Efficacy of critical incident monitoring for evaluating disaster medical readiness and response during the Sydney 2000 Olympic Games.

PubMed

Flabouris, Arthas; Nocera, Antony; Garner, Alan

2004-01-01

Multiple casualty incidents (MCI) are infrequent events for medical systems. This renders audit and quality improvement of the medical responses difficult. Quality tools and use of such tools for improvement is necessary to ensure that the design of medical systems facilitates the best possible response to MCI. To describe the utility of incident reporting as a quality monitoring and improvement tool during the deployment of medical teams for mass gatherings and multiple casualty incidents. Voluntary and confidential reporting of incidents was provided by members of the disaster medical response teams during the period of disaster medical team deployment for the 2000 Sydney Olympic Games. Qualitative evaluations were conducted of reported incidents. The main outcome measures included the nature of incident and associated contributing factors, minimization factors, harm potential, and comparison with the post-deployment, cold debriefings. A total of 53 incidents were reported. Management-based decisions, poor or non-existent protocols, and equipment and communication-related issues were the principal contributing factors. Eighty nine percent of the incidents were considered preventable. A potential for harm to patients and/or team members was documented in 58% of reports, of which 76% were likely to cause at least significant harm. Of equipment incidents, personal protective equipment (33%), medical equipment (27%), provision of equipment (22%), and communication equipment (17%) predominated. Personal protective equipment (50%) was reported as the most frequent occupational health and safety incident followed by fatigue (25%). Pre-deployment planning was the most important factor for future incident impact minimization. Incident monitoring was efficacious as a quality tool in identifying incident contributing factors. Incident monitoring allowed for greater systems evaluation. Further evaluation of this quality tool within different disaster settings is required.

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.

Recording pressure ulcer risk assessment and incidence.

PubMed

Plaskitt, Anne; Heywood, Nicola; Arrowsmith, Michaela

2015-07-15

This article reports on the introduction of an innovative computer-based system developed to record and report pressure ulcer risk and incidence at an acute NHS trust. The system was introduced to ensure that all patients have an early pressure ulcer risk assessment, which prompts staff to initiate appropriate management if a pressure ulcer is detected, thereby preventing further patient harm. Initial findings suggest that this electronic process has helped to improve the timeliness and accuracy of data on pressure ulcer risk and incidence. In addition, it has resulted in a reduced number of reported hospital-acquired pressure ulcers.

A quantification of the effectiveness of EPID dosimetry and software-based plan verification systems in detecting incidents in radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bojechko, Casey; Phillps, Mark; Kalet, Alan

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 differentmore » 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.« less

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 analysis in future studies. Since evidence gaps on medical device-related incidents exist, telephone interviews with frontline clinicians will be conducted to solicit information about their experiences with medical devices and suggested strategies for device surveillance improvement in a hospital context. Further research also should investigate the impact of human, system, organizational and education factors on the development and implementation of local medical device surveillance systems.

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, and generally had little difficulty recalling critical incidents. The results suggest that pilot interviews can be a productive method of gathering information on incidents that might not otherwise be reported. Some of the issues described in the reports have received significant attention in the literature, or are analogous to human factors of manned aircraft. In other cases, incident reports involved human factors that are poorly understood, and have not yet been the subject of extensive study. Although many of the reported incidents were related to pilot error, the participants also provided examples of the positive contribution that humans make to the operation of highly-automated systems.

Concept-Based Retrieval from Critical Incident Reports.

PubMed

Denecke, Kerstin

2017-01-01

Critical incident reporting systems (CIRS) are used as a means to collect anonymously entered information of incidents that occurred for example in a hospital. Analyzing this information helps to identify among others problems in the workflow, in the infrastructure or in processes. The entire potential of these sources of experiential knowledge remains often unconsidered since retrieval of relevant reports and their analysis is difficult and time-consuming, and the reporting systems often do not provide support for these tasks. The objective of this work is to develop a method for retrieving reports from the CIRS related to a specific user query. atural language processing (NLP) and information retrieval (IR) methods are exploited for realizing the retrieval. We compare standard retrieval methods that rely upon frequency of words with an approach that includes a semantic mapping of natural language to concepts of a medical ontology. By an evaluation, we demonstrate the feasibility of semantic document enrichment to improve recall in incident reporting retrieval. It is shown that a combination of standard keyword-based retrieval with semantic search results in highly satisfactory recall values. In future work, the evaluation should be repeated on a larger data set and real-time user evaluation need to be performed to assess user satisfactory with the system and results.

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.

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

ERIC Educational Resources Information Center

Walsh, Jeffrey A.; Krienert, Jessie L.

2009-01-01

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

[Rules and regulations applying to incidents in radiotherapy].

PubMed

Lohr, F; Baus, W; Vorwerk, H; Schlömp, B; André, L; Georg, D; Hodapp, N

2012-07-01

Radiotherapy is an essential and reliable element of the treatment armamentarium in oncology. Numerous rules, regulations, and protocols minimize the associated risks. It can, however, never be excluded that errors in the treatment delivery chain result in inadequate tumor doses or unnecessary damage to organs at risk. A legal framework governs the management of such incidents. The most important European and North American regulations are reported. Various directives issued by the European Union are differently implemented nationally. This applies particularly to the characterization of incidents that must be reported to authorities. Reporting thresholds, audit systems, and the extent of the integration of voluntary reporting systems vary. Radiotherapy incidents are dealt with differently on an international level. Changes are to be expected based on the European Basic Safety Standards Directive that is currently being prepared and will have to be implemented nationally in due course.

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.

PubMed

Antonacci, Anthony C; Lam, Steven; Lavarias, Valentina; Homel, Peter; Eavey, Roland D

2008-12-01

To study the profile of incidents affecting quality outcomes after surgery by developing a usable operating room and perioperative clinical incident report database and a functional electronic classification, triage, and reporting system. Previously, incident reports after surgery were handled on an individual, episodic basis, which limited the ability to perceive actuarial patterns and meaningfully improve outcomes. Clinical incident reports were experientially generated in the second largest health care system in New York City. Data were entered into a functional classification system organized into 16 categories, and weekly triage meetings were held to electronically review and report summaries on 40 to 60 incident reports per week. System development and deployment reviewed 1041 reports after 19,693 operative procedures. During the next 4 years, 3819 additional reports were generated from 83,988 operative procedures and were reported electronically to the appropriate departments. Number of incident reports generated annually. A significant decrease in volume-adjusted clinical incident reports occurred (from 53 to 39 reports per 1000 procedures) from 2001 to 2005 (P < .001). Reductions in incident reports were observed for ambulatory conversions (74% reduction), wasted implants (65%), skin breakdown (64%), complications in the operating room (42%), laparoscopic conversions (32%), and cancellations (23%) as a result of data-focused process and clinical interventions. Six of 16 categories of incident reports accounted for more than 88% of all incident reports. These data suggest that effective review, communication, and summary feedback of clinical incident reports can produce a statistically significant decrease in adverse outcomes.

Learning from Taiwan patient-safety reporting system.

PubMed

Lin, Chung-Chih; Shih, Chung-Liang; Liao, Hsun-Hsiang; Wung, Cathy H Y

2012-12-01

The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare. The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents. There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%). The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Same-Sex and Race-Based Disparities in Statutory Rape Arrests.

PubMed

Chaffin, Mark; Chenoweth, Stephanie; Letourneau, Elizabeth J

2016-01-01

This study tests a liberation hypothesis for statutory rape incidents, specifically that there may be same-sex and race/ethnicity arrest disparities among statutory rape incidents and that these will be greater among statutory rape than among forcible sex crime incidents. 26,726 reported incidents of statutory rape as defined under state statutes and 96,474 forcible sex crime incidents were extracted from National Incident-Based Reporting System data sets. Arrest outcomes were tested using multilevel modeling. Same-sex statutory rape pairings were rare but had much higher arrest odds. A victim-offender romantic relationship amplified arrest odds for same-sex pairings, but damped arrest odds for male-on-female pairings. Same-sex disparities were larger among statutory than among forcible incidents. Female-on-male incidents had uniformly lower arrest odds. Race/ethnicity effects were smaller than gender effects and more complexly patterned. The findings support the liberation hypothesis for same-sex statutory rape arrest disparities, particularly among same-sex romantic pairings. Support for race/ethnicity-based arrest disparities was limited and mixed. © The Author(s) 2014.

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.

Safety incidents involving confused and forgetful older patients in a specialised care setting--analysis of the safety incidents reported to the HaiPro reporting system.

PubMed

Kinnunen-Luovi, Kaisa; Saarnio, Reetta; Isola, Arja

2014-09-01

To describe the safety incidents involving confused and forgetful older patients in a specialised care setting entered in the HaiPro reporting system. About 10% of patients experience a safety incident during hospitalisation, which causes or could cause them harm. The possibility of a safety incident during hospitalisation increases significantly with age. A mild or moderate memory disorder and acute confusion are often present in the safety incidents originating with an older patient. The design of the study was action research with this study using findings from one of the first-phase studies, which included qualitative and quantitative analysed data. Data were collected from the reporting system for safety incidents (HaiPro) in a university hospital in Finland. There were 672 reported safety incidents from four acute medical wards during the years 2009-2011, which were scrutinised. Seventy-five of them were linked to a confused patient and were analysed. The majority of the safety incidents analysed involved patient-related accidents. In addition to challenging behaviour, contributing factors included ward routines, shortage of nursing staff, environmental factors and staff knowledge and skills. Nurses tried to secure the patient safety in many different ways, but the modes of actions were insufficient. Nursing staff need evidence-based information on how to assess the cognitive status of a confused patient and how to encounter such patients. The number of nursing staff and ward routines should be examined critically and put in proportion to the care intensity demands caused by the patient's confused state. The findings can be used as a starting point in the prevention of safety incidents and in improving the care of older patients. © 2013 John Wiley & Sons Ltd.

A web-based incident reporting system: a two years' experience in an Italian research and teaching hospital.

PubMed

Bodina, A; Demarchi, A; Castaldi, S

2014-01-01

A web-based incident reporting system (IRS) is a tool allowing healthcare workers to voluntary and anonymously report adverse events/near misses. In 2010, this system was introduced in a research and teaching hospital in metropolitan area in the North part of Italy, in order to detect errors and to learn from failures in care delivery. The aim of this paper is to assess whether and how IRS has proved to be a valuable tool to manage clinical risk and improve healthcare quality. Adverse events are reported anonymously by staff members with the use of an online template form available in the hospital intranet. We retrospectively reviewed the recorded data for each incident/near miss reported between January 2011 and December 2012. The number of reported incidents/near misses was 521 in 2011 and 442 in 2012. In the two years the admissions were 36.974 and 36.107 respectively. We noticed that nursing staff made more use of IRS and that reported errors were basically related to prescription and administration of medications. Much international literature reports that adverse events and near misses are 10% of admissions. Our data are far from that number, thus meaning that a failure in reporting adverse events exists. This consideration, together with the high number of near misses in comparison with occurred errors, leads us to speculate that adverse events with serious consequences for patients are marginally reported. Probably the lack of a strong leadership considering IRS as an instrument for improving quality and operators' reluctance to overcome the culture of blame may negatively affect IRS.

Critical incidents during prehospital cardiopulmonary resuscitation: what are the problems nobody wants to talk about?

PubMed

Hohenstein, Christian; Rupp, Peter; Fleischmann, Thomas

2011-02-01

We wanted to identify incidents that led or could have led to patient harm during prehospital cardiopulmonary resuscitation. A nationwide anonymous and Internet-based critical incident reporting system gave the data. During a 4-year period we received 548 reports of which 74 occurred during cardiopulmonary resuscitation. Human error was responsible for 85% of the incidents, whereas equipment failure contributed to 15% of the reports. Equipment failure was considered to be preventable in 61% of all the cases, whereas incidents because of human error could have been prevented in almost all the cases. In most cases, prevention can be accomplished by simple strategies with the Poka-Yoke technique. Insufficient training of emergency medical service physicians in Germany requires special attention. The critical incident reports raise concerns regarding the level of expertize provided by emergency medical service doctors.

Community exposures to chemical incidents: development and evaluation of the first environmental public health surveillance system in europe.

PubMed

Bowen, H J; Palmer, S R; Fielder, H M; Coleman, G; Routledge, P A; Fone, D L

2000-11-01

To describe the frequency, nature and location of acute chemical incidents in Wales, and the morbidity in employees, emergency responders and the general public who were exposed. Active multi-agency community-based surveillance system. Wales, 1993-5. Frequency, nature and location of incidents, populations potentially exposed and with symptoms. Most of the 402 incidents identified were not associated with sites governed by the Control of Industrial Major Accident Hazard Regulations but with smaller industrial sites and commercial premises. About two in every thousand of the estimated 236 000 members of the public considered to be at risk from exposure reported symptoms, which were mainly nausea, headaches, and irritation of the eye, skin and respiratory tract. The most commonly reported chemicals that members of the public were exposed to were smoke toxins, miscellaneous organics, toxic gases and flammable gases. A health authority was reported to be involved in only 34 (8%) of the incidents and in only 3 of the 29 incidents where more than 100 members of the public were exposed. A geographically defined, multi-agency surveillance system can identify high risk locations and types of incidents, together with the chemicals most likely to be involved. Such ongoing surveillance information is essential for appropriate policy making, emergency planning, operational management and training.

Evaluation of the effectiveness of ATM messages used during incidents : final report.

DOT National Transportation Integrated Search

2016-01-01

This project investigated the use of Intelligent Lane Control Signs based Active Traffic Management for : Incident Management on a heavily traveled urban freeway. The subject of the research was the ILCS : system on I-94 westbound in downtown Minneap...

Poster - 27: Incident Learning Practices in Ontario

DOE Office of Scientific and Technical Information (OSTI.GOV)

Angers, Crystal; Medlam, Gaylene; Liszewski, Brian

Purpose: The Radiation Incident and Safety Committee (RISC), established and supported by Cancer Care Ontario (CCO), is responsible for advising the Provincial Head of the Radiation Treatment program on matters relating to provincial reporting of radiation incidents with the goal of improved risk mitigation. Methods: The committee is made up of Radiation Incident Leads (RILs) with representation from each of the 14 radiation medicine programs in the province. RISC routinely meets to review recent critical incidents and to discuss provincial reporting processes and future directions of the committee. Regular face to face meetings have provided an excellent venue for sharingmore » incident learning practices. A summary of the incident learning practices across Ontario has been compiled. Results: Almost all programs in Ontario employ an incident learning committee to review incidents and identify corrective actions or process improvements. Tools used for incident reporting include: paper based reporting, a number of different commercial products and software solutions developed in-house. A wide range of classification schema (data taxonomies) are employed, although most have been influenced by national guidance documents. The majority of clinics perform root cause analyses but utilized methodologies vary significantly. Conclusions: Most programs in Ontario employ a committee approach to incident learning. However, the reporting tools and taxonomies in use vary greatly which represents a significant challenge to provincial reporting. RISC is preparing to adopt the National System for Incident Reporting – Radiation Therapy (NSIR-RT) which will standardize incident reporting and facilitate data analyses aimed at identifying targeted improvement initiatives.« less

Attitudes toward the large-scale implementation of an incident reporting system.

PubMed

Braithwaite, Jeffrey; Westbrook, Mary; Travaglia, Joanne

2008-06-01

An electronic Incident Information Management System implemented system-wide by the Department of Health, New South Wales, Australia was evaluated. We hypothesized that health professionals (i) would support the system via utilization and favourable attitudes and (ii) that their usage and attitudes would vary according to profession with nurses being most, and doctors least, favourably disposed. An online, anonymous questionnaire survey of 2185 health practitioners. Undertaking system training, satisfaction with training, reporting incidents, incident reporting rates since system introduction and attitude questions focusing on use, security and evaluation of the system and workplace safety cultures. The first hypothesis received partial support. The majority of respondents had undertaken training and rated it highly. Most had reported incidents and maintained their previous reporting levels. Most attitudes regarding using the system and its security were favourable. Mixed attitudes were held about workplace safety cultures and the value of the system. Deficiencies in quality of reporting, feedback on incident reports and resources to analyse incident data were problems identified. The second hypothesis was confirmed. Nurses were most, and doctors least, likely to undertake training, report incidents and express favourable attitudes. Allied health responses were intermediate to those of the other professions. The system implementation was relatively successful, but more so with some professions. Problems identified indicated that expectations as to the goals achievable in the short term were optimistic, but these are amenable to planned interventions.

Lexington incident detection system evaluation report : final report.

DOT National Transportation Integrated Search

2005-11-01

This report describes the evaluation of an experimental incident detection system implemented within the Lexington/Fayette County area by the Lexington Fayette Urban County Government Department of Traffic Engineering. The incident detection system i...

WE-G-BRA-03: Developing a Culture of Patient Safety Utilizing the National Radiation Oncology Incident Learning System (ROILS)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hasson, B; Workie, D; Geraghty, C

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 reportingmore » 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.« less

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.

Perceptions of reporting practices and barriers to reporting incidents among registered nurses and physicians in accredited and nonaccredited Jordanian hospitals.

PubMed

AbuAlRub, Raeda F; Al-Akour, Nemeh A; Alatari, Nour H

2015-10-01

To explore the awareness of the incident reporting system, incident reporting practices and barriers to reporting incidents among Jordanian staff nurses and physicians in accredited and nonaccredited hospitals. Reporting medical incidents is an important element of patient safety enhancement and quality of care improvement and it should be an integral part of the organisational culture. A descriptive exploratory survey was used for the present study. A modified version of the Incident Reporting Questionnaire was used to collect data from 307 nurses and 144 physicians at seven hospitals (four accredited and three not accredited) in Jordan. The response rate was 28·8% for nurses and 58·8% for physicians. Nurses were more aware of the incident reporting system than physicians. Physicians were less likely to report any incident on 50% or more of occasions. The major three barriers to reporting incidents were believing that there was no point in reporting near misses, lack of feedback and fear of disciplinary actions. The study showed significant differences between nurses in accredited and nonaccredited hospitals regarding barriers to reporting incidents and reporting practices. Nurse administrators should modify existing systems for reporting incidents to overcome the barriers as shown in the present study. © 2015 John Wiley & Sons Ltd.

Documentation and tagging of casualties in multiple casualty incidents.

PubMed

Garner, Alan

2003-01-01

The use of triage tags is widely advocated as a tool to improve the management of multiple casualty incident scenes. However, there are no published reports to suggest that triage tags have improved the management of incidents involving more than 24 persons, and a number of reports have detailed problems associated with triage tag use. Alternative systems of scene management such as geographical triage have been successfully used in very large incidents, and are recommended as an alternative to triage tags. Documentation cards attached to casualties may be of use in situations where casualties will pass through an extended evacuation chain, and clear labels for deceased casualties are of benefit as they discourage repeat assessments. Adoption of an evidence-based approach to multiple casualty incident scene management will require a paradigm shift in the thinking of ambulance services. A broad-based educational approach that encourages critical reappraisal of existing procedures is recommended.

Implementation of a critical incident reporting system in a neurosurgical department.

PubMed

Kantelhardt, P; Müller, M; Giese, A; Rohde, V; Kantelhardt, S R

2011-02-01

Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies. All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety. Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64%). Human error was involved in 86% of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42% (March 09) to 30% (September 09). Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments. © Georg Thieme Verlag KG Stuttgart · New York.

Learning and feedback from the Danish patient safety incident reporting system can be improved.

PubMed

Moeller, Anders Damgaard; Rasmussen, Kurt; Nielsen, Kent Jacob

2016-06-01

The perceived usefulness of incident reporting systems is an important motivational factor for reporting. The usefulness may be facilitated by well-established feedback mechanisms and by learning processes. The aim of this study was to investigate how feedback mechanisms and learning processes were implemented at four Danish hospital units all located in one of the five Danish regions. Based on the concepts of feedback and learning from incident processes, a questionnaire was developed and distributed to 335 patient safety representatives from 200 departments at four Danish hospital units in one of the five Danish regions. The study showed that external reporters were rarely contacted for dialogue, grouped front-line staff were sparsely involved in the learning process, few evaluated the effectiveness of implemented interventions and personal factors were frequently perceived as a primary contributory factor to these incidents. In contrast, the patient safety representatives perceived their competencies as sufficient for the job, internal reporters were often contacted for dialogue, evaluation was widely used and management supported the work with incident reports. The results of the study identified several shortcomings in the implementation of learning processes and feedback mechanisms. The apparent existence of a person-focused approach stands out as an element of notice. The insufficient implementation we observed indicates that there is room for improvement in the efforts made to maximise learning from incidents in the investigated population. not relevant. not relevant.

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.

International Cyber Incident Repository System: Information Sharing on a Global Scale

DOE Office of Scientific and Technical Information (OSTI.GOV)

Joyce, Amanda L.; Evans, PhD, Nathaniel; Tanzman, Edward A.

According to the 2016 Internet Security Threat Report, the largest number of cyber attacks were recorded last year (2015), reaching a total of 430 million incidents throughout the world. As the number of cyber incidents increases, the need for information and intelligence sharing increases, as well. This fairly large increase in cyber incidents is driving the need for an international cyber incident data reporting system. The goal of the cyber incident reporting system is to make available shared and collected information about cyber events among participating international parties. In its 2014 report, Insurance Industry Working Session Readout Report-Insurance for CyberRelatedmore » Critical Infrastructure Loss: Key Issues, on the outcomes of a working session on cyber insurance, the U.S. Department of Homeland Security observed that “many participants cited the need for a secure method through which organizations could pool and share cyber incident information” and noted that one underwriter emphasized the importance of internationally harmonized data taxonomies. This cyber incident data reporting system could benefit all nations that take part in reporting incidents to provide a more common operating picture. In addition, this reporting system could allow for trending and anticipated attacks and could potentially benefit participating members by enabling them to get in front of potential attacks. The purpose of this paper is to identify options for consideration for such a system in fostering cooperative cyber defense.« less

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

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 abstracts. Nine studies were included in this review. Cultural and demographic factors were the most significant factors in affecting nurses' attitudes towards incident reporting. Major perceived barriers included fear, administrative issues, and the reporting process. Also, nurses were more likely to report incidents that caused direct harm, and if reporting was kept anonymous. This review demonstrated that attitudes of nurses towards incident reporting vary across different study settings, with perceived barriers hindering the reporting process. Using the findings, interventions can be customised to increase reporting rates can be developed to curb the problem of underreporting.A non-punitive culture towards incident reporting has to be cultivated, and nursing authorities should provide frequent positive feedback to staff who reported incidents. Investigating system errors should be the focus rather than individual blame.Further research should target the development and evaluation of strategies to increase rates of incident reporting. Any differences between actual and perceived reporting rates should also be explored.

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.

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.

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

PubMed Central

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

2017-01-01

PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. PMID:28893816

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

PubMed

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

2013-04-01

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

Sci-Fri AM: Quality, Safety, and Professional Issues 06: An Evaluation of Incident Reporting and Learning using the Canadian National System for Incident Reporting – Radiation Treatment

DOE Office of Scientific and Technical Information (OSTI.GOV)

Montgomery, Logan; Kildea, John

We report on the development and clinical deployment of an in-house incident reporting and learning system that implements the taxonomy of the Canadian National System for Incident Reporting – Radiation Treatment (NSIR-RT). In producing our new system, we aimed to: Analyze actual incidents, as well as potentially dangerous latent conditions. Produce recommendations on the NSIR-RT taxonomy. Incorporate features to divide reporting responsibility among clinical staff and expedite incident categorization within the NSIR-RT framework. Share anonymized incident data with the national database. Our multistep incident reporting workflow is focused around an initial report and a detailed follow-up investigation. An investigator, chosenmore » at the time of reporting, is tasked with performing the investigation. The investigation feature is connected to our electronic medical records database to allow automatic field population and quick reference of patient and treatment information. Additional features include a robust visualization suite, as well as the ability to flag incidents for discussion at monthly Risk Management meetings and task ameliorating actions to staff. Our system was deployed into clinical use in January 2016. Over the first three months of use, 45 valid incidents were reported; 31 of which were reported as actual incidents as opposed to near-misses or reportable circumstances. However, we suspect there is ambiguity within our centre in determining the appropriate event type, which may be arising from the taxonomy itself. Preliminary trending analysis aided in revealing workflow issues pertaining to storage of treatment accessories and treatment planning delays. Extensive analysis will be undertaken as more data are accrued.« less

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

PubMed

Itri, Jason N; Krishnaraj, Arun

2012-05-01

The essential role of an incident reporting system as a tool to improve safety and reliability has been described in high-risk industries such as aviation and nuclear power, with anesthesia being the first medical specialty to successfully integrate incident reporting into a comprehensive quality improvement strategy. Establishing an incident reporting system for medical imaging that effectively captures system errors and drives improvement in the delivery of imaging services is a key component of developing and evaluating national quality improvement initiatives in radiology. Such a national incident reporting system would be most effective if implemented as one piece of a comprehensive quality improvement strategy designed to enhance knowledge about safety, identify and learn from errors, raise standards and expectations for improvement, and create safer systems through implementation of safe practices. The potential benefits of a national incident reporting system for medical imaging include reduced morbidity and mortality, improved patient and referring physician satisfaction, reduced health care expenses and medical liability costs, and improved radiologist satisfaction. The purposes of this article are to highlight the positive impact of external reporting systems, discuss how similar advancements in quality and safety can be achieved with an incident reporting system for medical imaging in the United States, and describe current efforts within the imaging community toward achieving this goal. Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study.

PubMed

Zwart, Dorien L M; Heddema, Wendelien S; Vermeulen, Margit I; van Rensen, Elizabeth L J; Verheij, Theo J M; Kalkman, Cor J

2011-10-01

There is an inherent tension between allowing trainees in general practice (GP) to feel comfortable to report and learn from errors in a blame-free environment while still assuring high-quality and safe patient care. Unfortunately, little is known about the types and potential severity of incidents that may confront GP trainees. Furthermore, incident reporting by resident trainees is hindered by their concern that such transparency might result in more negative performance evaluations. To explore the number and nature of incidents that were reported by GP trainees and to determine whether there were differences between the reporters and non-reporters based on their performance evaluations. Prospective cohort study. Confidential and voluntary incident reporting was implemented in GP vocational training of the University Medical Center Utrecht, the Netherlands. Seventy-nine GP trainees were asked to report incidents over 6 months. Mixed methods were used to analyse the data. 24 trainees reported a total of 44 incidents. 23 incidents concerned the work process and 17 concerned problems with diagnosis or therapy. Three-quarters (34/44) of incidents were determined to be not specifically related to the inexperience of the GP trainees. While actual patient harm was determined to be minimal or absent in two-thirds of incidents (29/44), the potential for moderate, major, or catastrophic harm was 89% (39/44). Trainees performing best on their performance assessment in the domain of clinical expertise reported incidents more often (43% vs 18%, p<0.03) than those who performed at a lower level. GP trainees rated highly by their faculty voluntarily reported incidents in the delivery of clinical care when given a safe, blame-free, and confidential reporting process. Most incidents were not found to be directly related to the inexperience of the trainee, but were caused by failing organisational processes in the healthcare delivery system. Moreover, the trainees who tended to report these incidents were those whose performance was highly evaluated in the domain of clinical expertise.

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.

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.

Using multiclass classification to automate the identification of patient safety incident reports by type and severity.

PubMed

Wang, Ying; Coiera, Enrico; Runciman, William; Magrabi, Farah

2017-06-12

Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals. Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with "balanced" datasets (n_ Type  = 2860, n_ SeverityLevel  = 1160) from a state-wide incident reporting system. Testing was also undertaken with imbalanced "stratified" datasets (n_ Type  = 6000, n_ SeverityLevel =5950) from the state-wide system and an independent hospital reporting system. Classifier performance was evaluated using a confusion matrix, as well as F-score, precision and recall. The most effective combination was a OvsO ensemble of binary SVM RBF classifiers with binary count feature extraction. For incident type, classifiers performed well on balanced and stratified datasets (F-score: 78.3, 73.9%), but were worse on independent datasets (68.5%). Reports about falls, medications, pressure injury, aggression and blood products were identified with high recall and precision. "Documentation" was the hardest type to identify. For severity level, F-score for severity assessment code (SAC) 1 (extreme risk) was 87.3 and 64% for SAC4 (low risk) on balanced data. With stratified data, high recall was achieved for SAC1 (82.8-84%) but precision was poor (6.8-11.2%). High risk incidents (SAC2) were confused with medium risk incidents (SAC3). Binary classifier ensembles appear to be a feasible method for identifying incidents by type and severity level. Automated identification should enable safety problems to be detected and addressed in a more timely manner. Multi-label classifiers may be necessary for reports that relate to more than one incident type.

Design of an infrared camera based aircraft detection system for laser guide star installations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Friedman, H.; Macintosh, B.

1996-03-05

There have been incidents in which the irradiance resulting from laser guide stars have temporarily blinded pilots or passengers of aircraft. An aircraft detection system based on passive near infrared cameras (instead of active radar) is described in this report.

Development and implementation of a radiation therapy incident learning system compatible with local workflow and a national taxonomy.

PubMed

Montgomery, Logan; Fava, Palma; Freeman, Carolyn R; Hijal, Tarek; Maietta, Ciro; Parker, William; Kildea, John

2018-01-01

Collaborative incident learning initiatives in radiation therapy promise to improve and standardize the quality of care provided by participating institutions. However, the software interfaces provided with such initiatives must accommodate all participants and thus are not optimized for the workflows of individual radiation therapy centers. This article describes the development and implementation of a radiation therapy incident learning system that is optimized for a clinical workflow and uses the taxonomy of the Canadian National System for Incident Reporting - Radiation Treatment (NSIR-RT). The described incident learning system is a novel version of an open-source software called the Safety and Incident Learning System (SaILS). A needs assessment was conducted prior to development to ensure SaILS (a) was intuitive and efficient (b) met changing staff needs and (c) accommodated revisions to NSIR-RT. The core functionality of SaILS includes incident reporting, investigations, tracking, and data visualization. Postlaunch modifications of SaILS were informed by discussion and a survey of radiation therapy staff. There were 240 incidents detected and reported using SaILS in 2016 and the number of incidents per month tended to increase throughout the year. An increase in incident reporting occurred after switching to fully online incident reporting from an initial hybrid paper-electronic system. Incident templating functionality and a connection with our center's oncology information system were incorporated into the investigation interface to minimize repetitive data entry. A taskable actions feature was also incorporated to document outcomes of incident reports and has since been utilized for 36% of reported incidents. Use of SaILS and the NSIR-RT taxonomy has improved the structure of, and staff engagement with, incident learning in our center. Software and workflow modifications informed by staff feedback improved the utility of SaILS and yielded an efficient and transparent solution to categorize incidents with the NSIR-RT taxonomy. © 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

The impact of occupational health service network and reporting system in Taiwan.

PubMed

Chu, Po-Ching; Fuh, Hwan-Ran; Luo, Jiin-Chyuan; Du, Chung-Li; Chuang, Hung-Yi; Guo, How-Ran; Liu, Chiu-Shong; Su, Chien-Tien; Tang, Feng-Cheng; Chen, Chun-Chieh; Yang, Hsiao-Yu; Guo, Yue Leon

2013-01-01

Underreporting occupational disease cases has been a long-standing problem in Taiwan, which hinders the progress in occupational health and safety. To address this problem, the government has founded the Network of Occupational Diseases and Injuries Service (NODIS) for occupational disease and injury services and established a new Internet-based reporting system. The aims of this study are to analyze the possible influence of the NODIS, comprised of Center for Occupational Disease and Injury Services and their local network hospitals, on compensable occupational diseases and describe the distribution of occupational diseases across occupations and industries from 2005 to 2010 in Taiwan. We conducted a secondary analysis of two datasets, including the NODIS reporting dataset and the National Labor Insurance scheme's dataset of compensated cases. For the NODIS dataset, demographics, disease distribution, and the time trends of occupational diseases were analyzed. The data of the Labor Insurance dataset was used to calculate the annual incidence of compensated cases. Furthermore, the annual incidence of reported occupational diseases from the NODIS was further compared with the annual incidence of compensable occupational diseases from the compensated dataset during the same period. After the establishment of the NODIS, the two annual incidence rates of reported and compensable occupational disease cases have increased by 1.2 and 2.0 folds from 2007 to 2010, respectively. The reason for this increased reporting may be the implementation of the new government-funded Internet-based system. The reason for the increased compensable cases may be the increasing availability of hospitals and clinics to provide occupational health services. During the 2008-2010 period, the most frequently reported occupational diseases were carpal tunnel syndrome, lumbar disc disorder, upper limb musculoskeletal disorders, and contact dermatitis. The new network and reporting system was successful in providing more occupational health services, providing more workers with compensation for occupational diseases, and reducing underreporting of occupational diseases. Therefore, the experience in Taiwan could serve as an example for other newly developed countries in a similar situation.

Incidence of whooping cough in Spain (1997-2010): an underreported disease.

PubMed

Fernández-Cano, María Isabel; Armadans Gil, Lluís; Martínez Gómez, Xavi; Campins Martí, Magda

2014-06-01

Whooping cough is currently the worst controlled vaccine-preventable disease in the majority of countries. In order to reduce its morbidity and mortality, it is essential to adapt vaccination programmes to data provided by epidemiological surveillance. A population-based retrospective epidemiological study to estimate the minimum annual undernotification rate of pertussis in Spain from 1997 to 2010 was performed. The incidence of pertussis cases reported to the National Notifiable Disease Surveillance System was compared with the incidence of hospital discharges for pertussis from the National Surveillance System for hospital data, Conjunto Mínimo Básico de Datos. The overall reported incidence and that of hospitalisation for whooping cough were 1.3 cases × 100,000 inhabitants in both cases. Minimum underreporting oscillated between 3.8 and 22.8 %, according to the year of the study. The greatest underreporting (50 %) was observed in children under the age of 1 year. Spanish epidemiological surveillance system of pertussis should be improved with complementary active systems to ascertain the real incidence. Paediatricians and general practitioners should be sensibilized to the importance of notification because this would be essential for adapting the prevention and control measures of this disease.

Corrections of clinical chemistry test results in a laboratory information system.

PubMed

Wang, Sihe; Ho, Virginia

2004-08-01

The recently released reports by the Institute of Medicine, To Err Is Human and Patient Safety, have received national attention because of their focus on the problem of medical errors. Although a small number of studies have reported on errors in general clinical laboratories, there are, to our knowledge, no reported studies that focus on errors in pediatric clinical laboratory testing. To characterize the errors that have caused corrections to have to be made in pediatric clinical chemistry results in the laboratory information system, Misys. To provide initial data on the errors detected in pediatric clinical chemistry laboratories in order to improve patient safety in pediatric health care. All clinical chemistry staff members were informed of the study and were requested to report in writing when a correction was made in the laboratory information system, Misys. Errors were detected either by the clinicians (the results did not fit the patients' clinical conditions) or by the laboratory technologists (the results were double-checked, and the worksheets were carefully examined twice a day). No incident that was discovered before or during the final validation was included. On each Monday of the study, we generated a report from Misys that listed all of the corrections made during the previous week. We then categorized the corrections according to the types and stages of the incidents that led to the corrections. A total of 187 incidents were detected during the 10-month study, representing a 0.26% error detection rate per requisition. The distribution of the detected incidents included 31 (17%) preanalytic incidents, 46 (25%) analytic incidents, and 110 (59%) postanalytic incidents. The errors related to noninterfaced tests accounted for 50% of the total incidents and for 37% of the affected tests and orderable panels, while the noninterfaced tests and panels accounted for 17% of the total test volume in our laboratory. This pilot study provided the rate and categories of errors detected in a pediatric clinical chemistry laboratory based on the corrections of results in the laboratory information system. A direct interface of the instruments to the laboratory information system showed that it had favorable effects on reducing laboratory errors.

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…

77 FR 25710 - Agency Information Collection Extension

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-01

... Accident/Incident Reporting System (CAIRS); Occurrence Reporting and Processing System (ORPS); Noncompliance Tracking System (NTS); Radiation Exposure Monitoring System (REMS); Annual Fire Protection Summary... following additional authorities: Computerized Accident/Incident Reporting System (CAIRS): DOE Order 231.1B...

Targeting errors in the ICU: use of a national database.

PubMed

Kleinpell, Ruth; Thompson, David; Kelso, Lynn; Pronovost, Peter J

2006-12-01

The authors believe that as we move from viewing adverse event reporting system as punitive, and as the safety culture improves, reporting will likely increase. Voluntary incident reporting systems can be used to improve patient safety in the ICU by identifying broken or inadequate systems that lead to adverse events [26]. Voluntary external reporting systems such as the ICUSRS can be used to target errors and produce evidence-based best practice measures to improve patient safety in the ICU.

Community exposures to chemical incidents: development and evaluation of the first environmental public health surveillance system in Europe

PubMed Central

Bowen, H; Palmer, S; Fielder, H; Coleman, G; Routledge, P; Fone, D

2000-01-01

OBJECTIVE—To describe the frequency, nature and location of acute chemical incidents in Wales, and the morbidity in employees, emergency responders and the general public who were exposed.
DESIGN—Active multi-agency community-based surveillance system.
SETTING—Wales, 1993-5.
MAIN OUTCOME MEASURES—Frequency, nature and location of incidents, populations potentially exposed and with symptoms.
RESULTS—Most of the 402 incidents identified were not associated with sites governed by the Control of Industrial Major Accident Hazard Regulations but with smaller industrial sites and commercial premises. About two in every thousand of the estimated 236 000 members of the public considered to be at risk from exposure reported symptoms, which were mainly nausea, headaches, and irritation of the eye, skin and respiratory tract. The most commonly reported chemicals that members of the public were exposed to were smoke toxins, miscellaneous organics, toxic gases and flammable gases. A health authority was reported to be involved in only 34 (8%) of the incidents and in only 3 of the 29 incidents where more than 100 members of the public were exposed.
CONCLUSION—A geographically defined, multi-agency surveillance system can identify high risk locations and types of incidents, together with the chemicals most likely to be involved. Such ongoing surveillance information is essential for appropriate policy making, emergency planning, operational management and training.


Keywords: surveillance; pollution; chemical PMID:11027203

Probabilistic fault tree analysis of a radiation treatment system.

PubMed

Ekaette, Edidiong; Lee, Robert C; Cooke, David L; Iftody, Sandra; Craighead, Peter

2007-12-01

Inappropriate administration of radiation for cancer treatment can result in severe consequences such as premature death or appreciably impaired quality of life. There has been little study of vulnerable treatment process components and their contribution to the risk of radiation treatment (RT). In this article, we describe the application of probabilistic fault tree methods to assess the probability of radiation misadministration to patients at a large cancer treatment center. We conducted a systematic analysis of the RT process that identified four process domains: Assessment, Preparation, Treatment, and Follow-up. For the Preparation domain, we analyzed possible incident scenarios via fault trees. For each task, we also identified existing quality control measures. To populate the fault trees we used subjective probabilities from experts and compared results with incident report data. Both the fault tree and the incident report analysis revealed simulation tasks to be most prone to incidents, and the treatment prescription task to be least prone to incidents. The probability of a Preparation domain incident was estimated to be in the range of 0.1-0.7% based on incident reports, which is comparable to the mean value of 0.4% from the fault tree analysis using probabilities from the expert elicitation exercise. In conclusion, an analysis of part of the RT system using a fault tree populated with subjective probabilities from experts was useful in identifying vulnerable components of the system, and provided quantitative data for risk management.

