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Sample records for incident reporting system

  1. Critical incident reporting systems.

    PubMed

    Ahluwalia, Jag; Marriott, Lin

    2005-02-01

    Approximately 10% of all hospital admissions are complicated by critical incidents in which harm is caused to the patient - this amounts to more than 850,000 incidents annually. Critical incident reporting (CIR) systems refer to the structured reporting, collation and analysis of such incidents. This article describes the attributes required for an effective CIR system. Example neonatal trigger events and a management pathway for handling a critical incident report are described. The benefits and limitations of CIR systems, reactive and prospective approaches to the analysis of actual or potential critical incidents and the assessment of risk are also reviewed. Individual human error is but one contributor in the majority of critical incidents. Recognition of this and the fostering of an organisational culture that views critical incident reports as an opportunity to learn and to improve future patient care is vital if CIR systems are to be effective.

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 3 2011-10-01 2011-10-01 false Distribution system: Incident report. 191.9... TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.9 Distribution system: Incident report. (a) Except as provided in paragraph (c) of...

  3. 49 CFR 191.9 - Distribution system: Incident report.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 3 2013-10-01 2013-10-01 false Distribution system: Incident report. 191.9... TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.9 Distribution system: Incident report. (a) Except as provided in paragraph (c) of...

  4. 49 CFR 191.9 - Distribution system: Incident report.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 49 Transportation 3 2014-10-01 2014-10-01 false Distribution system: Incident report. 191.9... TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.9 Distribution system: Incident report. (a) Except as provided in paragraph (c) of...

  5. 49 CFR 191.9 - Distribution system: Incident report.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 3 2012-10-01 2012-10-01 false Distribution system: Incident report. 191.9... TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.9 Distribution system: Incident report. (a) Except as provided in paragraph (c) of...

  6. Confidential incident reporting systems create vital awareness of safety problems.

    PubMed

    O'Leary, M; Chappell, S L

    1996-10-01

    The aviation safety reporting system (ASRS) developed by NASA is discussed as an example of aviation incident reporting. Approaches which encourage reporting include trust and confidentiality. Reporting and analysis systems and their administration at organizational and national levels are reviewed.

  7. Developing a user-centered voluntary medical incident reporting system.

    PubMed

    Hua, Lei; Gong, Yang

    2010-01-01

    Medical errors are one of leading causes of death among adults in the United States. According to the Institute of Medicine, reporting of medical incidents could be a cornerstone to learn from errors and to improve patient safety, if incident data are collected in a properly structured format which is useful for the detection of patterns, discovery of underlying factors, and generation of solutions. Globally, a number of medical incident reporting systems were deployed for collecting observable incident data in care delivery organizations (CDO) over the past several years. However, few researches delved into design of user-centered reporting system for improving completeness and accuracy of medical incident collection, let alone design models created for other institutes to follow. In this paper, we introduce the problems identified in a current using voluntary reporting system and our effort is being made towards complete, accurate and useful user-centered new reporting system through a usability engineering process.

  8. The evaluation of a web-based incident reporting system.

    PubMed

    Kuo, Ya-Hui; Lee, Ting-Ting; Mills, Mary Etta; Lin, Kuan-Chia

    2012-07-01

    A Web-based reporting system is essential to report incident events anonymously and confidentially. The purpose of this study was to evaluate a Web-based reporting system in Taiwan. User satisfaction and impact of system use were evaluated through a survey answered by 249 nurses. Incident events reported in paper and electronic systems were collected for comparison purposes. Study variables included system user satisfaction, willingness to report, number of reports, severity of the events, and efficiency of the reporting process. Results revealed that senior nurses were less willing to report events, nurses on internal medicine units had higher satisfaction than others, and lowest satisfaction was related to the time it took to file a report. In addition, the Web-based reporting system was used more often than the paper system. The percentages of events reported were significantly higher in the Web-based system in laboratory, environment/device, and incidents occurring in other units, whereas the proportions of reports involving bedsores and dislocation of endotracheal tubes were decreased. Finally, moderate injury event reporting decreased, whereas minor or minimal injury event reporting increased. The study recommends that the data entry process be simplified and the network system be improved to increase user satisfaction and reporting rates.

  9. Key Advantages of a Targeted Incident Reporting System for Severe and Critical Clostridium difficile Infection Incidents.

    PubMed

    Mahamed, Hibak; Lemieux, Camille; Hota, Susy

    2017-01-01

    There is little guidance on how to design and implement an incident reporting system (IRS) targeted at one of the most common types of adverse events in hospitals: hospital-associated infections. In this article, we describe an IRS for severe and critical Clostridium difficile infection incidents and highlight its key advantages.

  10. Data consistency in a voluntary medical incident reporting system.

    PubMed

    Gong, Yang

    2011-08-01

    Voluntary medical incident reporting systems are a valuable source for studying adverse events and near misses. Unfortunately, such systems usually contain a large amount of incomplete and inaccurate reports which negatively affect their utility for medical error research. To investigate the reporting quality and propose solutions towards quality voluntary reports, we employed a content analysis method to examine one-year voluntary medical incident reports of a University Hospital. Results indicate that there is a large amount of inconsistent records within the reports. About 25% of the reports were labeled as "miscellaneous" and "other". Through an in-depth analysis, those "miscellaneous" and "other" were substituted by their real incident types or error descriptions. Analysis shows that the pre-defined reporting categories serve well in general for the voluntary reporting need. In some cases, human factors play a key role in selecting accurate categories since reporters lack time or information to complete the report. We suggest that a human-centered, ontology based system design for voluntary reporting is feasible. Such a design could help improve the completeness and accuracy, and interoperability among national and international standards.

  11. Toward a human-centered voluntary medical incident reporting system.

    PubMed

    Gong, Yang

    2010-01-01

    Voluntary medical incident reports are a valuable source for studying adverse events and near misses. Underreporting and low quality of reports in local organizations, however, have become the impediments in identifying trends and patterns relating at the local, regional and national level. Human factors on usefulness and ease of use have shown their important role in acceptance of voluntary reporting systems. To understand and identify the obstacles of quality reporting, we employed a set of human-centered analysis methods to examine one-year voluntary medical incident reports of a University Hospital. We found about 30% of the reports labeled as "miscellaneous" and "other", and their real incident types or error descriptions were identified through an in-depth recoding. Human-centered analyses show that the pre-defined reporting categories could serve well for the voluntary reporting need if reporters' tasks were better represented on user-friendly interfaces. We suggest that a human-centered, ontology based system design for voluntary reporting is feasible which could help improve completeness, accuracy, and interoperability among national and international standards.

  12. 49 CFR 191.9 - Distribution system: Incident report.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 3 2010-10-01 2010-10-01 false Distribution system: Incident report. 191.9 Section 191.9 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY...

  13. Early Warning: Development of Confidential Incident Reporting Systems

    NASA Technical Reports Server (NTRS)

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

    1996-01-01

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

  14. Rates and types of events reported to established incident reporting systems in two US hospitals

    PubMed Central

    Nuckols, Teryl K; Bell, Douglas S; Liu, Honghu; Paddock, Susan M; Hilborne, Lee H

    2007-01-01

    Background US hospitals have had voluntary incident reporting systems for many years, but the effectiveness of these systems is unknown. To facilitate substantial improvements in patient safety, the systems should capture incidents reflecting the spectrum of adverse events that are known to occur in hospitals. Objective To characterise the incidents from established voluntary hospital reporting systems. Design Observational study examining about 1000 reports of hospitalised patients at each of two hospitals. Patients and setting 16 575 randomly selected patients from an academic and a community hospital in the US in 2001. Main outcome measures Rates of incidents reported per hospitalised patient and characteristics of reported incidents. Results 9% of patients had at least one reported incident; 17 incidents were reported per 1000 patient‐days in hospital. Nurses filed 89% of reports, physicians 1.9% and other providers 8.9%. The most common types were medication incidents (29%), falls (14%), operative incidents (15%) and miscellaneous incidents (16%); 59% seemed preventable and preventability was not clear for 32%. Among the potentially preventable incidents, 43% involved nurses, 16% physicians and 19% other types of providers. Qualitative examination of reports indicated that very few involved prescribing errors or high‐risk procedures. Conclusions Hospital reporting systems receive many reports, but capture a spectrum of incidents that differs from the adverse events known to occur in hospitals, thereby substantially underdetecting physician incidents, particularly those involving operations, high‐risk procedures and prescribing errors. Increasing the reporting of physician incidents will be essential to enhance the effectiveness of hospital reporting systems; therefore, barriers to reporting such incidents must be minimised. PMID:17545340

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

    PubMed

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

    2015-11-04

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

  16. What to do With Healthcare Incident Reporting Systems

    PubMed Central

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

    2013-01-01

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

  17. The German Critical Incident Reporting System for Anesthesiology: CIRSains.

    PubMed

    Welker, Andreas Stefan; St Pierre, Michael; Heinrichs, Wolfgang; Ghezel-Ahmadi, Verena; Schleppers, Alexander

    2015-12-01

    In June 2010, the Helsinki Declaration was passed. As a result, an online nationwide critical incident reporting system named CIRSmedical Anaesthesiology (CIRSains) was implemented in Germany. The aim of the article is to evaluate CIRSains for practicability and to provide solutions to the problems detected during evaluation. Every medical staff member could take part voluntarily. Data were deidentified. All reports for anesthesiology (1548) were taken into account. Data collection lasted from April 2010 to February 2011. Incident report forms were classified according to World Health Organization and National Patient Safety Agency taxonomy. Most reports (1347; 87.0%) contained American Society of Anaesthesiologists (ASA) classification, stratifying the severity of patients' underlying disease. Only some mentioned patients' age, even less sex. Physicians filed more reports than nurses. Staff-related factors constituted 794 (51.3%) choices, with attention issues (433; 28.0%) and routine violations (143; 9.2%) leading. Clinical processes (443; 28.6%), medication (347; 22.4%), and medical devices (530; 34.2%) were the leading incident category types. Most consequences ranged in low (398; 25.7%) and moderate (826; 53.4%) risk categories. Mitigating factors were barely mentioned. CIRSains displays the German effort to establish the Helsinki declaration. Easy accessibility, anonymity, medicolegal safety, and high flexibility resulted in high usage. The study shows a sufficient practicability of the database, but the data input has to be improved for better scientific use, for example, by implementation of more multiple-choice questions. Given the high magnitude and importance of patient safety problems, improving CIRSains remains a priority for the future.

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

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.; Reynard, William D.

    1993-01-01

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

  19. Characteristics of Inpatient Falls not Reported in an Incident Reporting System

    PubMed Central

    Toyabe, Shin-ichi

    2016-01-01

    An incident reporting system is the most commonly used method to identify patient safety incidents in a hospital. However, non-reporting of incidents for various reasons is a serious problem. We studied the rate of inpatient falls that were not reported in an incident reporting system but were recorded in medical charts and we evaluated characteristics of those falls by comparing with the falls reported in incident reports in a Japanese acute care hospital setting. Falls recorded in medical charts were detected by using a text mining method followed by a manual chart review. About 25% of the recorded falls were not reported in incident reports. Male patients, first fall, long lag time until recording, no witness at the time of the fall and physician profession were shown to be significant factors associated with non-reporting. Our results show that the rate of non-reporting of inpatient falls in a Japanese acute care hospital is compable to that shown in previous studies in other conutries and that the same barriers to incident reporting as those found in previous studies exist in the medical staff. PMID:26493421

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

    NASA Technical Reports Server (NTRS)

    McGreevy, Michael W.

    1996-01-01

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

  1. [Learning from mistakes in hospitals. A system perspective on errors and incident reporting systems].

    PubMed

    Hofinger, G

    2009-06-01

    Analysis of incidents and near-incidents is an important factor for continuous improvement in patient safety in hospitals and for the promotion of organizational learning. From a system perspective, accidents occur when decision-making at several levels of a working system is faulty and the safety barriers fail. Human error is inevitable but accidents are not. Errors can be used as an opportunity for organizational learning and this is especially true for incidents when patients come to no harm. Starting with explanations of a system perspective on errors, this paper deals with the prerequisites for organizational learning and general rules for establishing incident reporting systems in hospitals.

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

    PubMed

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

    2009-01-01

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

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

    SciTech Connect

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

    2013-03-15

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

  4. An evaluation of departmental radiation oncology incident reports: anticipating a national reporting system.

    PubMed

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

    2013-03-15

    Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement. Copyright © 2013 Elsevier Inc. All rights reserved.

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

    SciTech Connect

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

    2015-06-15

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

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

    PubMed Central

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

    2014-01-01

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

  7. Barriers to the Operation of Patient Safety Incident Reporting Systems in Korean General Hospitals

    PubMed Central

    Hwang, Jee-In; Lee, Sang-IL

    2012-01-01

    Objectives This study aimed to explore the barriers to and factors facilitating the operation of patient safety incident reporting systems. Methods A qualitative study that used a methodological triangulation method was conducted. Participants were those who were involved in or responsible for managing incident reporting at hospitals, and they were recruited via a snowballing sampling method. Data were collected via interviews or emails from 42 nurses at 42 general hospitals. A qualitative content analysis was performed to derive the major themes related to barriers to and factors facilitating incident reporting. Results Participants suggested 96 barriers to incident reporting in their hospitals at the organizational and individual levels. Low reporting rates, especially for near misses, were the most commonly reported issue, followed by poorly designed incident reporting systems and a lack of adequate patient safety leadership by mid-level managers. To resolve and overcome these barriers, 104 recommendations were suggested. The high-priority recommendations included introducing reward systems; improving incident reporting systems, by for instance implementing a variety of reporting channels and ensuring reporter anonymity; and creating a strong safety culture. Conclusions The barriers to and factors facilitating incident reporting include various organizational and individual factors. As an important way to address these challenging issues and to improve the incident reporting systems in hospitals, we suggest several feasible methods of doing so. PMID:23346479

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

    PubMed

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

    2016-03-01

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

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 49 Transportation 3 2014-10-01 2014-10-01 false Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT...

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 3 2011-10-01 2011-10-01 false Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT...

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 3 2012-10-01 2012-10-01 false Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT...

  12. 49 CFR 191.15 - Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 3 2013-10-01 2013-10-01 false Transmission systems; gathering systems; and liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT...

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

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.; Hubener, Simone

    1997-01-01

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

  14. Using Pareto Analysis with Trend Analysis: Statistical Techniques to Investigate Incident Reports within a Housing System

    ERIC Educational Resources Information Center

    Luna, Andrew L.

    1998-01-01

    The purpose of this study was to determine trends and difficulties concerning student incident reports within the residence halls as they relate to the incident reporting system from the Department of Housing and Residential Life at a Southeastern Doctoral I Granting Institution. This study used the frequency distributions of each classified…

  15. Risk factors for radiotherapy incidents and impact of an online electronic reporting system.

    PubMed

    Chang, David W; Cheetham, Lynn; te Marvelde, Luc; Bressel, Mathias; Kron, Tomas; Gill, Suki; Tai, Keen Hun; Ball, David; Rose, William; Silva, Linas; Foroudi, Farshad

    2014-08-01

    To ascertain the rate, type, significance, trends and the potential risk factors associated with radiotherapy incidents in a large academic department. Data for all radiotherapy activities from July 2001 to January 2011 were reviewed from radiotherapy incident reporting forms. Patient and treatment data were obtained from the radiotherapy record and verification database (MOSAIQ) and the patient database (HOSPRO). Logistic regression analyses were performed to determine variables associated with radiotherapy incidents. In that time, 65,376 courses of radiotherapy were delivered with a reported incident rate of 2.64 per 100 courses. The rate of incidents per course increased (1.96 per 100 courses to 3.52 per 100 courses, p<0.001) whereas the proportion of reported incidents resulting in >5% deviation in dose (10.50 to 2.75%, p<0.001) had decreased after the introduction of an online electronic reporting system. The following variables were associated with an increased rate of incidents: afternoon treatment time, paediatric patients, males, inpatients, palliative plans, head-and-neck, skin, sarcoma and haematological malignancies. In general, complex plans were associated with higher incidence rates. Radiotherapy incidents were infrequent and most did not result in significant dose deviation. A number of risk factors were identified and these could be used to highlight high-risk cases in the future. Introduction of an online electronic reporting system resulted in a significant increase in the number of incidents being reported. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  16. [Incident reporting systems in anesthesiology--methods and benefits using the example of PaSOS].

    PubMed

    Rall, Marcus; Reddersen, Silke; Zieger, Jörg; Schädle, Bertram; Hirsch, Patricia; Stricker, Eric; Martin, Jörg; Geldner, Götz; Schleppers, Alexander

    2008-09-01

    Preventing patient harm is one of the main tasks for the field of anesthesiology from early on. With the introduction of the national German incident reporting system PaSOS, which is hosted by the German anesthesia society, anesthesiology is again leading the field of patient safety. Important elements, success factors and background information for the introduction of successful incident reporting systems in an organization are given. Examples by and from PaSOS are given.

  17. Human Factors of Remotely Piloted Aircraft Systems: Lessons from Incident Reports

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Null, Cynthia

    2016-01-01

    An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. A total of 90 incidents were reported. Human factor issues included the impact of reduced sensory cues, traffic separation in the absence of an out-the-window view, control latencies, vigilance during monotonous and ultra-long endurance flights, control station design considerations, transfer of control between control stations, the management of lost link procedures, and decision-making during emergencies.

  18. An assessment of quality costs within electronic adverse incident reporting and recording systems: a case study.

    PubMed

    Walsh, Kerry; Antony, Jiju

    2009-01-01

    There are three main objectives of the research presented in this paper: to examine the challenges of using an electronic adverse incident recording and reporting system; to assess the method of using a prevention appraisal and failure model; and to identify the benefits of using quality costs in conjunction with incident reporting systems. Action diary, documentation and triangulation are used to obtain an understanding of the challenges and critical success factors in using quality costing within an adverse incident recording and reporting system. The paper provides healthcare professionals with the critical success factors for developing quality costing into an electronic adverse incident recording and reporting system. This approach would provide clinicians, managers and directors with information on patient safety issues following the effective use of data from an electronic adverse incident reporting and recording system. This paper makes an attempt of using a prevention, appraisal and failure model (PAF) within a quality-costing framework in relation to improving patient safety within an electronic adverse incident reporting and recording system.

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

    PubMed

    Panzica, M; Krettek, C; Cartes, M

    2011-09-01

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

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

    PubMed

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

    2015-02-01

    To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. Two major academic teaching hospitals in Sydney, Australia. Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. © The Author 2015. Published by Oxford University Press in association

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

    PubMed Central

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

    2015-01-01

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

  2. SU-E-T-511: Inter-Rater Variability in Classification of Incidents in a New Incident Reporting System

    SciTech Connect

    Pappas, D; Reis, S; Ali, A; Kapur, A

    2015-06-15

    Purpose To determine how consistent the results of different raters are when reviewing the same cases within the Radiation Oncology Incident Learning System (ROILS). Methods Three second-year medical physics graduate students filled out incident reports in spreadsheets set up to mimic ROILS. All students studied the same 33 cases and independently entered their assessments, for a total of 99 reviewed cases. The narratives for these cases were obtained from a published International Commission on Radiological Protection (ICRP) report which included shorter narratives selected from the Radiation Oncology Safety Information System (ROSIS) database. Each category of questions was reviewed to see how consistent the results were by utilizing free-marginal multirater kappa analysis. The percentage of cases where all raters shared full agreement or full disagreement was recorded to show which questions were answered consistently by multiple raters for a given case. The consistency among the raters was analyzed between ICRP and ROSIS cases to see if either group led to more reliable results. Results The categories where all raters agreed 100 percent in their choices were the event type (93.94 percent of cases 0.946 kappa) and the likelihood of the event being harmful to the patient (42.42 percent of cases 0.409 kappa). The categories where all raters disagreed 100 percent in their choices were the dosimetric severity scale (39.39 percent of cases 0.139 kappa) and the potential future toxicity (48.48 percent of cases 0.205 kappa). ROSIS had more cases where all raters disagreed than ICRP (23.06 percent of cases compared to 15.58 percent, respectively). Conclusion Despite reviewing the same cases, the results among the three raters was widespread. ROSIS narratives were shorter than ICRP, which suggests that longer narratives lead to more consistent results. This study shows that the incident reporting system can be optimized to yield more consistent results.

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

    SciTech Connect

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

    2014-06-01

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

  4. 49 CFR 191.15 - Transmission and gathering systems: Incident report.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 3 2010-10-01 2010-10-01 false Transmission and gathering systems: Incident report. 191.15 Section 191.15 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) PIPELINE...

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

    ERIC Educational Resources Information Center

    McCloskey, Kathy A.; Raphael, Desreen N.

    2005-01-01

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

  6. Anesthesia-related critical incidents in the perioperative period in children; a proposal for an anesthesia-related reporting system for critical incidents in children.

    PubMed

    de Graaff, Jurgen C; Sarfo, Marie-Christine; van Wolfswinkel, Leo; van der Werff, Désirée B M; Schouten, Antonius N J

    2015-06-01

    The incidence, type and severity of anesthesia-related critical incidents during the perioperative phase has been investigated less in children than in adults. The aim of the study was to identify and analyze anesthesia-related critical incidents in children to identify areas to improve current clinical practice, and to propose a specialized anesthesia-related critical incidence registration for children. All reported pediatric anesthesia-related critical incidents reported on a voluntary reporting based on a 20-item complication list of the Dutch Society of Anesthesiology between January 2007 and August 2013 were analyzed. An anesthesia-related critical incident was defined as 'any incident that affected, or could have affected, the safety of the patient while under the care of an anesthetist'. As the 20-item complications list was too crude for detailed analyses, all critical incidents were reclassified into the more detailed German classification lists with the adjustment of specific items for children (in total 10 categories with 101 different subcategories). During the 6-year period, a total of 1214 critical incidents were reported out of 35 190 anesthetics (cardiac and noncardiac anesthesia cases). The most frequently reported incidents (46.5%) were related to the respiratory system. Infants <1 year, children with ASA physical status III and IV, and emergency procedures had a higher rate of adverse incidents. Respiratory events were the most reported commonly critical incidents in children. Both the Dutch and German existing lists of critical incident definitions appeared not to be sufficient for accurate classification in children. The present list can be used for a new registration system for critical incidents in pediatric anesthesia. © 2015 John Wiley & Sons Ltd.

  7. Experience with an anonymous web-based state EMS safety incident reporting system.

    PubMed

    Gallagher, John M; Kupas, Douglas F

    2012-01-01

    Patient and provider safety is paramount in all aspects of emergency medical services (EMS) systems. The leaders, administrators, and policymakers of these systems must have an understanding of situations that present potential for harm to patients or providers. This study analyzed reports to a statewide EMS safety event reporting system with the purpose of categorizing the types of incidents reported and identifying opportunities to prevent future safety events. This statewide EMS safety incident reporting system is a Web-based system to which any individual can anonymously report any event or situation perceived to impact safety. We reviewed all reports between the system's inception in 2003 through August 2010. A stipulation of the system is that any entry containing information that identifies an EMS provider, agency, or patient will be deleted and thus not included in the analysis. Each event report included the description of the event, the relationship of the reporter, and the year in which the event occurred. Each entry was placed into a category that best represents the situation described. A total of 415 reports were received during the study period, and 186 reports were excluded-163 (39%) excluded by the state because of identifiable information and 23 (6%) excluded by the authors because of nonsensical description. Within the remaining 229 reports, there were 237 distinct safety events. These events were classified as actions/behavior (32%), vehicle/transportation (16%), staffing or ambulance availability (13%), communications (8%), medical equipment (9%), multiple patients/agencies/units and level-of-care issues (7%), medical procedure (6%), medication (5%), accident scene management/scene safety (3%), and protocol issues (1%). EMS providers directly involved in the event represented the largest reporting group (33%). We also provide examples of statewide system and policy changes that were made in direct response to these reports. This EMS safety

  8. Medication incidents related to automated dose dispensing in community pharmacies and hospitals--a reporting system study.

    PubMed

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

    2014-01-01

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

  9. RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience.

    PubMed

    Hoopes, David J; Dicker, Adam P; Eads, Nadine L; Ezzell, Gary A; Fraass, Benedick A; Kwiatkowski, Theresa M; Lash, Kathy; Patton, Gregory A; Piotrowski, Tom; Tomlinson, Cindy; Ford, Eric C

    2015-01-01

    Incident learning is a critical tool to improve patient safety. The Patient Safety and Quality Improvement Act of 2005 established essential legal protections to allow for the collection and analysis of medical incidents nationwide. Working with a federally listed patient safety organization (PSO), the American Society for Radiation Oncology and the American Association of Physicists in Medicine established RO-ILS: Radiation Oncology Incident Learning System (RO-ILS). This paper provides an overview of the RO-ILS background, development, structure, and workflow, as well as examples of preliminary data and lessons learned. RO-ILS is actively collecting, analyzing, and reporting patient safety events. As of February 24, 2015, 46 institutions have signed contracts with Clarity PSO, with 33 contracts pending. Of these, 27 sites have entered 739 patient safety events into local database space, with 358 events (48%) pushed to the national database. To establish an optimal safety culture, radiation oncology departments should establish formal systems for incident learning that include participation in a nationwide incident learning program such as RO-ILS. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

  10. Report: EPA Could Improve Processes for Managing Contractor Systems and Reporting Incidents

    EPA Pesticide Factsheets

    Report #2007-P-00007, January 11, 2007. Although EPA had defined the specific requirements for contractor systems, EPA had not established procedures to ensure identification of all contractor systems.

  11. Analyzing voluntary medical incident reports.

    PubMed

    Gong, Yang; Richardson, James; Zhijian, Luan; Alafaireet, Patricia; Yoo, Illhoi

    2008-11-06

    Voluntary medical incident reports lacking consistency and accuracy impede the ultimate use of the reports for patient safety research. To improve this, two coders examined harm score usage in a voluntary medical incident reporting system where the harm scores were selected from a predefined list by different reporters. The two coders inter-rater agreement percent was 82%. The major categories and reviewed harm score jointly demonstrate that this process is critical and necessary in preparing the voluntary reports for further content and semantics analysis.

  12. Use of a falls incident reporting system to improve care process documentation in nursing homes.

    PubMed

    Wagner, L M; Capezuti, E; Clark, P C; Parmelee, P A; Ouslander, J G

    2008-04-01

    Falls are the most frequently reported adverse event among frail nursing home residents and are an important resident safety issue. Incident reporting systems have been successfully used to improve quality and safety in healthcare. The purpose of this study was to test the effect of a systematically guided menu-driven incident reporting system (MDIRS) on documentation of post-fall evaluation processes in nursing homes. Six for-profit nursing homes in southeastern USA participated in the study. Over a 4-month period, MDIRS was used in three nursing homes matched with another three nursing homes which continued using their existing narrative incident report to document falls. Trained geriatric nurse practitioner auditors used a data collection audit tool to collect medical record documentation of the processes of care for residents who fell. Multivariate analysis of covariance was used to compare the post-fall nursing care processes documented in the medical records. 207 medical records of resident who fell were examined. Over 75% of the sample triggered at high risk for falls by the minimum data set. An adequate neurological assessment was documented for only 18.4% of residents who had experienced a fall. Although two-thirds of the sample had a diagnosis of incontinence, less than 20% of the records had incontinence-related interventions in the nursing care plan. Overall, there was more complete documentation of the post-fall evaluation process in the medical records in nursing homes using the MDIRS than in nursing homes using standard narrative incident reports (p<0.001). Further improvements are necessary in reporting mechanisms to improve the post-fall assessment in nursing home residents.

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

    PubMed

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

    2009-08-01

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

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

    PubMed Central

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

    2016-01-01

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

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

    NASA Technical Reports Server (NTRS)

    Withrow, Colleen A.; Reveley, Mary S.

    2014-01-01

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

  16. Evaluation of the Defense Criminal Investigative Organizations’ Defense Incident-Based Reporting System Reporting and Reporting Accuracy

    DTIC Science & Technology

    2014-10-29

    crime statistics . The Act directs Federal agencies that routinely investigate complaints of criminal activity to report details about such crimes to the...not reporting criminal incident data to the Federal Bureau of Investigation (FBI) for inclusion in the annual Uniform Crime Reports to the President...Federal law. The FBI uses the data to develop a reliable set of criminal statistics for U.S. law enforcement agencies. Recommendations • The

  17. The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008.

    PubMed

    Rutherford, J S; Flin, R; Irwin, A

    2015-07-01

    The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance". A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative non-technical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.

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

    PubMed Central

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

    2016-01-01

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

  19. The effect of a workflow-based response system on hospital-wide voluntary incident reporting rates.

    PubMed

    Wang, Szu-Chang; Li, Ying-Chun; Huang, Hung-Chi

    2013-02-01

    Hospital incident reporting systems are usually evaluated on their theoretical benefit to the hospital or increase in reporting rates alone. To evaluate a workflow-based response system on staff incident reporting rates. A prospective cohort study of incident reports made by staff members before (2006-2007) and after (2008-2009) the system was implemented on 1 January 2008 at a medical center in southern Taiwan. Pre-system and post-system data were based on 713 129 and 730 176 inpatient days and 160 692 and 168 850 emergency department visits. The addition of a workflow-based response system to a reporting system processing incident reports and intra-hospital responses. Voluntary incident reporting rates and distribution of incident severities. Inpatient reports [9.9 vs. 28.8 per 10 000 patient days; rate ratio (RR): 2.9, 95% confidence interval (CI): 2.7-3.2, P < 0.001] and emergency department reports (5.9 vs. 19.2 per 10 000 visits, RR: 3.3, 95% CI: 2.6-4.1, P < 0.001) increased significantly, particularly in doctors in inpatient areas (RR: 2.7, 95% CI: 1.8-4.1, P < 0.001), emergency department nurses (RR: 9.4, 95% CI: 6.1-14.4, P < 0.001) and allied health professionals in inpatient areas (RR: 2.2, 95% CI:1.8-2.6, P < 0.001). Post-system reported incidents were more evenly distributed over five severity levels than pre-sytem incidents, moving more toward the very severe level (RR: 17.6, 95% CI: 8.4-37.0, P < 0.001) and no harm level (RR: 6.2, 95% CI: 4.5-8.7, P < 0.001). The addition of the workflow-based response system to the hospital incident reporting system significantly increased hospital-wide voluntary incident report rates at all incident injury levels.

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

    SciTech Connect

    Briscoe, G.J.

    1993-06-07

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

  1. How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

    PubMed Central

    Stavropoulou, Charitini; Doherty, Carole; Tosey, Paul

    2015-01-01

    Context Incident-reporting systems (IRSs) are used to gather information about patient safety incidents. Despite the financial burden they imply, however, little is known about their effectiveness. This article systematically reviews the effectiveness of IRSs as a method of improving patient safety through organizational learning. Methods Our systematic literature review identified 2 groups of studies: (1) those comparing the effectiveness of IRSs with other methods of error reporting and (2) those examining the effectiveness of IRSs on settings, structures, and outcomes in regard to improving patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where, and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single-loop and double-loop learning. Findings In total, we identified 43 studies, 8 that compared IRSs with other methods and 35 that explored the effectiveness of IRSs on settings, structures, and outcomes. We did not find strong evidence that IRSs performed better than other methods. We did find some evidence of single-loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence of either improvements in outcomes or changes in the latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double-loop learning, that is, a cultural change or a change in mind-set. Conclusions The results indicate that IRSs could be more effective if the criteria for what counts as an incident were explicit, they were owned and led by clinical teams rather than centralized hospital departments, and they were embedded within organizations as part of wider safety programs. PMID:26626987

  2. INCIDENT REPORTING: LEARNING FROM EXPERIENCE

    SciTech Connect

    Weiner, Steven C.; Kinzey, Bruce R.; Dean, Jesse D.; Davis, Patrick B.; Ruiz, Antonio

    2007-09-12

    Experience makes a superior teacher. Sharing the details surrounding safety events is one of the best ways to help prevent their recurrence elsewhere. This approach requires an open, non-punitive environment to achieve broad benefits. The Hydrogen Incident Reporting Tool (www.h2incidents.org) is intended to facilitate the sharing of lessons learned and other relevant information gained from actual experiences using and working with hydrogen and hydrogen systems. Its intended audience includes those involved in virtually any aspect of hydrogen technology, systems and use, with an emphasis towards energy and transportation applications. The database contains records of safety events both publicly available and/or voluntarily submitted. Typical records contain a general description of the occurrence, contributing factors, equipment involved, and some detailing of consequences and changes that have been subsequently implemented to prevent recurrence of similar events in the future. The voluntary and confidential nature and other characteristics surrounding the database mean that any analysis of apparent trends in its contents cannot be considered statistically valid for a universal population. A large portion of reported incidents have occurred in a laboratory setting due to the typical background of the reporting projects, for example. Yet some interesting trends are becoming apparent even at this early stage of the database’s existence and general lessons can already be taken away from these experiences. This paper discusses the database and a few trends that have already become apparent for the reported incidents. Anticipated future uses of this information are also described. This paper is intended to encourage wider participation and usage of the incidents reporting database and to promote the safety benefits offered by its contents.

  3. 49 CFR 171.16 - Detailed hazardous materials incident reports.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Materials Incident Report to the Information Systems Manager, PHH-63, Pipeline and Hazardous Materials... Hazardous Material Incident Report to the Information System Manager, DHM-63, Research and Special Programs... INFORMATION, REGULATIONS, AND DEFINITIONS Incident Reporting, Notification, BOE Approvals and Authorization...

  4. A Laboratory Critical Incident and Error Reporting System for Experimental Biomedicine.

    PubMed

    Dirnagl, Ulrich; Przesdzing, Ingo; Kurreck, Claudia; Major, Sebastian

    2016-12-01

    We here propose the implementation of a simple and effective method to enhance the quality of basic and preclinical academic research: critical incident reporting (CIR). CIR has become a standard in clinical medicine but to our knowledge has never been implemented in the context of academic basic research. We provide a simple, free, open-source software tool for implementing a CIR system in research groups, laboratories, or large institutions (LabCIRS). LabCIRS was developed, tested, and implemented in our multidisciplinary and multiprofessional neuroscience research department. It is accepted by all members of the department, has led to the emergence of a mature error culture, and has made the laboratory a safer and more communicative environment. Initial concerns that implementation of such a measure might lead to a "surveillance culture" that would stifle scientific creativity turned out to be unfounded.

  5. A Laboratory Critical Incident and Error Reporting System for Experimental Biomedicine

    PubMed Central

    Dirnagl, Ulrich; Przesdzing, Ingo; Kurreck, Claudia; Major, Sebastian

    2016-01-01

    We here propose the implementation of a simple and effective method to enhance the quality of basic and preclinical academic research: critical incident reporting (CIR). CIR has become a standard in clinical medicine but to our knowledge has never been implemented in the context of academic basic research. We provide a simple, free, open-source software tool for implementing a CIR system in research groups, laboratories, or large institutions (LabCIRS). LabCIRS was developed, tested, and implemented in our multidisciplinary and multiprofessional neuroscience research department. It is accepted by all members of the department, has led to the emergence of a mature error culture, and has made the laboratory a safer and more communicative environment. Initial concerns that implementation of such a measure might lead to a “surveillance culture” that would stifle scientific creativity turned out to be unfounded. PMID:27906976

  6. Incident analysis report

    SciTech Connect

    Gregg, D.W.; Buerer, A.; Leeds, S.

    1996-02-20

    This document presents information about a fire that occurred in January 1996 at Lawrence Livermore National Laboratory. This fire was caused by the spontaneous combustion of 100% fuming nitric acid. Topics discussed include: Summary of the incident; technical background; procedural background; supervision; previous incidents with 100% fuming nitric acid; and judgment of potential hazards.

  7. New York City Board of Education Division of School Safety: Incident Reporting System Needs To Be Strengthened To Ensure Accurate Reporting of School Safety Incidents, No. A-7-95.

    ERIC Educational Resources Information Center

    New York State Office of the Comptroller, Albany.

    The New York State Board of Education's Division of School Safety is responsible for maintaining a safe and secure environment to ensure that schools are free from disruption. This report presents findings of an audit that investigated whether the division's incident reporting system database accurately captured all school safety incidents that…

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

    PubMed

    Bierie, David M

    2015-09-01

    The National Incident-Based Reporting System (NIBRS) is an important data set serving social scientists, policy makers, the business community, and the press. However, it is hampered by low participation rates among the nation's police agencies. This article outlines a strategy for enhancing NIBRS by (a) providing police agencies free and supported software to extract and transmit an agency's Record Management System (RMS) data in NIBRS format (or a data-entry system if an RMS does not exist), (b) including personal identifiers of arrestees, and (c) allowing police agencies to access the national data for routine police work. The article describes how taking these steps would decrease the costs of implementing and maintaining NIBRS, encourage widespread adoption, and increase data quality. These enhancements could foster substantial improvements in policing as well as other aspects of the criminal justice system. These changes would also open up new and exciting areas for academics and analysts, including the ability to study criminal careers over time as well as criminal networks within NIBRS. © The Author(s) 2014.

