory for this Pathway, the Idaho National Laboratory (INL) is tasked with developing and deploying methods and tools that support the quantification and management of safety margin and uncertainty.« less
-
Safety concerns related to modular/prefabricated building construction.
Fard, Maryam Mirhadi; Terouhid, Seyyed Amin; Kibert, Charles J; Hakim, Hamed
2017-03-01
The US construction industry annually experiences a relatively high rate of fatalities and injuries; therefore, improving safety practices should be considered a top priority for this industry. Modular/prefabricated building construction is a construction strategy that involves manufacturing of the whole building or some of its components off-site. This research focuses on the safety performance of the modular/prefabricated building construction sector during both manufacturing and on-site processes. This safety evaluation can serve as the starting point for improving the safety performance of this sector. Research was conducted based on Occupational Safety and Health Administration investigated accidents. The study found 125 accidents related to modular/prefabricated building construction. The details of each accident were closely examined to identify the types of injury and underlying causes. Out of 125 accidents, there were 48 fatalities (38.4%), 63 hospitalized injuries (50.4%), and 14 non-hospitalized injuries (11.2%). It was found that, the most common type of injury in modular/prefabricated construction was 'fracture', and the most common cause of accidents was 'fall'. The most frequent cause of cause (underlying and root cause) was 'unstable structure'. In this research, the accidents were also examined in terms of corresponding location, occupation, equipment as well as activities during which the accidents occurred. For improving safety records of the modular/prefabricated construction sector, this study recommends that future research be conducted on stabilizing structures during their lifting, storing, and permanent installation, securing fall protection systems during on-site assembly of components while working from heights, and developing training programmes and standards focused on modular/prefabricated construction.
-
Lee, Charlotte Tsz-Sum; Doran, Diane Marie
2017-06-01
Patient safety is compromised by medical errors and adverse events related to miscommunications among healthcare providers. Communication among healthcare providers is affected by human factors, such as interpersonal relations. Yet, discussions of interpersonal relations and communication are lacking in healthcare team literature. This paper proposes a theoretical framework that explains how interpersonal relations among healthcare team members affect communication and team performance, such as patient safety. We synthesized studies from health and social science disciplines to construct a theoretical framework that explicates the links among these constructs. From our synthesis, we identified two relevant theories: framework on interpersonal processes based on social relation model and the theory of relational coordination. The former involves three steps: perception, evaluation, and feedback; and the latter captures relational communicative behavior. We propose that manifestations of provider relations are embedded in the third step of the framework on interpersonal processes: feedback. Thus, varying team-member relationships lead to varying collaborative behavior, which affects patient-safety outcomes via a change in team communication. The proposed framework offers new perspectives for understanding how workplace relations affect healthcare team performance. The framework can be used by nurses, administrators, and educators to improve patient safety, team communication, or to resolve conflicts.
-
Ludikhuyze, L; Van Loey, A; Indrawati; Smout, C; Hendrickx, M
2003-01-01
Throughout the last decade, high pressure technology has been shown to offer great potential to the food processing and preservation industry in delivering safe and high quality products. Implementation of this new technology will be largely facilitated when a scientific basis to assess quantitatively the impact of high pressure processes on food safety and quality becomes available. Besides, quantitative data on the effects of pressure and temperature on safety and quality aspects of foods are indispensable for design and evaluation of optimal high pressure processes, i.e., processes resulting in maximal quality retention within the constraints of the required reduction of microbial load and enzyme activity. Indeed it has to be stressed that new technologies should deliver, apart from the promised quality improvement, an equivalent or preferably enhanced level of safety. The present paper will give an overview from a quantitative point of view of the combined effects of pressure and temperature on enzymes related to quality of fruits and vegetables. Complete kinetic characterization of the inactivation of the individual enzymes will be discussed, as well as the use of integrated kinetic information in process engineering.
-
Petschonek, Sarah; Burlison, Jonathan; Cross, Carl; Martin, Kathy; Laver, Joseph; Landis, Ronald S; Hoffman, James M
2013-12-01
Given the growing support for establishing a just patient safety culture in health-care settings, a valid tool is needed to assess and improve just patient safety culture. The purpose of this study was to develop a measure of individual perceptions of just culture for a hospital setting. The 27-item survey was administered to 998 members of a health-care staff in a pediatric research hospital as part of the hospital's ongoing patient safety culture assessment process. Subscales included balancing a blame-free approach with accountability, feedback and communication, openness of communication, quality of the event reporting process, continuous improvement, and trust. The final sample of 404 participants (40% response rate) included nurses, physicians, pharmacists, and other hospital staff members involved in patient care. Confirmatory factor analysis was used to test the internal structure of the measure and reliability analyses were conducted on the subscales. Moderate support for the factor structure was established with confirmatory factor analysis. After modifications were made to improve statistical fit, the final version of the measure included 6 subscales loading onto one higher-order dimension. Additionally, Cronbach α reliability scores for the subscales were positive, with each dimension being above 0.7 with the exception of one. The instrument designed and tested in this study demonstrated adequate structure and reliability. Given the uniqueness of the current sample, further verification of the JCAT is needed from hospitals that serve broader populations. A validated tool could also be used to evaluate the relation between just culture and patient safety outcomes.
-
Petschonek, Sarah; Burlison, Jonathan; Cross, Carl; Martin, Kathy; Laver, Joseph; Landis, Ronald S.; Hoffman, James M.
2014-01-01
Objectives Given the growing support for establishing a just patient safety culture in healthcare settings, a valid tool is needed to assess and improve just patient safety culture. The purpose of this study was to develop a measure of individual perceptions of just culture for a hospital setting. Methods The 27 item survey was administered to 998 members of a healthcare staff in a pediatric research hospital as part of the hospital's ongoing patient safety culture assessment process. Subscales included balancing a blame-free approach with accountability, feedback and communication, openness of communication, quality of the event reporting process, continuous improvement, and trust. The final sample of 404 participants (40% response rate) included nurses, physicians, pharmacists and other hospital staff members involved in patient care. Confirmatory factor analysis was used to test the internal structure of the measure and reliability analyses were conducted on the subscales. Results Moderate support for the factor structure was established with confirmatory factor analysis. After modifications were made to improve statistical fit, the final version of the measure included six subscales loading onto one higher-order dimension. Additionally, Cronbach's alpha reliability scores for the subscales were positive, with each dimension being above 0.7 with the exception of one. Conclusions The instrument designed and tested in this study demonstrated adequate structure and reliability. Given the uniqueness of the current sample, further verification of the JCAT is needed from hospitals that serve broader populations. A validated tool could also be used to evaluate the relation between just culture and patient safety outcomes. PMID:24263549
-
Teams communicating through STEPPS.
Stead, Karen; Kumar, Saravana; Schultz, Timothy J; Tiver, Sue; Pirone, Christy J; Adams, Robert J; Wareham, Conrad A
2009-06-01
To evaluate the effectiveness of the implementation of a TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program at an Australian mental health facility. TeamSTEPPS is an evidence-based teamwork training system developed in the United States. Five health care sites in South Australia implemented TeamSTEPPS using a train-the-trainer model over an 8-month intervention period commencing January 2008 and concluding September 2008. A team of senior clinical staff was formed at each site to drive the improvement process. Independent researchers used direct observation and questionnaire surveys to evaluate the effectiveness of the implementation in three outcome areas: observed team behaviours; staff attitudes and opinions; and clinical performance and outcome. The results reported here focus on one site, an inpatient mental health facility. Team knowledge, skills and attitudes; patient safety culture; incident reporting rates; seclusion rates; observation for the frequency of use of TeamSTEPPS tools. Outcomes included restructuring of multidisciplinary meetings and the introduction of structured communication tools. The evaluation of patient safety culture and of staff knowledge, skills and attitudes (KSA) to teamwork and communication indicated a significant improvement in two dimensions of patient safety culture (frequency of event reporting, and organisational learning) and a 6.8% increase in the total KSA score. Clinical outcomes included reduced rates of seclusion. TeamSTEPPS implementation had a substantial impact on patient safety culture, teamwork and communication at an Australian mental health facility. It encouraged a culture of learning from patient safety incidents and making continuous improvements.
-
FFTF Passive Safety Test Data for Benchmarks for New LMR Designs
DOE Office of Scientific and Technical Information (OSTI.GOV)
Wootan, David W.; Casella, Andrew M.
Liquid Metal Reactors (LMRs) continue to be considered as an attractive concept for advanced reactor design. Software packages such as SASSYS are being used to im-prove new LMR designs and operating characteristics. Significant cost and safety im-provements can be realized in advanced liquid metal reactor designs by emphasizing inherent or passive safety through crediting the beneficial reactivity feedbacks associ-ated with core and structural movement. This passive safety approach was adopted for the Fast Flux Test Facility (FFTF), and an experimental program was conducted to characterize the structural reactivity feedback. The FFTF passive safety testing pro-gram was developed to examine howmore » specific design elements influenced dynamic re-activity feedback in response to a reactivity input and to demonstrate the scalability of reactivity feedback results to reactors of current interest. The U.S. Department of En-ergy, Office of Nuclear Energy Advanced Reactor Technology program is in the pro-cess of preserving, protecting, securing, and placing in electronic format information and data from the FFTF, including the core configurations and data collected during the passive safety tests. Benchmarks based on empirical data gathered during operation of the Fast Flux Test Facility (FFTF) as well as design documents and post-irradiation examination will aid in the validation of these software packages and the models and calculations they produce. Evaluation of these actual test data could provide insight to improve analytical methods which may be used to support future licensing applications for LMRs« less
-
Derailments Decrease at a C3RS Site at Midterm
DOT National Transportation Integrated Search
2012-04-01
The Federal Railroad Administrations (FRA) Office of Railroad Policy and Development believes that in addition to process and technology innovations, human factors-based solutions can make a significant contribution to improving safety in the rail...