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

Code of Federal Regulations, 2011 CFR

2011-10-01

... under § 191.5 of this part. (b) LNG. Each operator of a liquefied natural gas plant or facility must... liquefied natural gas facilities: Incident report. 191.15 Section 191.15 Transportation Other Regulations...; gathering systems; and liquefied natural gas facilities: Incident report. (a) Transmission or Gathering...

National Patient Safety Program in Brazil: Incidents Reported Between 2014 and 2017.

PubMed

Faustino, Tássia Nery; Batalha, Edenise Maria Santos da Silva; Vieira, Silvana Lima; Nicole, Andressa Garcia; Morais, Alexandre Souza; Tronchin, Daisy Maria Rizatto; Melleiro, Marta Maria

2018-05-16

The aim of the study was to analyze the patient safety incidents reported to the Brazilian National Health Surveillance System from March 2014 to March 2017. A documentary study that used the records of the incidents published in the Reports of Adverse Events (AE) in Brazil. The following variables were selected: number of incidents by type, type of health service, hospital unit, and degree of harm. To find whether there was a significant difference across the Brazilian regions by notifications related to general incidents, AE, and deaths, the analysis of variance and the Tukey tests were used. A total of 109,082 incidents were reported, of which 75,088 were AE, with 649 deaths. In relation to the types of incidents reported, there was a higher frequency in the categories other (30.04%) and failures during health care (26.72%). A total of 93.90% of the incidents occurred in hospitals, with 54,950 cases registered in hospitalization units and 30,141 cases in intensive care units. Statistically significant differences across the Brazilian regions were observed in the number of incidents (P = 0.004), AE (P = 0.004), and deaths (P = 0.024). A significant underreporting of incidents was found in Brazil, demonstrating only the tip of a giant iceberg. More than half of the incidents were reported as AE and were registered in hospitals, reiterating the importance of establishing public health policies at national, state, and municipal levels, with adequate supervision of the health service regarding the implementation of the Patient Safety Nuclei and the preparation of new protocols based on the most prevalent incidents.

I-35w incident management and impact of incidents on freeway operations. Final report, 1976-1979

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lari, A.; Christianson, D.; Porter, S.

1982-01-01

I-35W and I-94 Traffic Management System have been in operation since 1974. As of December 1979, the TMS operation included six principal functional subsystems. These are (1) a 24 camera closed circuit television network (2) 38 ramp meter signals, (3) eleven express bus and/or carpool meter bypass ramps, (4) a motorist information program including changeable message signs, lane control signals, highway advisory radio and a traffic grade information sign, (5) the Traffic Management Center and (6) an incident detection and response program. The purpose of this study was twofold: first, available incident records accumulated on the TMS were analyzed tomore » develop a comprehensive view of the types and quantities of incidents that have occurred. Second, the incident data base and companion volume and occupancy data was used to determine the impact of 'typical' incidents and the impact of the total incident problem. Included in the report is an analysis of incident types detected, mode of incident detection, duration of incidents, and incident response activities.« less

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.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nyflot, MJ; Kusano, AS; Zeng, J

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 frommore » 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 their own incident learning systems.« less

Global surveillance for chemical incidents of international public health concern.

PubMed Central

Olowokure, B.; Pooransingh, S.; Tempowski, J.; Palmer, S.; Meredith, T.

2005-01-01

OBJECTIVE: In December 2001, an expert consultation convened by WHO identified strengthening national and global chemical incident preparedness and response as a priority. WHO is working towards this objective by developing a surveillance and response system for chemical incidents. This report describes the frequency, nature and geographical location of acute chemical incidents of potential international concern from August 2002 to December 2003. METHODS: Acute chemical incidents were actively identified through several informal (e.g. Internet-based resources) and formal (e.g. various networks of organizations) sources and assessed against criteria for public health emergencies of international concern using the then proposed revised International Health Regulations (IHR). WHO regional and country offices were contacted to obtain additional information regarding identified incidents. FINDINGS: Altogether, 35 chemical incidents from 26 countries met one or more of the IHR criteria. The WHO European Region accounted for 43% (15/35) of reports. The WHO Regions for Africa, Eastern Mediterranean and Western Pacific each accounted for 14% (5/35); South-East Asia and the Americas accounted for 9% (3/35) and 6% (2/35), respectively. Twenty-three (66%) events were identified within 24 hours of their occurrence. CONCLUSION: To our knowledge this is the first global surveillance system for chemical incidents of potential international concern. Limitations such as geographical and language bias associated with the current system are being addressed. Nevertheless, the system has shown that it can provide early detection of important events, as well as information on the magnitude and geographical distribution of such incidents. It can therefore contribute to improving global public health preparedness. PMID:16462985

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. PMID:25058321

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.

A review and discussion of flight management system incidents reported to the Aviation Safety Reporting System

DOT National Transportation Integrated Search

1992-02-01

This report covers the activities related to the description, classification and : analysis of the types and kinds of flight crew errors, incidents and actions, as : reported to the Aviation Safety Reporting System (ASRS) database, that can occur as ...

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 reporting and discussing the incidents internally. There appeared to be a mismatch between the recorded events and the category allocated to the incident in the historical record. In addition the database did not contain complete information for every incident, contributory factors were rarely recorded and relatively large numbers of incidents were recorded as "other" in the type of incident. There was also observed difficulty in updating the system as there is at least a months time lag between reporting or an incident and discussion/resolution of issues at the local departmental clinical risk management committee meetings. We used Leape's model for assessing the reporting system as a whole and found the system in the department to be relatively safe, fairly easy to use and moderately effective. Recommendations as a result of this study include the introduction of an electronic reporting system, limiting the number of staff who categorise the incidents--using clear definitions for classifications including a structured framework for contributory factors, and a process that allows incidents to be updated on the database locally after the discussion. This research may have implications for the incident reporting process in other specialities as well as in other hospitals.

Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetics.

PubMed

Wan, Sharon; Siow, Yew Nam; Lee, Su Min; Ng, Agnes

2013-02-01

This study reports our experience of audit and critical incidents observed by paediatric anaesthetics from 2000 to 2010 at a paediatric teaching hospital in Singapore. Data pertaining to patient demographics, practices and critical incidents during anaesthesia and in the perioperative period were prospectively collected via an audit form and retrospectively analysed thereafter. A total of 2,519 incidents were noted at the 75,331 anaesthetics performed during the study period. There were nine deaths reported. The majority of incidents reported were respiratory critical incidents (n = 1,757, 69.8%), followed by cardiovascular incidents (n = 238, 9.5%). Risk factors for critical incidents included age less than one year, and preterm and former preterm children. Critical incident reporting has value, as it provides insights into the system and helps to identify active and system errors, thus enabling the formulation of effective preventive strategies. By creating and maintaining an environment that encourages reporting, we have maintained a high and consistent reporting rate through the years. The teaching of analysis of critical incidents should be regarded by all clinicians as an important tool for improving patient safety.

New York integrated incident management system evaluation project final report

DOT National Transportation Integrated Search

2007-03-23

The Integrated Incident Management System (IIMS) enables incident response personnel to transmit data about an incident to other responders and dispatchers on a real-time basis. When an incident is entered into IIMS, the system uses GPS to identify t...

[Results of provisional use of a system for voluntary anonymous reporting of incidents that threaten patient safety in the emergency medical services of Asturias].

PubMed

Galván Núñez, Pablo; Santander Barrios, María Dolores; Villa Álvarez, María Cristina; Castro Delgado, Rafael; Alonso Lorenzo, Julio C; Arcos González, Pedro

2016-06-01

To describe the reported incidents and adverse events in the emergency medical services of Asturias, Spain, and assess their consequences, delays caused, and preventability. Prospective, observational study of incidents reported by the staff of the emergency medical services of Asturias after implementation of a system devised by the researchers. Incident reports were received for 0.48% (95% CI, 0.41%-0.54%) of the emergencies attended. Patient safety was compromised in 74.7% of the reported incidents. Problems arising in the emergency response coordination center (ERCC) accounted for 37.6% of the incidents, transport problems for 13.4%, vehicular problems for 10.8%, and communication problems for 8.8%. Seventy percent of the reported incidents caused delays in care; 55% of the reported incidents that put patients at risk (according to severity assessment code ratings) corresponded to problems related to human or material resources. A total of 88.1% of the incidents reported were considered avoidable. Some type of intervention was required to attenuate the effects of 46.2% of the adverse events reported. The measures that staff members most often proposed to prevent adverse events were to increase human and material resources (28.3%), establish protocols (14.5%), and comply with quality of care recommendations (9.7%). It is important to promote a culture of safety and incident reporting among health care staff in Asturias given the number of serious adverse events. Reporting is necessary for understanding the errors made and taking steps to prevent them. The ERCC is the point in the system where incidents are particularly likely to appear and be noticed and reported.

Development of an online incident-reporting system for management of medical risks at hospital.

PubMed

Kanda, Hirohito

2011-01-01

  To minimize their occurrence, it is important to gather and analyze data regarding cases of not only medical accidents but also of incidents involving potential harm to patients. In gathering data, we have separated reporting between the details of such incidents and information about their occurrence. We have implemented a system involving a first report to achieve prompt notification and a second report to provide details. An online report input system has been established taking into consideration both ease of input and promptness of information sharing. We discuss the input of the first and second reports in a total of 951 cases over a period of 6 months. From the data regarding the timing of the first report, 307 and 789 cases were reported within 24 h and 48 h, respectively, indicating that the first report was input mostly without delay in accordance with the operational guidelines. On the other hand, it took 14 days to surpass a second report rate of 80%. Cases that took more than 2 weeks to be reported would likely have gone unreported had there not been a first report to indicate and confirm that an incident had even occurred. Investigation is needed, especially for problematic cases, so we assume that discovering important incidents via the first report has been successful. In addition, details of incidents can be input into this system in free-text, yielding information that cannot be acquired with multiple choice input as in standard reporting systems.

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.

A Real-Time Safety and Quality Reporting System: Assessment of Clinical Data and Staff Participation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rahn, Douglas A.; Kim, Gwe-Ya; Mundt, Arno J.

Purpose: To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation. Methods and Materials: On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment). Results: During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entriesmore » in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program. Conclusions: Incident learning systems are a useful and practical means of improving safety and quality in patient care.« less

Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.

PubMed

Nuttall, Gregory A; Abenstein, John P; Stubbs, James R; Santrach, Paula; Ereth, Mark H; Johnson, Pamela M; Douglas, Emily; Oliver, William C

2013-04-01

To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes. Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010. A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001). Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events. Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Classifying health information technology patient safety related incidents - an approach used in Wales.

PubMed

Warm, D; Edwards, P

2012-01-01

Interest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents. This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1(st) January 2009 and 31(st) May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested. On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error). In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.

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.

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/

Active and passive surveillance of enoxaparin generics: a case study relevant to biosimilars.

PubMed

Grampp, Gustavo; Bonafede, Machaon; Felix, Thomas; Li, Edward; Malecki, Michael; Sprafka, J Michael

2015-03-01

This retrospective analysis assessed the capability of active and passive safety surveillance systems to track product-specific safety events in the USA for branded and generic enoxaparin, a complex injectable subject to immune-related and other adverse events (AEs). Analysis of heparin-induced thrombocytopenia (HIT) incidence was performed on benefit claims for commercial and Medicare supplemental-insured individuals newly treated with enoxaparin under pharmacy benefit (1 January 2009 - 30 June 2012). Additionally, spontaneous reports from the FDA AE Reporting System were reviewed to identify incidence and attribution of enoxaparin-related reports to specific manufacturers. Specific, dispensed products were identifiable from National Drug Codes only in pharmacy-benefit databases, permitting sensitive comparison of HIT incidence in nearly a third of patients treated with brand or generic enoxaparin. After originator medicine's loss of exclusivity, only 5% of spontaneous reports were processed by generic manufacturers; reports attributable to specific generics were approximately ninefold lower than expected based on market share. Claims data were useful for active surveillance of enoxaparin generics dispensed under pharmacy benefits but not for products administered under medical benefits. These findings suggest that the current spontaneous reporting system will not distinguish product-specific safety signals for products distributed by multiple manufacturers, including biosimilars.

The role of patient simulation and incident reporting in the development and evaluation of medical devices and the training of their users.

PubMed

Dieckmann, P; Rall, M; Ostergaard, D

2009-01-01

We describe how simulation and incident reporting can be used in combination to make the interaction between people, (medical) technology and organisation safer for patients and users. We provide the background rationale for our conceptual ideas and apply the concepts to the analysis of an actual incident report. Simulation can serve as a laboratory to analyse such cases and to create relevant and effective training scenarios based on such analyses. We will describe a methodological framework for analysing simulation scenarios in a way that allows discovering and discussing mismatches between conceptual models of the device design and mental models users hold about the device and its use. We further describe how incident reporting systems can be used as one source of data to conduct the necessary needs analyses - both for training and further needs for closer analysis of specific devices or some of their special features or modes during usability analyses.

A Summary of NASA and USAF Hypergolic Propellant Related Spills and Fires

NASA Technical Reports Server (NTRS)

Nufer, Brian M.

2009-01-01

Several unintentional hypergolic fluid related spills, fires, and explosions from the Apollo Program, the Space Shuttle Program, the Titan Program, and a few others have occurred over the past several decades. Spill sites include the following government facilities: Kennedy Space Center (KSC), Johnson Space Center (JSC), White Sands Test Facility (WSTF), Vandenberg Air Force Base (VAFB), Cape Canaveral Air Force Station (CCAFS), Edwards Air Force Base (EAFB), Little Rock AFB, and McConnell AFB. Until now, the only method of capturing the lessons learned from these incidents has been "word of mouth" or by studying each individual incident report. The root causes and consequences of the incidents vary drastically; however, certain "themes" can be deduced and utilized for future hypergolic propellant handling. Some of those common "themes" are summarized below: (1) Improper configuration control and internal or external human performance shaping factors can lead to being falsely comfortable with a system (2) Communication breakdown can escalate an incident to a level where injuries occur and/or hardware is damaged (3) Improper propulsion system and ground support system designs can destine a system for failure (4) Improper training of technicians, engineers, and safety personnel can put lives in danger (5) Improper PPE, spill protection, and staging of fire extinguishing equipment can result in unnecessary injuries or hardware damage if an incident occurs (6) Improper procedural oversight, development, and adherence to the procedure can be detrimental and quickly lead to an undesirable incident (7) Improper materials cleanliness or compatibility and chemical reactivity can result in fires or explosions (8) Improper established "back-out" and/or emergency safing procedures can escalate an event The items listed above are only a short list of the issues that should be recognized prior to handling hypergolic fluids or processing vehicles containing hypergolic propellants. The summary of incidents in this report is intended to cover many more issues than those listed above.

Incidents/accidents classification and reporting in Statoil.

PubMed

Berentsen, Rune; Holmboe, Rolf H

2004-07-26

Based on requirements in the new petroleum regulations from Norwegian Petroleum Directorate (NPD) and the realisation of a need to improve and rationalise the routines for reporting and follow up of incidents, Statoil Exploration & Production Norway (Statoil E&P Norway) has formulated a new strategy and process for handling of incidents/accidents. The following past experiences serve as basis for the changes made to incident reporting in Statoil E&P Norway; too much resources were spent on a comprehensive handling and analysis of a vast amount of incidents with less importance for the safety level, taking the focus away from the more severe and important issues at hand, the assessment of "Risk Factor", i.e. the combination of recurrence frequency and consequence, was difficult to use. The high degree of subjectivity involved in the determination of the "Risk Factor" (in particular the estimation of the recurrence frequency) resulted in poor data quality and lack of consistency in the data material. The new system for categorisation and handling of undesirable incidents was established in January 2002. The intention was to get a higher degree of focus on serious incidents (injuries, damages, loss and near misses), with a thorough handling and follow-up. This is reflected throughout the handling of the serious incidents, all the way from immediate notification of the incident, through investigation and follow-up of corrective and preventive actions. Simultaneously, it was also an objective to rationalise/simplify the handling of less serious incidents. These incidents are, however, subjected to analyses twice a year in order to utilize the learning opportunity that they also provide. A year after the introduction of this new system for categorisation and follow-up of undesirable incidents, Statoil's experiences are predominantly good; the intention to get a higher degree of focus on serious incidents (injuries, damages, loss and near misses), has been met, the data quality for the more serious incidents (5% of the total number of incidents registered) has improved, the improved handling of incidents has contributed to more reliable and accurate HSE indicators at a corporate level, more user friendly codes in place for incident registration (based on MTO methodology), the revised matrix gives distinct criteria with respect to which investigation level to be initiated for a specific incident. All activities related to handling of undesirable incidents have been summarised and illustrated on a two-sided plastic form, incorporating both the categorisation matrix and the activity flowchart (see Figs. 1 and 4).

Improving the governance of patient safety in emergency care: a systematic review of interventions

PubMed Central

Hesselink, Gijs; Berben, Sivera; Beune, Thimpe

2016-01-01

Objectives To systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility. Design A systematic review of the literature. Methods PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews and PsychInfo were searched for studies published between January 1990 and July 2014. We included studies evaluating interventions relevant for higher management to oversee and manage patient safety, in prehospital emergency medical service (EMS) organisations and hospital-based emergency departments (EDs). Two reviewers independently selected candidate studies, extracted data and assessed study quality. Studies were categorised according to study quality, setting, sample, intervention characteristics and findings. Results Of the 18 included studies, 13 (72%) were non-experimental. Nine studies (50%) reported data on the reliability and/or validity of the intervention. Eight studies (44%) reported on the feasibility of the intervention. Only 4 studies (22%) reported statistically significant effects. The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively. Conclusions Characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in EMS organisations and EDs. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base. PMID:26826151

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.

Personal Electronic Devices and Their Interference with Aircraft Systems

NASA Technical Reports Server (NTRS)

Ross, Elden; Ely, Jay J. (Technical Monitor)

2001-01-01

A compilation of data on personal electronic devices (PEDs) attributed to having created anomalies with aircraft systems. Charts and tables display 14 years of incidents reported by pilots to the Aviation Safety Reporting System (ASRS). Affected systems, incident severity, sources of anomaly detection, and the most frequently identified PEDs are some of the more significant data. Several reports contain incidents of aircraft off course when all systems indicated on course and of critical events that occurred during landings and takeoffs. Additionally, PEDs that should receive priority in testing are identified.

Critical incident reporting in emergency medicine: results of the prehospital reports.

PubMed

Hohenstein, Christian; Hempel, Dorothea; Schultheis, Kerstin; Lotter, Oliver; Fleischmann, Thomas

2014-05-01

Medical errors frequently contribute to morbidity and mortality. Prehospital emergency medicine is prone to incidents that can lead to immediate deadly consequences. Critical incident reporting can identify typical problems and be the basis for structured risk management in order to reduce and mitigate these incidents. We set up a free access internet website for German-speaking countries, with an anonymous reporting system for emergency medical services personnel. After a 7-year study period, an expert team analysed and classified the incidents into staff related, equipment related, organisation and tactics, or other. 845 reports were entered in the study period. Physicians reported 44% of incidents, paramedics 42%. Most patients were in a life-threatening or potentially life-threatening situation (82%), and only 53% of all incidents had no influence on the outcome of the patient. Staff-related problems were responsible for 56% of the incidents, when it came to harm, 78% of these incidents were staff related. Incident reporting in prehospital emergency medicine can identify system weaknesses. Most of the incidents were reported during care of patients in life-threatening conditions with a high impact on patient outcome. Staff-related problems contributed to the most frequent and most severe incidents. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

A critical incident reporting system in anaesthesia.

PubMed

Madzimbamuto, F D; Chiware, R

2001-01-01

To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Between May and October 2000, 62 completed critical incident forms were collected. The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome. Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff.

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 significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates [r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02)]. The NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors report more harm incidents than near misses. Staff survey results showed that open environments and reduced fear of punitive response increases incident reporting. We suggest that reporting rates should not be used to assess hospital safety. Different healthcare professionals focus on different types of safety incidents and focusing on these areas whilst creating a responsive, confidential learning environment will increase staff engagement with error disclosure.

Incidence of second cancers after radiotherapy and systemic chemotherapy in heritable retinoblastoma survivors: A report from the German reference center.

PubMed

Temming, Petra; Arendt, Marina; Viehmann, Anja; Eisele, Lewin; Le Guin, Claudia H D; Schündeln, Michael M; Biewald, Eva; Astrahantseff, Kathy; Wieland, Regina; Bornfeld, Norbert; Sauerwein, Wolfgang; Eggert, Angelika; Jöckel, Karl-Heinz; Lohmann, Dietmar R

2017-01-01

Survivors of heritable retinoblastoma carry a high risk to develop second cancers. Eye-preserving radiotherapy raises this risk, while the impact of chemotherapy remains less defined. This population-based study characterizes the impact of all treatment modalities on second cancers incidence and type after retinoblastoma treatment in Germany. Data on second cancer incidence in 648 patients with heritable retinoblastoma treated between 1940 and 2008 at the German national reference center for retinoblastoma were analyzed to identify associations with treatment. The cumulative incidence ratio (per 1,000 person years) of second cancers was 8.6 (95% confidence interval 7.0-10.4). Second cancer incidence was influenced by type of retinoblastoma treatment but not by the year of diagnosis or by sex. Radiotherapy and systemic chemotherapy increased the incidence of second cancers (by 3.0- and 1.8-fold, respectively). While radiotherapy was specifically associated with second cancers arising within the periorbital region in the previously irradiated field, chemotherapy was the strongest risk factor for second cancers in other localizations. Soft tissue sarcomas and osteosarcomas were the most prevalent second cancers (standardized incidence ratio 179.35 compared to the German population). Second cancers remain a major concern in heritable retinoblastoma survivors. Consistent with previous reports, radiotherapy increased second cancer incidence and influenced type and localization. However, chemotherapy was the strongest risk factor for second malignancies outside the periorbital region. Our results provide screening priorities during life-long oncological follow-up based on the curative therapy the patient has received and emphasize the need for less-detrimental therapies for children with heritable retinoblastoma. © 2016 Wiley Periodicals, Inc.

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.

Integrated Incident Management System (IIMS) web client application development, deployment and evaluation Staten Island (SI) demonstration project : final report.

DOT National Transportation Integrated Search

2015-09-27

This evaluation report provides background on the development and findings. The aim of the UTRC project was to develop and : deploy Portable IIMS based on Smartphone web applications. Previously, traditional IIMS was deployed in the field vehicles : ...

32 CFR 1290.9 - Forms and reports.

Code of Federal Regulations, 2014 CFR

2014-07-01

.... Magistrate system is based on use of a four-ply ticket designed to provide legal notice to violators and... departments. The DD Form 1805 is printed on chemically carbonized paper and prenumbered in series for... 635, Security/Criminal Incident Report, denoting the date, time, place, and type of violation, and the...

32 CFR 1290.9 - Forms and reports.

Code of Federal Regulations, 2013 CFR

2013-07-01

.... Magistrate system is based on use of a four-ply ticket designed to provide legal notice to violators and... departments. The DD Form 1805 is printed on chemically carbonized paper and prenumbered in series for... 635, Security/Criminal Incident Report, denoting the date, time, place, and type of violation, and the...

32 CFR 1290.9 - Forms and reports.

Code of Federal Regulations, 2012 CFR

2012-07-01

.... Magistrate system is based on use of a four-ply ticket designed to provide legal notice to violators and... departments. The DD Form 1805 is printed on chemically carbonized paper and prenumbered in series for... 635, Security/Criminal Incident Report, denoting the date, time, place, and type of violation, and the...

[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.

The casualty profile from the Reading train crash, November 2004: proposals for improved major incident reporting and the application of trauma scoring systems.

PubMed

Howells, N R; Dunne, N; Reddy, S

2006-07-01

To report the casualty profile of the major incident at the Royal Berkshire Hospital, Reading, following the Ufton Nervet Train crash, November 2004. To make further proposals regarding major incident reporting and implementation of trauma-scoring systems. Retrospective analysis of emergency department and hospital notes. Calculation of index Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS) in all patients. Of 61 casualties, the majority (74%) were seen in the minors area of our emergency department with a mixture of blunt impact and penetrating glass injuries. One died and 16 were admitted. 10% had an ISS >16. All surviving patients had a TRISS predicted probability of survival >90%. We propose mandatory major incident reporting within 6 months of a major incident to aid development of a national database. As previously proposed, this will aid education and facilitate future major incident planning. We further propose the widespread use of trauma scoring systems to facilitate comparative analysis between major incidents, perhaps extrapolating this to develop a major incident score.

Multimodal observational assessment of quality and productivity benefits from the implementation of wireless technology for out of hours working

PubMed Central

Blakey, John D; Guy, Debbie; Simpson, Carl; Fearn, Andrew; Cannaby, Sharon; Wilson, Petra

2012-01-01

Objectives The authors investigated if a wireless system of call handling and task management for out of hours care could replace a standard pager-based system and improve markers of efficiency, patient safety and staff satisfaction. Design Prospective assessment using both quantitative and qualitative methods, including interviews with staff, a standard satisfaction questionnaire, independent observation, data extraction from work logs and incident reporting systems and analysis of hospital committee reports. Setting A large teaching hospital in the UK. Participants Hospital at night co-ordinators, clinical support workers and junior doctors handling approximately 10 000 tasks requested out of hours per month. Outcome measures Length of hospital stay, incidents reported, co-ordinator call logging activity, user satisfaction questionnaire, staff interviews. Results Users were more satisfied with the new system (satisfaction score 62/90 vs 82/90, p=0.0080). With the new system over 70 h/week of co-ordinator time was released, and there were fewer untoward incidents related to handover and medical response (OR=0.30, p=0.02). Broad clinical measures (cardiac arrest calls for peri-arrest situations and length of hospital stay) improved significantly in the areas covered by the new system. Conclusions The introduction of call handling software and mobile technology over a medical-grade wireless network improved staff satisfaction with the Hospital at Night system. Improvements in efficiency and information flow have been accompanied by a reduction in untoward incidents, length of stay and peri-arrest calls. PMID:22466035

Evaluation of the in-hospital hemovigilance by introduction of the information technology-based system.

PubMed

Fujihara, Harumi; Yamada, Chiaki; Furumaki, Hiroaki; Nagai, Seiya; Shibata, Hiroki; Ishizuka, Keiko; Watanabe, Hiroko; Kaneko, Makoto; Adachi, Miwa; Takeshita, Akihiro

2015-12-01

Hemovigilance is an important aspect of transfusion medicine. However, the frequency of the adverse reactions often varies using different reporters. Recently, we have employed a new information technology (IT)-based in-hospital hemovigilance system. Here, we evaluated changes in practice after implementation of an IT-based reporting system. We compared the rate of frequency and details of blood transfusion-related adverse reactions 3 years before and after introduction of the IT-based reporting system. Contents and severity of the adverse reactions were reported in a paper-based reporting system, but input by selecting items in an IT-based reporting system. The details of adverse reactions are immediately sent to the blood transfusion unit online. After we introduced the IT-based reporting system, the reported rate of transfusion-related adverse reactions increased approximately 10-fold from 0.20% to 2.18% (p < 0.001), and frequencies of urticaria, pruritus, rash, fever (p < 0.001), hypertension (p = 0.001), tachycardia (p = 0.003), and nausea and vomiting (p = 0.010) increased significantly. Although there was no error report in the paper-based reporting, incorrect reports were observed in 90 cases (0.52%) in the IT-based reporting (p < 0.001). The advantages of IT-based reporting were: 1) a significant increase in the frequency of adverse reaction reporting and 2) a significant decrease in underreporting, although the true frequency has yet to be clarified. The disadvantage of the IT-based reporting was an increased incidence of incorrect inputs, all of which was unnoticed by the reporters. Our results showed several important points in need of monitoring after introduction of an IT-based reporting system. © 2015 AABB.

MO-DE-BRA-02: From Teaching to Learning: Systems-Based-Practice and Practice-Based-Learning Innovations in Medical Physics Education Programs

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kapur, A

Purpose: The increasing complexity in the field of radiation medicine and concomitant rise in patient safety concerns call for enhanced systems-level training for future medical physicists and thus commensurate innovations in existing educational program curricula. In this work we report on the introduction of three learning opportunities to augment medical physics educational programs towards building systems-based practice and practice-based learning competencies. Methods: All initiatives were introduced for senior -level graduate students and physics residents in an institution with a newly established medical-physics graduate program and therapeutic-physics residency program. The first, centered on incident learning, was based on a spreadsheet toolmore » that incorporated the reporting structure of the Radiation Oncology-incident Learning System (ROILS), included 120 narratives of published incidents and enabled inter-rater variability calculations. The second, centered on best-practices, was a zero-credit seminar course, where students summarized select presentations from the AAPM virtual library on a weekly basis and moderated class discussions using a point/counterpoint approach. Presentation styles were critiqued. The third; centered on learning-by-teaching, required physics residents to regularly explain fundamental concepts in radiological physics from standard textbooks to board certified physics faculty members. Results: Use of the incident-learning system spreadsheet provided a platform to recast known accidents into the framework of ROILS, thereby increasing awareness of factors contributing to unsafe practice and appreciation for inter-rater variability. The seminar course enhanced awareness of best practices, the effectiveness of presentation styles and encouraged critical thinking. The learn-by-teaching rotation allowed residents to stay abreast of and deepen their knowledge of relevant subjects. Conclusion: The incorporation of systems-driven initiatives broadens comprehension of the wider systems context of medical physics, enhances awareness of resources for innovation, communication and sustained learning while maintaining a metric-driven focus on patient safety within the formative phase of student careers. The initiatives were well-received, feasible, and utilized available or shared-resources translatable across educational programs.« less

Human factors in airport surface incidents : an analysis of pilot reports submitted to the Aviation Safety Reporting System (ASRS)

DOT National Transportation Integrated Search

2006-12-01

The purpose of this study was to examine human factors involved in airport surface incidents as reported by pilots. Reports submitted to the : Aviation Safety Reporting System (ASRS) are a good source of information regarding the human performance is...

Evaluation of the national Notifiable Diseases Surveillance System for dengue fever in Taiwan, 2010-2012.

PubMed

McKerr, Caoimhe; Lo, Yi-Chun; Edeghere, Obaghe; Bracebridge, Sam

2015-03-01

In Taiwan, around 1,500 cases of dengue fever are reported annually and incidence has been increasing over time. A national web-based Notifiable Diseases Surveillance System (NDSS) has been in operation since 1997 to monitor incidence and trends and support case and outbreak management. We present the findings of an evaluation of the NDSS to ascertain the extent to which dengue fever surveillance objectives are being achieved. We extracted the NDSS data on all laboratory-confirmed dengue fever cases reported during 1 January 2010 to 31 December 2012 to assess and describe key system attributes based on the Centers for Disease Control and Prevention surveillance evaluation guidelines. The system's structure and processes were delineated and operational staff interviewed using a semi-structured questionnaire. Crude and age-adjusted incidence rates were calculated and key demographic variables were summarised to describe reporting activity. Data completeness and validity were described across several variables. Of 5,072 laboratory-confirmed dengue fever cases reported during 2010-2012, 4,740 (93%) were reported during July to December. The system was judged to be simple due to its minimal reporting steps. Data collected on key variables were correctly formatted and usable in > 90% of cases, demonstrating good data completeness and validity. The information collected was considered relevant by users with high acceptability. Adherence to guidelines for 24-hour reporting was 99%. Of 720 cases (14%) recorded as travel-related, 111 (15%) had an onset >14 days after return, highlighting the potential for misclassification. Information on hospitalization was missing for 22% of cases. The calculated PVP was 43%. The NDSS for dengue fever surveillance is a robust, well maintained and acceptable system that supports the collection of complete and valid data needed to achieve the surveillance objectives. The simplicity of the system engenders compliance leading to timely and accurate reporting. Completeness of hospitalization information could be further improved to allow assessment of severity of illness. To minimize misclassification, an algorithm to accurately classify travel cases should be established.

Evaluation of a Web-based Error Reporting Surveillance System in a Large Iranian Hospital.

PubMed

Askarian, Mehrdad; Ghoreishi, Mahboobeh; Akbari Haghighinejad, Hourvash; Palenik, Charles John; Ghodsi, Maryam

2017-08-01

Proper reporting of medical errors helps healthcare providers learn from adverse incidents and improve patient safety. A well-designed and functioning confidential reporting system is an essential component to this process. There are many error reporting methods; however, web-based systems are often preferred because they can provide; comprehensive and more easily analyzed information. This study addresses the use of a web-based error reporting system. This interventional study involved the application of an in-house designed "voluntary web-based medical error reporting system." The system has been used since July 2014 in Nemazee Hospital, Shiraz University of Medical Sciences. The rate and severity of errors reported during the year prior and a year after system launch were compared. The slope of the error report trend line was steep during the first 12 months (B = 105.727, P = 0.00). However, it slowed following launch of the web-based reporting system and was no longer statistically significant (B = 15.27, P = 0.81) by the end of the second year. Most recorded errors were no-harm laboratory types and were due to inattention. Usually, they were reported by nurses and other permanent employees. Most reported errors occurred during morning shifts. Using a standardized web-based error reporting system can be beneficial. This study reports on the performance of an in-house designed reporting system, which appeared to properly detect and analyze medical errors. The system also generated follow-up reports in a timely and accurate manner. Detection of near-miss errors could play a significant role in identifying areas of system defects.

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.

National and regional breast cancer incidence and mortality trends in Mexico 2001-2011: Analysis of a population-based database.

PubMed

Soto-Perez-de-Celis, Enrique; Chavarri-Guerra, Yanin

2016-04-01

Breast cancer is the most common malignancy in Mexican women since 2006. However, due to a lack of cancer registries, data is scarce. We sought to describe breast cancer trends in Mexico using population-based data from a national database and to analyze geographical and age-related differences in incidence and mortality rates. All incident breast cancer cases reported to the National Epidemiological Surveillance System and all breast cancer deaths registered by the National Institute of Statistics and Geography in Mexico from 2001 to 2011 were included. Incidence and mortality rates were calculated for each age group and for 3 geographic regions of the country. Joinpoint regression analysis was performed to examine trends in BC incidence and mortality. We estimated annual percentage change (APC) using weighted least squares log-linear regression. We found an increase in the reported national incidence, with an APC of 5.9% (95% CI 4.1-7.7, p<0.05). Women aged 60-65 had the highest increase in incidence (APC 7.89%; 95% CI 5.5 -10.3, p<0.05). Reported incidence rates were significantly increased in the Center and in the South of the country, while in the North they remained stable. Mortality rates also showed a significant increase, with an APC of 0.4% (95% CI 0.1-0.7, p<0.05). Women 85 and older had the highest increase in mortality (APC 2.99%, 95% CI 1.9-4.1; p<0.05). The reporting of breast cancer cases in Mexico had a continuous increase, which could reflect population aging, increased availability of screening, an improvement in the number of clinical facilities and better reporting of cases. Although an improvement in the detection of cases is the most likely explanation for our findings, our results point towards an epidemiological transition in Mexico and should help in guiding national policy in developing countries. Copyright © 2016 Elsevier Ltd. All rights reserved.

[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.

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.

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process.

PubMed

Howell, Ann-Marie; Burns, Elaine M; Hull, Louise; Mayer, Erik; Sevdalis, Nick; Darzi, Ara

2017-02-01

Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally. 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/.

Patient Safety Incident Reporting: Current Trends and Gaps Within the Canadian Health System.

PubMed

Boucaud, Sarah; Dorschner, Danielle

2016-01-01

Patient safety incidents are a national-level phenomenon, requiring a pan-Canadian approach to ensure that incidents are reported and lessons are learned and broadly disseminated. This work explores the variation in current provincial and local approaches to reporting through a literature review. Trends are consolidated and recommendations are offered to foster better alignment of existing systems. These include adopting a common terminology, defining the patient role in reporting, increasing system users' perception of safety and further investigating the areas of home and community care in ensuring standard approaches at the local level. These steps can promote alignment, reducing barriers to a future pan-Canadian reporting and learning system.

Cyber Incidents Involving Control Systems

DOE Office of Scientific and Technical Information (OSTI.GOV)

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 Managementmore » 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 Department of Homeland Security (DHS) and others who require it. This report summarizes the rise in frequency of cyber attacks, describes the perpetrators, and identifies the means of attack. This type of analysis, when used in conjunction with vulnerability analyses, can be used to support a proactive approach to prevent cyber attacks. CSSC will use this document to evolve a standardized approach to incident reporting and analysis. This document will be updated as needed to record additional event analyses and insights regarding incident reporting. This report represents 120 cyber security incidents documented in a number of sources, including: the British Columbia Institute of Technology (BCIT) Industrial Security Incident Database, the 2003 CSI/FBI Computer Crime and Security Survey, the KEMA, Inc., Database, Lawrence Livermore National Laboratory, the Energy Incident Database, the INL Cyber Incident Database, and other open-source data. The National Memorial Institute for the Prevention of Terrorism (MIPT) database was also interrogated but, interestingly, failed to yield any cyber attack incidents. The results of this evaluation indicate that historical evidence provides insight into control system related incidents or failures; however, that the limited available information provides little support to future risk estimates. The documented case history shows that activity has increased significantly since 1988. The majority of incidents come from the Internet by way of opportunistic viruses, Trojans, and worms, but a surprisingly large number are directed acts of sabotage. A substantial number of confirmed, unconfirmed, and potential events that directly or potentially impact control systems worldwide are also identified. Twelve selected cyber incidents are presented at the end of this report as examples of the documented case studies (see Appendix B).« less

SU-F-T-223: Radiotherapy Incident Reporting and Analysis System (RIRAS):Early Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kapoor, R; Palta, J; Hagan, M

Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reportingmore » facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly diminished when the analysts do not have the ability to request additional information.« less

Physicians' and Nurses' Perceptions of and Attitudes Toward Incident Reporting in Palestinian Hospitals.

PubMed

Rashed, Anan; Hamdan, Motasem

2015-06-22

Underreporting of incidents that happen in health care services undermines the ability of the systems to improve patient safety. This study assessed the attitudes of physicians and nurses toward incident reporting and the factors influencing reporting in Palestinian hospitals. It also examined clinicians' views about the preferred features of incident reporting system. Cross-sectional self-administered survey of 475 participants, 152 physicians and 323 nurses, from 11 public hospitals in the West Bank; response rate, 81.3%. There was a low level of event reporting among participants in the past year (40.3%). Adjusted for sex and age, physicians were 2.1 times more likely to report incidents than nurses (95% confidence interval, 1.32-3.417; P = 0.002). Perceived main barriers for reporting were grouped under lack of proper structure for reporting, prevalence of blame, and punitive environment. The clinicians indicated fear of administrative sanctions, social and legal liability, and of their competence being questioned (P > 0.05). Getting help for patients, learning from mistakes, and ethical obligation were equally indicated motivators for reporting (P > 0.05). Meanwhile, clinicians prefer formal reporting (77.8%) of all type of errors (65.5%), disclosure of reporters (52.7%), using reports to improve patient safety (80.3%), and willingness to report to immediate supervisors (57.6%). Clinicians acknowledge the importance of reporting incidents; however, prevalence of punitive culture and inadequate reporting systems are key barriers. Improving feedback about reported errors, simplifying procedures, providing clear guidelines on what and who should report, and avoiding blame are essential to enhance reporting. Moreover, health care organizations should consider the opinions of the clinicians in developing reporting systems.