  9. Improving incident reporting among junior doctors

    PubMed Central

    Hotton, Emily; Jordan, Lesley; Peden, Carol

    2014-01-01

    To ensure systems in hospitals improve to make patient care safer, learning must occur when things go wrong. Incident reporting is one of the commonest mechanisms used to learn from harm events and near misses. Only a relatively small number of incidents that occur are actually reported and different groups of staff have different rates of reporting. Nationally, junior doctors are low reporters of incidents, a finding supported by our local data. We set out to explore the culture and awareness around incident reporting among our junior doctors, and to improve the incident reporting rate within this important staff group. In order to achieve this we undertook a number of work programmes focused on junior doctors, including: assessment of their knowledge, confidence and understanding of incident reporting, education on how and why to report incidents with a focus on reporting on clinical themes during a specific time period, and evaluation of the experience of those doctors who reported incidents. Junior doctors were asked to focus on incident reporting during a one week period. Before and after this focussed week, they were invited to complete a questionnaire exploring their confidence about what an incident was and how to report. Prior to “Incident Reporting Week”, on average only two reports were submitted a month by junior doctors compared with an average of 15 per month following the education and awareness week. This project highlights the fact that using a focussed reporting period and/or specific clinical themes as an education tool can benefit a hospital by promoting awareness of incidents and by increasing incident reporting rates. This can only assist in improving hospital systems, and ultimately increase patient safety. PMID:26734264

  10. Improving incident reporting among junior doctors.

    PubMed

    Hotton, Emily; Jordan, Lesley; Peden, Carol

    2014-01-01

    To ensure systems in hospitals improve to make patient care safer, learning must occur when things go wrong. Incident reporting is one of the commonest mechanisms used to learn from harm events and near misses. Only a relatively small number of incidents that occur are actually reported and different groups of staff have different rates of reporting. Nationally, junior doctors are low reporters of incidents, a finding supported by our local data. We set out to explore the culture and awareness around incident reporting among our junior doctors, and to improve the incident reporting rate within this important staff group. In order to achieve this we undertook a number of work programmes focused on junior doctors, including: assessment of their knowledge, confidence and understanding of incident reporting, education on how and why to report incidents with a focus on reporting on clinical themes during a specific time period, and evaluation of the experience of those doctors who reported incidents. Junior doctors were asked to focus on incident reporting during a one week period. Before and after this focussed week, they were invited to complete a questionnaire exploring their confidence about what an incident was and how to report. Prior to "Incident Reporting Week", on average only two reports were submitted a month by junior doctors compared with an average of 15 per month following the education and awareness week. This project highlights the fact that using a focussed reporting period and/or specific clinical themes as an education tool can benefit a hospital by promoting awareness of incidents and by increasing incident reporting rates. This can only assist in improving hospital systems, and ultimately increase patient safety.

  11. Improving Incident Reporting Among Physician Trainees.

    PubMed

    Krouss, Mona; Alshaikh, Jumana; Croft, Lindsay; Morgan, Daniel J

    2016-09-09

    Preventable medical harm is a leading cause of death in the United States. Incident reporting systems have been identified as the primary method to capture medical error and harm. Incidents are rarely reported, particularly among physician trainees. We conducted a single-center, quasi-experimental study to examine the effect of education on the importance of and how to file an incident report for physician trainees on reporting rates. Trainees were provided laminated plastic instructions, and reporting was reinforced with weekly patient safety rounds. In addition, trainees completed anonymous surveys preintervention and postintervention to determine barriers to reporting. A χ test compared the number of reports preintervention and postintervention. For 6 months, 73 resident physicians participated in the study. Median incident reports entered by trainees increased from 1 report per month during the preintervention period to 10 reports per month after the intervention (P = 0.005). The most common barriers to reporting incidents before intervention were not knowing how to report (72.6%), what to report (56.2%), and lack of time (42.5%). A total of 13.7% reported fear of retaliation. Most incident reports were due to delay in patient care (40.9%) and medical errors (33.3%). Real-time education and regular reinforcement increased incident reporting among resident physicians. This educational approach may increase incidence reporting in other institutions.

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

    NASA Technical Reports Server (NTRS)

    Withrow, Colleen A.; Reveley, Mary S.

    2014-01-01

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

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

    PubMed Central

    2015-01-01

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

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

    PubMed

    Howell, Ann-Marie; Burns, Elaine M; Bouras, George; Donaldson, Liam J; Athanasiou, Thanos; Darzi, Ara

    2015-01-01

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

  15. Cyber Incidents Involving Control Systems

    SciTech Connect

    Robert J. Turk

    2005-10-01

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

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

    PubMed Central

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

    2012-01-01

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

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

    PubMed

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

    2012-10-01

    A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1 January 2005 and 31 December 2010 was undertaken. The 526,186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394,951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44,952) from primary care, representing 8.5% of the total. Of 86,821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263,228; 50%) and prescribing (97,097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82,028; 16%) and wrong dose (80,170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance. © 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.

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

    PubMed Central

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

    2015-01-01

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

  19. Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system.

    PubMed

    Shorr, Ronald I; Mion, Lorraine C; Chandler, A Michelle; Rosenblatt, Linda C; Lynch, Debra; Kessler, Lori A

    2008-04-01

    To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care. Six-month observational study. Sixteen adult nursing units (349 beds) in an urban, academically affiliated, community hospital. Patients admitted to the study units during the study period. Nursing staff identifying falls were instructed to notify, using a pager, a trained nurse "fall evaluator." Fall evaluators provided 24-hour-per-day 7-day-per-week coverage throughout the study. Data on patient falls gathered by fall evaluators were compared with falls data obtained through the hospital's incident reporting system. During 51,180 patient-days of observation, 191 falls were identified according to incident reports (3.73 falls/1,000 patient-days), whereas the evaluation service identified 228 falls (4.45 falls/1,000 patient-days). Combining falls reported from both data sources yielded 266 falls (5.20 falls/1,000 patient-days), a 39% relative rate increase compared with incident reports alone (P<.001). For falls with injury, combining data from both sources yielded 79 falls (1.54 injurious falls/1,000 patient-days), compared with 57 falls (1.11 injurious falls/1,000 patient-days) filed in incident reports--a 28% increase (P=.06). In the 16 nursing units, the relative percentage increase of captured fall events using the combined data sources versus the incident reporting system alone ranged from 13% to 125%. Incident reports significantly underestimate both injurious and noninjurious falls in acute care settings and should not be used as the sole source of data for research or quality improvement initiatives.

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

    SciTech Connect

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

    2006-02-07

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

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

    NASA Technical Reports Server (NTRS)

    Bergeron, H. P.

    1983-01-01

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

  2. Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System.

    PubMed

    Catchpole, K; Bell, M D D; Johnson, S

    2008-04-01

    The incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12,606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.

  3. [Which definition and taxonomy of incident to use for a French reporting system in primary care settings?].

    PubMed

    Keriel-Gascou, M; Brami, J; Chanelière, M; Haeringer-Cholet, A; Larrieu, C; Villebrun, F; Robert, T; Michel, P

    2014-02-01

    There is no widely accepted definition of incident for primary care doctors in France and no taxonomic classification system for epidemiological use. In preparation for a future epidemiological study on primary care incidents in France (the ESPRIT study), this work was designed to identify the definitions and taxonomic classifications used internationally along with the usual methods and results in terms of frequency in the literature. The goal was to determine a French definition and taxonomy. Systematic review of the literature and consensus methods. An exhaustive search of epidemiological surveys was performed. A structured grid was used. After having identified the definitions used in the literature, a definition was chosen using the focus groups method. Taxonomies identified in the literature were classified by relationship, architecture, code number, and number of studies published. Subsequently, a consensus among experts, who independently tested these taxonomies on six incidents, was reached for choosing the most appropriate for epidemiological data collection (little information on a large number of cases). Twenty-four papers reporting 17 studies were selected among 139 articles. Five definitions and eight taxonomies were found. The chosen definition of incident was based on the WHO definition "A patient safety incident is an event or circumstance that could have resulted, or did result, in harm to a patient, and whose wish it is not repeated again". The test of incidents resulted in the choice of the TAPS version of the International Taxonomy of Medical Error in Primary Care for a reproducible and internationally recognized codification and the tempos method for its current use in French general practice. The definitions, taxonomies, data collection characteristics and frequency of incidents results in the international literature on incidents in primary care are key components for the preparation of an epidemiological survey on incidents in primary care

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

    NASA Technical Reports Server (NTRS)

    Bergeron, H. P.

    1980-01-01

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

  5. SU-E-T-469: Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

    SciTech Connect

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

    2015-06-15

    Purpose: This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process. Results: Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of

  6. Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports.

    PubMed

    Mansouri, Mohammad; Shaqdan, Khalid W; Aran, Shima; Raja, Ali S; Lev, Michael H; Abujudeh, Hani H

    2015-12-01

    The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.

  7. Major incident in Kent: a case report.

    PubMed

    Hardy, Sophie Elizabeth Jap

    2015-09-22

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

  8. Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP.

    PubMed

    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.

  9. Detection of Medical Errors in Kidney Transplantation: A Pilot Study Comparing Proactive Clinician Debriefings to a Hospital-Wide Incident Reporting System

    PubMed Central

    McElroy, Lisa M.; Daud, Amna; Lapin, Brittany; Ross, Olivia; Woods, Donna M.; Skaro, Anton; Holl, Jane L.; Ladner, Daniela P.

    2014-01-01

    Background Rates of medical errors and adverse events remain high for kidney transplant patients, who are particularly vulnerable due to the complexity of their disease and the kidney transplant procedure. Although institutional incident reporting systems are utilized in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems. Methods Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011 and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported. Results A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared to incident reports, more attending physicians completed the debriefings (32.0 vs. 3.5%). Discussion The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants. PMID:25444312

  10. Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the System-Wide Safety and Assurance Technologies Project

    NASA Technical Reports Server (NTRS)

    Withrow, Colleen A.; Reveley, Mary S.

    2015-01-01

    The Aviation Safety Program (AvSP) System-Wide Safety and Assurance Technologies (SSAT) Project asked the AvSP Systems and Portfolio Analysis Team to identify SSAT-related trends. SSAT had four technical challenges: advance safety assurance to enable deployment of NextGen systems; automated discovery of precursors to aviation safety incidents; increasing safety of human-automation interaction by incorporating human performance, and prognostic algorithm design for safety assurance. This report reviews incident data from the NASA Aviation Safety Reporting System (ASRS) for system-component-failure- or-malfunction- (SCFM-) related and human-factor-related incidents for commercial or cargo air carriers (Part 121), commuter airlines (Part 135), and general aviation (Part 91). The data was analyzed by Federal Aviation Regulations (FAR) part, phase of flight, SCFM category, human factor category, and a variety of anomalies and results. There were 38 894 SCFM-related incidents and 83 478 human-factorrelated incidents analyzed between January 1993 and April 2011.

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

    PubMed Central

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

    2016-01-01

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

  12. 78 FR 14877 - Pipeline Safety: Incident and Accident Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-07

    ... Pipeline and Hazardous Materials Safety Administration Pipeline Safety: Incident and Accident Reports... availability of revised incident and accident report forms and request for supplemental reports. SUMMARY: In... Gathering Pipeline Systems and PHMSA F 7000-1--Accident Report--Hazardous Liquid Pipeline Systems....

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

    ERIC Educational Resources Information Center

    Guthrie, Susan; Lecko, Caroline; Roddam, Hazel

    2015-01-01

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

  14. Reasons for not reporting adverse incidents: an empirical study.

    PubMed

    Vincent, C; Stanhope, N; Crowley-Murphy, M

    1999-02-01

    A previous study (Stanhope et al. 1998) established that staff in two obstetric units reported less than a quarter of designated incidents to the units' risk managers. A questionnaire was administered to 42 obstetricians and 156 midwives at the same two obstetric units, exploring the reasons for low rates of reporting. Questions concerned their knowledge of their unit's incident reporting system; whether they would report a series of 10 designated adverse obstetric incidents to the risk manager; and their views on 12 potential reasons for not reporting incidents. Most staff knew about the incident-reporting system in their unit, but almost 30% did not know how to find a list of reportable incidents. Views on the necessity of reporting the 10 designated obstetric incidents varied considerably. For example, 96% of staff stated they would always report a maternal death, whereas less than 40% would report a baby's unexpected admission to the Special Care Baby Unit. Midwives said they were more likely to report incidents than doctors, and junior staff were more likely to report than senior staff. The main reasons for not reporting were fears that junior staff would be blamed, high workload and the belief (even though the incident was designated as reportable) that the circumstances or outcome of a particular case did not warrant a report. Junior doctors felt less supported by their colleagues than senior doctors. Current systems of incident reporting, while providing some valuable information, do not provide a reliable index of the rate of adverse incidents. Recommended measures to increase reliability include clearer definitions of incidents, simplified methods of reporting, designated staff to record incidents and education, feedback and reassurance to staff about the nature and purpose of such systems.

  15. Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy.

    PubMed

    Phipps, Denham L; Tam, W Vanessa; Ashcroft, Darren M

    2017-03-01

    To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis. Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records. Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.

  16. Frequency and nature of reported incidents during Emergency Department care.

    PubMed

    Considine, Julie; Mitchell, Belinda; Stergiou, Helen E

    2011-05-01

    The aim of this study was to examine reported incidents affecting Emergency Department (ED) episodes of care. A retrospective audit of ED patients was carried out in an urban district hospital in Melbourne, Australia from 1 January 2008 to 31 December 2008. The main outcome measure was presence or absence of reported patient-related incident(s) during ED care. There were 984 patient-related incidents (n=984) during 2008.The most common incidents were related to patient behaviour (66.4%), patient management (10.1%) and medications (6.5%). Patients whose ED care involved reported incident(s) were older, had higher triage categories, longer length of ED stay and were more likely to need hospital admission or leave at their own risk. Eighteen per cent of reported incidents occurred in patients aged 65 years and over. Incidents affecting older patients were more likely to be related to breach of skin integrity, patient management, diagnosis and patient identification, and less likely to involve patient behaviour. Reported incident(s) occurred in 0.47% of ED episodes of care. Differences in personal and clinical characteristics of patients whose ED care involved reported incident(s) highlights the need for better understanding of incidents occurring in the ED in order to improve systems for high-risk patients.

  17. Incident reporting at a tertiary care hospital in Saudi Arabia.

    PubMed

    Arabi, Yaseen; Alamry, Ahmed; Al Owais, Souzan M; Al-Dorzi, Hasan; Noushad, Seema; Taher, Saadi

    2012-06-01

    This study aimed to examine the rates and categories of incident reports in an academic tertiary care center in Saudi Arabia both hospital-wide and in the intensive care unit (ICU). Such information would help in redesigning systems and in planning and developing strategies with the goal of improving patient safety and quality of care. In this descriptive study, we evaluated all incident reports submitted through the paper-based reporting system in the hospital and the ICU for the year 2008. Incident report rates were calculated as the number of incident reports per 1000 patient days. We also reviewed the major and minor categories of the generated reports. A total of 3041 incident reports were submitted from all hospital areas; yielding a rate of 5.8 per 1000 patient days. Sixty-two incident reports were reported from the ICU, yielding a rate of 5.8 per 1000 patient days. The most frequent type of incident reports was procedural variances (37%), followed by behavior and communication incidents (34%), hazardous and safety incidents (9.5%), and medication errors (7.4%). In the ICU, the most frequently reported type of incidents was behavior and communication incidents (30.6%), followed by procedural variances (21%) and medication errors (13%). Rates of incident reports at a tertiary care center in Saudi Arabia were low compared with reported international rates. The main categories of incident reports were related to procedural variances and behavior and communication incidents. These findings suggest that patient safety initiatives should focus primarily on these 2 domains. Additional prospective research is needed in this important area to further understand patient safety challenges and reporting practice and culture in the country.

  18. [Malposition of epidural catheter: an 8-year retrospective analysis on an incident reporting system at an urban university hospital].

    PubMed

    Date, Yoriko; Ishikawa, Seiji; Fujisawa, Akiko; Uchida, Tokujirou; Nakazawa, Koichi; Makita, Koshi

    2010-10-01

    Epidural anesthesia is widely used in patients who undergo thoracic, abdominal or lower extremity surgeries and generally considered useful for perioperative analgesic management. Epidural catheterization is often associated with some complications including misplacement of the catheter. Epidural catheters are known to be misplaced or migrate into subarachnoidal space, subdural space, vessels and thoracic cavities ; however, frequency, predominant sites of misplacement, and the timing of detection are not fully understood regarding the misplacement of the catheters. In this retrospective study, our incident reporting system dealt with a period of 8 years (from 1999 to 2007) at our university hospital. Out of 8 patients who had misplacement of the catheter, 6 patients were male and 2 patients were female. Epidural catheters were misplaced to subarachnoid space in 6 cases and thoracic cavity in 2 cases. The misplacement of the catheters was found before the induction of general anesthesia in 2 patients, after induction of general anesthesia in 1 patient, during surgical procedure in 3 patients, and postoperatively in 2 patients. Since misplacement of epidural catheters can occur at any moment during perioperative period, continuous monitoring and observation of patients seem to be very important to prevent and minimize the adverse events related to the misplacement of epidural catheters.

  19. Semantic Theme Analysis of Pilot Incident Reports

    NASA Technical Reports Server (NTRS)

    Thirumalainambi, Rajkumar

    2009-01-01

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

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

    ERIC Educational Resources Information Center

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

    2014-01-01

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

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

    ERIC Educational Resources Information Center

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

    2014-01-01

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

  2. Incident reporting: the bureau investigation.

    PubMed

    Mains, Paul

    2015-01-01

    The Bureau Investigation (BI) is a type of report that lends itself to the internal complaints often generated within a bureaucracy, the author reports, and ranges from discourtesy complaints on a single shift or a single officer to the more complex, sensitive inquiries called for by the senior administration. In this article he explores the many facets of the BI which must be mastered.

  3. Incidence | Cancer Trends Progress Report

    Cancer.gov

    The Cancer Trends Progress Report, first issued in 2001, summarizes our nation's advances against cancer in relation to Healthy People targets set forth by the Department of Health and Human Services.

  4. Patient safety and incident reporting: survey of Italian healthcare workers.

    PubMed

    Albolino, Sara; Tartaglia, Riccardo; Bellandi, Tommaso; Amicosante, Anna Maria Vincenza; Bianchini, Elisa; Biggeri, Annibale

    2010-10-01

    Incident-reporting systems (IRS) are tools that allow front-line healthcare workers to voluntary report adverse events and near misses. The WHO has released guidelines that outline the basic principles on how to design and implement successful IRS in healthcare organisations. A written survey was administered with an assisted self-assessment technique to a representative sample of healthcare workers in Italian hospitals with and without IRS. Data were collected using two different 16-item questionnaires. The questionnaires targeted two issues: (1) workers' experience of patient safety incidents and (2) their expectations on incident reporting. 70% of respondents confirmed involvement in a patient safety incident, but only 40% utilised an IRS to formally report the event. The data indicate that information regarding patient safety incidents is not communicated throughout the entire organisation. Research findings are consistent with the available evidence on healthcare workers' experience of patient safety incidents.

  5. Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center

    PubMed Central

    Huang, Szu-Fen; Liang, Huey-Wen; Chen, Li-Chin; Lin, Chia-Kuei; Huang, Hsiao-Fang; Hsieh, Ming-Yuan; Sun, Jui-Sheng

    2017-01-01

    Objective There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs. Methods We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data. Results Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125). Conclusions The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts. PMID:28166260

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

    PubMed

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

    2014-09-01

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

  7. Attitudes and perceived barriers influencing incident reporting by nurses and their correlation with reported incidents: A systematic review.

    PubMed

    Fung, Wing Mei; Koh, Serena Siew Lin; Chow, Yeow Leng

    2012-01-01

    Clinical incident reporting is an integral feature of risk management system in the healthcare sector. By reporting clinical incidents, nurses allow for learning from errors, identification of error patterns and development of error preventive strategies. The need to understand attitudes to reporting, perceived barriers and incident reporting patterns by nurses are the core highlights of this review. INCLUSION CRITERIA: This review considered descriptive quantitative studies that examined nurses' attitudes or perceived barriers towards incident reporting.The participants in this review were nurses working in acute care settings or step-down care settings. Studies that included non-nursing healthcare personnel were excluded.This review considered studies which examined nurses' attitudes towards incident reporting, perceived barriers and incident reporting practices.The outcomes of interest were the attitudes that nurses have towards incident reporting, perceived barriers and the types of reported incidents in correlation with nurses' attitudes and barriers. A three-step search strategy was utilised in this review. An initial limited search of CINAHL and MEDLINE was undertaken. Search strategies were then developed using identified keywords and index terms. Lastly, the reference lists of all identified articles were examined. All searches were limited to studies published in English, between 1991 and 2010. The studies were independently assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal Checklist for Descriptive/ Case Series studies. The reviewers extracted data independently from included studies using the Joanna Briggs Institute Data Extraction Form for Descriptive/ Case Series studies. Due to the descriptive nature of the study designs, statistical pooling was not possible. Therefore, the findings of this systematic review are presented in a narrative summary. Fifty-five papers were identified from the searches based on their titles and

  8. C2-Related Incidents Reported by UAS Pilots

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

    2016-01-01

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

  9. Possible solutions for barriers in incident reporting by residents.

    PubMed

    Martowirono, Kartinie; Jansma, José D; van Luijk, Scheltus J; Wagner, Cordula; Bijnen, A Bart

    2012-02-01

    Incident reporting can contribute to safer health care. Since the rate of reporting by residents is low, it is useful to investigate which barriers exist and how these can be solved. Data were collected in a large teaching hospital in the Netherlands. The hospital uses a confidential, voluntary and web-based incident reporting system. Residents working in the hospital participated in focus group discussions to explore barriers and possible solutions. A grounded theory approach was used to analyse the transcribed discussions. In each focus group six to eight residents participated, resulting in a total number of 22 participants. After three focus group discussions, information saturation had been reached. Residents do not report all incidents because of a negative attitude towards incident reporting, because they experience a non-stimulating culture and because of a lack of perceived ability to report. Residents suggest several solutions to solve the barriers: providing the possibility to report anonymously, providing feedback, creating an incident reporting culture, simplifying the procedure, clarifying what and how to report, and exciting residents to report. Residents have useful suggestions to resolve the barriers that prevent them from reporting incidents. They include solutions that influence attitude, culture and perceived ability. These suggestions should be considered when making an effort to improve incident reporting by residents. © 2010 Blackwell Publishing Ltd.

  10. A Meta-Analysis of the Incidence of Patient-Reported Dysphagia After Anterior Cervical Decompression and Fusion with the Zero-Profile Implant System.

    PubMed

    Yang, Yi; Ma, Litai; Liu, Hao; Xu, MangMang

    2016-04-01

    Dysphagia is a well-known complication following anterior cervical surgery. It has been reported that the Zero-profile Implant System can decrease the incidence of dysphagia following surgery, however, dysphagia after anterior cervical decompression and fusion (ACDF) with the Zero-profile Implant System remains controversial. Previous studies only focus on small sample sizes. The objective of this study was to determine the incidence of dysphagia after ACDF with the Zero-profile Implant System. Studies were collected from PubMed, EMBASE, the Cochrane library and the China Knowledge Resource Integrated Database using the keywords "Zero-profile OR Zero-p) AND (dysphagia OR [swallowing dysfunction]". The software STATA (Version 13.0) was used for statistical analysis. Statistical heterogeneity across the various trials, a test of publication bias and sensitivity analysis was performed. 30 studies with a total of 1062 patients were included in this meta-analysis. The occurrence of post-operative transient dysphagia ranged from 0 to 76 % whilst the pooled incidence was 15.6 % (95 % CI, 12.6, 18.5 %). 23 studies reported no persistent dysphagia whilst seven studies reported persistent dysphagia ranging from 1 to 7 %). In summary, the present study observed a low incidence of both transient and persistent dysphagia after ACDF using the Zero-profile Implant System. Most of the dysphagia was mild and gradually decreased during the following months. Moderate or severe dysphagia was uncommon. Future randomized controlled multi-center studies and those focusing on the mechanisms of dysphagia and methods to reduce its incidence are required.

  11. Development of Incident Report Database for Organizational Learning

    NASA Astrophysics Data System (ADS)

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

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

  12. How to Report a Pesticide Incident Involving Exposures to People

    EPA Pesticide Factsheets

    Pesticides incidents must be reported by pesticide registrants. Others, such as members of the public and environmental professionals, would like to report pesticide incidents. This website will facilitate such incident reporting.

  13. Contributing factors identified by hospital incident report narratives.

    PubMed

    Nuckols, T K; Bell, D S; Paddock, S M; Hilborne, L H

    2008-10-01

    A major purpose of incident reporting is to understand contributing factors so that causes of errors can be uncovered and systems made safer. For established reporting systems in US hospitals, little is known about how well the reports identify contributing factors. To characterise the information incident report narratives provide about contributing factors using a taxonomy we developed for this purpose. Descriptive study examining 2228 reports for 16 575 randomly selected patients discharged from an academic and a community hospital in the US between 1 January and 31 December 2001. Reports in which patient, system and provider (errors, mistakes and violations) factors were identifiable. 80% of reports described at least one contributing factor. Patient factors were identifiable in 32%, most frequently illness (61% of these reports) and behaviour (24%). System factors were identifiable in 32%, most commonly equipment malfunction or difficulty of use (38%), problems coordinating care among providers (31%), provider unavailability (24%) and tasks that were difficult to execute correctly (20%). Provider factors were evident in 46%, but half of these reports contained insufficient detail to determine which specific factor. When detail sufficed, slips (52%), exceptional violations (22%), lapses (15%) and applying incorrect rules (13%) were common. Contributing factors could be identified in most incident-report narratives from these hospitals. However, each category of factors was present in a minority of reports, and provider factors were often insufficently elucidated. Greater detail about contributing factors would make incident reports more useful for improving patient safety.

  14. Clinical incidents involving students on placement: an analysis of incident reports to identify potential risk factors.

    PubMed

    Gaida, J E; Maloney, S; Lo, K; Morgan, P

    2015-06-01

    Students are sometimes involved in incidents during clinical training. To the authors' knowledge, no quantitative studies of incidents specifically involving physiotherapy students on clinical placement are available in the literature. A retrospective audit (2008 to 2011) of incident reports involving physiotherapy students was conducted to identify the nature and features of incidents. The study aimed to determine if injuries to a student or patient were more or less likely when the supervisor was in close proximity, and whether students with lower academic performance in their preclinical semester were more likely to be involved in an incident. There were 19 care-delivery-related and three equipment-related incidents. There were no incidents of violent, aggressive or demeaning behaviour towards students. The incident rate was 9.0/100,000 student-hours for third-year students and 6.8/100,000 student-hours for fourth-year students. The majority of incidents (55%) occurred from 11 am to 12-noon and from 3 pm to 3.30 pm. Incidents more often resulted in patient or student injury when the supervisor was not in close proximity (approximately 50% vs approximately 20%), although the difference was not significant (P=0.336). The academic results of students involved in incidents were equivalent to the whole cohort in their preclinical semester {mean 75 [standard deviation (SD) 6] vs 76 (SD 7); P=0.488}. The unexpected temporal clustering of incidents warrants further investigation. Student fatigue may warrant attention as a potential contributor; however, contextual factors, such as staff workload, along with organisational systems, structures and procedures may be more relevant. The potential relationship between supervisor proximity and injury also warrants further exploration. The findings of the present study should be integrated into clinical education curricula and communicated to clinical educators. Copyright © 2014 Chartered Society of Physiotherapy. Published by

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

    PubMed

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

    2006-01-01

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

  16. Visually Exploring Worldwide Incidents Tracking System Data

    SciTech Connect

    Chhatwal, Shree D.; Rose, Stuart J.

    2008-01-27

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

  17. Sibling sexual abuse: an empirical analysis of offender, victim, and event characteristics in National Incident-Based Reporting System (NIBRS) data, 2000-2007.

    PubMed

    Krienert, Jessie L; Walsh, Jeffrey A

    2011-01-01

    Sibling sexual abuse is identified as the most common form of familial sexual abuse. Extant literature is plagued by definitional inconsistencies, data limitations, and inadequate research methodology. Trivialized as "normal" sexual exploration, sibling sexual abuse has been linked to psychosocial/psychosexual dysfunction. Research has relied on retrospective, convenience, and/or homogenous samples. This work drew on eight years of National Incident-Based Reporting System data (2000-2007) to provide aggregate level baseline information. This work extended prior research exploring victim-, offender-, and incident-based characteristics. Results highlight the need for expanded definitional criteria relating to both age and gender to better inform risk assessment and prevention. Findings both corroborate and contrast prior work and suggest victim- and offender-based gender differences.

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

    PubMed

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

    2014-06-01

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

  19. Patterns of Error in Confidential Maintenance Incident Reports

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Kanki, Barbara G.

    2008-01-01

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

  20. Patterns of Error in Confidential Maintenance Incident Reports

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Kanki, Barbara G.

    2008-01-01

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

  1. Critical incident reporting in anaesthesia: a prospective internal audit.

    PubMed

    Gupta, Sunanda; Naithani, Udita; Brajesh, Saroj Kumar; Pathania, Vikrant Singh; Gupta, Apoorva

    2009-08-01

    Critical incident monitoring is useful in detecting new problems, identifying 'near misses' and analyzing factors or events leading to mishaps, which can be instructive for trainees. This study was aimed at investigating potential risk factors and analyze events leading to peri-operative critical incidents in order to develop a critical incident reporting system. We conducted a one year prospective analysis of voluntarily reported 24- hour-perioperative critical incidents, occurring in patients subjected to anaesthesia. During a one year period from December 2006 to December 2007, 14,134 anaesthetics were administered and 112(0.79%) critical incidents were reported with complete recovery in 71.42%(n=80) and mortality in 28.57% (n=32) cases. Incidents occurred maximally in 0-10 years age (23.21%), ASA 1(61.61%), in general surgery patients (43.75%), undergoing emergency surgery (52.46%) and during day time (75.89%). Incidence was more in the operating theatre (77.68%), during maintenance (32.04%) and post-operative phase (25.89%) and in patients who received general anaesthesia (75.89%). Critical incidents occurred clue to factors related to anaesthesia (42.85%), patient (37.50%) and surgery (16.96%). Among anaesthesia related critical incidents (42.85% n=48/112), respiratory events were maximum (66.66%) mainly at induction (37.5%) and emergence (43.75%), and factors responsible were human error (85.41%), pharmacological factors (10.41%) and equipment error (4.17%). Incidence of mortality was 22.6 per 10, 000 anaesthetics (32/14,314), mostly attributable to risk factors in patient (59.38%) as compared to anaesthesia (25%) and surgery (9.38%). There were 8 anaesthesia related deaths (5.6 per 10, 000 anaesthetics) where human error (75%) attributed to lack of judgment (67.50%) was an important causative factor. We conclude that critical incident reporting system may be a valuable part of quality assurance to develop policies to prevent recurrence and enhance patient

  2. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND... a monthly report of all railroad accidents/incidents described in § 225.19. The report shall be made... the month during which the accidents/incidents occurred. Reports shall be completed as required by the...

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

    PubMed

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

    2015-12-01

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

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

    PubMed Central

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

    2015-01-01

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

  5. Exploring Health Care Professionals' Perceptions of Incidents and Incident Reporting in Rehabilitation Settings.

    PubMed

    Espin, Sherry; Carter, Celina; Janes, Nadine; McAllister, Mary

    2015-06-12

    Research exploring patient safety in rehabilitation settings is limited. This study's aim was to describe team members' perceptions of incidents and incident reporting in rehabilitation settings. Semistructured interviews were conducted with 18 health care professionals from multiple rehabilitation units (medical, neurological, and orthopedic) at 2 inner-city rehabilitation centers. Five hypothetical scenarios were presented to participants during the interviews. Participants were asked to classify the scenarios and whether they would report any identified incidents. Data were analyzed using a descriptive thematic approach. Participants classified events based on 2 parameters: the nature of the outcome and deviation from professional practice. Factors influencing participants' decisions to file incident reports included their classification of the events in the scenarios (i.e., events classified as critical incidents were more often reported than those classified as incident or near miss); the severity of the impact on the client; and their profession's perceived role in reporting specific incidents. When participants said they would report incidents, all agreed that they would report only objective facts. The study findings demonstrate gaps between incident-reporting policy and practice, and opportunities to address these gaps. Organizational leaders can work with all health care professions to support their roles in reporting. Interprofessional team building, focused on valuing all team members, may improve interprofessional communication and reporting. Setting standards for classifying events could increase consistency in reporting. Ultimately, encouraging reporting of near misses and incidents can create a culture of learning focused on problem solving and improved patient safety.

  6. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 4 2013-10-01 2013-10-01 false Reporting of accidents/incidents. 225.11 Section... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.11 Reporting of accidents/incidents. (a) Each railroad subject to this part shall submit...

  7. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 4 2012-10-01 2012-10-01 false Reporting of accidents/incidents. 225.11 Section... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.11 Reporting of accidents/incidents. (a) Each railroad subject to this part shall submit...

  8. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

  9. 49 CFR 225.11 - Reporting of accidents/incidents.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 49 Transportation 4 2014-10-01 2014-10-01 false Reporting of accidents/incidents. 225.11 Section... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.11 Reporting of accidents/incidents. (a) Each railroad subject to this part shall submit...

  10. Use of Critical Incident Reports in Medical Education

    PubMed Central

    Branch, William T

    2005-01-01

    Critical incident reports are now being widely used in medical education. They are short narrative accounts focusing on the most important professional experiences of medical students, residents, and other learners. As such, critical incident reports are ideally suited for addressing values and attitudes, and teaching professional development. This manuscript describes critical incident reports and gives examples of their use, provides a theoretical underpinning that explains their effectiveness, and describes the educational impacts of critical incident reports and similar methods that use reflective learning. The author recommends critical incident reports as an especially effective means to address learners' most deeply held values and attitudes in the context of their professional experiences. PMID:16307635

  11. Perceptions of Canadian labour and delivery nurses about incident reporting: a qualitative descriptive focus group study.

    PubMed

    Waters, Norna F; Hall, Wendy A; Brown, Helen; Espezel, Hilary; Palmer, Lynne

    2012-07-01

    Estimates of incidents (adverse events) occurring during inpatient hospital stays suggest patient safety demands attention. Improving the safety of health care systems requires understanding incidents and their causes. Labour and delivery nurses can contribute to understanding incidents and incident reporting because they actively identify and report incidents in practice. To explore Canadian labour and delivery nurses' perceptions about reporting incidents in practice and identify factors facilitating or constraining incident reporting. A descriptive qualitative study design using focus groups to collect data. Three labour and delivery units within one health authority in the province of British Columbia. Sixteen registered nurses participated in one of four focus groups between 2009 and 2010. We audio-taped interviews, transcribed the data, and analysed interview data using inductive content analysis and constant comparison. We identified four main themes. The themes included determining an incident, the labour and delivery context, and barriers and facilitating factors for incident reporting. The nurses viewed incidents they identified as unique to their practice. Rather than being a single error, a series of events, which nurses often regarded as out of their control, could lead to incidents. The practice context for labour and delivery, specifically fear of litigation and complexity of decision-making about incidents, affected nurses' perceptions of incidents and incident reporting. Positive team dynamics complicated the process of incident identification and reporting. Nurses viewed lack of time and fatigue, inadequate reporting tools, and unit culture as barriers to incident reporting. Facilitating factors were learning opportunities, practice improvement, and professional responsibility. Team work in Canadian labour and delivery practice settings influences determinations of what constitutes incidents and how they are managed. The complexity of incidents

  12. The role of the emergency medical dispatch centre (EMDC) and prehospital emergency care safety: results from an incident report (IR) system.

    PubMed

    Mortaro, Alberto; Pascu, Diana; Zerman, Tamara; Vallaperta, Enrico; Schönsberg, Alberto; Tardivo, Stefano; Pancheri, Serena; Romano, Gabriele; Moretti, Francesca

    2015-07-01

    The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives. An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010. During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population. Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a "learning organization" and improve both efficacy and safety of first aid care.

  13. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 33 Navigation and Navigable Waters 2 2010-07-01 2010-07-01 false Reporting a pollution incident. 150.830 Section 150.830 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY... pollution incident. Oil pollution incidents involving a deepwater port are reported according to §§ 135.305...

  14. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

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

  15. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

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

  16. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

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

  17. 33 CFR 150.830 - Reporting a pollution incident.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

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

  18. 46 CFR 148.115 - Report of incidents.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 46 Shipping 5 2012-10-01 2012-10-01 false Report of incidents. 148.115 Section 148.115 Shipping... MATERIALS THAT REQUIRE SPECIAL HANDLING Minimum Transportation Requirements § 148.115 Report of incidents... any instructions given. (b) Any incident or casualty occurring while transporting a material covered...

  19. 46 CFR 148.115 - Report of incidents.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 46 Shipping 5 2014-10-01 2014-10-01 false Report of incidents. 148.115 Section 148.115 Shipping... MATERIALS THAT REQUIRE SPECIAL HANDLING Minimum Transportation Requirements § 148.115 Report of incidents... any instructions given. (b) Any incident or casualty occurring while transporting a material covered...

  20. 46 CFR 148.115 - Report of incidents.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 46 Shipping 5 2011-10-01 2011-10-01 false Report of incidents. 148.115 Section 148.115 Shipping... MATERIALS THAT REQUIRE SPECIAL HANDLING Minimum Transportation Requirements § 148.115 Report of incidents... any instructions given. (b) Any incident or casualty occurring while transporting a material covered...

  1. 46 CFR 148.115 - Report of incidents.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 46 Shipping 5 2013-10-01 2013-10-01 false Report of incidents. 148.115 Section 148.115 Shipping... MATERIALS THAT REQUIRE SPECIAL HANDLING Minimum Transportation Requirements § 148.115 Report of incidents... any instructions given. (b) Any incident or casualty occurring while transporting a material covered...