-
Update from C3RS lessons learned team : four demonstration pilots.
DOT National Transportation Integrated Search
2014-07-01
The Federal Railroad Administration (FRA) believes that, in addition to process and technology innovations, human-factors-based solutions can significantly contribute to improving safety in the railroad industry. To test this assumption, FRA implemen...
-
Investigation of a “Sharps” Incident
Cournoyer, Michael Edward; Trujillo, Stanley; Schreiber, Stephen Bruce
2016-08-03
Special nuclear material research, process development, technology demonstration, and manufacturing capabilities are provided at the Los Alamos National Laboratory Plutonium Facility. Engineered barriers provide the most effective protection from radioactive and hazardous materials. The Worker Safety Security Team augments these passive safety feature by investigating incidents to identify appropriate prevention and mitigation measures. “Learning Teams” facilitate employee feedback loop and integration toward process improvement. Here, this article reports an investigation of a “Sharps” incident and reviews a case study of a technician that cuts his left thumb while making a gasket. Causal analysis of the sharps incident uncovered contributing factorsmore » that created the environment in which the incident occurred. Finally, latent organizational conditions that created error-likely situations or weakened defenses were identified and controlled. Effective improvements that reduce the probability or consequence of similar sharps incidents were implemented.« less
-
Do safety checklists improve teamwork and communication in the operating room? A systematic review.
Russ, Stephanie; Rout, Shantanu; Sevdalis, Nick; Moorthy, Krishna; Darzi, Ara; Vincent, Charles
2013-12-01
The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.
-
NASA Technical Reports Server (NTRS)
Smiles, Michael D.; Blythe, Michael P.; Bejmuk, Bohdan; Currie, Nancy J.; Doremus, Robert C.; Franzo, Jennifer C.; Gordon, Mark W.; Johnson, Tracy D.; Kowaleski, Mark M.; Laube, Jeffrey R.
2015-01-01
The Chief Engineer of the Exploration Systems Development (ESD) Office requested that the NASA Engineering and Safety Center (NESC) perform an independent assessment of the ESD's integrated hazard development process. The focus of the assessment was to review the integrated hazard analysis (IHA) process and identify any gaps/improvements in the process (e.g., missed causes, cause tree completeness, missed hazards). This document contains the outcome of the NESC assessment.
-
NASA Technical Reports Server (NTRS)
Smiles, Michael D.; Blythe, Michael P.; Bejmuk, Bohdan; Currie, Nancy J.; Doremus, Robert C.; Franzo, Jennifer C.; Gordon, Mark W.; Johnson, Tracy D.; Kowaleski, Mark M.; Laube, Jeffrey R.
2015-01-01
The Chief Engineer of the Exploration Systems Development (ESD) Office requested that the NASA Engineering and Safety Center (NESC) perform an independent assessment of the ESD's integrated hazard development process. The focus of the assessment was to review the integrated hazard analysis (IHA) process and identify any gaps/improvements in the process (e.g. missed causes, cause tree completeness, missed hazards). This document contains the outcome of the NESC assessment.
-
Novak, Avrey; Nyflot, Matthew J; Ermoian, Ralph P; Jordan, Loucille E; Sponseller, Patricia A; Kane, Gabrielle M; Ford, Eric C; Zeng, Jing
2016-05-01
Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically during the documentation of patient positioning and localization of the patient. Incidents were most frequently detected during treatment delivery (30%), and incidents identified at this point also had higher severity scores than other workflow areas (NMRI = 1.6). Incidents identified during on-treatment quality management were also more severe (NMRI = 1.7), and the specific process steps of reviewing portal and CBCT images tended to catch highest-severity incidents. On average, safety barriers caught 46% of all incidents, most frequently at physics chart review, therapist's chart check, and the review of portal images; however, most of the incidents that pass through a particular safety barrier are not designed to be capable of being captured at that barrier. Incident learning systems can be used to assess the most common points of error origination and detection in radiation oncology. This can help tailor safety improvement efforts and target the highest impact portions of the workflow. The most severe near-miss events tend to originate during simulation, with the most severe near-miss events detected at the time of patient treatment. Safety barriers can be improved to allow earlier detection of near-miss events.
-
Researchers' Roles in Patient Safety Improvement.
Pietikäinen, Elina; Reiman, Teemu; Heikkilä, Jouko; Macchi, Luigi
2016-03-01
In this article, we explore how researchers can contribute to patient safety improvement. We aim to expand the instrumental role researchers have often occupied in relation to patient safety improvement. We reflect on our own improvement model and experiences as patient safety researchers in an ongoing Finnish multi-actor innovation project through self-reflective narration. Our own patient safety improvement model can be described as systemic. Based on the purpose of the innovation project, our improvement model, and the improvement models of the other actors in the project, we have carried out a wide range of activities. Our activities can be summarized in 8 overlapping patient safety improvement roles: modeler, influencer, supplier, producer, ideator, reflector, facilitator, and negotiator. When working side by side with "practice," researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds-as well as other actors involved in patient safety improvement-in structuring their work and collaborating productively.
-
A task force model for statewide change in nursing education: building quality and safety.
Mundt, Mary H; Clark, Margherita Procaccini; Klemczak, Jeanette Wrona
2013-01-01
The purpose of this article was to describe a statewide planning process to transform nursing education in Michigan to improve quality and safety of patient care. A task force model was used to engage diverse partners in issue identification, consensus building, and recommendations. An example of a statewide intervention in nursing education and practice that was executed was the Michigan Quality and Safety in Nursing Education Institute, which was held using an integrated approach to academic-practice partners from all state regions. This paper describes the unique advantage of leadership by the Michigan Chief Nurse Executive, the existence of a nursing strategic plan, and a funding model. An overview of the Task Force on Nursing Education is presented with a focus on the model's 10 process steps and resulting seven recommendations. The Michigan Nurse Education Council was established to implement the recommendations that included quality and safety. Copyright © 2013 Elsevier Inc. All rights reserved.
-
NASA Astrophysics Data System (ADS)
Shin, Sanghyun
The National Transportation Safety Board (NTSB) has recently emphasized the importance of analyzing flight data as one of the most effective methods to improve eciency and safety of helicopter operations. By analyzing flight data with Flight Data Monitoring (FDM) programs, the safety and performance of helicopter operations can be evaluated and improved. In spite of the NTSB's effort, the safety of helicopter operations has not improved at the same rate as the safety of worldwide airlines, and the accident rate of helicopters continues to be much higher than that of fixed-wing aircraft. One of the main reasons is that the participation rates of the rotorcraft industry in the FDM programs are low due to the high costs of the Flight Data Recorder (FDR), the need of a special readout device to decode the FDR, anxiety of punitive action, etc. Since a video camera is easily installed, accessible, and inexpensively maintained, cockpit video data could complement the FDR in the presence of the FDR or possibly replace the role of the FDR in the absence of the FDR. Cockpit video data is composed of image and audio data: image data contains outside views through cockpit windows and activities on the flight instrument panels, whereas audio data contains sounds of the alarms within the cockpit. The goal of this research is to develop, test, and demonstrate a cockpit video data analysis algorithm based on data mining and signal processing techniques that can help better understand situations in the cockpit and the state of a helicopter by efficiently and accurately inferring the useful flight information from cockpit video data. Image processing algorithms based on data mining techniques are proposed to estimate a helicopter's attitude such as the bank and pitch angles, identify indicators from a flight instrument panel, and read the gauges and the numbers in the analogue gauge indicators and digital displays from cockpit image data. In addition, an audio processing algorithm based on signal processing and abrupt change detection techniques is proposed to identify types of warning alarms and to detect the occurrence times of individual alarms from cockpit audio data. Those proposed algorithms are then successfully applied to simulated and real helicopter cockpit video data to demonstrate and validate their performance.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Baldwin, N.D.; Spooner, K.G.; Walkden, P.