Finding clusters of similar events within clinical incident reports: a novel methodology combining case based reasoning and information retrieval

PubMed Central

Tsatsoulis, C; Amthauer, H

2003-01-01

A novel methodological approach for identifying clusters of similar medical incidents by analyzing large databases of incident reports is described. The discovery of similar events allows the identification of patterns and trends, and makes possible the prediction of future events and the establishment of barriers and best practices. Two techniques from the fields of information science and artificial intelligence have been integrated—namely, case based reasoning and information retrieval—and very good clustering accuracies have been achieved on a test data set of incident reports from transfusion medicine. This work suggests that clustering should integrate the features of an incident captured in traditional form based records together with the detailed information found in the narrative included in event reports. PMID:14645892

78 FR 14877 - Pipeline Safety: Incident and Accident Reports

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-07

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket ID PHMSA-2013-0028] Pipeline Safety: Incident and Accident Reports AGENCY: Pipeline and Hazardous Materials... PHMSA F 7100.2--Incident Report--Natural and Other Gas Transmission and Gathering Pipeline Systems and...

Homicide-Followed-by-Suicide Incidents Involving Child Victims

PubMed Central

Logan, Joseph E.; Walsh, Sabrina; Patel, Nimeshkumar; Hall, Jeffrey E.

2015-01-01

Objectives To describe homicide-followed-by-suicide incidents involving child victims Methods Using 2003–2009 National Violent Death Reporting System data, we characterized 129 incidents based on victim and perpetrator demographic information, their relationships, the weapons/mechanisms involved, and the perpetrators’ health and stress-related circumstances. Results These incidents accounted for 188 child deaths; 69% were under 11 years old, and 58% were killed with a firearm. Approximately 76% of perpetrators were males, and 75% were parents/caregivers. Eighty-one percent of incidents with paternal perpetrators and 59% with maternal perpetrators were preceded by parental discord. Fifty-two percent of incidents with maternal perpetrators were associated with maternal psychiatric problems. Conclusions Strategies that resolve parental conflicts rationally and facilitate detection and treatment of parental mental conditions might help prevention efforts. PMID:23985234

Factors Related to Rape Reporting Behavior in Brazil: Examining the Role of Spatio-Temporal Factors.

PubMed

Melo, Silas Nogueira de; Beauregard, Eric; Andresen, Martin A

2016-07-01

The reporting of rape to police is an important component of this crime to have the criminal justice system involved and, potentially, punish offenders. However, for a number of reasons (fear of retribution, self-blame, etc.), most rapes are not reported to police. Most often, the research investigating this phenomenon considers incident and victim factors with little attention to the spatio-temporal factors of the rape. In this study, we consider incident, victim, and spatio-temporal factors relating to rape reporting in Campinas, Brazil. Our primary research question is whether or not the spatio-temporal factors play a significant role in the reporting of rape, over and above incident and victim factors. The subjects under study are women who were admitted to the Women's Integrated Healthcare Center at the State University of Campinas, Brazil, and surveyed by a psychologist or a social worker. Rape reporting to police was measured using a dichotomous variable. Logistic regression was used to predict the probability of rape reporting based on incident, victim, and spatio-temporal factors. Although we find that incident and victim factors matter for rape reporting, spatio-temporal factors (rape/home location and whether the rape was in a private or public place) play an important role in rape reporting, similar to the literature that considers these factors. This result has significant implications for sexual violence education. Only when we know why women decide not to report a rape may we begin to work on strategies to overcome these hurdles.

Bus incident reporting, tracking and analysis system

DOT National Transportation Integrated Search

2006-08-01

Many Florida transit systems do little formal analysis of all accidents on an aggregate basis. In many transit system accidents and incidents are not being tracked or analyzed to identify common trends from types of incidents, location, driver, bus r...

[Cancer incidence in the military: an update].

PubMed

Peragallo, Mario Stefano; Urbano, Francesco; Sarnicola, Giuseppe; Lista, Florigio; Vecchione, Alfredo

2011-01-01

An abnormally elevated rate of Hodgkin's lymphoma was reported in 2001 among Italian soldiers in Bosnia and Kosovo since 1995: a surveillance system was therefore set up for the military community. Preliminary results for a longer period (1996-2007) have shown incidence rates lower than expected for all malignancies. No significant difference was registered between observed and expected cases of Hodkin's lymphoma: the excess of reported cases for this malignancy in 2001-2002 was probably due to a peak occurred in 2000 among the whole military; it is therefore unrelated to deployment in the Balkans, and probably represents a chance event. Moreover, a significant excess of thyroid cancer was reported among the whole military.The estimated number of incident cases, including those missed by the surveillance system, was not significantly higher than expected for all cancers; conversely, the estimated incidence rate of thyroid cancer was significantly increased; this excess, however, is probably due to a selection bias.These data concerning cancer surveillance in the Italian military are consistent with lacking evidence of an increased cancer incidence among troops of other countries deployed in the areas of Iraq, Bosnia, and Kosovo, where armour penetrating depleted uranium shells have been used. However, a comprehensive assessment of cancer morbidity in the military requires a revision of the privacy regulations, in order to link individual records of military personnel and data bases of the National Health Service.

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

Incident management under SCAT adaptive control system : FAST-TRAC phase III deliverable. #11, Final report on incident management under SCATS adaptive control system

DOT National Transportation Integrated Search

1998-04-01

The report documents the results of a study designed to test the effectiveness of ATMS and ATIS strategies to reduce delay resulting from an incident. The study had two main sections: a simulation study to test the effectiveness of several control st...

[Clinical risk management in german hospitals - does size really matter?].

PubMed

Bohnet-Joschko, S; Jandeck, L M; Zippel, C; Andersen, M; Krummenauer, F

2011-06-01

In the last years, German hospitals have implemented different measures to increase patient safety. Special importance has been attached to near miss reporting systems (critical incident reporting system, CIRS) as instruments for risk identification in health care, instruments that promise high potential for organisational learning. To gain insight into the current status of critical incident reporting systems and other instruments for clinical risk management, a survey among 341 hospitals was carried out in 2009. Questions covered a process of six steps: from risk strategy to methods for risk identification, to risk analysis and risk assessment, to risk controlling and risk monitoring. Structured telephone interviews were conducted with 341 German hospitals, featuring in their statutory quality reports certain predefined key terms that indicated the concluded or planned implementation of clinical risk management. The main objective of those interviews was to check the relation between status/organisation of self-reported risk management and both operator (private, public, NPO) and size of hospital. The implementation of near miss reporting systems (CIRS) in German hospitals has been constantly rising since 2004: in 2009, 54 % of the interviewed hospitals reported an implemented CIRS; of these, 72 % reported the system to be hospital-wide. An association between CIRS and private, public or NPO-operator could not be detected (Fisher p = 1.000); however, the degree of CIRS implementation was significantly increasing with the size of the hospital, i.e., the number of beds (Fisher p = 0.008): only 38 % of the hospitals with less than 100 beds reported CIRS implementation against 52 % of those between 100 to 500 beds, and 67 % of those with more than 500 beds. While 62 % of the hospitals interviewed reported the maintenance of a risk management committee, only 14 % reported the implementation of risk analysing techniques. As to clinical risk management, 92 % of the hospitals see potential for internal improvement; 44 % have already communicated with external consultants. While identification of clinical risks with near miss and other incident reporting systems meets increasing acceptance, the learning potential based on incident reporting is not yet appropriately being used. There is a deficit regarding systematic and comprehensive risk assessment and controlling; this will have to be met by improving the organisational framework for clinical risk management. © Georg Thieme Verlag KG Stuttgart · New York.

Differences in reported sepsis incidence according to study design: a literature review.

PubMed

Mariansdatter, Saga Elise; Eiset, Andreas Halgreen; Søgaard, Kirstine Kobberøe; Christiansen, Christian Fynbo

2016-10-12

Sepsis and severe sepsis are common conditions in hospital settings, and are associated with high rates of morbidity and mortality, but reported incidences vary considerably. In this literature review, we describe the variation in reported population-based incidences of sepsis and severe sepsis. We also examine methodological and demographic differences between studies that may explain this variation. We carried out a literature review searching three major databases and reference lists of relevant articles, to identify all original studies reporting the incidence of sepsis or severe sepsis in the general population. Two authors independently assessed all articles, and the final decision to exclude an article was reached by consensus. We extracted data according to predetermined variables, including study country, sepsis definition, and data source. We then calculated descriptive statistics for the reported incidences of sepsis and severe sepsis. The studies were classified according to the method used to identify cases of sepsis or severe sepsis: chart-based (i.e. review of patient charts) or code-based (i.e. predetermined International Classification of Diseases [ICD] codes). Among 482 articles initially screened, we identified 23 primary publications reporting incidence of sepsis and/or severe sepsis in the general population. The reported incidences ranged from 74 to 1180 per 100,000 person-years and 3 to 1074 per 100,000 person-years for sepsis and severe sepsis, respectively. Most chart-based studies used the Bone criteria (or a modification hereof) and Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study criteria to identify cases of sepsis and severe sepsis. Most code-based studies used ICD-9 codes, but the number of codes used ranged from 1 to more than 1200. We found that the incidence varied according to how sepsis was identified (chart-based vs. code-based), calendar year, data source, and world region. The reported incidences of sepsis and severe sepsis in the general population varied greatly between studies. Such differences may be attributable to differences in the methods used to collect the data, the study period, or the world region where the study was undertaken. This finding highlights the importance of standardised definitions and acquisition of data regarding sepsis and severe sepsis.

A summary and integration of research concerning single pilot IFR operational problems

NASA Technical Reports Server (NTRS)

Chapman, G. C.

1983-01-01

A review of seven research studies pertaining to Single Pilot IFR (SPIFR) operations was performed. Two studies were based on questionnaire surveys; two based on National Transportation Safety Board (NTSB) reports; two were based on Aviation Safety Reporting System (ASRS) incident reports, and one report used event analysis and statistics to forecast problems. The results obtained in each study were extracted and integrated. Results were synthesized and key issues pertaining to SPIFR operations problems were identified. The research that was recommended by the studies and that addressed the key issues is catalogued for each key issue.

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

DOE Office of Scientific and Technical Information (OSTI.GOV)

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

2012-11-15

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

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

PubMed

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

2015-01-01

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

Effects and Satisfaction of Medical Device Safety Information Reporting System Using Electronic Medical Record.

PubMed

Jang, Hye Jung; Choi, Young Deuk; Kim, Nam Hyun

2017-04-01

This paper describes an evaluation study on the effectiveness of developing an in-hospital medical device safety information reporting system for managing safety information, including adverse incident data related to medical devices, following the enactment of the Medical Device Act in Korea. Medical device safety information reports were analyzed for 190 cases that took place prior to the application of a medical device safety information reporting system and during a period when the reporting system was used. Also, questionnaires were used to measure the effectiveness of the medical device safety information reporting system. The analysis was based on the questionnaire responses of 15 reporters who submitted reports in both the pre- and post-reporting system periods. Sixty-two reports were submitted in paper form, but after the system was set up, this number more than doubled to 128 reports in electronic form. In terms of itemized reporting, a total of 45 items were reported. Before the system was used, 23 items had been reported, but this increased to 32 items after the system was put to use. All survey variables of satisfaction received a mean of over 3 points, while positive attitude , potential benefits , and positive benefits all exceeded 4 points, each receiving 4.20, 4.20, and 4.13, respectively. Among the variables, time-consuming and decision-making had the lowest mean values, each receiving 3.53. Satisfaction was found to be high for system quality and user satisfaction , but relatively low for time-consuming and decision-making . We were able to verify that effective reporting and monitoring of adverse incidents and the safety of medical devices can be implemented through the establishment of an in-hospital medical device safety information reporting system that can enhance patient safety and medical device risk management.

[Monitoring nosocomial infections using a laboratory-based system].

PubMed

Montella, F; Gallo, S; Leacche, G; Macchia, G

1998-01-01

In this paper we report the results of a nosocomial infections surveillance system "Laboratory Based". The system started in August 1995 at San Giovanni Hospital, Rome. All the specimens sent to the Microbiology Laboratory have been registered using a computerized input form. 12,204 forms, attributable to patients between 0 and 97 years (median 43 years) resulted evaluable. The global rate of incidence of nosocomial infection was, in the study period, 16 per one thousand person/day. The rate of incidence, when stratified for the medical, surgical and emergency boards, was, respectively, 19 per one thousand person/day in the medical facilities, 15 per one thousand person/day in surgical and 17 per one thousand person/year in emergency facilities. The nosocomial infections incidence correlated well with the age of the patients and the time of bed stay. The bulk of infections were localized to the respiratory apparatus. Localization to urinary apparatus and sepsis follow. The isolated microbes were (38%) gram-negative microbes; the 38% of the isolates are gram-negative microbes and the 24% are Mycetes. Our data validate the surveillance system in a great hospital of Rome metropolitan area.

Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis.

PubMed

2017-01-01

A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies. The objective of this review was to address two research questions: (a) what are the barriers to and facilitators of successful adoption of a patient safety learning system reported by health professionals and (b) what design components maximize successful adoption and implementation? To answer the first question, we used a published systematic review. To answer the second question, we used scoping study methodology. Common barriers reported in the literature by health care professionals included fear of blame, legal penalties, the perception that incident reporting does not improve patient safety, lack of organizational support, inadequate feedback, lack of knowledge about incident reporting systems, and lack of understanding about what constitutes an error. Common facilitators included a non-accusatory environment, the perception that incident reporting improves safety, clarification of the route of reporting and of how the system uses reports, enhanced feedback, role models (such as managers) using and promoting reporting, legislated protection of those who report, ability to report anonymously, education and training opportunities, and clear guidelines on what to report. Components of a patient safety learning system that increased successful adoption and implementation were emphasis on a blame-free culture that encourages reporting and learning, clear guidelines on how and what to report, making sure the system is user-friendly, organizational development support for data analysis to generate meaningful learning outcomes, and multiple mechanisms to provide feedback through routes to reporters and the wider community (local meetings, email alerts, bulletins, paper contributions, etc.). The design of a patient safety learning system can be optimized by an awareness of the barriers to and facilitators of successful adoption and implementation identified by health care professionals. Evaluation of the effectiveness of a patient safety learning system is needed to refine its design.

A well-designed online transfusion reaction reporting system improves the estimation of transfusion reaction incidence and quality of care in transfusion practice.

PubMed

Yeh, Su-Peng; Chang, Ci-Wen; Chen, Ju-Chuan; Yeh, Wan-Chen; Chen, Pei-Chi; Chuang, Su-Jung; Lin, Chiou-Ping; Hsu, Ling-Nu; Chen, Han-Mih; Lu, Jang-Jih; Peng, Ching-Tien

2011-12-01

Recognizing and reporting a transfusion reaction is important in transfusion practice. However, the actual incidence of transfusion reactions is frequently underestimated. We designed an online transfusion reaction reporting system for nurses who take care of transfusion recipients. The common management before and after transfusion and the 18 most common transfusion reactions were itemized as tick boxes. We found the overall documented incidence of transfusion reaction increased dramatically, from 0.21% to 0.61% per unit of blood, after we started using an online reporting system. Overall, 94% (30/32) of nurses took only 1 week to become familiar with the new system, and 88% (28/32) considered the new system helpful in improving the quality of clinical transfusion care. By using an intranet connection, blood bank physicians can also identify patients who are having a reaction and provide appropriate recommendations immediately. A well-designed online reporting system may improve the ability to estimate the incidence of transfusion reactions and the quality of transfusion care.

A Practical Guide to Interpretation of Large Collections of Incident Narratives Using the QUORUM Method

NASA Technical Reports Server (NTRS)

McGreevy, Michael W.

1997-01-01

Analysis of incident reports plays an important role in aviation safety. Typically, a narrative description, written by a participant, is a central part of an incident report. Because there are so many reports, and the narratives contain so much detail, it can be difficult to efficiently and effectively recognize patterns among them. Recognizing and addressing recurring problems, however, is vital to continuing safety in commercial aviation operations. A practical way to interpret large collections of incident narratives is to apply the QUORUM method of text analysis, modeling, and relevance ranking. In this paper, QUORUM text analysis and modeling are surveyed, and QUORUM relevance ranking is described in detail with many examples. The examples are based on several large collections of reports from the Aviation Safety Reporting System (ASRS) database, and a collection of news stories describing the disaster of TWA Flight 800, the Boeing 747 which exploded in mid- air and crashed near Long Island, New York, on July 17, 1996. Reader familiarity with this disaster should make the relevance-ranking examples more understandable. The ASRS examples illustrate the practical application of QUORUM relevance ranking.

Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting.

PubMed

Anderson, Janet E; Kodate, Naonori; Walters, Rhiannon; Dodds, Anneliese

2013-04-01

Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. Qualitative research design using documentary analysis and semi-structured interviews. Two large teaching hospitals in London; one providing acute and the other mental healthcare. Sixty-two healthcare practitioners with experience of reporting and analysing incidents. Incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals. Incident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.

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.

Incidence of CNS Injury for a Cohort of 111 Patients Treated With Proton Therapy for Medulloblastoma: LET and RBE Associations for Areas of Injury

DOE Office of Scientific and Technical Information (OSTI.GOV)

Giantsoudi, Drosoula; Sethi, Roshan V.; Yeap, Beow Y.

Background: Central nervous system (CNS) injury is a rare complication of radiation therapy for pediatric brain tumors, but its incidence with proton radiation therapy (PRT) is less well defined. Increased linear energy transfer (LET) and relative biological effectiveness (RBE) at the distal end of proton beams may influence this risk. We report the incidence of CNS injury in medulloblastoma patients treated with PRT and investigate correlations with LET and RBE values. Methods and Materials: We reviewed 111 consecutive patients treated with PRT for medulloblastoma between 2002 and 2011 and selected patients with clinical symptoms of CNS injury. Magnetic resonance imagingmore » (MRI) findings for all patients were contoured on original planning scans (treatment change areas [TCA]). Dose and LET distributions were calculated for the treated plans using Monte Carlo system. RBE values were estimated based on LET-based published models. Results: At a median follow-up of 4.2 years, the 5-year cumulative incidence of CNS injury was 3.6% for any grade and 2.7% for grade 3+. Three of 4 symptomatic patients were treated with a whole posterior fossa boost. Eight of 10 defined TCAs had higher LET values than the target but statistically nonsignificant differences in RBE values (P=.12). Conclusions: Central nervous system and brainstem injury incidence for PRT in this series is similar to that reported for photon radiation therapy. The risk of CNS injury was higher for whole posterior fossa boost than for involved field. Although no clear correlation with RBE values was found, numbers were small and additional investigation is warranted to better determine the relationship between injury and LET.« less

Associations between task, training and social environmental factors and error types involved in rail incidents and accidents.

PubMed

Read, Gemma J M; Lenné, Michael G; Moss, Simon A

2012-09-01

Rail accidents can be understood in terms of the systemic and individual contributions to their causation. The current study was undertaken to determine whether errors and violations are more often associated with different local and organisational factors that contribute to rail accidents. The Contributing Factors Framework (CFF), a tool developed for the collection and codification of data regarding rail accidents and incidents, was applied to a sample of investigation reports. In addition, a more detailed categorisation of errors was undertaken. Ninety-six investigation reports into Australian accidents and incidents occurring between 1999 and 2008 were analysed. Each report was coded independently by two experienced coders. Task demand factors were significantly more often associated with skill-based errors, knowledge and training deficiencies significantly associated with mistakes, and violations significantly linked to social environmental factors. Copyright © 2012 Elsevier Ltd. All rights reserved.

49 CFR 171.16 - Detailed hazardous materials incident reports.

Code of Federal Regulations, 2014 CFR

2014-10-01

... quantity of hazardous waste; (3) A specification cargo tank with a capacity of 1,000 gallons or greater..., DC 20590-0001, or an electronic Hazardous Material Incident Report to the Information System Manager..., submit a written or electronic copy of the Hazardous Materials Incident Report to the FAA Security Field...

49 CFR 171.16 - Detailed hazardous materials incident reports.

Code of Federal Regulations, 2012 CFR

2012-10-01

... quantity of hazardous waste; (3) A specification cargo tank with a capacity of 1,000 gallons or greater..., DC 20590-0001, or an electronic Hazardous Material Incident Report to the Information System Manager..., submit a written or electronic copy of the Hazardous Materials Incident Report to the FAA Security Field...

49 CFR 171.16 - Detailed hazardous materials incident reports.

Code of Federal Regulations, 2013 CFR

2013-10-01

... quantity of hazardous waste; (3) A specification cargo tank with a capacity of 1,000 gallons or greater..., DC 20590-0001, or an electronic Hazardous Material Incident Report to the Information System Manager..., submit a written or electronic copy of the Hazardous Materials Incident Report to the FAA Security Field...

Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies.

PubMed

Ng, Siew C; Shi, Hai Yun; Hamidi, Nima; Underwood, Fox E; Tang, Whitney; Benchimol, Eric I; Panaccione, Remo; Ghosh, Subrata; Wu, Justin C Y; Chan, Francis K L; Sung, Joseph J Y; Kaplan, Gilaad G

2018-12-23

Inflammatory bowel disease is a global disease in the 21st century. We aimed to assess the changing incidence and prevalence of inflammatory bowel disease around the world. We searched MEDLINE and Embase up to and including Dec 31, 2016, to identify observational, population-based studies reporting the incidence or prevalence of Crohn's disease or ulcerative colitis from 1990 or later. A study was regarded as population-based if it involved all residents within a specific area and the patients were representative of that area. To be included in the systematic review, ulcerative colitis and Crohn's disease needed to be reported separately. Studies that did not report original data and studies that reported only the incidence or prevalence of paediatric-onset inflammatory bowel disease (diagnosis at age <16 years) were excluded. We created choropleth maps for the incidence (119 studies) and prevalence (69 studies) of Crohn's disease and ulcerative colitis. We used temporal trend analyses to report changes as an annual percentage change (APC) with 95% CI. We identified 147 studies that were eligible for final inclusion in the systematic review, including 119 studies of incidence and 69 studies of prevalence. The highest reported prevalence values were in Europe (ulcerative colitis 505 per 100 000 in Norway; Crohn's disease 322 per 100 000 in Germany) and North America (ulcerative colitis 286 per 100 000 in the USA; Crohn's disease 319 per 100 000 in Canada). The prevalence of inflammatory bowel disease exceeded 0·3% in North America, Oceania, and many countries in Europe. Overall, 16 (72·7%) of 22 studies on Crohn's disease and 15 (83·3%) of 18 studies on ulcerative colitis reported stable or decreasing incidence of inflammatory bowel disease in North America and Europe. Since 1990, incidence has been rising in newly industrialised countries in Africa, Asia, and South America, including Brazil (APC for Crohn's disease +11·1% [95% CI 4·8-17·8] and APC for ulcerative colitis +14·9% [10·4-19·6]) and Taiwan (APC for Crohn's disease +4·0% [1·0-7·1] and APC for ulcerative colitis +4·8% [1·8-8·0]). At the turn of the 21st century, inflammatory bowel disease has become a global disease with accelerating incidence in newly industrialised countries whose societies have become more westernised. Although incidence is stabilising in western countries, burden remains high as prevalence surpasses 0·3%. These data highlight the need for research into prevention of inflammatory bowel disease and innovations in health-care systems to manage this complex and costly disease. None. Copyright © 2017 Elsevier Ltd. All rights reserved.

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

DOE Office of Scientific and Technical Information (OSTI.GOV)

Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric

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,more » (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.« less

Supporting staff recovery and reintegration after a critical incident resulting in infant death.

PubMed

Roesler, Roberta; Ward, Debra; Short, Mary

2009-08-01

A critical incident is described as any sudden unexpected event that has the power to overwhelm the usual effective coping skills of an individual or a group and can cause significant psychological distress in usually healthy persons. A Just Culture model to deal with critical incidents is an approach that seeks to identify and balance system events and personal accountability. This article reports a critical incident that occurred at the Neonatal Intensive Care Unit, Methodist Hospital of Indianapolis, when 5 infants received an overdose of heparin that resulted in the death of 3 infants. Although care of the family after the critical incident was the immediate priority, the focus of this article was on the recovery and reintegration of the NICU staff after a critical incident based on the Just Culture philosophy.

Medical students' perceptions of a novel institutional incident reporting system : A thematic analysis.

PubMed

Gordon, Morris; Parakh, Dillan

2017-10-01

Errors in healthcare are a major patient safety issue, with incident reporting a key solution. The incident reporting system has been integrated within a new medical curriculum, encouraging medical students to take part in this key safety process. The aim of this study was to describe the system and assess how students perceived the reporting system with regards to its role in enhancing safety. Employing a thematic analysis, this study used interviews with medical students at the end of the first year. Thematic indices were developed according to the information emerging from the data. Through open, axial and then selective stages of coding, an understanding of how the system was perceived was established. Analysis of the interview specified five core themes: (1) Aims of the incident reporting system; (2) internalized cognition of the system; (3) the impact of the reporting system; (4) threshold for reporting; (5) feedback on the systems operation. Selective analysis revealed three overriding findings: lack of error awareness and error wisdom as underpinned by key theoretical constructs, student support of the principle of safety, and perceptions of a blame culture. Students did not interpret reporting as a manner to support institutional learning and safety, rather many perceived it as a tool for a blame culture. The impact reporting had on students was unexpected and may give insight into how other undergraduates and early graduates interpret such a system. Future studies should aim to produce interventions that can support a reporting culture.

Integration of the incident command system (ICS) protocol for effective coordination of multi-agency response to traffic incidents : final report.

DOT National Transportation Integrated Search

2017-06-13

In recent years, there has been an increased focus on Traffic Incident Management (TIM) and : incorporation of the Incident Command System (ICS) to reduce traffic congestion on the nation's : Interstates. In fact, studies show that for every minute a...

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.

Prognostic scoring systems for myelodysplastic syndromes (MDS) in a population-based setting: a report from the Swedish MDS register.

PubMed

Moreno Berggren, Daniel; Folkvaljon, Yasin; Engvall, Marie; Sundberg, Johan; Lambe, Mats; Antunovic, Petar; Garelius, Hege; Lorenz, Fryderyk; Nilsson, Lars; Rasmussen, Bengt; Lehmann, Sören; Hellström-Lindberg, Eva; Jädersten, Martin; Ejerblad, Elisabeth

2018-06-01

The myelodysplastic syndromes (MDS) have highly variable outcomes and prognostic scoring systems are important tools for risk assessment and to guide therapeutic decisions. However, few population-based studies have compared the value of the different scoring systems. With data from the nationwide Swedish population-based MDS register we validated the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R) and the World Health Organization (WHO) Classification-based Prognostic Scoring System (WPSS). We also present population-based data on incidence, clinical characteristics including detailed cytogenetics and outcome from the register. The study encompassed 1329 patients reported to the register between 2009 and 2013, 14% of these had therapy-related MDS (t-MDS). Based on the MDS register, the yearly crude incidence of MDS in Sweden was 2·9 per 100 000 inhabitants. IPSS-R had a significantly better prognostic power than IPSS (P < 0·001). There was a trend for better prognostic power of IPSS-R compared to WPSS (P = 0·05) and for WPSS compared to IPSS (P = 0·07). IPSS-R was superior to both IPSS and WPSS for patients aged ≤70 years. Patients with t-MDS had a worse outcome compared to de novo MDS (d-MDS), however, the validity of the prognostic scoring systems was comparable for d-MDS and t-MDS. In conclusion, population-based studies are important to validate prognostic scores in a 'real-world' setting. In our nationwide cohort, the IPSS-R showed the best predictive power. © 2018 John Wiley & Sons Ltd.

Carbon monoxide from neighbouring restaurants: the need for an integrated multi-agency response.

PubMed

Keshishian, C; Sandle, H; Meltzer, M; Young, Y; Ward, R; Balasegaram, S

2012-12-01

Carbon monoxide (CO) is a colourless, odourless toxic gas produced during incomplete combustion of carbon-based fuels. Most CO incidents reported to the UK Health Protection Agency (HPA) are due to faulty gas appliances, and legislation exists to ensure gas appliances are properly installed. We present three CO poisoning incidents of unusual origin reported to the HPA. In each, residents living above restaurants were poisoned after workers left charcoal smouldering overnight in specialist or traditional ovens whilst ventilation systems were turned off. This led to production of CO, which travelled through floorboards and built up to dangerous concentrations in the flats. Working with local authorities, these incidents were investigated and resolved, and work was conducted to prevent further occurrences. The novel nature of these CO incidents led to delays in recognition and subsequent remedial action. Although previously undescribed, it is likely that due to the number of residences built above restaurants and the rising popularity of traditional cooking methods, similar incidents may be occurring and could increase in frequency. Multi-agency response and reporting mechanisms could be strengthened. Awareness raising in professional groups and the public on the importance of correct ventilation of such appliances is vital.

DIRECT operational field test evaluation natural use study. Part 3, Evaluation of driver behavior and measurement of effectiveness of DIRECT communications technologies based on vehicle tracking around incidents

DOT National Transportation Integrated Search

1998-08-01

Vehicle tracking systems were installed on all DIRECT vehicles to help investigate the : relationships between the drivers actual travel experiences and their opinions about the : systems they used. The purpose of this report is to look more caref...

Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

PubMed

Van de Vreede, Melita; McGrath, Anne; de Clifford, Jan

2018-05-14

Objective. The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions. Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

Applying the compound Poisson process model to the reporting of injury-related mortality rates.

PubMed

Kegler, Scott R

2007-02-16

Injury-related mortality rate estimates are often analyzed under the assumption that case counts follow a Poisson distribution. Certain types of injury incidents occasionally involve multiple fatalities, however, resulting in dependencies between cases that are not reflected in the simple Poisson model and which can affect even basic statistical analyses. This paper explores the compound Poisson process model as an alternative, emphasizing adjustments to some commonly used interval estimators for population-based rates and rate ratios. The adjusted estimators involve relatively simple closed-form computations, which in the absence of multiple-case incidents reduce to familiar estimators based on the simpler Poisson model. Summary data from the National Violent Death Reporting System are referenced in several examples demonstrating application of the proposed methodology.

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.

Measurement Matters: Comparing Old and New Definitions of Rape in Federal Statistical Reporting.

PubMed

Bierie, David M; Davis-Siegel, James C

2015-10-01

National statistics on the incidence of rape play an important role in the work of policymakers and academics. The Uniform Crime Reports (UCR) have provided some of the most widely used and influential statistics on the incidence of rape across the United States over the past 80 years. The definition of rape used by UCR changed in 2012 to include substantially more types of sexual assault. This article draws on 20 years of data from the National Incident-Based Reporting System to describe the impact this definitional change will have on estimates of the incidence of rape and trends over time. Drawing on time series as well as panel random effects methodologies, we show that 40% of sexual assaults have been excluded by the prior definition and that the magnitude of this error has grown over time. However, the overall trend in rape over time (year-to-year change) was not substantially different when comparing events meeting the prior definition and the subgroups of sexual assault that will now be counted. © The Author(s) 2014.

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.

A Summary of NASA and USAF Hypergolic Propellant Related Spills and Fires

NASA Technical Reports Server (NTRS)

Nufer, Brian

2010-01-01

Several unintentional hypergolic fluid related spills, fires, and explosions from the Apollo Program, the Space Shuttle Program, the Titan Program, and a few others have occurred over the past several decades. Spill sites include the following government facilities: Kennedy Space Center (KSC), Johnson Space Center (JSC), White Sands Test Facility (WSTF), Vandenberg Air Force Base (VAFB), Cape Canaveral Air Force Station (CCAFS), Edwards Air Force Base (EAFB), Little Rock AFB, and McConnell AFB. Until now, the only method of capturing the lessons learned from these incidents has been "word of mouth" or by studying each individual incident report. Through studying several dozen of these incidents, certain root cause themes are apparent. Scrutinizing these themes could prove to be highly beneficial to future hypergolic system test, checkout, and operational use.

Hypergolic Propellants: The Handling Hazards and Lessons Learned from Use

NASA Technical Reports Server (NTRS)

Nufer, Brian

2010-01-01

Several unintentional hypergolic fluid related spills, fires, and explosions from the Apollo Program, the Space Shuttle Program, the Titan Program, and a few others have occurred over the past several decades. Spill sites include the following government facilities: Kennedy Space Center (KSC), Johnson Space Center (JSC), White Sands Test Facility (WSTF), Vandenberg Air Force Base (VAFB), Cape Canaveral Air Force Station (CCAFS), Edwards Air Force Base (EAFB), Little Rock AFB, and McConnell AFB. Until now, the only method of capturing the lessons learned from these incidents has been "word of mouth" or by studying each individual incident report. Through studying several dozen of these incidents, certain root cause themes are apparent. Scrutinizing these themes could prove to be highly beneficial to future hypergolic system testing, checkout, and operational use.

Municipality Level Simulations of Dengue Fever Incidence in Puerto Rico Using Ground Based and Remotely Sensed Climate Data

NASA Technical Reports Server (NTRS)

Quattrochi, Dale A.; Morin, Cory

2015-01-01

Dengue fever (DF) is caused by a virus transmitted between humans and Aedes genus mosquitoes through blood feeding. In recent decades incidence of the disease has drastically increased in the tropical Americas, culminating with the Pan American outbreak in 2010 which resulted in 1.7 million reported cases. In Puerto Rico dengue is endemic, however, there is significant inter-annual, intraannual, and spatial variability in case loads. Variability in climate and the environment, herd immunity and virus genetics, and demographic characteristics may all contribute to differing patterns of transmission both spatially and temporally. Knowledge of climate influences on dengue incidence could facilitate development of early warning systems allowing public health workers to implement appropriate transmission intervention strategies. In this study, we simulate dengue incidence in several municipalities in Puerto Rico using population and meteorological data derived from ground based stations and remote sensing instruments. This data was used to drive a process based model of vector population development and virus transmission. Model parameter values for container composition, vector characteristics, and incubation period were chosen by employing a Monte Carlo approach. Multiple simulations were performed for each municipality and the results were compared with reported dengue cases. The best performing simulations were retained and their parameter values and meteorological input were compared between years and municipalities. Parameter values varied by municipality and year illustrating the complexity and sensitivity of the disease system. Local characteristics including the natural and built environment impact transmission dynamics and produce varying responses to meteorological conditions.

Workload management and geographic disorientation in aviation incidents: A review of the ASRS data base

NASA Technical Reports Server (NTRS)

Williams, Henry P.; Tham, Mingpo; Wickens, Christopher D.

1993-01-01

NASA's Aviation Safety Reporting System (ASRS) incident reports are reviewed in two related areas: pilots' failures to appropriately manage tasks, and breakdowns in geographic orientation. Examination of 51 relevant reports on task management breakdowns revealed that altitude busts and inappropriate runway usee were the most frequently reported consequences. Task management breakdowns appeared to occur at all levels of expertise, and prominent causal factors were related to breakdowns in crew communications, over-involvement with the flight management system and, for small (general aviation) aircraft, preoccupation with weather. Analysis of the 83 cases of geographic disorientation suggested that these too occurred at all levels of pilot experience. With regard to causal factors, a majority was related to poor cockpit resource management, in which inattention led to a loss of geographic awareness. Other leading causes were related to poor weather and poor decision making. The potential of the ASRS database for contributing to research and design issues is addressed.

Reported occupational respiratory diseases in Catalonia.

PubMed

Orriols, R; Costa, R; Albanell, M; Alberti, C; Castejon, J; Monso, E; Panades, R; Rubira, N; Zock, J-P

2006-04-01

A voluntary surveillance system was implemented in Catalonia (Spain) to ascertain the feasibility, incidence, and characteristics of occupational respiratory diseases and compare them with those of the compulsory official system. In 2002, in collaboration with the Occupational and Thoracic Societies of Catalonia, occupational and chest physicians and other specialists were invited to report, on a bimonthly basis, newly diagnosed cases of occupational respiratory diseases. Information requested on each case included diagnosis, age, sex, place of residence, occupation, suspected agent, and physician's opinion on the likelihood that the condition was work related. Compulsory official system data derived from statistics on work related diseases for possible disability benefits declared by insurance companies, which are responsible for declaring these diseases to the Autonomous Government of Catalonia. Of 142 physicians seeing patients with occupational respiratory diseases approached, 102 (74%) participated. Three hundred and fifty nine cases were reported, of which asthma (48.5%), asbestos related diseases (14.5%), and acute inhalations (12.8%) were the most common. Physicians rated 63% of suspected cases as highly likely, 28% as likely, and 8% as low likelihood. The most frequent suspected agents reported for asthma were isocyanates (15.5%), persulphates (12.1%), and cleaning products (8.6%). Mesothelioma (5.9%) was the most frequent diagnosis among asbestos related diseases. The number of acute inhalations reported was high, with metal industries (26%), cleaning services (22%), and chemical industries (13%) being the most frequently involved. The frequency of occupational respiratory diseases recorded by this voluntary surveillance system was four times higher than that reported by the compulsory official system. The compulsory scheme for reporting occupational lung diseases is seriously underreporting in Catalonia. A surveillance programme based on voluntary reporting by physicians may provide better understanding of the incidence and characteristics of these diseases. Persulphates and cleaning products, besides isocyanates, were the most reported causes of occupational asthma. Metal industries and cleaning services were the occupations most frequently involved in acute inhalations with a remarkably high incidence in our register.