  2. Fourth-year nursing student perceptions of incidents and incident reporting.

    PubMed

    Espin, Sherry; Meikle, Diane

    2014-04-01

    This study explored how fourth-year nursing students (n = 10) from one urban baccalaureate nursing program perceived incidents potentially harmful to patients, as well as incident reporting. Individual interviews were conducted. Five scenarios were presented in the interviews, with each scenario portraying a situation that varied in terms of the severity of potential for patient harm and the clinical team members involved. Participants' responses were analyzed using a descriptive thematic approach. Of the 50 events (10 participants × 5 scenarios), participants identified 37 events as incidents. Three themes emerged regarding how participants identified an incident: scope of practice, professional roles, and harm to the patient. Regarding 48 of the 50 events, participants said they would report these incidents either informally or formally. Findings from this study suggest a need for nursing education regarding what constitutes an incident, as well as how and when to report incidents.

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

    NASA Technical Reports Server (NTRS)

    Minton, Jacquie

    1997-01-01

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

  4. Motivational antecedents of incident reporting: evidence from a survey of nurses and physicians.

    PubMed

    Pfeiffer, Yvonne; Briner, Matthias; Wehner, Theo; Manser, Tanja

    2013-11-12

    Underreporting is a major issue when using incident reporting systems to improve safety in hospitals. Based on a psychological framework, this study investigated the motivational antecedents of the willingness to report into incident reporting systems in healthcare. Individual, organisational and system-related influences on the willingness to report incidents were investigated in a survey of physicians and nurses from five Swiss hospitals. The motivational antecedents were tested using structural equation modelling. The sample consisted of 818 respondents, 546 nurses and 230 physicians; the response rate was 32%. The willingness to report was assessed by using a self-report scale, validated with the self-reported number of reported incidents during the previous year. The most important influence on the willingness to report was the transparency of the incident reporting system procedures to potential users, such as. knowing how and what kind of events to report. At the individual level, the perceived effectiveness of reporting was a relevant antecedent. At the organisational level, management support positively influenced the willingness to report. Different antecedents were found to be relevant for nurses and physicians. Implications are discussed that open up alternatives for the design and implementation of incident reporting systems in healthcare. For example, the results of the study point to opportunities for making incident reporting systems more transparent and participatory and to allow for experience of how they actually improve patient safety.

  5. 30 CFR 285.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What incidents must I report, and when must I... must I report, and when must I report them? (a) You must report the following incidents to us... provide a written report of the following incidents to us within 15 days after the incident: (1) Any...

  6. An error taxonomy system for analysis of haemodialysis incidents.

    PubMed

    Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

    2014-12-01

    This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

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

    PubMed

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

    2010-05-01

    Hospitals can apply prospective and retrospective methods to reduce the large number of medical errors. Retrospective methods are used to identify errors after they occur and to facilitate learning. Prospective methods aim to determine, assess and minimise risks before incidents happen. This paper questions whether the order of implementation of those two methods influences the resultant impact on incident reporting behaviour. From November 2007 until June 2008, twelve wards of two Dutch general hospitals participated in a quasi-experimental reversed-treatment non-equivalent control group design. The six units of Hospital 1 first conducted a prospective analysis, after which a sophisticated incident reporting and analysis system was implemented. On the six units of Hospital 2 the two methods were implemented in reverse order. Data from the incident reporting and analysis system and from a questionnaire were used to assess between-hospital differences regarding the number of reported incidents, the spectrum of reported incident types, and the profession of reporters. The results show that carrying out a prospective analysis first can improve incident reporting behaviour in terms of a wider spectrum of reported incident types and a larger proportion of incidents reported by doctors. However, the proposed order does not necessarily yield a larger number of reported incidents. This study fills an important gap in safety management research regarding the order of the implementation of prospective and retrospective methods, and contributes to literature on incident reporting. This research also builds on the network theory of social contagion. The results might indicate that health care employees can disseminate their risk perceptions through communication with their direct colleagues. Copyright 2010 Elsevier Ltd. All rights reserved.

  8. Accounting for reporting fatigue is required to accurately estimate incidence in voluntary reporting health schemes.

    PubMed

    Gittins, Matthew; McNamee, Roseanne; Holland, Fiona; Carter, Lesley-Anne

    2017-01-01

    Accurate estimation of the true incidence of ill-health is a goal of many surveillance systems. In surveillance schemes including zero reporting to remove ambiguity with nonresponse, reporter fatigue might increase the likelihood of a false zero case report in turn underestimating the true incidence rate and creating a biased downward trend over time. Multilevel zero-inflated negative binomial models were fitted to incidence case reports of three surveillance schemes running between 1996 and 2012 in the United Kingdom. Estimates of the true annual incidence rates were produced by weighting the reported number of cases by the predicted excess zero rate in addition to the within-scheme standard adjustment for response rate and the participation rate. Time since joining the scheme was associated with the odds of excess zero case reports for most schemes, resulting in weaker calendar trends. Estimated incidence rates (95% confidence interval) per 100,000 person years, were approximately doubled to 30 (21-39), 137 (116-157), 33 (27-39), when excess zero-rate adjustment was applied. If we accept that excess zeros are in reality nonresponse by busy reporters, then usual estimates of incidence are likely to be significantly underestimated and previously thought strong downward trends overestimated. Copyright © 2016 Elsevier Inc. All rights reserved.

  9. 28 CFR 541.14 - Incident report and investigation.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... the investigation, and staff may not question the inmate until the Federal Bureau of Investigation or... report and investigation. (a) Incident report. The Bureau of Prisons encourages informal resolution... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Incident report and investigation....

  10. 36 CFR 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... § 1230.14 How do agencies report incidents? The agency must report promptly any unlawful or accidental... 36 Parks, Forests, and Public Property 3 2012-07-01 2012-07-01 false How do agencies report incidents? 1230.14 Section 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS...

  11. 36 CFR 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... § 1230.14 How do agencies report incidents? The agency must report promptly any unlawful or accidental... 36 Parks, Forests, and Public Property 3 2014-07-01 2014-07-01 false How do agencies report incidents? 1230.14 Section 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS...

  12. 36 CFR 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... § 1230.14 How do agencies report incidents? The agency must report promptly any unlawful or accidental... 36 Parks, Forests, and Public Property 3 2011-07-01 2011-07-01 false How do agencies report incidents? 1230.14 Section 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS...

  13. Nephrogenic systemic fibrosis: change in incidence following a switch in gadolinium agents and adoption of a gadolinium policy--report from two U.S. universities.

    PubMed

    Altun, Ersan; Martin, Diego R; Wertman, Rebecca; Lugo-Somolinos, Aida; Fuller, Edwin R; Semelka, Richard C

    2009-12-01

    To determine the incidence of nephrogenic systemic fibrosis (NSF) in tertiary care centers of two U.S. universities following the switch from the use of gadodiamide to gadobenate dimeglumine and gadopentetate dimeglumine, and the adoption of restrictive gadolinium-based contrast agent (GBCA) policies. Institutional review board approval with waiver of informed consent was obtained for this Health Insurance Portability and Accountability Act-compliant retrospective study. NSF patients were identified between January 2000 and December 2006 at center A and between October 2003 and February 2007 at center B (preadoption periods); and from June 2007 to June 2008 at both centers (postadoption period). The numbers of patients who underwent gadolinium-enhanced magnetic resonance at each center, patients at risk for NSF at center A, and dialysis patients at center B were identified in the pre- and postadoption periods. Gadodiamide was the only agent used in the preadoption period. Gadobenate dimeglumine and gadopentetate dimeglumine were the agents used in the postadoption period. A restrictive GBCA policy that limits the use and dose of GBCAs in patients with risk factors was adopted in the postadoption period. Follow-up lasted 9 months from July 2008 to March 2009. Corresponding incidences were determined and compared with the Fisher exact test. Respective total benchmark incidence of NSF at both centers, at-risk incidence of NSF at center A, and dialysis incidence of NSF at center B were 37 of 65 240, 28 of 925, and nine of 312 in the preadoption period and zero of 25 167, zero of 147, and zero of 402 in the postadoption period. All three incidences demonstrated significant differences (P < .0001, .024, and .001, respectively) between the pre- and postadoption periods. Following the switch from gadodiamide to gadobenate dimeglumine and gadopentetate dimeglumine, and the adoption of restrictive GBCA policies, no NSF cases were observed at either center.

  14. 78 FR 71033 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-27

    ... Other Gas Transmission and Gathering Pipeline Systems; PHMSA F 7100.3 Incident Report--Liquefied Natural Gas Facilities; and PHMSA F 7100.3-1 Annual Report for Calendar Year 20xx Liquefied Natural Gas... Calendar Year 20xx for Distribution Operators; PHMSA F 7100.2 Incident Report-- Natural and Other...

  15. Patient safety incidents are common in primary care: A national prospective active incident reporting survey

    PubMed Central

    Brami, Jean; Chanelière, Marc; Kret, Marion; Mosnier, Anne; Dupie, Isabelle; Haeringer-Cholet, Anouk; Keriel-Gascou, Maud; Maradan, Claire; Villebrun, Frédéric; Makeham, Meredith; Quenon, Jean-Luc

    2017-01-01

    Background The study objectives were to describe the incidence and the nature of patient safety incidents (PSIs) in primary care general practice settings, and to explore the association between these incidents and practice or organizational characteristics. Methods GPs, randomly selected from a national influenza surveillance network (n = 800) across France, prospectively reported any incidents observed each day over a one-week period between May and July 2013. An incident was an event or circumstance that could have resulted, or did result, in harm to a patient, which the GP would not wish to recur. Primary outcome was the incidence of PSIs which was determined by counting reports per total number of patient encounters. Reports were categorized using existing taxonomies. The association with practice and organizational characteristics was calculated using a negative binomial regression model. Results 127 GPs (participation rate 79%) reported 317 incidents of which 270 were deemed to be a posteriori judged preventable, among 12,348 encounters. 77% had no consequences for the patient. The incidence of reported PSIs was 26 per 1000 patient encounters per week (95% CI [23‰ -28‰]). Incidents were three times more frequently related to the organization of healthcare than to knowledge and skills of health professionals, and especially to the workflow in the GPs’ offices and to the communication between providers and with patients. Among GP characteristics, three were related with an increased incidence in the final multivariable model: length of consultation higher than 15 minutes, method of receiving radiological results (by fax compared to paper or email), and being in a multidisciplinary clinic compared with sole practitioners. Conclusions Patient safety incidents (PSIs) occurred in mean once every two days in the sampled GPs and 2% of them were associated with a definite possibility for harm. Studying the association between organizational features of general

  16. The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of anesthetic equipment failure/malfunction: an analysis of 1996 incident reports.

    PubMed

    Kusumaphanyo, Chaiyapruk; Charuluxananan, Somrat; Sriramatr, Dujduen; Pulnitiporn, Aksorn; Sriraj, Wimonrat

    2009-11-01

    The present study is a part of the multi-centered study of model of anesthesia relating adverse events in Thailand by incident report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective was to identify the frequency distribution, contributing factors, and factors minimizing incident of equipment failure/malfunction. As a prospective descriptive research design, anesthesia providers reported the data as soon as the incidents of equipment failure/malfunction occurred. Standardized forms of incident report were then mailed to the center at Chulalongkorn University and three anesthesiologists reviewed the data. Ninety-two cases of equipment failure/malfunction were reported from 51 hospitals across Thailand Between January and June 2007, 92 incidents of equipment failure/malfunction were reported out of 1996 anesthesia-related incidents (4.6%). Failed/malfunctioned equipment included anesthetic circuit (17.4%), anesthesia machine (15.2%), capnography (15.2%), laryngoscope (15.2%), ventilator (12%), pulse oximeter (8.7%), vaporizer (4.3%), endotracheal tube (3.3%), sodalime (3.3%), and electrocardiogram (2.2%). All 16 anesthetic circuit incidents (100%) were detected by clinical signs whereas five incidents (31.3%) were detected firstly by monitors. All 14 laryngoscope malfunction (100%) were detected solely by clinical signs. Only one out of eight (12.5%) of pulse oximeter incidents was detected by clinical signs before the pulse oximeter itself. Three out of four (75%) incidents of vaporizer were detected by clinical signs before monitors. The majority of equipment malfunction was considered as related to anesthetic (69.6%) and system factors (69.6%) and 71.7% of incidents were preventable. Seventy-four incidents (80.4%) were caused by human error and, specifically, rule-based error in three fourths. Contributing factors were ineffective equipment, haste, lack of experience, ineffective monitors, and inadequate equipment. Factors minimizing

  17. 36 CFR 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... incidents? 1230.14 Section 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT UNLAWFUL OR ACCIDENTAL REMOVAL, DEFACING, ALTERATION, OR DESTRUCTION OF RECORDS § 1230.14 How do agencies report incidents? The agency must report promptly any unlawful or accidental...

  18. Wrong intraocular lens implant; learning from reported patient safety incidents.

    PubMed

    Kelly, S P; Jalil, A

    2011-06-01

    To consider wrong intraocular lens (IOL) implant events in cataract surgical care reported through a national incident reporting database. To propose potential solutions for such events where possible. Thematic retrospective review of wrong IOL implantation incidents, as reported through clinical incident reporting methods in NHS care in England and Wales from 2003 to 2010, ascertained from database mining at the National Patient Safety Agency. In total, 164 patient safety incident (PSI) reports of wrong IOL implantation were located from the study period and considered. There were 47 reports where further surgical intervention was required. All, but one of these required IOL exchange surgery. A total of 62 reports did not provide any causal reason for the wrong IOL implantation and thus provide little if any potential learning. Inaccurate biometry (n=29), wrong IOL selection (n=21), transcription errors (n=10) and handwriting misinterpretations (n=7) were causal reasons reported and are thus potential areas for ophthalmic teams to review and improve practice. Although infrequent, biometry/IOL implant errors or wrong implants do occasionally occur during cataract care and are thus a threat to quality. There is room for improvement in incident reporting in NHS cataract care as root causation of error was usually lacking in the PSI reports. Nevertheless, lessons for improvement of care from a national incident reporting database for a frequently undertaken surgical procedure were found. Suggestions are proposed for improving quality by reducing wrong IOL problems in cataract care based on analysis of such reports.

  19. Wrong intraocular lens implant; learning from reported patient safety incidents

    PubMed Central

    Kelly, S P; Jalil, A

    2011-01-01

    Purpose To consider wrong intraocular lens (IOL) implant events in cataract surgical care reported through a national incident reporting database. To propose potential solutions for such events where possible. Methods Thematic retrospective review of wrong IOL implantation incidents, as reported through clinical incident reporting methods in NHS care in England and Wales from 2003 to 2010, ascertained from database mining at the National Patient Safety Agency. Results In total, 164 patient safety incident (PSI) reports of wrong IOL implantation were located from the study period and considered. There were 47 reports where further surgical intervention was required. All, but one of these required IOL exchange surgery. A total of 62 reports did not provide any causal reason for the wrong IOL implantation and thus provide little if any potential learning. Inaccurate biometry (n=29), wrong IOL selection (n=21), transcription errors (n=10) and handwriting misinterpretations (n=7) were causal reasons reported and are thus potential areas for ophthalmic teams to review and improve practice. Conclusion Although infrequent, biometry/IOL implant errors or wrong implants do occasionally occur during cataract care and are thus a threat to quality. There is room for improvement in incident reporting in NHS cataract care as root causation of error was usually lacking in the PSI reports. Nevertheless, lessons for improvement of care from a national incident reporting database for a frequently undertaken surgical procedure were found. Suggestions are proposed for improving quality by reducing wrong IOL problems in cataract care based on analysis of such reports. PMID:21350567

  20. Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database.

    PubMed

    Cooper, Jennifer; Edwards, Adrian; Williams, Huw; Sheikh, Aziz; Parry, Gareth; Hibbert, Peter; Butlin, Amy; Donaldson, Liam; Carson-Stevens, Andrew

    2017-09-01

    A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports. We characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame. Health care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%-47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated. The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others' behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture. © 2017 Annals of Family Medicine, Inc.

  1. Non-Hodgkin's lymphoma incidence and survival in European children and adolescents (1978-1997): report from the Automated Childhood Cancer Information System project.

    PubMed

    Izarzugaza, M Isabel; Steliarova-Foucher, Eva; Martos, M Carmen; Zivkovic, Snezana

    2006-09-01

    Non-Hodgkin's lymphomas (NHLs) constitute a large and heterogeneous group of malignant tumours. This paper describes and interprets geographical patterns (1988-1997) and time trends (1978-1997) of NHL incidence and survival in European children and adolescents. All 7702 lymphomas that were not Hodgkin's, were extracted from the Automated Childhood Cancer Information System (ACCIS) database and included in different analyses. In children under 15 years of age and for the period 1988-1997, the overall NHL age-adjusted incidence rate was 9.4 per million and has been increasing over 20 years by 0.9% per year on average (P=0.002). In adolescents aged 15-19 years, the age-specific incidence rate was 15.9 per million, increasing annually by 1.7% (P=0.007). Five-year survival of children diagnosed in 1988-1997 was 77%, ranging from 58% in the East to 83% in the West. A substantial increase in survival was observed in all European regions. Systematic monitoring and evaluation of childhood and adolescent data on NHL will contribute to further improvement in public health policy for the young population of Europe.

  2. Honey bees, neonicotinoids and bee incident reports: the Canadian situation.

    PubMed

    Cutler, G Christopher; Scott-Dupree, Cynthia D; Drexler, David M

    2014-05-01

    Neonicotinoid insecticides have been the target of much scrutiny as possible causes of recent declines observed in pollinator populations. Although neonicotinoids have been implicated in honey bee pesticide incidents, there has been little examination of incident report data. Here we summarize honey bee incident report data obtained from the Canadian Pest Management Regulatory Agency (PMRA). In Canada, there were very few honey bee incidents reported in 2007-2011 and data were not collected prior to 2007. In 2012, a significant number of incidents were reported in the province of Ontario, where exposure to neonicotinoid dust during planting of corn was suspected to have caused the incident in up to 70% of cases. Most of these incidents were classified as 'minor' by the PMRA, and only six cases were considered 'moderate' or 'major'. In that same year, there were over three times as many moderate or major incidents due to older non-neonicotinoid pesticides, involving numbers of hives or bees far greater than the number of moderate or major incidents suspected to be due to neonicotinoid poisoning. These data emphasize that, while exposure of honey bees to neonicotinoid-contaminated dust during corn planting needs to be mitigated, other pesticides also pose a risk. © 2013 Society of Chemical Industry.

  3. Self-report as an indicator of incident disease.

    PubMed

    Oksanen, Tuula; Kivimäki, Mika; Pentti, Jaana; Virtanen, Marianna; Klaukka, Timo; Vahtera, Jussi

    2010-07-01

    Epidemiological studies use self-reports from repeated surveys to ascertain incident disease. However, the accuracy of such measurements remains unknown, as validity studies have typically relied on data from prevalent, rather than incident, disease. This study examined the validity of self-reports in the detection of new-onset disease with measurements at baseline and follow-up conditions. We conducted a prospective cohort study of 34,616 Finnish public-sector employees. Data from self-reported, physician-diagnosed diseases from two surveys approximately 4 years apart were compared with corresponding records in comprehensive national health registers used as the validity criterion. There was a considerable degree of misclassification for self-reports as a measure of incident disease. The specificity of self-reports was equally high for the prevalent and incident diseases (range, 93%-99%), but the sensitivity of self-reports was considerably lower for incident than for prevalent diseases: hypertension (55% vs. 86%), diabetes (62% vs. 96%), asthma (63% vs. 91%), coronary heart disease (62% vs. 78%), and rheumatoid arthritis (63% vs. 83%). This study suggests that the sensitivity of self-reports is substantially worse for incident than for prevalent diseases. Results from studies on self-reported incident chronic conditions should be interpreted with caution. 2010 Elsevier Inc. All rights reserved.

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

    NASA Technical Reports Server (NTRS)

    Villeda, Eric B.

    1996-01-01

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

  5. Narrativizing errors of care: critical incident reporting in clinical practice.

    PubMed

    Iedema, Rick; Flabouris, Arthas; Grant, Susan; Jorm, Christine

    2006-01-01

    This paper considers the rise across acute care settings in the industrialized world of techniques that encourage clinicians to record their experiences about adverse events they are personally involved in; that is, to share narratives about errors, mishaps or 'critical incidents'. The paper proposes that critical incident reporting and the 'root cause' investigations it affords, are both central to the effort to involve clinicians in managing and organizing their work, and a departure from established methods and approaches to achieve clinicians' involvement in these non-clinical domains of health care. We argue that critical incident narratives render visible details of the clinical work that have thus far only been discussed in closed, paperless meetings, and that, as narratives, they incite individuals to share personal experiences with parties previously excluded from knowledge about failure. Drawing on a study of 124 medical retrieval incident reports, the paper provides illustrations and interpretations of both the narrative and the meta-discursive dimensions of critical incident reporting. We suggest that, as a new and complex genre, critical incident reporting achieves three important objectives. First, it provides clinicians with a channel for dealing with incidents in a way that brings problems to light in a non-blaming way and that might therefore be morally satisfying and perhaps even therapeutic. Second, these narrations make available new spaces for the apprehension, identification and performance of self. Here, the incident report becomes a space where clinicians publicly perform concern about what happened. Third, incident reporting becomes the basis for radically altering the clinician-organization relationship. As a complex expression of clinical failure and its re-articulation into organizational meta-discourse, incident reporting puts doctors' selves and feelings at risk not just within the relative safety of personal or intra

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

    ERIC Educational Resources Information Center

    Snyder, Howard N.

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

  7. UK Age-Related Macular Degeneration Electronic Medical Record System (AMD EMR) Users Group Report IV: Incidence of Blindness and Sight Impairment in Ranibizumab-Treated Patients.

    PubMed

    Johnston, Robert L; Lee, Aaron Y; Buckle, Miranda; Antcliff, Richard; Bailey, Clare; McKibbin, Martin; Chakravarthy, Usha; Tufail, Adnan

    2016-11-01

    To study the incidence of blindness and sight impairment in treatment-naive patients receiving ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) in the United Kingdom (UK) National Health Service. Multicenter nAMD database study. A total of 11 135 patients who collectively received 92 976 treatment episodes to 12 951 eyes. Data were extracted from 14 UK centers using the same electronic medical record system (EMR). The EMR-mandated collection of a data set (defined before first data entry) including: age, Early Treatment Diabetic Retinopathy Study visual acuity letter score (VA) for both eyes at all visits, and injection episodes. Participating centers used overwhelmingly a pro re nata re-treatment posology at intended monthly follow-up visits following a loading phase of 3 monthly injections. Incidence of blindness and sight impairment (VA in the better-seeing eye <38 letters [≤20/200 Snellen, approximately], and <68 letters [≤20/50 Snellen, approximately] at 2 consecutive visits, or 1 visit if no further follow-up data) in each year after initiating treatment. Information from >300 000 clinic visits (2.8 million data points) collected over 5 years was collated from 14 centers. Mean age at first treatment was 79.7 years (standard deviation = 9.19 years), with a female preponderance (63%). The mean (median) VA at baseline in the better-seeing eye was 67.2 (72.0) letters, 20/40- (20/40+) approximate Snellen conversion. The cumulative incidence of new blindness and sight impairment in patients with treated nAMD in at least 1 eye at years 1 to 4 after first injection were 5.1%, 8.6%, 12% and 15.6% for new blindness and 29.6%, 41.0%, 48.7%, and 53.7% for new sight impairment, but with significant reductions in the rates between year cohorts initiating treatment (blindness [P = 4.72 × 10(-08)], sight impaired [P = 3.27 × 10(-06)]). To the best of our knowledge, this is the first multicenter real-world study on the

  8. Committee's report on ruthenium fall-out incident

    SciTech Connect

    Borkowski, C.J.; Crawford, J.H.; Livingston, R.; Ritchie, R.H.; Rupp, A.F.; Taylor, E.H.

    1983-07-01

    Investigations of the fall-out incident of November 11 and 12, 1959, by responsible parties (Health Physics Division and Operations Division personnel) established beyond reasonable doubt that the incident had its origin in the expulsion of particles, heavily contaminated with ruthenium, which had been detached from the walls of the electric fan housing and ducts in the off-gas system associated with the brick stack. All available evidence indicates that the particles were loosened during maintenance work on the exhaust damper and the bearings of the electric fan and were carried up the stack in two bursts as particulate fall-out when this fan was put back into service. Radiographic and chemical analysis showed the activity to be almost entirely ruthenium (Ru/sup 106/) and its daughter rhodium (Rh/sup 106/) with very little, if any, strontium being present. This report summarizes the findings and sets forth the conclusions and recommendations of the Committee asked to investigate the incident.

  9. Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices.

    PubMed

    Hewitt, Tanya; Chreim, Samia; Forster, Alan

    2017-09-01

    Voluntary reporting of incidents is a common approach for improving patient safety. Reporting behaviors may vary because of different frames within and across professions, where frames are templates that individuals hold and that guide interpretation of events. Our objectives were to investigate frames of physicians and nurses who report into a voluntary incident reporting system as well as to understand enablers and inhibitors of self-reporting and peer reporting. This is a qualitative case study-confidential in-depth interviews with physicians and nurses in General Internal Medicine in a Canadian tertiary care hospital. Frames that health care practitioners use in their reporting practices serve as enablers and inhibitors for self-reporting and peer reporting. Frames that inhibit reporting are shared by physicians and nurses, such as the fear of blame frame regarding self-reporting and the tattletale frame regarding peer reporting. These frames are underpinned by a focus on the individual, despite the organizational message of reporting for learning. A learning frame is an enabler to incident reporting. Viewing the objective of voluntary incident reporting as learning allows practitioners to depersonalize incident reporting. The focus becomes preventing recurrence and not the individual reporting or reported on. Physicians and nurses use various frames that bound their views of self and peer incident reporting-further progress should incorporate an understanding of these deep-seated views and beliefs.

  10. Incidence of systemic mycoses in autopsy material.

    PubMed

    Koch, S; Höhne, F-M; Tietz, H-J

    2004-02-01

    The incidence of systemic mycoses was investigated in the autopsy material of the Institute of Pathology of the Humaine Hospital in Bad Saarow, Germany. This hospital provides qualified standard care in east Brandenburg with a wide spectrum of medical disciplines caring for patients with acute medical conditions as well as oncological cases (660 beds). Between 1973 and 2001, 47 systemic mycoses were diagnosed in 4813 autopsies of deceased adults, corresponding to 0.98%. During the period of investigation, both the care provided by the hospital and the organization of the health service changed. The autopsy frequency fell from about 80% (1973-1991) to about 28% (1992-2001). This is thus still far higher than the average of about 3% assumed for the Federal Republic of Germany. Although the incidence of systemic mycoses increased during the entire 29-year period of investigation, the number of cases in whom this was the immediate cause of death decreased. Whereas candidoses predominated from 1973 to 1991, a shift in favor of aspergilloses was noticed in the period from 1992 to 2001. Systemic mycosis was diagnosed intravitally in only three of 47 cases. The present study therefore underscores the significance of clinical autopsy as a diagnostic method and means of medical quality control.

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

    PubMed

    Hasan, Syeda Fauzia; Hamid, Mohammad

    2015-12-01

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

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

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

    2016-01-01

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

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

    NASA Astrophysics Data System (ADS)

    Hiatt, Keith L.; Rash, Clarence E.

    2011-06-01

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

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

    PubMed

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

    2016-01-01

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

  15. Spatial Distribution of Black Bear Incident Reports in Michigan

    PubMed Central

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

    2016-01-01

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

  16. Measles incidence and reporting trends in Germany, 2007–2011

    PubMed Central

    Wichmann, Ole; Rieck, Thorsten; Matysiak-Klose, Dorothea

    2014-01-01

    Abstract Objective We aimed to quantify progress towards measles elimination in Germany from 2007 to 2011 and to estimate any potential underreporting over this period. Methods We determined the annual incidence of notified cases of measles – for each year – in northern, western, eastern and southern Germany and across the whole country. We then used measles-related health insurance claims to estimate the corresponding incidence. Findings In each year between 2007 and 2011, there were 6.9–19.6 (mean: 10.8) notified cases of measles per million population. Incidence decreased with age and showed geographical variation, with highest mean incidence – 20.3 cases per million – in southern Germany. Over the study period, incidence decreased by 10% (incidence rate ratio, IRR: 0.90; 95% confidence interval, CI: 0.85–0.95) per year in western Germany but increased by 77% (IRR: 1.77; 95% CI: 1.62–1.93) per year in eastern Germany. Although the estimated incidence of measles based on insurance claims showed similar trends, these estimates were 2.0- to 4.8-fold higher than the incidence of notified cases. Comparisons between the data sets indicated that the underreporting increased with age and was generally less in years when measles incidence was high than in low-incidence years. Conclusion Germany is still far from achieving measles elimination. There is substantial regional variation in measles epidemiology and, therefore, a need for region-specific interventions. Our analysis indicates underreporting in the routine surveillance system between 2007 and 2011, especially among adults. PMID:25378728

  17. Major incidents in Britain over the past 28 years: the case for the centralised reporting of major incidents

    PubMed Central

    Carley, S.; Mackway-Jones, K.; Donnan, S.

    1998-01-01

    STUDY OBJECTIVES: To describe the incidence and epidemiology of major incidents occurring in Britain over the past 28 years. METHODS: Major incidents were identified through a MEDLINE search, a hand search of journals and government reports at the Home Office Emergency Planning College, newspaper reports, a postal survey of ambulance emergency planning officers, and through requests for information posted on the internet. MAIN RESULTS: Brief incidents profiles from 108 British major incidents are presented. Most major incidents pass unreported in the medical literature. On average three to four major incidents occur in Britain each year (range 0-11). Sixty three of 108 (59.2%) of incidents involve public transportation. The next two largest groups are civil disturbance 22 of 108 (20.3%) and industrial accidents 16 of 108 (14.8%). Although incidents at sports stadiums are rare they produce large numbers of casualties. The data currently available on major incidents are difficult to find and of questionable accuracy. CONCLUSIONS: The lack of data makes planning for major incidents and exercising major incident plans difficult. Casualty incident profiles (CIPs) may assist major incidents exercises and planning. CIPs from future major incidents should be collated and made available to all major incident planners.   PMID:9764261

  18. 75 FR 5640 - Pipeline Safety: Implementation of Revised Incident/Accident Report Forms for Distribution...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-03

    ... Liquid Systems AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA), DOT. ACTION... facilities and hazardous liquid pipeline facilities that the incident/ accident report forms for their... Transmission and Gathering Systems, and (3) PHMSA Form F 7000-1--Accident Report for Hazardous Liquid Pipeline...

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

    NASA Technical Reports Server (NTRS)

    Reynard, W. D.

    1983-01-01

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

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

    NASA Technical Reports Server (NTRS)

    Reynard, W. D.

    1983-01-01

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

  1. Study of model of anesthesia related adverse event by incident report at King Chulalongkorn Memorial Hospital.

    PubMed

    Narasethkamol, Arunchai; Charuluxananan, Somrat; Kyokong, Oranuch; Premsamran, Porntep; Kundej, Sarawut

    2011-01-01

    As a site of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS), the authors continued data collection of incident reports to find out the frequency, clinical course, contributing factors, factors minimizing adverse events, and investigation of model appropriate for possible corrective strategies in a Thai university hospital. A standardized anesthesia incident report form that included close-end and open-end questions was provided to the attending anesthesia personnel of King Chulalongkorn Memorial Hospital between January I and December 31, 2007. They filled it on a voluntary and anonymous basis. Each incident report was reviewed by three reviewers. Any disagreement was discussed to achieve a consensus. One hundred sixty three incident reports were filled reporting 191 incidents. There were fewer male (44%) than female (56%) patients and they had an ASA physical status classification 1 (41%), 2 (43%), 3 (10%), 4 (4%) and 5 (2%). Surgical specialties that posed high risk of incidents were general, orthopedic, gynecological, otorhino-laryngological and urological surgery. Locations of incident were operating room (85%), ward (8%) and recovery room (2%). The common adverse incidents were oxygen desaturation (23%), arrhythmia needing treatment (14%), equipment malfunction (13%), drug error (9%), difficult intubation (6%), esophageal intubation (5%), cardiac arrest (5%), reintubation (4%), and endobronchial intubation (4%). Adverse events were detected by monitoring only (27%), by monitoring before clinical diagnosis (26%), by clinical diagnosis before monitoring (21%), and by clinical diagnosis only (26%). Incidents were considered to be from anesthesia related factor (73%), system factor (16%) and preventable (47%). Common factors related to incident were inexperience, lack of vigilance, haste, inappropriate decision, not comply with guidelines, and lack of equipment maintenance. Suggested corrective strategies were quality assurance activity, additional

  2. Media actors' perceptions of their roles in reporting food incidents.

    PubMed

    Wilson, Annabelle M; Henderson, Julie; Coveney, John; Meyer, Samantha B; Webb, Trevor; Calnan, Michael; Caraher, Martin; Lloyd, Sue; McCullum, Dean; Elliott, Anthony; Ward, Paul R

    2014-12-18

    Previous research has shown that the media can play a role in shaping consumer perceptions during a public health crisis. In order for public health professionals to communicate well-informed health information to the media, it is important that they understand how media view their role in transmitting public health information to consumers and decide what information to present. This paper reports the perceptions of media actors from three countries about their role in reporting information during a food incident. This information is used to present ideas and suggestions for public health professionals working with media during food incidents. Thirty three semi-structured interviews with media actors from Australia, New Zealand and the United Kingdom were conducted and analysed thematically. Media actors were recruited via purposive sampling using a sampling strategy, from a variety of formats including newspaper, television, radio and online. Media actors said that during a food incident, they play two roles. First, they play a role in communicating information to consumers by acting as a conduit for information between the public and the relevant authorities. Second, they play a role as investigators by acting as a public watchdog. Media actors are an important source of consumer information during food incidents. Public health professionals can work with media by actively approaching them with information about food incidents; promoting to media that as public health professionals, they are best placed to provide the facts about food incidents; and by providing angles for further investigation and directing media to relevant and correct information to inform such investigations. Public health professionals who adapt how they work with media are more likely to influence media to portray messages that fit what they would like the public to know and that are in line with public health recommendations and enable consumers to engage in safe and health promoting

  3. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

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

  4. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

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

  5. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

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

  6. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

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

  7. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

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

  8. Blind Persons Report Critical Incidents of Science and Mathematics Instruction.

    ERIC Educational Resources Information Center

    Sica, Morris G.

    This project identified over 500 critical incidents of successful and unsuccessful instruction in science and mathematics courses reported through interviews of 105 blind college students. The principal categories of effective teacher behavior included planned concrete learning experiences, creative use of learning materials, and detailed…

  9. Infections and exposures: reported incidents associated with unsuccessful decontamination of reusable surgical instruments.

    PubMed

    Southworth, P M

    2014-11-01

    Reusable surgical instruments provide a potential route for the transmission of pathogenic agents between patients in healthcare facilities. As such, the decontamination process between uses is a vital component in the prevention of healthcare-associated infections. This article reviews reported outbreaks and incidents associated with inappropriate, inadequate, or unsuccessful decontamination of surgical instruments, indicating potential pitfalls of decontamination practices worldwide. To the author's knowledge, this is the first review of surgical instrument decontamination failures. Databases of medical literature, Medline and Embase, were searched systematically. Articles detailing incidents associated with unsuccessful decontamination of surgical instruments were identified. Twenty-one articles were identified reporting incidents associated with failures in decontamination. A large proportion of incidents involved the attempted disinfection, rather than sterilization, of surgical instruments (43% of articles), counter to a number of national guidelines. Instruments used in eye surgery were most frequently reported to be associated with decontamination failures (29% of articles). Of the few articles detailing potential or confirmed pathogenic transmission, Pseudomonas aeruginosa and Mycobacterium spp. were most represented. One incident of possible variant Creutzfeldt-Jakob disease transmission was also identified. Limitations of analysing only published incidents mean that the likelihood of under-reporting (including reluctance to publish failure) must be considered. Despite these limitations, the small number of articles identified suggests a relatively low risk of cross-infection through reusable surgical instruments when cleaning/sterilization procedures are adhered to. The diverse nature of reported incidents also suggests that failures are not systemic.

  10. Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework.

    PubMed

    Taylor, Diana; Upadhyay, Ushma D; Fjerstad, Mary; Battistelli, Molly F; Weitz, Tracy A; Paul, Maureen E

    2017-07-01

    To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events. As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework. The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%). Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care. The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first

  11. 30 CFR 250.188 - What incidents must I report to MMS and when must I report them?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What incidents must I report to MMS and when... report to MMS and when must I report them? (a) You must report the following incidents to the District... report of the following incidents to the District Manager within 15 calendar days after the incident: (1...