2007-07-01
In the United Kingdom there have been significant recent changes to the management of civil nuclear liabilities. With the formation in April 2005 of the Nuclear Decommissioning Authority (NDA), ownership of the civil nuclear licensed sites in the UK, including the Magnox Reactor Stations, passed to this new organisation. The NDAs mission is to seek acceleration of the nuclear clean up programme and deliver increased value for money and, consequently, are driving their contractors to seek more innovative ways of performing work. British Nuclear Group manages the UK Magnox stations under contract to the NDA. This paper summarises the approachmore » being taken within its Reactor Sites business to work with suppliers to enhance working arrangements at sites, improve the delivery of decommissioning programmes and deliver improvements in safety and environmental performance. The UK Magnox stations are 1. generation gas-graphite reactors, constructed in the 1950's and 1960's. Two stations are currently still operating, three are shut-down undergoing defueling and the other five are being decommissioned. Despite the distractions of industry restructuring, an uncompromising policy of demanding improved performance in conjunction with improved safety and environmental standards has been adopted. Over the past 5 years, this policy has resulted in step-changes in performance at Reactor Sites, with increased electrical output and accelerated defueling and decommissioning. The improvements in performance have been mirrored by improvements in safety (DACR of 0 at 5 sites); environmental standards (reductions in energy and water consumption, increased waste recycling) and the overall health of the workforce (20% reduction in sickness absence). These achievements have, in turn, been recognised by external bodies, resulting in several awards, including: the world's first ISRS and IERS level 10 awards (Sizewell, 2006), the NUMEX plant maintenance award (Bradwell, 2006), numerous RoSPA awards at site and sector level and nomination, at Company level, for the RoSPA George Earle trophy for outstanding performance in Health and Safety (Reactor Sites, 2006). After 'setting the scene' and describing the challenges that the company has had to respond to, the paper explains how these improvements have been delivered. Specifically it explains the process that has been followed and the parts played by sites and suppliers to deliver improved performance. With the experience of already having transitioned several Magnox stations from operations to defueling and then to decommissioning, the paper describes the valuable experience that has been gained in achieving an optimum change process and maintaining momentum. (authors)« less
-
Zhang, Shuping; Su, Yinhai; Xu, Dan; Zhu, Shuguang; Zhang, Houlei; Liu, Xinzhi
2018-06-01
Two kinds of biofuels were produced and compared from hydrothermal carbonization (HTC) and coupling washing with torrefaction (CWT) processes of bamboo sawdust in this study. The mass and energy yields, mass energy density, fuel properties, structural characterizations, combustion behavior and ash behavior during combustion process were investigated. Significant increases in the carbon contents resulted in the improvement of mass energy density and fuel properties of biofuels obtained. Both HTC and CWT improved the safety of the biofuels during the process of handling, storing and transportation. The ash-related issues of the biofuels were significantly mitigated and combustion behavior was remarkably improved after HTC and CWT processes of bamboo sawdust. In general, both HTC and CWT processes are suitable to produce biofuels with high fuel quality from bamboo sawdust. Copyright © 2018 Elsevier Ltd. All rights reserved.
-
Lutz, Mark F; Haines, Stuart T; Lesch, Christine A; Szumita, Paul M
2016-10-01
Results of the MENTORED QUALITY IMPROVEMENT IMPACT PROGRAM℠ (MQIIP) on Ensuring Insulin Pen Safety in Hospitals, which was part of an ASHP educational initiative aimed at ensuring the safe use of insulin pens in hospitals, are described. During this ASHP initiative, which also included continuing-education activities and Web-based resources, distance mentoring by pharmacists with expertise in the safe use of insulin pens was provided to interprofessional teams at 14 hospitals between September 2014 and May 2015. The results of baseline assessments of nursing staff knowledge of insulin pen use, insulin pen storage and labeling audits, and insulin pen injection observations conducted in September and October 2014 were the basis for insulin pen quality-improvement plans. Postintervention data were collected in April and May 2015. Compared with the baseline period, significant improvements in nurses' knowledge of insulin pen use, insulin pen labeling and storage, and insulin pen administration were observed in the postintervention period despite the relatively short time frame for implementation of quality-improvement plans. Program participants are committed to sustaining and building on improvements achieved during the program. The outcome measures described in this report could be adapted by other health systems to identify opportunities to improve the safety of insulin pen use. Focused attention on insulin pen safety through an interprofessional team approach during the MQIIP enabled participating sites to detect potential safety issues based on collected data, develop targeted process changes, document improvements, and identify areas requiring further intervention. A sustained organizational commitment is required to ensure the safe use of insulin pen devices in hospitals. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
-
Safety Surveillance of Traditional Chinese Medicine: Current and Future
Liu, Shwu-Huey; Chuang, Wu-Chang; Lam, Wing; Jiang, Zaoli
2015-01-01
Herbal medicine, including traditional Chinese medicine, has been used for the prevention, treatment, and cure of disorders or diseases for centuries. In addition to being used directly as therapeutic agents, medicinal plants are also important sources for pharmacological drug research and development. With the increasing consumption of herbal products intended to promote better health, it is extremely important to assure the safety and quality of herbal preparations. However, under current regulation surveillance, herbal preparations may not meet expectations in safety, quality, and efficacy. The challenge is how to assure the safety and quality of herbal products for consumers. It is the responsibility of producers to minimize hazardous contamination and additives during cultivation, harvesting, handling, processing, storage, and distribution. This article reviews the current safety obstacles that have been involved in traditional Chinese herbal medicine preparations with examples of popular herbs. Approaches to improve the safety of traditional Chinese medicine are proposed. PMID:25647717
-
Applying Sensor-Based Technology to Improve Construction Safety Management.
Zhang, Mingyuan; Cao, Tianzhuo; Zhao, Xuefeng
2017-08-11
Construction sites are dynamic and complicated systems. The movement and interaction of people, goods and energy make construction safety management extremely difficult. Due to the ever-increasing amount of information, traditional construction safety management has operated under difficult circumstances. As an effective way to collect, identify and process information, sensor-based technology is deemed to provide new generation of methods for advancing construction safety management. It makes the real-time construction safety management with high efficiency and accuracy a reality and provides a solid foundation for facilitating its modernization, and informatization. Nowadays, various sensor-based technologies have been adopted for construction safety management, including locating sensor-based technology, vision-based sensing and wireless sensor networks. This paper provides a systematic and comprehensive review of previous studies in this field to acknowledge useful findings, identify the research gaps and point out future research directions.
-
Applying Sensor-Based Technology to Improve Construction Safety Management
Zhang, Mingyuan; Cao, Tianzhuo; Zhao, Xuefeng
2017-01-01
Construction sites are dynamic and complicated systems. The movement and interaction of people, goods and energy make construction safety management extremely difficult. Due to the ever-increasing amount of information, traditional construction safety management has operated under difficult circumstances. As an effective way to collect, identify and process information, sensor-based technology is deemed to provide new generation of methods for advancing construction safety management. It makes the real-time construction safety management with high efficiency and accuracy a reality and provides a solid foundation for facilitating its modernization, and informatization. Nowadays, various sensor-based technologies have been adopted for construction safety management, including locating sensor-based technology, vision-based sensing and wireless sensor networks. This paper provides a systematic and comprehensive review of previous studies in this field to acknowledge useful findings, identify the research gaps and point out future research directions. PMID:28800061
-
Donnelly, Helen; Alemayehu, Demissie; Botgros, Radu; Comic-Savic, Sabrina; Eisenstein, Barry; Lorenz, Benjamin; Merchant, Kunal; Pelfrene, Eric; Reith, Christina; Santiago, Jonas; Tiernan, Rosemary; Wunderink, Richard; Tenaerts, Pamela; Knirsch, Charles
2016-08-15
Resistant bacteria are one of the leading causes of hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP). HABP/VABP trials are complex and difficult to conduct due to the large number of medical procedures, adverse events, and concomitant medications involved. Differences in the legislative frameworks between different regions of the world may also lead to excessive data collection. The Clinical Trials Transformation Initiative (CTTI) seeks to advance antibacterial drug development (ABDD) by streamlining clinical trials to improve efficiency and feasibility while maintaining ethical rigor, patient safety, information value, and scientific validity. In 2013, CTTI engaged a multidisciplinary group of experts to discuss challenges impeding the conduct of HABP/VABP trials. Separate workstreams identified challenges associated with current data collection processes. Experts defined "data collection" as the act of capturing and reporting certain data on the case report form as opposed to recording of data as part of routine clinical care. The ABDD Project Team developed strategies for streamlining safety data collection in HABP/VABP trials using a Quality by Design approach. Current safety data collection processes in HABP/VABP trials often include extraneous information. More targeted strategies for safety data collection in HABP/VABP trials will rely on optimal protocol design and prespecification of which safety data are essential to satisfy regulatory reporting requirements. A consensus and a cultural change in clinical trial design and conduct, which involve recognition of the need for more efficient data collection, are urgently needed to advance ABDD and to improve HABP/VABP trials in particular. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.
-
Siroli, Lorenzo; Patrignani, Francesca; Serrazanetti, Diana I; Tabanelli, Giulia; Montanari, Chiara; Gardini, Fausto; Lanciotti, Rosalba
2015-05-01
Outbreaks of food-borne disease associated with the consumption of fresh and minimally processed fruits and vegetables have increased dramatically over the last few years. Traditional chemical sanitizers are unable to completely eradicate or kill the microorganisms on fresh produce. These conditions have stimulated research to alternative methods for increasing food safety. The use of protective cultures, particularly lactic acid bacteria (LAB), has been proposed for minimally processed products. However, the application of bioprotective cultures has been limited at the industrial level. From this perspective, the main aims of this study were to select LAB from minimally processed fruits and vegetables to be used as biocontrol agents and then to evaluate the effects of the selected strains, alone or in combination with natural antimicrobials (2-(E)-hexenal/hexanal, 2-(E)-hexenal/citral for apples and thyme for lamb's lettuce), on the shelf-life and safety characteristics of minimally processed apples and lamb's lettuce. The results indicated that applying the Lactobacillus plantarum strains CIT3 and V7B3 to apples and lettuce, respectively, increased both the safety and shelf-life. Moreover, combining the selected strains with natural antimicrobials produced a further increase in the shelf-life of these products without detrimental effects on the organoleptic qualities. Copyright © 2014 Elsevier Ltd. All rights reserved.