Reported occupational respiratory diseases in Catalonia

PubMed Central

Orriols, R; Costa, R; Albanell, M; Alberti, C; Castejon, J; Monso, E; Panades, R; Rubira, N; Zock, J‐P

2006-01-01

Objectives A voluntary surveillance system was implemented in Catalonia (Spain) to ascertain the feasibility, incidence, and characteristics of occupational respiratory diseases and compare them with those of the compulsory official system. Methods In 2002, in collaboration with the Occupational and Thoracic Societies of Catalonia, occupational and chest physicians and other specialists were invited to report, on a bimonthly basis, newly diagnosed cases of occupational respiratory diseases. Information requested on each case included diagnosis, age, sex, place of residence, occupation, suspected agent, and physician's opinion on the likelihood that the condition was work related. Compulsory official system data derived from statistics on work related diseases for possible disability benefits declared by insurance companies, which are responsible for declaring these diseases to the Autonomous Government of Catalonia. Results Of 142 physicians seeing patients with occupational respiratory diseases approached, 102 (74%) participated. Three hundred and fifty nine cases were reported, of which asthma (48.5%), asbestos related diseases (14.5%), and acute inhalations (12.8%) were the most common. Physicians rated 63% of suspected cases as highly likely, 28% as likely, and 8% as low likelihood. The most frequent suspected agents reported for asthma were isocyanates (15.5%), persulphates (12.1%), and cleaning products (8.6%). Mesothelioma (5.9%) was the most frequent diagnosis among asbestos related diseases. The number of acute inhalations reported was high, with metal industries (26%), cleaning services (22%), and chemical industries (13%) being the most frequently involved. The frequency of occupational respiratory diseases recorded by this voluntary surveillance system was four times higher than that reported by the compulsory official system. Conclusions The compulsory scheme for reporting occupational lung diseases is seriously underreporting in Catalonia. A surveillance programme based on voluntary reporting by physicians may provide better understanding of the incidence and characteristics of these diseases. Persulphates and cleaning products, besides isocyanates, were the most reported causes of occupational asthma. Metal industries and cleaning services were the occupations most frequently involved in acute inhalations with a remarkably high incidence in our register. PMID:16556745

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.

Analysing the quality of routine malaria data in Mozambique.

PubMed

Chilundo, Baltazar; Sundby, Johanne; Aanestad, Margunn

2004-03-03

In Mozambique, malaria is the principal cause of morbidity and mortality. Efforts are being made to increase control activities within communities. These activities require management decisions based on evidence of malaria incidence. Although some data generated are of poor quality, there is little research towards improving the reporting systems. An analysis of the quality of routine malaria data was performed in selected districts in Southern Mozambique from August to September 2003. The aim was to assess the quality of the source data in terms of completeness, correctness and consistency across management levels. Analysis revealed primary data to be of poor quality. The diversity of reporting systems with limited coordination give rise to redundancies and wastage of resources. There was evidence of "invention" of data in health facilities contributing to an incorrect representation of malaria incidence. Large, "non-clinical", time-based variations of malaria cases due to reporting delays were also noted, contributing to false alerts of outbreaks.Furthermore, targets established in the national strategic plan for malaria cannot be calculated through the existing systems; this is the case, for example, for data related to pregnant women and children under-five years. The existing reporting system for malaria is currently not satisfying the information needs of managers. It is suggested that one standardized system, including the creation of one form to include the essential variables required for the calculation of key indicators by age, gender and pregnancy status, and to establish a national database that maps malaria by location.

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.

ITS Architecture Development Program, Phase I; Summary Report

DOT National Transportation Integrated Search

1994-11-01

IN-VEHICLE EMISSIONS DIAGNOSIS, COMMERCIAL VEHICLES OPERATIONS OR CVO, ADVANCED VEHICLE CONTROL AND SAFETY SYSTEMS OR AVCSS, ADVANCED PUBLIC TRANSPORTATION SYSTEMS OR APTS, INCIDENT MANAGEMENT/INCIDENT DETECTION, COLLISION AVOIDANCE SYSTEM, AUTOMATED...

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 Section 191.9 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE;...

Hospital referral patterns: how emergency medical care is accessed in a disaster.

PubMed

Reilly, Michael J; Markenson, David

2010-10-01

A prevalent assumption in hospital emergency preparedness planning is that patient arrival from a disaster scene will occur through a coordinated system of patient distribution based on the number of victims, capabilities of the receiving hospitals, and the nature and severity of illness or injury. In spite of the strength of the emergency medical services system, case reports in the literature and major incident after-action reports have shown that most patients who present at a health care facility after a disaster or other major emergency do not necessarily arrive via ambulance. If these reports of arrival of patients outside an organized emergency medical services system are accurate, then hospitals should be planning differently for the impact of an unorganized influx of patients on the health care system. Hospitals need to consider alternative patterns of patient referral, including the mass convergence of self-referred patients, when performing major incident planning. We conducted a retrospective review of published studies from the past 25 years to identify reports of patient care during disasters or major emergency incidents that described the patients' method of arrival at the hospital. Using a structured mechanism, we aggregated and analyzed the data. Detailed data on 8303 patients from more than 25 years of literature were collected. Many reports suggest that only a fraction of the patients who are treated in emergency departments following disasters arrive via ambulance, particularly in the early postincident stages of an event. Our 25 years of aggregate data suggest that only 36% of disaster victims are transported to hospitals via ambulance, whereas 63% use alternate means to seek emergency medical care. Hospitals should evaluate their emergency plans to consider the implications of alternate referral patterns of patients during a disaster. Additional consideration should be given to mass triage, site security, and the potential need for decontamination after a major incident.

Surveillance for Lyme Disease — United States, 2008–2015

PubMed Central

Schwartz, Amy M.; Hinckley, Alison F.; Mead, Paul S.; Hook, Sarah A.

2017-01-01

Problem/Condition Lyme disease is the most commonly reported vectorborne disease in the United States but is geographically focal. The majority of Lyme disease cases occur in the Northeast, mid-Atlantic, and upper Midwest regions. Lyme disease can cause varied clinical manifestations, including erythema migrans, arthritis, facial palsy, and carditis. Lyme disease occurs most commonly among children and older adults, with a slight predominance among males. Reporting Period 2008–2015. Description of System Lyme disease has been a nationally notifiable condition in the United States since 1991. Possible Lyme disease cases are reported to local and state health departments by clinicians and laboratories. Health department staff conduct case investigations to classify cases according to the national surveillance case definition. Those that qualify as confirmed or probable cases of Lyme disease are reported to CDC through the National Notifiable Diseases Surveillance System. States with an average annual incidence during this reporting period of ≥10 confirmed Lyme disease cases per 100,000 population were classified as high incidence. States that share a border with those states or that are located between areas of high incidence were classified as neighboring states. All other states were classified as low incidence. Results During 2008–2015, a total of 275,589 cases of Lyme disease were reported to CDC (208,834 confirmed and 66,755 probable). Although most cases continue to be reported from states with high incidence in the Northeast, mid-Atlantic, and upper Midwest regions, case counts in most of these states have remained stable or decreased during the reporting period. In contrast, case counts have increased in states that neighbor those with high incidence. Overall, demographic characteristics associated with confirmed cases were similar to those described previously, with a slight predominance among males and a bimodal age distribution with peaks among young children and older adults. Yet, among the subset of cases reported from states with low incidence, infection occurred more commonly among females and older adults. In addition, probable cases occurred more commonly among females and with a higher modal age than confirmed cases. Interpretation Lyme disease continues to be the most commonly reported vectorborne disease in the United States. Although concentrated in historically high-incidence areas, the geographic distribution is expanding into neighboring states. The trend of stable to decreasing case counts in many states with high incidence could be a result of multiple factors, including actual stabilization of disease incidence or artifact due to modifications in reporting practices employed by some states to curtail the resource burden associated with Lyme disease surveillance. Public Health Action This report highlights the continuing public health challenge of Lyme disease in states with high incidence and demonstrates its emergence in neighboring states that previously experienced few cases. Educational efforts should be directed accordingly to facilitate prevention, early diagnosis, and appropriate treatment. As Lyme disease emerges in neighboring states, clinical suspicion of Lyme disease in a patient should be based on local experience rather than incidence cutoffs used for surveillance purposes. A diagnosis of Lyme disease should be considered in patients with compatible clinical signs and a history of potential exposure to infected ticks, not only in states with high incidence but also in areas where Lyme disease is known to be emerging. These findings underscore the ongoing need to implement personal prevention practices routinely (e.g., application of insect repellent and inspection for and removal of ticks) and to develop other effective interventions. PMID:29120995

Nurses' attitudes towards the reporting of violence in the emergency department.

PubMed

Hogarth, Kathryn M; Beattie, Jill; Morphet, Julia

2016-05-01

The incidence of workplace violence against nurses in emergency departments is underreported. Thus, the true nature and frequency of violent incidents remains unknown. It is therefore difficult to address the problem. To identify the attitudes, barriers and enablers of emergency nurses to the reporting of workplace violence. Using a phenomenological approach, two focus groups were conducted at a tertiary emergency department. The data were audio-recorded, transcribed verbatim and analysed using thematic analysis. Violent incidents in this emergency department were underreported. Nurses accepted violence as part of their normal working day, and therefore were less likely to report it. Violent incidents were not defined as 'violence' if no physical injury was sustained, therefore it was not reported. Nurses were also motivated to report formally in order to protect themselves from any possible future complaints made by perpetrators. The current formal reporting system was a major barrier to reporting because it was difficult and time consuming to use. Nurses reported violence using methods other than the designated reporting system. While emergency nurses do report violence, they do not use the formal reporting system. When they did use the formal reporting system they were motivated to do so in order to protect themselves. As a consequence of underreporting, the nature and extent of workplace violence remains unknown. Copyright © 2015 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

PubMed Central

Kapur, Ajay; Goode, Gina; Riehl, Catherine; Zuvic, Petrina; Joseph, Sherin; Adair, Nilda; Interrante, Michael; Bloom, Beatrice; Lee, Lucille; Sharma, Rajiv; Sharma, Anurag; Antone, Jeffrey; Riegel, Adam; Vijeh, Lili; Zhang, Honglai; Cao, Yijian; Morgenstern, Carol; Montchal, Elaine; Cox, Brett; Potters, Louis

2013-01-01

By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice. PMID:24380074

Introduction of a prehospital critical incident monitoring system--pilot project results.

PubMed

Stella, Julian; Davis, Anna; Jennings, Paul; Bartley, Bruce

2008-01-01

Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited. Implementation of an incident monitoring process in a prehospital setting. This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations. Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9-5.5%). The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types. The large proportion of incidents in the "near miss" category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.

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.

Crime in Schools and Colleges: A Study of Offenders and Arrestees Reported via National Incident-Based Reporting System Data. The CARD Report: Crime Analysis, Research and Development Unit

ERIC Educational Resources Information Center

Noonan, James H.; Vavra, Malissa C.

2007-01-01

Data from a variety of sources about crime in schools and colleges and characteristics of the people who commit these offenses provide key input in developing theories and operational applications that can help combat crime in this nation's schools, colleges, and universities. Given the myriad of data available, the objective of this study is to…

Application of diffusion maps to identify human factors of self-reported anomalies in aviation.

PubMed

Andrzejczak, Chris; Karwowski, Waldemar; Mikusinski, Piotr

2012-01-01

A study investigating what factors are present leading to pilots submitting voluntary anomaly reports regarding their flight performance was conducted. Diffusion Maps (DM) were selected as the method of choice for performing dimensionality reduction on text records for this study. Diffusion Maps have seen successful use in other domains such as image classification and pattern recognition. High-dimensionality data in the form of narrative text reports from the NASA Aviation Safety Reporting System (ASRS) were clustered and categorized by way of dimensionality reduction. Supervised analyses were performed to create a baseline document clustering system. Dimensionality reduction techniques identified concepts or keywords within records, and allowed the creation of a framework for an unsupervised document classification system. Results from the unsupervised clustering algorithm performed similarly to the supervised methods outlined in the study. The dimensionality reduction was performed on 100 of the most commonly occurring words within 126,000 text records describing commercial aviation incidents. This study demonstrates that unsupervised machine clustering and organization of incident reports is possible based on unbiased inputs. Findings from this study reinforced traditional views on what factors contribute to civil aviation anomalies, however, new associations between previously unrelated factors and conditions were also found.

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 the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.

Real-time incident detection using social media data.

DOT National Transportation Integrated Search

2016-05-09

The effectiveness of traditional incident detection is often limited by sparse sensor coverage, and reporting incidents to emergency response systems : is labor-intensive. This research project mines tweet texts to extract incident information on bot...

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 mitigation. PMID:25583702

Prevalence and Incidence of Systemic Lupus Erythematosus in a Population-Based Registry of American Indian and Alaska Native People, 2007–2009

PubMed Central

Ferucci, Elizabeth D.; Johnston, Janet M.; Gaddy, Jasmine R.; Sumner, Lisa; Posever, James O.; Choromanski, Tammy L.; Gordon, Caroline; Lim, S. Sam; Helmick, Charles G.

2015-01-01

Objective Few studies have investigated the epidemiology of systemic lupus erythematosus (SLE) in American Indian and Alaska Native populations. The objective of this study was to determine the prevalence and incidence of SLE in the Indian Health Service (IHS) active clinical population in 3 regions of the US. Methods For this population-based registry within the IHS, the denominator consisted of individuals in the IHS active clinical population in 2007, 2008, and/or 2009 and residing in a community in 1 of 3 specified regions. Potential SLE cases were identified based on the presence of a diagnostic code for SLE or related disorder in the IHS National Data Warehouse. Detailed medical record abstraction was performed for each potential case. The primary case definition was documentation in the medical record of ≥4 of the revised American College of Rheumatology criteria for the classification of SLE. Prevalence was calculated for 2007, and the mean annual incidence was calculated for the years 2007 through 2009. Results The age-adjusted prevalence and incidence of SLE according to the primary definition were 178 per 100,000 person-years (95% confidence interval [95% CI] 157–200) and 7.4 per 100,000 person-years (95% CI 5.1–10.4). Among women, the age-adjusted prevalence was 271, and the age-adjusted incidence was 10.4. The prevalence was highest in women ages 50–59 years and in the Phoenix Area IHS. Conclusion The first population-based lupus registry in the US American Indian and Alaska Native population has demonstrated that the prevalence and incidence of SLE are high. Our estimates are as high as or higher than the rates reported in the US black population. PMID:24891315

Application of human reliability analysis to nursing errors in hospitals.

PubMed

Inoue, Kayoko; Koizumi, Akio

2004-12-01

Adverse events in hospitals, such as in surgery, anesthesia, radiology, intensive care, internal medicine, and pharmacy, are of worldwide concern and it is important, therefore, to learn from such incidents. There are currently no appropriate tools based on state-of-the art models available for the analysis of large bodies of medical incident reports. In this study, a new model was developed to facilitate medical error analysis in combination with quantitative risk assessment. This model enables detection of the organizational factors that underlie medical errors, and the expedition of decision making in terms of necessary action. Furthermore, it determines medical tasks as module practices and uses a unique coding system to describe incidents. This coding system has seven vectors for error classification: patient category, working shift, module practice, linkage chain (error type, direct threat, and indirect threat), medication, severity, and potential hazard. Such mathematical formulation permitted us to derive two parameters: error rates for module practices and weights for the aforementioned seven elements. The error rate of each module practice was calculated by dividing the annual number of incident reports of each module practice by the annual number of the corresponding module practice. The weight of a given element was calculated by the summation of incident report error rates for an element of interest. This model was applied specifically to nursing practices in six hospitals over a year; 5,339 incident reports with a total of 63,294,144 module practices conducted were analyzed. Quality assurance (QA) of our model was introduced by checking the records of quantities of practices and reproducibility of analysis of medical incident reports. For both items, QA guaranteed legitimacy of our model. Error rates for all module practices were approximately of the order 10(-4) in all hospitals. Three major organizational factors were found to underlie medical errors: "violation of rules" with a weight of 826 x 10(-4), "failure of labor management" with a weight of 661 x 10(-4), and "defects in the standardization of nursing practices" with a weight of 495 x 10(-4).

Investigating incidents of EHR failures in China: analysis of search engine reports.

PubMed

Lei, Jianbo; Guan, Pengcheng; Gao, Kaihua; Lu, Xueqing; Sittig, Dean

2013-01-01

As the healthcare industry becomes increasingly dependent on information technology (IT), the failure of computerized systems could cause catastrophic effects on patient safety. We conducted an empirical study to analyze news articles available on the internet using Baidu and Google. 116 distinct EHR outage news reports were identified. We examined characteristics, potential causes, and possible preventive strategies. Risk management strategies based are discussed.

Trials and tribulations: how we established a major incident database.

PubMed

Hardy, S E J; Fattah, S

2017-01-25

We describe the process of setting up a database of major incident reports and its potential future application. A template for reporting on major incidents was developed using a consensus-based process involving a team of experts in the field. A website was set up as a platform from which to launch the template and as a database of submitted reports. This paper describes the processes involved in setting up a major incident reporting database. It describes how specific difficulties have been overcome and anticipates challenges for the future. We have successfully set up a major incident database, the main purpose of which is to have a repository of standardised major incident reports that can be analysed and compared in order to learn from them.

Reporting Sexual Victimization During Incarceration: Using Ecological Theory as a Framework to Inform and Guide Future Research.

PubMed

Kubiak, Sheryl Pimlott; Brenner, Hannah; Bybee, Deborah; Campbell, Rebecca; Fedock, Gina

2016-03-08

The U.S. Department of Justice estimates that between 149,200 and 209,400 incidents of sexual victimization occur annually in prisons and jails. However, very few individuals experiencing sexual victimization during incarceration report these incidents to correctional authorities. Federal-level policy recommendations derived from the Prison Rape Elimination Act suggest mechanisms for improving reporting as well as standards for the prevention, investigation, and prosecution of prison-based sexual victimization. Despite these policy recommendations, sexual assault persists in prisons and jails, with only 8% of prisoners who experience sexual assault reporting their victimization. This review focuses on gaps in the existing research about what factors influence whether adult victims in incarcerated systems will report that they have been sexually assaulted. Using ecological theory to guide this review, various levels of social ecology are incorporated, illuminating a variety of factors influencing the reporting of sexual victimization during incarceration. These factors include the role of individual-level behavior, assault characteristics, the unique aspects and processes of the prison system, and the social stigma that surrounds individuals involved in the criminal/legal system. This review concludes with recommendations for future research, policy, and practice, informed by an ecological conceptualization of reporting. © The Author(s) 2016.

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

PubMed

Denecke, Kerstin

2016-01-01

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

Using database reports to reduce workplace violence: Perceptions of hospital stakeholders

PubMed Central

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

2016-01-01

BACKGROUND Documented incidents of violence provide the foundation for any workplace violence prevention program. However, no published research to date has examined stakeholders’ preferences for workplace violence data reports in healthcare settings. If relevant data are not readily available and effectively summarized and presented, the likelihood is low that they will be utilized by stakeholders in targeted efforts to reduce violence. OBJECTIVE To discover and describe hospital system stakeholders’ perceptions of database-generated workplace violence data reports. PARTICIPANTS Eight hospital system stakeholders representing Human Resources, Security, Occupational Health Services, Quality and Safety, and Labor in a large, metropolitan hospital system. METHODS The hospital system utilizes a central database for reporting adverse workplace events, including incidents of violence. A focus group was conducted to identify stakeholders’ preferences and specifications for standardized, computerized reports of workplace violence data to be generated by the central database. The discussion was audio-taped, transcribed verbatim, processed as text, and analyzed using stepwise content analysis. RESULTS Five distinct themes emerged from participant responses: Concerns, Etiology, Customization, Use, and Outcomes. In general, stakeholders wanted data reports to provide “the big picture,” i.e., rates of occurrence; reasons for and details regarding incident occurrence; consequences for the individual employee and/or the workplace; and organizational efforts that were employed to deal with the incident. CONCLUSIONS Exploring stakeholder views regarding workplace violence summary reports provided concrete information on the preferred content, format, and use of workplace violence data. Participants desired both epidemiological and incident-specific data in order to better understand and work to prevent the workplace violence occurring in their hospital system. PMID:25059315

Using database reports to reduce workplace violence: Perceptions of hospital stakeholders.

PubMed

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

2015-01-01

Documented incidents of violence provide the foundation for any workplace violence prevention program. However, no published research to date has examined stakeholders' preferences for workplace violence data reports in healthcare settings. If relevant data are not readily available and effectively summarized and presented, the likelihood is low that they will be utilized by stakeholders in targeted efforts to reduce violence. To discover and describe hospital system stakeholders' perceptions of database-generated workplace violence data reports. Eight hospital system stakeholders representing Human Resources, Security, Occupational Health Services, Quality and Safety, and Labor in a large, metropolitan hospital system. The hospital system utilizes a central database for reporting adverse workplace events, including incidents of violence. A focus group was conducted to identify stakeholders' preferences and specifications for standardized, computerized reports of workplace violence data to be generated by the central database. The discussion was audio-taped, transcribed verbatim, processed as text, and analyzed using stepwise content analysis. Five distinct themes emerged from participant responses: Concerns, Etiology, Customization, Use, and Outcomes. In general, stakeholders wanted data reports to provide ``the big picture,'' i.e., rates of occurrence; reasons for and details regarding incident occurrence; consequences for the individual employee and/or the workplace; and organizational efforts that were employed to deal with the incident. Exploring stakeholder views regarding workplace violence summary reports provided concrete information on the preferred content, format, and use of workplace violence data. Participants desired both epidemiological and incident-specific data in order to better understand and work to prevent the workplace violence occurring in their hospital system.

What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group.

PubMed

Caba Barrientos, F; Rodríguez Morillo, A; Galisteo Domínguez, R; Del Nozal Nalda, M; Almeida González, C V; Echevarría Moreno, M

2018-05-01

Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS). Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed. Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken. The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

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.

TxDOT Video Analytics System User Manual

DOT National Transportation Integrated Search

2012-08-01

The TxDOT video analytics demonstration system is designed to monitor traffic conditions by collecting data such as speed and counts, detecting incidents such as stopped vehicles and reporting such incidents to system administrators. : As illustrated...

Real-time incidence of travel-related symptoms through a smartphone-based app remote monitoring system: a pilot study.

PubMed

Rodriguez-Valero, N; Carbayo, M J Ledesma; Sanchez, D Cuadrado; Vladimirov, A; Espriu, M; Vera, I; Roldan, M; de Alba, T; Sanz, S; Moreno, J L Gonzalez; Oroz, M Luengo; Muñoz, J

2018-01-01

Trip Doctor®, a Smartphone-based app monitoring system, was developed to detect infections among travelers in real-time. For testing, 106 participants were recruited (62.2% male, mean age 36 years (SD = 11)). Majority of trips were for tourism and main destinations were in South East Asia. Mean travel duration was 14 days (SD = 10). Diarrhea was the most frequently reported symptom (15.5%). The system demonstrated adequate usability and is ready to be used on a larger scale.

Estimating the real incidence of invasive listeriosis through an integrated surveillance model in use in Lombardy (Italy, 2006-2014).

PubMed

Zolin, A; Amato, E; D'Auria, M; Gori, M; Huedo, P; Bossi, A; Pontello, M

2017-07-01

The annual incidence of listeriosis in Italy is lower (0·19-0·27 per 100 000 inhabitants per year) than in Europe (0·34-0·52 per 100 000 inhabitants per year). Since the observed incidence of listeriosis may be biased downward for underdiagnosis or under-reporting, this work aims to estimate the real incidence of listeriosis during a 9-year period in the Lombardy region, Italy. Data on listeriosis cases were collected from national mandatory notification system (MAINF) and Laboratory-based Surveillance System (LabSS). The two sources were cross-matched and capture-recapture method was applied to estimate the number of undetected cases and the real incidence of invasive listeriosis. Five hundred and eighty invasive listeriosis cases were detected by the two sources between 2006 and 2014: 50·2% were identified only via MAINF, 16·7% were recorded only via LabSS, overlaps occurred in 192 cases (33·1%). The mean annual incidence detected only by MAINF was 0·56 per 100 000 inhabitants, which rose to 0·67 per 100 000 considering also the cases detected by LabSS. The capture-recapture method allowed to estimate an incidence of 0·84 per 100 000. The high incidence of listeriosis may be due to improved sensitivity of the surveillance system, but also reflect a real increase, associated with an increased population at risk.

Oral cancer statistics in India on the basis of first report of 29 population-based cancer registries

PubMed Central

Sharma, Swati; Satyanarayana, L; Asthana, Smitha; Shivalingesh, KK; Goutham, Bala Subramanya; Ramachandra, Sujatha

2018-01-01

Objectives: To summarize and provide an overview of age-specific oral cancer incidence reported in 29 population-based cancer registry in India. Materials and Methods: Secondary data on age-adjusted rates (AARs) of incidence of oral cancer and other associated sites for all ages (0–75 years) were collected from the report of the National Cancer Registry Programme 2012–2014 in 29 population-based control registries. Results: Among both males and females, mouth cancer had maximum Age adjusted incidence rates (64.8) in the central zone, while oropharynx cancer had minimum AAR (0) in all regions. Conclusion: Oral cancer incidence increases with age with typical pattern of cancer of associated sites of oral cavity seen in the northeast region. PMID:29731552

Case based measles surveillance in Pune: evidence to guide current and future measles control and elimination efforts in India.

PubMed

Bose, Anindya Sekhar; Jafari, Hamid; Sosler, Stephen; Narula, Arvinder Pal Singh; Kulkarni, V M; Ramamurty, Nalini; Oommen, John; Jadi, Ramesh S; Banpel, R V; Henao-Restrepo, Ana Maria

2014-01-01

According to WHO estimates, 35% of global measles deaths in 2011 occurred in India. In 2013, India committed to a goal of measles elimination by 2020. Laboratory supported case based measles surveillance is an essential component of measles elimination strategies. Results from a case-based measles surveillance system in Pune district (November 2009 through December 2011) are reported here with wider implications for measles elimination efforts in India. Standard protocols were followed for case identification, investigation and classification. Suspected measles cases were confirmed through serology (IgM) or epidemiological linkage or clinical presentation. Data regarding age, sex, vaccination status were collected and annualized incidence rates for measles and rubella cases calculated. Of the 1011 suspected measles cases reported to the surveillance system, 76% were confirmed measles, 6% were confirmed rubella, and 17% were non-measles, non-rubella cases. Of the confirmed measles cases, 95% were less than 15 years of age. Annual measles incidence rate was more than 250 per million persons and nearly half were associated with outbreaks. Thirty-nine per cent of the confirmed measles cases were vaccinated with one dose of measles vaccine (MCV1). Surveillance demonstrated high measles incidence and frequent outbreaks in Pune where MCV1 coverage in infants was above 90%. Results indicate that even high coverage with a single dose of measles vaccine was insufficient to provide population protection and prevent measles outbreaks. An effective measles and rubella surveillance system provides essential information to plan, implement and evaluate measles immunization strategies and monitor progress towards measles elimination.

Case Based Measles Surveillance in Pune: Evidence to Guide Current and Future Measles Control and Elimination Efforts in India

PubMed Central

Bose, Anindya Sekhar; Jafari, Hamid; Sosler, Stephen; Narula, Arvinder Pal Singh; Kulkarni, V. M.; Ramamurty, Nalini; Oommen, John; Jadi, Ramesh S.; Banpel, R. V.; Henao-Restrepo, Ana Maria

2014-01-01

Background According to WHO estimates, 35% of global measles deaths in 2011 occurred in India. In 2013, India committed to a goal of measles elimination by 2020. Laboratory supported case based measles surveillance is an essential component of measles elimination strategies. Results from a case-based measles surveillance system in Pune district (November 2009 through December 2011) are reported here with wider implications for measles elimination efforts in India. Methods Standard protocols were followed for case identification, investigation and classification. Suspected measles cases were confirmed through serology (IgM) or epidemiological linkage or clinical presentation. Data regarding age, sex, vaccination status were collected and annualized incidence rates for measles and rubella cases calculated. Results Of the 1011 suspected measles cases reported to the surveillance system, 76% were confirmed measles, 6% were confirmed rubella, and 17% were non-measles, non-rubella cases. Of the confirmed measles cases, 95% were less than 15 years of age. Annual measles incidence rate was more than 250 per million persons and nearly half were associated with outbreaks. Thirty-nine per cent of the confirmed measles cases were vaccinated with one dose of measles vaccine (MCV1). Conclusion Surveillance demonstrated high measles incidence and frequent outbreaks in Pune where MCV1 coverage in infants was above 90%. Results indicate that even high coverage with a single dose of measles vaccine was insufficient to provide population protection and prevent measles outbreaks. An effective measles and rubella surveillance system provides essential information to plan, implement and evaluate measles immunization strategies and monitor progress towards measles elimination. PMID:25290339

The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies.

PubMed

Ferris, Mollie; Quan, Samuel; Kaplan, Belle S; Molodecky, Natalie; Ball, Chad G; Chernoff, Greg W; Bhala, Nij; Ghosh, Subrata; Dixon, Elijah; Ng, Siew; Kaplan, Gilaad G

2017-08-01

We compared the incidence of appendicitis or appendectomy across the world and evaluated temporal trends. Population-based studies reported the incidence of appendicitis. We searched MEDLINE and EMBASE databases for population-based studies reporting the incidence of appendicitis or appendectomy. Time trends were explored using Poisson regression and reported as annual percent change (APC) with 95% confidence intervals (CI). APC were stratified by time periods and pooled using random effects models. Incidence since 2000 was pooled for regions in the Western world. The search retrieved 10,247 citations with 120 studies reporting on the incidence of appendicitis or appendectomy. During the 21st century the pooled incidence of appendicitis or appendectomy (in per 100,000 person-years) was 100 (95% CI: 91, 110) in Northern America, and the estimated number of cases in 2015 was 378,614. The pooled incidence ranged from 105 in Eastern Europe to 151 in Western Europe. In Western countries, the incidence of appendectomy steadily decreased since 1990 (APC after 1989=-1.54; 95% CI: -2.22, -0.86), whereas the incidence of appendicitis stabilized (APC=-0.36; 95% CI: -0.97, 0.26) for both perforated (APC=0.95; 95% CI: -0.25, 2.17) and nonperforated appendicitis (APC=0.44; 95% CI: -0.84, 1.73). In the 21st century, the incidence of appendicitis or appendectomy is high in newly industrialized countries in Asia (South Korea pooled: 206), the Middle East (Turkey pooled: 160), and Southern America (Chile: 202). Appendicitis is a global disease. The incidence of appendicitis is stable in most Western countries. Data from newly industrialized countries is sparse, but suggests that appendicitis is rising rapidly.

Idea Project Final Report, A Sequential Hypothesis Testing-Based Decision-Making System For Freeway Incident Response

DOT National Transportation Integrated Search

1995-10-01

THIS INVESTIGATION WAS COMPLETED AS PART OF THE ITS-IDEA PROGRAM WHICH IS ONE OF THREE IDEA PROGRAMS MANAGED BY THE TRANSPORTATION RESEARCH BOARD (TRB) TO FOSTER INNOVATIONS IN SURFACE TRANSPORTATION. IT FOCUSES ON PRODUCTS AND RESULT FOR THE DEVELOP...

Casualty data analysis of the world merchant fleet for reported fire and explosion incidents resulting in marine pollution

DOT National Transportation Integrated Search

1995-02-01

World wide merchant vessel fire and explosion data were analyzed to determine the contribution of these casualties to the marine pollution problem. The source of information is the Lloyd's Casualty Information System Data Base. The major findings of ...

Improving the Capture of Fall Events in Hospitals: Combining a Service for Evaluating Inpatient Falls with an Incident Report System

PubMed Central

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

2008-01-01

OBJECTIVES To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care. DESIGN Six-month observational study. SETTING Sixteen adult nursing units (349 beds) in an urban, academically affiliated, community hospital. PARTICIPANTS Patients admitted to the study units during the study period. INTERVENTION 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. RESULTS 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%. CONCLUSION 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. PMID:18205761

The increase in prescriptions of bisphosphonates and the incidence proportion of osteonecrosis of the jaw after risk communication activities in Japan: a hospital-based cohort study†

PubMed Central

Sumi, Eriko; Yamazaki, Toru; Tanaka, Shiro; Yamamoto, Keiichi; Nakayama, Takeo; Bessho, Kazuhisa; Yokode, Masayuki

2014-01-01

Purpose The purpose of this study was to investigate the impact of risk communication about bisphosphonate (BP)-related osteonecrosis of the jaw (ONJ) on the number of reported cases to the Drug Adverse Reactions Reporting System and on the incidence proportion of ONJ in a hospital-based cohort study in Japan. Method We conducted a survey of the safety information on BP-related ONJ available from regulatory authorities, pharmaceutical manufacturers and academic associations. We also performed a trend analysis of a dataset from the Drug Adverse Reactions Reporting System and a sub-analysis, using previously constructed data from a retrospective cohort study. Results Risk communication from pharmaceutical manufacturers and academic associations began within 1 year after revisions were made to the package inserts, in October 2006. Twenty times more cases of ONJ have been reported to regulatory authority since 2007, compared with the period before 2007. In our cohort, the incidence proportion of ONJ during and after 2009 was four times greater than before 2009. During this period, BPs were frequently prescribed, whereas there was no increase in the use of alternative agents, such as selective estrogen receptor modulators. Conclusion ONJ was increasingly diagnosed after risk communication efforts, but the impact of the communications was not clear. Safety notifications were diligently disseminated after the package insert was revised. However, there was no surveillance for ONJ before the revision. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd. PMID:24399628

Incidence of Esophageal Cancer in Iran, a Population-Based Study: 2001-2015.

PubMed

Moradzadeh, Rahmatollah; Golmohammadi, Parvaneh; Ghaitasi, Bahman; Nadrian, Haidar; Najafi, Athareh

2018-05-09

Even though Kurdistan, the western province of Iran, has a cancer surveillance system, a detailed analysis of incidence rate has not been yet performed. We describe Age Standardized Incidence Rates (ASRs) for esophageal cancer (EC) in Kurdistan Province of Iran in 2001-2015. Incidence cases of EC were obtained from a population-based cancer registry. We obtained ASRs and 95% confidence intervals (CI) per 100,000 populations for each calendar year group. Between 2001 and 2015, 1362 incidence cases with EC were reported to the cancer registry. Annual ASRs in 2006-2010 were more than the other years in both men and women, respectively. Most ASRs were reported among women in Divandarreh (18.95, 95% CI 14.76, 23.92), Saqez (12.75, 95% CI 10.73, 15.01), Sanandaj (8.84, 95% CI 7.64, 10.17), and Qorveh (8.19, 95% CI 6.54, 10.12), and among men in Divandarreh (19.38, 95% CI 15.38, 24.06), Saqez (13.64, 95% CI 11.49, 16.05), Sanandaj (8.70, 95% CI 7.56, 9.96), and Marivan (7.93, 95% CI 6.26, 9.88). It was concluded that EC in Divandarreh, Saqez, and Sanandaj has the highest ASRs, and these areas are considered as high-risk areas for this disease in the Iranian province of Kurdistan. Therefore, to understand the reasons of these problems, a considerable work is needed.

A review of in-flight emergencies in the ASRS data base

NASA Technical Reports Server (NTRS)

Porter, R. F.

1981-01-01

A series of 154 in-flight emergencies as reported to the Aviation Safety Reporting System are described. The various types of emergencies are examined and an attempt is made to determine the human errors and other factors associated with each incident, as well as the measures taken to resolve the emergency. It is concluded that nearly one half of those emergencies reported were related to failure or malfunction of aircraft subsystems. Of all the emergencies, nearly one quarter were associated with power plant failure. Other frequently encountered emergency types are associated with operation in instrument meteorological conditions without appropriate clearance or qualification, and with low fuel state situations. Human error is prominently featured in many of the incidents, appearing in the actions of pilots and air traffic controllers.

[A study of culture-based easy identification system for Malassezia].

PubMed

Kaneko, Takamasa

2011-01-01

Most species of this genus are lipid-dependent yeasts, which colonize the seborrheic part of the skin, and they have been reported to be associated with pityriasis versicolor, Malassezia folliculitis, seborrheic dermatitis, and atopic dermatitis. Malassezia have been re-classified into 7 species based on molecular biological analysis of nuclear ribosomal DNA/RNA and new Malassezia species were reported. As members of the genus Malassezia share similar morphological and biochemical characteristics, it was thought to be difficult to differentiate between them based on phenotypic features. While molecular biological techniques are the most reliable methods for identification of Malassezia, they are not available in most clinical laboratories. We studied ( i ) development of an efficient isolation media and culture based easy identification system, ( ii ) the incidence of atypical biochemical features in Malassezia species and propose a culture-based easy identification system for clinically important Malassezia species, M. globosa, M. restricta, and M. furfur.

TU-CD-BRD-00: Incident Learning / RO-ILS

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

2015-06-15

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less

Using incident reports to inform the prevention of medication administration errors.

PubMed

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

2017-11-01

To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health professionals to manage daily medications should be prioritised. © 2017 John Wiley & Sons Ltd.

Epidemiological characteristics of male sexual assault in a criminological database.

PubMed

Choudhary, Ekta; Gunzler, Douglas; Tu, Xin; Bossarte, Robert M

2012-02-01

Sexual assault among males, compared with females, is understudied, and may also be significantly underreported. Past studies have relied primarily on population-based survey data to estimate the prevalence of sexual assault and associated health outcomes. However, survey-based studies rely primarily on self-reports of victimization and may not accurately estimate the true prevalence of male sexual assault victimization. In order to obtain a detailed assessment of sexual assault among males, criminological databases like the National Incident Based Reporting System (NIBRS) may provide an important and unique source of information. The objective of the current study was to use data from the 2001-2005 NIBRS to construct an epidemiological profile of sexual assault among males. Our results suggest that the incidence of sexual assault was higher among young males (less than 19 years of age), with approximately 90% of all cases being reported among members of this age group. Among males of all ages, forcible fondling and sodomy were the most prevalent forms of sexual assault. Results from additional analyses include age- and race-specific rates of male sexual assault, the prevalence and severity of injury, and time trends detailing incidence by time of the day and location of the incident. Our analyses show that sexual assault is experienced by males of all age groups. However, the rate of sexual assault is higher among younger males. Despite some limitations, results from this study suggest that NIBRS data may provide a important complement to survey data for understanding breadth and consequences of male sexual assault.

Mapping the residual incidence of taeniasis and cysticercosis in Colombia, 2009–2013, using geographical information systems: Implications for public health and travel medicine☆

PubMed Central

Rodríguez-Morales, Alfonso J.; Yepes-Echeverri, María Camila; Acevedo-Mendoza, Wilmer F.; Marín-Rincón, Hamilton A.; Culquichicón, Carlos; Parra-Valencia, Esteban; Cardona-Ospina, Jaime A.; Flisser, Ana

2018-01-01

Background In Colombia, taeniasis and cysticercosis have been significantly reduced over the past decades, however still reported with implications for public health and travel medicine. Methods An observational, retrospective study, in which the incidence of taeniasis and cysticercosis (ICD-10 codes B68s/B69s) in Colombia, 2009–2013, was estimated based on data extracted from the Individual Health Records System (Registro Individual de Prestación de Servicios, RIPS) was performed. The Geographic Information System (GIS) generated national maps showing the distribution of taeniasis and cysticercosis by department by year. Results During the period, 3626 cases were reported (median 796/year), for a cumulative crude national rate of 7.7 cases/100,000pop; 58.2% corresponded to male; 57% were < 40 year-old (10.2% < 9.9 year-old). Cases were 57.6% neurocysticercosis, the rest were taeniasis due to T. solium, T. saginata, ocular cysticercosis and cysticerci in other organs. Bolivar, a touristic department, had the highest cumulated incidence rate (16.17 cases/100,000pop), as also evident across the map series developed in this study. Conclusion Despite the limitations of this study, data presented provide recent estimates of national taeniasis and cysticercosis incidence in the country useful in public health and for travel medicine practitioners, as some highly touristic areas presented higher disease incidence. Improved control, particularly of taeniasis, should be an attainable goal, which among other strategies would require improved sanitation and health education to prevent transmission, but also enhanced surveillance. PMID:29288739

Mapping the residual incidence of taeniasis and cysticercosis in Colombia, 2009-2013, using geographical information systems: Implications for public health and travel medicine.