  12. Use of incident reports by physicians and nurses to document medical errors in pediatric patients.

    PubMed

    Taylor, James A; Brownstein, Dena; Christakis, Dimitri A; Blackburn, Susan; Strandjord, Thomas P; Klein, Eileen J; Shafii, Jaleh

    2004-09-01

    To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports. A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large children's hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with chi(2) tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors. A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported <20% of their perceived medical errors in the previous 12 months, and 32.6% had reported <40% of perceived errors committed by colleagues. After controlling for potentially confounding variables, nurses were significantly more likely to report >or=80% of their own medical errors than physicians (odds ratio: 2.8; 95% confidence interval: 1.3-6.0). Commonly listed reasons for underreporting included lack of certainty about what is considered an error (indicated by 40.7% of respondents) and concerns about implicating others (37%). Potential interventions that would lead to increased reporting included education about which errors should be reported (listed by 65.4% of respondents), feedback on a regular basis about the errors reported (63.8%) and about individual events (51.2%), evidence of

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

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Cardoza, Colleen; Null, Cynthia

    2015-01-01

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

  14. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management... Incident Data § 102-33.445 What accident and incident data must we report? You must report within 14..., all aviation accidents and incidents that your agency is required to report to the NTSB. You may also...

  15. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management... Incident Data § 102-33.445 What accident and incident data must we report? You must report within 14..., all aviation accidents and incidents that your agency is required to report to the NTSB. You may also...

  16. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management... Incident Data § 102-33.445 What accident and incident data must we report? You must report within 14..., all aviation accidents and incidents that your agency is required to report to the NTSB. You may also...

  17. 41 CFR 102-33.445 - What accident and incident data must we report?

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... incident data must we report? 102-33.445 Section 102-33.445 Public Contracts and Property Management... Incident Data § 102-33.445 What accident and incident data must we report? You must report within 14..., all aviation accidents and incidents that your agency is required to report to the NTSB. You may also...

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

    PubMed

    Rea, David; Griffiths, Sarah

    2016-07-01

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

  19. Central or local incident reporting? A comparative study in Dutch GP out-of-hours services

    PubMed Central

    Zwart, Dorien LM; Van Rensen, Elizabeth LJ; Kalkman, Cor J; Verheij, Theo JM

    2011-01-01

    Background Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented. Aim To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure. Design of study Quasi experiment. Setting Three GPs' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention. Method A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported. Results At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems. Conclusion It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues

  20. Central or local incident reporting? A comparative study in Dutch GP out-of-hours services.

    PubMed

    Zwart, Dorien L M; Van Rensen, Elizabeth L J; Kalkman, Cor J; Verheij, Theo J M

    2011-03-01

    Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented. To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure. Quasi experiment. Three GPs' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention. A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported. At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems. It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues. The advantages of both approaches should be combined.

  1. Reasons for not reporting patient safety incidents in general practice: A qualitative study

    PubMed Central

    Kousgaard, Marius Brostrøm; Joensen, Anne Sofie; Thorsen, Thorkil

    2012-01-01

    Objective To explore the reasons for not reporting patient safety incidents in general practice. Design Qualitative interviews with general practitioners and members of the project group. Setting General practice clinics in the Region of Northern Jutland in Denmark. Subjects Twelve general practitioners. Main outcome measures The experiences and reflections of the involved professionals with regard to system use and non-use. Results While most respondents were initially positive towards the idea of reporting and learning from patient safety incidents, they actually reported very few incidents. The major reasons for the low reporting rates are found to be a perceived lack of practical usefulness, issues of time and effort in a busy clinic with competing priorities, and considerations of appropriateness in relation to other professionals. Conclusion The results suggest that the visions of formal, comprehensive, and systematic reporting of (and learning from) patient safety incidents will be quite difficult to realize in general practice. Future studies should investigate how various ways of organizing incident reporting at the regional level influence local activities of reporting and learning in general practice. PMID:23113662

  2. Attitudes and perceived barriers of tertiary level health professionals towards incident reporting in Pakistan.

    PubMed

    Malik, Muhammad Raees; Alam, Ali Yawar; Mir, Azeem Sultan; Malik, Ghulam Mustafa; Abbas, Syed Muslim

    2010-02-01

    A limited framework of incident reporting exists in most of the health care system in Pakistan. This poses a risk to the patient population and therefore there is a need to find the causes behind the lack of such a system in healthcare settings in Pakistan. To determine the attitudes and perceived barriers towards incident reporting among tertiary care health professionals in Pakistan The study was done in Shifa International Hospitals and consisted of a questionnaire given to 217 randomly selected doctors and nurses. Mean ± SD of continuous variables and frequency (percentage %) of categorical variables are presented. Chi square statistical analysis was used to test the significance of association among doctors and nurses with various outcome variables (motivators to report, perceived barriers, preferred person to report and patient's outcome that influence reporting behaviors). P value of <0.05 was considered significant. Student doctors and student nurses were not included in the study. Unlike consultant, registrars, medical officers and nurses (more than 95% are willing to report), only 20% of house officers will report the incident happened through them. Sixty nine percent of doctors and 67% of nurses perceive 'administration sanction' as a common barrier to incident reporting. Sixty percent of doctors and 80% of nurses would prefer reporting to the head of the department. By giving immunity from administrative sanction, providing prompt feedback and assurance that the incident reporting will be used to make changes in the system, there is considerable willingness of doctors and nurses to take time out of their busy schedules to submit reports.

  3. 30 CFR 285.832 - How do I report incidents requiring immediate notification?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 30 Mineral Resources 2 2011-07-01 2011-07-01 false How do I report incidents requiring immediate... Activities Conducted Under SAPs, COPs and GAPs Incident Reporting and Investigation § 285.832 How do I report incidents requiring immediate notification? For an incident requiring immediate notification under § 285.831...

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

    PubMed

    Machackova, Hana; Dedkova, Lenka; Mezulanikova, Katerina

    2015-08-01

    This study examined the bystander effect in cyberbullying. Using self-reported data from 257 Czech respondents who had witnessed a cyberbullying attack, we tested whether provided help decreased with increased number of other bystanders. We controlled for several individual and contextual factors, including empathy, social self-efficacy, empathic response to victimization, and relationship to the victim. Results showed that participants tend to help the victims more in incidents with only one or two other bystanders. We also found that, as in the "offline" realm, bystander effect is not linear: no significant differences were found between incidents with a moderate number (3-10) and a larger number of total bystanders. Our findings, thus, provide support for the presence of the bystander effect in cyberbullying. Copyright © 2015 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

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

    PubMed

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

    2010-01-01

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

  6. Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

    SciTech Connect

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

    2016-05-15

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

  7. Reported pica behavior in a sample of incident dialysis patients.

    PubMed

    Ward, P; Kutner, N G

    1999-01-01

    In a prospective study, pica behavior was investigated during baseline interviews with a cohort of incident patients (n = 226) who began chronic dialysis therapy in metropolitan Atlanta, GA, during 1996 to 1997. Pica, defined as current pica behavior and/or reported history of pica behavior, was reported by 16% of the sample. Patients reporting pica were significantly more likely to be African American women and were significantly younger than the remainder of the sample. Approximately two thirds of patients who reported pica behaviors craved and excessively consumed ice; the remainder craved and consumed starch, dirt, flour, or aspirin. Among patients reporting pica, average serum albumin values were low and average phosphorus was increased. The average hematocrit of patients reporting ice pica was low. Over half of the hemodialysis patients reporting pica behavior had excessive usual interdialytic weight gain. Potential symptoms/problems affecting quality of life among patients practicing pica, eg, cramps, are shown in a case report. The data indicate the need for targeted education and support for dietitians' increased interaction with dialysis patients involved in pica behaviors.

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

    PubMed Central

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

    2014-01-01

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

  9. A self-report critical incident assessment tool for army night vision goggle helicopter operations.

    PubMed

    Renshaw, Peter F; Wiggins, Mark W

    2007-04-01

    The present study sought to examine the utility of a self-report tool that was designed as a partial substitute for a face-to-face cognitive interview for critical incidents involving night vision goggles (NVGs). The use of NVGs remains problematic within the military environment, as these devices have been identified as a factor in a significant proportion of aircraft accidents and incidents. The self-report tool was structured to identify some of the cognitive features of human performance that were associated with critical incidents involving NVGs. The tool incorporated a number of different levels of analysis, ranging from specific behavioral responses to broader cognitive constructs. Reports were received from 30 active pilots within the Australian Army using the NVG Critical Incident Assessment Tool (NVGCIAT). The results revealed a correspondence between specific types of NVG-related errors and elements of the Human Factors Analysis and Classification System (HFACS). In addition, uncertainty emerged as a significant factor associated with the critical incidents that were recalled by operators. These results were broadly consistent with previous research and provide some support for the utility of subjective assessment tools as a means of extracting critical incident-related data when face-to-face cognitive interviews are not possible. In some circumstances, the NVGCIAT might be regarded as a substitute cognitive interview protocol with some level of diagnosticity.

  10. Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai Anesthesia Incident Monitoring Study): methodology.

    PubMed

    Punjasawadwong, Yodying; Suraseranivongse, Suwanee; Charuluxananan, Somrat; Jantorn, Prasatnee; Thienthong, Somboon; Chanchayanon, Thavat; Tanudsintum, Surasak

    2007-11-01

    Determine the appropriate model for incident study of adverse or undesirable events in more extensive levels from primary to tertiary hospitals across Thailand. The present study was mainly a qualitative research design. Participating anesthesia providers are asked to report, on anonymous and voluntary basis, by completing the standardized incident report form as soon as they find a predetermined adverse or undesirable event during anesthesia, and until 24 hours after the operation. Data from the incident report will be reviewed by three peer reviewers and analyzed to identify contributing factors by consensus. The THAI anesthesia incidents monitoring study can be used as a model for the development of a local system to provide review and feedback information. This should help generate real improvement in the patient care.

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

    Code of Federal Regulations, 2010 CFR

    2010-07-01

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

  12. 49 CFR 225.15 - Accidents/incidents not to be reported.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  13. 14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 4 2014-01-01 2014-01-01 false Reports by air carriers on incidents... REPORTS § 234.13 Reports by air carriers on incidents involving animals during air transport. (a) Any air... Consumer Protection Division a report on any incidents involving the loss, injury, or death of an animal...

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

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 14 Aeronautics and Space 4 2011-01-01 2011-01-01 false Reports by air carriers on incidents... REPORTS § 234.13 Reports by air carriers on incidents involving animals during air transport. (a) Any air... Consumer Protection Division a report on any incidents involving the loss, injury, or death of an animal...

  15. 14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 4 2013-01-01 2013-01-01 false Reports by air carriers on incidents... REPORTS § 234.13 Reports by air carriers on incidents involving animals during air transport. (a) Any air... Consumer Protection Division a report on any incidents involving the loss, injury, or death of an animal...

  16. 14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 14 Aeronautics and Space 4 2012-01-01 2012-01-01 false Reports by air carriers on incidents... REPORTS § 234.13 Reports by air carriers on incidents involving animals during air transport. (a) Any air... Consumer Protection Division a report on any incidents involving the loss, injury, or death of an animal...

  17. Toward learning from patient safety reporting systems.

    PubMed

    Pronovost, Peter J; Thompson, David A; Holzmueller, Christine G; Lubomski, Lisa H; Dorman, Todd; Dickman, Fern; Fahey, Maureen; Steinwachs, Donald M; Engineer, Lilly; Sexton, J Bryan; Wu, Albert W; Morlock, Laura L

    2006-12-01

    To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

  18. Professional attitudes toward incident reporting: can we measure and compare improvements in patient safety culture?

    PubMed

    Tricarico, Pierfrancesco; Castriotta, Luigi; Battistella, Claudio; Bellomo, Fabrizio; Cattani, Giovanni; Grillone, Lucrezia; Degan, Stefania; De Corti, Daniela; Brusaferro, Silvio

    2017-04-01

    To establish categories of professionals' attitudes toward incident reporting by analyzing the trends in incident reporting while accounting for general risk indicators. The incident reporting system was evaluated over 6 years. Reporting rates, stratified by year and profession, were estimated using the non-mandatory reported events/full-time equivalent (NM-IR/FTE) rate. Other indicators were collected using the hospital's official database. Staff attitudes toward self-reporting were analyzed. Univariate and multivariable analyses were performed. A 1000-bed Italian academic hospital. Staff of the hospital (over 3200 professionals). None. NM-IT/FTE rates, self-reported rates, patient complaints/praises, work accidents among professionals and 30-day readmissions. The overall reporting rate was 0.44 (95% confidence interval [CI]: 0.42-0.46) among doctors and 0.40 (95% CI: 0.39-0.41) among nurses. Between 2010 and 2015, only the doctors' reporting rate increased significantly (P = 0.04), from 0.29 (95% CI: 0.25-0.34) to 0.67 (95% CI: 0.60-0.73). Patient complaints decreased from 384 to 224 (P < 0.001) and work accidents decreased from 296 to 235 (P = 0.01), while other indicators remained constant. Multivariable logistic regression showed that self-reporting was more likely among nurses than doctors (odds ratio: 1.51; 95% CI: 1.31-1.73) and for severe events than near misses (odds ratio: 1.78; 95% CI: 1.11-2.87). Because the doctors' reporting rates increased during the study period, doctors may be more likely to report adverse events than nurses, although nurses reported more events. Incident reporting trends and other routinely collected risk indicators may be useful to improve our understanding and measurement of patient safety issues.

  19. The key incident monitoring and management system - history and role in quality improvement.

    PubMed

    Badrick, Tony; Gay, Stephanie; Mackay, Mark; Sikaris, Ken

    2017-08-03

    The determination of reliable, practical Quality Indicators (QIs) from presentation of the patient with a pathology request form through to the clinician receiving the report (the Total Testing Process or TTP) is a key step in identifying areas where improvement is necessary in laboratories. The Australasian QIs programme Key Incident Monitoring and Management System (KIMMS) began in 2008. It records incidents (process defects) and episodes (occasions at which incidents may occur) to calculate incident rates. KIMMS also uses the Failure Mode Effects Analysis (FMEA) to assign quantified risk to each incident type. The system defines risk as incident frequency multiplied by both a harm rating (on a 1-10 scale) and detection difficulty score (also a 1-10 scale). Between 2008 and 2016, laboratories participating rose from 22 to 69. Episodes rose from 13.2 to 43.4 million; incidents rose from 114,082 to 756,432. We attribute the rise in incident rate from 0.86% to 1.75% to increased monitoring. Haemolysis shows the highest incidence (22.6% of total incidents) and the highest risk (26.68% of total risk). "Sample is suspected to be from the wrong patient" has the second lowest frequency, but receives the highest harm rating (10/10) and detection difficulty score (10/10), so it is calculated to be the 8th highest risk (2.92%). Similarly, retracted (incorrect) reports QI has the 10th highest frequency (3.9%) but the harm/difficulty calculation confers the second highest risk (11.17%). TTP incident rates are generally low (less than 2% of observed episodes), however, incident risks, their frequencies multiplied by both ratings of harm and discovery difficulty scores, concentrate improvement attention and resources on the monitored incident types most important to manage.

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

    PubMed

    Miles, Elizabeth N

    2006-03-17

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

  1. Incident Command Systems: Because Life Happens

    ERIC Educational Resources Information Center

    Isaac, Gayle; Moore, Brian

    2011-01-01

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

  2. Safe incident reporting in out-of-hours primary care: an exploratory study.

    PubMed

    Augustyns, Nele; Lesaffer, Caroline; Teughels, Stefan; Philips, Hilde; Remmen, Roy

    2016-12-01

    The goal of safe incident reporting (SIR) is to recognize avoidable incidents to prevent future harm. Data on the use of SIR in Belgium's out-of-hours primary care (OOHC) services are lacking. We investigated a priori attitudes of managers and GPs, and their willingness to report in OOHC services. We mapped which methods are used. A telephone questionnaire was conducted with the managers of all 27 OOHC centers in Flanders. It assessed the design of used reporting systems and the attitudes towards SIR. A paper survey was administered to assess GPs' attitudes in two large out-of-hours primary care centers. All managers participated (N = 23). Seventy percent used some form of incident reporting system, with a large design variation. All managers thought SIR is important to improve quality and safety. Seven managers predicted that GPs would be hesitant to use SIR. In the GPs' survey (response rate 58%), 69.7% of responders had experienced an incident and 74.5% would tend to report it. 81.1% agreed that an incident has to be analyzed, discussed, and should lead to an improvement plan. The majority believed SIR could create openness about adverse events and would improve job satisfaction. One out of five feared that it would make their job more difficult, and 39% were afraid the report could be used against the reporter. OOHC center managers and GPs show positive attitudes towards SIR. There is a large variation in the currently used methods. Future projects could focus on interventions of implementation of SIR in OOHC.

  3. 75 FR 922 - Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft, and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-07

    ...The NTSB is amending its regulations concerning notification and reporting requirements regarding aircraft accidents or incidents. In particular, the NTSB is adding regulations to require operators to report certain incidents to the NTSB. The NTSB is also amending existing regulations to provide clarity and ensure that the appropriate means for notifying the NTSB of a reportable incident is......

  4. 41 CFR 102-33.450 - How must we report accident and incident data?

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... § 102-33.450 How must we report accident and incident data? You must report accident and incident data... 41 Public Contracts and Property Management 3 2014-01-01 2014-01-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal...

  5. 49 CFR 225.9 - Telephonic reports of certain accidents/incidents and other events.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 4 2012-10-01 2012-10-01 false Telephonic reports of certain accidents/incidents...: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.9 Telephonic reports of certain accidents/incidents and other events. (a) Types of accidents/incidents and other events to be reported—(1) Certain deaths or...

  6. 49 CFR 225.9 - Telephonic reports of certain accidents/incidents and other events.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 49 Transportation 4 2014-10-01 2014-10-01 false Telephonic reports of certain accidents/incidents...: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.9 Telephonic reports of certain accidents/incidents and other events. (a) Types of accidents/incidents and other events to be reported—(1) Certain deaths or...

  7. 49 CFR 225.9 - Telephonic reports of certain accidents/incidents and other events.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 4 2010-10-01 2010-10-01 false Telephonic reports of certain accidents/incidents...: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.9 Telephonic reports of certain accidents/incidents and other events. (a) Types of accidents/incidents and other events to be reported—(1) Certain deaths or...

  8. 49 CFR 225.9 - Telephonic reports of certain accidents/incidents and other events.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 4 2013-10-01 2013-10-01 false Telephonic reports of certain accidents/incidents...: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.9 Telephonic reports of certain accidents/incidents and other events. (a) Types of accidents/incidents and other events to be reported—(1) Certain deaths or...

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

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... § 102-33.450 How must we report accident and incident data? You must report accident and incident data... 41 Public Contracts and Property Management 3 2011-01-01 2011-01-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal...

  10. 28 CFR 541.7 - Unit Discipline Committee (UDC) review of the incident report.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... the incident report. 541.7 Section 541.7 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... § 541.7 Unit Discipline Committee (UDC) review of the incident report. A Unit Discipline Committee (UDC) will review the incident report once the staff investigation is complete. The UDC's review involves the...

  11. 28 CFR 541.7 - Unit Discipline Committee (UDC) review of the incident report.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... the incident report. 541.7 Section 541.7 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... § 541.7 Unit Discipline Committee (UDC) review of the incident report. A Unit Discipline Committee (UDC) will review the incident report once the staff investigation is complete. The UDC's review involves the...

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

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... § 102-33.450 How must we report accident and incident data? You must report accident and incident data... 41 Public Contracts and Property Management 3 2013-07-01 2013-07-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal...

  13. 49 CFR 225.9 - Telephonic reports of certain accidents/incidents and other events.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 4 2011-10-01 2011-10-01 false Telephonic reports of certain accidents/incidents...: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.9 Telephonic reports of certain accidents/incidents and other events. (a) Types of accidents/incidents and other events to be reported—(1) Certain deaths or...

  14. 41 CFR 102-33.450 - How must we report accident and incident data?

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... § 102-33.450 How must we report accident and incident data? You must report accident and incident data... 41 Public Contracts and Property Management 3 2012-01-01 2012-01-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal...

  15. 46 CFR 148.02-5 - Report of hazardous materials incidents.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 46 Shipping 5 2010-10-01 2010-10-01 false Report of hazardous materials incidents. 148.02-5... CARRIAGE OF SOLID HAZARDOUS MATERIALS IN BULK Vessel Requirements § 148.02-5 Report of hazardous materials incidents. In the event of an incident involving hazardous materials, an immediate report must be sent in...

  16. 28 CFR 541.7 - Unit Discipline Committee (UDC) review of the incident report.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... the incident report. 541.7 Section 541.7 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... § 541.7 Unit Discipline Committee (UDC) review of the incident report. A Unit Discipline Committee (UDC) will review the incident report once the staff investigation is complete. The UDC's review involves the...

  17. 77 FR 53779 - Reports by Air Carriers on Incidents Involving Animals During Air Transport

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-04

    ... carriers only submit a report during the months when the carriers have a reportable animal incident... associated with collecting more information to report, i.e., not only on incidents involving pets but also... Incidents Involving Animals During Air Transport AGENCY: Office of the Secretary (OST), Department of...

  18. Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

    PubMed

    Kaestli, Laure-Zoé; Cingria, Laurence; Fonzo-Christe, Caroline; Bonnabry, Pascal

    2014-10-01

    Discharging patients from hospital is a complex multidisciplinary process that can lead to non-compliance and medication-related problems. To evaluate risks of discontinuity of pharmaceutical care at paediatric hospital discharge and assess potential improvement strategies, using two complementary methods: a prospective risk analysis and a spontaneous incident reporting system. Geneva University hospitals and community pharmacies. A multidisciplinary team analysed the paediatric medication discharge process applying the failure modes (FM), effects, and criticality analysis (FMECA), using ibuprofen, morphine, valganciclovir as model drugs. Over 46 months, incidents with discharge prescriptions, reported by community pharmacists, were classified according to FMECA's FM. FM, criticality indexes (CI), incidents. Twenty-four FM were identified. The highest criticality scores were given for prescribing the wrong dosage [mean criticality index (CI = 205)], early treatment discontinuation by the patient (CI = 195), and continuation of contraindicated treatment by the general practitioner (CI = 191). Implementation of eight improvement strategies covering the eight most critical FM led to a 64 % reduction in criticality scores (CI 496 vs 1,392). Improvement of the computerized-physician-order-entry system was the single most effective strategy (CI 843 vs 1,392). Only 52 incidents were spontaneously reported (17 for paediatric patients). Paediatric problems most frequently reported (lack of information, 35 %; delay in drug supply, 18 %) were consistent with the highest frequencies scored by FMECA. Spontaneous incident reporting leads to high levels of under-reporting, but highlighted similar problems at paediatric hospital discharge to FMECA. Using FMECA allowed estimations of criticalities at each step and the potential impact of safety improvement strategies. Proactive and reactive methods proved complementary and would help to set up effective targeted improvement

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

    ERIC Educational Resources Information Center

    New York State Education Department, 2006

    2006-01-01

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

  20. Nationwide incidence of motor neuron disease using the French health insurance information system database.

    PubMed

    Kab, Sofiane; Moisan, Frédéric; Preux, Pierre-Marie; Marin, Benoît; Elbaz, Alexis

    2017-08-01

    There are no estimates of the nationwide incidence of motor neuron disease (MND) in France. We used the French health insurance information system to identify incident MND cases (2012-2014), and compared incidence figures to those from three external sources. We identified incident MND cases (2012-2014) based on three data sources (riluzole claims, hospitalisation records, long-term chronic disease benefits), and computed MND incidence by age, gender, and geographic region. We used French mortality statistics, Limousin ALS registry data, and previous European studies based on administrative databases to perform external comparisons. We identified 6553 MND incident cases. After standardisation to the United States 2010 population, the age/gender-standardised incidence was 2.72/100,000 person-years (males, 3.37; females, 2.17; male:female ratio = 1.53, 95% CI1.46-1.61). There was no major spatial difference in MND distribution. Our data were in agreement with the French death database (standardised mortality ratio = 1.01, 95% CI = 0.96-1.06) and Limousin ALS registry (standardised incidence ratio = 0.92, 95% CI = 0.72-1.15). Incidence estimates were in the same range as those from previous studies. We report French nationwide incidence estimates of MND. Administrative databases including hospital discharge data and riluzole claims offer an interesting approach to identify large population-based samples of patients with MND for epidemiologic studies and surveillance.

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

    PubMed Central

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

    2014-01-01

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

  2. Assessment of the adequacy of a criticality incident detection system

    SciTech Connect

    Cartwright, C.M.; Finnerty, M.D.

    1993-12-31

    The primary purpose of a criticality incident detection (CID) and alarm system is to minimize, by means of building evacuation, the radiation doses received by plant personnel. The adequacy of a CID systems installed in a nuclear plant within the UK was investigated. Results are described.

  3. Problem Reporting System

    NASA Technical Reports Server (NTRS)

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

    2008-01-01

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

  4. Incident Reporting Behaviours and Associated Factors among Nurses Working in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia

    PubMed Central

    2016-01-01

    Background. A comprehensive and systematic approach to incident reporting would help learn from errors and adverse events within a healthcare facility. Objective. The aim of the study was to assess incident reporting behaviours and associated factors among nurses. Methods. An institution-based cross-sectional study was conducted from April 14 to 29, 2015. Simple random sampling technique was used to select the study participants. Data were coded, entered into Epi Info 7, and exported to SPSS version 20 software for analysis. A multivariate logistic regression model was fitted and adjusted odds ratio with 95% confidence interval was used to determine the strength of association. Results. The proportion of nurses who reported incidents was 25.4%. Training on incident reporting (Adjusted Odds Ratio (AOR) [95% CI] 2.96 [1.34–6.26]), reason to report (to help patient) (AOR [95% CI] 3.08 [1.70–5.59]), fear of administrative sanctions (AOR [95% CI] 0.27 [0.12–0.58]), fear of legal penalty (AOR [95% CI] 0.09 [0.03–0.21]), and fear of loss of prestige among colleagues (AOR [95% CI] 0.25 [0.12–0.53]) were significantly associated factors with the incident reporting behaviour of nurses. Conclusion and Recommendation. The proportion of nurses who reported incidents was very low. Establishing a system which promotes incident reporting is vital. PMID:28116219

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

    SciTech Connect

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

    2014-06-15

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

  6. Pilot Test of New Template for Enhanced Pet Spot-on Product Incident Reporting

    EPA Pesticide Factsheets

    EPA is working toward standardizing enhanced incident reporting for pet spot-on products. View the draft template for use by registrants submitting information on incidents involving spot-on pet products and learn about a webinar and comment opportunity.

  7. Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals.

    PubMed

    Travaglia, Joanne F; Westbrook, Mary T; Braithwaite, Jeffrey

    2009-05-01

    Incident reporting systems have become a central mechanism of most health services patient safety strategies. In this article we compare health professionals' anonymous, free text responses in an evaluation of a newly implemented electronic incident management system. The professions' answers were compared using classic content analysis and Leximancer, a computer assisted text analysis package. The classic analysis identified issues which differentiated the professions. More doctors commented on lack of feedback following incidents and evaluated the system negatively. More allied health staff found that the system lacked fields necessary to report incidents. More nurses complained incident reporting was time consuming. The Leximancer analysis revealed that while the professions all used the more frequently employed concepts (which described basic components of the reporting system), nurses and allied health shared many additional concepts concerned with actual reporting. Doctors applied fewer and more unique (used only by one profession) concepts when writing about the system. Doctors' unique concepts centred on criticism of the incident management system and the broader implications of safety issues, while the other professions' unique concepts focused on more practical issues. The classic analysis identified specific problems needing to be targeted in ongoing modifications of the system. The Leximancer findings, while complementing the classical analysis results, gave greater insight into professional groups' attitudes that relate to use of the system, e.g. doctors' relatively limited conceptual vocabulary regarding the system was consistent with their lower incident reporting rates. Such professional differences in reaction to healthcare innovations may constrain inter-disciplinary communication and cooperation.

  8. [Analysis of an incident notification system and register in a critical care unit].

    PubMed

    Murillo-Pérez, M A; García-Iglesias, M; Palomino-Sánchez, I; Cano Ruiz, G; Cuenca Solanas, M; Alted López, E

    2016-01-01

    To analyse the incident communicated through a notification system and register in a critical care unit. A cross-sectional descriptive study was conducted by performing an analysis of the records of incidents communicated anonymously and voluntarily from January 2007 to December 2013 in a critical care unit of adult patients with severe trauma. incident type and class, professional reports, and suggestions for improvement measures. A descriptive analysis was performed on the variables. Out of a total of 275 incidents reported, 58.5% of them were adverse events. Incident distributed by classes: medication, 33.7%; vascular access-drainage-catheter-sensor, 19.6%; devices-equipment, 13.3%, procedures, 11.5%; airway tract and mechanical ventilation, 10%; nursing care, 4.1%; inter-professional communication, 3%; diagnostic test, 3%; patient identification, 1.1%, and transfusion 0.7%. In the medication group, administrative errors accounted for a total of 62%; in vascular access-drainage-catheter-sensor group, central venous lines, a total of 27%; in devices and equipment group, respirators, a total of 46.9%; in airway self-extubations, a total of 32.1%. As regards to medication errors, 62% were incidents without damage. Incident notification by profession: doctors, 43%, residents, 5.6%, nurses, 51%, and technical assistants, 0.4%. Adverse events are the most communicated incidents. The events related to medication administration are the most frequent, although most of them were without damage. Nurses and doctors communicate the incidents with the same frequency. In order to highlight the low incident notification despite it being an anonymous and volunteer system, therefore, it is suggested to study measurements to increase the level of communication. Copyright © 2016 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

  9. Incident Reporting by Health-Care Workers in Noninstitutional Care Settings.

    PubMed

    Campbell, Colleen L

    2016-01-13

    Patient-perpetrated violence and aggression toward health-care workers, specifically in noninstitutional health-care settings, cause concerns for both health-care providers and the clients whom they serve. Consequentially, this presents a public affairs problem for the entire health-care system, which the current research has failed to adequately address. While the literature overwhelmingly supports the assertion that accurate incident reporting is critical to fully understanding patient violence and aggression toward health-care providers, there is limited research examining provider decision making related to reporting incidents of patient violence and aggression targeted toward the provider. There is an even greater paucity of research specifically examining this issue in noninstitutional health-care settings. It is therefore the objective of this review to examine this phenomenon across disciplines and service settings in order to offer a comprehensive review of incident reporting and to examine rationales for providers reporting or failing to report instances of patient violence and aggression toward health-care providers. © The Author(s) 2016.

  10. Implementing the incident command system in the healthcare setting.

    PubMed

    Huser, T J

    The author discusses a new requirement in NFPA 99 for healthcare facilities--the implementation of an Incident Command System in the event of a disaster. He offers suggestions on how facilities can change their disaster plans to meet this new standard.

  11. School Crisis Teams within an Incident Command System

    ERIC Educational Resources Information Center

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

    2006-01-01

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

  12. 75 FR 33760 - Information Collection; Virtual Incident Procurement (VIPR) System Existing Vendor Survey

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-15

    ... Forest Service Information Collection; Virtual Incident Procurement (VIPR) System Existing Vendor Survey... organizations on the new information collection, Virtual Incident Procurement (VIPR) System Existing Vendor User.... SUPPLEMENTARY INFORMATION: Title: Virtual Incident Procurement (VIPR) Existing Vendor User Survey. OMB...

  13. Analysis of FEL optical systems with grazing incidence mirrors

    SciTech Connect

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

    1986-01-01

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

  14. Reporting of the incidence of hospitalised injuries: numerator issues

    PubMed Central

    Boufous, S; Williamson, A

    2003-01-01

    Objectives: To examine and discuss the implications on the incidence of hospitalised injuries of selecting cases from principal diagnosis field only compared with considering all diagnosis fields, the inclusion compared with the exclusion of medical injuries, and the impact of identifying multiple admissions. Methods: Analysis of data from the 1999–2000 New South Wales Inpatient Statistics Collection, Australia, including an internal linkage of the same dataset. Results: Approximately 27.5% of records with a non-injury primary diagnosis include a nature of injury diagnosis in a subsequent diagnostic field. This figure increased to more than half (53%) of discharges for medical injuries. The internal linkage showed that 6.5% of discharges were repeat admissions for the same International Classification of Diseases, 10th revision (ICD-10) injury code and that 13.8% were repeat admissions for any ICD-10 injury code. The proportions of repeat admissions varied according to the type and the mechanism of injury. Conclusions: Selecting hospitalised injury cases from the principal diagnosis alone would underestimate medical injury cases as well as other injuries occurring in hospital. Repeat admissions should always be considered particularly in the case of thermal injuries, self harm, and medical injuries. Due to the limitations of data linkage, alternative methods need to be developed to identify repeat admissions. Other areas in which further research would be beneficial to a more uniform reporting of injury hospitalisations include better identification of injuries occurring in hospital, a review of ICD-10 injury codes, and the development an ICD-10 based severity measure which can be readily used with hospital discharge data. PMID:14693903

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

    PubMed Central

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

    2009-01-01

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

  16. Rates of safety incident reporting in MRI in a large academic medical center.

    PubMed

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

    2016-04-01

    To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center. This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident. A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290). MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents. © 2015 Wiley Periodicals, Inc.

  17. 78 FR 38803 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ... 7100.3 Incident Report--Liquefied Natural Gas Facilities; and PHMSA F 7100.3-1 Annual Report for Calendar Year 20---- Liquefied Natural Gas Facilities. In accordance with the Paperwork Reduction Act of.... Incident Report--Liquefied Natural Gas Facilities (PHMSA F 7100.3) PHMSA proposes to revise the PHMSA...

  18. 36 CFR § 1230.14 - How do agencies report incidents?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... § 1230.14 How do agencies report incidents? The agency must report promptly any unlawful or accidental... 36 Parks, Forests, and Public Property 3 2013-07-01 2012-07-01 true How do agencies report incidents? § 1230.14 Section § 1230.14 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS...

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

    PubMed

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

    2016-02-01

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

  20. 40 CFR 68.81 - Incident investigation.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be... system to promptly address and resolve the incident report findings and recommendations. Resolutions and...) Incident investigation reports shall be retained for five years. ...

  1. 40 CFR 68.81 - Incident investigation.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be... system to promptly address and resolve the incident report findings and recommendations. Resolutions and...) Incident investigation reports shall be retained for five years. ...

  2. 40 CFR 68.81 - Incident investigation.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be... system to promptly address and resolve the incident report findings and recommendations. Resolutions and...) Incident investigation reports shall be retained for five years. ...

  3. 40 CFR 68.81 - Incident investigation.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be... system to promptly address and resolve the incident report findings and recommendations. Resolutions and...) Incident investigation reports shall be retained for five years. ...

  4. 40 CFR 68.81 - Incident investigation.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... appropriate knowledge and experience to thoroughly investigate and analyze the incident. (d) A report shall be... system to promptly address and resolve the incident report findings and recommendations. Resolutions and...) Incident investigation reports shall be retained for five years. ...

  5. The relationship between incidence and report of medication errors and working conditions.

    PubMed

    Joolaee, S; Hajibabaee, F; Peyrovi, H; Haghani, H; Bahrani, N

    2011-03-01

    Medication errors are considered to be a serious threat to patients' safety. Efforts to detect and prevent these errors have increased considerably in recent years. To determine the incidence and reporting rate of medication errors as reported by Iranian nurses and their relationship with work conditions in hospitals under the authority of Iran University of Medical Sciences. This descriptive-analytical study was carried out in six hospitals. Through a stratified multiple stage sampling, 300 nurses were selected. A researcher-constructed, three-part, self-report questionnaire was used to collect data regarding the nurses' medication errors, medication error reports and their perceived working conditions during the previous 3 months. The data were processed using descriptive statistics and Kruskal-Wallis one-way analysis of variance. The mean of medication errors that nurses recalled was 19.5, and the mean of error reporting was 1.3 cases during the previous 3 months. The relationship between error incidence and work conditions as perceived by nurses was statistically significant (df = 3, P ≤ 0.0001); however, there was no significant relationship between reporting the occurred error and nurses' perceived work conditions (df = 3, P ≤ 0.255). The establishment of an efficient reporting system, documentation of errors and removal of obstacles to reporting may result in reduced frequency of medication errors. Considering the relationship between medication error incidence and working conditions, it seems that creating a work condition in which nurses feel more comfortable and decreasing work tensions may pave the way to preventing nursing errors. © 2011 The Authors. International Nursing Review © 2011 International Council of Nurses.

  6. Comparing the Attitudes and Knowledge Toward Incident Reporting in Junior Physicians and Nurses in a District General Hospital.

    PubMed

    Bagenal, Jessamy; Sahnan, Kapil; Shantikumar, Saran

    2016-03-01

    The practice of open reporting and instituting a blame-free culture improves a system's ability to deal with risky processes, and the attitude of staff toward safety processes is a critical factor. We compared the attitudes and knowledge of incident reporting between junior physicians and nurses in a district general hospital. A questionnaire was designed to examine health care workers' attitudes toward reporting and errors. It also assessed knowledge of incident reporting and attitudes toward training in patient safety. Staff nurses (n = 50) and junior physicians (n = 50) were sampled on a voluntary basis and completed the survey online and anonymously. Although similar proportions of each group knew a safety organization (70% of nurses versus 58% of physicians, P = 0.21), significantly more nurses had filled out an incident report (96% of nurses versus 52% of physicians, P < 0.001). The physicians felt that they did not have sufficient training in patient safety (66% of physicians versus 24% of nurses, P < 0.001), and consequently, fewer felt confident with patient safety issues (38% versus 72%, P < 0.001) The majority of all respondents agreed that incident reporting was beneficial (69%, P = 0.001), although a large proportion also felt that they would be blamed for errors (61%, P = 0.03). This study suggests that junior physicians are lacking in confidence and disengaged with incident reporting. Nurses generally have a more positive and confident view toward patient safety issues and thus are more involved in reporting practices. Health care institutions should focus on promoting a safety culture in the organization through blame-free incident reporting systems. This should include ensuring that junior physicians obtain a comprehensive education in incident reporting and patient safety.