-
Kuperman, Gilad J; Boyer, Aurelia; Cole, Curt; Forman, Bruce; Stetson, Peter D; Cooper, Mary
2006-01-01
At NewYork-Presbyterian Hospital, we are committed to the delivery of high quality care. We have implemented a strategic planning process to determine the information technology initiatives that will best help us improve quality. The process began with the creation of a Clinical Quality and IT Committee. The Committee identified 2 high priority goals that would enable demonstrably high quality care: 1) excellence at data warehousing, and 2) optimal use of automated clinical documentation to capture encounter-related quality and safety data. For each high priority goal, a working group was created to develop specific recommendations. The Data Warehousing subgroup has recommended the implementation of an architecture management process and an improved ability for users to get access to aggregate data. The Structured Documentation subgroup is establishing recommendations for a documentation template creation process. The strategic planning process at times is slow, but assures that the organization is focusing on the information technology activities most likely to lead to improved quality.
-
Hung, Sheng-Hui; Wang, Pa-Chun; Lin, Hung-Chun; Chen, Hung-Ying; Su, Chao-Ton
2015-01-01
Specimen handling is a critical patient safety issue. Problematic handling process, such as misidentification (of patients, surgical site, and specimen counts), specimen loss, or improper specimen preparation can lead to serious patient harms and lawsuits. Value stream map (VSM) is a tool used to find out non-value-added works, enhance the quality, and reduce the cost of the studied process. On the other hand, healthcare failure mode and effect analysis (HFMEA) is now frequently employed to avoid possible medication errors in healthcare process. Both of them have a goal similar to Six Sigma methodology for process improvement. This study proposes a model that integrates VSM and HFMEA into the framework, which mainly consists of define, measure, analyze, improve, and control (DMAIC), of Six Sigma. A Six Sigma project for improving the process of surgical specimen handling in a hospital was conducted to demonstrate the effectiveness of the proposed model.
-
Kuperman, Gilad J.; Boyer, Aurelia; Cole, Curt; Forman, Bruce; Stetson, Peter D.; Cooper, Mary
2006-01-01
At NewYork-Presbyterian Hospital, we are committed to the delivery of high quality care. We have implemented a strategic planning process to determine the information technology initiatives that will best help us improve quality. The process began with the creation of a Clinical Quality and IT Committee. The Committee identified 2 high priority goals that would enable demonstrably high quality care: 1) excellence at data warehousing, and 2) optimal use of automated clinical documentation to capture encounter-related quality and safety data. For each high priority goal, a working group was created to develop specific recommendations. The Data Warehousing subgroup has recommended the implementation of an architecture management process and an improved ability for users to get access to aggregate data. The Structured Documentation subgroup is establishing recommendations for a documentation template creation process. The strategic planning process at times is slow, but assures that the organization is focusing on the information technology activities most likely to lead to improved quality. PMID:17238381
-
NASA Astrophysics Data System (ADS)
Nam, Young Jin; Oh, Dae Yang; Jung, Sung Hoo; Jung, Yoon Seok
2018-01-01
Owing to their potential for greater safety, higher energy density, and scalable fabrication, bulk-type all-solid-state lithium-ion batteries (ASLBs) employing deformable sulfide superionic conductors are considered highly promising for applications in battery electric vehicles. While fabrication of sheet-type electrodes is imperative from the practical point of view, reports on relevant research are scarce. This might be attributable to issues that complicate the slurry-based fabrication process and/or issues with ionic contacts and percolation. In this work, we systematically investigate the electrochemical performance of conventional dry-mixed electrodes and wet-slurry fabricated electrodes for ASLBs, by varying the different fractions of solid electrolytes and the mass loading. This information calls for a need to develop well-designed electrodes with better ionic contacts and to improve the ionic conductivity of solid electrolytes. As a scalable proof-of-concept to achieve better ionic contacts, a premixing process for active materials and solid electrolytes is demonstrated to significantly improve electrochemical performance. Pouch-type 80 × 60 mm2 all-solid-state LiNi0·6Co0·2Mn0·2O2/graphite full-cells fabricated by the slurry process show high cell-based energy density (184 W h kg-1 and 432 W h L-1). For the first time, their excellent safety is also demonstrated by simple tests (cutting with scissors and heating at 110 °C).
-
Human factors and safety in emergency medicine
NASA Technical Reports Server (NTRS)
Schaefer, H. G.; Helmreich, R. L.; Scheidegger, D.
1994-01-01
A model based on an input process and outcome conceptualisation is suggested to address safety-relevant factors in emergency medicine. As shown in other dynamic and demanding environments, human factors play a decisive role in attaining high quality service. Attitudes held by health-care providers, organisational shells and work-cultural parameters determine communication, conflict resolution and workload distribution within and between teams. These factors should be taken into account to improve outcomes such as operational integrity, job satisfaction and morale.
-
Hagland, Mark
2009-09-01
True CPOE success is about facilitating improved patient safety, care quality, and efficiency in a multidisciplinar environment, and on an ongoing basis. CPOE implementation forces clinician leaders to examine and rework long-ingrained care delivery processes, especially as they build or adapt order sets. The likelihood that CPOE will be a requirement of meaningful use could compel a rapid acceleration in implementation.
-
Improved obstetric safety through programmatic collaboration.
Goffman, Dena; Brodman, Michael; Friedman, Arnold J; Minkoff, Howard; Merkatz, Irwin R
2014-01-01
Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety. © 2014 American Society for Healthcare Risk Management of the American Hospital Association.
-
DOT National Transportation Integrated Search
2000-04-01
Incident management is the process of managing multi-agency, multi-jurisdictional responses to highway traffic disruptions. Efficient and coordinated management of incidents reduces their adverse impacts on public safety, traffic conditions, and the ...
-
DOT National Transportation Integrated Search
1997-01-01
Intelligent transportation systems (ITS) are systems that utilize advanced technologies, including computer, communications and process control technologies, to improve the efficiency and safety of the transportation system. These systems encompass a...
-
DOT National Transportation Integrated Search
2017-01-01
This project aimed to improve coordination and : cooperation among various entities in the : planning process for developing safer and more : efficient connections between intermodal : facilities and the highway network. Coordination : and cooperatio...
-
Koji--where East meets West in fermentation.
Zhu, Yang; Tramper, Johannes
2013-12-01
Almost all biotechnological processes originate from traditional food fermentations, i.e. the many indigenous processes that can be found already in the written history of thousands of years ago. We still consume many of these fermented foods and beverages on a daily basis today. The evolution of these traditional processes, in particular since the 19th century, stimulated and influenced the development of modern biotechnological processes. In return, the development of modern biotechnology and related advanced techniques will no doubt improve the process, the product quality and the safety of our favourite fermented foods and beverages. In this article, we describe the relationship between these traditional food fermentations and modern biotechnology. Using Koji and its derived product soy sauce as examples, we address the mutual influences that will provide us with a better future concerning the quality, safety and nutritional effect of many fermented food products. © 2013.
-
Meaningful use and good catches: More appropriate metrics for checklist effectiveness.
Putnam, Luke R; Anderson, Kathryn T; Diffley, Michael B; Hildebrandt, Aubrey A; Caldwell, Kelly M; Minzenmayer, Andrew N; Covey, Sarah E; Kawaguchi, Akemi L; Lally, Kevin P; Tsao, KuoJen
2016-12-01
The benefit of utilizing surgical safety checklists has been recently questioned. We evaluated our checklist performance after implementing a program that includes checklist-related good catches. Multifaceted interventions aimed at the preincision checklist and 5 prospective audits were conducted from 2011-2015. We documented adherence to the checklist (verbalization of each checkpoint), fidelity (meaningful performance of each checkpoint), and good catches (events with the potential to cause the patient harm but that were prevented from occurring). Good catches were divided into quality improvement-based categories (processes, medication, safety, communication, and equipment). A total of 1,346 checklist performances were observed (range, 144-373/yr). Adherence to the preincision checklist improved from 30% to 95% (P < .001), while adherence to the preinduction and debriefing checklists decreased (71% to 56%, P = .002) and remained unchanged (76%), respectively. Preincision fidelity decreased from 86% to 76% (P = .012). Good catches were identified during 16% of preincision checklist performances; process issues were most common (32%) followed by issues of medication administration (30%) and safety (22%). Implementation of a systematic checklist program resulted in significant and sustainable improvement in performance. Meaningful use and associated good catches may be more appropriate metric than actual patient harm for measuring checklist effectiveness. Although not previously described, checklist-related good catches represent an unknown benefit of checklists. Copyright © 2016 Elsevier Inc. All rights reserved.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Hunt, Farren J.