PubMed

Rodríguez-Morales, Alfonso J; Yepes-Echeverri, María Camila; Acevedo-Mendoza, Wilmer F; Marín-Rincón, Hamilton A; Culquichicón, Carlos; Parra-Valencia, Esteban; Cardona-Ospina, Jaime A; Flisser, Ana

In Colombia, taeniasis and cysticercosis have been significantly reduced over the past decades, however still reported with implications for public health and travel medicine. An observational, retrospective study, in which the incidence of taeniasis and cysticercosis (ICD-10 codes B68s/B69s) in Colombia, 2009-2013, was estimated based on data extracted from the Individual Health Records System (Registro Individual de Prestación de Servicios, RIPS) was performed. The Geographic Information System (GIS) generated national maps showing the distribution of taeniasis and cysticercosis by department by year. During the period, 3626 cases were reported (median 796/year), for a cumulative crude national rate of 7.7 cases/100,000pop; 58.2% corresponded to male; 57% were <40 year-old (10.2% < 9.9 year-old). Cases were 57.6% neurocysticercosis, the rest were taeniasis due to T. solium, T. saginata, ocular cysticercosis and cysticerci in other organs. Bolivar, a touristic department, had the highest cumulated incidence rate (16.17 cases/100,000pop), as also evident across the map series developed in this study. Despite the limitations of this study, data presented provide recent estimates of national taeniasis and cysticercosis incidence in the country useful in public health and for travel medicine practitioners, as some highly touristic areas presented higher disease incidence. Improved control, particularly of taeniasis, should be an attainable goal, which among other strategies would require improved sanitation and health education to prevent transmission, but also enhanced surveillance. Copyright © 2017 Elsevier Ltd. All rights reserved.

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature

PubMed Central

Hull, Louise; Soukup, Tayana; Mayer, Erik; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara

2017-01-01

Objectives The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. Design To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. Results The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). Conclusion A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement. PMID:29284714

Survey to identify depth of penetration of critical incident reporting systems in Austrian healthcare facilities

PubMed Central

Sendlhofer, Gerald; Eder, Harald; Leitgeb, Karina; Gorges, Roland; Jakse, Heidelinde; Raiger, Marianne; Türk, Silvia; Petschnig, Walter; Pregartner, Gudrun; Kamolz, Lars-Peter; Brunner, Gernot

2018-01-01

Incident reporting systems or so-called critical incident reporting systems (CIRS) were first recommended for use in health care more than 15 years ago. The uses of these CIRS are highly variable among countries, ranging from being used to report critical incidents, falls, or sentinel events resulting in death. In Austria, CIRS have only been introduced to the health care sector relatively recently. The goal of this work, therefore, was to determine whether and specifically how CIRS are used in Austria. A working group from the Austrian Society for Quality and Safety in Healthcare (ASQS) developed a survey on the topic of CIRS to collect information on penetration of CIRS in general and on how CIRS reports are used to increase patient safety. Three hundred seventy-one health care professionals from 274 health care facilities were contacted via e-mail. Seventy-eight respondents (21.0%) completed the online survey, thereof 66 from hospitals and 12 from other facilities (outpatient clinics, nursing homes). In all, 64.1% of the respondents indicated that CIRS were used in the entire health care facility; 20.6% had not yet introduced CIRS and 15.4% used CIRS only in particular areas. Most often, critical incidents without any harm to patients were reported (76.9%); however, some health care facilities also use their CIRS to report patient falls (16.7%), needle stick injuries (17.9%), technical problems (51.3%), or critical incidents involving health care professionals. CIRS are not yet extensively or homogeneously used in Austria. Inconsistencies exist with respect to which events are reported as well as how they are followed up and reported to health care professionals. Further recommendations for general use are needed to support the dissemination in Austrian health care environments. PMID:29310496

Survey to identify depth of penetration of critical incident reporting systems in Austrian healthcare facilities.

PubMed

Sendlhofer, Gerald; Eder, Harald; Leitgeb, Karina; Gorges, Roland; Jakse, Heidelinde; Raiger, Marianne; Türk, Silvia; Petschnig, Walter; Pregartner, Gudrun; Kamolz, Lars-Peter; Brunner, Gernot

2018-01-01

Incident reporting systems or so-called critical incident reporting systems (CIRS) were first recommended for use in health care more than 15 years ago. The uses of these CIRS are highly variable among countries, ranging from being used to report critical incidents, falls, or sentinel events resulting in death. In Austria, CIRS have only been introduced to the health care sector relatively recently. The goal of this work, therefore, was to determine whether and specifically how CIRS are used in Austria. A working group from the Austrian Society for Quality and Safety in Healthcare (ASQS) developed a survey on the topic of CIRS to collect information on penetration of CIRS in general and on how CIRS reports are used to increase patient safety. Three hundred seventy-one health care professionals from 274 health care facilities were contacted via e-mail. Seventy-eight respondents (21.0%) completed the online survey, thereof 66 from hospitals and 12 from other facilities (outpatient clinics, nursing homes). In all, 64.1% of the respondents indicated that CIRS were used in the entire health care facility; 20.6% had not yet introduced CIRS and 15.4% used CIRS only in particular areas. Most often, critical incidents without any harm to patients were reported (76.9%); however, some health care facilities also use their CIRS to report patient falls (16.7%), needle stick injuries (17.9%), technical problems (51.3%), or critical incidents involving health care professionals. CIRS are not yet extensively or homogeneously used in Austria. Inconsistencies exist with respect to which events are reported as well as how they are followed up and reported to health care professionals. Further recommendations for general use are needed to support the dissemination in Austrian health care environments.

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.

PubMed

Archer, Stephanie; Hull, Louise; Soukup, Tayana; Mayer, Erik; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara

2017-12-27

The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Retinoblastoma incidence and survival in European children (1978-1997). Report from the Automated Childhood Cancer Information System project.

PubMed

MacCarthy, A; Draper, G J; Steliarova-Foucher, Eva; Kingston, J E

2006-09-01

Based on 2283 cases of retinoblastoma diagnosed in children aged 0-14 years, incidence and survival in Europe during the period 1978-1997 are described. Data were provided to the Automated Childhood Cancer Information System (ACCIS) from 60 paediatric and general cancer registries. During 1988-1997, the cumulative incidence of retinoblastoma in the ACCIS regions was found to be between 44.2 and 67.9 per million births. The highest incidence was seen in the first year of life. The age-standardised (World standard) incidence rate for the age-range 0-14 years was 4.1 per million. Approximately one-third of cases had bilateral tumours. Overall incidence increased over the period 1978-1997 by 1% per year, as derived from a model adjusted for sex, age group and type of registry (general or paediatric). The 5-year survival rate improved from 89% to 95% during the period covered by the study. This improvement was seen in both unilateral and bilateral cases but was significant only for the unilateral tumours. Survival was lower in the East region, although smaller differences were also observed between the other four regions (British Isles, North, South and West). Availability and quality of registration data on retinoblastoma need to be improved for effective evaluation of incidence and survival.

Men's sexual interest in children: one-year incidence and correlates in a population-based sample of Finnish male twins.

PubMed

Santtila, Pekka; Antfolk, Jan; Räfså, Anna; Hartwig, Maria; Sariola, Heikki; Sandnabba, N Kenneth; Mokros, Andreas

2015-01-01

In a study of 1,310 Finnish adult male twins we found that sexual interest in children aged 12 or younger was reported by 0.2% of the sample. Sexual interest in children aged 15 or younger was reported by 3.3%. Participants reporting sexual interest in children aged 15 or younger were younger, reported stronger sexual desire, and had experienced more childhood sexual and nonsexual abuse. The present study is the first to give a population-based estimate of the incidence of sexual interest in children among adult men. The 12-month incidence of sexual interest in children below the age of 16 years is roughly comparable to the one-year incidence of major depression or the lifetime prevalence of transvestitic fetishism.

Analysing the quality of routine malaria data in Mozambique

PubMed Central

Chilundo, Baltazar; Sundby, Johanne; Aanestad, Margunn

2004-01-01

Background In Mozambique, malaria is the principal cause of morbidity and mortality. Efforts are being made to increase control activities within communities. These activities require management decisions based on evidence of malaria incidence. Although some data generated are of poor quality, there is little research towards improving the reporting systems. Methods An analysis of the quality of routine malaria data was performed in selected districts in Southern Mozambique from August to September 2003. The aim was to assess the quality of the source data in terms of completeness, correctness and consistency across management levels. Results Analysis revealed primary data to be of poor quality. The diversity of reporting systems with limited coordination give rise to redundancies and wastage of resources. There was evidence of "invention" of data in health facilities contributing to an incorrect representation of malaria incidence. Large, "non-clinical", time-based variations of malaria cases due to reporting delays were also noted, contributing to false alerts of outbreaks. Furthermore, targets established in the national strategic plan for malaria cannot be calculated through the existing systems; this is the case, for example, for data related to pregnant women and children under-five years. Discussion and recommendations The existing reporting system for malaria is currently not satisfying the information needs of managers. It is suggested that one standardized system, including the creation of one form to include the essential variables required for the calculation of key indicators by age, gender and pregnancy status, and to establish a national database that maps malaria by location. PMID:14998435

Maryland Public School Suspensions by School and Major Offense Category In-School and Out-of-School Suspensions and Expulsions 2010-2011. Revised

ERIC Educational Resources Information Center

Maryland State Department of Education, 2012

2012-01-01

This report contains revised data on the number of incidents in each Maryland local school system and school during the 2010-11 school year. The data have been disaggregated by gender and race. The incident counts for students with disabilities are also reported. Student incident data are available for reporting by Out-of-School Suspensions and…

[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. Copyright © 2014. Published by Elsevier Masson SAS.

A Physician-based Voluntary Reporting System for Adverse Events and Medical Errors

PubMed Central

Weingart, Saul N; Callanan, Lawrence D; Ship, Amy N; Aronson, Mark D

2001-01-01

OBJECTIVE To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients. DESIGN Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers' reports with hospital incident reports and conducted a retrospective chart review. SETTING The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital. INTERVENTION Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds. MEASUREMENTS AND MAIN RESULTS Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (26%), and failure to provide clinical and support services (29%). We corroborated 84% of reported events in the medical record. Participants found voluntary peer reporting of medical errors unobtrusive and agreed that it could be implemented on a regular basis. CONCLUSIONS A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians. PMID:11903759

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

PubMed

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

2017-01-01

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. 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. 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). 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.

Different perspectives: a comparison of newspaper articles to medical examiner data in the reporting of violent deaths.

PubMed

Genovesi, Andrea L; Donaldson, Amy E; Morrison, Brynna L; Olson, Lenora M

2010-03-01

This study compared violent death information reported in state-wide newspaper articles to the medical examiner reports collected for a state public health surveillance system-the National Violent Death Reporting System (NVDRS). While suicides accounted for 83% of deaths in the NVDRS database, more than three-quarters (79%) of violent deaths reported in newspaper articles were homicides. The majority of the suicide incidents were reported in 1-2 newspaper articles whereas the majority of homicide incidents were reported in 11-34 articles. For suicide incidents, the NVDRS reported more circumstances related to mental health problems while newspaper articles reported recent crisis more often. Results show that there is a mismatch in both frequency and type of information reported between a public health surveillance system (NVDRS) and newspaper reporting of violent deaths. As a result of these findings, scientists and other public health professionals may want to engage in media advocacy to provide newspaper reporters with timely and important health information related to the prevention and intervention of violent deaths in their community. Copyright 2009 Elsevier Ltd. All rights reserved.

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.

Characteristics of homicide followed by suicide incidents in multiple states, 2003-04.

PubMed

Bossarte, R M; Simon, T R; Barker, L

2006-12-01

To calculate the prevalence of homicide followed by suicide (homicide/suicide) and provide contextual information on the incidents and demographic information about the individuals involved using data from a surveillance system that is uniquely equipped to study homicide/suicide. Data are from the National Violent Death Reporting System (NVDRS). This active state-based surveillance system includes data from seven states for 2003 and 13 states for 2004. The incident-level structure facilitates identification of homicide/suicide incidents. Within participating states, 65 homicide/suicide incidents (homicide rate = 0.230/100,000) occurred in 2003 and 144 incidents (homicide rate = 0.238/100,000) occurred in 2004. Most victims (58%) were a current or former intimate partner of the perpetrator. Among all male perpetrators of intimate partner homicide 30.6% were also suicides. A substantial proportion of the victims (13.7%) were the children of the perpetrator. Overall, most victims (74.6%) were female and most perpetrators were male (91.9%). A recent history of legal problems (25.3%), or financial problems (9.3%) was common among the perpetrators. The results support earlier research documenting the importance of intimate partner violence (IPV) and situational stressors on homicide/suicide. These results suggest that efforts to provide assistance to families in crisis and enhance the safety of IPV victims are needed to reduce risk for homicide/suicide. The consistency of the results from the NVDRS with those from past studies and the comprehensive information available in the NVDRS highlight the promise of this system for studying homicide/suicide incidents and for evaluating the impact of prevention policies and programs.

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.

Characterization of Chemical Suicides in the United States and Its Adverse Impact on Responders and Bystanders

PubMed Central

Anderson, Ayana R.

2016-01-01

Introduction A suicide trend that involves mixing household chemicals to produce hydrogen sulfide or hydrogen cyanide, commonly referred to as a detergent, hydrogen sulfide, or chemical suicide is a continuing problem in the United States (U.S.). Because there is not one database responsible for tracking chemical suicides, the actual number of incidents in the U.S. is unknown. To prevent morbidity and mortality associated with chemical suicides, it is important to characterize the incidents that have occurred in the U.S. Methods The author analyzed data from 2011–2013 from state health departments participating in the Agency for Toxic Substances and Disease Registry’s National Toxic Substance Incidents Program (NTSIP). NTSIP is a web-based chemical incident surveillance system that tracks the public health consequences (e.g., morbidity, mortality) from acute chemical releases. Reporting sources for NTSIP incidents typically include first responders, hospitals, state environmental agencies, and media outlets. To find chemical suicide incidents in NTSIP’s database, the author queried open text fields in the comment, synopsis, and contributing factors variables for potential incidents. Results Five of the nine states participating in NTSIP reported a total of 22 chemical suicide incidents or attempted suicides during 2011–2013. These states reported a total of 43 victims: 15 suicide victims who died, seven people who attempted suicide but survived, eight responders, and four employees working at a coroner’s office; the remainder were members of the general public. None of the injured responders reported receiving HazMat technician-level training, and none had documented appropriate personal protective equipment. Conclusion Chemical suicides produce lethal gases that can pose a threat to responders and bystanders. Describing the characteristics of these incidents can help raise awareness among responders and the public about the dangers of chemical suicides. Along with increased awareness, education is also needed on how to protect themselves. PMID:27833671

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…

National Infectious Diseases Surveillance data of South Korea.

PubMed

Park, Sunhee; Cho, Eunhee

2014-01-01

The Korea Centers for Disease Control and Prevention (KCDC) operate infectious disease surveillance systems to monitor national disease incidence. Since 1954, Korea has collected data on various infectious diseases in accordance with the Infectious Disease Control and Prevention Act. All physicians (including those working in Oriental medicine) who diagnose a patient with an infectious disease or conduct a postmortem examination of an infectious disease case are obliged to report the disease to the system. These reported data are incorporated into the database of the National Infectious Disease Surveillance System, which has been providing web-based real-time surveillance data on infectious diseases since 2001. In addition, the KCDC analyzes reported data and publishes the Infectious Disease Surveillance Yearbook annually.

Incidence of childhood pneumonia: facility-based surveillance estimate compared to measured incidence in a South African birth cohort study

PubMed Central

le Roux, David M; Myer, Landon; Nicol, Mark P; Zar, Heather J

2015-01-01

Background Pneumonia is the leading cause of childhood mortality and a major contributor to childhood morbidity, but accurate measurement of pneumonia incidence is challenging. We compared pneumonia incidence using a facility-based surveillance system to estimates from a cohort study conducted contemporaneously in the same community in Cape Town, South Africa. Methods A surveillance system was developed in six public sector primary care clinics and in a regional referral hospital, to detect childhood pneumonia cases. Nurses recorded all children presenting to facilities who met WHO case definitions of pneumonia, and hospital records were reviewed. Estimates of pneumonia incidence and severity were compared with incidence rates based on active surveillance in the Drakenstein Child Health Study. Results From June 2012 until September 2013, the surveillance system detected 306 pneumonia episodes in children under 1 year of age, an incidence of 0.20 episodes/child-year (e/cy) (95% CI 0.17 to 0.22 e/cy). The incidence in the cohort study from the same period was 0.27 e/cy (95% CI 0.23 to 0.32 e/cy). Pneumonia incidence in the surveillance system was almost 30% lower than in the birth cohort; incidence rate ratio 0.72 (95% CI 0.58 to 0.89). In the surveillance system, 18% were severe pneumonia cases, compared to 23% in the birth cohort, rate ratio 0.81 (95% CI 0.55 to 1.18). Conclusions In this setting, facility-based pneumonia surveillance detected fewer cases of pneumonia, and fewer severe cases, compared to the corresponding cohort study. Facility pneumonia surveillance using data collected by local healthcare workers provides a useful estimate of the epidemiology of childhood pneumonia but may underestimate incidence and severity. PMID:26685027

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 with the International Society for Quality in Health Care.

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.

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.

PubMed

Okafor, Nnaemeka; Payne, Velma L; Chathampally, Yashwant; Miller, Sara; Doshi, Pratik; Singh, Hardeep

2016-04-01

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED. 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/

Epidemiology of fishing related upper extremity injuries presenting to the emergency department in the United States.

PubMed

Gil, Joseph A; Elia, Gregory; Shah, Kalpit N; Owens, Brett D; Got, Christopher

2018-04-16

Fishing injuries commonly affect the hands. The goal of this study was to quantify the incidence of fishing-related upper extremity injuries that present to emergency departments in the United States. We examined the reported cases of fishing-related upper extremity injuries in the National Electronic Injury Surveillance System database. Analysis was performed based on age, sex and the type of injury reported. The national incidence of fishing-related upper extremity injuries was 119.6 per 1 million person-years in 2014. The most common anatomic site for injury was the finger (63.3%), followed by the hand (20.3%). The most common type of injury in the upper extremity was the presence of a foreign body (70.4%). The incidence of fishing-related upper extremity injuries in males was 200 per 1 million person-years, which was significantly higher than the incidence in females (41 per 1 million person-years). The incidence of fishing-related upper extremity injuries that present to the Emergency Department was 120 per 1 million person-years. The incidence was significantly higher in males. With the widespread popularity of the activity, it is important for Emergency Physicians and Hand Surgeons to understand how to properly evaluate and manage these injuries.

Characteristics of bias-based harassment incidents reported by a national sample of U.S. adolescents.

PubMed

Jones, Lisa M; Mitchell, Kimberly J; Turner, Heather A; Ybarra, Michele L

2018-06-01

Using a national sample of youth from the U.S., this paper examines incidents of bias-based harassment by peers that include language about victims' perceived sexual orientation, race/ethnicity, religion, weight or height, or intelligence. Telephone interviews were conducted with youth who were 10-20 years old (n = 791). One in six youth (17%) reported at least one experience with bias-based harassment in the past year. Bias language was a part of over half (52%) of all harassment incidents experienced by youth. Perpetrators of bias-based harassment were similar demographically to perpetrators of non-biased harassment. However, bias-based incidents were more likely to involve multiple perpetrators, longer timeframes and multiple harassment episodes. Even controlling for these related characteristics, the use of bias language in incidents of peer harassment resulted in significantly greater odds that youth felt sad as a result of the victimization, skipped school, avoided school activities, and lost friends, compared to non-biased harassment incidents. Copyright © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Incidence and Etiologies of Acquired Third Nerve Palsy Using a Population-Based Method

PubMed Central

Fang, Chengbo; Leavitt, Jacqueline A.; Hodge, David O.; Holmes, Jonathan M.; Mohney, Brian G.; Chen, John J.

2017-01-01

IMPORTANCE Among cranial nerve palsies, a third nerve palsy is important because a subset is caused by life-threatening aneurysms. However, there is significant disagreement regarding its incidence and the reported etiologies. OBJECTIVE To determine the incidence and etiologies of acquired third nerve palsy using a population-based method. DESIGN, SETTING, AND PARTICIPANTS All newly diagnosed cases of acquired third nerve palsy from January 1, 1978, through December 31, 2014, in Olmsted County, Minnesota, were identified using the Rochester Epidemiology Project, a record-linkage system of medical records for all patient-physician encounters among Olmsted County residents. All medical records were reviewed to confirm a diagnosis of acquired third nerve palsy and determine the etiologies, presenting signs, and symptoms. Incidence rates were adjusted to the age and sex distribution of the 2010 US white population. MAIN OUTCOMES AND MEASURES Incidence and etiologies of acquired third nerve palsies. The secondary outcome was incidence of pupil involvement in acquired third nerve palsies. RESULTS We identified 145 newly diagnosed cases of acquired third nerve palsy in Olmsted County, Minnesota, over the 37-year period. The age- and sex-adjusted annual incidence of acquired third nerve palsy was 4.0 per 100 000 (95% CI, 3.3–4.7 per 100 000). The annual incidence in patients older than 60 was greater than patients younger than 60 (12.5 vs 1.7 per 100 000; difference, 10.8 per 100 000; 95% CI, 4.7–16.9; P < .001). The most common causes of acquired third nerve palsy were presumed microvascular (42%), trauma (12%), compression from neoplasm (11%), postneurosurgery (10%), and compression from aneurysm (6%). Ten patients (17%) with microvascular third nerve palsies had pupil involvement, while pupil involvement was seen in 16 patients (64%) with compressive third nerve palsies. CONCLUSIONS AND RELEVANCE This population-based cohort demonstrates a higher incidence of presumed microvascular third nerve palsies and a lower incidence of aneurysmal compression than previously reported in non–population-based studies. While compressive lesions had a higher likelihood of pupil involvement, pupil involvement did not exclude microvascular third nerve palsy and lack of pupil involvement did not rule out compressive third nerve palsy. PMID:27893002

[EuCliD 5TM Clinic Variance Report: a means to improve the safety of patients and staff].

PubMed

Oggero, Anna Rita; Palmieri, Veronica; Cerreto, Maria; Manna, Luisa; Lettieri, Iolanda; Napoli, Antonio; Ravone, Virginia; Pelliccia, Francesco; Moretti, Manuela; Parisotto, Maria Teresa

2010-01-01

The collection of information about events in the healthcare sector has been documented internationally for more than 25 years. Incident reporting is used for the structured acquisition of information about adverse events to improve patient and healthcare staff safety, prepare corrective action, and prevent event recurrence in the future. The establishment of an incident reporting system requires that the staff involved should be capable of recognizing events which require reporting. The aim of this work was to encourage operators to use the incident reporting system and gradually achieve 100% compliance in the reporting of adverse events and corrective and preventive actions taken. The project was carried out by the staff of one NephroCare dialysis center. The parameters observed were how many times the Variance Report was used, how problems were analyzed, and how many times and by what means the medical and nursing staff took action to correct problems. Ten months from the start of the project 100% reporting was achieved. All selected adverse advents were correctly reported and corrective or preventive action was taken to improve patient care and dialysis center organization. Only effective feedback on the results achieved in terms of safety and tangible improvements by staff will allow the number of reports to be kept high, and maintain participants' compliance with the incident reporting system over the long term.

Crimes against Children by Babysitters. Crimes against Children Series. Juvenile Justice Bulletin.

ERIC Educational Resources Information Center

Finkelhor, David; Ormrod, Richard

This bulletin, part of the Office of Juvenile Justice and Delinquency Prevention's "Crimes against Children Series," draws on the FBI's National Incident-Based Reporting System to provide data on the frequency and nature of crimes against children committed by babysitters. According to the bulletin, babysitters account for approximately 4 percent…

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.

The nature of violence: a multilevel analysis of gun use and victim injury in violent interpersonal encounters.

PubMed

Burgason, Kyle A; Thomas, Shaun A; Berthelot, Emily R

2014-02-01

A large number of studies have examined predictors of crime quantities yet considerably less attention has been directed toward exploring patterns in the nature or quality of violence within and across communities. The current study adds to the literature on qualitative variations in violence by assessing the incident and contextual-level predictors of offender gun use and physical injuries sustained by victims of robbery and aggravated assault. Specifically, we examine incident-level data from the National Incident Based Reporting System in conjunction with contextual-level data on the cities in which the incidents occurred. We use hierarchical linear and nonlinear modeling techniques to explore variations in predictors of offender gun use and extent of victim injury. Supporting cultural effects explicated by Anderson, results reveal certain individual-level predictors are conditioned by community characteristics.

Toward the way forward: the national children's disaster mental health concept of operations.

PubMed

Schreiber, Merritt; Pfefferbaum, Betty; Sayegh, Lisa

2012-06-01

Although increasing evidence suggests that children are at particular risk from disasters and evidence-based practices have been developed to triage and treat them effectively, no strategy or concept of operations linking best practices for disaster response is currently in place. To our knowledge, this report describes the first effort to address this critical gap and outlines a triage-driven children's disaster mental health incident response strategy for seamless preparedness, response, and recovery elements that can be used now. The national children's disaster mental health concept of operations (NCDMH CONOPS) details the essential elements needed for an interoperable, coordinated response for the mental health needs of children by local communities, counties, regions, and states to better meet the needs of children affected by disasters and terrorism incidents. This CONOPS for children proposes the use of an evidence-based, rapid triage system to provide a common data metric to incident response and recovery action and to rationally align limited resources to those at greater need in a population-based approach.

50 CFR Appendix E to Part 404 - Content and Syntax for Papaha

Code of Federal Regulations, 2010 CFR

2010-10-01

... Papahanaumokuakea Ship Reporting System Immediately upon crossing the reporting area boundary, notification should... number zero.) Q/Include details as required// R Pollution incident or goods lost overboard** Description of pollution incident or goods lost overboard within the Monument, the Reporting Area, or the U.S...

50 CFR Appendix E to Part 404 - Content and Syntax for Papaha

Code of Federal Regulations, 2014 CFR

2014-10-01

... Ship Reporting System Immediately upon crossing the reporting area boundary, notification should be... number zero.) Q/Include details as required// R Pollution incident or goods lost overboard** Description of pollution incident or goods lost overboard within the Monument, the Reporting Area, or the U.S...

50 CFR Appendix E to Part 404 - Content and Syntax for Papaha

Code of Federal Regulations, 2013 CFR

2013-10-01

... Papahanaumokuakea Ship Reporting System Immediately upon crossing the reporting area boundary, notification should... number zero.) Q/Include details as required// R Pollution incident or goods lost overboard** Description of pollution incident or goods lost overboard within the Monument, the Reporting Area, or the U.S...

50 CFR Appendix E to Part 404 - Content and Syntax for Papaha

Code of Federal Regulations, 2012 CFR

2012-10-01

... Papahanaumokuakea Ship Reporting System Immediately upon crossing the reporting area boundary, notification should... number zero.) Q/Include details as required// R Pollution incident or goods lost overboard** Description of pollution incident or goods lost overboard within the Monument, the Reporting Area, or the U.S...

Fatigue, pilot deviations and time of day

NASA Technical Reports Server (NTRS)

Baker, Susan P.

1989-01-01

The relationships between pilot fatigue, pilot deviations, reported incidents, and time of day are examined. A sample of 200 Aviation Safety Reporting System (ASRS) reports were analyzed from 1985 and 200 reports from 1987, plus 100 reports from late 1987 and early 1988 that were selected because of possible association with fatigue. The FAA pilot deviation data and incident data were analyzed in relation to denominator data that summarized the hourly operations (landings and takeoffs of scheduled flights) at major U.S. airports. Using as numerators FAA data on pilot deviations and incidents reported to the FAA, the rates by time of day were calculated. Pilot age was also analyzed in relation to the time of day, phase of flight, and type of incident.

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.

Contributory factors in surgical incidents as delineated by a confidential reporting system.

PubMed

Mushtaq, F; O'Driscoll, C; Smith, Fct; Wilkins, D; Kapur, N; Lawton, R

2018-05-01

Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) - with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures - those closest in time and space to the adverse event - pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.

Human factors in aircraft incidents - Results of a 7-year study (Andre Allard Memorial Lecture)

NASA Technical Reports Server (NTRS)

Billings, C. E.; Reynard, W. D.

1984-01-01

It is pointed out that nearly all fatal aircraft accidents are preventable, and that most such accidents are due to human error. The present discussion is concerned with the results of a seven-year study of the data collected by the NASA Aviation Safety Reporting System (ASRS). The Aviation Safety Reporting System was designed to stimulate as large a flow as possible of information regarding errors and operational problems in the conduct of air operations. It was implemented in April, 1976. In the following 7.5 years, 35,000 reports have been received from pilots, controllers, and the armed forces. Human errors are found in more than 80 percent of these reports. Attention is given to the types of events reported, possible causal factors in incidents, the relationship of incidents and accidents, and sources of error in the data. ASRS reports include sufficient detail to permit authorities to institute changes in the national aviation system designed to minimize the likelihood of human error, and to insulate the system against the effects of errors.

Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system: the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery.

PubMed

Motomura, Noboru; Miyata, Hiroaki; Tsukihara, Hiroyuki; Takamoto, Shinichi

2008-09-30

The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery. The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%; ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively. This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.

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.

Clothing hanger injuries: pediatric head and neck traumas in the United States, 2002-2012.

PubMed

Walls, Andrew; Pierce, Matthew; Wang, Hongkun; Harley, Earl H

2014-02-01

To discuss pediatric clothing hanger injuries and review the National Electronic Injury Surveillance System to elucidate frequency and promote increased public awareness among pediatric otolaryngologists. Cross-sectional analysis of a national database. National Electronic Injury Surveillance System Database. A retrospective review of the National Electronic Injury Surveillance System provided a nationally weighted sampling estimate of 394 pediatric incident reports involving clothing hangers. Each incident report was analyzed for impalement, facial laceration, and contusion injuries to the mouth, face, and head. In addition, hospital disposition and location of the described incident were also obtained. Upon review of the National Electronic Injury Surveillance System, incident rates of pediatric oral impalement (95% confidence interval [CI], 0.10-0.41), facial laceration (95% CI, 0.22-0.41), and facial abrasion injuries (95% CI, 0.15-0.44) frequently involved the metal clothing hanger design. In addition, most of the reported injuries occurred within the home and involved lacerations to the oral cavity. This is the first multiyear, nationally representative study to analyze clothing hanger injuries in the pediatric population. We demonstrate that these injuries occur more frequently than the medical literature currently reports and also elucidate that children are more likely to obtain laceration injuries by metal clothing hangers within the home. Furthermore, we provide a recommendation for standardization of the National Electronic Injury Surveillance System such that product safety analysis may occur and reduce further pediatric incidents.

Evaluation of Incident Detection Methodologies

DOT National Transportation Integrated Search

1999-10-01

Original Report Date: October 1998. The detection of freeway incidents is an essential element of an area's traffic management system. Incidents need to be detected and handled as promptly as possible to minimize delay to the public. Various algorith...

Ultrasound-Guided Regional Anesthesia and Patient Safety: Update of an Evidence-Based Analysis.

PubMed

Neal, Joseph M

2016-01-01

In 2010, the American Society of Regional Anesthesia and Pain Medicine's evidence-based medicine assessment of ultrasound (US)-guided regional anesthesia (UGRA) analyzed the effect of this nerve localization technology on patient safety. That analysis focused on 4 important regional anesthesia complications: peripheral nerve injury, local anesthetic systemic toxicity (LAST), hemidiaphragmatic paresis (HDP), and pneumothorax. In the intervening 5 years, further research has allowed us to refine our original conclusions. This update reviews previous findings and critically evaluates new literature published since late 2009 that compares the patient safety attributes of UGRA with those of traditional nerve localization methods. As with the previous version of this exercise, analysis focused on randomized controlled trials that compared UGRA with an alternative neural localization method and case series of more than 500 patients. The Jadad score was used to grade individual study quality, and conclusions were graded as to strength of evidence. Of those randomized controlled trials identified by our search techniques, 28 compared the incidence of postoperative nerve symptoms, 27 assessed LAST parameters, 7 studied HDP, and 9 reported the incidence of pneumothorax. The current analysis strengthens our original conclusions that US guidance has no significant effect on the incidence of postoperative neurologic symptoms and that UGRA reduces the incidence and intensity of HDP but does so in an unpredictable manner. Conversely, emerging evidence supports the effectiveness of US guidance for reducing LAST across its clinical presentation continuum. The predicted frequency of pneumothorax has grown smaller in tandem with increased experience with US-guided supraclavicular block. This evidence-based review summarizes both the power and the limitations of UGRA as a tool for improving patient safety. Since the original 2010 publication of this analysis, evidence has continued to support the concept that ultrasound (US) guidance does not meaningfully affect the incidence of peripheral nerve injury (PNI) associated with regional anesthesia. Similar confirmatory evidence attests to US guidance reducing the incidence and intensity of hemidiaphragmatic paresis (HDP) but not eliminating it. Literature published since late 2009 reports the effective role of US guidance in reducing the incidence of local anesthetic systemic toxicity and allows calculation of a lower predicted frequency of pneumothorax associated with US-guided supraclavicular blocks.

Performance of Implementing Guideline Driven Cervical Cancer Screening Measures in an Inner City Hospital System

PubMed Central

Wieland, Daryl L.; Reimers, Laura L.; Wu, Eijean; Nathan, Lisa M.; Gruenberg, Tammy; Abadi, Maria; Einstein, Mark H.

2013-01-01

Objective In 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) updated evidence based guidelines recommending screening intervals for women with abnormal cervical cytology. In our low-income inner city population, we sought to improve performance by uniformly applying the guidelines to all patients. We report the prospective performance of a comprehensive tracking, evidence-based algorithmically driven call-back and appointment scheduling system for cervical cancer screening in a resource-limited inner city population. Materials and Methods Outreach efforts were formalized with algorithm-based protocols for triage to colposcopy, with universal adherence to evidence-based guidelines. During implementation from August 2006 through July 2008, we prospectively tracked performance using the electronic medical record with administrative and pathology reports to determine performance variables such as the total number of Pap tests, colposcopy visits, and the distribution of abnormal cytology and histology results, including all CIN 2,3 diagnoses. Results 86,257 gynecologic visits and 41,527 Pap tests were performed system-wide during this period of widespread and uniform implementation of standard cervical cancer screening guidelines. The number of Pap tests performed per month varied little. The incidence of CIN 1 significantly decreased from 117/171 (68.4%) the first tracked month to 52/95 (54.7%) the last tracked month (p=0.04). The monthly incidence rate of CIN 2,3, including incident cervical cancers did not change. The total number of colposcopy visits declined, resulting in a 50% decrease in costs related to colposcopy services and approximately a 12% decrease in costs related to excisional biopsies. Conclusions Adherence to cervical cancer screening guidelines reduced the number of unnecessary colposcopies without increasing numbers of potentially missed CIN 2,3 lesions, including cervical cancer. Uniform implementation of administrative-based performance initiatives for cervical cancer screening minimizes differences in provider practices and maximizes performance of screening while containing cervical cancer screening costs. PMID:21959573

Global estimate of the incidence of clinical pneumonia among children under five years of age.

PubMed Central

Rudan, Igor; Tomaskovic, Lana; Boschi-Pinto, Cynthia; Campbell, Harry

2004-01-01

OBJECTIVE: Clinical pneumonia (defined as respiratory infections associated with clinical signs of pneumonia, principally pneumonia and bronchiolitis) in children under five years of age is still the leading cause of childhood mortality in the world. In this paper we aim to estimate the worldwide incidence of clinical pneumonia in young children. METHODS: Our estimate for the developing world is based on an analysis of published data on the incidence of clinical pneumonia from community based longitudinal studies. Among more than 2000 studies published since 1961, we identified 46 studies that reported the incidence of clinical pneumonia, and 28 of these met pre-defined quality criteria. FINDINGS: The estimate of the median incidence from those studies was 0.28 episodes per child-year (e/cy). The 25-75% interquartile range was 0.21-0.71. We assessed the plausibility of this estimate using estimates of global mortality from acute respiratory infections and reported case fatality rates for all episodes of clinical pneumonia reported in community-based studies or the case-fatality rate reported only for severe cases and estimates of the proportion of severe cases occurring in a defined population or community. CONCLUSION: The overlap between the ranges of the estimates implies that a plausible incidence estimate of clinical pneumonia for developing countries is 0.29 e/cy. This equates to an annual incidence of 150.7 million new cases, 11-20 million (7-13%) of which are severe enough to require hospital admission. In the developed world no comparable data are available. However, large population-based studies report that the incidence of community-acquired pneumonia among children less than five years old is approximately 0.026 e/cy, suggesting that more than 95% of all episodes of clinical pneumonia in young children worldwide occur in developing countries. PMID:15654403

Increasing incidence of Rocky Mountain spotted fever among the American Indian population in the United States.

PubMed

Holman, Robert C; McQuiston, Jennifer H; Haberling, Dana L; Cheek, James E

2009-04-01

To examine trends of Rocky Mountain spotted fever (RMSF) incidence among American Indians compared with other race groups, a retrospective analysis of national RMSF surveillance data reported to the National Electronic Telecommunications System for Surveillance and the Tickborne Rickettsial Disease Case Report Forms system were used. The RMSF incidence for American Indians, which was comparable to those for other race groups during 1990-2000, increased at a disproportionate rate during 2001-2005. The average annual incidence of RMSF reported among American Indians for 2001-2005 was 16.8 per 1,000,000 persons compared with 4.2, 2.6, and 0.5 for white, black, and Asian/Pacific Islander persons, respectively. Most cases in American Indians were reported from Oklahoma (113.1 cases per 1,000,000), North Carolina (60.0), and Arizona (17.2). The incidence of RMSF increased dramatically among American Indians disproportionately to trends for other race groups. Education about tick-borne disease and prevention measures should be addressed for high-risk American Indian populations.

Medication safety in the home care setting: Development and piloting of a Critical Incident Reporting System

PubMed

Meyer-Massetti, Carla; Krummenacher, Evelyne; Hedinger-Grogg, Barbara; Luterbacher, Stephan; Hersberger, Kurt E

2016-09-01

Background: While drug-related problems are among the most frequent adverse events in health care, little is known about their type and prevalence in home care in the current literature. The use of a Critical Incident Reporting System (CIRS), known as an economic and efficient tool to record medication errors for subsequent analysis, is widely implemented in inpatient care, but less established in ambulatory care. Recommendations on a possible format are scarce. A manual CIRS was developed based on the literature and subsequently piloted and implemented in a Swiss home care organization. Aim: The aim of this work was to implement a critical incident reporting system specifically for medication safety in home care. Results: The final CIRS form was well accepted among staff. Requiring limited resources, it allowed preliminary identification and trending of medication errors in home care. The most frequent error reports addressed medication preparation at the patients’ home, encompassing the following errors: omission (30 %), wrong dose (17.5 %) and wrong time (15 %). The most frequent underlying causes were related to working conditions (37.9 %), lacking attention (68.2 %), time pressure (22.7 %) and interruptions by patients (9.1 %). Conclusions: A manual CIRS allowed efficient data collection and subsequent analysis of medication errors in order to plan future interventions for improvement of medication safety. The development of an electronic CIRS would allow a reduction of the expenditure of time regarding data collection and analysis. In addition, it would favour the development of a national CIRS network among home care institutions.