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

    PubMed

    Fattah, Sabina; Rehn, Marius; Lockey, David; Thompson, Julian; Lossius, Hans Morten; Wisborg, Torben

    2014-01-30

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

  8. [Construction of index system for early warning of persistent organic pollutants (POPs) pollution incidents in China].

    PubMed

    Wang, Lin; Lü, Yong-Long; He, Gui-Zhen; Wang, Tie-Yu

    2014-10-01

    Early warning of pollution incidents caused by persistent organic pollutants (POPs) is urgently needed for China in the circumstances of serious POPs pollution and in increasing demand for improvement in chemical risk management. Given different categories of POPs and pollution incidents, the index system for early warning of POPs pollution accidents was built based on lifecycle theory and POPs formation mechanisms. It will be helpful for decision makers to enhance the early warning management of POPs pollution incidents in China. The index system for early warning includes two parts, early warning and mechanism for system operation. The indices include risk source indicators, warning indicators and warning level indicators. To ensure the effective implementation of this system, the mechanisms for response and policy guarantee were also formulated. These mechanisms contain dynamic inventory management and periodical assessment of risk sources, timely and effective report of warning conditions, as well as coordination and cooperation among the relevant departments.

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

    PubMed

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

    2015-07-01

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

  10. Nonmelanoma skin cancer in Japanese ethnic Hawaiians in Kauai, Hawaii: an incidence report.

    PubMed

    Chuang, T Y; Reizner, G T; Elpern, D J; Stone, J L; Farmer, E R

    1995-09-01

    Incidence reports of nonmelanoma skin cancer (NMSC) in Japanese persons are limited. Most studies have relied primarily on hospital records or voluntary reporting systems. Our purpose was to determine the incidence of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and Bowen's disease (BD) in a defined Japanese population. A prospective 5-year population-based incidence study was conducted on the island of Kauai, Hawaii from 1983 through 1987. Thirty Japanese Kauai residents, 12 men and 18 women, developed BCC during the 5-year study period. At the same time, 24 Japanese, 6 men and 18 women, were identified with SCC, and 11 had BD, three men and eight women. When standardized to the Japanese population in Japan, the annual BCC incidence rate was 30 per 100,000 Japanese Kauai residents with an average patient age of 75 years. More than 80% of these BCCs were localized to the head and neck. New BCCs developed in four patients with BCC, but none was a recurrence of a previously treated lesion. Five patients with BCC had SCC or BD concurrently or at other times. The SCC incidence was 23 per 100,000 Japanese Kauai residents with an average patient age of 80 years. The head and neck were again the most common anatomic sites. New SCCs subsequently occurred in two patients, in one of whom a localized recurrence also developed. Five patients with SCC had BCC simultaneously or at other times. The incidence of BD was 13 per 100,000 Japanese Kauai residents with an average patient age of 74 years. The extremities were the most common anatomic sites. One patient later had a new BD lesion and a recurrent BD lesion. Two patients had BCC or SCC at other times. We report incidence rates of BCC, SCC, and BD at least 45 times higher in the Japanese population in Kauai, Hawaii than rates for the Japanese population in Japan. Kauai's intense UV radiation and emphasis on outdoor activities may contribute. More Japanese women had NMSC than men, a sex difference not observed in

  11. 76 FR 30855 - Accident/Incident Reporting Requirements

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-27

    ... of accident/incident in the definition is an obvious error and a technical amendment is an... preamble language was an obvious error and a technical amendment is an appropriate action to correct this... sidewalk/walkway D5--In airport; D6- In airplane; D7--In hotel room; E1--On parking lot; E2--In building...

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

    ERIC Educational Resources Information Center

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

    2013-01-01

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

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

    ERIC Educational Resources Information Center

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

    2013-01-01

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

  14. Folie-a-deux: report of two incidents.

    PubMed

    Lawal, R A; Orija, O B; Malomo, I O; Ladapo, H T; Oluwatayo, O G

    1997-01-01

    Two incidents of shared delusions are presented, one between two brothers and the other between an elderly couple. Their presentation and management are discussed. The possible role of projection and overvalued ideas as aetiological factors in Nigerians with shared delusions are highlighted.

  15. Wavefront Sensing Analysis of Grazing Incidence Optical Systems

    NASA Technical Reports Server (NTRS)

    Rohrbach, Scott; Saha, Timo

    2012-01-01

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

  16. Relationship between tort claims and patient incident reports in the Veterans Health Administration

    PubMed Central

    Schmidek, J; Weeks, W

    2005-01-01

    Objective: The Veterans Health Administration's patient incident reporting system was established to obtain comprehensive data on adverse events that affect patients and to act as a harbinger for risk management. It maintains a dataset of tort claims that are made against Veterans Administration's employees acting within the scope of employment. In an effort to understand the thoroughness of reporting, we examined the relationship between tort claims and patient incident reports (PIRs). Methods: Using social security and record numbers, we matched 8260 tort claims and 32 207 PIRs from fiscal years 1993–2000. Tort claims and PIRs were considered to be related if the recorded dates of incident were within 1 month of each other. Descriptive statistics, odds ratios, and two sample t tests with unequal variances were used to determine the relationship between PIRs and tort claims. Results: 4.15% of claims had a related PIR. Claim payment (either settlement or judgment for plaintiff) was more likely when associated with a PIR (OR 3.62; 95% CI 2.87 to 4.60). Payment was most likely for medication errors (OR 8.37; 95% CI 2.05 to 73.25) and least likely for suicides (OR 0.25; 95% CI 0.11 to 0.55). Conclusions: Although few tort claims had a related PIR, if a PIR was present the tort claim was more likely to result in a payment; moreover, the payment was likely to be higher. Underreporting of patient incidents that developed into tort claims was evident. Our findings suggest that, in the Veterans Health Administration, there is a higher propensity to both report and settle PIRs with bad outcomes. PMID:15805457

  17. Relationship between tort claims and patient incident reports in the Veterans Health Administration.

    PubMed

    Schmidek, J M; Weeks, W B

    2005-04-01

    The Veterans Health Administration's patient incident reporting system was established to obtain comprehensive data on adverse events that affect patients and to act as a harbinger for risk management. It maintains a dataset of tort claims that are made against Veterans Administration's employees acting within the scope of employment. In an effort to understand the thoroughness of reporting, we examined the relationship between tort claims and patient incident reports (PIRs). Using social security and record numbers, we matched 8260 tort claims and 32 207 PIRs from fiscal years 1993-2000. Tort claims and PIRs were considered to be related if the recorded dates of incident were within 1 month of each other. Descriptive statistics, odds ratios, and two sample t tests with unequal variances were used to determine the relationship between PIRs and tort claims. 4.15% of claims had a related PIR. Claim payment (either settlement or judgment for plaintiff) was more likely when associated with a PIR (OR 3.62; 95% CI 2.87 to 4.60). Payment was most likely for medication errors (OR 8.37; 95% CI 2.05 to 73.25) and least likely for suicides (OR 0.25; 95% CI 0.11 to 0.55). Although few tort claims had a related PIR, if a PIR was present the tort claim was more likely to result in a payment; moreover, the payment was likely to be higher. Underreporting of patient incidents that developed into tort claims was evident. Our findings suggest that, in the Veterans Health Administration, there is a higher propensity to both report and settle PIRs with bad outcomes.

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

    NASA Technical Reports Server (NTRS)

    Claassen, J. P.; Eckerman, J.

    1978-01-01

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

  19. Medical trainees' formal and informal incident reporting across a five-hospital academic medical center.

    PubMed

    Logio, Lia S; Ramanujam, Rangaraj

    2010-01-01

    Despite the importance of incident reporting for promoting patient safety, the extent to which residents and fellows (trainees) in graduate medical education (GME) programs report incidents is not well understood. A study was conducted to determine the prevalence of and variations in incident reporting across hospitals in an academic medical center. Trainees enrolled in GME programs sponsored by the Indiana University School of Medicine (IUSM) completed (1) the Behavior Index Survey (BIS), which asked respondents if they knew how to locate incident forms and if they ever submitted an incident form, and (2) the Safety Culture Survey (SCS), which asked about the frequencies of their formal and informal incident reporting behaviors. Some 443 of 992 invited trainees (45% response rate) participated in the study. Of the 305 BIS respondents who rotated through all five hospitals, varying proportions knew how to locate an incident form (22.3%-31.5%) and had completed an incident form (6.2%-20%) in each hospital. Incident report completion rates were higher (20.1%-81.3%) among trainees who knew how to locate an incident form. Higher proportions of the 443 SCS respondents had informally discussed an incident with other trainees (90%), faculty physicians (70%), and at resident meetings and conferences (73%). The study confirms that GME trainees formally report incidents rarely. The flow of communication to and from trainees about patient safety and incidents is low, despite an organizational focus on safety and quality. Discussion of safety issues among trainees occurs more informally among colleagues and peers than with faculty or through formal reporting mechanisms. The data suggest a number of strategies to increase the culture of safety among GME trainees.

  20. Do specialty registrars change their attitudes, intentions and behaviour towards reporting incidents following a patient safety course?

    PubMed Central

    2010-01-01

    Background Reporting incidents can contribute to safer health care, as an awareness of the weaknesses of a system could be considered as a starting point for improvements. It is believed that patient safety education for specialty registrars could improve their attitudes, intentions and behaviour towards incident reporting. The objective of this study was to examine the effect of a two-day patient safety course on the attitudes, intentions and behaviour concerning the voluntary reporting of incidents by specialty registrars. Methods A patient safety course was designed to increase specialty registrars' knowledge, attitudes and skills in order to recognize and cope with unintended events and unsafe situations at an early stage. Data were collected through an 11-item questionnaire before, immediately after and six months after the course was given. Results The response rate at all three points in time assessed was 100% (n = 33). There were significant changes in incident reporting attitudes and intentions immediately after the course, as well as during follow-up. However, no significant changes were found in incident reporting behaviour. Conclusions It is shown that patient safety education can have long-term positive effects on attitudes towards reporting incidents and the intentions of registrars. However, further efforts need to be undertaken to induce a real change in behaviour. PMID:20416053

  1. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis.

    PubMed

    Kingston, Marilyn J; Evans, Sue M; Smith, Brian J; Berry, Jesia G

    2004-07-05

    (i) To examine attitudes of medical and nursing staff towards reporting incidents (adverse events and near-misses), and (ii) to identify measures to facilitate incident reporting. Qualitative study. In March 2002, semistructured questions were administered to five focus groups--one each for consultants, registrars, resident medical officers, senior nurses, and junior nurses. 14 medical and 19 nursing staff recruited using purposive sampling from three metropolitan public hospitals in Adelaide, South Australia. Attitudes and barriers to incident reporting; differences in reporting behaviour between disciplines; how to facilitate incident reporting. Cultural differences between doctors and nurses, identified using Triandis' theory of social behaviour, were found to underpin attitudes to incident reporting. Nurses reported more habitually than doctors due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents "in-house" and was less reliant on directives. Common barriers to reporting incidents included time constraints, unsatisfactory processes, deficiencies in knowledge, cultural norms, inadequate feedback, beliefs about risk, and a perceived lack of value in the process. Strategies to improve incident reporting must address cultural issues.

  2. [Pressure ulcer care quality indicator: analysis of medical records and incident report].

    PubMed

    dos Santos, Cássia Teixeira; Oliveira, Magáli Costa; Pereira, Ana Gabriela da Silva; Suzuki, Lyliam Midori; Lucena, Amália de Fátima

    2013-03-01

    Cross-sectional study that aimed to compare the data reported in a system for the indication of pressure ulcer (PU) care quality, with the nursing evolution data available in the patients' medical records, and to describe the clinical profile and nursing diagnosis of those who developed PU grade 2 or higher Sample consisted of 188 patients at risk for PU in clinical and surgical units. Data were collected retrospectively from medical records and a computerized system of care indicators and statistically analyzed. Of the 188 patients, 6 (3%) were reported for pressure ulcers grade 2 or higher; however, only 19 (10%) were recorded in the nursing evolution records, thus revealing the underreporting of data. Most patients were women, older adults and patients with cerebrovascular diseases. The most frequent nursing diagnosis was risk of infection. The use of two or more research methodologies such as incident reporting data and retrospective review of patients' records makes the results trustworthy.

  3. Case report of critical incident stress debriefing through translators.

    PubMed

    True, P K

    2000-01-01

    The United States Navy has SPRINT (Special Psychiatric Rapid Intervention Team) teams stationed in National Naval Medical Center in Bethesda, Maryland, Naval Regional Medical Center in Portsmouth, Virginia, Naval Regional Medical Center in San Diego, California, and US Naval Hospital, Bremerton, Washington. These teams are large units of psychiatrists, psychologists, nurses, chaplains, and hospital corpsmen who are trained in the techniques of Critical Incident Stress using the model developed by Jeffrey T. Mitchell and George S. Everly, Jr. (Mitchell & Everly, 1996; Everly & Mitchell, 1999). In addition to these large SPRINT teams, smaller Critical Incident Stress Management (CISM) teams exist at several Navy commands, including US Naval Hospital, Jacksonville, Florida. Since the formation of SPRINT teams, there have been several hundred interventions done at various military sites. This article discusses an intervention that was particularly unusual in that it was done by US military personnel for the members of the Argentine military, none of whom could speak English.

  4. 41 CFR 102-33.450 - How must we report accident and incident data?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false How must we report accident and incident data? 102-33.450 Section 102-33.450 Public Contracts and Property Management Federal...-MANAGEMENT OF GOVERNMENT AIRCRAFT Reporting Information on Government Aircraft Accident and Incident...

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

    ERIC Educational Resources Information Center

    Brenner, Eliot; Freundlich, Madelyn

    2006-01-01

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

  6. 75 FR 51953 - Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft, and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-24

    ... SAFETY BOARD 49 CFR Part 830 Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft, and Preservation of Aircraft Wreckage, Mail, Cargo, and Records AGENCY: National Transportation... notification and reporting of aircraft accidents or incidents by adding a definition of ``unmanned aircraft...

  7. 40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... Published reports and material contained in the public incident investigation dockets. (a) Demands for... 40 Protection of Environment 33 2014-07-01 2014-07-01 false Published reports and material contained in the public incident investigation dockets. 1612.3 Section 1612.3 Protection of Environment...

  8. 40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... Published reports and material contained in the public incident investigation dockets. (a) Demands for... 40 Protection of Environment 33 2011-07-01 2011-07-01 false Published reports and material contained in the public incident investigation dockets. 1612.3 Section 1612.3 Protection of Environment...

  9. 40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... Published reports and material contained in the public incident investigation dockets. (a) Demands for... 40 Protection of Environment 34 2012-07-01 2012-07-01 false Published reports and material contained in the public incident investigation dockets. 1612.3 Section 1612.3 Protection of Environment...

  10. 40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... Published reports and material contained in the public incident investigation dockets. (a) Demands for... 40 Protection of Environment 34 2013-07-01 2013-07-01 false Published reports and material contained in the public incident investigation dockets. 1612.3 Section 1612.3 Protection of Environment...

  11. 40 CFR 1612.3 - Published reports and material contained in the public incident investigation dockets.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... Published reports and material contained in the public incident investigation dockets. (a) Demands for... 40 Protection of Environment 32 2010-07-01 2010-07-01 false Published reports and material contained in the public incident investigation dockets. 1612.3 Section 1612.3 Protection of Environment...

  12. The angle detecting inclined sensor (ADIS) system: Measuring particle angles of incidence without position sensing detectors

    NASA Astrophysics Data System (ADS)

    Connell, J. J.; Lopate, C.; McKibben, R. B.

    2003-04-01

    We report on a novel system, the Angle Detecting Inclined Sensors (ADIS), for determining the angles of incidence of Solar energetic particles, Galactic cosmic rays and anomalous cosmic rays. This system would be especially applicable to compact, high-resolution energetic particle telescopes. The response of a charged particle detector to incident particles varies with particle's pathlength, which depends upon its angle of incidence to the detector. Achieving good elemental and isotopic resolution requires correcting for this effect. ADIS consists of three detectors, two of which are inclined at an angle to the telescope axis, forming the first detectors in a multi-element telescope. By comparing the signals from the ADIS detectors, the angle of incidence may be determined. Thus the ADIS system can replace hodoscopes using conventional position sensing detectors (PSD's). PSD's add significant complexity and require additional electronics, increasing instrument mass, power usage and, in many cases, telemetry requirements. Using our ADIS system, we derive simple equations for the incident particle charge and trajectory. These calculations are well within the capabilities of even the slowest on-board processor. We present Monte-Carlo modeling of such an instrument to demonstrate the system's capabilities.

  13. [The clinical risk management: an initial experience of incident reporting in a surgical department].

    PubMed

    Savà, Giuseppina; Rumi, Tiziana; Meneghini, Antonella

    2010-01-01

    With the aim of adverse events monitoring in a critical care area, an initial experience of a near miss events registration in a department of surgery at Fondazione IRCCS Cà Granda Ospedale Policlinico di Milano is reported in this article. A period of time of two weeks for the anonymous compilation of reporting forms has been scheduled. Data derived from this survey focused the attention on two main problems: the drug prescribing and administration errors and those related to the clinical management of the patient. The second main issue that deserves to be discussed is the incident reporting interruption during the second week, due to a perception of futility of this procedure still linked to a mentality not adequately prepared to learn from errors. The thinking about adverse events has shifted from the person approach-blaming individuals for errors-to the system approach. The experience here reported underlines the importance of training courses and adequate preparation of health personnel on the aims and how to communicate an adverse event, in order to resume an effective and continuous incident reporting activity in a critical care area.

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

    PubMed

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

    2015-12-01

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

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

    NASA Technical Reports Server (NTRS)

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

    2006-01-01

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

  16. Understanding the investigation-stage overrepresentation of First Nations children in the child welfare system: an analysis of the First Nations component of the Canadian Incidence Study of Reported Child Abuse and Neglect 2008.

    PubMed

    Sinha, Vandna; Trocmé, Nico; Fallon, Barbara; MacLaurin, Bruce

    2013-10-01

    The overrepresentation of Aboriginal children in child welfare systems in the U.S., Canada, and Australia is well documented, but limited attention has been paid to investigation-stage disproportionality. This paper examines the overrepresentation of First Nations (the largest of three federally recognized Aboriginal groups in Canada) children, focusing on three questions: (1) What is the level/nature of First Nations overrepresentation at the investigation stage? (2) What is known about the source of referrals in child welfare investigations involving First Nations children? (3) What risk factors and child functioning concerns are identified for investigated First Nations children and families? The First Nations Component of the Canadian Incidence Study of Reported Child Abuse and Neglect (FNCIS-2008) was designed to address limitations in existing Aboriginal child welfare data: it sampled one quarter of the Aboriginally governed child welfare agencies that conduct investigations in Canada, gathered data on over 3,000 investigations involving First Nations children, and incorporated weights designed for analysis of First Nations data. Bivariate analyses are used to compare investigations involving First Nations and non-Aboriginal children. The rate of investigations for First Nations children living in the areas served by sampled agencies was 4.2 times that for non-Aboriginal children; investigation-stage overrepresentation was compounded by each short term case disposition examined. A higher proportion of First Nations than non-Aboriginal investigations involved non-professional referrals, a pattern consistent with disparities in access to alternative services. Workers expressed concerns about multiple caregiver risk factor concerns for more than ½ of investigated First Nations families and, with the exception of "health issues", identified every caregiver/household risk factor examined in a greater percentage of First Nations than non-Aboriginal households. It

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

    PubMed Central

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

    2015-01-01

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

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

    PubMed

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

    2015-12-01

    Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital. To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice. A mixed methods analysis of 598 patient safety incident reports in England and Wales related to 'Discharge' from the National Reporting and Learning System. Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice. A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with 'safe discharge' checklists, discharge coordinators, and family involvement. Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely. © British Journal of General Practice 2015.

  19. Pharmaceutical sales of pseudoephedrine: the impact of electronic tracking systems on methamphetamine crime incidents.

    PubMed

    Mazerolle, Lorraine; McGuffog, Ingrid; Ferris, Jason; Chamlin, Mitchell B

    2017-03-01

    Electronic tracking systems (ETS) are used extensively in pharmacies across the United States and Australia to control suspicious sales of pseudoephedrine. This study measures the impact of one ETS-Project STOP-on the capacity of police to reduce production, supply and possession of methamphetamine. Using official police data of incidents of production, supply and possession from January 1996 to December 2011 (n = 192 data points/months over 16 years), we used a quasi-experimental, time-series approach. The State of Queensland, Australia. No individual participants are included in the study. The unit of analysis is reported police incidents. The study examines the impact of the ETS on production (n = 5938 incidents), drug supply and trafficking (n = 20 094 incidents) and drug possession or use (n = 118 926) of methamphetamine. Introduction of the ETS in November 2005 was associated with an insignificant decrease (P = 0.15) in the production of methamphetamine. The intervention was associated with a statistically significant increase in supply incidents (P = 0.0001). There was no statistically significant effect on the incidence of possession (P = 0.59). Electronic tracking systems can reduce the capacity of people to produce methamphetamine domestically, but seem unlikely to affect other aspects of the methamphetamine problem such as possession, distribution and importation. © 2016 Society for the Study of Addiction.

  20. The Australian Incident Monitoring Study. Crisis management--validation of an algorithm by analysis of 2000 incident reports.

    PubMed

    Runciman, W B; Webb, R K; Klepper, I D; Lee, R; Williamson, J A; Barker, L

    1993-10-01

    Anaesthetists are called upon to manage complex life-threatening crises at a moment's notice. As there is evidence that this may require cognitive tasking beyond the information-processing capacity of the human brain, it was decided to try and develop a generic crisis management algorithm analogous to the "Phase I" immediate response routine used by airline pilots. Such an algorithm, based on the mnemonic "COVER ABCD, A SWIFT CHECK", was developed and refined over 3 meetings, each attended by 60-100 anaesthetists and aviation psychologists. It was validated against 1301 relevant incidents among the first 2000 incidents reported to the Australian Incident Monitoring Study. It proved sufficiently robust and safe to recommend its general use as an initial response to any incident or crisis which occurs when a patient is breathing gas from an anesthetic machine. It requires a limited knowledge base and is easily learnt and rehearsed during the anaesthetist's working day. It will provide a functional diagnosis in over 99% of cases and will correct 62% of the problems in 40-60 seconds. In the remaining 37% it will allow the anaesthetist to proceed with a "sub-algorithm", confident in the knowledge that some important step has not been missed. In just over 30% of incidents this will be for a problem familiar to all anaesthetists (e.g. laryngospasm, bradycardia); in just over 6% it will be for a less common, more complex, but finite, set of problems (3% cardiac arrest, 1% air embolism, 1% anaphylaxis, 1% for the remaining desaturations); in less than 1% diagnosis and correction will require a more complex checklist (e.g. for malignant hyperthermia, pneumothorax). The next stage, the development of specific sub-algorithms and a structured team approach for ongoing problems, is in progress.

  1. Nuclear medicine incident reporting in Australia: control charts and notification rates inform quality improvement.

    PubMed

    Larcos, G; Collins, L T; Georgiou, A; Westbrook, J I

    2015-06-01

    Australia has a statutory incident reporting system for radiopharmaceutical maladministrations, but additional research into registry data is required for the purpose of quality improvement in nuclear medicine. We (i) used control charts to identify factors contributing to special cause variation (indicating higher than expected rates) in maladministrations and (ii) evaluated the impact of heterogeneous notification criteria and extent of underreporting among jurisdictions and individual facilities, respectively. Anonymised summaries of Australian Radiation Incident Register reports permitted calculation of national monthly maladministration notification rates for 2007-2012 and preparation of control charts. Multivariate logistic regression assessed the association of population, insurance and regulatory characteristics with maladministration notifications in each Australian State and Territory. Maladministration notification rates from two facilities with familiarity of notification processes and commitment to radiation protection were compared with those elsewhere. Special cause variation occurred in only 3 months, but contributed to 21% of all incidents (42 of 197 patients), mainly because of 'clusters' of maladministrations (n = 24) arising from errors in bulk radiopharmaceutical dispensing. Maladministration notification rates varied significantly between jurisdictions (0 to 12.2 maladministrations per 100 000 procedures (P < 0.05)) and individual facilities (31.7 vs 5.8 per 100 000; χ(2) = 40; 1 degree of freedom, P < 0.001). Unexpected increases in maladministration notifications predominantly relate to incident 'clusters' affecting multiple patients. The bulk preparation of radiopharmaceuticals is a vulnerable process and merits additional safeguards. Maladministration notification rates in Australia are heterogeneous. Adopting uniform maladministration notification criteria among States and Territories and methods to overcome underreporting are

  2. Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

    PubMed Central

    2012-01-01

    Background Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes. PMID:23122411

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

    ERIC Educational Resources Information Center

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

    2010-01-01

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

  4. A pilot asthma incidence surveillance system and case definition: lessons learned.

    PubMed

    Trepka, Mary Jo; Martin, Pilar; Mavunda, Kunjana; Rodriguez, Diana; Zhang, Guoyan; Brown, Clive

    2009-01-01

    Surveillance for incident asthma in the general population could provide timely information about asthma trends and new, emerging etiologic factors. We sought to determine the feasibility of an asthma incidence surveillance system using voluntary reporting of asthma by outpatient clinics and emergency departments (EDs). Voluntary reporting occurred from July 2002 through June 2006. We classified reported asthma based on a case definition adapted from one developed by the Council of State and Territorial Epidemiologists. We validated the case definition by having pulmonologists review data from participant interviews, medical record abstractions, and pulmonary function test (PFT) results. The positive predictive value (PPV) of meeting any of the case definition criteria for asthma was 80% to 82%. The criterion of taking at least one rescue and one controller medication had the highest PPV (97% to 100%). Only 7% of people meeting the incident case definition had a PFT documented in their medical record, limiting the usefulness of PFT results for case classification. Compared with pediatric participants, adult participants were more likely to be uninsured and to obtain asthma care at EDs. The surveillance system cost $5129 per enrolled person meeting the incident case definition and was difficult to implement in participating clinics and EDs because asthma reporting was not mandatory and informed consent was necessary. The project was useful in evaluating the case definition's validity and in describing the participants' characteristics and health-care use patterns. However, without mandatory reporting laws, reporting of incident asthma in the general population by clinicians is not likely to be a feasible method for asthma surveillance.

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

    NASA Astrophysics Data System (ADS)

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

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

  6. Self-reported uptake of recommendations after dissemination of medication incident alerts.

    PubMed

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

    2012-12-01

    In the Netherlands, a Central Medication Incidents Registration (CMR) system is operational. To prevent recurrence of reported medication incidents the CMR sends medication incident alerts with recommendations. It is up to the healthcare workers whether or not to implement the recommendations in clinical practice, which may lead to variations in degrees of uptake of the recommendations. The aim of this study was to explore the degree of self-reported uptake of the recommendations and to identify potential determinants associated with successful uptake. This is a cross-sectional study conducted within a convenience sample of 33 Dutch hospital pharmacies. The study was carried out from April 2009 to September 2010. Three alerts were selected for the study: administration of methotrexate in a dosage of once a day instead of once a week, administration of undiluted potassium-sodium-phosphate concentrate, and administration of glucose 50% instead of 5%. The primary outcome was the degree of self-reported uptake of the specific recommendations and the associations of the degree of uptake with several potential determinants. Twenty-one hospitals (63.6%) had adopted all recommendations about methotrexate. A quarter of the hospitals (24.2%) had adopted all recommendations related to potassium-sodium-phosphate concentrate. For the alert about glucose 50%, none of the hospitals had implemented all the recommendations. No statistically significant associations between potential determinants and the degree of uptake were found. This study is the first to investigate the degree of uptake of the recommendations of three different CMR alerts. The alerts varied in the degrees of self-reported uptake of the recommendations, with the methotrexate alert having the highest degree of uptake. No significant associations with potential determinants were found.

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed

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

    2015-02-01

    To explore catalysts to, and circumstances surrounding, patient-to-worker violent incidents recorded by employees in a hospital system database. Violence by patients towards healthcare workers (Type II workplace violence) is a significant occupational hazard in hospitals worldwide. Studies to date have failed to investigate its root causes due to a lack of empirical research based on documented episodes of patient violence. Qualitative content analysis. Content analysis was conducted on the total sample of 214 Type II incidents documented in 2011 by employees of an American hospital system with a centralized reporting system. The majority of incidents were reported by nurses (39·8%), security staff (15·9%) and nurse assistants (14·4%). Three distinct themes were identified from the analysis: Patient Behaviour, Patient Care and Situational Events. Specific causes of violence related to Patient Behaviour were cognitive impairment and demanding to leave. Catalysts related to patient care were the use of needles, patient pain/discomfort and physical transfers of patients. Situational factors included the use/presence of restraints; transitions in the care process; intervening to protect patients and/or staff; and redirecting patients. Identifying catalysts and situations involved in patient violence in hospitals informs administrators about potential targets for intervention. Hospital staff can be trained to recognize these specific risk factors for patient violence and can be educated in how to best mitigate or prevent the most common forms of violent behaviour. A social-ecological model can be adapted to the hospital setting as a framework for prevention of patient violence towards staff. © 2014 John Wiley & Sons Ltd.

  9. [Foodborne illness report systems in China].

    PubMed

    Zhu, Jianghui; Li, Fengqin; Li, Ning; Yan, Weixing; Xu, Haibin; Ma, Ning; Song, Xiaoyu; Liang, Jiang; Wang, Xiaodan; Gao, Peng

    2013-09-01

    To introduce the current foodborne illness report system in China. Foodborne illness (food poisoning included) report system and food related unusual cases reported system were characterized by their report definitions, scopes and report procedures as well as their differences. From October, 2010 to June, 2012, there are 2961 centers of disease control and prevention and heath executive organizations at the different local levels registered in the foodborne illness (food poisoning included) report system and 1525 incidents were reported. There were 553 hospitals registered in the food related unusual cases reported system while only 38 cases reported. The foodborne illness report system has been set up in China and further efforts in capacities building are needed.

  10. Incidence of road injuries in Mexico: country report.

    PubMed

    Bartels, D; Bhalla, K; Shahraz, S; Abraham, J; Lozano, R; Murray, C J L

    2010-09-01

    We used data from various sources to triangulate to a national snapshot of the incidence of fatal and non-fatal road traffic injuries in Mexico in 2005. Data sources used include national death registration data, national hospital discharge data and a nationally representative health survey. We estimate that in 2005, 19,389 people died due to injuries and nearly one million were injured in road traffic crashes. While deaths in high-income countries are declining, this is not the case in Mexico. Young adult males are the demographic at the highest risk in non-fatal crashes, but the elderly have the highest road death rates primarily due to pedestrian crashes. Pedestrians alone comprise nearly half (48%) of all deaths. Cars pose a substantial threat to occupants (38% of deaths and 39% of hospital admissions) and to other road users.

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

    PubMed

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

    2012-11-01

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

  12. Properties and performance of grazing-incidence mirror systems

    NASA Astrophysics Data System (ADS)

    Aspnes, D. E.; Kelso, S. M.

    1982-04-01

    We investigate the performance of, and the origin of aberrations in, beam lines based on simple and the recently proposed CARSA mirror elements. New results include the identification of the sums of off-grazing angles and their squares as figures of merit for total reflectance and scattering losses in near-grazing-incidence systems, and the discovery that the usual image distortions and aberrations previously associated with simple elements can essentially be eliminated with pairs of elliptical mirrors having a common rotational symmetry axis. Slit throughput efficiencies and sensitivities to system stability are calculated for both horizontal and vertical dispersion for several representative beam lines using a ray-tracing program developed for CARSA systems. We find that high-resolution operation is possible with no entrance slit for CARSA combinations.

  13. Diffraction-limited performance of grazing incidence optical systems

    NASA Technical Reports Server (NTRS)

    Harvey, James E.

    1986-01-01

    Diffraction effects of X-ray optical systems are often (justifiably) ignored due to the small wavelength of the X-ray radiation. However, the extremely large obscuration ratio inherent to grazing incidence optical systems produces a profound degradation of the diffraction image over that produced by a moderately obscured aperture of the same diameter. The contradictory requirements of large collecting area and relatively short length of optical elements has tended to result in proposed designs containing many concentric shells with increasingly higher obscuration ratios. In this paper it is shown that diffraction effects in such systems can significantly affect the achievable optical performance at the low energy (long wavelength) end of the intended operating spectral range. Parametric diffraction-limited performance predictions for both imaging and spectrographic applications will be presented and compared to AXAF performance goals and/or BBXRT fabrication techniques.

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

    PubMed Central

    2009-01-01

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

  15. Population-Based Incidence and Prevalence of Systemic Lupus Erythematosus

    PubMed Central

    Somers, Emily C.; Marder, Wendy; Cagnoli, Patricia; Lewis, Emily E.; DeGuire, Peter; Gordon, Caroline; Helmick, Charles G.; Wang, Lu; Wing, Jeffrey J.; Dhar, J. Patricia; Leisen, James; Shaltis, Diane; McCune, W. Joseph

    2014-01-01

    Objective To estimate the incidence and prevalence of systemic lupus erythematosus (SLE) in a sociodemographically diverse southeastern Michigan source population of 2.4 million people. Methods SLE cases fulfilling the American College of Rheumatology classification criteria (primary case definition) or meeting rheumatologist-judged SLE criteria (secondary definition) and residing in Wayne or Washtenaw Counties during 2002–2004 were included. Case finding was performed from 6 source types, including hospitals and private specialists. Age-standardized rates were computed, and capture–recapture was performed to estimate underascertainment of cases. Results The overall age-adjusted incidence and prevalence (ACR definition) per 100,000 persons were 5.5 (95% confidence interval [95% CI] 5.0–6.1) and 72.8 (95% CI 70.8–74.8). Among females, the incidence was 9.3 per 100,000 persons and the prevalence was 128.7 per 100,000 persons. Only 7 cases were estimated to have been missed by capture–recapture, adjustment for which did not materially affect the rates. SLE prevalence was 2.3-fold higher in black persons than in white persons, and 10-fold higher in females than in males. Among incident cases, the mean ± SD age at diagnosis was 39.3 ± 16.6 years. Black SLE patients had a higher proportion of renal disease and end-stage renal disease (ESRD) (40.5% and 15.3%, respectively) as compared to white SLE patients (18.8% and 4.5%, respectively). Black patients with renal disease were diagnosed as having SLE at younger age than white patients with renal disease (mean ± SD 34.4 ± 14.9 years versus 41.9 ± 21.3 years; P = 0.05). Conclusion SLE prevalence was higher than has been described in most other population-based studies and reached 1 in 537 among black female persons. There were substantial racial disparities in the burden of SLE, with black patients experiencing earlier age at diagnosis, >2-fold increases in SLE incidence and prevalence, and increased

  16. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    .../accident response. 91.1021 Section 91.1021 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... incident/accident response. (a) Each program manager must establish an internal anonymous safety reporting.... (b) Each program manager must establish procedures to respond to an aviation incident/accident....

  17. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    .../accident response. 91.1021 Section 91.1021 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... incident/accident response. (a) Each program manager must establish an internal anonymous safety reporting.... (b) Each program manager must establish procedures to respond to an aviation incident/accident....

  18. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    .../accident response. 91.1021 Section 91.1021 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... incident/accident response. (a) Each program manager must establish an internal anonymous safety reporting.... (b) Each program manager must establish procedures to respond to an aviation incident/accident....

  19. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    .../accident response. 91.1021 Section 91.1021 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... incident/accident response. (a) Each program manager must establish an internal anonymous safety reporting.... (b) Each program manager must establish procedures to respond to an aviation incident/accident....

  20. 14 CFR 91.1021 - Internal safety reporting and incident/accident response.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    .../accident response. 91.1021 Section 91.1021 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... incident/accident response. (a) Each program manager must establish an internal anonymous safety reporting.... (b) Each program manager must establish procedures to respond to an aviation incident/accident....

  1. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

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

  2. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

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

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

    ERIC Educational Resources Information Center

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

    1999-01-01

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

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

    ERIC Educational Resources Information Center

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

    1999-01-01

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

  5. 30 CFR 285.833 - What are the reporting requirements for incidents requiring written notification?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

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

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

    NASA Technical Reports Server (NTRS)

    Enders, J.

    1984-01-01

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

  7. Plutonium Reclamation Facility incident response project progress report

    SciTech Connect

    Austin, B.A.

    1997-11-25

    This report provides status of Hanford activities in response to process deficiencies highlighted during and in response to the May 14, 1997, explosion at the Plutonium Reclamation Facility. This report provides specific response to the August 4, 1997, memorandum from the Secretary which requested a progress report, in 120 days, on activities associated with reassessing the known and evaluating new vulnerabilities (chemical and radiological) at facilities that have been shut down, are in standby, are being deactivated or have otherwise changed their conventional mode of operation in the last several years. In addition, this report is intended to provide status on emergency response corrective activities as requested in the memorandum from the Secretary on August 28, 1997. Status is also included for actions requested in the second August 28, 1997, memorandum from the Secretary, regarding timely notification of emergencies.

  8. Incidence and Mortality Tables | Cancer Trends Progress Report

    Cancer.gov

    The Cancer Trends Progress Report, first issued in 2001, summarizes our nation's advances against cancer in relation to Healthy People targets set forth by the Department of Health and Human Services.