Idaho National Laboratory’s (INL’s) Integrated Safety Management System (ISMS) effectiveness review of fiscal year (FY) 2016 shows that INL has integrated management programs and safety elements throughout the oversight and operational activities performed at INL. The significant maturity of Contractor Assurance System (CAS) processes, as demonstrated across INL’s management systems and periodic reporting through the Management Review Meeting process, over the past two years has provided INL with current real-time understanding and knowledge pertaining to the health of the institution. INL’s sustained excellence of the Integrated Safety and effective implementation of the Worker Safety and Health Program is also evidencedmore » by other external validations and key indicators. In particular, external validations include VPP, ISO 14001, DOELAP accreditation, and key Laboratory level indicators such as ORPS (number, event frequency and severity); injury/illness indicators such as Days Away, Restricted and Transfer (DART) case rate, back & shoulder metric and open reporting indicators, demonstrate a continuous positive trend and therefore improved operational performance over the last few years. These indicators are also reflective of the Laboratory’s overall organizational and safety culture improvement. Notably, there has also been a step change in ESH&Q Leadership actions that have been recognized both locally and complex-wide. Notwithstanding, Laboratory management continues to monitor and take action on lower level negative trends in numerous areas including: Conduct of Operations, Work Control, Work Site Analysis, Risk Assessment, LO/TO, Fire Protection, and Life Safety Systems, to mention a few. While the number of severe injury cases has decreased, as evidenced by the reduction in the DART case rate, the two hand injuries and the fire truck/ambulance accident were of particular concern. Aggressive actions continue in order to understand the causes and define actions needed to prevent similar injuries and accidents in the future. While our injury rate is not where we want it to be, it is not the only indicator that defines our ISMS program, safety culture, and efforts to be a continuous learning organization. When reviewing the entire year’s performance, and all areas that integrate ISMS principles and core functions, INL has an “effective” ISMS program that is continually improving.« less
-
NASA Astrophysics Data System (ADS)
Soilán, M.; Riveiro, B.; Sánchez-Rodríguez, A.; González-deSantos, L. M.
2018-05-01
During the last few years, there has been a huge methodological development regarding the automatic processing of 3D point cloud data acquired by both terrestrial and aerial mobile mapping systems, motivated by the improvement of surveying technologies and hardware performance. This paper presents a methodology that, in a first place, extracts geometric and semantic information regarding the road markings within the surveyed area from Mobile Laser Scanning (MLS) data, and then employs it to isolate street areas where pedestrian crossings are found and, therefore, pedestrians are more likely to cross the road. Then, different safety-related features can be extracted in order to offer information about the adequacy of the pedestrian crossing regarding its safety, which can be displayed in a Geographical Information System (GIS) layer. These features are defined in four different processing modules: Accessibility analysis, traffic lights classification, traffic signs classification, and visibility analysis. The validation of the proposed methodology has been carried out in two different cities in the northwest of Spain, obtaining both quantitative and qualitative results for pedestrian crossing classification and for each processing module of the safety assessment on pedestrian crossing environments.
-
Rittenhouse, Diane R; Schmidt, Laura A; Wu, Kevin J; Wiley, James
2014-02-01
To evaluate safety-net clinics' responses to a novel community-wide Patient-Centered Medical Home (PCMH) financial incentive program in post-Katrina New Orleans. Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery. Multiwave, longitudinal, observational study of a local safety-net primary care system. Clinic-level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records. Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall. Findings demonstrate that widespread PCMH implementation is possible in a safety-net environment when external financial incentives are aligned with the goal of practice innovation. © Health Research and Educational Trust.
-
"No-Go Considerations" for In Situ Simulation Safety.
Bajaj, Komal; Minors, Anjoinette; Walker, Katie; Meguerdichian, Michael; Patterson, Mary
2018-06-01
In situ simulation is the practice of simulation in the actual clinical environment and has demonstrated utility in the assessment of system processes, identification of latent safety threats, and improvement in teamwork and communication. Nonetheless, performing simulated events in a real patient care setting poses potential risks to patient and staff safety. One integral aspect of a comprehensive approach to ensure the safety of in situ simulation includes the identification and establishment of "no-go considerations," that is, key decision-making considerations under which in situ simulations should be canceled, postponed, moved to another area, or rescheduled. These considerations should be modified and adjusted to specific clinical units. This article provides a framework of key essentials in developing no-go considerations.
-
Evolution of Safety Analysis to Support New Exploration Missions
NASA Technical Reports Server (NTRS)
Thrasher, Chard W.
2008-01-01
NASA is currently developing the Ares I launch vehicle as a key component of the Constellation program which will provide safe and reliable transportation to the International Space Station, back to the moon, and later to Mars. The risks and costs of the Ares I must be significantly lowered, as compared to other manned launch vehicles, to enable the continuation of space exploration. It is essential that safety be significantly improved, and cost-effectively incorporated into the design process. This paper justifies early and effective safety analysis of complex space systems. Interactions and dependences between design, logistics, modeling, reliability, and safety engineers will be discussed to illustrate methods to lower cost, reduce design cycles and lessen the likelihood of catastrophic events.
-
Design of Hack-Resistant Diabetes Devices and Disclosure of Their Cyber Safety.
Sackner-Bernstein, Jonathan
2017-03-01
The focus of the medical device industry and regulatory bodies on cyber security parallels that in other industries, primarily on risk assessment and user education as well as the recognition and response to infiltration. However, transparency of the safety of marketed devices is lacking and developers are not embracing optimal design practices with new devices. Achieving cyber safe diabetes devices: To improve understanding of cyber safety by clinicians and patients, and inform decision making on use practices of medical devices requires disclosure by device manufacturers of the results of their cyber security testing. Furthermore, developers should immediately shift their design processes to deliver better cyber safety, exemplified by use of state of the art encryption, secure operating systems, and memory protections from malware.
-
Thesis - keeping the management system {open_quotes}live{close_quotes} and reaching the workforce
DOE Office of Scientific and Technical Information (OSTI.GOV)
Primrose, M.J.; Bentley, P.D.; Graaf, G.C. van der
1996-12-31
Previous papers given to SPE conferences have described the Shell Group approach to Safety Management Systems and to Safety Cases. Their extension to HSE MS and to HSE Cases has also been addressed. Since 1984 the Enhanced Safety Management (ESM) programme within Shell companies has led to a significant improvement in the management of safety but it was only when structured management systems (based upon an understanding of the business processes) were introduced that true integration of HSE as a line responsibility became a reality. This paper describes the THESIS software package and the way that management systems have beenmore » made {open_quote}live{close_quote} and how workforce involvement can be demonstrated.« less
-
Congdon, Heather Brennan; Eldridge, Barbara Hoffman; Truong, Hoai-An
2013-11-01
Development and implementation of an interprofessional navigator-facilitated care coordination algorithm (NAVCOM) for low-income, uninsured patients with uncontrolled diabetes at a safety-net clinic resulted in improvement of disease control as evidenced by improvement in hemoglobin A1C. This report describes the process and lessons learned from the development and implementation of NAVCOM and patient success stories.
-
Safe patient handling in diagnostic imaging.
Murphey, Susan L
2010-01-01
Raising awareness of the risk to diagnostic imaging personnel from manually lifting, transferring, and repositioning patients is critical to improving workplace safety and staff utilization. The aging baby boomer generation and growing bariatric population exacerbate the problem. Also, legislative initiatives are increasing nationwide for hospitals to implement safe patient handling programs. A management process designed to improve working conditions through implementing ergonomic programs can reduce losses and improve productivity and patient care outcome measures for imaging departments.
-
Armstrong, David; Barkun, Alan; Bridges, Ron; Carter, Rose; de Gara, Chris; Dubé, Catherine; Enns, Robert; Hollingworth, Roger; MacIntosh, Donald; Borgaonkar, Mark; Forget, Sylviane; Leontiadis, Grigorios; Meddings, Jonathan; Cotton, Peter; Kuipers, Ernst J; Valori, Roland
2012-01-01
BACKGROUND: Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy. OBJECTIVE: To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery. METHODS: A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants. RESULTS: Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), quality assurance (statements 10 to 13: 94% to 100%), training, education, competency and privileges (statements 14 to 19: 97% to 100%), endoscopy reporting standards (statements 20 and 21: 97% to 100%) and patient perceptions (statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified. DISCUSSION: The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services. CONCLUSIONS: The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy. PMID:22308578
-
Goodman, Richard E; Tetteh, Afua O
2011-08-01
Genetically modified (GM) plants are increasingly used for food production and industrial applications. As the global population has surpassed 7 billion and per capita consumption rises, food production is challenged by loss of arable land, changing weather patterns, and evolving plant pests and disease. Previous gains in quantity and quality relied on natural or artificial breeding, random mutagenesis, increased pesticide and fertilizer use, and improved farming techniques, all without a formal safety evaluation. However, the direct introduction of novel genes raised questions regarding safety that are being addressed by an evaluation process that considers potential increases in the allergenicity, toxicity, and nutrient availability of foods derived from the GM plants. Opinions vary regarding the adequacy of the assessment, but there is no documented proof of an adverse effect resulting from foods produced from GM plants. This review and opinion discusses current practices and new regulatory demands related to food safety.