Incidence and Clinical Features of Rare Cutaneous Malignancies in Olmsted County, Minnesota, 2000 to 2010.

PubMed

Tolkachjov, Stanislav N; Schmitt, Adam R; Muzic, John G; Weaver, Amy L; Baum, Christian L

2017-01-01

The incidence of rare cutaneous malignancies is unknown. Current estimates of rare cutaneous malignancy incidences are based on broad epidemiologic data or single institution experiences, not population-based data. To determine the incidence of several rare nonmelanoma skin cancers. The authors conducted a retrospective chart review of a population-based cohort between the years 2000 and 2010. Residents of Olmsted County, Minnesota, who were diagnosed with a biopsy-proven nonmelanoma skin cancer-excluding basal cell carcinoma and squamous cell carcinoma-were included in this study. The primary outcome was tumor incidence. Additionally, the authors extracted patient demographics, tumor characteristics, treatment modalities, and outcomes. The age-adjusted and sex-adjusted incidences per 100,000 persons of multiple rare cutaneous malignancies were: atypical fibroxanthoma (1.8), sebaceous carcinoma (0.8), dermatofibrosarcoma protuberans (0.4), microcystic adnexal carcinoma (0.7), eccrine carcinoma (0.4), eccrine porocarcinoma (0.2), and leiomyosarcoma (0.2). The authors report population-based incidences and clinical characteristics for these rare cutaneous malignancies. The immune status and smoking status of patients and the treatment and outcomes of these tumors are reported. Additional studies in a broader population are needed to further define the epidemiology and outcomes of these malignancies.

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

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ford, Eric C., E-mail: eford@uw.edu; Terezakis, Stephanie; Souranis, Annette

Purpose: To quantify the error-detection effectiveness of commonly used quality control (QC) measures. Methods: We analyzed incidents from 2007-2010 logged into a voluntary in-house, electronic incident learning systems at 2 academic radiation oncology clinics. None of the incidents resulted in patient harm. Each incident was graded for potential severity using the French Nuclear Safety Authority scoring scale; high potential severity incidents (score >3) were considered, along with a subset of 30 randomly chosen low severity incidents. Each report was evaluated to identify which of 15 common QC checks could have detected it. The effectiveness was calculated, defined as the percentagemore » of incidents that each QC measure could detect, both for individual QC checks and for combinations of checks. Results: In total, 4407 incidents were reported, 292 of which had high-potential severity. High- and low-severity incidents were detectable by 4.0 {+-} 2.3 (mean {+-} SD) and 2.6 {+-} 1.4 QC checks, respectively (P<.001). All individual checks were less than 50% sensitive with the exception of pretreatment plan review by a physicist (63%). An effectiveness of 97% was achieved with 7 checks used in combination and was not further improved with more checks. The combination of checks with the highest effectiveness includes physics plan review, physician plan review, Electronic Portal Imaging Device-based in vivo portal dosimetry, radiation therapist timeout, weekly physics chart check, the use of checklists, port films, and source-to-skin distance checks. Some commonly used QC checks such as pretreatment intensity modulated radiation therapy QA do not substantially add to the ability to detect errors in these data. Conclusions: The effectiveness of QC measures in radiation oncology depends sensitively on which checks are used and in which combinations. A small percentage of errors cannot be detected by any of the standard formal QC checks currently in broad use, suggesting that further improvements are needed. These data require confirmation with a broader incident-reporting database.« less

Pleasing some of the people some of the time: How authors, subjects, and readers assess "Audience" in wildland fire incident reviews

Treesearch

Jennifer A. Ziegler; Anne E. Black

2012-01-01

When unexpected outcomes occur in wildland fire, reports from incident reviews carry a symbolic value beyond the factual information they contain. Popular perception of incident reviews is that the organization has identified the root cause with an eye toward system change, and that the final report chronicles "the" final, definitive, and authoritative...

Implications from Under-reporting at Lifetime, Death Certificate Notifications and Trace-back on the Recorded Incidence of a "Newly" Established Population-based Cancer Registry.

PubMed

Holleczek, B; Brenner, H

2016-01-01

Population-based cancer registries (CRs) are powerful tools for measuring cancer burden and progress against cancer. The study's objective was to investigate the effects of under-reporting at lifetime, death certificate notifications, and trace-back on the incidence a newly established population-based CR may record during its initial 15 years of operation. Using cancer data of nine CRs of the SEER programme we performed model calculations to investigate temporal trends of the recorded incidence that might be expected if registration started in 1995 with gradually increasing proportions of cancers reported to the CR. It was assumed that the CR obtains all death certificates providing cancer as the underlying cause of death. Different scenarios with regard to the development of the proportions of cancers reported to the CR and the use of trace-back were evaluated. Our model calculations demonstrated that the inclusion of cancers notified from death certificates which were diagnosed prior to the start of registration and which attribute to the incidence estimates of the year of death ('prevalent' cases) may compensate under-reporting typically observed right after the start of a CR. The recorded incidence may even be overestimated during the first years of registration, if large amounts of prevalent cancers are notified from death certificates (e.g. overestimation of lung cancer incidence by 8% and 21% in the first year of registration, if the proportions of cases reported were 50% and 70% in that year, overestimation of myeloma incidence still exceeding 5% after eight years of registration, if the proportion of cases reported to the CR had reached 97.5% after six years). Trace-back may effectively reduce the recorded surplus cancer cases. During the initial years of registration, the inclusion of prevalent cancers from death certificates may compensate the higher amount of underreporting right after the start of a CR. Accurate incidence estimates may nevertheless be observed for highly fatal cancers if substantial proportions of cancer cases are missed at lifetime, however apparent incidence trends observed in the initial years of registration need to be interpreted with caution.

Race as a Factor in Juvenile Arrests. Juvenile Justice Bulletin.

ERIC Educational Resources Information Center

Pope, Carl E.; Snyder, Howard E.

This bulletin examines the effect of race on police decisions to take juvenile offenders into custody. Analysis of 1997 and 1998 data on 17 states from the Federal Bureau of Investigation's National Incident-Based Reporting System indicates that there is no evidence to support the hypothesis that police are more likely to arrest nonwhite juvenile…

Predicting medical staff intention to use an online reporting system with modified unified theory of acceptance and use of technology.

PubMed

Chang, I-Chiu; Hsu, Hui-Mei

2012-01-01

Barriers to report incident events using an online information system (IS) may be different from those of a paper-based reporting system. The nationwide online Patient-Safety Reporting System (PSRS) contains a value judgment behind use of the system, similar to the Value of Perceived Consequence (VPC), which is seldom discussed in ISs applications of other disciplines. This study developed a more adequate research framework by integrating the VPC construct into the well-known Unified Theory of Acceptance and Use of Technology (UTAUT) model as a theoretical base to explore the predictors of medical staff's intention to use online PSRS. The results showed that management support was an important factor to influence medical staff's intention of using PSRS. The effects of factors such as performance expectancy, perceived positive, and perceived negative consequence on medical staff's intention of using PSRS were moderated by gender, age, experience, and occupation. The results proved that the modified UTAUT model is significant and useful in predicting medical staff's intention of using the nationwide online PSRS.

Feedback from incident reporting: information and action to improve patient safety.

PubMed

Benn, J; Koutantji, M; Wallace, L; Spurgeon, P; Rejman, M; Healey, A; Vincent, C

2009-02-01

Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. The research comprised a mixed methods review to investigate mechanisms of effective feedback for healthcare, drawing upon experience within established reporting programmes in high-risk industry and transport domains. Systematic searches of published literature were undertaken, and 23 case studies describing incident reporting programmes with feedback were identified for analysis from the international healthcare literature. Semistructured interviews were undertaken with 19 subject matter experts across a range of domains, including: civil aviation, maritime, energy, rail, offshore production and healthcare. In analysis, qualitative information from several sources was synthesised into practical requirements for developing effective feedback in healthcare. Both action and information feedback mechanisms were identified, serving safety awareness, improvement and motivational functions. The provision of actionable feedback that visibly improved systems was highlighted as important in promoting future reporting. Fifteen requirements for the design of effective feedback systems were identified, concerning: the role of leadership, the credibility and content of information, effective dissemination channels, the capacity for rapid action and the need for feedback at all levels of the organisation, among others. Above all, the safety-feedback cycle must be closed by ensuring that reporting, analysis and investigation result in timely corrective actions that effectively address vulnerabilities in existing work systems. Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.

The correspondence between the Staff Observation Aggression Scale-Revised and two other indicators for aggressive incidents.

PubMed

Tenneij, Nienke H; Goedhard, Laurette E; Stolker, Joost J; Nijman, Henk; Koot, Hans M

2009-08-01

Previous research has shown good psychometric properties of the Staff Observation Aggression Scale-Revised (SOAS-R). However, it has never been investigated what proportion of aggressive incidents occurring in facilities is documented with the SOAS-R. Furthermore, if incidents are underreported, the consequences for the categorization of clients into aggressive and nonaggressive subgroups based on the SOAS-R are unknown. To examine this, in four inpatient psychiatric facilities for adults with mild intellectual disabilities, aggressive incidents were documented with the SOAS-R and two other indicators of aggressive incidents: the daily staff reports on clients' behavior and reports on of the use of restraints. Less than half of the incidents documented with the staff and restraint reports were also documented with the SOAS-R. On the other way around, however, it was also found that a substantial proportion of incidents reported on SOAS-R forms were not documented in the daily staff reports, which points to a more general problem of underreporting aggressive behavior. Apart from that, categorization of clients into an aggressive and a nonaggressive subgroup with SOAS-R data collected during 1 month or longer corresponded largely with the categorization based on both other indicators. This study showed that underreporting of aggressive incidents is likely to occur with the SOAS-R, making the instrument less suitable to assess absolute aggression incidence in facilities. Still, the SOAS-R seems a good instrument to categorize clients into aggressive and nonaggressive subgroups. Ways to improve the compliance of the ward team to document all aggressive incidents are addressed in the Discussion section of this article.

TU-CD-BRD-02: Henry Ford Hospital System Experience, with Focus On Motivating and Reviewing

DOE Office of Scientific and Technical Information (OSTI.GOV)

Miller, B.

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less

Remotely sensed vegetation moisture as explanatory variable of Lyme borreliosis incidence

NASA Astrophysics Data System (ADS)

Barrios, J. M.; Verstraeten, W. W.; Maes, P.; Clement, J.; Aerts, J. M.; Farifteh, J.; Lagrou, K.; Van Ranst, M.; Coppin, P.

2012-08-01

The strong correlation between environmental conditions and abundance and spatial spread of the tick Ixodes ricinus is widely documented. I. ricinus is in Europe the main vector of the bacterium Borrelia burgdorferi, the pathogen causing Lyme borreliosis (LB). Humidity in vegetated systems is a major factor in tick ecology and its effects might translate into disease incidence in humans. Time series of two remotely sensed indices with sensitivity to vegetation greenness and moisture were tested as explanatory variables of LB incidence. Wavelet-based multiresolution analysis allowed the examination of these signals at different temporal scales in study sites in Belgium, where increases in LB incidence were reported in recent years. The analysis showed the potential of the tested indices for disease monitoring, the usefulness of analyzing the signal in different time frames and the importance of local characteristics of the study area for the selection of the vegetation index.

TRANSMIT system evaluation : final report

DOT National Transportation Integrated Search

1998-06-30

This report presents the evaluation results of TRANSCOMs System for Managing Incidents and Traffic (TRANSMIT). The TRANSMIT system utilizes Electronic Toll and Traffic Management (ETTM) equipment, which is compatible with the E-Z Pass system, for ...

Fire detection and incidents localization based on public information channels and social media

NASA Astrophysics Data System (ADS)

Thanos, Konstantinos-Georgios; Skroumpelou, Katerina; Rizogiannis, Konstantinos; Kyriazanos, Dimitris M.; Astyakopoulos, Alkiviadis; Thomopoulos, Stelios C. A.

2017-05-01

In this paper a solution is presented aiming to assist the early detection and localization of a fire incident by exploiting crowdsourcing and unofficial civilian online reports. It consists of two components: (a) the potential fire incident detection and (b) the visualization component. The first component comprises two modules that run in parallel and aim to collect reports posted on public platforms and conclude to potential fire incident locations. It collects the public reports, distinguishes reports that refer to a potential fire incident and store the corresponding information in a structured way. The second module aggregates all these stored reports and conclude to a probable fire location, based on the amount of reports per area, the time and location of these reports. In further the result is entered to a fusion module which combines it with information collected by sensors if available in order to provide a more accurate fire event detection capability. The visualization component is a fully - operational public information channel which provides accurate and up-to-date information about active and past fires, raises awareness about forest fires and the relevant hazards among citizens. The channel has visualization capabilities for presenting in an efficient way information regarding detected fire incidents fire expansion areas, and relevant information such as detecting sensors and reporting origin. The paper concludes with insight to current CONOPS end user with regards to the inclusion of the proposed solution to the current CONOPS of fire detection.

Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy: The Primary Experience in a New Established Program with Advanced Technology

PubMed Central

Yang, Ruijie; Wang, Junjie; Zhang, Xile; Sun, Haitao; Gao, Yang; Liu, Lu; Lin, Lei

2014-01-01

Objective. To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program. Materials and Methods. With reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically established for reporting, investigating, and learning of individual incidents. The incidents that occurred in external beam radiotherapy from February, 2012, to February, 2014, were reported. Results. A total of 28 near misses and 5 incidents were reported. Among them, 5 originated in imaging for planning, 25 in planning, and 1 in plan transfer, commissioning, and delivery, respectively. One near miss/incident was classified as wrong patient, 7 wrong sites, 6 wrong laterality, and 5 wrong dose. Five reported incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, and inadequate training contributed to 19, 15, and 12 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4. Conclusion. Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety. PMID:25140309

Time series analysis of malaria in Afghanistan: using ARIMA models to predict future trends in incidence.

PubMed

Anwar, Mohammad Y; Lewnard, Joseph A; Parikh, Sunil; Pitzer, Virginia E

2016-11-22

Malaria remains endemic in Afghanistan. National control and prevention strategies would be greatly enhanced through a better ability to forecast future trends in disease incidence. It is, therefore, of interest to develop a predictive tool for malaria patterns based on the current passive and affordable surveillance system in this resource-limited region. This study employs data from Ministry of Public Health monthly reports from January 2005 to September 2015. Malaria incidence in Afghanistan was forecasted using autoregressive integrated moving average (ARIMA) models in order to build a predictive tool for malaria surveillance. Environmental and climate data were incorporated to assess whether they improve predictive power of models. Two models were identified, each appropriate for different time horizons. For near-term forecasts, malaria incidence can be predicted based on the number of cases in the four previous months and 12 months prior (Model 1); for longer-term prediction, malaria incidence can be predicted using the rates 1 and 12 months prior (Model 2). Next, climate and environmental variables were incorporated to assess whether the predictive power of proposed models could be improved. Enhanced vegetation index was found to have increased the predictive accuracy of longer-term forecasts. Results indicate ARIMA models can be applied to forecast malaria patterns in Afghanistan, complementing current surveillance systems. The models provide a means to better understand malaria dynamics in a resource-limited context with minimal data input, yielding forecasts that can be used for public health planning at the national level.

Discriminating electromagnetic radiation based on angle of incidence

DOEpatents

Hamam, Rafif E.; Bermel, Peter; Celanovic, Ivan; Soljacic, Marin; Yeng, Adrian Y. X.; Ghebrebrhan, Michael; Joannopoulos, John D.

2015-06-16

The present invention provides systems, articles, and methods for discriminating electromagnetic radiation based upon the angle of incidence of the electromagnetic radiation. In some cases, the materials and systems described herein can be capable of inhibiting reflection of electromagnetic radiation (e.g., the materials and systems can be capable of transmitting and/or absorbing electromagnetic radiation) within a given range of angles of incidence at a first incident surface, while substantially reflecting electromagnetic radiation outside the range of angles of incidence at a second incident surface (which can be the same as or different from the first incident surface). A photonic material comprising a plurality of periodically occurring separate domains can be used, in some cases, to selectively transmit and/or selectively absorb one portion of incoming electromagnetic radiation while reflecting another portion of incoming electromagnetic radiation, based upon the angle of incidence. In some embodiments, one domain of the photonic material can include an isotropic dielectric function, while another domain of the photonic material can include an anisotropic dielectric function. In some instances, one domain of the photonic material can include an isotropic magnetic permeability, while another domain of the photonic material can include an anisotropic magnetic permeability. In some embodiments, non-photonic materials (e.g., materials with relatively large scale features) can be used to selectively absorb incoming electromagnetic radiation based on angle of incidence.

Craniofacial Duplication: A Case Report

PubMed Central

Suryawanshi, Pradeep; Deshpande, Mandar; Verma, Nitin; Mahendrakar, Vivek; Mahendrakar, Sandhya

2013-01-01

A craniofacial duplication or diprosopus is an unusual variant of conjoined twinning. The reported incidence is one in 180,000-15 million births and 35 cases have been reported till date. The phenotype is wide, with the partial duplication of a few facial structures to complete dicephalus. A complete duplication is associated with a high incidence of anomalies in the central nervous system, cardiovascular system, gastrointestinal system and the respiratory system, whereas no major anomalies are found in the infants with a partial duplication. A term baby with the features of a craniofacial duplication has been described, with the proposed theories on embryogenesis and a brief review of the literature. PMID:24179933

Craniofacial duplication: a case report.

PubMed

Suryawanshi, Pradeep; Deshpande, Mandar; Verma, Nitin; Mahendrakar, Vivek; Mahendrakar, Sandhya

2013-09-01

A craniofacial duplication or diprosopus is an unusual variant of conjoined twinning. The reported incidence is one in 180,000-15 million births and 35 cases have been reported till date. The phenotype is wide, with the partial duplication of a few facial structures to complete dicephalus. A complete duplication is associated with a high incidence of anomalies in the central nervous system, cardiovascular system, gastrointestinal system and the respiratory system, whereas no major anomalies are found in the infants with a partial duplication. A term baby with the features of a craniofacial duplication has been described, with the proposed theories on embryogenesis and a brief review of the literature.

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

Classification of medication incidents associated with information technology.

PubMed

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

2014-02-01

Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals. The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary. The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process. From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital. A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ezzell, G.

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less

TU-CD-BRD-04: UCLA Experience, with Focus On Developing Metrics and Using RO-ILS

DOE Office of Scientific and Technical Information (OSTI.GOV)

Beron, P.

2015-06-15

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less

TU-CD-BRD-03: UCSD Experience, with Focus On Implementing Change

DOE Office of Scientific and Technical Information (OSTI.GOV)

Brown, D.

2015-06-15

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less

[Implementation of a form for adverse effect notification: results for the 1st year].

PubMed

Pérez Blanco, Verónica; Rubio Gómez, Isabel; Alarcón Gascueña, Piedad; Mateos Rubio, José; Herradón Cano, Matilde; Delgado García, Amadeo

2009-02-01

To describe the introduction of an incident monitoring system by electronic reporting in the Complejo Hospitalario de Toledo (CHT) and to analyse the initial results. CHT is a public hospital with 750 beds, 59 for critical patients, an ambulatory surgery unit and three outpatient clinics. Access to the electronic reporting system is on the main screen of the hospital intranet. The reporting system is voluntary and confidential. It was introduced at the same time as setting up website on clinical safety and the provision of specific training on the subject. A total of 62 reports were received on the electronic system over a period of 12 months (December 2006 to December 2007), of which 74.5% were reported by nursing staff. The service from where it was reported most often was Geriatrics (43.1%). Most of the incidents were classified by the notifiers themselves as "no injury" (64.7%) and as "avoidable" 92.2%. A total of 56.9% were related to care. Some reports led to the issuing of three documents of recommendations by the Quality Unit and the Pharmacy Department. Most of the notifications were incidents related to care and were reported by nurses. The reporting system can complement other tools in promoting a clinical safety culture and defining the risk profile of a health organisation.

Salmonella enterica Infections in the United States and Assessment of Coefficients of Variation: A Novel Approach to Identify Epidemiologic Characteristics of Individual Serotypes, 1996-2011.

PubMed

Boore, Amy L; Hoekstra, R Michael; Iwamoto, Martha; Fields, Patricia I; Bishop, Richard D; Swerdlow, David L

2015-01-01

Despite control efforts, salmonellosis continues to cause an estimated 1.2 million infections in the United States (US) annually. We describe the incidence of salmonellosis in the US and introduce a novel approach to examine the epidemiologic similarities and differences of individual serotypes. Cases of salmonellosis in humans reported to the laboratory-based National Salmonella Surveillance System during 1996-2011 from US states were included. Coefficients of variation were used to describe distribution of incidence rates of common Salmonella serotypes by geographic region, age group and sex of patient, and month of sample isolation. During 1996-2011, more than 600,000 Salmonella isolates from humans were reported, with an average annual incidence of 13.1 cases/100,000 persons. The annual reported rate of Salmonella infections did not decrease during the study period. The top five most commonly reported serotypes, Typhimurium, Enteritidis, Newport, Heidelberg, and Javiana, accounted for 62% of fully serotyped isolates. Coefficients of variation showed the most geographically concentrated serotypes were often clustered in Gulf Coast states and were also more frequently found to be increasing in incidence. Serotypes clustered in particular months, age groups, and sex were also identified and described. Although overall incidence rates of Salmonella did not change over time, trends and epidemiological factors differed remarkably by serotype. A better understanding of Salmonella, facilitated by this comprehensive description of overall trends and unique characteristics of individual serotypes, will assist in responding to this disease and in planning and implementing prevention activities.

Pleasing some of the people some of the time: How authors, subjects, and readers assess the complex landscape of "audience" in wildland fire incident reviews (Abstract)

Treesearch

Jennifer Ziegler; Anne E. Black

2012-01-01

When unexpected outcomes occur in wildland fire, reports from incident reviews carry a symbolic value beyond the factual information they contain. Popular perception of incident reviews is that the organization has identified the root cause with an eye toward system change, and that the final report chronicles "the" final, definitive, and authoritative...

OEM Emergency Response Information

EPA Pesticide Factsheets

The Office of Emergency Management retains records of all incident responses in which it participates. This data asset includes three major sources of information: (1) records maintained by the Regional Office On-Scene Coordinators, principally at the EPAOSC.org web site, (2) all records of incidents managed at the EPA National Response Center (NRC) at EPA Headquarters in Washington, DC and (3) records of responses to oil spills under the Clean Water Act, for which EPA is the oil spill response lead for inland waters. Regional response information is available through EPAOSC.org, but may also be stored elsewhere if the incident is of national significance. EPAOSC.org is a resource for On-Scene Coordinators to access, track and share information with OSCs throughout the country, but it also contains information open to the public.Incident-related environmental sampling data is maintained by the regional offices in the SCRIBE system.NRC records have been maintained in the Emergency Response Notification System (ERNS). This information is available to the public through the Right to Know Network (RTKnet.ombwatch.org). Incidents reported to NRC range from minor to serious, from an oil-sheen on water to a release of thousands of gallons. NRC reports are extensive, but also known to be incomplete, as many incidents are never reported, and those that are reported generally are not subject to verification.

[The coverage of hepatitis A vaccine among 2-29 year olds and the reporting incidence of hepatitis A in China, 2014].

PubMed

Wang, F Z; Zheng, H; Liu, J H; Sun, X J; Miao, N; Shen, L P; Zhang, G M; Cui, F Q

2016-08-10

To evaluate the hepatitis A vaccine coverage among 2-29 year olds and the reported incidence rates of hepatitis A, in China. Based on data from the national sero-survey on hepatitis B in 2014, information on hepatitis A vaccine immunization was collected and the coverage of hepatitis A vaccine was analyzed with SAS software (Version 9.4). Incidence data on hepatitis A was also collected from the National Notifiable Disease Reporting System between 2004 and 2014, and analyzed using the micro-software Excel 2007. Totally, data involving 29 058 people aged 2-29 years were available for analysis and the overall hepatitis A vaccine coverage was 44.6%. The younger the age, the higher the coverage appeared. Among the 2-6 year and the 7-14 year olds, rates of hepatitis A vaccine coverage were 91.2% and 76.0% respectively. From 2004 to 2014, the incidence rates of hepatitis A in the whole population were declining, annually. The incidence rates showed continuously declining as 82.5%, 90.6%, 72.1% among children at the age groups of 2-6 years, 7-14 years and in the whole population, from 2007 to 2013. After the inclusion of hepatitis A vaccine into the Expanded Programe on Immunization (EPI), the coverage of hepatitis A vaccine among the 2-6 year olds increased to over 90%, with no obvious difference between the urban and rural areas. Incidence of hepatitis A in the 2-6 year olds showed a more rapid decline than that in the whole population.

Four-year incidence of sick leave because of neck and shoulder pain and its association with work and lifestyle.

PubMed

Alipour, Akbar; Ghaffari, Mostafa; Shariati, Batoul; Jensen, Irene; Vingard, Eva

2009-02-15

Four-year prospective cohort study. To find the incidence of sick leave because of neck and shoulder pain (NSP) in industrial workers, and its association with work and lifestyle risk factors. Longitudinal studies to investigate NSP incidence and risk factors are rare, and even fewer have been conducted in middle- and low-income countries. After inviting all full-time employees of an Iranian car manufacturing company with 18,031 employees to participate in a baseline study, they were followed for 4 years. New episodes of sick leave because of NSP have been calculated based on sickness absence registration between the years 2003 and 2007. The incidence was compared for participants and nonparticipants. The association between sick leave, physical, and psychosocial risk factors at work, and previous self-reported NSP, was calculated for the remaining population of baseline participants (12,184 employees) during a 4-year follow-up. During a 4-year follow-up of study subjects for the remaining participants of the baseline study, the incidence of sick leave was 0.8% (98 sick leave cases in 12,184 employees). For nonparticipants this incidence was 4.2% (130 cases in 3127 employees). In the final regression model for sick leave cases, the remaining factors for potential physical risk factors were repetitive work and sitting positions at work; for psychosocial factors unattractive work was the only significant remaining factor. The incidence of NSP based on sick leave is definitely very low compared with previous studies in high-income countries. This incidence varies between participants and nonparticipants. Risk factors for sick leave differ from risk factors for self-reported pain. A young population, job security, the insurance system, different health behaviors, and healthy worker bias, are all factors that may affect the results, and sick-leave as an outcome must be interpreted with more caution in middle- and low-income countries.

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.

Experiences of Racism and the Incidence of Adult-Onset Asthma in the Black Women’s Health Study

PubMed Central

Yu, Jeffrey; O’Connor, George T.; Brown, Timothy A.; Cozier, Yvette C.; Palmer, Julie R.; Rosenberg, Lynn

2014-01-01

Background: Chronic stress resulting from experiences of racism may increase the incidence of adult-onset asthma through effects on the immune system and the airways. We conducted prospective analyses of the relation of experiences of racism with asthma incidence in the Black Women’s Health Study, a prospective cohort of black women in the United States followed since 1995 with mailed biennial questionnaires. Methods: Among 38,142 participants followed from 1997 to 2011, 1,068 reported incident asthma. An everyday racism score was created based on five questions asked in 1997 and 2009 about the frequency in daily life of experiences of racism (eg, poor service in stores), and a lifetime racism score was based on questions about racism on the job, in housing, and by police. We used Cox regression models to derive multivariable incidence rate ratios (IRRs) and 95% CIs for categories of each racism score in relation to incident asthma. Results: The IRRs were 1.45 (95% CI, 1.19-1.78) for the highest compared with the lowest quartile of the 1997 everyday racism score (P for trend <.0001) and 1.44 (95% CI, 1.18-1.75) for the highest compared with the lowest category of 1997 lifetime racism. Among women who reported the same levels of racism in 1997 and 2009, the IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55-2.91) and 1.66 (95% CI, 1.20-2.30), respectively. Conclusions: Given the high prevalence of experiences of racism and asthma in black women in the United States, a positive association between racism and asthma is of public health importance. PMID:23887828

Experiences of racism and the incidence of adult-onset asthma in the Black Women's Health Study.

PubMed

Coogan, Patricia F; Yu, Jeffrey; O'Connor, George T; Brown, Timothy A; Cozier, Yvette C; Palmer, Julie R; Rosenberg, Lynn

2014-03-01

Chronic stress resulting from experiences of racism may increase the incidence of adult-onset asthma through effects on the immune system and the airways. We conducted prospective analyses of the relation of experiences of racism with asthma incidence in the Black Women's Health Study, a prospective cohort of black women in the United States followed since 1995 with mailed biennial questionnaires. Among 38,142 participants followed from 1997 to 2011, 1,068 reported incident asthma. An everyday racism score was created based on five questions asked in 1997 and 2009 about the frequency in daily life of experiences of racism (eg, poor service in stores), and a lifetime racism score was based on questions about racism on the job, in housing, and by police. We used Cox regression models to derive multivariable incidence rate ratios (IRRs) and 95% CIs for categories of each racism score in relation to incident asthma. The IRRs were 1.45 (95% CI, 1.19-1.78) for the highest compared with the lowest quartile of the 1997 everyday racism score (P for trend<.0001) and 1.44 (95% CI, 1.18-1.75) for the highest compared with the lowest category of 1997 lifetime racism. Among women who reported the same levels of racism in 1997 and 2009, the IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55-2.91) and 1.66 (95% CI, 1.20-2.30), respectively. Given the high prevalence of experiences of racism and asthma in black women in the United States, a positive association between racism and asthma is of public health importance.

Annual report to the nation on the status of cancer, 1975-2007, featuring tumors of the brain and other nervous system.

PubMed

Kohler, Betsy A; Ward, Elizabeth; McCarthy, Bridget J; Schymura, Maria J; Ries, Lynn A G; Eheman, Christie; Jemal, Ahmedin; Anderson, Robert N; Ajani, Umed A; Edwards, Brenda K

2011-05-04

The American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute, and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information on cancer occurrence and trends in the United States. This year's report highlights brain and other nervous system (ONS) tumors, including nonmalignant brain tumors, which became reportable on a national level in 2004. Cancer incidence data were obtained from the National Cancer Institute, CDC, and NAACCR, and information on deaths was obtained from the CDC's National Center for Health Statistics. The annual percentage changes in age-standardized incidence and death rates (2000 US population standard) for all cancers combined and for the top 15 cancers for men and for women were estimated by joinpoint analysis of long-term (1992-2007 for incidence; 1975-2007 for mortality) trends and short-term fixed interval (1998-2007) trends. Analyses of malignant neuroepithelial brain and ONS tumors were based on data from 1980-2007; data on nonmalignant tumors were available for 2004-2007. All statistical tests were two-sided. Overall cancer incidence rates decreased by approximately 1% per year; the decrease was statistically significant (P < .05) in women, but not in men, because of a recent increase in prostate cancer incidence. The death rates continued to decrease for both sexes. Childhood cancer incidence rates continued to increase, whereas death rates continued to decrease. Lung cancer death rates decreased in women for the first time during 2003-2007, more than a decade after decreasing in men. During 2004-2007, more than 213 500 primary brain and ONS tumors were diagnosed, and 35.8% were malignant. From 1987-2007, the incidence of neuroepithelial malignant brain and ONS tumors decreased by 0.4% per year in men and women combined. The decrease in cancer incidence and mortality reflects progress in cancer prevention, early detection, and treatment. However, major challenges remain, including increasing incidence rates and continued low survival for some cancers. Malignant and nonmalignant brain tumors demonstrate differing patterns of occurrence by sex, age, and race, and exhibit considerable biologic diversity. Inclusion of nonmalignant brain tumors in cancer registries provides a fuller assessment of disease burden and medical resource needs associated with these unique tumors.

Hyperthyroidism incidence fluctuates widely in and around pregnancy and is at variance with some other autoimmune diseases: a Danish population-based study.

PubMed

Andersen, Stine Linding; Olsen, Jørn; Carlé, Allan; Laurberg, Peter

2015-03-01

Hyperthyroidism in women of reproductive age is predominantly caused by Graves' disease. Pregnancy associated changes in the immune system may influence the onset of disease, but population-based incidence rates in and around pregnancy have not been reported. The objective of the study was to estimate the incidence of maternal hyperthyroidism (defined by redeemed prescription of antithyroid drugs) in and around pregnancy and to compare this with the incidence of other autoimmune diseases such as rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). This was a population-based cohort study. The study used the Danish nationwide registers. The participants were women who gave birth to singleton liveborn children in Denmark from 1999 to 2008 (n = 403,958). Incidence rates (IR) of maternal hyperthyroidism during a 4-year period beginning 2 years before and ending 2 years after the date when the mother was giving birth for the first time in the study period were measured. Altogether 3673 women (0.9%) were identified with an onset of hyperthyroidism from 1997 to 2010, and the overall IR of maternal hyperthyroidism was 65.0/100,000/year. The IR of hyperthyroidism in and around pregnancy varied widely and was high in the first 3 months of pregnancy [incidence rate ratio (IRR) vs the remaining study period: 1.50 (95% CI 1.09-2.06)), very low in the last 3 months of pregnancy (0.26 (0.15-0.44)], and reached the highest level 7-9 months postpartum [3.80 (2.88-5.02)]. The incidence variation in and around pregnancy was different for RA and IBD. These are the first population-based data on the incidence of hyperthyroidism in and around pregnancy. The incidence of hyperthyroidism was high in early pregnancy and postpartum, whereas such particular pattern was not observed for other diseases of autoimmune origin.

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…

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.

In 'big bang' major incidents do triage tools accurately predict clinical priority?: a systematic review of the literature.

PubMed

Kilner, T M; Brace, S J; Cooke, M W; Stallard, N; Bleetman, A; Perkins, G D

2011-05-01

The term "big bang" major incidents is used to describe sudden, usually traumatic,catastrophic events, involving relatively large numbers of injured individuals, where demands on clinical services rapidly outstrip the available resources. Triage tools support the pre-hospital provider to prioritise which patients to treat and/or transport first based upon clinical need. The aim of this review is to identify existing triage tools and to determine the extent to which their reliability and validity have been assessed. A systematic review of the literature was conducted to identify and evaluate published data validating the efficacy of the triage tools. Studies using data from trauma patients that report on the derivation, validation and/or reliability of the specific pre-hospital triage tools were eligible for inclusion.Purely descriptive studies, reviews, exercises or reports (without supporting data) were excluded. The search yielded 1982 papers. After initial scrutiny of title and abstract, 181 papers were deemed potentially applicable and from these 11 were identified as relevant to this review (in first figure). There were two level of evidence one studies, three level of evidence two studies and six level of evidence three studies. The two level of evidence one studies were prospective validations of Clinical Decision Rules (CDR's) in children in South Africa, all the other studies were retrospective CDR derivation, validation or cohort studies. The quality of the papers was rated as good (n=3), fair (n=7), poor (n=1). There is limited evidence for the validity of existing triage tools in big bang major incidents.Where evidence does exist it focuses on sensitivity and specificity in relation to prediction of trauma death or severity of injury based on data from single or small number patient incidents. The Sacco system is unique in combining survivability modelling with the degree by which the system is overwhelmed in the triage decision system. The practicalities, training implications, performance characteristics and reliance on computer technology during a mass casualty incident require further evaluation. 2010 Elsevier Ltd. All rights reserved.

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

PubMed

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

2018-01-26

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.

Computer Simulation for Emergency Incident Management

DOE Office of Scientific and Technical Information (OSTI.GOV)

Brown, D L

2004-12-03

This report describes the findings and recommendations resulting from the Department of Homeland Security (DHS) Incident Management Simulation Workshop held by the DHS Advanced Scientific Computing Program in May 2004. This workshop brought senior representatives of the emergency response and incident-management communities together with modeling and simulation technologists from Department of Energy laboratories. The workshop provided an opportunity for incident responders to describe the nature and substance of the primary personnel roles in an incident response, to identify current and anticipated roles of modeling and simulation in support of incident response, and to begin a dialog between the incident responsemore » and simulation technology communities that will guide and inform planned modeling and simulation development for incident response. This report provides a summary of the discussions at the workshop as well as a summary of simulation capabilities that are relevant to incident-management training, and recommendations for the use of simulation in both incident management and in incident management training, based on the discussions at the workshop. In addition, the report discusses areas where further research and development will be required to support future needs in this area.« less

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.

Effect of the incidence angle to free space optical communication based on cat-eye modulating retro-reflector

NASA Astrophysics Data System (ADS)

Zhang, Lai-xian; Sun, Hua-yan; Zhao, Yan-zhong; Zheng, Yong-hui; Shan, Cong-miao

2013-08-01

Based on the cat-eye effect of optical system, free space optical communication based on cat-eye modulating retro-reflector can build communication link rapidly. Compared to classical free space optical communication system, system based on cat-eye modulating retro-reflector has great advantages such as building communication link more rapidly, a passive terminal is smaller, lighter and lower power consuming. The incident angle is an important factor of cat-eye effect, so it will affect the retro-reflecting communication link. In this paper, the principle and work flow of free space optical communication based on cat-eye modulating retro-reflector were introduced. Then, using the theory of geometric optics, the equivalent model of modulating retro-reflector with incidence angle was presented. The analytical solution of active area and retro-reflected light intensity of cat-eye modulating retro-reflector were given. Noise of PIN photodetector was analyzed, based on which, bit error rate of free space optical communication based on cat-eye modulating retro-reflector was presented. Finally, simulations were done to study the effect of incidence angle to the communication. The simulation results show that the incidence angle has little effect on active area and retro-reflected light intensity when the incidence beam is in the active field angle of cat-eye modulating retro-reflector. With certain system and condition, the communication link can rapidly be built when the incidence light beam is in the field angle, and the bit error rate increases greatly with link range. When link range is smaller than 35Km, the bit error rate is less than 10-16.

Interference between active implanted medical devices and electromagnetic field emitting devices is rare but real: results of an incidence study in a population of physicians in France.