  9. Flight Attendant Fatigue. Part IV. Analysis of Incident Reports

    DTIC Science & Technology

    2009-12-01

    strategy was not uniformly applied and cannot be generalized, the trend in the ASrS database suggests the percentage of full-form reports dis- cussing...fatigue is increasing. See Table 3 for the number and corresponding percentage of fatigue-related reports receiving full-form processing each year...Figure 3 shows the relative percentage of occurrence for the issues identified as fatigue-related factors in the cabin crew narratives. A number of

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

    NASA Technical Reports Server (NTRS)

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

    2003-01-01

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

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

    NASA Technical Reports Server (NTRS)

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

    2003-01-01

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

  12. Reporting Helicopter Emergency Medical Services in Major Incidents: A Delphi Study.

    PubMed

    Fattah, Sabina; Johnsen, Anne Siri; Sollid, Stephen J M; Wisborg, Torben; Rehn, Marius; Sóti, Ákos; Truhlář, Anatolij; Krüger, Andreas J; Gunnarsson, Björn; Gryth, Dan; Ohlén, David; Fevang, Espen; Sunde, Geir Arne; Breitenmoser, Ivo; Kurola, Jouni; Nurmi, Jouni; Fredriksen, Knut; Rognås, Leif; Temesvari, Peter; Mikkelsen, Søren; Magnusson, Vidar; Voelckel, Wolfgang

    Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences. This type of database presently exists for major incident reporting at www.majorincidentreporting.net. This study aimed to develop a HEMS-specific major incident template. This Delphi study included 17 prehospital critical care physicians with current or previous HEMS experience. All participants interacted through e-mail. We asked these experts to define data variables and rank which were most important to report during an immediate prehospital medical response to a major incident. Five rounds were conducted. In the first round, the experts suggested 98 variables. After 5 rounds, 21 variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. Based on opinions from European experts, we established a consensus-based template for reporting on HEMS responses to major incidents. This template will facilitate uniformity in the collection, analysis, and exchange of experience. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

  13. Changes in reports and incidence of child abuse following natural disasters.

    PubMed

    Curtis, T; Miller, B C; Berry, E H

    2000-09-01

    The aim of this research was to investigate if there is a higher incidence of child abuse following major natural disasters. Child abuse reports and substantiations were analyzed, by county, for 1 year before and after Hurricane Hugo, the Loma Prieta Earthquake. and Hurricane Andrew. Counties were included if damage was widespread, the county was part of a presidential disaster declaration, and if there was a stable data collection system in place. Based on analyses of numbers, rates, and proportions, child abuse reports were disproportionately higher in the quarter and half year following two of the three disaster events (Hurricane Hugo and Loma Prieta Earthquake). Most, but not all, of the evidence presented indicates that child abuse escalates after major disasters. Conceptual and methodological issues need to be resolved to more conclusively answer the question about whether or not child abuse increases in the wake of natural disasters. Replications of this research are needed based on more recent disaster events.

  14. Discovering patterns of activity in unstructured incident reports at scale

    DTIC Science & Technology

    2015-05-12

    indicators and exploit reporting patterns across agencies and tickets. • Indicator similarity • Indicator communities Parse free text descriptions of...Unstructured Field: • Notes (free text allowed) The unstructured notes field contains most of the information about each ticket. Data Description 6Discovering

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

    NASA Technical Reports Server (NTRS)

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

    2003-01-01

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

  16. 29 CFR 1904.39 - Reporting fatalities and multiple hospitalization incidents to OSHA.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

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

  17. 30 CFR 250.187 - What are MMS' incident reporting requirements?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... ENFORCEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE OIL AND GAS AND SULPHUR OPERATIONS IN THE OUTER CONTINENTAL... incidents that may be required by other regulatory agencies. (d) You must report all spills of oil or...

  18. Non-melanoma skin cancer and keratoacanthoma in Filipinos: an incidence report from Kauai, Hawaii.

    PubMed

    Chuang, T Y; Reizner, G T; Elpern, D J; Stone, J L; Farmer, E R

    1993-10-01

    Non-melanoma skin cancer is the most common malignancy in the white population of the United States with an estimated 700,000 new cases each year. Regrettably, data on minority racial groups are either scarce or lacking entirely. This study was designed as a 5-year prospective incidence study of non-melanoma skin cancer and keratoacanthoma by using an island-wide survey of Kauai's Filipino residents and covers the years of 1983 to 1987. Seven basal cell carcinoma (incidence: 12.3/100,000), one squamous cell carcinoma (incidence: 1.8/100,000) and four keratoacanthoma (incidence: 7/100,000) patients are reported. To the best of our knowledge, this is the first population-based incidence report on non-melanoma skin cancer and keratoacanthoma in this population.

  19. The Angle Detecting Inclined Sensors (ADIS) System: Measuring Particle Angles of Incidence without Position Sensing Detectors

    NASA Astrophysics Data System (ADS)

    Connell, J. J.; Lopate, C.; McKibben, R. B.

    2001-08-01

    We report on a novel system, the Angle Detecting Inclined Sensors (ADIS), for determining the angles of incidence of Solar energetic particles, Galactic cosmic rays and anomalous cosmic rays. This system would be especially applicable to compact high resolution energetic particle telescopes. The response of charged particle detectors varies with particle pathlength, which depends on angle of incidence. Achieving good elemental and isotopic resolution requires correcting for this effect. ADIS consists of three detectors, two of which are inclined at an angle to the telescope axis, forming the first detectors in a multi-element telescope. By comparing the signals from the ADIS detectors, and using the computable angle dependent pathlengths through the detectors, the angle of incidence may be determined. The ADIS system thus can replace hodoscopes using conventional position sensing detectors (PSD's). PSD's add significant complexity and require additional electronics, increasing instrument mass, power usage and, in many cases, telemetry requirements. We derive simple equations for the incident particle charge and trajectory. These calculations are well within the capabilities of even the slowest on-board processors. We present Monte-Carlo modeling of such an instrument to demonstrate the system's capabilities.

  20. Postoperative central nervous system infection: incidence and associated factors in 2111 neurosurgical procedures.

    PubMed

    McClelland, Shearwood; Hall, Walter A

    2007-07-01

    Postoperative central nervous system infection (PCNSI) in patients undergoing neurosurgical procedures represents a serious problem that requires immediate attention. PCNSI most commonly manifests as meningitis, subdural empyema, and/or brain abscess. Recent studies (which have included a minimum of 1000 operations) have reported that the incidence of PCNSI after neurosurgical procedures is 5%-7%, and many physicians believe that the true incidence is even higher. To address this issue, we examined the incidence of PCNSI in a sizeable patient population. The medical records and postoperative courses for patients involved in 2111 neurosurgical procedures at our institution during 1991-2005 were reviewed retrospectively to determine the incidence of PCNSI, the identity of offending organisms, and the factors associated with infection. The median age of patients at the time of surgery was 45 years. Of the 1587 cranial operations, 14 (0.8%) were complicated by PCNSI, whereas none of the 32 peripheral nerve operations resulted in PCNSI. The remaining 492 operative cases involved spinal surgery, of which 2 (0.4%) were complicated by PCNSI. The overall incidence of PCNSI was 0.8% (occurring after 16 of 2111 operations); the incidence of bacterial meningitis was 0.3% (occurring after 4 of 1587 operations), and the incidence of brain abscess was 0.2% (occurring after 3 of 1587 operations). The most common offending organism was Staphylococcus aureus (8 cases; 50% of infections), followed by Propionibacterium acnes (4 cases; 25% of infections). Cerebrospinal fluid leakage, diabetes mellitus, and male sex were not associated with PCNSI (P>.05). In one of the largest neurosurgical studies to have investigated PCNSI, the incidence of infection after neurosurgical procedures was <1%--more than 6 times lower than that reported in recent series of comparable numerical size. Cerebrospinal fluid leak, diabetes mellitus, and male sex were not associated with an increased incidence of

  1. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports.

    PubMed

    Cooper, Alison; Edwards, Adrian; Williams, Huw; Evans, Huw P; Avery, Anthony; Hibbert, Peter; Makeham, Meredith; Sheikh, Aziz; J Donaldson, Liam; Carson-Stevens, Andrew

    2017-09-01

    older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting. to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care. a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013. 1,591 primary care patient safety incident reports regarding patients aged 65 years and older. we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care. the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm). priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.

  2. Analysis of immediate transfusion incidents reported in a regional blood bank

    PubMed Central

    de Sousa Neto, Adriana Lemos; Barbosa, Maria Helena

    2011-01-01

    Background Blood transfusion is imperative when treating certain patients; however, it is not risk free. In addition to the possible transmission of contagious infectious diseases, incidents can occur immediately after transfusion and at a later time. Aims This study aimed to examine the immediate transfusion incidents reported in a regional blood bank in the state of Minas Gerais between December 2006 and December 2009. A retrospective quantitative epidemiological study was conducted. Data were obtained from 202 transfusion incident reports of 42 health institutions served by the blood bank. Data processing and analysis were carried out using the Statistical Package for the Social Sciences (SPSS) software. Results The rate of immediate transfusion incidents reported in the period was 0.24%; febrile non-hemolytic reactions were the most common type of incident (56.4%). The most frequent clinical manifestations listed in transfusion incident reports were chills (26.9%) and fever (21.6%). There was a statistically significant association (p-value < 0.05) between the infusion of platelet concentrates and febrile non-hemolytic reactions and between fresh frozen plasma and febrile non-hemolytic reaction. The majority (73.3%) of transfused patients who suffered immediate transfusion incidents had already been transfused and 36.5% of the cases had previous transfusion incident reports. Conclusions Data from the present study corroborate the implementation of new professional training programs aimed at blood transfusion surveillance. These measures should emphasize prevention, identification and reporting of immediate transfusion incidents aiming to increase blood transfusion quality and safety. PMID:23049336

  3. Improved incident reporting following the implementation of a standardized emergency department peer review process.

    PubMed

    Reznek, Martin A; Barton, Bruce A

    2014-06-01

    Incident reporting is an important component of health care quality improvement. The objective of this investigation was to evaluate the effectiveness of an emergency department (ED) peer review process in promoting incident reporting. An observational, interrupted time-series analysis of health care provider (HCP) incident reporting to the ED during a 30-month study period prior to and following the peer review process implementation and a survey-based assessment of physician perceptions of the peer review process' educational value and its effectiveness in identifying errors. Large, urban, academic ED. HCPs were invited to participate in a standardized, non-punitive, non-anonymous peer review process that involved analysis and structured discussion of incident reports submitted to ED physician leadership. Monthly frequency of incident reporting by HCPs and physician perceptions of the peer review process. HCPs submitted 314 incident reports to the ED over the study period. Following the intervention, frequency of reporting by HCPs within the hospital increased over time. The frequencies of self-reporting, reporting by other ED practitioners and reporting by non-ED practitioners within the hospital increased compared with a control group of outside HCPs (P = 0.0019, P = 0.0025 and P < 0.0001). Physicians perceived the peer review process to be educational and highly effective in identifying errors. The implementation of a non-punitive peer review process that provides timely feedback and is perceived as being valuable for error identification and education can lead to increased incident reporting by HCPs. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

  4. Nursing aide reports of combative behavior by residents with dementia: results from a detailed prospective incident diary.

    PubMed

    Morgan, Debra G; Cammer, Allison; Stewart, Norma J; Crossley, Margaret; D'Arcy, Carl; Forbes, Dorothy A; Karunanayake, Chandima

    2012-03-01

    This study examined nursing aides' (NAs) perspectives of specific incidents of combative behavior from nursing home residents with dementia, particularly their attributions for the behaviors. This research is part of a larger mixed-method study exploring combative behavior as experienced by NAs. The data for this component were collected using a cross-sectional survey design. NAs used a prospective event-reporting log or "diary" to record consecutive incidents of combative resident behaviors. Eleven rural nursing homes located in a mid-Western Canadian province. Eighty-three full-time, part-time, and casual NAs. NAs used the diary instrument to document details of each incident of combative behavior over a 144-hour period. Findings from the diaries were explored in subsequent focus groups (reported elsewhere). The 83 NAs reported 409 incidents linked to residents with dementia, with a range of 1 to 28 incidents per aide. The frequency of incidents in the preceding month was reported as follows: none (11.1%), 1-5 times (58.7%), 6-10 times (11.1%), more than 10 times (19.0%). Most incidents occurred in residents' rooms (65%) during personal care, with the most frequent behaviors reported as slapping, squeezing, punching or hitting, and shoving. The main perceived causes of the behavior were cognitive impairment and residents not wanting care. NAs reported they could control or modify the cause in only 3% of incidents, and they were not optimistic about preventing future combative behaviors. They continued to provide care in 89% of incidents. In the diaries, NAs identified resident-related factors (cognitive impairment and not wanting care) as the main causes of combative behavior, and they reported having no control over these factors. In the focus groups conducted to explore diary findings, NAs reported system-level factors, also beyond their control, which affected their practices and increased their risk of exposure to combative behavior. Taken together, the

  5. The incidence of systemic lupus erythematosus in North American Indians.

    PubMed

    Morton, R O; Gershwin, M E; Brady, C; Steinberg, A D

    1976-06-01

    The annual incidence (AI) of systemic lupus erythematosus (SLE) was determined in 75 highly inbred North American Indian tribes, a total of approximately 800,000 people, during the fiscal years 1971-1975. Seventy-two of the Indian tribes had an AI of SLE which was of similar magnitude to previously published studies from Sweden, Rochester (Minn.), Alabama, New York City, and San Francisco. However, Three tribes, the Crow, Arapahoe, and Sioux Indians, had a markedly elevated AI of SLE. These three tribes share common historical, geographic, and cultural characteristics. Further, they all reside in the northern half of the United States, in states that do not receive intense sun exposure, thereby eliminating photosensitivity as a major determinant of this increased prevalence. Finally, the AI of SLE in the Sioux Indians was highest for "full-blooded" members and lowest for genetic admixtures.

  6. A progress report on grazing incidence optics fabrication and evaluation

    NASA Technical Reports Server (NTRS)

    Teague, Peter F.; Ulmer, Melville P.; Matsui, Yutaka; Briel, Ulrich; Burkert, Wolfgang

    1989-01-01

    The progress being made on a mirror array telescope for high energies (MARTHE) project is reported. As a first step, small mirror flats and full-size Wolter I mirrors are produced that are lacquer coated (mandrels) and then coated with gold or palladium. The up-to-date results of fabricating and testing these mirrors are presented. Currently, results can be provided on the micro-roughness, marco-figure, X-ray scattering, and reflectivity up to 8 keV from flats and Wolter I mirrors as well as optical measurements of the flats.

  7. A progress report on grazing incidence optics fabrication and evaluation

    NASA Technical Reports Server (NTRS)

    Teague, Peter F.; Ulmer, Melville P.; Matsui, Yutaka; Briel, Ulrich; Burkert, Wolfgang

    1989-01-01

    The progress being made on a mirror array telescope for high energies (MARTHE) project is reported. As a first step, small mirror flats and full-size Wolter I mirrors are produced that are lacquer coated (mandrels) and then coated with gold or palladium. The up-to-date results of fabricating and testing these mirrors are presented. Currently, results can be provided on the micro-roughness, marco-figure, X-ray scattering, and reflectivity up to 8 keV from flats and Wolter I mirrors as well as optical measurements of the flats.

  8. 30 CFR 250.188 - What incidents must I report to MMS and when must I report them?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... calendar days after the incident: (1) All fatalities. (2) All injuries that require the evacuation of the.... (4) All fires and explosions. (5) All reportable releases of hydrogen sulfide (H2S) gas, as...

  9. Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes.

    PubMed

    Winsvold Prang, Ida; Jelsness-Jørgensen, Lars-Petter

    2014-01-01

    Adverse events, errors and acts of inadequate care have been shown to occur quite frequently in hospitals, and there is growing evidence that this poor care may also occur in nursing homes. Based on hospital studies, we know that incidents are only reported to a limited extent and that there may be a high number of unrecorded cases. Moreover, little is known about the barriers to incident reporting in nursing homes compared to hospitals. Consequently, the aim of this study was to explore the barriers to incident reporting in nursing homes. Thematic analysis of 13 semi-structured interviews with nurses revealed that unclear outcomes, lack of support and culture, fear of vilification and conflicts, unclear routines, technological knowledge and confidence, time and degree of severity were the main drivers of not reporting incidents. These findings may be important in planning quality and safety improvement interventions in nursing homes. Copyright © 2014 Elsevier Inc. All rights reserved.

  10. 77 FR 69925 - Assessment of Hazardous Materials Incident Data Collection, Analysis, Reporting, and Use

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-21

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

  11. The NASA Aviation Safety Reporting System

    NASA Technical Reports Server (NTRS)

    1983-01-01

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

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

    PubMed Central

    Yamashita, Yuichi; Tanihara, Shinichi; Maeda, Chiemi

    2014-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  14. Multicentered study of model of anesthesia related adverse events in Thailand by incident report (The Thai Anesthesia Incidents Monitoring Study): results.

    PubMed

    Charuluxananan, Somrat; Suraseranivongse, Suwanee; Jantorn, Prasatnee; Sriraj, Wimonrat; Chanchayanon, Thavat; Tanudsintum, Surasak; Kusumaphanyo, Chaiyapruk; Suratsunya, Thanarat; Poajanasupawun, Surachart; Klanarong, Sireeluck; Pulnitiporn, Aksorn; Akavipat, Phuping; Punjasawadwong, Yodying

    2008-07-01

    The Thai Anesthesia Incidents Monitoring Study (Thai AIMS) was aimed to identify and analyze anesthesia incidents in order to find out the frequency distribution, clinical courses, management of incidents, and investigation of model appropriate for possible corrective strategies. Fifty-one hospitals (comprising of university, military, regional, general, and district hospitals across Thailand) participated in the present study. Each hospital was invited to report, on an anonymous and voluntary basis, any unintended anesthesia incident during six months (January to June 2007). A standardized incident report form was developed in order to fill in what, where, when, how, and why it happened in both the close-end and open-end questionnaire. Each incident report was reviewed by three reviewers. Any disagreement was discussed and judged to achieve a consensus. Among 1996 incident reports and 2537 incidents, there were more male (55%) than female (45%) patients with ASA PS 1, 2, 3, 4, and 5 = 22%, 36%, 24%, 11%, and 7%, respectively. Surgical specialties that posed high risk of incidents were neurosurgical, otorhino-laryngological, urological, and cardiac surgery. Common places where incidents occurred were operating room (61%), ward (10%), and recovery room (9%). Common occurred incidents were arrhythmia needing treatment (25%), desaturation (24%), death within 24 hr (20%), cardiac arrest (14%), reintubation (10%), difficult intubation (8%), esophageal intubation (5%), equipment failure (5%), and drug error (4%) etc. Monitors that first detected incidents were EKG (46%), Pulse oximeter (34%), noninvasive blood pressure (12%), capnometry (4%), and mean arterial pressure (1%). Common factors related to incidents were inexperience, lack of vigilance, inadequate preanesthetic evaluation, inappropriate decision, emergency condition, haste, inadequate supervision, and ineffective communication. Suggested corrective strategies were quality assurance activity, clinical practice

  15. 49 CFR 191.11 - Distribution system: Annual report.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.11 Distribution system: Annual report. (a) General. Except as provided in paragraph (b) of this... 49 Transportation 3 2012-10-01 2012-10-01 false Distribution system: Annual report. 191.11 Section...

  16. 49 CFR 191.11 - Distribution system: Annual report.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.11 Distribution system: Annual report. (a) General. Except as provided in paragraph (b) of this... 49 Transportation 3 2011-10-01 2011-10-01 false Distribution system: Annual report. 191.11 Section...

  17. 49 CFR 191.11 - Distribution system: Annual report.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.11 Distribution system: Annual report. (a) General. Except as provided in paragraph (b) of this... 49 Transportation 3 2014-10-01 2014-10-01 false Distribution system: Annual report. 191.11 Section...

  18. 49 CFR 191.11 - Distribution system: Annual report.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED CONDITION REPORTS § 191.11 Distribution system: Annual report. (a) General. Except as provided in paragraph (b) of this... 49 Transportation 3 2013-10-01 2013-10-01 false Distribution system: Annual report. 191.11 Section...

  19. 49 CFR 225.12 - Rail Equipment Accident/Incident Reports alleging employee human factor as cause; Employee Human...

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 4 2011-10-01 2011-10-01 false Rail Equipment Accident/Incident Reports alleging... RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.12 Rail Equipment Accident/Incident Reports alleging employee human factor as...

  20. 49 CFR 225.12 - Rail Equipment Accident/Incident Reports alleging employee human factor as cause; Employee Human...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 4 2010-10-01 2010-10-01 false Rail Equipment Accident/Incident Reports alleging... RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.12 Rail Equipment Accident/Incident Reports alleging employee human factor as...

  1. 49 CFR 225.12 - Rail Equipment Accident/Incident Reports alleging employee human factor as cause; Employee Human...

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 4 2012-10-01 2012-10-01 false Rail Equipment Accident/Incident Reports alleging... RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD ACCIDENTS/INCIDENTS: REPORTS CLASSIFICATION, AND INVESTIGATIONS § 225.12 Rail Equipment Accident/Incident Reports alleging employee human factor as...

  2. Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data.

    PubMed

    Ferroli, Paolo; Caldiroli, Dario; Acerbi, Francesco; Scholtze, Maurizio; Piro, Alfonso; Schiariti, Marco; Orena, Eleonora F; Castiglione, Melina; Broggi, Morgan; Perin, Alessandro; DiMeco, Francesco

    2012-11-01

    Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within

  3. Self-reported estrogen use and newly incident urinary incontinence among postmenopausal community-dwelling women.

    PubMed

    Northington, Gina M; de Vries, Heather F; Bogner, Hillary R

    2012-03-01

    The aim of this study was to examine the relationship between self-reported estrogen use and newly incident urinary incontinence (UI) among community-dwelling postmenopausal women. The study was a population-based longitudinal survey of postmenopausal women who did not report UI in 1993 and for whom complete data were available. Women were classified as having newly incident UI if they reported uncontrolled urine loss within 12 months of the 2004 interview. Condition-specific functional loss secondary to UI was assessed using questions on the participants' inability to engage in certain activities because of UI. The duration of hormone therapy containing estrogen was obtained in 1993 using a structured questionnaire. Among the 167 postmenopausal women who did not report UI in 1993, 47 (28.1%) reported newly incident UI, and 31 (18.6%) reported newly incident UI with condition-specific functional loss in 2004. Of the 167 postmenopausal women, 46 (27.5%) reported using hormone therapy containing estrogen ever, and 14 (8.3%) women reported using hormone therapy containing estrogen for 5 years or more in 1993. Estrogen use for 5 years or more was significantly associated with newly incident UI with condition-specific functional loss compared with estrogen use for less than 5 years or having no reported history of estrogen (adjusted relative odds, 3.97; 95% CI, 1.02-15.43) in multivariate models controlling for potentially influential characteristics. Postmenopausal community-dwelling women with a history of estrogen use for 5 years or more were more likely to report newly incident UI with condition-specific functional loss after 10 years of follow-up.

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

    PubMed Central

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

    2016-01-01

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

  5. How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center.

    PubMed

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

    2016-07-01

    Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

  6. Quality Indicator System Report.

    ERIC Educational Resources Information Center

    Colorado Commission on Higher Education, Denver.

    This report is a product of the implementation of a quality indicator system for Colorado's public higher education system. In 1999, the Colorado Commission on Higher Education established a core set of nine indicators, for which data were gathered and benchmarks were identified for measuring performance in terms of these benchmarks. The first…

  7. Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour.

    PubMed

    Williams, Steven David; Phipps, Denham L; Ashcroft, Darren

    2015-08-01

    To assess the effect of factors within hospital pharmacists' practice on the likelihood of their reporting a medication safety incident. Theory of planned behaviour (TPB) survey. Twenty-one general and teaching hospitals in the North West of England. Two hundred and seventy hospital pharmacists (response rate = 45%). Hospital pharmacists were invited to complete a TPB survey, based on a prescribing error scenario that had resulted in serious patient harm. Multiple regression was used to determine the relative influence of different TPB variables, and participant demographics, on the pharmacists' self-reported intention to report the medication safety incident. The TPB variables predicting intention to report: attitude towards behaviour, subjective norm, perceived behavioural control and descriptive norm. Overall, the hospital pharmacists held strong intentions to report the error, with senior pharmacists being more likely to report. Perceived behavioural control (ease or difficulty of reporting), Descriptive Norms (belief that other pharmacists would report) and Attitudes towards Behaviour (expected benefits of reporting) showed good correlation with, and were statistically significant predictors of, intention to report the error [R = 0.568, R(2) = 0.323, adjusted R(2) = 0.293, P < 0.001]. This study suggests that efforts to improve medication safety incident reporting by hospital pharmacists should focus on their behavioural and control beliefs about the reporting process. This should include instilling greater confidence about the benefits of reporting and not harming professional relationships with doctors, greater clarity about what/not to report and a simpler reporting system. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

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

    PubMed

    Ahmed, Aliya; Yasir, Muhammad

    2015-01-01

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

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

    PubMed

    Yee, Kwang Chien

    2007-01-01

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

  10. An Analysis of Incident/Accident Reports from the Texas Secondary School Science Safety Survey, 2001

    ERIC Educational Resources Information Center

    Stephenson, Amanda L.; West, Sandra S.; Westerlund, Julie F.; Nelson, Nancy C.

    2003-01-01

    This study investigated safety in Texas secondary school science laboratory, classroom, and field settings. The Texas Education Agency (TEA) drew a random representative sample consisting of 199 secondary public schools in Texas. Eighty-one teachers completed Incident/Accident Reports. The reports were optional, anonymous, and open-ended; thus,…

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

    ERIC Educational Resources Information Center

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

    2016-01-01

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

  12. 40 CFR 159.184 - Toxic or adverse effect incident reports.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 40 Protection of Environment 23 2010-07-01 2010-07-01 false Toxic or adverse effect incident reports. 159.184 Section 159.184 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) PESTICIDE PROGRAMS STATEMENTS OF POLICIES AND INTERPRETATIONS Reporting Requirements for Risk/Benefit...

  13. 30 CFR 585.833 - What are the reporting requirements for incidents requiring written notification?

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 30 Mineral Resources 2 2014-07-01 2014-07-01 false What are the reporting requirements for incidents requiring written notification? 585.833 Section 585.833 Mineral Resources BUREAU OF OCEAN ENERGY... report must contain the following information: (1) Date and time of occurrence; (2) Identification and...

  14. 30 CFR 585.833 - What are the reporting requirements for incidents requiring written notification?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 30 Mineral Resources 2 2013-07-01 2013-07-01 false What are the reporting requirements for incidents requiring written notification? 585.833 Section 585.833 Mineral Resources BUREAU OF OCEAN ENERGY... report must contain the following information: (1) Date and time of occurrence; (2) Identification and...

  15. 30 CFR 585.833 - What are the reporting requirements for incidents requiring written notification?

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 30 Mineral Resources 2 2012-07-01 2012-07-01 false What are the reporting requirements for incidents requiring written notification? 585.833 Section 585.833 Mineral Resources BUREAU OF OCEAN ENERGY... report must contain the following information: (1) Date and time of occurrence; (2) Identification and...

  16. Increased incidence of second primary malignancy in patients with carcinoid tumors: case report and literature review.

    PubMed Central

    Rivadeneira, D. E.; Tuckson, W. B.; Naab, T.

    1996-01-01

    There is an increased incidence of second noncarcinoid neoplasms in patients with carcinoid tumors. This article reports a case of a synchronous malignant ileal carcinoid tumor in a patient with an adenocarcinoma of the sigmoid colon. This report illustrates the increased association of carcinoid tumors with other gastrointestinal malignancies. Images Figure 1 Figure 2 Figure 3 PMID:8667441

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

    ERIC Educational Resources Information Center

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

    2016-01-01

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

  18. An Analysis of Incident/Accident Reports from the Texas Secondary School Science Safety Survey, 2001

    ERIC Educational Resources Information Center

    Stephenson, Amanda L.; West, Sandra S.; Westerlund, Julie F.; Nelson, Nancy C.

    2003-01-01

    This study investigated safety in Texas secondary school science laboratory, classroom, and field settings. The Texas Education Agency (TEA) drew a random representative sample consisting of 199 secondary public schools in Texas. Eighty-one teachers completed Incident/Accident Reports. The reports were optional, anonymous, and open-ended; thus,…

  19. An updated report of the trends in cancer incidence and mortality in Japan.

    PubMed

    Katanoda, Kota; Matsuda, Tomohiro; Matsuda, Ayako; Shibata, Akiko; Nishino, Yoshikazu; Fujita, Manabu; Soda, Midori; Ioka, Akiko; Sobue, Tomotaka; Nishimoto, Hiroshi

    2013-05-01

    The analysis of cancer trends in Japan has only been sporadically reported. We present a comprehensive report on the trends in cancer incidence and mortality in Japan using the most recent population-based data. National cancer mortality data between 1958 and 2011 were obtained from published vital statistics. Cancer incidence data between 1985 and 2007 were obtained from high-quality population-based cancer registries of four prefectures (Miyagi, Yamagata, Fukui and Nagasaki). Joinpoint regression analysis was performed to examine the trends in age-standardized rates of cancer incidence and mortality. All-cancer mortality decreased from the mid-1990s, with an annual percent change of -1.3% (95% confidence interval: -1.4, -1.3), while all-cancer incidence continually increased from 1985, with an annual percent change of 0.7% (95% confidence interval: 0.6, 0.8). Major cancer sites, particularly the liver, colorectum and lung (males), showed a pattern of increasing incidence and mortality rates until the mid-1990s, stabilizing or decreasing thereafter. Stomach cancer showed a long-term decreasing trend for both incidence and mortality, while female breast cancer showed a continuously increasing trend. The incidence of prostate cancer, particularly at the localized stage, increased rapidly between 2000 and 2003, while that of mortality decreased from 2004. No changes were detected in the incidence or mortality for colorectal, female breast or cervical cancers after the establishment of national screening programs for these cancers. The analysis of cancer trends in Japan revealed a recent decrease in mortality and a continuous increase in incidence, which are considered to reflect changes in the underlying risk factors such as tobacco smoking and infection, and are partially explained by early detection and improved treatment.

  20. Incidence and prevalence of systemic lupus erythematosus among the native Arab population in UAE.

    PubMed

    Al Dhanhani, A M; Agarwal, M; Othman, Y S; Bakoush, O

    2017-05-01

    Background and objectives There is a paucity of information about the epidemiology of systemic lupus erythematosus (SLE) amongst Arabs. The objective of this study was to determine the incidence and prevalence of SLE among the native Arab population of United Arab Emirates (UAE). Methods Patients with SLE were identified from three sources: medical records of two local tertiary hospitals (four years; 2009 to 2012), laboratory requests for serum double stranded deoxyribonucleic acid and serum anti-nuclear antibody and confirmed histopathologic diagnosis of SLE (skin and kidney biopsy specimens). All the patients identified with SLE met the criteria of the American College of Rheumatology. Incidence and prevalence were calculated using the state records of the UAE native population as the denominator. The age-adjusted incidence was calculated by direct standardization using the World Health Organization world standard population 2000-2025. Results Sixteen new cases (13 females and three males) fulfilled the American College of Rheumatology SLE criteria. The mean (±SD) age at time of diagnosis was 28.6 ± 12.4 years. The crude incidence ratio (per 100,000 population) was 3.5, 1.1, 2.1 and 2.1 in years 2009, 2010, 2011, 2012, respectively. The age-standardized incidence per 100,000 population for the four years was 8.6 (95% confidence interval 4.2-15.9). The age-standardized prevalence of SLE among the native population according to the 2012 population consensus was 103/100,000 population (95% confidence interval 84.5-124.4). Conclusion The age-adjusted incidence and prevalence among UAE Arabs is higher than has been reported among most other Caucasian populations. Furthermore, the prevalence of SLE in UAE seems much higher than other similar Arab countries in the Gulf region.

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

    PubMed

    Leggat, Peter A; Leggat, Frances W

    2003-05-01

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

  2. Linguistic analysis of large-scale medical incident reports for patient safety.

    PubMed

    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.

  3. A quantification of the effectiveness of EPID dosimetry and software-based plan verification systems in detecting incidents in radiotherapy

    SciTech Connect

    Bojechko, Casey; Phillps, Mark; Kalet, Alan; Ford, Eric C.

    2015-09-15

    Purpose: Complex treatments in radiation therapy require robust verification in order to prevent errors that can adversely affect the patient. For this purpose, the authors estimate the effectiveness of detecting errors with a “defense in depth” system composed of electronic portal imaging device (EPID) based dosimetry and a software-based system composed of rules-based and Bayesian network verifications. Methods: The authors analyzed incidents with a high potential severity score, scored as a 3 or 4 on a 4 point scale, recorded in an in-house voluntary incident reporting system, collected from February 2012 to August 2014. The incidents were categorized into different failure modes. The detectability, defined as the number of incidents that are detectable divided total number of incidents, was calculated for each failure mode. Results: In total, 343 incidents were used in this study. Of the incidents 67% were related to photon external beam therapy (EBRT). The majority of the EBRT incidents were related to patient positioning and only a small number of these could be detected by EPID dosimetry when performed prior to treatment (6%). A large fraction could be detected by in vivo dosimetry performed during the first fraction (74%). Rules-based and Bayesian network verifications were found to be complimentary to EPID dosimetry, able to detect errors related to patient prescriptions and documentation, and errors unrelated to photon EBRT. Combining all of the verification steps together, 91% of all EBRT incidents could be detected. Conclusions: This study shows that the defense in depth system is potentially able to detect a large majority of incidents. The most effective EPID-based dosimetry verification is in vivo measurements during the first fraction and is complemented by rules-based and Bayesian network plan checking.

  4. A quantification of the effectiveness of EPID dosimetry and software-based plan verification systems in detecting incidents in radiotherapy.

    PubMed

    Bojechko, Casey; Phillps, Mark; Kalet, Alan; Ford, Eric C

    2015-09-01

    Complex treatments in radiation therapy require robust verification in order to prevent errors that can adversely affect the patient. For this purpose, the authors estimate the effectiveness of detecting errors with a "defense in depth" system composed of electronic portal imaging device (EPID) based dosimetry and a software-based system composed of rules-based and Bayesian network verifications. The authors analyzed incidents with a high potential severity score, scored as a 3 or 4 on a 4 point scale, recorded in an in-house voluntary incident reporting system, collected from February 2012 to August 2014. The incidents were categorized into different failure modes. The detectability, defined as the number of incidents that are detectable divided total number of incidents, was calculated for each failure mode. In total, 343 incidents were used in this study. Of the incidents 67% were related to photon external beam therapy (EBRT). The majority of the EBRT incidents were related to patient positioning and only a small number of these could be detected by EPID dosimetry when performed prior to treatment (6%). A large fraction could be detected by in vivo dosimetry performed during the first fraction (74%). Rules-based and Bayesian network verifications were found to be complimentary to EPID dosimetry, able to detect errors related to patient prescriptions and documentation, and errors unrelated to photon EBRT. Combining all of the verification steps together, 91% of all EBRT incidents could be detected. This study shows that the defense in depth system is potentially able to detect a large majority of incidents. The most effective EPID-based dosimetry verification is in vivo measurements during the first fraction and is complemented by rules-based and Bayesian network plan checking.

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

    NASA Technical Reports Server (NTRS)

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

    1989-01-01

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

  6. [Decentralization and health system reform: what is their impact on malaria incidence in Colombian municipalities?].

    PubMed

    Borrero, Elizabeth; Carrasquilla, Gabriel; Alexander, Neal

    2012-03-01

    Colombia is one of the Latin-American countries with higher malaria incidence and its control is the responsibility of the departments and municipalities. To assess the effect of decentralization within the context of the Social Security Health System on the incidence of malaria in Colombian municipalities. An ecological trend study was carried out in municipalities which reported at least five cases of malaria in 5 of the 7 years between 1998 and 2004. Information on indicators of decentralization of the municipalities, population with health insurance in either the subsidized or contributive regimes as well as incidence of malaria was requested from the health authorities of the departments and municipalities. Socioeconomic and demographic variables were also collected. The behavior of the malaria rates was assessed in relation to the decentralization status of the municipalities. A repeated measure analysis was performed using the generalized estimating equation. The decentralization status of the municipality (IRR=2.36; 95%CI: 1.57-3.56), its proportion of unmet basic needs (IRR=9.35; 95%CI: 3.66-23.89) and of population younger than 40 years of age (IRR=1.8; 95%CI: 1.13-1.23) were associated with malaria incidence in Colombian municipalities. Decentralization status as well as socioeconomic and demographic factors are associated with increased malaria risk in Colombian municipalities.

  7. Bowen's disease (squamous cell carcinoma in situ) in Kauai, Hawaii. A population-based incidence report.

    PubMed

    Reizner, G T; Chuang, T Y; Elpern, D J; Stone, J L; Farmer, E R

    1994-10-01

    The incidence of Bowen's disease (squamous cell carcinoma in situ) is rarely investigated. Our purpose was to report the incidence of Bowen's disease in a defined Caucasian population in Kauai, Hawaii. We conducted a prospective 5-year population study. We found 71 Caucasian residents, 44 men and 27 women, who had an initial episode of Bowen's disease during the 5-year period. The average annual incidence rate per 100,000 Caucasian residents of Kauai, standardized to the 1980 U.S. Caucasian population, was 174 for men and 115 for women, with a combined rate of 142. The incidence increased in older age groups. The mean age of the patients was 65.2 years. The most common anatomic site was the extremities. Subsequent Bowen's disease occurred in eight patients (11.3%). Recurrence after treatment developed in only one patient (1.4%). Twenty-six patients (36.6%) had concurrent skin cancers, either basal cell carcinoma or squamous cell carcinoma, or both. There was no increased incidence of internal malignancy. The incidence of Bowen's disease is high in Caucasian residents of Kauai and is 10 times higher than that reported from a northern Midwestern community. Kauai's intense ambient UV light and greater opportunity for year-round outdoor activities likely contributes to this higher rate.