-
Massive parallelization of serial inference algorithms for a complex generalized linear model
Suchard, Marc A.; Simpson, Shawn E.; Zorych, Ivan; Ryan, Patrick; Madigan, David
2014-01-01
Following a series of high-profile drug safety disasters in recent years, many countries are redoubling their efforts to ensure the safety of licensed medical products. Large-scale observational databases such as claims databases or electronic health record systems are attracting particular attention in this regard, but present significant methodological and computational concerns. In this paper we show how high-performance statistical computation, including graphics processing units, relatively inexpensive highly parallel computing devices, can enable complex methods in large databases. We focus on optimization and massive parallelization of cyclic coordinate descent approaches to fit a conditioned generalized linear model involving tens of millions of observations and thousands of predictors in a Bayesian context. We find orders-of-magnitude improvement in overall run-time. Coordinate descent approaches are ubiquitous in high-dimensional statistics and the algorithms we propose open up exciting new methodological possibilities with the potential to significantly improve drug safety. PMID:25328363
-
NASA Space Technology Draft Roadmap Area 13: Ground and Launch Systems Processing
NASA Technical Reports Server (NTRS)
Clements, Greg
2011-01-01
This slide presentation reviews the technology development roadmap for the area of ground and launch systems processing. The scope of this technology area includes: (1) Assembly, integration, and processing of the launch vehicle, spacecraft, and payload hardware (2) Supply chain management (3) Transportation of hardware to the launch site (4) Transportation to and operations at the launch pad (5) Launch processing infrastructure and its ability to support future operations (6) Range, personnel, and facility safety capabilities (7) Launch and landing weather (8) Environmental impact mitigations for ground and launch operations (9) Launch control center operations and infrastructure (10) Mission integration and planning (11) Mission training for both ground and flight crew personnel (12) Mission control center operations and infrastructure (13) Telemetry and command processing and archiving (14) Recovery operations for flight crews, flight hardware, and returned samples. This technology roadmap also identifies ground, launch and mission technologies that will: (1) Dramatically transform future space operations, with significant improvement in life-cycle costs (2) Improve the quality of life on earth, while exploring in co-existence with the environment (3) Increase reliability and mission availability using low/zero maintenance materials and systems, comprehensive capabilities to ascertain and forecast system health/configuration, data integration, and the use of advanced/expert software systems (4) Enhance methods to assess safety and mission risk posture, which would allow for timely and better decision making. Several key technologies are identified, with a couple of slides devoted to one of these technologies (i.e., corrosion detection and prevention). Development of these technologies can enhance life on earth and have a major impact on how we can access space, eventually making routine commercial space access and improve building and manufacturing, and weather forecasting for example for the effect of these process improvements on our daily lives.
-
O'Rourke, Kathleen; Teel, Joseph; Nicholls, Erika; Lee, Daniel D; Colwill, Alyssa Covelli; Srinivas, Sindhu K
2018-03-01
To improve staff perception of the quality of the patient admission process from obstetric triage to the labor and delivery unit through standardization. Preassessment and postassessment online surveys. A 13-bed labor and delivery unit in a quaternary care, Magnet Recognition Program, academic medical center in Pennsylvania. Preintervention (n = 100), postintervention (n = 52), and 6-month follow-up survey respondents (n = 75) represented secretaries, registered nurses, surgical technicians, certified nurse-midwives, nurse practitioners, maternal-fetal medicine fellows, anesthesiologists, and obstetric and family medicine attending and resident physicians from triage and labor and delivery units. We educated staff and implemented interventions, an admission huddle and safety time-out whiteboard, to standardize the admission process. Participants were evaluated with the use of preintervention, postintervention, and 6-month follow-up surveys about their perceptions regarding the admission process. Data tracked through the electronic medical record were used to determine compliance with the admission huddle and whiteboards. A 77% reduction (decrease of 49%) occurred in the perception of incomplete patient admission processes from baseline to 6-month follow-up after the intervention. Postintervention and 6-month follow-up survey results indicated that 100% of respondents responded strongly agree/agree/neutral that the new admission process improved communication surrounding care for patients. Data in the electronic medical record indicated that compliance with use of admission huddles and whiteboards increased from 50% to 80% by 6 months. The new patient admission process, including a huddle and safety time-out board, improved staff perception of the quality of admission from obstetric triage to the labor and delivery unit. Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
-
Bruny, Jennifer; Ziegler, Moritz
2015-12-01
Innovation is a crucial part of surgical history that has led to enhancements in the quality of surgical care. This comprises both changes which are incremental and those which are frankly disruptive in nature. There are situations where innovation is absolutely required in order to achieve quality improvement or process improvement. Alternatively, there are innovations that do not necessarily arise from some need, but simply are a new idea that might be better. All change must assure a significant commitment to patient safety and beneficence. Innovation would ideally enhance patient care quality and disease outcomes, as well stimulate and facilitate further innovation. The tensions between innovative advancement and patient safety, risk and reward, and demonstrated effectiveness versus speculative added value have created a contemporary "surgical conundrum" that must be resolved by a delicate balance assuring optimal patient/provider outcomes. This article will explore this delicate balance and the rules that govern it. Recommendations are made to facilitate surgical innovation through clinical research. In addition, we propose options that investigators and institutions may use to address competing priorities. Copyright © 2015 Elsevier Inc. All rights reserved.
-
Toxic release consequence analysis tool (TORCAT) for inherently safer design plant.
Shariff, Azmi Mohd; Zaini, Dzulkarnain
2010-10-15
Many major accidents due to toxic release in the past have caused many fatalities such as the tragedy of MIC release in Bhopal, India (1984). One of the approaches is to use inherently safer design technique that utilizes inherent safety principle to eliminate or minimize accidents rather than to control the hazard. This technique is best implemented in preliminary design stage where the consequence of toxic release can be evaluated and necessary design improvements can be implemented to eliminate or minimize the accidents to as low as reasonably practicable (ALARP) without resorting to costly protective system. However, currently there is no commercial tool available that has such capability. This paper reports on the preliminary findings on the development of a prototype tool for consequence analysis and design improvement via inherent safety principle by utilizing an integrated process design simulator with toxic release consequence analysis model. The consequence analysis based on the worst-case scenarios during process flowsheeting stage were conducted as case studies. The preliminary finding shows that toxic release consequences analysis tool (TORCAT) has capability to eliminate or minimize the potential toxic release accidents by adopting the inherent safety principle early in preliminary design stage. 2010 Elsevier B.V. All rights reserved.
-
Investigation of criticality safety control infraction data at a nuclear facility
Cournoyer, Michael E.; Merhege, James F.; Costa, David A.; ...
2014-10-27
Chemical and metallurgical operations involving plutonium and other nuclear materials account for most activities performed at the LANL's Plutonium Facility (PF-4). The presence of large quantities of fissile materials in numerous forms at PF-4 makes it necessary to maintain an active criticality safety program. The LANL Nuclear Criticality Safety (NCS) Program provides guidance to enable efficient operations while ensuring prevention of criticality accidents in the handling, storing, processing and transportation of fissionable material at PF-4. In order to achieve and sustain lower criticality safety control infraction (CSCI) rates, PF-4 operations are continuously improved, through the use of Lean Manufacturing andmore » Six Sigma (LSS) business practices. Employing LSS, statistically significant variations (trends) can be identified in PF-4 CSCI reports. In this study, trends have been identified in the NCS Program using the NCS Database. An output metric has been developed that measures ADPSM Management progress toward meeting its NCS objectives and goals. Using a Pareto Chart, the primary CSCI attributes have been determined in order of those requiring the most management support. Data generated from analysis of CSCI data help identify and reduce number of corresponding attributes. In-field monitoring of CSCI's contribute to an organization's scientific and technological excellence by providing information that can be used to improve criticality safety operation safety. This increases technical knowledge and augments operational safety.« less
-
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Castle, Lon; Franzblau-Isaac, Ellen; Paulsen, Jim
2005-06-01
Medco Health Solutions, Inc. conducted a project to reduce medication errors in its home-delivery service, which is composed of eight prescription-processing pharmacies, three dispensing pharmacies, and six call-center pharmacies. Medco uses the Six Sigma methodology to reduce process variation, establish procedures to monitor the effectiveness of medication safety programs, and determine when these efforts do not achieve performance goals. A team reviewed the processes in home-delivery pharmacy and suggested strategies to improve the data-collection and medication-dispensing practices. A variety of improvement activities were implemented, including a procedure for developing, reviewing, and enhancing sound-alike/look-alike (SALA) alerts and system enhancements to improve processing consistency across the pharmacies. "External nonconformances" were reduced for several categories of medication errors, including wrong-drug selection (33%), wrong directions (49%), and SALA errors (69%). Control charts demonstrated evidence of sustained process improvement and actual reduction in specific medication error elements. Establishing a continuous quality improvement process to ensure that medication errors are minimized is critical to any health care organization providing medication services.