PubMed

Hours, Martine; Khati, Inès; Hamelin, Joel

2014-03-01

Assessing the behavior of active implanted medical devices (AIMDs) in response to electromagnetic field (EMF) transmitters is a current issue of great importance. Given the numerous telecommunication systems and our lack of knowledge as to the impact of electromagnetic effects, this study investigated the reality of possible AIMD disturbance by EMFs by interviewing health professionals. A self-administered postal questionnaire was sent to almost 5,000 physicians in five specialties: cardiology; endocrinology; ears, nose, and throat; urology; and neurology. It collected data on the existence and annual number of incidents observed and the conditions under which they occurred, the EMF sources involved, and the means of managing the malfunctions. A total of 1,188 physicians agreed to participate. Sixteen percent of participants reported cases of implant failure, three-quarters of whom, mainly in cardiology, reported rates of at least one incident per year-amounting to more than 100 incidents per year in all. Severity appeared to be moderate (discomfort or transient symptoms), but frequently required resetting or, more rarely, replacing the device. Some serious incidents were, however, reported. The sources implicated were basically of two types: electronic security systems (antitheft and airport gates) and medical electromagnetic radiation devices. These incidents were poorly reported within the public health system, preventing follow-up and effective performance of alert and surveillance functions. Although minor, the risk of interference between EMF sources and AIMDs is real and calls for vigilance. It particularly concerns antitheft and airport security gates, though other sources may also cause incidents. ©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.

A Population-Based Study of the Incidence of Burning Mouth Syndrome

PubMed Central

Kohorst, John J.; Bruce, Alison J.; Torgerson, Rochelle R.; Schenck, Louis A.; Davis, Mark D. P.

2015-01-01

Objective To calculate the incidence of burning mouth syndrome (BMS) in Olmsted County, Minnesota, from 2000 to 2010. Patients and Methods Using the medical record linkage system of the Rochester Epidemiology Project, we identified newly diagnosed cases of BMS from January 1, 2000, through December 31, 2010. Diagnoses were confirmed through the presence of burning pain symptoms of the oral mucosa with normal oral examination findings and no associated clinical signs. Incidence was estimated using decennial census data for Olmsted County. Results In total, 169 incident cases were identified, representing an annual age- and sex-adjusted incidence of BMS of 11.4 per 100,000 person-years. Age-adjusted incidence was significantly higher in women than men (18.8 [95% CI, 16.4–22.9] vs 3.7 [95% CI, 2.6–5.7] per 100,000 person-years [P<.001]). Postmenopausal women aged 50 to 89 years had the highest disease incidence, with the maximal rate in women aged 70 to 79 years (70.3 per 100,000 person-years). After age 50 years, BMS incidence in men and women significantly increased across age-groups (P=.02). Olmsted County study participants were predominantly white, which is a study limitation. In addition, diagnostic criteria for identifying BMS in the present study may not apply for all situations because no diagnostic criteria are universally recognized for identifying BMS. Conclusion To our knowledge, this is the first population-based incidence study of BMS reported to date. The data show that BMS is an uncommon disease highly associated with female sex and advancing age. PMID:25176397

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

Sibling Sexual Abuse: An Empirical Analysis of Offender, Victim, and Event Characteristics in National Incident-Based Reporting System (NIBRS) Data, 2000-2007

ERIC Educational Resources Information Center

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…

Physical, emotional and sexual adolescent abuse victimisation in South Africa: prevalence, incidence, perpetrators and locations

PubMed Central

Meinck, Franziska; Cluver, Lucie D; Boyes, Mark E; Loening-Voysey, Heidi

2016-01-01

Background Physical, emotional and sexual abuse of children is a major problem in South Africa, with severe negative outcomes for survivors. To date, no known studies have used data directly obtained from community-based samples of children to investigate prevalence, incidence, locations and perpetrators of child abuse victimisation. This study aims to investigate prevalence and incidence, perpetrators, and locations of child abuse victimisation in South Africa using a multicommunity sample. Methods 3515 children aged 10–17 years (56.6% female) were interviewed from all households in randomly selected census enumeration areas in two South African provinces. Child self-report questionnaires were completed at baseline and at 1-year follow-up (96.7% retention). Results Prevalence was 56.3% for lifetime physical abuse (18.2% past-year incidence), 35.5% for lifetime emotional abuse (12.1% incidence) and 9% for lifetime sexual abuse (5.3% incidence). 68.9% of children reported any type of lifetime victimisation and 27.1% reported lifetime multiple abuse victimisation. Main perpetrators of abuse were reported: for physical abuse, primary caregivers and teachers; for emotional abuse, primary caregivers and relatives; and for sexual abuse, girlfriend/boyfriends or other peers. Conclusions This is the first study assessing current self-reported child abuse through a large, community-based sample in South Africa. Findings of high rates of physical, emotional and sexual abuse demonstrate the need for targeted and effective interventions to prevent incidence and re-victimisation. PMID:26962202

77 FR 7171 - Agency Information Collection Activities: Proposed Collection; Comment Request, National Fire...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-10

..., National Fire Incident Reporting System (NFIRS) v5.0 AGENCY: Federal Emergency Management Agency, DHS... accordance with the Paperwork Reduction Act of 1995, this notice seeks comments concerning National Fire... standardized reporting methods, to collect and analyze fire incident data at the Federal, State, and local...

Reported Neuroinvasive Cases of West Nile Virus by State, 2002-2014

EPA Pesticide Factsheets

This map shows the average annual incidence of neuroinvasive West Nile virus disease in each state, which is calculated as the average number of new cases per 100,000 people per year from 2002 to 2014. The map is based on cases that local and state health departments report to CDC??s national disease tracking system. Neuroinvasive cases are those that affect the brain or cause neurologic dysfunction. For more information: www.epa.gov/climatechange/science/indicators

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: U.S.A., 2009-2011.

PubMed

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 U.S. 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 U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Federal Bureau of Investigation (FBI) during a 2-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. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

Evaluating the Reliability of Emergency Response Systems for Large-Scale Incident Operations

DTIC Science & Technology

2010-01-01

for describing response performance or other reliability related measures include Kolesar et al., 1975; Chelst and Jarvis , 1979; Revelle and Hogan...Chemicals,” Journal of Hazardous Materials, Vol. 159, 2008, pp. 2–12. Mason, Steve , Final Report, Incident Name: Teris LLC Explosion and Fire, El Dorado...Arkansas, EPA Region 6, Emergency Readiness Team, Response and Prevention Branch, March 2005. Mason, Steve , Final Report, Incident Name: Union Pacific

College law enforcement and security department responses to alcohol-related incidents: a national study.

PubMed

Bernat, Debra H; Lenk, Kathleen M; Nelson, Toben F; Winters, Ken C; Toomey, Traci L

2014-08-01

Campus police and security personnel are often the first to respond to alcohol-related incidents on campus. The purpose of this study is to examine how campus law enforcement and security respond to alcohol-related incidents, and how consequences and communication differ based on characteristics of the incident. Directors of campus police/security from 343 colleges across the United States completed a survey regarding usual practice following serious, underage, and less serious alcohol incidents on and off campus. Campus law enforcement and security most commonly reported contacting campus officials. A minority reported issuing citations and referring students to the health center. Enforcement actions were more commonly reported for serious and underage incidents than for less serious incidents. Large (vs. small) colleges, public (vs. private) colleges, and those located in small (vs. large) towns more consistently reported taking actions against drinkers. Understanding how campus police and security respond to alcohol-related incidents is essential for reducing alcohol-related problems on college campuses. Copyright © 2014 by the Research Society on Alcoholism.

Analysis of mass incident diffusion in Weibo based on self-organization theory

NASA Astrophysics Data System (ADS)

Pan, Jun; Shen, Huizhang

2018-02-01

This study introduces some theories and methods of self-organization system to the research of the diffusion mechanism of mass incidents in Weibo (Chinese Twitter). Based on the analysis on massive Weibo data from Songjiang battery factory incident happened in 2013 and Jiiangsu Qidong OJI PAPER incident happened in 2012, we find out that diffusion system of mass incident in Weibo satisfies Power Law, Zipf's Law, 1/f noise and Self-similarity. It means this system is the self-organization criticality system and dissemination bursts can be understood as one kind of Self-organization behavior. As the consequence, self-organized criticality (SOC) theory can be used to explain the evolution of mass incident diffusion and people may come up with the right strategy to control such kind of diffusion if they can handle the key ingredients of Self-organization well. Such a study is of practical importance which can offer opportunities for policy makers to have good management on these events.

32 CFR 635.16 - General.

Code of Federal Regulations, 2011 CFR

2011-07-01

... the COPS MPRS and a systems administrator to ensure that the system is properly functioning. Reporting... System (DIBRS). The Army inputs its data into DIBRS utilizing COPS. Any data reported to DIBRS is only as good as the data reported into COPS, so the need for accuracy in reporting incidents and utilizing...

32 CFR 635.16 - General.

Code of Federal Regulations, 2014 CFR

2014-07-01

... the COPS MPRS and a systems administrator to ensure that the system is properly functioning. Reporting... System (DIBRS). The Army inputs its data into DIBRS utilizing COPS. Any data reported to DIBRS is only as good as the data reported into COPS, so the need for accuracy in reporting incidents and utilizing...

32 CFR 635.16 - General.

Code of Federal Regulations, 2012 CFR

2012-07-01

... the COPS MPRS and a systems administrator to ensure that the system is properly functioning. Reporting... System (DIBRS). The Army inputs its data into DIBRS utilizing COPS. Any data reported to DIBRS is only as good as the data reported into COPS, so the need for accuracy in reporting incidents and utilizing...

32 CFR 635.16 - General.

Code of Federal Regulations, 2013 CFR

2013-07-01

... the COPS MPRS and a systems administrator to ensure that the system is properly functioning. Reporting... System (DIBRS). The Army inputs its data into DIBRS utilizing COPS. Any data reported to DIBRS is only as good as the data reported into COPS, so the need for accuracy in reporting incidents and utilizing...

Pilot Alcohol Violations Reported in U.S. Newspapers, 1990–2006

PubMed Central

Kraus, Chadd K.; Li, Guohua

2009-01-01

Introduction Alcohol violations by airline pilots are rare yet remain a public concern. Such incidents often generate widespread news coverage. This study examines the frequency and characteristics of alcohol violation incidents involving airline pilots reported in U.S. newspapers. Methods The database of Lexis-Nexis™, which contains full-text articles for over 350 newspapers, was searched to identify alcohol violation incidents involving airline pilots in the U.S. between January 1990 and June 2006. Information pertaining to the pilot, flight, blood alcohol concentration (BAC), and consequence was ascertained for each incident based on the newspaper coverage. Results During the study period, newspapers reported on a total of 13 incidents of alcohol violations involving 17 pilots. All but two of the incidents occurred during January 2002 through June 2006. The majority (85%) of the incidents were first identified by airport personnel, such as security screeners, based on suspicion of alcohol use by the pilot. Subsequent alcohol testing revealed a mean BAC of 90 mg/dL (ranging from 10 mg · dL−1 to 182 mg · dL−1). Of the 17 pilots, 6 were known to be prosecuted criminally, including 5 who were sentenced to jail terms. Discussion Incidents of alcohol violations by airline pilots reported in U.S. newspapers have increased in recent years. This increase is likely due in part to increased detection resulting from enhanced aviation security and enforcement following the September 2001 terrorist attacks. PMID:17183928

Final Documentation: Incident Management And Probabilities Courses of action Tool (IMPACT).

DOE Office of Scientific and Technical Information (OSTI.GOV)

Edwards, Donna M.; Ray, Jaideep; Tucker, Mark D.

This report pulls together the documentation produced for the IMPACT tool, a software-based decision support tool that provides situational awareness, incident characterization, and guidance on public health and environmental response strategies for an unfolding bio-terrorism incident.

Surveillance of laboratory exposures to human pathogens and toxins: Canada 2016.

PubMed

Bienek, A; Heisz, M; Su, M

2017-11-02

Canada recently enacted legislation to authorize the collection of data on laboratory incidents involving a biological agent. This is done by the Public Health Agency of Canada (PHAC) as part of a comprehensive national program that protects Canadians from the health and safety risks posed by human and terrestrial animal pathogens and toxins. To describe the first year of data on laboratory exposure incidents and/or laboratory-acquired infections in Canada since the Human Pathogens and Toxins Regulations came into effect. Incidents that occurred between January 1 and December 31, 2016 were self-reported by federally-regulated parties across Canada using a standardized form from the Laboratory Incident Notification Canada (LINC) surveillance system. Exposure incidents were described by sector, frequency of occurrence, timeliness of reporting, number of affected persons, human pathogens and toxins involved, causes and corrective actions taken. Microsoft Excel 2010 was used for basic descriptive analyses. In 2016, 46 exposure incidents were reported by holders of 835 active licences in Canada representing 1,352 physical areas approved for work involving a biological agent, for an overall incidence of 3.4%. The number of incidents was highest in the academic (n=16; 34.8%) and hospital (n=12; 26.1%) sectors, while the number of reported incidents was relatively low in the private industry sector. An average of four to five incidents occurred each month; the month of September presented as an outlier with 10 incidents. ​: A total of 100 people were exposed, with no reports of secondary exposure. Four incidents led to suspected (n=3) or confirmed (n=1) cases of laboratory-acquired infection. Most incidents involved pathogens classified at a risk group 2 level that were manipulated in a containment level 2 laboratory (91.3%). Over 22 different species of human pathogens and toxins were implicated, with bacteria the most frequent (34.8%), followed by viruses (26.1%). Eleven (23.9%) incidents involved a security sensitive biologic agent. Procedure breaches (n=15) and sharps-related incidents (n=14) were the most common antecedents to an exposure. In 10 (21.7%) cases, inadvertent possession (i.e., isolation of an unexpected biological agent during routine work) played a role. Possible improvements to standard operating procedures were cited in 71.7% of incidents. Improvements were also indicated for communication (26.1%) and management (23.9%). The Laboratory Incident Notification Canada is one of the first surveillance systems in the world to gather comprehensive data on laboratory incidents involving human pathogens and toxins. Exposure incidents reported in the first year were relatively rare, occurring in less than 4% of containment zones within laboratory settings.

Surveillance of laboratory exposures to human pathogens and toxins: Canada 2016

PubMed Central

Bienek, A; Heisz, M; Su, M

2017-01-01

Background Canada recently enacted legislation to authorize the collection of data on laboratory incidents involving a biological agent. This is done by the Public Health Agency of Canada (PHAC) as part of a comprehensive national program that protects Canadians from the health and safety risks posed by human and terrestrial animal pathogens and toxins. Objective To describe the first year of data on laboratory exposure incidents and/or laboratory-acquired infections in Canada since the Human Pathogens and Toxins Regulations came into effect. Methods Incidents that occurred between January 1 and December 31, 2016 were self-reported by federally-regulated parties across Canada using a standardized form from the Laboratory Incident Notification Canada (LINC) surveillance system. Exposure incidents were described by sector, frequency of occurrence, timeliness of reporting, number of affected persons, human pathogens and toxins involved, causes and corrective actions taken. Microsoft Excel 2010 was used for basic descriptive analyses. Results In 2016, 46 exposure incidents were reported by holders of 835 active licences in Canada representing 1,352 physical areas approved for work involving a biological agent, for an overall incidence of 3.4%. The number of incidents was highest in the academic (n=16; 34.8%) and hospital (n=12; 26.1%) sectors, while the number of reported incidents was relatively low in the private industry sector. An average of four to five incidents occurred each month; the month of September presented as an outlier with 10 incidents. ​ A total of 100 people were exposed, with no reports of secondary exposure. Four incidents led to suspected (n=3) or confirmed (n=1) cases of laboratory-acquired infection. Most incidents involved pathogens classified at a risk group 2 level that were manipulated in a containment level 2 laboratory (91.3%). Over 22 different species of human pathogens and toxins were implicated, with bacteria the most frequent (34.8%), followed by viruses (26.1%). Eleven (23.9%) incidents involved a security sensitive biologic agent. Procedure breaches (n=15) and sharps-related incidents (n=14) were the most common antecedents to an exposure. In 10 (21.7%) cases, inadvertent possession (i.e., isolation of an unexpected biological agent during routine work) played a role. Possible improvements to standard operating procedures were cited in 71.7% of incidents. Improvements were also indicated for communication (26.1%) and management (23.9%). Conclusions The Laboratory Incident Notification Canada is one of the first surveillance systems in the world to gather comprehensive data on laboratory incidents involving human pathogens and toxins. Exposure incidents reported in the first year were relatively rare, occurring in less than 4% of containment zones within laboratory settings. PMID:29770052

ATC system error and appraisal of controller proficiency.

DOT National Transportation Integrated Search

1965-07-01

The report presents suggestions for the design of an air traffic control (ATC) incident-reporting system aimed at maximizing the amount of corrective feedback to the ATC system. The approach taken is system-oriented rather than controller-oriented. I...

Incidence of vertebral hemangioma on spinal magnetic resonance imaging in Northern Iran.

PubMed

Barzin, M; Maleki, I

2009-03-15

The incidence of vertebral hemangiomas as the most common benign spinal neoplasms has been differently reported from 10 to 27% based on autopsy series, plain X-rays and MRI reviews. In this study, we reviewed consecutive 782 standard spinal MRI with axial and sagital T1 weighted and T2 weighted images looking for hemangiomas. In this study, the incidence of hemangioma was 26.9%, more common in females (30%) than males (23%), in older age group and in lumbar spine. Most hemangiomas (65%) were less than 10 mm in diameter. Multiple hemangiomas were seen in 33% of cases. The results of this study are similar to another Mediterranean study reported based on MRI findings, but differ from other reports using X-ray or autopsy as diagnostic tool, suggesting the influence of either the race or the sensitivity of the diagnostic tool on the incidence of vertebral hemangioma.

Characteristics of homicide followed by suicide incidents in multiple states, 2003–04

PubMed Central

Bossarte, R M; Simon, T R; Barker, L

2006-01-01

Objective To calculate the prevalence of homicide followed by suicide (homicide/suicide) and provide contextual information on the incidents and demographic information about the individuals involved using data from a surveillance system that is uniquely equipped to study homicide/suicide. Methods Data are from the National Violent Death Reporting System (NVDRS). This active state‐based surveillance system includes data from seven states for 2003 and 13 states for 2004. The incident‐level structure facilitates identification of homicide/suicide incidents. Results Within participating states, 65 homicide/suicide incidents (homicide rate  =  0.230/100 000) occurred in 2003 and 144 incidents (homicide rate  =  0.238/100 000) occurred in 2004. Most victims (58%) were a current or former intimate partner of the perpetrator. Among all male perpetrators of intimate partner homicide 30.6% were also suicides. A substantial proportion of the victims (13.7%) were the children of the perpetrator. Overall, most victims (74.6%) were female and most perpetrators were male (91.9%). A recent history of legal problems (25.3%), or financial problems (9.3%) was common among the perpetrators. Conclusions The results support earlier research documenting the importance of intimate partner violence (IPV) and situational stressors on homicide/suicide. These results suggest that efforts to provide assistance to families in crisis and enhance the safety of IPV victims are needed to reduce risk for homicide/suicide. The consistency of the results from the NVDRS with those from past studies and the comprehensive information available in the NVDRS highlight the promise of this system for studying homicide/suicide incidents and for evaluating the impact of prevention policies and programs. PMID:17170169

A Bayesian approach for estimating under-reported dengue incidence with a focus on non-linear associations between climate and dengue in Dhaka, Bangladesh.

PubMed

Sharmin, Sifat; Glass, Kathryn; Viennet, Elvina; Harley, David

2018-04-01

Determining the relation between climate and dengue incidence is challenging due to under-reporting of disease and consequent biased incidence estimates. Non-linear associations between climate and incidence compound this. Here, we introduce a modelling framework to estimate dengue incidence from passive surveillance data while incorporating non-linear climate effects. We estimated the true number of cases per month using a Bayesian generalised linear model, developed in stages to adjust for under-reporting. A semi-parametric thin-plate spline approach was used to quantify non-linear climate effects. The approach was applied to data collected from the national dengue surveillance system of Bangladesh. The model estimated that only 2.8% (95% credible interval 2.7-2.8) of all cases in the capital Dhaka were reported through passive case reporting. The optimal mean monthly temperature for dengue transmission is 29℃ and average monthly rainfall above 15 mm decreases transmission. Our approach provides an estimate of true incidence and an understanding of the effects of temperature and rainfall on dengue transmission in Dhaka, Bangladesh.

Dimensional scaling for impact cratering and perforation

NASA Technical Reports Server (NTRS)

Watts, Alan; Atkinson, Dale; Rieco, Steve

1993-01-01

This report summarizes the development of two physics-based scaling laws for describing crater depths and diameters caused by normal incidence impacts into aluminum and TFE Teflon. The report then describes equations for perforations in aluminum and TFE Teflon for normal impacts. Lastly, this report also studies the effects of non-normal incidence on cratering and perforation.

The use of an electronic medical record system for mandatory reporting of drug hypersensitivity reactions has been shown to improve the management of patients in the university hospital in Korea.

PubMed

Park, Chan Sun; Kim, Tae-Bum; Kim, Seoung Lan; Kim, Jae Youn; Yang, Kyung Ai; Bae, Yun-Jeong; Cho, You Sook; Moon, Hee-Bom

2008-09-01

This study was conducted to evaluate the effectiveness of a computerized surveillance system for adverse drug events (ADEs) reinforced with mandatory reporting of all past drug hypersensitivity reactions (DHSRs) and supervision of the processes by allergy specialists in a university hospital. All information on both prior and newly developed DHSRs was collected via the surveillance system described above and compared with the data from previous system based on voluntary reporting of DHSRs by attending physicians. The report rate of past DHSRs was greatly increased and the estimated incidence of new events decreased under the new system. The occurrence rate of new DHSRs during hospitalization, which were caused by the repeated administration of the agents previously suspected as culprit drugs enormously, decreased from 15% of previous system to 1% of new system. The mandatory reporting system for past DHSRs and the supervision by allergy specialists appear to be important in improving the management of patients with drug hypersensitivity and in preventing the occurrence of DHSRs in a general hospital.

The rising incidence of intentional ingestion of ethanol-containing hand sanitizers.

PubMed

Gormley, Nicole J; Bronstein, Alvin C; Rasimas, Joseph J; Pao, Maryland; Wratney, Angela T; Sun, Junfeng; Austin, Howard A; Suffredini, Anthony F

2012-01-01

To describe a case of intentional ingestion of hand sanitizer in our hospital and to review published cases and those reported to the American Association of Poison Control Centers' National Poison Data System. A case report, a literature review of published cases, and a query of the National Poison Data System. Medical intensive care unit. Seventeen-yr-old male 37-kg with an intentional ingestion of a hand sanitizer product into his gastrostomy tube. Intubation, ventilation, and hemodialysis. Incidence and outcome of reported cases of unintentional and intentional ethanol containing-hand sanitizer ingestion in the United States from 2005 through 2009. A literature search found 14 detailed case reports of intentional alcohol-based hand sanitizer ingestions with one death. From 2005 to 2009, the National Poison Data System received reports of 68,712 exposures to 96 ethanol-based hand sanitizers. The number of new cases increased by an average of 1,894 (95% confidence interval [CI] 1266-2521) cases per year (p =.002). In 2005, the rate of exposures, per year, per million U.S. residents was 33.7 (95% CI 28.4-39.1); from 2005 to 2009, this rate increased on average by 5.87 per year (95% CI 3.70-8.04; p = .003). In 2005, the rate of intentional exposures, per year, per million U.S. residents, was 0.68 (95% CI 0.17-1.20); from 2005 to 2009, this rate increased on average by 0.32 per year (95% CI 0.11-0.53; p = .02). The number of new cases per year of intentional hand sanitizer ingestion significantly increased during this 5-yr period. Although the majority of cases of hand sanitizer ingestion have a favorable outcome, 288 moderate and 12 major medical outcomes were reported in this National Poison Data System cohort. Increased awareness of the risks associated with intentional ingestion is warranted, particularly among healthcare providers caring for persons with a history of substance abuse, risk-taking behavior, or suicidal ideation.

Surveillance for Lyme Disease - United States, 2008-2015.

PubMed

Schwartz, Amy M; Hinckley, Alison F; Mead, Paul S; Hook, Sarah A; Kugeler, Kiersten J

2017-11-10

Lyme disease is the most commonly reported vectorborne disease in the United States but is geographically focal. The majority of Lyme disease cases occur in the Northeast, mid-Atlantic, and upper Midwest regions. Lyme disease can cause varied clinical manifestations, including erythema migrans, arthritis, facial palsy, and carditis. Lyme disease occurs most commonly among children and older adults, with a slight predominance among males. 2008-2015. Lyme disease has been a nationally notifiable condition in the United States since 1991. Possible Lyme disease cases are reported to local and state health departments by clinicians and laboratories. Health department staff conduct case investigations to classify cases according to the national surveillance case definition. Those that qualify as confirmed or probable cases of Lyme disease are reported to CDC through the National Notifiable Diseases Surveillance System. States with an average annual incidence during this reporting period of ≥10 confirmed Lyme disease cases per 100,000 population were classified as high incidence. States that share a border with those states or that are located between areas of high incidence were classified as neighboring states. All other states were classified as low incidence. During 2008-2015, a total of 275,589 cases of Lyme disease were reported to CDC (208,834 confirmed and 66,755 probable). Although most cases continue to be reported from states with high incidence in the Northeast, mid-Atlantic, and upper Midwest regions, case counts in most of these states have remained stable or decreased during the reporting period. In contrast, case counts have increased in states that neighbor those with high incidence. Overall, demographic characteristics associated with confirmed cases were similar to those described previously, with a slight predominance among males and a bimodal age distribution with peaks among young children and older adults. Yet, among the subset of cases reported from states with low incidence, infection occurred more commonly among females and older adults. In addition, probable cases occurred more commonly among females and with a higher modal age than confirmed cases. Lyme disease continues to be the most commonly reported vectorborne disease in the United States. Although concentrated in historically high-incidence areas, the geographic distribution is expanding into neighboring states. The trend of stable to decreasing case counts in many states with high incidence could be a result of multiple factors, including actual stabilization of disease incidence or artifact due to modifications in reporting practices employed by some states to curtail the resource burden associated with Lyme disease surveillance. This report highlights the continuing public health challenge of Lyme disease in states with high incidence and demonstrates its emergence in neighboring states that previously experienced few cases. Educational efforts should be directed accordingly to facilitate prevention, early diagnosis, and appropriate treatment. As Lyme disease emerges in neighboring states, clinical suspicion of Lyme disease in a patient should be based on local experience rather than incidence cutoffs used for surveillance purposes. A diagnosis of Lyme disease should be considered in patients with compatible clinical signs and a history of potential exposure to infected ticks, not only in states with high incidence but also in areas where Lyme disease is known to be emerging. These findings underscore the ongoing need to implement personal prevention practices routinely (e.g., application of insect repellent and inspection for and removal of ticks) and to develop other effective interventions.

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 training, clinical practice guidelines, equipment maintenance, and improvement of supervision.

[Miscommunication as a risk focus in patient safety : Work process analysis in prehospital emergency care].

PubMed

Wilk, S; Siegl, L; Siegl, K; Hohenstein, C

2018-04-01

In an analysis of a critical incident reporting system (CIRS) in out-of-hospital emergency medicine, it was demonstrated that in 30% of cases deficient communication led to a threat to patients; however, the analysis did not show what exactly the most dangerous work processes are. Current research shows the impact of poor communication on patient safety. An out-of-hospital workflow analysis collects data about key work processes and risk areas. The analysis points out confounding factors for a sufficient communication. Almost 70% of critical incidents are based on human factors. Factors, such as communication and teamwork have an impact but fatigue, noise levels and illness also have a major influence. (I) CIRS database analysis The workflow analysis was based on 247 CIRS cases. This was completed by participant observation and interviews with emergency doctors and paramedics. The 247 CIRS cases displayed 282 communication incidents, which are categorized into 6 subcategories of miscommunication. One CIRS case can be classified into different categories if more communication incidents were validated by the reviewers and four experienced emergency physicians sorted these cases into six subcategories. (II) Workflow analysis The workflow analysis was carried out between 2015 and 2016 in Jena and Berlin, Germany. The focal point of research was to find accumulation of communication risks in different parts of prehospital patient care. During 30 h driving with emergency ambulances, the author interviewed 12 members of the emergency medical service of which 5 were emergency physicians and 7 paramedics. A total of 11 internal medicine cases and one automobile accident were monitored. After patient care the author asked in a 15-min interview if miscommunication or communication incidents occurred. (I) CIRS analysis Between 2005 and 2015, 845 reports were reported to the database. The experts identified 247 incident reports with communication failure. All communication aspects were analyzed and classified. We identified 282 communication incidents. (II) Workflow analysis The analysis showed three phases of prehospital patient care: 1. incoming emergency call and dispatch of ambulance service, 2. prehospital treatment, 3. transportation to a hospital. Overall, the number of incidences is increasing as a consequence of parallel workflows. Category 1 was particularly significant and predominantly, paramedics criticized that emergency physicians did not acknowledge their advice (n = 73 vs. n = 9). Category 3 with n = 63, category 4 with n = 20 and category 2 with n = 13 were the major reasons for incidents. A better interface communication helps to coordinate patient transfer and is an option for optimizing resources. Frequent training in communication is an option to avoid incidents.

Cancer incidence patterns among children and adolescents in Taiwan from 1995 to 2009: A population-based study

PubMed Central

Hung, Giun-Yi; Horng, Jiun-Lin; Lee, Yu-Sheng; Yen, Hsiu-Ju; Chen, Chao-Chun; Lee, Chih-Ying

2014-01-01

BACKGROUND Currently, little information is available on childhood cancer incidence rates in Eastern Asia. The objective of this study was to report the first population-based cancer surveillance of children and adolescents in Taiwan. METHODS Data from the Taiwan Cancer Registry were examined for cancer frequencies and incidence rates among individuals ages birth to 19 years from 1995 to 2009. Types of cancers were grouped according to the International Classification of Childhood Cancer. Rates were compared by sex and age. For further comparisons with other countries, rates were age standardized to the 2000 world standard population in 5-year age groups. Trends in incidence rates also were evaluated. RESULTS In total, 12,315 individuals were diagnosed with childhood cancers, for an age-standardized incidence rate (ASR) of 132.1 per million person-years from 1995 to 2009. The male-to-female incidence rate ratio was 1.19. Overall, leukemias were the most common cancer (ASR, 39.1 per million person-years), followed by central nervous system neoplasms (15.8 per million person-years), and lymphomas (15.3 per million person-years). During the 15-year study period, the incidence rates increased by 1% annually. Compared with other countries, the rate of hepatic tumors was 2 times greater in Taiwan. The rate of germ cell neoplasms in Taiwan was similar to that in the United States and was 1.3 to 1.9 times greater compared with Canada, Brazil, Israel, and Japan. CONCLUSIONS Based on the current data, the observed increase in overall incidence rates was attributable only marginally to improvements in case ascertainment and diagnostic procedures. The high rates of malignant hepatic tumors and germ cell neoplasms in Taiwan suggest variations in the background risk factors. Cancer 2014;120:3545–3553. © 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. The authors examine cancer incidence patterns in children and adolescents based on a national, population-based cancer registry of 12,315 individuals in Taiwan from 1995 to 2009. The high rates of malignant hepatic tumors and germ cell neoplasms in Taiwan suggest variations in background risk factors. PMID:25043411

Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care.

PubMed

Li, Qi; Melton, Kristin; Lingren, Todd; Kirkendall, Eric S; Hall, Eric; Zhai, Haijun; Ni, Yizhao; Kaiser, Megan; Stoutenborough, Laura; Solti, Imre

2014-01-01

Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment. This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs. From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported. Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting. Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

[Situation of pesticide poisoning in Huzhou from 2006 to 2009].

PubMed

Liu, Tao; Zhang, Chuan-hui; Zhang, Peng; Jin, Mei-hua

2011-01-01

To understand the situations of pesticide poisoning in Huzhou and take preventive strategy and measures against the pesticide poisoning. Case reports between 2006 and 2009 in the data base of reporting system for occupational diseases were computed by Excel for windows and statistical significance by SPSS12.0. A total of 2298 patients were reported from 2006 to 2009. Among them, the incidence of occupational poisoning accounted for 25.59% (588 cases), including 4 fatalities (fatality rate, 0.68%). Male patients (458 cases, 77.89%) were more than female ones (130 cases, 22.11%) in occupational pesticides poisoning. Summer and autumn were the most seasons in occupational pesticides poisoning occurring. The incidence of non-occupational pesticides poisoning accounted for 74.41% (1710, cases), including 112 fatalities (fatality rate, 6.55%). Female patients (952 cases, 55.67%) were more than male ones (758 cases, 44.33%) in non-occupational pesticides poisoning. 15 - 55 years were the highest incidences among non-occupational pesticides poisoning patients. Insecticides especially organophosphorus insecticides such as methamidophos, parathion, and omethoate comprised a higher proportion, accounting for 79.98% of the pesticides poisoning. The incidence and the fatality rate of occupational pesticide poisoning were reduced in the city. However, more attention should be paid to non-occupational pesticides poisoning. To decrease the numbers of pesticide poisoning and the risks of death, the relevant departments should take preventive strategy and measures against the pesticide poisoning.

Summary report of the Lightning and Static Electricity Committee

NASA Technical Reports Server (NTRS)

Plumer, J. A.

1979-01-01

Lightning protection technology as applied to aviation and identifying these technology needs are presented. The flight areas of technical needs include; (1) the need for In-Flight data on lightning electrical parameters; (2) technology base and guidelines for protection of advanced systems and structures; (3) improved laboratory test techniques; (4) analysis techniques for predicting induced effects; (5) lightning strike incident data from General Aviation; (6) lightning detection systems; (7) obtain pilot reports of lightning strikes; and (8) better training in lightning awareness. The nature of each problem, timeliness, impact of solutions, degree of effort required, and the roles of government and industry in achieving solutions are discussed.

Pediatric anesthesia after APRICOT (Anaesthesia PRactice In Children Observational Trial): who should do it?

PubMed

Habre, Walid

2018-06-01

This review highlights the requirements for harmonization of training, certification and continuous professional development and discusses the implications for anesthesia management of children in Europe. A large prospective cohort study, Anaesthesia PRactice In Children Observational Trial (APRICOT), revealed a high incidence of perioperative severe critical events and a large variability of anesthesia practice across 33 European countries. Relevantly, quality improvement programs have been implemented in North America, which precisely define the requirements to manage anesthesia care for children. These programs, with the introduction of an incident-reporting system at local and national levels, could contribute to the improvement of anesthesia care for children in Europe. The main factors that likely contributed to the APRICOT study results are discussed with the goal of defining clear requirement guidelines for anesthetizing children. Emphasis is placed on the importance of an incident-reporting system that can be used for both competency-based curriculum for postgraduate training as well as for continuous professional development. Variability in training as well as in available resources, equipment and facilities limit the generalization of some of the APRICOT results. Finally, the impact on case outcome of the total number of pediatric cases attended by the anesthesiologist should be taken into consideration along with the level of expertise of the anesthesiologist for complex pediatric anesthesia cases.

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

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kakinohana, Y; Toita, T; Heianna, J

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’ itemmore » 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 department, therefore, the primary action to prevent/reduce similar incidents should be ‘communication improvement’.« less

Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study

PubMed Central

Seclen, Segundo Nicolas; Rosas, Moises Ernesto; Arias, Arturo Jaime; Medina, Cecilia Alexandra

2017-01-01

Objective A recent report from a non-nationally representative, geographically diverse sample in four separate communities in Peru suggests an unusually high diabetes incidence. We aimed to estimate the national diabetes incidence rate using PERUDIAB, a probabilistic, national urban population-based longitudinal study. Research design and methods 662 subjects without diabetes, selected by multistage, cluster, random sampling of households, representing the 24 administrative and the 3 (coast, highlands and jungle) natural regions across the country, from both sexes, aged 25+ years at baseline, enrolled in 2010–2012, were followed for 3.8 years. New diabetes cases were defined as fasting blood glucose ≥126 mg/dL or on medical diabetes treatment. Results There were 49 cases of diabetes in 2408 person-years follow-up. The weighted cumulative incidence of diabetes was 7.2% while the weighted incidence rate was estimated at 19.5 (95% CI 13.9 to 28.3) new cases per 1000 person-years. Older age, obesity and technical or higher education were statistically associated with the incidence of diabetes. Conclusion Our results confirm that the incidence of diabetes in Peru is among the highest reported globally. The fast economic growth in the last 20 years, high overweight and obesity rates may have triggered this phenomenon. PMID:28878935

Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study.

PubMed

Seclen, Segundo Nicolas; Rosas, Moises Ernesto; Arias, Arturo Jaime; Medina, Cecilia Alexandra

2017-01-01

A recent report from a non-nationally representative, geographically diverse sample in four separate communities in Peru suggests an unusually high diabetes incidence. We aimed to estimate the national diabetes incidence rate using PERUDIAB, a probabilistic, national urban population-based longitudinal study. 662 subjects without diabetes, selected by multistage, cluster, random sampling of households, representing the 24 administrative and the 3 (coast, highlands and jungle) natural regions across the country, from both sexes, aged 25+ years at baseline, enrolled in 2010-2012, were followed for 3.8 years. New diabetes cases were defined as fasting blood glucose ≥126 mg/dL or on medical diabetes treatment. There were 49 cases of diabetes in 2408 person-years follow-up. The weighted cumulative incidence of diabetes was 7.2% while the weighted incidence rate was estimated at 19.5 (95% CI 13.9 to 28.3) new cases per 1000 person-years. Older age, obesity and technical or higher education were statistically associated with the incidence of diabetes. Our results confirm that the incidence of diabetes in Peru is among the highest reported globally. The fast economic growth in the last 20 years, high overweight and obesity rates may have triggered this phenomenon.

Salmonella enterica Infections in the United States and Assessment of Coefficients of Variation: A Novel Approach to Identify Epidemiologic Characteristics of Individual Serotypes, 1996–2011

PubMed Central

Boore, Amy L.; Hoekstra, R. Michael; Iwamoto, Martha; Fields, Patricia I.; Bishop, Richard D.; Swerdlow, David L.

2015-01-01

Background Despite control efforts, salmonellosis continues to cause an estimated 1.2 million infections in the United States (US) annually. We describe the incidence of salmonellosis in the US and introduce a novel approach to examine the epidemiologic similarities and differences of individual serotypes. Methods Cases of salmonellosis in humans reported to the laboratory-based National Salmonella Surveillance System during 1996–2011 from US states were included. Coefficients of variation were used to describe distribution of incidence rates of common Salmonella serotypes by geographic region, age group and sex of patient, and month of sample isolation. Results During 1996–2011, more than 600,000 Salmonella isolates from humans were reported, with an average annual incidence of 13.1 cases/100,000 persons. The annual reported rate of Salmonella infections did not decrease during the study period. The top five most commonly reported serotypes, Typhimurium, Enteritidis, Newport, Heidelberg, and Javiana, accounted for 62% of fully serotyped isolates. Coefficients of variation showed the most geographically concentrated serotypes were often clustered in Gulf Coast states and were also more frequently found to be increasing in incidence. Serotypes clustered in particular months, age groups, and sex were also identified and described. Conclusions Although overall incidence rates of Salmonella did not change over time, trends and epidemiological factors differed remarkably by serotype. A better understanding of Salmonella, facilitated by this comprehensive description of overall trends and unique characteristics of individual serotypes, will assist in responding to this disease and in planning and implementing prevention activities. PMID:26701276

Quality control quantification (QCQ): a tool to measure the value of quality control checks in radiation oncology.