  8. Self-reported incidence of skin and soft tissue infections among deployed US military.

    PubMed

    May, Larissa; Porter, Chad; Tribble, David; Armstrong, Adam; Mostafa, Manal; Riddle, Mark

    2011-07-01

    The incidence of skin and soft tissue infections has steadily increased over the past decade, and military populations, particularly recruits, have been affected. However, the epidemiology of skin and soft tissue infections in deployed personnel has not previously been described. We conducted a cross-sectional study of United States military personnel in mid-deployment using self-reported questionnaire data containing 11 demographic questions and 20 questions related to skin and soft tissue infections. The primary outcome was self-reported incident SSTI. Descriptive analyses were conducted and incidence estimates calculated. Multivariable regression models were developed to evaluate the association between SSTI and important covariates. Self-reported treatment modalities and effect on work performance were also assessed. The study was approved by the Institutional Review Board. 2125 questionnaires were completed over 12 months using convenience sampling. 110 personnel (5%) reported one or more skin and soft tissue infection during their most recent employment, for an incidence of 52 cases per 100,000 person-days. The majority reported a single infection. A higher proportion of individuals reporting skin and soft tissue infection were female, reported antibiotic use in the 6 months prior to completing the survey, had a family member in the healthcare occupation, and were senior enlisted or officers. 40 (36%) were treated with antibiotics and 24 (22%) underwent incision and drainage. Less than 5% (3 patients) required admission. Eighty eight respondents (81%), reported no days of lost job performance. There is a higher than expected incidence of skin and soft tissue infections in deployed military personnel. Although fewer than 20% of patients report missing at least one day of work, this can have a significant impact on the military mission. Further study should be conducted into how to prevent skin and soft tissue infections in military populations. Copyright

  9. Time-sampled versus continuous-time reporting for measuring incidence.

    PubMed

    McNamee, Roseanne; Chen, Yiqun; Hussey, Louise; Agius, Raymond

    2010-05-01

    Accuracy of incidence estimates may be affected by biases that depend on frequency of approach to reporters and reporting window length. A time-sampling strategy enables infrequent approaches with short windows but has never been evaluated. A randomized crossover trial compared incidence estimates of work-related diseases using time-sampled versus continuous-time reporting. Physicians were randomly allocated either to report every month (12/12) in 2004 and for 1 randomly chosen month (1/12) in 2005, or to the reverse sequence. Numbers of new cases of work-related disease reported per reporter per month for 1/12 and 12/12 reporting periods were compared. Response rates were high (87%). Withdrawal from the study was higher under 12/12 reporting. The rate ratio for 1/12 versus 12/12 reporting was 1.26 (95% confidence interval = 1.11-1.42). Rates declined gradually in the 12/12 groups over the year, consistent with reporting fatigue. Increased frequency of data collection may reduce incidence estimates.

  10. Age-related trends in injection site reaction incidence induced by the tumor necrosis factor-α (TNF-α) inhibitors etanercept and adalimumab: the Food and Drug Administration adverse event reporting system, 2004-2015

    PubMed Central

    Matsui, Toshinobu; Umetsu, Ryogo; Kato, Yamato; Hane, Yuuki; Sasaoka, Sayaka; Motooka, Yumi; Hatahira, Haruna; Abe, Junko; Fukuda, Akiho; Naganuma, Misa; Kinosada, Yasutomi; Nakamura, Mitsuhiro

    2017-01-01

    Tumor necrosis factor-α (TNF-α) inhibitors are increasingly being used as treatment for rheumatoid arthritis (RA). However, the administration of these drugs carries the risk of inducing injection site reaction (ISR). ISR gives rise to patient stress, nervousness, and a decrease in quality of life (QoL). In order to alleviate pain and other symptoms, early countermeasures must be taken against this adverse event. In order to improve understanding of the risk factors contributing to the induction of ISR, we evaluated the association between TNF-α inhibitors and ISR by applying a logistic regression model to age-stratified data obtained from the Food and Drug Administration Adverse Event Reporting System (FAERS) database. The FAERS database contains 7,561,254 reports from January 2004 to December 2015. Adjusted reporting odds ratios (RORs) (95% Confidence Intervals) were obtained for interaction terms for age-stratified groups treated with etanercept (ETN) and adalimumab (ADA). The adjusted RORs for ETN* ≥ 70 and ADA* ≥ 70 groups were the lowest among the age-stratified groups undergoing the respective monotherapies. Furthermore, we found that crude RORs for ETN + methotrexate (MTX) combination therapy and ADA + MTX combination therapy were lower than those for the respective monotherapies. This study was the first to evaluate the relationship between aging and ISR using the FAERS database. PMID:28260984

  11. Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

    PubMed

    Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

    2012-12-01

    Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  12. A study of cases reported as incidents in a public hospital from 2011 to 2014.

    PubMed

    Göttems, Leila Bernarda Donato; Santos, Maria do Livramento Gomes Dos; Carvalho, Paloma Aparecida; Amorim, Fábio Ferreira

    2016-01-01

    Analyzing incidents reported in a public hospital in the Federal District, Brasilia, according to the characteristics and outcomes involving patients. A descriptive and retrospective study of incidents reported between January 2011 and September 2014. 209 reported incidents were categorized as reportable occurrences (n = 22, 10.5%), near misses (n = 16, 7.7%); incident without injury (n = 4, 1.9%) and incident with injury (adverse events) (n = 167, 79.9%). The average age of patients was 44 years and the hospitalization time until the moment of the incident was on average 38.5 days. Nurses were the healthcare professionals who most reported the incidents (n = 55, 67%). No outcomes resulted in death. Incidents related to blood/hemoderivatives, medical devices/equipment, patient injuries and intravenous medication/fluids were the most frequent. Standardizing the reporting processes and enhancing participation by professionals in managing incidents is recommended. Analisar os incidentes notificados em um hospital público do Distrito Federal, segundo as características e os desfechos quando envolveram pacientes. Estudo descritivo e retrospectivo dos incidentes notificados entre janeiro de 2011 e setembro de 2014. Notificados 209 incidentes categorizados em ocorrência comunicável (n = 22, 10,5%), quase evento (n = 16, 7,7%), incidente sem dano (n = 4, 1,9%) e incidente com dano (eventos adversos) (n = 167, 79,9%). A idade média dos pacientes foi de 44 anos e o tempo da internação até o momento do incidente teve média de 38,5 dias. Os enfermeiros foram os que mais notificaram (n = 55, 67%). Nenhum desfecho resultou em morte. Os incidentes relacionados a sangue/hemoderivados, dispositivos/equipamento médico, acidentes do doente e medicação/fluidos endovenosos foram os mais frequentes. Recomenda-se padronizar os processos de notificação e potencializar a participação dos profissionais no manejo dos incidentes.

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

    PubMed

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

    2016-01-01

    The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs. Copyright © 2016. Published by Elsevier Inc.

  14. Mobile DIORAMA-II: infrastructure less information collection system for mass casualty incidents.

    PubMed

    Ganz, Aura; Schafer, James M; Yang, Zhuorui; Yi, Jun; Lord, Graydon; Ciottone, Gregory

    2014-01-01

    In this paper we introduce DIORAMA-II system that provides real time information collection in mass casualty incidents. Using a mobile platform that includes active RFID tags and readers as well as Smartphones, the system can determine the location of victims and responders. The system provides user friendly multi dimensional user interfaces as well as collaboration tools between the responders and the incident commander. We conducted two simulated mass casualty incidents with 50 victims each and professional responders. DIORAMA-II significantly reduces the evacuation time by up to 43% when compared to paper based triage systems. All responders that participated in all trials were very satisfied. They felt in control of the incident and mentioned that the system significantly reduced their stress level during the incident. They all mentioned that they would use the system in an actual incident.

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

    SciTech Connect

    Stenner, Robert D.

    2007-04-24

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

  16. 30 CFR 285.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... cannot continue until repairs are made; (6) Incidents involving crane or personnel/material handling.... Property or equipment damage means the cost of labor and material to restore all affected items to...

  17. Decision-support information system to manage mass casualty incidents at a level 1 trauma center.

    PubMed

    Bar-El, Yaron; Tzafrir, Sara; Tzipori, Idan; Utitz, Liora; Halberthal, Michael; Beyar, Rafael; Reisner, Shimon

    2013-12-01

    Mass casualty incidents are probably the greatest challenge to a hospital. When such an event occurs, hospitals are required to instantly switch from their routine activity to conditions of great uncertainty and confront needs that exceed resources. We describe an information system that was uniquely designed for managing mass casualty events. The web-based system is activated when a mass casualty event is declared; it displays relevant operating procedures, checklists, and a log book. The system automatically or semiautomatically initiates phone calls and public address announcements. It collects real-time data from computerized clinical and administrative systems in the hospital, and presents them to the managing team in a clear graphic display. It also generates periodic reports and summaries of available or scarce resources that are sent to predefined recipients. When the system was tested in a nationwide exercise, it proved to be an invaluable tool for informed decision making in demanding and overwhelming situations such as mass casualty events.

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

    PubMed

    Christiaans-Dingelhoff, Ingrid; Smits, Marleen; Zwaan, Laura; Lubberding, Sanne; van der Wal, Gerrit; Wagner, Cordula

    2011-02-28

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

  19. Recommendations for Nuclear Medicine Technologists Drawn from an Analysis of Errors Reported in Australian Radiation Incident Registers.

    PubMed

    Kearney, Nicole; Denham, Gary

    2016-12-01

    When a radiation incident occurs in nuclear medicine in Australia, the incident is reported to the relevant state or territory authority, which performs an investigation and sends its findings to the Australian Radiation Protection and Nuclear Safety Agency. The agency then includes these data in its Australian Radiation Incident Register and makes them available to the public as an annual summary report on its website. The aim of this study was to analyze the radiation incidents included in these annual reports and in the publically available state and territory registers, identify any recurring themes, and make recommendations to minimize future incidents.

  20. The Incidence and Prevalence of Systemic Lupus Erythematosus, 2002–2004: The Georgia Lupus Registry

    PubMed Central

    Lim, S. Sam; Bayakly, A. Rana; Helmick, Charles G.; Gordon, Caroline; Easley, Kirk; Drenkard, Cristina

    2015-01-01

    Objective The Georgia Lupus Registry is a population-based registry designed to improve our ability to estimate incidence and prevalence of systemic lupus erythematosus (SLE) in a large population. Methods Potential cases were identified from multiple sources during the years 2002 through 2004. Cases were defined by the American College of Rheumatology (ACR) Criteria for SLE or a combined definition. Age-standardized rates were determined and stratified by race and sex. With capture-recapture analyses, we estimated the under-ascertainment of cases. Results Using the ACR case definition, the overall crude and age-adjusted incidence rate was 5.6/100,000, with capture-recapture and combined definition rates being slightly higher. The age-adjusted incidence rate for women was >5 times higher (9.2 vs. 1.8) than that for men. Black women had an incidence rate nearly 3 times higher than that for white women with a significantly higher rate in the 30 to 59 years age group. The overall crude and age-adjusted prevalence rates were 74.4 and 73/100,000, respectively. The age-adjusted prevalence rate for women was nearly 9 times higher (127.6 vs. 14.7) than that for men. Black women had very high rates (196.2). A striking difference was seen in the proportion with end-stage renal disease in prevalent cases, with a sevenfold greater involvement among blacks. Conclusion With more complete case finding, our incidence and prevalence rates are among the highest reported in the United States. Results continue to underscore striking gender, age, and racial disparities between blacks and whites. PMID:24504808

  1. Report of stroke-like symptoms predicts incident cognitive impairment in a stroke-free cohort.

    PubMed

    Kelley, Brendan J; McClure, Leslie A; Letter, Abraham J; Wadley, Virginia G; Unverzagt, Frederick W; Kissela, Brett M; Kleindorfer, Dawn; Howard, George

    2013-07-09

    The present study characterizes the relationship between report of stroke symptoms (SS) or TIA and incident cognitive impairment in the large biracial cohort of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. The REGARDS Study is a population-based, biracial, longitudinal cohort study that has enrolled 30,239 participants from the United States. Exclusion of those with baseline cognitive impairment, stroke before enrollment, or incomplete data resulted in a sample size of 23,830. Participants reported SS/TIA on the Questionnaire for Verifying Stroke-free Status at baseline and every 6 months during follow-up. Incident cognitive impairment was detected using the Six-item Screener, which was administered annually. Logistic regression found significant association between report of SS/TIA and subsequent incident cognitive impairment. Among white participants, the odds ratio for incident cognitive impairment was 2.08 (95% confidence interval: 1.81, 2.39) for those reporting at least one SS/TIA compared with those reporting no SS/TIA. Among black participants, the odds ratio was 1.66 (95% confidence interval: 1.45, 1.89) using the same modeling. The magnitude of impact was largest among those with fewer traditional stroke risk factors, particularly among white participants. Report of SS/TIA showed a strong association with incident cognitive impairment and supports the use of the Questionnaire for Verifying Stroke-free Status as a quick, low-cost instrument to screen for people at increased risk of cognitive decline.

  2. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals

    PubMed Central

    Evans, Sue M; Smith, Brian J; Esterman, Adrian; Runciman, William B; Maddern, Guy; Stead, Karen; Selim, Pam; O'Shaughnessy, Jane; Muecke, Sandy; Jones, Sue

    2007-01-01

    Objectives To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident‐reporting rates and change the types of incidents reported. Design, setting and participants Non‐equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia. Main outcome measures Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units. Results The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10 000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10 000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10 000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10 000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10 000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression‐related incidents in intervention units. In intervention units, more reports were submitted on one‐page forms than via the call centre (1005 vs 264 reports, respectively). Conclusions A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units. PMID:17545341

  3. 77 FR 38747 - Reports by Air Carriers on Incidents Involving Animals During Air Transport

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-29

    ... all cats and dogs transported by the carrier, regardless of whether the cat or dog is transported as a... required to report all incidents involving the loss, injury, or death of cats and dogs that occur while they are traveling in an airline's care, custody, or control, regardless of whether the cat or dog is...

  4. 14 CFR 234.13 - Reports by air carriers on incidents involving animals during air transport.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Reports by air carriers on incidents involving animals during air transport. 234.13 Section 234.13 Aeronautics and Space OFFICE OF THE SECRETARY, DEPARTMENT OF TRANSPORTATION (AVIATION PROCEEDINGS) ECONOMIC REGULATIONS AIRLINE SERVICE QUALITY PERFORMANCE...

  5. Groups with Historically High Incidences of Unemployment. A Report to the Congress.

    ERIC Educational Resources Information Center

    Helmeke, Kerry; And Others

    This report dealing with groups with historically high incidences of unemployment is made in response to Section 4 (d) (3) of the Fair Labor Standards Act. (These groups include teenagers; 20-24 year-olds; veterans [20-24 year-olds]; females; blacks and other minorities; persons of Hispanic origin; and the elderly [65 years and older]). The report…

  6. 76 FR 34812 - Proposed Information Collection (Report of Medical, Legal, and Other Expenses Incident to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-14

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

  7. 30 CFR 285.830 - What are my incident reporting requirements?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What are my incident reporting requirements? 285.830 Section 285.830 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF THE INTERIOR... Environmental and Safety Management, Inspections, and Facility Assessments for Activities Conducted Under SAPs...

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

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 30 Mineral Resources 2 2010-07-01 2010-07-01 false How do I report incidents requiring immediate notification? 285.832 Section 285.832 Mineral Resources MINERALS MANAGEMENT SERVICE, DEPARTMENT OF THE INTERIOR... Environmental and Safety Management, Inspections, and Facility Assessments for Activities Conducted Under SAPs...

  9. 75 FR 35329 - Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft, and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-22

    ... SAFETY BOARD 49 CFR Part 830 Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft, and Preservation of Aircraft Wreckage, Mail, Cargo, and Records AGENCY: National Transportation... aircraft operating at public- use airports on land. These amendments function to considerably narrow the...

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

    PubMed

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

    2016-04-01

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

  11. Lessons learnt from incidents involving the airway and breathing reported from Australasian emergency departments.

    PubMed

    Crock, Carmel; Hansen, Kim; Fogg, Toby; Cahill, Angela; Deakin, Anita; Runciman, William B

    2017-08-16

    To review incident reports relating to problems encountered during the ED management of patients with 'airway or breathing' problems, with the aim of finding and highlighting common themes within these rare events, and making recommendations to further improve patient safety in the areas in which deficiencies have been identified. Thematic analysis of 36 incidents reported from Australasian EDs, which were related to problems with airway and breathing. In all, 51 problems were identified among the 36 incidents related to airway and/or breathing. Fourteen involved clinical decision-making, 11 equipment, nine communication, seven intubation, five surgical access and five pneumothorax. Eight incidents involved children and there were nine deaths within hours or days. Recommendations for improving preparedness of ED staff and facilities have been made for each of the problem areas identified with respect to clinical practice, equipment, communication and clinical process. Analysis of incidents from the Australasian Emergency Medicine Events Register allows clusters of like-events to be identified and characterised, providing the possibility of getting a better idea of how problems present and progress, with some information about contributing factors, characteristics and context. This will pave the way for earlier and better detection of life-threatening problems and the development and reinforcement of preventive and corrective strategies. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

  12. Benzene Monitor System report

    SciTech Connect

    Livingston, R.R.

    1992-10-12

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

  13. Integrated system design report

    SciTech Connect

    Not Available

    1989-07-01

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

  14. Integrated system design report

    SciTech Connect

    Not Available

    1989-07-01

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

  15. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency.

    PubMed

    Thomas, A N; Panchagnula, U

    2008-07-01

    We reviewed all patient safety incidents reported to the UK National Patient Safety Agency between 1st August 2006 and 28th February 2007 from intensive care or high dependency units. Incidents involving medications were then categorised. 12 084 incidents were submitted from 151 organisations (median 40, range 1-634/organisation). 2428 incidents were associated with medication use involving 355 different drugs, most commonly morphine (207 incidents), gentamicin (190 incidents) and noradrenaline (133 incidents). Noradrenaline (55 incidents of harm) and insulin (48 incidents of harm) were most commonly associated with patient harm. Sixty-one percent of medication incidents were associated with drug administration and 26% with prescription. Two hundred and eighty-seven medication incidents caused temporary harm and 43 more than temporary harm. Five per cent of medication incidents were associated with staff communication during transfer from theatre or recovery. Categorisation of medication-associated incidents has allowed us to suggest changes to improve the reporting of incidents and to improve medication safety.

  16. Environmental Protection for Hazardous Materials Incidents. Volume 1. Hazardous Materials Incident Management System

    DTIC Science & Technology

    1990-11-01

    227 9. Cloves ............................................ 2’h 10. Footwear .......................................... 231...Occupational Safety and Health Xvi NOAA National Oceanic and Atmospheric Administration NSN National Stock Number OHM-TADS Oil and Hazardous Materials...8217rechnical Assistance Data Systems OHSPC Oil and Hazardous Substance Pollution Contingency "ORM Other Regulated Material ORNL Oak Ridge National Laboratory

  17. Critical steps in learning from incidents: using learning potential in the process from reporting an incident to accident prevention.

    PubMed

    Drupsteen, Linda; Groeneweg, Jop; Zwetsloot, Gerard I J M

    2013-01-01

    Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.

  18. Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

    PubMed Central

    Goode, Natassia; Read, Gemma J. M.; van Mulken, Michelle R. H.; Clacy, Amanda; Salmon, Paul M.

    2016-01-01

    Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system. PMID:28066296

  19. Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies.

    PubMed

    Goode, Natassia; Read, Gemma J M; van Mulken, Michelle R H; Clacy, Amanda; Salmon, Paul M

    2016-01-01

    Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the "broken components." However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

  20. Emergency radiology and mass casualty incidents-report of a mass casualty incident at a level 1 trauma center.

    PubMed

    Bolster, Ferdia; Linnau, Ken; Mitchell, Steve; Roberge, Eric; Nguyen, Quynh; Robinson, Jeffrey; Lehnert, Bruce; Gross, Joel

    2017-02-01

    The aims of this article are to describe the events of a recent mass casualty incident (MCI) at our level 1 trauma center and to describe the radiology response to the event. We also describe the findings and recommendations of our radiology department after-action review. An MCI activation was triggered after an amphibious military vehicle, repurposed for tourist activities, carrying 37 passengers, collided with a charter bus carrying 45 passengers on a busy highway bridge in Seattle, WA, USA. There were 4 deaths at the scene, and 51 patients were transferred to local hospitals following prehospital scene triage. Nineteen patients were transferred to our level 1 trauma center. Eighteen casualties arrived within 72 min. Sixteen arrived within 1 h of the first patient arrival, and 1 casualty was transferred 3 h later having initially been assessed at another hospital. Eighteen casualties (94.7 %) underwent diagnostic imaging in the emergency department. Of these 18 casualties, 15 had a trauma series (portable chest x-ray and x-ray of pelvis). Whole-body trauma computed tomography scans (WBCT) were performed on 15 casualties (78.9 %), 12 were immediate and performed during the initial active phase of the MCI, and 3 WBCTs were delayed. The initial 12 WBCTs were completed in 101 min. The mean number of radiographic studies performed per patient was 3 (range 1-8), and the total number of injuries detected was 88. The surge in imaging requirements during an MCI can be significant and exceed normal operating capacity. This report of our radiology experience during a recent MCI and subsequent after-action review serves to provide an example of how radiology capacity and workflow functioned during an MCI, in order to provide emergency radiologists and response planners with practical recommendations for implementation in the event of a future MCI.

  1. Complaints and incident reports related to anaesthesia service are foremost attributed to nontechnical skills.

    PubMed

    Koetsier, Eva; Boer, Christa; Loer, Stephan A

    2011-01-01

    While anaesthesiology is still perceived as a rather technical specialty, nontechnical skills of anaesthesiologists become increasingly important. In this context, we hypothesised that complaints and incident reports about anaesthesia service are often related to nontechnical skills. To test this hypothesis, we attributed complaints and incident reports to the seven roles of CanMEDS (Canadian Medical Educational Directives for Specialists), which are the role of 'medical expert', 'communicator', 'collaborator', 'health advocate', 'manager', 'scholar' and the role of 'professional'. All complaints and incidents reported to the Anaesthesiology Department of the VU University Medical Centre Amsterdam (2001-2007) were analysed and attributed to the seven CanMEDS roles. In total, 169 reports could be identified, of which the majority were related to changes in operating room schedules (24%), teeth damage during laryngoscopy (9%), insufficient information about anaesthetic procedures (9%) or insufficient communication with other professionals (9%). Most reports were attributed to the roles of medical expert (39%) or manager (38%), followed by reports about the roles as professional (9%) and communicator (8%). Our data suggest an increased importance of nontechnical skills in addition to medical expertise in anaesthesia service. We propose to take this aspect into consideration in postgraduate training programmes of anaesthesiologists to improve satisfaction of patients as well as colleagues.

  2. The Incidence of Primary Systemic Vasculitis in Jerusalem: A 20-year Hospital-based Retrospective Study.

    PubMed

    Nesher, Gideon; Ben-Chetrit, Eli; Mazal, Bracha; Breuer, Gabriel S

    2016-06-01

    The incidence of primary systemic vasculitides varies among different geographic regions and ethnic origins. The aim of this study was to examine the incidence rates of vasculitides in the Jerusalem Jewish population, and to examine possible trends in incidence rates over a 20-year period. The clinical databases of inpatients at the 2 medical centers in Jerusalem were searched for patients with vasculitis diagnosed between 1990-2009. Individual records were then reviewed by one of the authors. The significance of trends in incidence rates throughout the study period was evaluated by Pearson correlation coefficient. The average annual incidence rate of polyarteritis nodosa was 3.6/million adults (95% CI 1.6-4.7). Incidence rates did not change significantly during this period (r = 0.39, p = 0.088). The incidence of granulomatosis with polyangiitis (GPA) was 4.1 (2.2-5.9) for the whole period, during which it increased significantly (r = 0.53, p < 0.05). The incidence of microscopic polyangiitis (MPA) was lower: 2.3 (1.2-3.5)/million. It also increased significantly (r = 0.55, p < 0.05). The incidence of eosinophilic granulomatosis with polyangiitis was 1.2 (0.4-1.9), which remained stable throughout the study period. The incidence of Takayasu arteritis was 2.1/million (95% CI 1.2-2.9), and it also remained stable. Giant cell arteritis (GCA) incidence was 8.1 (5.7-10.6)/100,000 population aged 50 years or older. In sharp contrast with other vasculitides, its incidence decreased significantly throughout the study period (r = -0.61, p < 0.01). The incidence rates of vasculitides in the Jewish population of Jerusalem are in the lower range of global incidence rates. While GPA and MPA incidence are increasing, GCA incidence is decreasing.

  3. The impact of under-reporting of cases on the estimates of childhood cancer incidence and survival in Estonia.

    PubMed

    Paapsi, Keiu; Mägi, Margit; Mikkel, Sirje; Saks, Kadri; Aareleid, Tiiu; Innos, Kaire

    2017-06-09

    About 35 new childhood cancer cases are diagnosed in Estonia (population 1.3 million in 2011) every year. Despite continuous improvements in the healthcare system and available cancer treatment options, the survival rates for childhood cancers have appeared to remain lower than the European average. These observations and the accompanying decrease in incidence led us to hypothesize that some nonfatal cases might be missing from the Estonian Cancer Registry (ECR). The aim of this study was to evaluate the completeness of reporting of childhood cancer cases to the ECR and its impact on the estimates of cancer incidence and survival. All cases of benign and malignant tumours, diagnosed in 2000-2011 among children aged 0-17 years and eligible for registration in the ECR, were included in the study. Completeness of reporting was evaluated for cases aged 0-17 years, and incidence and survival were analysed for cases aged 0-14 for international comparisons. The total number of new cancer cases increased from 459 to 515. Overall completeness of case ascertainment was estimated to be 89.5%. After adding the missing cases, the overall incidence rate increased from 12.9 to 14.9/100 000 (from 3.4 to 4.7 for leukaemias). The 2010-2014 period estimate of the 5-year survival increased from 70 to 76% for all sites combined and from 71 to 82% for leukaemias. In conclusion, the under-reporting of nonfatal childhood cancer cases to the ECR had an important impact on incidence and survival rates, causing a considerable underestimation of both.

  4. Incidence of physician-diagnosed asthma in adults--a real incidence or a result of increased awareness? Report from The Obstructive Lung Disease in Northern Sweden Studies.

    PubMed

    Lundbäck, B; Rönmark, E; Jönsson, E; Larsson, K; Sandström, T

    2001-08-01

    Only limited data are available about the incidence of asthma based on longitudinal prospective studies. Further, the results from different studies on incidence vary considerably depending on the age composition of the cohorts under study, the used methods and the criteria for disease. Also among adults high incidence rates have been reported during recent years. The aim of this study was to examine to what extent the incidence of physician-diagnosed asthma could be explained by a real incidence of the disease, and to what extend by an increased diagnostic activity or altered diagnostic praxis. Another aim was to study risk factors for asthma based on incident cases. Three cross-sectional surveys have been performed in the same population sample living in the northern-most province of Sweden, Norrbotten. The first survey was performed in 1986, and 5698 subjects, 86% of those invited, responded to a postal questionnaire. Of these, 4754 subjects (83%) participated at the third survey in 1996. After exclusion of all subjects who had reported that they had asthma in 1986, or had been classified as having asthma in 1986, 68 men and 98 women (P=0.02) reported in 1996 that they had been diagnosed as having asthma by a physician. Thus, the cumulative incidence for the 10-year period was 3.2% among men and 4.5% among women. After correction for subjects who already in 1986 had reported symptoms common in asthma, or had been classified as having chronic bronchitis, 97 subjects with incident asthma remained, which corresponded to an annual incidence rate among men of 1.7 and among women of 2.9/1000 persons year(-1) (P=0.1). Clinical examinations confirmed asthma in a large majority of these 97 subjects. Significant risk factors were family history of asthma, both ex- and current smoking, and female sex. The socio-economic groups manual workers and assistant non-manual employees were associated with incident asthma, although not significantly. The increasing prevalence of

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

    ERIC Educational Resources Information Center

    Maryland State Department of Education, 2008

    2008-01-01

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

  6. An expert system for automating security incident assessment using OPS5 in an Ada environment

    SciTech Connect

    Canales, T.W.; Smart, J.C.

    1988-01-29

    An expert system that automatically assesses security incidents is being developed at Lawrence Livermore National Laboratory. The expert system associates, classifies, and prioritizes monitored sensor events. The outcome of these processes is a dynamic representation of the state of Laboratory security in the form of security ''incidents''. A graphical representation of the incidents is integrated into a map-oriented console monitor that provides the operator with a comprehensive view of incidents and their locations. A prototype expert system has been developed using the OPS5 rule-based language. A large Ada-based program provides control of the map display system and interfaces to the various monitoring and access-control devices. In addition to the expert system operation, the issues and methods involved in integrating the OPS5-based incident-assessment system to the large Ada-based control program are discussed. 7 refs., 7 figs.

  7. Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review.

    PubMed

    Polisena, Julie; Gagliardi, Anna; Urbach, David; Clifford, Tammy; Fiander, Michelle

    2015-03-29

    Medical devices have improved the treatment of many medical conditions. Despite their benefit, the use of devices can lead to unintended incidents, potentially resulting in unnecessary harm, injury or complications to the patient, a complaint, loss or damage. Devices are used in hospitals on a routine basis. Research to date, however, has been primarily limited to describing incidents rates, so the optimal design of a hospital-based surveillance system remains unclear. Our research objectives were twofold: i) to explore factors that influence device-related incident recognition, reporting and resolution and ii) to investigate interventions or strategies to improve the recognition, reporting and resolution of medical device-related incidents. We searched the bibliographic databases: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and PsycINFO database. Grey literature (literature that is not commercially available) was searched for studies on factors that influence incident recognition, reporting and resolution published and interventions or strategies for their improvement from 2003 to 2014. Although we focused on medical devices, other health technologies were eligible for inclusion. Thirty studies were included in our systematic review, but most studies were concentrated on other health technologies. The study findings indicate that fear of punishment, uncertainty of what should be reported and how incident reports will be used and time constraints to incident reporting are common barriers to incident recognition and reporting. Relevant studies on the resolution of medical errors were not found. Strategies to improve error reporting include the use of an electronic error reporting system, increased training and feedback to frontline clinicians about the reported error. The available evidence on factors influencing medical device-related incident recognition, reporting and resolution by healthcare professionals can inform data collection and

  8. An updated report on the trends in cancer incidence and mortality in Japan, 1958-2013.

    PubMed

    Katanoda, Kota; Hori, Megumi; Matsuda, Tomohiro; Shibata, Akiko; Nishino, Yoshikazu; Hattori, Masakazu; Soda, Midori; Ioka, Akiko; Sobue, Tomotaka; Nishimoto, Hiroshi

    2015-04-01

    The analysis of cancer trends in Japan requires periodic updating. Herein, we present a comprehensive report on the trends in cancer incidence and mortality in Japan using recent population-based data. National cancer mortality data between 1958 and 2013 were obtained from published vital statistics. Cancer incidence data between 1985 and 2010 were obtained from high-quality population-based cancer registries of three prefectures (Yamagata, Fukui and Nagasaki). Joinpoint regression analysis was performed to examine the trends in age-standardized rates of cancer incidence and mortality. All-cancer mortality decreased from the mid-1990s, with an annual percent change of -1.3% (95% confidence interval [CI]: -1.4, -1.3). During the most recent 10 years, over 60% of the decrease in cancer mortality was accounted for by a decrease in stomach and liver cancers (63% for males and 66% for females). The long-term increase in female breast cancer mortality, beginning in the 1960s, plateaued in 2008. All-cancer incidence continuously increased, with annual percent changes of 0.6% (95% CI: 0.5, 0.8) between 1985 and 2005, and 1.8% (95% CI: 0.6, 2.9) between 2005 and 2010. During the most recent 10 years, almost half of the increase in cancer incidence was accounted for by an increase in prostate cancer (60%) in males and breast cancer (46%) in females. The cancer registry quality indices also began to increase from ∼2005. Decreases in stomach and liver cancers observed for incidence and mortality reflect the reduced attribution of infection-related factors (i.e. Helicobacter pylori and hepatitis virus). However, it should be noted that cervical cancer incidence and mortality rates began to increase from ∼1990. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  9. Impact of nutritional factors on incident kidney stone formation: a report from the WHI OS.

    PubMed

    Sorensen, Mathew D; Kahn, Arnold J; Reiner, Alex P; Tseng, Timothy Y; Shikany, James M; Wallace, Robert B; Chi, Thomas; Wactawski-Wende, Jean; Jackson, Rebecca D; O'Sullivan, Mary Jo; Sadetsky, Natalia; Stoller, Marshall L

    2012-05-01

    Increased fluid intake, and decreased dietary sodium and animal protein intake are thought to reduce the risk of kidney stones but the role of calcium intake is controversial. We evaluated the relationship between dietary factors and incident kidney stone formation. Secondary analysis was done of 78,293 women from the prospective WHI OS (Women's Health Initiative Observational Study) with no history of nephrolithiasis who completed the validated food frequency questionnaire. Multivariate logistic regression was used to determine demographic and dietary factors, and supplement use independently associated with incident kidney stones. Overall 1,952 women (2.5%) reported an incident kidney stone in 573,575 person-years of followup. The risk of incident kidney stones was decreased by 5% to 28% (p = 0.01) with higher dietary calcium intake and by 13% to 31% (p = 0.002) with higher water intake after adjusting for nephrolithiasis risk factors. Conversely higher dietary sodium intake increased the risk of nephrolithiasis by 11% to 61% (p <0.001) after adjustment with the most pronounced effect in women with the highest intake. Higher body mass index independently increased the risk of incident nephrolithiasis (adjusted OR 1.19-2.01, p <0.001). Animal protein intake was not associated with nephrolithiasis on multivariate analysis. This study adds to the growing evidence underscoring the importance of maintaining adequate fluid and dietary calcium intake. Greater dietary calcium intake significantly decreased the risk of incident kidney stones. In contrast, excess sodium intake increased the risk of incident nephrolithiasis, especially in women with the highest intake. Animal protein intake was not independently associated with nephrolithiasis. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  10. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

    PubMed

    Williams, Tamara L; Tung, Derrick K; Steelman, Victoria M; Chang, Phillip K; Szekendi, Marilyn K

    2014-09-01

    Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  11. Discrepancy Reporting Management System

    NASA Technical Reports Server (NTRS)

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

    2004-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  13. Reliability studies of incident coding systems in high hazard industries: A narrative review of study methodology.

    PubMed

    Olsen, Nikki S

    2013-03-01

    This paper reviews the current literature on incident coding system reliability and discusses the methods applied in the conduct and measurement of reliability. The search strategy targeted three electronic databases using a list of search terms and the results were examined for relevance, including any additional relevant articles from the bibliographies. Twenty five papers met the relevance criteria and their methods are discussed. Disagreements in the selection of methods between reliability researchers are highlighted as are the effects of method selection on the outcome of the trials. The review provides evidence that the meaningfulness of and confidence in results is directly affected by the methodologies employed by the researcher during the preparation, conduct and analysis of the reliability study. Furthermore, the review highlights the heterogeneity of methodologies employed by researchers measuring reliability of incident coding techniques, reducing the ability to critically compare and appraise techniques being considered for the adoption of report coding and trend analysis by client organisations. It is recommended that future research focuses on the standardisation of reliability research and measurement within the incident coding domain.

  14. The incidence of medically reported work-related ill health in the UK construction industry.

    PubMed

    Stocks, S J; McNamee, R; Carder, M; Agius, R M

    2010-08-01

    Self-reported work-related ill health (SWI) data show a high incidence of occupational ill health and a high burden of cancer attributable to occupational factors in the UK construction industry. However, there is little information on the incidence of medically reported work-related ill health (WRI) within this industry. This study aims to examine the incidence of WRI within the UK construction industry. Standardised incidence rate ratios (SRRs) were used to compare incidence rates of reports of medically certified work-related ill health returned to The Health and Occupation Reporting network (THOR) within the UK construction industry with all other UK industries combined. Male UK construction industry workers aged under 65 years had significantly raised SRRs for respiratory (3.8, 95% CI 3.5 to 4.2), skin (1.6, 1.4 to 1.8) and musculoskeletal disorders (MSD; 1.9, 1.6 to 2.2). These SRRs were further raised for those working within a construction trade. The increased SRRs for skin disease within male construction industry workers were due to contact dermatitis (1.4, 1.2 to 1.6) and neoplasia (4.2, 3.3 to 5.3). For respiratory disease, the increased SRRs were due to non-malignant pleural disease (7.1, 6.3 to 8.1), mesothelioma (7.1, 6.0 to 8.3), lung cancer (5.4, 3.2 to 8.9) and pneumoconiosis (5.5, 3.7 to 8.0), but the SRRs for asthma (0.09, 0.06 to 0.11) and mental ill health (0.3, 0.1 to 0.4) were significantly reduced. The significantly raised SRRs for medically reported MSD and significantly reduced SRRs for mental ill health in construction workers confirm self-reported UK data. These SRRs provide a baseline of the incidence of WRI in the UK construction industry from which to monitor the effects of changes in policy or exposures.