-
Frost, Karen L; van Roosmalen, Linda; Bertocci, Gina; Cross, Douglas J
2012-01-01
An overview of the current status of wheelchair transportation safety in fixed route and demand-responsive, non-rail, public transportation vehicles within the US is presented. A description of each mode of transportation is provided, followed by a discussion of the primary issues affecting safety, accessibility, and usability. Technologies such as lifts, ramps, securement systems, and occupant restraint systems, along with regulations and voluntary industry standards have been implemented with the intent of improving safety and accessibility for individuals who travel while seated in their wheeled mobility device (e.g., wheelchair or scooter). However, across both fixed route and demand-responsive transit systems a myriad of factors such as nonuse and misuse of safety systems, oversized wheeled mobility devices, vehicle space constraints, and inadequate vehicle operator training may place wheeled mobility device (WhMD) users at risk of injury even under non-impact driving conditions. Since WhMD-related incidents also often occur during the boarding and alighting process, the frequency of these events, along with factors associated with these events are described for each transit mode. Recommendations for improving WhMD transportation are discussed given the current state of
-
Shui, Irene; Kennedy, Allison; Wooten, Karen; Schwartz, Benjamin; Gust, Deborah
2005-01-01
OBJECTIVE: To examine the vaccine safety concerns of African-American mothers who, despite concerns, have their children immunized. METHODS: Six focus groups of Atlanta-area African-American mothers who were very concerned about vaccine safety but whose children were fully vaccinated were conducted. RESULTS: Major factors influencing participants' concerns about immunizations included: lack of information and mistrust of the medical community and government. Factors that convinced parents to have their child immunized despite their concerns included social norms and/or laws supporting immunization and fear of the consequences of not immunizing. Suggestions given to reduce concerns included improving available information that addressed their concerns and provider-patient communication. CONCLUSIONS: Addressing mothers' concerns about immunization is important both from an ethical perspective, in assuring that they are fully informed of the risks and benefits of immunizations, as well as from a practical one, in reducing the possibility that they will decide not to immunize their child. Changes in the childhood immunization process should be made to reduce parental concern about vaccine safety. Some changes that may be considered include improved provider communication about immunizations and additional tailored information about the necessity and safety of vaccines. PMID:15926642
-
Jain, Anshu K; Fennell, Mary L; Chagpar, Anees B; Connolly, Hannah K; Nembhard, Ingrid M
2016-11-01
Effective communication is a requirement in the teamwork necessary for improved coordination to deliver patient-centered, value-based cancer care. Communication is particularly important when care providers are geographically distributed or work across organizations. We review organizational and teams research on communication to highlight psychological safety as a key determinant of high-quality communication within teams. We first present the concept of psychological safety, findings about its communication effects for teamwork, and factors that affect it. We focus on five factors applicable to cancer care delivery: familiarity, clinical hierarchy-related status differences, geographic dispersion, boundary spanning, and leader behavior. To illustrate how these factors facilitate or hinder psychologically safe communication and teamwork in cancer care, we review the case of a patient as she experiences the treatment-planning process for early-stage breast cancer in a community setting. Our analysis is summarized in a key principle: Teamwork in cancer care requires high-quality communication, which depends on psychological safety for all team members, clinicians and patients alike. We conclude with a discussion of the implications of psychological safety in clinical care and suggestions for future research.
-
Sustaining Vaccine Confidence in the 21st Century
Hardt, Karin; Schmidt-Ott, Ruprecht; Glismann, Steffen; Adegbola, Richard A.; Meurice, François P.
2013-01-01
Vaccination provides many health and economic benefits to individuals and society, and public support for immunization programs is generally high. However, the benefits of vaccines are often not fully valued when public discussions on vaccine safety, quality or efficacy arise, and the spread of misinformation via the internet and other media has the potential to undermine immunization programs. Factors associated with improved public confidence in vaccines include evidence-based decision-making procedures and recommendations, controlled processes for licensing and monitoring vaccine safety and effectiveness and disease surveillance. Community engagement with appropriate communication approaches for each audience is a key factor in building trust in vaccines. Vaccine safety/quality issues should be handled rapidly and transparently by informing and involving those most affected and those concerned with public health in effective ways. Openness and transparency in the exchange of information between industry and other stakeholders is also important. To maximize the safety of vaccines, and thus sustain trust in vaccines, partnerships are needed between public health sector stakeholders. Vaccine confidence can be improved through collaborations that ensure high vaccine uptake rates and that inform the public and other stakeholders of the benefits of vaccines and how vaccine safety is constantly assessed, assured and communicated. PMID:26344109
-
Groves, Patricia S; Bunch, Jacinda L
2018-05-18
The aim of this paper is discussion of a new middle-range theory of patient safety goal priming via safety culture communication. Bedside nurses are key to safe care, but there is little theory about how organizations can influence nursing behavior through safety culture to improve patient safety outcomes. We theorize patient safety goal priming via safety culture communication may support organizations in this endeavor. According to this theory, hospital safety culture communication activates a previously held patient safety goal and increases the perceived value of actions nurses can take to achieve that goal. Nurses subsequently prioritize and are motivated to perform tasks and risk assessment related to achieving patient safety. These efforts continue until nurses mitigate or ameliorate identified risks and hazards during the patient care encounter. Critically, this process requires nurses to have a previously held safety goal associated with a repertoire of appropriate actions. This theory suggests undergraduate educators should foster an outcomes focus emphasizing the connections between nursing interventions and safety outcomes, hospitals should strategically structure patient safety primes into communicative activities, and organizations should support professional development including new skills and the latest evidence supporting nursing practice for patient safety. © 2018 John Wiley & Sons Ltd.
-
Updated CCPS Investigation Guidelines book.
Philley, J; Pearson, K; Sepeda, A
2003-11-14
Incident investigation standards and performance criteria continue to improve. In recognition, the Center for Chemical Process Safety (CCPS) undertook a major project to upgrade and update the Incident Investigation Guidelines originally published in 1992. These significantly expanded guidelines provide a practical resource for effective investigation of process-related incidents, and reflect changes in good practices and expectations of regulators. This paper highlights the content of the new guidelines with special emphasis on what is new and improved. Entirely new chapters address the topics of legal considerations, the near-miss event, and continuous improvement of the investigation system. The objective of the guidelines is to allow chemical process organizations to develop and implement an incident investigation management system that is effective in identifying underlying causes.
-
Can Leader–Member Exchange Contribute to Safety Performance in An Italian Warehouse?
Mariani, Marco G.; Curcuruto, Matteo; Matic, Mirna; Sciacovelli, Paolo; Toderi, Stefano
2017-01-01
Introduction: The research considers safety climate in a warehouse and wants to analyze the Leader–Member Exchange (LMX) role in respect to safety performance. Griffin and Neal’s safety model was adopted and Leader-Member Exchange was inserted as moderator in the relationships between safety climate and proximal antecedents (motivation and knowledge) of safety performance constructs (compliance and participation). Materials and Methods: Survey data were collected from a sample of 133 full-time employees in an Italian warehouse. The statistical framework of Hayes (2013) was adopted for moderated mediation analysis. Results: Proximal antecedents partially mediated the relationship between Safety climate and safety participation, but not safety compliance. Moreover, the results from the moderation analysis showed that the Leader–Member Exchange moderated the influence of safety climate on proximal antecedents and the mediation exist only at the higher level of LMX. Conclusion: The study shows that the different aspects of leadership processes interact in explaining individual proficiency in safety practices. Practical Implications: Organizations as warehouses should improve the quality of the relationship between a leader and a subordinate based upon the dimensions of respect, trust, and obligation for high level of safety performance. PMID:28553244
-
Can Leader-Member Exchange Contribute to Safety Performance in An Italian Warehouse?
Mariani, Marco G; Curcuruto, Matteo; Matic, Mirna; Sciacovelli, Paolo; Toderi, Stefano
2017-01-01
Introduction: The research considers safety climate in a warehouse and wants to analyze the Leader-Member Exchange (LMX) role in respect to safety performance. Griffin and Neal's safety model was adopted and Leader-Member Exchange was inserted as moderator in the relationships between safety climate and proximal antecedents (motivation and knowledge) of safety performance constructs (compliance and participation). Materials and Methods: Survey data were collected from a sample of 133 full-time employees in an Italian warehouse. The statistical framework of Hayes (2013) was adopted for moderated mediation analysis. Results: Proximal antecedents partially mediated the relationship between Safety climate and safety participation, but not safety compliance. Moreover, the results from the moderation analysis showed that the Leader-Member Exchange moderated the influence of safety climate on proximal antecedents and the mediation exist only at the higher level of LMX. Conclusion: The study shows that the different aspects of leadership processes interact in explaining individual proficiency in safety practices. Practical Implications: Organizations as warehouses should improve the quality of the relationship between a leader and a subordinate based upon the dimensions of respect, trust, and obligation for high level of safety performance.
-
Lessons learned from measuring safety culture: an Australian case study.
Allen, Suellen; Chiarella, Mary; Homer, Caroline S E
2010-10-01
adverse events in maternity care are relatively common but often avoidable. International patient safety strategies advocate measuring safety culture as a strategy to improve patient safety. Evidence suggests it is necessary to fully understand the safety culture of an organisation to make improvements to patient safety. this paper reports a case study examining the safety culture in one maternity service in Australia and considers the benefits of using surveys and interviews to understand safety culture as an approach to identify possible strategies to improve patient safety in this setting. the study took place in one maternity service in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure which was part of a major health reform agenda. The priorities of the reform included improving the quality of care and patient safety; and, creating a more efficient health system by reducing administration inefficiencies and duplication. a descriptive case study using three approaches: the safety culture was identified to warrant improvement across all six safety culture domains. There was reduced infrastructure and capacity to support incident management activities required to improve safety, which was influenced by instability from the organisational restructure. There was a perceived lack of leadership at all levels to drive safety and quality and improving the safety culture was neither a key priority nor was it valued by the organisation. the safety culture was complex as was undertaking this study. We were unable to achieve a desired 60% response rate highlighting the limitations of using safety culture surveys in isolation as a strategy to improve safety culture. Qualitative interviews provided greater insight into the factors influencing the safety culture. The findings of this study provide evidence of the benefits of including qualitative methods with quantitative surveys when examining safety culture. Undertaking research in this way requires local engagement, commitment and capacity from the study site. The absence of these factors is likely to limit the practicality of this approach in the clinical setting. the use of safety culture surveys as the only method of assessing safety culture is of limited value in identifying strategies to potentially improve the safety culture. Copyright © 2010 Elsevier Ltd. All rights reserved.