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

    PubMed Central

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

    2015-01-01

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

  16. Violent behaviour in a forensic psychiatric hospital in Finland: an analysis of violence incident reports.

    PubMed

    Kuivalainen, S; Vehviläinen-Julkunen, K; Putkonen, A; Louheranta, O; Tiihonen, J

    2014-04-01

    The aim of this paper was to explore the frequency and provocation of physically violent incidents in a Finnish forensic psychiatric hospital. Three years (2007-2009) of violent incident reports were analysed retrospectively. The data were analysed by content analysis, and statistically by Poisson regression analysis. During the study period a total of 840 incidents of physical violence occurred. Six main categories were found to describe the provocation of violence where three of these categories seemed to be without a specified reason (61%), and three represented a reaction to something (36%). The risk for violent behaviour was highest for the civil patients (RR = 11.96; CI 95% 9.43-15.18; P < 0.001), compared to criminal patients (RR = 1). The civil patients represented 36.7% of the patients, and in 43.6% of the studied patient days, they caused 89.8% of the reported violence incidents. Patients undergoing a forensic mental examination did not frequently behave aggressively (RR = 1.97; CI 95% 0.91-4.28). These results can be used in the reorganization of health-care practices and the allocation of resources. © 2013 John Wiley & Sons Ltd.

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

    NASA Technical Reports Server (NTRS)

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

    2006-01-01

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

  18. Application of Human Factors Analysis and Classification System (HFACS) to UK rail safety of the line incidents.

    PubMed

    Madigan, Ruth; Golightly, David; Madders, Richard

    2016-12-01

    Minor safety incidents on the railway cause disruption, and may be indicators of more serious safety risks. The following paper aimed to gain an understanding of the relationship between active and latent factors, and particular causal paths for these types of incidents by using the Human Factors Analysis and Classification System (HFACS) to examine rail industry incident reports investigating such events. 78 reports across 5 types of incident were reviewed by two authors and cross-referenced for interrater reliability using the index of concordance. The results indicate that the reports were strongly focused on active failures, particularly those associated with work-related distraction and environmental factors. Few latent factors were presented in the reports. Different causal pathways emerged for memory failures for events such a failure to call at stations, and attentional failures which were more often associated with signals passed at danger. The study highlights a need for the rail industry to look more closely at latent factors at the supervisory and organisational levels when investigating minor safety of the line incidents. The results also strongly suggest the importance of a new factor - operational environment - that captures unexpected and non-routine operating conditions which have a risk of distracting the driver. Finally, the study provides further demonstration of the utility of HFACS to the rail industry, and of the usefulness of the index of concordance measure of interrater reliability. Copyright © 2016 Elsevier Ltd. All rights reserved.

  19. Characteristics of health IT outage and suggested risk management strategies: an analysis of historical incident reports in China.

    PubMed

    Lei, Jianbo; Guan, Pengcheng; Gao, Kaihua; Lu, Xueqin; Chen, Yunan; Li, Yuefeng; Meng, Qun; Zhang, Jiajie; Sittig, Dean F; Zheng, Kai

    2014-02-01

    The healthcare industry has become increasingly dependent on using information technology (IT) to manage its daily operations. Unexpected downtime of health IT systems could therefore wreak havoc and result in catastrophic consequences. Little is known, however, regarding the nature of failures of health IT. To analyze historical health IT outage incidents as a means to better understand health IT vulnerabilities and inform more effective prevention and emergency response strategies. We studied news articles and incident reports publicly available on the internet describing health IT outage events that occurred in China. The data were qualitatively analyzed using a deductive grounded theory approach based on a synthesized IT risk model developed in the domain of information systems. A total of 116 distinct health IT incidents were identified. A majority of them (69.8%) occurred in the morning; over 50% caused disruptions to the patient registration and payment collection functions of the affected healthcare facilities. The outpatient practices in tertiary hospitals seem to be particularly vulnerable to IT failures. Software defects and overcapacity issues, followed by malfunctioning hardware, were among the principal causes. Unexpected health IT downtime occurs more and more often with the widespread adoption of electronic systems in healthcare. Risk identification and risk assessments are essential steps to developing preventive measures. Equally important is institutionalization of contingency plans as our data show that not all failures of health IT can be predicted and thus effectively prevented. The results of this study also suggest significant future work is needed to systematize the reporting of health IT outage incidents in order to promote transparency and accountability. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

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

    PubMed

    Heggie, Travis W

    2005-08-01

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

  1. Incidence of childhood linear scleroderma and systemic sclerosis in the UK and Ireland.

    PubMed

    Herrick, Ariane L; Ennis, Holly; Bhushan, Monica; Silman, Alan J; Baildam, Eileen M

    2010-02-01

    Childhood scleroderma encompasses a rare, poorly understood spectrum of conditions. Our aim was to ascertain the incidence of childhood scleroderma in its different forms in the UK and Ireland, and to describe the age, sex, and ethnicity of the cases. The members of 5 specialist medical associations including pediatricians, dermatologists, and rheumatologists were asked to report all cases of abnormal skin thickening suspected to be localized (including linear) scleroderma or systemic sclerosis (SSc) in children <16 years of age first seen between July 2005 and July 2007. We received notification of 185 potential cases, and 94 valid cases were confirmed: 87 (93%) with localized scleroderma and 7 (7%) with SSc. This gave an incidence rate per million children per year of 3.4 (95% confidence interval [95% CI] 2.7-4.1) for localized scleroderma, including an incidence rate of 2.5 (95% CI 1.8-3.1) for linear scleroderma, and 0.27 (95% CI 0.1-0.5) for SSc. Of the 87 localized cases, 62 (71%) had linear disease. Of localized disease cases, 55 (63%) were female, 71 (82%) were classified as white British, and the patients' mean age when first seen in secondary care was 10.4 years. Of the 7 SSc cases, all were female, 6 (86%) were white British, and the mean age when first seen was 12.1 years. The median delay between onset and being first seen was 13.1 months for localized scleroderma and 7.2 months for SSc. These data provide additional estimates of the incidence of this rare disorder and its subforms.

  2. Integrated system checkout report

    SciTech Connect

    Not Available

    1991-08-14

    The planning and preparation phase of the Integrated Systems Checkout Program (ISCP) was conducted from October 1989 to July 1991. A copy of the ISCP, DOE-WIPP 90--002, is included in this report as an appendix. The final phase of the Checkout was conducted from July 10, 1991, to July 23, 1991. This phase exercised all the procedures and equipment required to receive, emplace, and retrieve contact handled transuranium (CH TRU) waste filled dry bins. In addition, abnormal events were introduced to simulate various equipment failures, loose surface radioactive contamination events, and personnel injury. This report provides a detailed summary of each days activities during this period. Qualification of personnel to safely conduct the tasks identified in the procedures and the abnormal events were verified by observers familiar with the Bin-Scale CH TRU Waste Test requirements. These observers were members of the staffs of Westinghouse WID Engineering, QA, Training, Health Physics, Safety, and SNL. Observers representing a number of DOE departments, the state of new Mexico, and the Defense Nuclear Facilities Safety Board observed those Checkout activities conducted during the period from July 17, 1991, to July 23, 1991. Observer comments described in this report are those obtained from the staff member observers. 1 figs., 1 tab.

  3. Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

    PubMed

    Thomas, A N; Taylor, R J

    2012-07-01

    We categorised and established the rates of patient safety incidents reported during 2009 and 2010 from critical care units in 12 hospital trusts in North-West England. We identified a total of 4219 incidents reported during 127, 467 calendar days of critical care with a median (IQR [range]) of 31 (26-45 [20-57]) incidents per 1000 days per trust. A median (IQR [range]) of 10 (7-13 [3.5-27]) incidents per 1000 days were associated with harm. Pressure sores were the most common cause of harm, with a median (IQR [range]) of 3.9 (1.0-6.6 [0-20.4]) incidents per 1000 days. Only 89 (2.1%) incidents described more than temporary harm, of which 12 were airway related incidents. Five incidents described the use of inappropriate arterial flush solutions. It is possible to compare rates of incident reporting in different trusts over time to determine if different methods of care are associated with different reporting rates. The wide range of reported pressure sore rates suggests that their incidence could be reduced. Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.

  4. ExpIR-RO: A Collaborative International Project for Experimenting Voluntary Incident Reporting In the Public Healthcare Sector in Romania

    PubMed Central

    Tereanu, C; Minca, DG; Costea, R; Janta, D; Grego, S; Ravera, L; Pezzano, D; Viganò, P

    2011-01-01

    Background: Patient safety within healthcare systems is a central aspect of health policy in most developed countries. From April 2007 to May 2009, the pilot project ExpIR-RO tested a voluntary incident reporting system in a public hospital in Bucharest Romania, in collaboration with two Italian hospitals (in Genoa and Milan). Methods: Data were collected anonymously through a form based on the Australian Incident Monitoring System. After appropriate training in reporting adverse events (AEs), staff in the participating Departments voluntarily completed the form. The study lasted 12 months in the Bucharest and Genoa hospitals and 3 months in the Milan hospital. Frequency distributions of replies and AE rates per 1,000 hospitalization days per month were assessed. Results: Overall, 185 AEs were reported (58 in Bucharest, 75 in Genoa and 52 in Milan). The corresponding rates (per 1,000 hospitalization days per month) were 1 in Bucharest, 3 in Genoa and 15 in Milan. Most AEs were related to diagnostic (28%) and surgical (14%) procedures and patient falls (12%) in Bucharest; patient falls (32%), nursing care (20%) and diagnostic procedures (19%) in Genoa; and nursing care (25%), drug prescription/administration (21%) and diagnostic procedures (17%) in Milan. Seventy-three per cent of respondents in Bucharest informed the patient of the AE, versus 64% in Genoa and 43% in Milan. Conversely, 75% of respondents in Genoa entered AEs in medical records versus 53% in Bucharest and 36% in Milan. Conclusion: ExpIR-RO experience suggests that incident reporting could be introduced on a larger scale in Romania. PMID:23113051

  5. Department of the Navy Suicide Incident Report (DONSIR): Summary of Findings, 1999-2007

    DTIC Science & Technology

    2009-03-24

    in body weight (p < .01), with 25 out of 330 decedents evidencing recent change. This is possibly a spurious result based on over- or under- eating ...acute than chronic, with major psychological disorders and physical 1999–2007 DON Suicide Incident Report 35 illnesses less prevalent in comparison...performance histories than other personnel, and that perfectionism may distinguish certain types of suicidal behavior such as completed versus attempted

  6. Reduced incidence of Crohn's disease in systemic sclerosis: a nationwide population study.

    PubMed

    Tseng, Chia-Chun; Yen, Jeng-Hsien; Tsai, Wen-Chan; Ou, Tsan-Teng; Wu, Cheng-Chin; Sung, Wan-Yu; Hsieh, Ming-Chia; Chang, Shun-Jen

    2015-09-14

    To date, there has been no studies to evaluate the incidence of Crohn's disease in systemic sclerosis patients. The goals of this study were to evaluate the incidence of Crohn's disease and its relationship with sex and age in patients with systemic sclerosis. We enrolled patients with systemic sclerosis and controls from Taiwan's Registry of Catastrophic Illness Database and National Health Insurance Research Database. Every systemic sclerosis patient was matched to at most three controls by sex, age, month and year of initial diagnosis of systemic sclerosis. The standardized incidence ratio (SIR) of Crohn's disease in systemic sclerosis patients, and 95% confidence interval (95% CI) were calculated. Cox hazard regression was used to calculate the hazard ratio (HR). The study enrolled 2,829 patients with systemic sclerosis and 8,257 controls. Male and female patients with systemic sclerosis both had lower rates of incident Crohn's disease (SIR: 0.18, 95% CI = 0.05-0.62; SIR: 0.10, 95% CI = 0.05-0.21, respectively). The risk of incident Crohn's disease in systemic sclerosis was still lower than in controls when we stratified the patients according to their ages. In Cox hazard regression, the hazard rates of Crohn's disease were lower in systemic sclerosis patients after adjusting for genders and ages (HR: 0.12, 95% CI = 0.06-0.21, p < 0.001). Systemic sclerosis is associated with decreased incidence of, irrespective of sex and age of the patients.

  7. Self-reported physical work exposures and incident carpal tunnel syndrome.

    PubMed

    Dale, Ann Marie; Gardner, Bethany T; Zeringue, Angelique; Strickland, Jaime; Descatha, Alexis; Franzblau, Alfred; Evanoff, Bradley A

    2014-11-01

    To prospectively evaluate associations between self-reported physical work exposures and incident carpal tunnel syndrome (CTS). Newly employed workers (n = 1,107) underwent repeated nerve conduction studies (NCS), and periodic surveys on hand symptoms and physical work exposures including average daily duration of wrist bending, forearm rotation, finger pinching, using vibrating tools, finger/thumb pressing, forceful gripping, and lifting >2 pounds. Multiple logistic regression models examined relationships between peak, most recent, and time-weighted average exposures and incident CTS, adjusting for age, gender, and body mass index. 710 subjects (64.1%) completed follow-up NCS; 31 incident cases of CTS occurred over 3-year follow-up. All models describing lifting or forceful gripping exposures predicted future CTS. Vibrating tool use was predictive in some models. Self-reported exposures showed consistent risks across different exposure models in this prospective study. Workers' self-reported job demands can provide useful information for targeting work interventions. © 2014 Wiley Periodicals, Inc.

  8. Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.

    PubMed

    Booth, C M A; Moore, C E; Eddleston, J; Sharman, M; Atkinson, D; Moore, J A

    2011-10-01

    The incidence and prevalence of obesity are increasing world wide. In the UK, obesity governmental strategy has primarily focused on prevention measures, with less focus on the demands of treating obese patients in hospital. Increasing service demand by obese patients coupled with a lack of adequate provision for care of these patients may lead to an increase in patient safety incidents. By classifying patient safety incidents associated with obesity reported to the National Patient Safety Agency, this report aims to identify areas for improvement in the quality and safety of care of the obese patient. A search of the National Reporting and Learning System database was conducted for all incidents caused by or relating to obesity for the period 1 January 2005 to 31 August 2008. The keywords 'obesity', 'overweight', 'BMI' (body mass index), and 'bariatric' were used. The relevant free text fields of the resulting set of incidents were then searched for the terms designed to isolate incidents occurring in anaesthesia, critical care, and surgery. Reported incidents were analysed and subsequently categorised to identify incident themes. Levels of harm were also established. 555 patient safety incidents were identified; 388 met inclusion criteria for analysis. 148 incidents were related to assessment, diagnosis or treatment, 213 related to infrastructure and 27 related to staffing. The majority of incidents were classified as no or low harm. Three deaths were reported, all within the domain of anaesthesia. This report identifies that the majority of safety incidents associated with obesity were related to infrastructure, suggesting that there is inadequate provision in place for the care of obese patients. While levels of harm were mostly low, the occurrence of incidents resulting in severe harm or death highlights the specific dangers associated with the care of the obese patient. A global approach to improving the safety of care delivery for obese patients is

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

    PubMed

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

    2016-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  11. Change in Reported Lyme Disease Incidence in the Northeast and Upper Midwest, 1991-2014

    EPA Pesticide Factsheets

    This indicator shows how reported Lyme disease incidence has changed by state since 1991, based on the number of new cases per 100,000 people. The total change has been estimated from the average annual rate of change in each state. This map is limited to the 14 states where Lyme disease is most common, where annual rates are consistently above 10 cases per 100,000. Connecticut, New York, and Rhode Island had too much year-to-year variation in reporting practices to allow trend calculation. For more information: www.epa.gov/climatechange/science/indicators

  12. Learning from incident reports in the Australian medical imaging setting: handover and communication errors.

    PubMed

    Hannaford, N; Mandel, C; Crock, C; Buckley, K; Magrabi, F; Ong, M; Allen, S; Schultz, T

    2013-02-01

    To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings. Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

  13. Self-Reported Minimalist Running Injury Incidence and Severity: A Pilot Study.

    PubMed

    Ostermann, Katrina; Ridpath, Lance; Hanna, Jandy B

    2016-08-01

    Minimalist running entails using shoes with a flexible thin sole and is popular in the United States. Existing literature disagrees over whether minimalist running shoes (MRS) improve perceived severity of injuries associated with running in traditional running shoes (TRS). Additionally, the perceived injury patterns associated with MRS are relatively unknown. To examine whether injury incidence and severity (ie, degree of pain) by body region change after switching to MRS, and to determine if transition times affect injury incidences or severity with MRS. Runners who were either current or previous users of MRS were recruited to complete an Internet-based survey regarding self-reported injury before switching to MRS and whether self-reported pain from that injury decreased after switching. Questions regarding whether new injuries developed in respondents after switching to MRS were also included. Analyses were calculated using t tests, Wilcoxon signed rank tests, and Fischer exact tests. Forty-seven runners completed the survey, and 16 respondents reported injuries before switching to MRS. Among these respondents, pain resulting from injuries of the feet (P=.03) and knees (P=.01) decreased. Eighteen respondents (38.3%) indicated they sustained new injuries after switching to MRS, but the severity of these did not differ significantly from no injury. Neither time allowed for transition to MRS nor use or disuse of a stretching routine during this period was correlated with an increase in the incidence or severity of injuries. After switching to MRS, respondents perceived an improvement in foot and knee injuries. Additionally, respondents using MRS reported an injury rate of 38.3%, compared with the approximately 64% that the literature reports among TRS users. Future studies should be expanded to determine the full extent of the differences in injury patterns between MRS and TRS.

  14. The Reported Incidence and Nature of Voice Disorders in the Private Healthcare Context of Gauteng.

    PubMed

    Fourie, Kayla; Richardson, Maeve; van der Linde, Jeannie; Abdoola, Shabnam; Mosca, Renata

    2017-03-23

    The study aimed to determine the incidence and nature of voice disorders, as reported by ear, nose, and throat specialists (ENTs), in the Gauteng private healthcare context. This is a cross-sectional survey design. The respondents had to be certified ENTs working in the private healthcare context in Gauteng. The survey was sent out electronically to all 94 ENTs, registered with the ENT Society, working in the private healthcare context; thus, no additional requirements had to be met. The survey inquired about the total number of referrals from January 2015 to January 2016, the total number of referrals who were diagnosed with a voice disorder, as well as information regarding the patients such as the nature of the voice disorders. Of the 94 surveys sent out, 24 of them were completed (25.5%). The incidence of voice disorders reported was 5.2%. The most commonly diagnosed voice disorder is acute laryngitis (32%). The majority of ENTs (75%) received referrals from general practitioners and referred to speech-language pathologists if the patient presented with a voice disorder. The results from this study may enable healthcare professionals to adequately plan service delivery resource allocations to provide appropriate services. Additional studies are required to examine the incidence of voice disorders in the public healthcare context as well as the prevalence of voice disorders in Gauteng. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

  15. Self harm in adult inpatient psychiatric care: a national study of incident reports in the UK.

    PubMed

    James, Karen; Stewart, Duncan; Wright, Steve; Bowers, Len

    2012-10-01

    appropriate ways of supporting service users. Future research should also investigate how staff behaviour may contribute to self harm. The development of a reporting system which requires a detailed account of incidents would aid future research in these areas. Copyright © 2012 Elsevier Ltd. All rights reserved.

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

    PubMed

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

    2012-12-01

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

  17. Estimated and reported incidence of pertussis in Estonian adults: A seroepidemiological study.

    PubMed

    Jõgi, Piia; Oona, Marje; Toompere, Karolin; Lutsar, Irja

    2015-09-11

    Rates of pertussis immunisation among children in Estonia are high (∼95%), but pertussis is still the most common vaccine preventable childhood disease. Adults are suspected to be sources of pertussis in children. We aimed to measure pertussis toxin (PT) IgG in adults to estimate pertussis infection activity and compare estimated and reported pertussis incidences. In a cross-sectional serosurvey, consecutive leftover blood sera (n=3327) from subjects aged 20-99 years old were collected at Quattromed HTI laboratories between the 7th January and 27th February 2013. Anti-PT IgG concentration was measured by ELISA (Euroimmun, Lübeck, Germany). Estimated annual pertussis incidence was calculated for 10-year age classes using de Melker et al. (2006. J Infect. 53(2):106-13) formula. The mean number of samples in each 10-year age class was 466 (SD 20.5), except for 90-99 year olds which contained 65 samples. More than half of all subjects (58.1%) had anti-PT IgG <5.0IU/mL, 2.7% had 62.5 to <125IU/mL and 0.6% ≥125IU/mL; no differences occurred between 10-year age classes. Estimated incidence of pertussis infection was 5.8% (95% CI 4.8-7.0) in 2012, with peaks observed in 20-29 year olds (11.0%; 95% CI 7.4-15.6) and 90-99 year olds (10.8%; 95% CI 3.0-26.2). Estimated pertussis incidence rate was 915 times higher than reported. Of 80 subjects with anti-PT IgG ≥62.5IU/mL, 25 (31.3%) had complained of coughing to their GP during the previous six months. The frequency of pertussis infection was similar for all ages, suggesting similar Bordetella pertussis activity in adults and children. The wide gap between reported and estimated incidence indicates poor recognition of pertussis, likely owing to it being an asymptomatic or mild disease. Copyright © 2015 Elsevier Ltd. All rights reserved.

  18. Identifying Meningitis During an Anthrax Mass Casualty Incident: Systematic Review of Systemic Anthrax Since 1880

    PubMed Central

    Katharios-Lanwermeyer, Stefan; Holty, Jon-Erik; Person, Marissa; Sejvar, James; Haberling, Dana; Tubbs, Heather; Meaney-Delman, Dana; Pillai, Satish K.; Hupert, Nathaniel; Bower, William A.; Hendricks, Katherine

    2016-01-01

    BACKGROUND Bacillus anthracis, the causative agent of anthrax, is a potential bioterrorism agent. Anthrax meningitis may be a manifestation of B. anthracis infection, has high mortality, and requires more aggressive treatment than anthrax without meningitis. Rapid identification and treatment of anthrax meningitis are essential for successful management of an anthrax mass casualty incident. METHODS Three hundred six published reports from 1880 through 2013 met pre-defined inclusion criteria. We calculated descriptive statistics for abstracted cases and conducted multivariable regression on separate derivation and validation cohorts to identify clinical diagnostic and prognostic factors for anthrax meningitis. RESULTS One hundred thirty-two of 363 (36%) cases with systemic anthrax met anthrax meningitis criteria. Severe headache, altered mental status, meningeal signs, and other neurological signs at presentation independently predicted meningitis in the derivation cohort and are proposed as a four-item screening tool for use during mass casualty incidents. Presence of any one factor on admission had a sensitivity for finding anthrax meningitis of 89% (83%) in the adult (pediatric) validation cohorts. Anthrax meningitis was unlikely in the absence of any of these signs or symptoms ([LR−]=0.12 [0.19] for adult [pediatric] cohorts), while presence of two or more factors made meningitis very likely ([LR+]=26.5 [29.2]). Survival of anthrax meningitis was predicted by treatment with a bactericidal agent (P=0.005) and use of multiple antimicrobials (P=0.012). CONCLUSIONS We developed an evidence-based triage tool for screening patients for meningitis during an anthrax mass casualty incident; its use could improve both patient outcomes and resource allocation in such an event. PMID:27025833

  19. Aviation Safety Reporting System: Process and Procedures

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.

    1997-01-01

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

  20. Injury causation in the great outdoors: A systems analysis of led outdoor activity injury incidents.

    PubMed

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

    2014-02-01

    Despite calls for a systems approach to assessing and preventing injurious incidents within the led outdoor activity domain, applications of systems analysis frameworks to the analysis of incident data have been sparse. This article presents an analysis of 1014 led outdoor activity injury and near miss incidents whereby a systems-based risk management framework was used to classify the contributing factors involved across six levels of the led outdoor activity 'system'. The analysis identified causal factors across all levels of the led outdoor activity system, demonstrating the framework's utility for accident analysis efforts in the led outdoor activity injury domain. In addition, issues associated with the current data collection framework that potentially limited the identification of contributing factors outside of the individuals, equipment, and environment involved were identified. In closing, the requirement for new and improved data systems to be underpinned by the systems philosophy and new models of led outdoor activity accident causation is discussed.

  1. WE-G-BRA-03: Developing a Culture of Patient Safety Utilizing the National Radiation Oncology Incident Learning System (ROILS)

    SciTech Connect

    Hasson, B; Workie, D; Geraghty, C

    2015-06-15

    Purpose: To transition from an in-house incident reporting system to a ROILS standards system with the intent to develop a safety focused culture in the Department and enroll in ROILS. Methods: Since the AAPM Safety Summit (2010) several safety and reporting systems have been implemented within the Department. Specific checklists and SBAR reporting systems were introduced. However, the active learning component was lost due to reporting being viewed with distrust and possible retribution.To Facilitate introducing ROILS each leader in the Department received a copy of the ROILS participation guide. Four specific tasks were assigned to each leader: develop a reporting tree, begin the ROILS based system, facilitate adopting ROILS Terminology, and educate the staff on expectations of safety culture. Next, the ROILS questions were broken down into area specific questions (10–15) per departmental area. Excel spreadsheets were developed for each area and setup for error reporting entries. The Role of the Process Improvement Committee (PI) has been modified to review and make recommendations based on the ROILS entries. Results: The ROILS based Reporting has been in place for 4 months. To date 64 reports have been entered. Since the adoption of ROILS the reporting of incidents has increased from 2/month to 18/month on average. Three reports had a dosimetric effect on the patient (<5%) dose variance. The large majority of entries have been Characterized as Processes not followed or not sure how to Characterize, and Human Behavior. Conclusion: The majority of errors are typo’s that create confusion. The introduction of the ROILS standards has provided a platform for making changes to policies that increase patient safety. The goal is to develop a culture that sees reporting at a national level as a safe and effective way to improve our safety, and to dynamically learn from other institutions reporting.

  2. An increasing incidence of chickenpox central nervous system complications in children: what's happening in Tuscany?

    PubMed

    Frenos, Stefano; Galli, Luisa; Chiappini, Elena; de Martino, Maurizio

    2007-04-01

    The most frequent noncutaneous site of involvement of chickenpox is the central nervous system (CNS) and complications include cerebellar ataxia, encephalitis, and meningitis. We have recently observed an unusually high number of children with chickenpox CNS complications in our university children's hospital. A study to evaluate the incidence of these complications over time in children living in Tuscany was carried out. We evaluated all cases of chickenpox and chickenpox complications leading to hospitalization in children aged 1 month-14 years reported to the Tuscany public health centre between 1997 and 2004. The International Classification of Disease Ninth Revision-CM hospital discharge diagnostic codes and medical records were used. The incidence (95% confidence interval) of CNS complications/1000 chickenpox cases was stable between 1997 and 2001 [1997: 0.80 (0.29-1.74); 1998: 0.73 (0.29-1.50); 1999: 0.67 (0.25-1.46); 2000: 0.56 (0.15-1.44); 2001: 0.59 (0.16-1.50)] but increased significantly (chi(2) for trend: 9.401; p=.0021) in 2002 [1.56 (0.83-2.66)], in 2003 [1.73 (0.95-2.90)] and in 2004 [1.51 (0.74-2.27)]. Non-CNS complications remained stable over time. Possible factors biasing the result were taken into account. Reasons of increased CNS complications remain unknown, but the possible emergence of a particularly neurotropic strain of varicella-zoster virus should be further investigated.

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

    SciTech Connect

    NSTec Environmental Restoration

    2007-04-01

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

  4. Model incidence measurement using the SAAB Eloptopos system

    NASA Astrophysics Data System (ADS)

    Fuijkschot, P. H.

    For measuring the angle of attack of models in the NLR transonic wind tunnel, a SAAB Eloptopos system was acquired. The system consists of two infrared light-emitting diodes mounted fore and aft in the fuselage of the model, two linear array CCD cameras, and special processors. The cameras are mounted on the sidewall of the wind tunnel and have a viewing angle of 60 deg in the vertical direction. Thanks to an individual calibration and a special optimizing algorithm the camera resolution is enhanced to 0.001 deg. At a viewing distance of 1 m the resulting resolution in angle of attack of the model is typically 0.0026 deg. The system is individually calibrated for each model under wind-off conditions, using an extremely accurate gravity-sensing inclinometer as a reference. This procedure ensures the required accuracy of 0.01 deg in angle of attack under wind-on conditions.

  5. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1976-01-01

    During the second quarter of the Aviation Safety Reporting System (ASRS) operation, 1,497 reports were received from pilots, controllers, and others in the national aviation system. Details of the administration and results of the program to date are presented. Examples of alert bulletins disseminated to the aviation community are presented together with responses to those bulletins. Several reports received by ASRS are also presented to illustrate the diversity of topics covered by reports to the system.

  6. Pesticide exposure and self-reported incident depression among wives in the Agricultural Health Study.

    PubMed

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

    2013-10-01

    Depression in women is a public health problem. Studies have reported positive associations between pesticides and depression, but few studies were prospective or presented results for women separately. We evaluated associations between pesticide exposure and incident depression among farmers' wives in the Agricultural Health Study, a prospective cohort study in Iowa and North Carolina. We used data on 16,893 wives who did not report physician-diagnosed depression at enrollment (1993-1997) and who completed a follow-up telephone interview (2005-2010). Among these wives, 1054 reported physician diagnoses of depression at follow-up. We collected information on potential confounders and on ever use of any pesticide, 11 functional and chemical classes of pesticides, and 50 specific pesticides by wives and their husbands via self-administered questionnaires at enrollment. We used inverse probability weighting to adjust for potential confounders and to account for possible selection bias induced by the death or loss of 10,639 wives during follow-up. We used log-binomial regression models to estimate risk ratios and 95% confidence intervals. After weighting for age at enrollment, state of residence, education level, diabetes diagnosis, and drop out, wives' incident depression was positively associated with diagnosed pesticide poisoning, but was not associated with ever using any pesticide. Use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives' depression. Among wives who never used pesticides, husbands' ever use of individual pesticides or functional or chemical classes of pesticides was generally not associated with wives' incident depression. Our study adds further evidence that high level pesticide exposure, such as pesticide poisoning, is associated with increased risk of depression and sets a lower bound on the level of exposure related to depression, thereby providing reassurance that the moderate levels

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

    PubMed Central

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

    2013-01-01

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

  8. A unique insight into the incidence of rugby injuries using referee replacement reports

    PubMed Central

    Sharp, J; Murray, G; Macleod, D

    2001-01-01

    Objectives—To obtain further information on the incidence of injuries and playing positions affected in club rugby in Scotland. Methods—Routine reports of injury (permanent) and blood (temporary) replacements occurring in competitive club rugby matches by referees to the Scottish Rugby Union during seasons 1990–1991 to 1996–1997 were analysed. Results—A total of 3513 injuries (87 per 100 scheduled matches) and 1000 blood replacements (34 per 100 scheduled matches) were reported. Forwards accounted for 60% of the injury and 72% of the blood replacements. Flankers and the front row were the most commonly replaced forwards while wing and centre three quarters were the most vulnerable playing positions among backs. The incidence of injury replacements increased as the match progressed up until the last 10 minutes when the trend was reversed. Blood replacements showed a different pattern with 60% occurring during the first half of the match. Conclusion—The most important finding of the study was reliability of referees in documenting the vulnerability of certain playing positions, and the timing when injuries took place, thus assisting coaches and team selectors when choosing replacement players for competitive club and representative rugby matches. This study re-emphasises the need for continuing epidemiological research. Key Words: rugby injuries; referee replacement reports; Scottish Rugby Union PMID:11157459

  9. Cancer incidence, mortality, and survival in Eastern Libya: updated report from the Benghazi Cancer Registry.

    PubMed

    El Mistiri, Mufid; Salati, Massimiliano; Marcheselli, Luigi; Attia, Adel; Habil, Salah; Alhomri, Faraj; Spika, Devon; Allemani, Claudia; Federico, Massimo

    2015-08-01

    Despite the increasing burden of cancer occurred over recent years in the African continent, epidemiologic data from Northern Africa area have been so far sparse or absent. We present most recently available data from the Benghazi Cancer Registry concerning cancer incidence and mortality as well as the most comprehensive survival data set so far generated for cases diagnosed during 2003 to 2005 in Eastern Libya. We collected and analyzed data on cancer incidence, mortality and survival that were obtained over a 3-year study period from January 1st 2003 to December 31st 2005 from the Benghazi Cancer Registry. A total of 3307 cancer patients were registered among residents during the study period. The world age-standardized incidence rate for all sites was 135.4 and 107.1 per 100,000 for males and females, respectively. The most common malignancies in men were cancers of lung (18.9%), colorectum (10.4%), bladder (10.1%), and prostate (9.4%); among women, they were breast (23.2%), colorectum (11.2%), corpus uteri (6.7%), and leukemia (5.1%). A total of 1367 deaths for cancer were recorded from 2003 to 2005; the leading causes of cancer death were cancers of the lung (29.3%), colorectum (8.2%), and brain (7.3%) in males and cancers of breast (14.8%), colorectum (10.6%), and liver (7%) in females. The 5-year relative survival for all cancer combined was 22.3%; survival was lower in men (19.8%) than in women (28.2%). This study provides an updated report on cancer incidence, mortality, and survival, in Eastern Libya which may represent a useful tool for planning future interventions toward a better cancer control. Copyright © 2015 Elsevier Inc. All rights reserved.

  10. Introduction to Pesticide Incidents

    EPA Pesticide Factsheets

    Pesticides incidents must be reported by pesticide registrants. Others, such as members of the public and environmental professionals, would like to report pesticide incidents. This website will explain and facilitate such incident reporting.

  11. 30 CFR 585.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... report them? 585.831 Section 585.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY AND ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER... person(s) from the facility to shore or to another offshore facility; (3) Fires and explosions;...

  12. 30 CFR 585.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... report them? 585.831 Section 585.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY AND ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER... person(s) from the facility to shore or to another offshore facility; (3) Fires and explosions;...

  13. 30 CFR 585.831 - What incidents must I report, and when must I report them?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... report them? 585.831 Section 585.831 Mineral Resources BUREAU OF OCEAN ENERGY MANAGEMENT, DEPARTMENT OF THE INTERIOR OFFSHORE RENEWABLE ENERGY AND ALTERNATE USES OF EXISTING FACILITIES ON THE OUTER... person(s) from the facility to shore or to another offshore facility; (3) Fires and explosions;...

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

    PubMed Central

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

    2015-01-01

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

  15. System integration report

    NASA Technical Reports Server (NTRS)

    Badler, N. I.; Korein, J. D.; Meyer, C.; Manoochehri, K.; Rovins, J.; Beale, J.; Barr, B.

    1985-01-01

    Several areas that arise from the system integration issue were examined. Intersystem analysis is discussed as it relates to software development, shared data bases and interfaces between TEMPUS and PLAID, shaded graphics rendering systems, object design (BUILD), the TEMPUS animation system, anthropometric lab integration, ongoing TEMPUS support and maintenance, and the impact of UNIX and local workstations on the OSDS environment.

  16. 30 CFR 585.832 - How do I report incidents requiring immediate notification?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... and telephone number (if a contractor is involved in the incident or injury/fatality); (d) Lease...; (f) Type of incident or injury/fatality; (g) Activity at time of incident; and (h) Description of the incident, damage, or injury/fatality. ...

  17. 30 CFR 585.832 - How do I report incidents requiring immediate notification?

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... and telephone number (if a contractor is involved in the incident or injury/fatality); (d) Lease...; (f) Type of incident or injury/fatality; (g) Activity at time of incident; and (h) Description of the incident, damage, or injury/fatality. ...

  18. 30 CFR 585.832 - How do I report incidents requiring immediate notification?

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... and telephone number (if a contractor is involved in the incident or injury/fatality); (d) Lease...; (f) Type of incident or injury/fatality; (g) Activity at time of incident; and (h) Description of the incident, damage, or injury/fatality. ...

  19. Fuels Reporting System Data

    EPA Pesticide Factsheets

    This asset includes compliance data (registrations and reports), including reports related to reformulated gasoline and conventional gasoline (anti-dumping), gasoline sulfur, mobile source air toxics (including gasoline benzene), sulfur content of on-road and non-road diesel fuel, and renewable fuels under 40 CFR Part 80; and includes registration and compositional information related to fuels and fuel additives under 40 CFR Part 79.

  20. Manual for Defense Incident-Based Reporting System,

    DTIC Science & Technology

    1996-11-29

    ASSAULT: HARM INFLICTED, OTHER 13A 129-- BURGLARY 220. 130-- ! HOUSEBREAKING 220 A-7 UCMJ CODE TABLE UCMJ CODE DESCRIPTION NIBRS 131-A- PERJURY: GIVING...C4 ASSAULT: INTENT TO RAPE 11A 134-C5 ASSAULT: INTENT TO ROB 13A 134-C6 ASSAULT: INTENT TO SODOMIZE 11B 134-C7 ASSAULT: INTENT TO HOUSEBREAK 13A 134...but not household pets such a dogs and cats 19 Merchandise items held for sale 20 Money legal tender; i.e., coins and paper currency 21 Negotiable