-
Vallejo-Gutiérrez, Paula; Bañeres-Amella, Joaquim; Sierra, Eduardo; Casal, Jesús; Agra, Yolanda
2014-01-01
To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test. Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system. The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.
-
Locatelli, Paolo; Montefusco, Vittorio; Sini, Elena; Restifo, Nicola; Facchini, Roberta; Torresani, Michele
2013-01-01
The volume and the complexity of clinical and administrative information make Information and Communication Technologies (ICTs) essential for running and innovating healthcare. This paper tells about a project aimed to design, develop and implement a set of organizational models, acknowledged procedures and ICT tools (Mobile & Wireless solutions and Automatic Identification and Data Capture technologies) to improve actual support, safety, reliability and traceability of a specific therapy management (stem cells). The value of the project is to design a solution based on mobile and identification technology in tight collaboration with physicians and actors involved in the process to ensure usability and effectivenes in process management.
-
Informed consent in blood transfusion: knowledge and administrative issues in Uganda hospitals.
Kajja, Isaac; Bimenya, Gabriel S; Smit Sibinga, Cees Th
2011-02-01
Blood as a transplant is not free of risks. Clinicians and patients ought to know the parameters of a transfusion informed consent. A mixed methodology to explore patients' and clinicians' knowledge and opinions of administration and strategies to improve the transfusion informed consent process was conducted. The clinicians' level of knowledge was limited to provision of information about and the right to consent to a transfusion. They disagreed on administrative issues but had acceptable opinions on improving the process. Patients perceived this process as a way of assurance of blood safety. This process is important and should not be omitted. Copyright © 2010 Elsevier Ltd. All rights reserved.
-
Hirani, Saima Shams; Karmaliani, Rozina; McFarlane, Judith; Asad, Nargis; Madhani, Farhana; Shehzad, Shireen; Ali, Nazbano Ahmed
2010-02-01
Violence against women is a global epidemic phenomenon that can result in major mental health problems. Not only are women affected but also the health and well-being of their children are in jeopardy. To prevent violence and promote women's safety, several strategies have been tested in various cultural contexts. This article describes the process of developing and validating an economic skill building intervention for women of an urban slum area of Karachi, Pakistan. The purpose of the intervention is to increase women's economic independence, promote women's safety, and improve the behavioral functioning of their children.
-
Hammer, Leslie B.; Truxillo, Donald M.; Bodner, Todd; Rineer, Jennifer; Pytlovany, Amy C.; Richman, Amy
2015-01-01
The goal of this study was to test the effectiveness of a workplace intervention targeting work-life stress and safety-related psychosocial risk factors on health and safety outcomes. Data were collected over time using a randomized control trial design with 264 construction workers employed in an urban municipal department. The intervention involved family- and safety-supportive supervisor behavior training (computer-based), followed by two weeks of behavior tracking and a four-hour, facilitated team effectiveness session including supervisors and employees. A significant positive intervention effect was found for an objective measure of blood pressure at the 12-month follow-up. However, no significant intervention results were found for self-reported general health, safety participation, or safety compliance. These findings suggest that an intervention focused on supervisor support training and a team effectiveness process for planning and problem solving should be further refined and utilized in order to improve employee health with additional research on the beneficial effects on worker safety. PMID:26557703
-
Karim, Abdool Z
2009-01-01
The regional processing centre at Sunnybrook Health Sciences Centre recently faced the substantial challenge of increasing cleaning capacity to meet the current workload and anticipated future demand without increasing its operating budget. The solution, upgrading its cleaning and decontamination system to a highly automated system, met both objectives. An analysis of the impact of the change found that the new system provided additional benefits, including improved productivity and cleaning quality; decreased costs; reduced water, electricity and chemical use; improved worker safety and morale; and decreased overtime. Investing in innovative technology improved key departmental outcomes while meeting institutional environmental and cost savings objectives.
-
Schleyer, Anneliese M; Robinson, Ellen; Dumitru, Roxana; Taylor, Mark; Hayes, Kimberly; Pergamit, Ronald; Beingessner, Daphne M; Zaros, Mark C; Cuschieri, Joseph
2016-12-01
Hospital-acquired venous thromboembolism (HA-VTE) is a potentially preventable cause of morbidity and mortality. Despite high rates of venous thromboembolism (VTE) prophylaxis in accordance with an institutional guideline, VTE remains the most common hospital-acquired condition in our institution. To improve the safety of all hospitalized patients, examine current VTE prevention practices, identify opportunities for improvement, and decrease rates of HA-VTE. Pre/post assessment. Urban academic tertiary referral center, level 1 trauma center, safety net hospital; all patients. We formed a multidisciplinary VTE task force to review all HA-VTE events, assess prevention practices relative to evidence-based institutional guidelines, and identify improvement opportunities. The task force developed an electronic tool to facilitate efficient VTE event review and designed decision-support and reporting tools, now integrated into the electronic health record, to bring optimal VTE prevention practices to the point of care. Performance is shared transparently across the institution. Harborview benchmarks process and outcome performance, including patient safety indicators and core measures, against hospitals nationally using Hospital Compare and Vizient data. Our program has resulted in >90% guideline-adherent VTE prevention and zero preventable HA-VTEs. Initiatives have resulted in a 15% decrease in HA-VTE and a 21% reduction in postoperative VTE. Keys to success include the multidisciplinary approach, clinical roles of task force members, senior leadership support, and use of quality improvement analytics for retrospective review, prospective reporting, and performance transparency. Ongoing task force collaboration with frontline providers is critical to sustained improvements. Journal of Hospital Medicine 2016;11:S38-S43. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.
-
Murray, Marry Ellen; Douglas, Stephen; Girdley, Diana; Jarzemsky, Paula
2010-08-01
Practicing nurses are required to engage in quality improvement work as a part of their clinical practice, but few undergraduate nursing education programs offer course work and applied experience in this area. This article presents a description of class content and teaching strategies, assignments, and evaluation strategies designed to achieve the Quality and Safety Education in Nursing competencies related to quality improvement and interdisciplinary teams. Students demonstrate their application of the quality improvement process by designing and implementing a small-scale quality improvement project that they report in storyboard format on a virtual conference Web site.
-
Failure Mode and Effect Analysis for Delivery of Lung Stereotactic Body Radiation Therapy
DOE Office of Scientific and Technical Information (OSTI.GOV)
Perks, Julian R., E-mail: julian.perks@ucdmc.ucdavis.edu; Stanic, Sinisa; Stern, Robin L.
2012-07-15
Purpose: To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method. Methods: The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers).more » The failure modes with the highest risk priority numbers were then considered to implement process improvement measures. Results: A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures. Conclusion: Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.« less
-
Simons, Pascale A M; Houben, Ruud; Vlayen, Annemie; Hellings, Johan; Pijls-Johannesma, Madelon; Marneffe, Wim; Vandijck, Dominique
2015-02-01
The importance of a safety culture to maximize safety is no longer questioned. However, achieving sustainable culture improvements are less evident. Evidence is growing for a multifaceted approach, where multiple safety interventions are combined. Lean management is such an integral approach to improve safety, quality and efficiency and therefore, could be expected to improve the safety culture. This paper presents the effects of lean management activities on the patient safety culture in a radiotherapy institute. Patient safety culture was evaluated over a three year period using triangulation of methodologies. Two surveys were distributed three times, workshops were performed twice, data from an incident reporting system (IRS) was monitored and results were explored using structured interviews with professionals. Averages, chi-square, logistical and multi-level regression were used for analysis. The workshops showed no changes in safety culture, whereas the surveys showed improvements on six out of twelve dimensions of safety climate. The intention to report incidents not reaching patient-level decreased in accordance with the decreasing number of reports in the IRS. However, the intention to take action in order to prevent future incidents improved (factorial survey presented β: 1.19 with p: 0.01). Due to increased problem solving and improvements in equipment, the number of incidents decreased. Although the intention to report incidents not reaching patient-level decreased, employees experienced sustained safety awareness and an increased intention to structurally improve. The patient safety culture improved due to the lean activities combined with an organizational restructure, and actual patient safety outcomes might have improved as well. Copyright © 2014 Elsevier Ltd. All rights reserved.
-
Senior Cross-Functional Support -- Essential for Implementing Corrective Actions at C3RS Sites
DOT National Transportation Integrated Search
2012-08-01
The Federal Railroad Administrations (FRA) Office of Railroad Policy and Development believes that, in addition to process and technology innovations, human factors-based solutions can make a significant contribution to improving safety in the rai...