PubMed

Ford, Eric C; Terezakis, Stephanie; Souranis, Annette; Harris, Kendra; Gay, Hiram; Mutic, Sasa

2012-11-01

To quantify the error-detection effectiveness of commonly used quality control (QC) measures. We analyzed incidents from 2007-2010 logged into a voluntary in-house, electronic incident learning systems at 2 academic radiation oncology clinics. None of the incidents resulted in patient harm. Each incident was graded for potential severity using the French Nuclear Safety Authority scoring scale; high potential severity incidents (score >3) were considered, along with a subset of 30 randomly chosen low severity incidents. Each report was evaluated to identify which of 15 common QC checks could have detected it. The effectiveness was calculated, defined as the percentage of incidents that each QC measure could detect, both for individual QC checks and for combinations of checks. In total, 4407 incidents were reported, 292 of which had high-potential severity. High- and low-severity incidents were detectable by 4.0 ± 2.3 (mean ± SD) and 2.6 ± 1.4 QC checks, respectively (P<.001). All individual checks were less than 50% sensitive with the exception of pretreatment plan review by a physicist (63%). An effectiveness of 97% was achieved with 7 checks used in combination and was not further improved with more checks. The combination of checks with the highest effectiveness includes physics plan review, physician plan review, Electronic Portal Imaging Device-based in vivo portal dosimetry, radiation therapist timeout, weekly physics chart check, the use of checklists, port films, and source-to-skin distance checks. Some commonly used QC checks such as pretreatment intensity modulated radiation therapy QA do not substantially add to the ability to detect errors in these data. The effectiveness of QC measures in radiation oncology depends sensitively on which checks are used and in which combinations. A small percentage of errors cannot be detected by any of the standard formal QC checks currently in broad use, suggesting that further improvements are needed. These data require confirmation with a broader incident-reporting database. Copyright © 2012 Elsevier Inc. All rights reserved.

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.

Deaths Due to Use of Lethal Force by Law Enforcement: Findings From the National Violent Death Reporting System, 17 U.S. States, 2009-2012.

PubMed

DeGue, Sarah; Fowler, Katherine A; Calkins, Cynthia

2016-11-01

Several high-profile cases in the U.S. have drawn public attention to the use of lethal force by law enforcement (LE), yet research on such fatalities is limited. Using data from a public health surveillance system, this study examined the characteristics and circumstances of these violent deaths to inform prevention. All fatalities (N=812) resulting from use of lethal force by on-duty LE from 2009 to 2012 in 17 U.S. states were examined using National Violent Death Reporting System data. Case narratives were coded for additional incident circumstances. Victims were majority white (52%) but disproportionately black (32%) with a fatality rate 2.8 times higher among blacks than whites. Most victims were reported to be armed (83%); however, black victims were more likely to be unarmed (14.8%) than white (9.4%) or Hispanic (5.8%) victims. Fatality rates among military veterans/active duty service members were 1.4 times greater than among their civilian counterparts. Four case subtypes were examined based on themes that emerged in incident narratives: about 22% of cases were mental health related; 18% were suspected "suicide by cop" incidents, with white victims more likely than black or Hispanic victims to die in these circumstances; 14% involved intimate partner violence; and about 6% were unintentional deaths due to LE action. Another 53% of cases were unclassified and did not fall into a coded subtype. Regression analyses identified victim and incident characteristics associated with each case subtype and unclassified cases. Knowledge about circumstances of deaths due to the use of lethal force can inform the development of prevention strategies, improve risk assessment, and modify LE response to increase the safety of communities and officers and prevent fatalities associated with LE intervention. Copyright © 2016. Published by Elsevier Inc.

An analysis of computer-related patient safety incidents to inform the development of a classification.

PubMed

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

2010-01-01

To analyze patient safety incidents associated with computer use to develop the basis for a classification of problems reported by health professionals. Incidents submitted to a voluntary incident reporting database across one Australian state were retrieved and a subset (25%) was analyzed to identify 'natural categories' for classification. Two coders independently classified the remaining incidents into one or more categories. Free text descriptions were analyzed to identify contributing factors. Where available medical specialty, time of day and consequences were examined. Descriptive statistics; inter-rater reliability. A search of 42,616 incidents from 2003 to 2005 yielded 123 computer related incidents. After removing duplicate and unrelated incidents, 99 incidents describing 117 problems remained. A classification with 32 types of computer use problems was developed. Problems were grouped into information input (31%), transfer (20%), output (20%) and general technical (24%). Overall, 55% of problems were machine related and 45% were attributed to human-computer interaction. Delays in initiating and completing clinical tasks were a major consequence of machine related problems (70%) whereas rework was a major consequence of human-computer interaction problems (78%). While 38% (n=26) of the incidents were reported to have a noticeable consequence but no harm, 34% (n=23) had no noticeable consequence. Only 0.2% of all incidents reported were computer related. Further work is required to expand our classification using incident reports and other sources of information about healthcare IT problems. Evidence based user interface design must focus on the safe entry and retrieval of clinical information and support users in detecting and correcting errors and malfunctions.

[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.

Simulation of Automatic Incidents Detection Algorithm on the Transport Network

ERIC Educational Resources Information Center

Nikolaev, Andrey B.; Sapego, Yuliya S.; Jakubovich, Anatolij N.; Berner, Leonid I.; Ivakhnenko, Andrey M.

2016-01-01

Management of traffic incident is a functional part of the whole approach to solving traffic problems in the framework of intelligent transport systems. Development of an effective process of traffic incident management is an important part of the transport system. In this research, it's suggested algorithm based on fuzzy logic to detect traffic…

A probabilistic safety analysis of incidents in nuclear research reactors.

PubMed

Lopes, Valdir Maciel; Agostinho Angelo Sordi, Gian Maria; Moralles, Mauricio; Filho, Tufic Madi

2012-06-01

This work aims to evaluate the potential risks of incidents in nuclear research reactors. For its development, two databases of the International Atomic Energy Agency (IAEA) were used: the Research Reactor Data Base (RRDB) and the Incident Report System for Research Reactor (IRSRR). For this study, the probabilistic safety analysis (PSA) was used. To obtain the result of the probability calculations for PSA, the theory and equations in the paper IAEA TECDOC-636 were used. A specific program to analyse the probabilities was developed within the main program, Scilab 5.1.1. for two distributions, Fischer and chi-square, both with the confidence level of 90 %. Using Sordi equations, the maximum admissible doses to compare with the risk limits established by the International Commission on Radiological Protection (ICRP) were obtained. All results achieved with this probability analysis led to the conclusion that the incidents which occurred had radiation doses within the stochastic effects reference interval established by the ICRP-64.

An assessment of occupation and industry data from death certificates and hospital medical records for population-based cancer surveillance.

PubMed Central

Swanson, G M; Schwartz, A G; Burrows, R W

1984-01-01

This study analyzed 30,194 incident cases and 4,301 death certificates for completeness of occupational reporting. Analysis of data accuracy was based upon a comparison of more than 2,000 death certificates with incident abstracts and 352 death certificates with interview data. Death certificates had a higher proportion with occupation (94.3%) and industry (93.4%) reported than did incident abstracts of hospital medical records (39.0% and 63.5%, respectively). Compared with occupational history data obtained by interview, 76.1% of the death certificates were exact matches for usual occupation and industry. PMID:6711720

Sensitivity of fenestration solar gain to source spectrum and angle of incidence

DOE Office of Scientific and Technical Information (OSTI.GOV)

McCluney, W.R.

1996-12-31

The solar heat gain coefficient (SHGC) is the fraction of solar radiant flux incident on a fenestration system entering a building as heat gain. In general it depends on both the angle of incidence and the spectral distribution of the incident solar radiation. In attempts to improve energy performance and user acceptance of high-performance glazing systems, manufacturers are producing glazing systems with increasing spectral selectivity. This poses potential difficulties for calculations of solar heat gain through windows based upon the use of a single solar spectral weighting function. The sensitivity of modern high-performance glazing systems to both the angle ofmore » incidence and the shape of the incident solar spectrum is examined using a glazing performance simulation program. It is found that as the spectral selectivity of the glazing system increases, the SHGC can vary as the incident spectral distribution varies. The variations can be as great as 50% when using several different representative direct-beam spectra. These include spectra having low and high air masses and a standard spectrum having an air mass of 1.5. The variations can be even greater if clear blue diffuse skylight is considered. It is recommended that the current broad-band shading coefficient method of calculating solar gain be replaced by one that is spectral based.« less

All-cause Healthcare Costs and Mortality in Patients with Systemic Sclerosis with Lung Involvement.

PubMed

Fischer, Aryeh; Kong, Amanda M; Swigris, Jeffrey J; Cole, Ashley L; Raimundo, Karina

2018-02-01

Patients with systemic sclerosis (SSc) often develop interstitial lung disease (ILD) and/or pulmonary arterial hypertension (PAH). The effect of ILD and PAH on healthcare costs among patients with SSc is not well described. The objective of this analysis was to describe healthcare costs in patients with newly diagnosed SSc and SSc patients newly diagnosed with ILD and/or PAH in the United States. This retrospective cohort analysis was conducted in the Truven Health MarketScan Commercial and Medicare Supplemental healthcare claims databases from 2003 to 2014. Based on International Classification of Diseases-9-Clinical Modification diagnosis codes on medical claims, patients were classified into 3 groups: incident SSc, SSc with incident ILD (SSc-ILD), and SSc with incident PAH (SSc-PAH). Patients were required to have continuous enrollment for 5 years to measure all-cause healthcare costs. Costs (adjusted to US$) were reported overall and by service type and year following diagnosis. Because of the overlap between groups, statistical comparisons were not conducted. There were 1957 patients with incident SSc, 219 with incident SSc-ILD, and 108 patients with incident SSc-PAH. Average (mean ± SD) all-cause healthcare costs over followup were higher for patients with incident SSc-ILD ($191,107 ± $322,193) or patients with incident SSc-PAH ($254,425 ± $240,497), compared to patients with incident SSc ($101,839 ± $167,155). Average annual costs over the 5-year period ranged from $18,513 to $23,268 for patients with incident SSc, from $31,285 to $55,446 for patients with incident SSc-ILD, and from $44,454 to $63,320 for patients with incident SSc-PAH. Costs tended to be the highest in the fifth year of followup. Among patients with SSc, ILD and PAH can result in substantial increases in healthcare costs.

Using administrative medical claims data to supplement state disease registry systems for reporting zoonotic infections.

PubMed

Jones, Stephen G; Coulter, Steven; Conner, William

2013-01-01

To determine what, if any, opportunity exists in using administrative medical claims data for supplemental reporting to the state infectious disease registry system. Cases of five tick-borne (Lyme disease (LD), babesiosis, ehrlichiosis, Rocky Mountain spotted fever (RMSF), tularemia) and two mosquito-borne diseases (West Nile virus, La Crosse viral encephalitis) reported to the Tennessee Department of Health during 2000-2009 were selected for study. Similarly, medically diagnosed cases from a Tennessee-based managed care organization (MCO) claims data warehouse were extracted for the same time period. MCO and Tennessee Department of Health incidence rates were compared using a complete randomized block design within a general linear mixed model to measure potential supplemental reporting opportunity. MCO LD incidence was 7.7 times higher (p<0.001) than that reported to the state, possibly indicating significant under-reporting (∼196 unreported cases per year). MCO data also suggest about 33 cases of RMSF go unreported each year in Tennessee (p<0.001). Three cases of babesiosis were discovered using claims data, a significant finding as this disease was only recently confirmed in Tennessee. Data sharing between MCOs and health departments for vaccine information already exists (eg, the Vaccine Safety Datalink Rapid Cycle Analysis project). There may be a significant opportunity in Tennessee to supplement the current passive infectious disease reporting system with administrative claims data, particularly for LD and RMSF. There are limitations with administrative claims data, but health plans may help bridge data gaps and support the federal administration's vision of combining public and private data into one source.

The CSB Incident Screening Database: description, summary statistics and uses.

PubMed

Gomez, Manuel R; Casper, Susan; Smith, E Allen

2008-11-15

This paper briefly describes the Chemical Incident Screening Database currently used by the CSB to identify and evaluate chemical incidents for possible investigations, and summarizes descriptive statistics from this database that can potentially help to estimate the number, character, and consequences of chemical incidents in the US. The report compares some of the information in the CSB database to roughly similar information available from databases operated by EPA and the Agency for Toxic Substances and Disease Registry (ATSDR), and explores the possible implications of these comparisons with regard to the dimension of the chemical incident problem. Finally, the report explores in a preliminary way whether a system modeled after the existing CSB screening database could be developed to serve as a national surveillance tool for chemical incidents.

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

Stressful Encounters with Social Work Clients: A Descriptive Account Based on Critical Incidents

ERIC Educational Resources Information Center

Savaya, Riki; Gardner, Fiona; Stange, Dorit

2011-01-01

This article presents the findings of an analysis of 130 critical incidents reported by social workers in Israel. Almost all the incidents turned out to be upsetting events that caused the writers a great deal of pain, frustration, and self-doubt. Content analysis yielded four main categories of incidents or events: (1) client hostility and…

Hip fracture incidence 2003-2013 and projected cases until 2050 in Austria: a population-based study.

PubMed

Concin, Hans; Brozek, Wolfgang; Benedetto, Karl-Peter; Häfele, Hartmut; Kopf, Joachim; Bärenzung, Thomas; Schnetzer, Richard; Schenk, Christian; Stimpfl, Elmar; Waheed-Hutter, Ursula; Ulmer, Hanno; Rapp, Kilian; Zwettler, Elisabeth; Nagel, Gabriele

2016-12-01

Elevated hip fracture incidence is a major public health problem looming to aggravate in industrialized countries due to demographic developments. We report hip fracture incidence and expected future cases from Vorarlberg, the westernmost province of Austria, results potentially representative of Central European populations. Crude and standardized hip fracture incidence rates in Vorarlberg 2003-2013 are reported. Based on the age-specific incidence in 2013 or trends 2003-2013, we predict hip fractures till 2050. Female age-standardized hip fracture incidence decreased 2005-2013, whereas for men, the trend was rather unclear. Uncorrected forecasts indicate that by 2050, female and male cases will each have more than doubled from 2015 in all demographic core scenarios. Corrected by incidence trends before 2013, cases are expected to drop among women but rise among men. We anticipate rising hip fracture numbers in Vorarlberg within the next decades, unless prevention programs that presumably account for decreasing incidence rates, particularly among women since 2005, take further effect to counteract the predicted steady increase due to demographic changes. Concomitantly, augmented endeavors to target the male population by these programs are needed.

Measles in Poland in 2012.

PubMed

Rogalska, Justyna; Karasek, Ewa; Paradowska-Stankiewicz, Iwona

2014-01-01

In 1998 Poland, along with all other Member States in the WHO European Region, implemented Measles Elimination Program coordinated by WHO. It requires achieving and maintaining very high vaccine coverage (>95%), recording all cases and suspected cases of measles, and laboratory testing of all suspected measles cases in the WHO Reference Laboratory. In Poland it is a Laboratory of Department of Virology, NIPH-NIH. To assess epidemiological situation of measles in Poland in 2012, including vaccination coverage in Polish population, and Measles Elimination Program implementation status. The descriptive analysis was based on data retrieved from routine mandatory surveillance system and published in the annual bulletins "Infectious diseases and poisonings in Poland in 2012" and "Vaccinations in Poland in 2012", and measles case-based reports from 2012 sent to the Department of Epidemiology NIPH-NIH by Sanitary-Epidemiological Stations. In total, there were 70 measles cases registered in Poland in 2012 (incidence 0.18 per 100 000). The highest incidence rate was observed among infants (2.08 per 100 000) and children aged 1 year (2.47 per 100 000). In 2012, 37 cases (52,9%) were hospitalized due to measles. No deaths from measles were reported. Vaccination coverage of children and youth aged 2-11 years ranged from 83.6% do 99.6% (primary vaccination in children born in 2011-2006) and from 76.6% do 96.7% (booster dose in children born in 2003-2001). Performance of the surveillance system was insufficient with only 127 measles-compatible cases reported in 2012 (33% of expected reports). Fifty cases (71%) were confirmed by IgM ELISA test. The epidemiological situation of measles deteriorated in 2012 in comparison to proceding year. The results indicate a need to further promote Measles Elimination Program in Poland, maintain the high immunisation coverage and improve measles surveillance system.

Annual Report to the Nation on the Status of Cancer, 1975–2007, Featuring Tumors of the Brain and Other Nervous System

PubMed Central

Ward, Elizabeth; McCarthy, Bridget J.; Schymura, Maria J.; Eheman, Christie; Jemal, Ahmedin; Anderson, Robert N.; Ajani, Umed A.; Edwards, Brenda K.

2011-01-01

Background The American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute, and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information on cancer occurrence and trends in the United States. This year’s report highlights brain and other nervous system (ONS) tumors, including nonmalignant brain tumors, which became reportable on a national level in 2004. Methods Cancer incidence data were obtained from the National Cancer Institute, CDC, and NAACCR, and information on deaths was obtained from the CDC’s National Center for Health Statistics. The annual percentage changes in age-standardized incidence and death rates (2000 US population standard) for all cancers combined and for the top 15 cancers for men and for women were estimated by joinpoint analysis of long-term (1992–2007 for incidence; 1975–2007 for mortality) trends and short-term fixed interval (1998–2007) trends. Analyses of malignant neuroepithelial brain and ONS tumors were based on data from 1980–2007; data on nonmalignant tumors were available for 2004–2007. All statistical tests were two-sided. Results Overall cancer incidence rates decreased by approximately 1% per year; the decrease was statistically significant (P < .05) in women, but not in men, because of a recent increase in prostate cancer incidence. The death rates continued to decrease for both sexes. Childhood cancer incidence rates continued to increase, whereas death rates continued to decrease. Lung cancer death rates decreased in women for the first time during 2003–2007, more than a decade after decreasing in men. During 2004–2007, more than 213 500 primary brain and ONS tumors were diagnosed, and 35.8% were malignant. From 1987–2007, the incidence of neuroepithelial malignant brain and ONS tumors decreased by 0.4% per year in men and women combined. Conclusions The decrease in cancer incidence and mortality reflects progress in cancer prevention, early detection, and treatment. However, major challenges remain, including increasing incidence rates and continued low survival for some cancers. Malignant and nonmalignant brain tumors demonstrate differing patterns of occurrence by sex, age, and race, and exhibit considerable biologic diversity. Inclusion of nonmalignant brain tumors in cancer registries provides a fuller assessment of disease burden and medical resource needs associated with these unique tumors. PMID:21454908

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/

Risk-based Classification of Incidents

NASA Technical Reports Server (NTRS)

Greenwell, William S.; Knight, John C.; Strunk, Elisabeth A.

2003-01-01

As the penetration of software into safety-critical systems progresses, accidents and incidents involving software will inevitably become more frequent. Identifying lessons from these occurrences and applying them to existing and future systems is essential if recurrences are to be prevented. Unfortunately, investigative agencies do not have the resources to fully investigate every incident under their jurisdictions and domains of expertise and thus must prioritize certain occurrences when allocating investigative resources. In the aviation community, most investigative agencies prioritize occurrences based on the severity of their associated losses, allocating more resources to accidents resulting in injury to passengers or extensive aircraft damage. We argue that this scheme is inappropriate because it undervalues incidents whose recurrence could have a high potential for loss while overvaluing fairly straightforward accidents involving accepted risks. We then suggest a new strategy for prioritizing occurrences based on the risk arising from incident recurrence.

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

DOE Office of Scientific and Technical Information (OSTI.GOV)

Arnold, Anthony, E-mail: anthony.arnold@sesiahs.health.nsw.gov.a; Delaney, Geoff P.; Cassapi, Lynette

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

Laser exposure incidents: pilot ocular health and aviation safety issues.

PubMed

Nakagawara, Van B; Wood, Kathryn J; Montgomery, Ron W

2008-09-01

A database of aviation reports involving laser illumination of flight crewmembers has been established and maintained at the Civil Aerospace Medical Institute. A review of recent laser illumination reports was initiated to investigate the significance of these events. Reports that involved laser exposures of civilian aircraft in the United States were analyzed for the 13-month period (January 1, 2004, through January 31, 2005). There were 90 reported instances of laser illumination during the study period. A total of 53 reports involved laser exposure of commercial aircraft. Lasers illuminated the cockpit in 41 (46%) of the incidents. Of those, 13 (32%) incidents resulted in a visual impairment or distraction to a pilot, including 1 incident that reportedly resulted in an ocular injury. Nearly 96% of these reports occurred in the last 3 months of the study period. There were no aviation accidents in which laser light illumination was found to be a contributing factor. Operational problems have resulted from laser illumination incidents in the national airspace system. Eye care practitioners, to provide effective consultations to their pilot patients, should be familiar with the problems that can occur with laser exposure.

Human Factors in Financial Trading: An Analysis of Trading Incidents.

PubMed

Leaver, Meghan; Reader, Tom W

2016-09-01

This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents. In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. © 2016, Human Factors and Ergonomics Society.

Scombrotoxic fish poisoning in Britain: features of over 250 suspected incidents from 1976 to 1986.

PubMed Central

Bartholomew, B. A.; Berry, P. R.; Rodhouse, J. C.; Gilbert, R. J.; Murray, C. K.

1987-01-01

Between 1976 and 1986, 258 incidents of suspected scombrotoxic fish poisoning were reported in Britain. Histamine analysis was carried out on 240 fish samples from these incidents, and 101 were found to contain greater than 5 mg histamine/100 g fish. The symptoms most consistently reported were rash, diarrhoea, flushing and headache. In recent years there has been a decrease in the number of confirmed scombrotoxic outbreaks and a trend towards more sporadic incidents. Of fish samples with greater than 20 mg histamine/100 g, 94% were from incidents in which scombrotoxic symptoms were characteristic, but where fish had 5-20 mg/100 g only 38% of incidents were clinically distinctive. Guidelines are presented based on the interpretation of quantitative histamine analysis of fish samples from scombrotoxic poisoning incidents. PMID:3428380

Leukemia in Iran: Epidemiology and Morphology Trends.

PubMed

Koohi, Fatemeh; Salehiniya, Hamid; Shamlou, Reza; Eslami, Soheyla; Ghojogh, Ziyaeddin Mahery; Kor, Yones; Rafiemanesh, Hosein

2015-01-01

Leukemia accounts for 8% of total cancer cases and involves all age groups with different prevalence and incidence rates in Iran and the entire world and causes a significant death toll and heavy expenses for diagnosis and treatment processes. This study was done to evaluate epidemiology and morphology of blood cancer during 2003-2008. This cross- sectional study was carried out based on re- analysis of the Cancer Registry Center report of the Health Deputy in Iran during a 6-year period (2003 - 2008). Statistical analysis for incidence time trends and morphology change percentage was performed with joinpoint regression analysis using the software Joinpoint Regression Program. During the studied years a total of 18,353 hematopoietic and reticuloendothelial system cancers were recorded. Chi square test showed significant difference between sex and morphological types of blood cancer (P-value<0.001). Joinpoint analysis showed a significant increasing trend for the adjusted standard incidence rate (ASIR) for both sexes (P-value<0.05). Annual percent changes (APC) for women and men were 18.7 and 19.9, respectively. The most common morphological blood cancers were ALL, ALM, MM and CLL which accounted for 60% of total hematopoietic system cancers. Joinpoint analyze showed a significant decreasing trend for ALM in both sexes (P-value<0.05). Hematopoietic system cancers in Iran demonstrate an increasing trend for incidence rate and decreasing trend for ALL, ALM and CLL morphology.

Air-ground information transfer in the National Airspace System

NASA Technical Reports Server (NTRS)

Lee, Alfred T.; Lozito, Sandra

1989-01-01

This paper reviews NASA's Aviation Safety Reporting System incident data for a two-year period in order to identify the frequency of air-ground information transfer errors and the factors associated with their occurrence. Of the more than 14,000 primary reports received during the 1985 and 1986 reporting period, one out of four reports concerned problems of information transfer between aircraft and ATC. Approximately half of these errors were associated directly or indirectly with aircraft deviations from assigned heading or altitude. The majority of incidents cited some human-system problem such as workload, cockpit distractions, etc., as the primary contributing factor. Improvements in air-ground information transfer using existing and future (e.g., data link) technology are proposed centering on the development and application of user-centered information management principles.

Neural network model for automatic traffic incident detection : final report, August 2001.

DOT National Transportation Integrated Search

2001-08-01

Automatic freeway incident detection is an important component of advanced transportation management systems (ATMS) that provides information for emergency relief and traffic control and management purposes. In this research, a multi-paradigm intelli...

UNDERSTANDING HUMAN OVER-RELIANCE ON TECHNOLOGY.

PubMed

2017-01-01

THROUGH THE ANALYSIS OF AN INCIDENT RECEIVED FROM THE NATIONAL SYSTEM FOR INCIDENT REPORTING (NSIR), THIS ISMP CANADA SAFETY BULLETIN HIGHLIGHTS HUMAN OVER-RELIANCE ON TECHNOLOGY BY INTRODUCING TWO RELATED HUMAN COGNITIVE LIMITATIONS: AUTOMATION BIAS AND AUTOMATION COMPLACENCY.

Prevalence and incidence of epilepsy in the Nordic countries.

PubMed

Syvertsen, Marte; Koht, Jeanette; Nakken, Karl O

2015-10-06

Updated knowledge on the prevalence of epilepsy is valuable for planning of health services to this large and complex patient group. Comprehensive epidemiological research on epilepsy has been undertaken, but because of variations in methodology, the results are difficult to compare. The objective of this article is to present evidence-based estimates of the prevalence and incidence of epilepsy in the Nordic countries. The article is based on a search in PubMed with the search terms epilepsy and epidemiology, combined with each of the Nordic countries separately. Altogether 38 original articles reported incidence and/or prevalence rates of epilepsy in a Nordic country. Four studies had investigated the prevalence of active epilepsy in all age groups, with results ranging from 3.4 to 7.6 per 1,000 inhabitants. Only two studies had investigated the incidence of epilepsy in a prospective material that included all age groups. The reported incidence amounted to 33 and 34 per 100,000 person-years respectively. A prospective study that only included adults reported an incidence of 56 per 100,000 person-years. We estimate that approximately 0.6% of the population of the Nordic countries have active epilepsy, i.e. approximately 30,000 persons in Norway. Epilepsy is thus one of the most common neurological disorders. The incidence data are more uncertain, but we may reasonably assume that 30-60 new cases occur per 100,000 person-years.

Three year follow up of a self certification system for the assessment of fitness to dive in Scotland

PubMed Central

Glen, S

2004-01-01

Background: The need for routine medical examinations of sport divers in the Scottish Sub-Aqua Club (Scot-SAC) was revised in March 2000, and a new system using a self administered screening questionnaire was developed to allow divers to be assessed when necessary by doctors with diving medicine experience. Objective: To assess the effect of the new medical system on medical referee workload, diver exclusion rates, and diving incident frequency. Methods: All divers were required to complete a questionnaire to screen for conditions that might affect fitness to dive. Divers answering "Yes" to any of the questions had their medical background assessed by a diving doctor, and, if necessary, received a clinical examination or investigation. The rate of diver exclusions based on the questionnaire response was recorded in conjunction with analysis of the incident reports. Results: The number of forms requiring review by diving doctors increased from 1.2% to 5.7% (p<0.0001, 95% confidence interval (CI) –0.06 to –0.03) in the year after the introduction of the new medical system and gradually increased in subsequent years to 7.7% (p<0.0001, 95% CI –0.08 to –0.05). The number of divers failing to be certified fit to dive increased slightly from 0.7% to 1.0% after one year (p = 0.26, 95% CI –0.01 to 0.00) and subsequently to 2.0% (p = 0.0003, 95% CI 0.02 to –0.01) after three years. Most divers were certified fit to dive on the basis of the questionnaire alone, and only 0.9% required objective investigation (such as exercise testing or echocardiography). Analysis of the incidents during three years of follow up confirmed that no incident occurred because of an undetected pre-existing medical condition. Two incidents involved divers with hypertension, but both had received medical examinations and investigation based on their responses to the questionnaire. Conclusion: The new self administered questionnaire system appears to be an effective screening tool for the detection of divers requiring detailed assessment by doctors with diving medicine experience. PMID:15562174

2016 Earth System Grid Federation Annual Report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Williams, Dean N.

The Earth System Grid Federation (ESGF) experienced a major setback in June 2015, when it experienced a security incident that brought all systems to a halt for more than half a year. However, federation developers and management committee members turned the incident into an opportunity to dramatically upgrade the system security and functionality and to develop planning and policy documents to guide ESGF evolution and success. Moreover, despite the incident, ESGF developer working teams continue to make strong and significant progress on various enhancement projects that will help ensure ESGF can meet the needs of the climate community in themore » coming years.« less

Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators.

PubMed

Carlfjord, Siw; Öhrn, Annica; Gunnarsson, Anna

2018-02-14

Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care. Using qualitative methods is a way to reveal how IR is used and perceived in health care practice. The aim of the present study was to explore the experiences of IR from two different perspectives, including heads of departments and IR coordinators, to better understand how they value the practice and their thoughts regarding future application. Data collection was performed in Östergötland County, Sweden, where an electronic IR system was implemented in 2004, and the authorities explicitly have advocated IR from that date. A purposive sample of nine heads of departments from three hospitals were interviewed, and two focus group discussions with IR coordinators took place. Data were analysed using qualitative content analysis. Two main themes emerged from the data: "Incident reporting has come to stay" building on the categories entitled perceived advantages, observed changes and value of the IR system, and "Remaining challenges in incident reporting" including the categories entitled need for action, encouraged learning, continuous culture improvement, IR system development and proper use of IR. After 10 years, the practice of IR is widely accepted in the selected setting. IR has helped to put patient safety on the agenda, and a cultural change towards no blame has been observed. The informants suggest an increased focus on action, and further development of the tools for reporting and handling incidents.

Patient ratings of case managers in a medical home: associations with patient satisfaction and health care utilization.

PubMed

Jubelt, Lindsay E; Graham, Jove; Maeng, Daniel D; Li, Huilin; Epstein, Andrew J; Metlay, Joshua P

2014-11-18

Case managers are employed in medical homes to coordinate care for clinically complex patients. To measure the association of patient perceptions of case manager performance with overall satisfaction and subsequent health care utilization. Retrospective cohort study. Integrated health system in Pennsylvania. Members of the health system-owned health plan who 1) received primary care in the health system's clinics, 2) were exposed to clinic-embedded case managers, and 3) completed a survey of satisfaction with care. Survey assessment of case manager performance and overall satisfaction with care and claims-based assessment of case manager performance and subsequent hospitalizations or emergency department visits. Survey measures were dichotomized into very good versus less than very good. A total of 1755 patients (44%) completed the survey and 1415 met study criteria. Survey respondents who reported very good ratings of case manager performance across all items had a higher probability of reporting very good overall satisfaction with care (92.2% vs. 62.5%; P < 0.001) and had a lower incidence of subsequent emergency department visits (incidence rate ratio, 0.79 [95% CI, 0.64 to 0.98]; P = 0.029) but not hospitalizations (incidence rate ratio, 0.92 [CI, 0.75 to 1.11]; P = 0.37) up to 2 years after the survey compared with survey respondents who reported less-than-very good case manager performance on 1 or more questions on the survey. Satisfaction data demonstrated substantial ceiling effects. Survey nonresponse may have introduced bias in the results. Patients' favorable perceptions of case managers are associated with higher overall satisfaction with care and may lower risk for future acute care use. Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs.

Population-based epidemiology of non-fatal injuries in Tehran, Iran.

PubMed

Hashemi, Esmatolsadat; Zangi, Mahdi; Sadeghi-Bazargani, Homayoun; Soares, Joaquim; Viitasara, Eija; Mohammadi, Reza

2018-01-01

Background: Our aim in this survey was to explore descriptive epidemiology of injuries in Tehran in 2012 and to report the recalled estimates of injury incidence rates. Methods: A population survey was conducted in Tehran during 2012, within which a total of 8626 participants were enrolled. The cluster sampling was used to draw samples in 100 clusters with a pre-specified cluster size of 25 households per cluster. Data were collected on demographic features, accident and injury characteristics based on the International Classification of Diseases (ICD10). Results: A total of 618 injuries per 3 months were reported, within which 597 cases (96.6%)were unintentional injuries. More than 82% of all injuries were those caused by exposure to inanimate mechanical forces, traffic accidents, falls and burns. Above 80% of the traffic injuries happened among men (P<0.001). About 43% of the unintentional injuries were mild injuries.After the age of 40, women, unlike men, had higher risks for being injured. The estimated annual incidence rate for all types of injuries was 284.8 per 1000 (95% CI: 275.4-294.4) and for unintentional injuries was 275.2 per 1000. Conclusion: Injuries are major health problems in Tehran with a highly reported incidence. The status is not substantially improved over the recent years which urges the need to be adequately and emergently addressed. As the incidence rate was estimated based on participant recalls, the real incidence rate may even be higher than those reported in the current study.

Evaluation of an Internet-based monitoring system for influenza-like illness in Sweden.

PubMed

Rehn, Moa; Carnahan, AnnaSara; Merk, Hanna; Kühlmann-Berenzon, Sharon; Galanis, Ilias; Linde, Annika; Nyrén, Olof

2014-01-01

To complement traditional influenza surveillance with data on disease occurrence not only among care-seeking individuals, the Swedish Institute for Communicable Disease Control (SMI) has tested an Internet-based monitoring system (IMS) with self-recruited volunteers submitting weekly on-line reports about their health in the preceding week, upon weekly reminders. We evaluated IMS acceptability and to which extent participants represented the Swedish population. We also studied the agreement of data on influenza-like illness (ILI) occurrence from IMS with data from a previously evaluated population-based system (PBS) with an actively recruited random sample of the population who spontaneously report disease onsets in real-time via telephone/Internet, and with traditional general practitioner based sentinel and virological influenza surveillance, in the 2011-2012 and 2012-2013 influenza seasons. We assessed acceptability by calculating the participation proportion in an invited IMS-sample and the weekly reporting proportion of enrolled self-recruited IMS participants. We compared distributions of socio-demographic indicators of self-recruited IMS participants to the general Swedish population using chi-square tests. Finally, we assessed the agreement of weekly incidence proportions (%) of ILI in IMS and PBS with cross-correlation analyses. Among 2,511 invited persons, 166 (6.6%) agreed to participate in the IMS. In each season, 2,552 and 2,486 self-recruited persons participated in the IMS respectively. The weekly reporting proportion among self-recruited participants decreased from 87% to 23% (2011-2012) and 82% to 45% (2012-2013). Women, highly educated, and middle-aged persons were overrepresented among self-recruited IMS participants (p<0.01). IMS (invited and self-recruited) and PBS weekly incidence proportions correlated strongest when no lags were applied (r = 0.71 and r = 0.69, p<0.05). This evaluation revealed socio-demographic misrepresentation and limited compliance among the self-recruited IMS participants. Yet, IMS offered a reasonable representation of the temporal ILI pattern in the community overall during the 2011-2012 and 2012-2013 influenza seasons and could be a simple tool for collecting community-based ILI data.

Bridging the gap: linking a legacy hospital information system with a filmless radiology picture archiving and communications system within a nonhomogeneous environment.

PubMed

Rubin, R K; Henri, C J; Cox, R D

1999-05-01

A health level 7 (HL7)-conformant data link to exchange information between the mainframe hospital information system (HIS) of our hospital and our home-grown picture archiving and communications system (PACS) is a result of a collaborative effort between the HIS department and the PACS development team. Based of the ability to link examination requisitions and image studies, applications have been generated to optimise workflow and to improve the reliability and distribution of radiology information. Now, images can be routed to individual radiologists and clinicians; worklists facilitate radiology reporting; applications exist to create, edit, and view reports and images via the internet; and automated quality control now limits the incidence of "lost" cases and errors in image routing. By following the HL7 standard to develop the gateway to the legacy system, the development of a radiology information system for booking, reading, reporting, and billing remains universal and does not preclude the option to integrate off-the-shelf commercial products.

An analysis of computer-related patient safety incidents to inform the development of a classification

PubMed Central

Ong, Mei-Sing; Runciman, William; Coiera, Enrico

2010-01-01

Objective To analyze patient safety incidents associated with computer use to develop the basis for a classification of problems reported by health professionals. Design Incidents submitted to a voluntary incident reporting database across one Australian state were retrieved and a subset (25%) was analyzed to identify ‘natural categories’ for classification. Two coders independently classified the remaining incidents into one or more categories. Free text descriptions were analyzed to identify contributing factors. Where available medical specialty, time of day and consequences were examined. Measurements Descriptive statistics; inter-rater reliability. Results A search of 42 616 incidents from 2003 to 2005 yielded 123 computer related incidents. After removing duplicate and unrelated incidents, 99 incidents describing 117 problems remained. A classification with 32 types of computer use problems was developed. Problems were grouped into information input (31%), transfer (20%), output (20%) and general technical (24%). Overall, 55% of problems were machine related and 45% were attributed to human–computer interaction. Delays in initiating and completing clinical tasks were a major consequence of machine related problems (70%) whereas rework was a major consequence of human–computer interaction problems (78%). While 38% (n=26) of the incidents were reported to have a noticeable consequence but no harm, 34% (n=23) had no noticeable consequence. Conclusion Only 0.2% of all incidents reported were computer related. Further work is required to expand our classification using incident reports and other sources of information about healthcare IT problems. Evidence based user interface design must focus on the safe entry and retrieval of clinical information and support users in detecting and correcting errors and malfunctions. PMID:20962128

Incidence of Achalasia in South Australia Based on Esophageal Manometry Findings.

PubMed

Duffield, Jaime A; Hamer, Peter W; Heddle, Richard; Holloway, Richard H; Myers, Jennifer C; Thompson, Sarah K

2017-03-01

Achalasia is a disorder of esophageal motility with a reported incidence of 0.5 to 1.6 per 100,000 persons per year in Europe, Asia, Canada, and America. However, estimates of incidence values have been derived predominantly from retrospective searches of databases of hospital discharge codes and personal communications with gastroenterologists, and are likely to be incorrect. We performed a cohort study based on esophageal manometry findings to determine the incidence of achalasia in South Australia. We collected data from the Australian Bureau of Statistics on the South Australian population. Cases of achalasia diagnosed by esophageal manometry were identified from the 3 adult manometry laboratory databases in South Australia. Endoscopy reports and case notes were reviewed for correlations with diagnoses. The annual incidence of achalasia in the South Australian population was calculated for the decade 2004 to 2013. Findings were standardized to those of the European Standard Population based on age. The annual incidence of achalasia in South Australia ranged from 2.3 to 2.8 per 100,000 persons. The mean age at diagnosis was 62.1 ± 18.1 years. The incidence of achalasia increased with age (Spearman rho, 0.95; P < .01). The age-standardized incidence ranged from 2.1 (95% CI, 1.8-2.3) to 2.5 (95% CI, 2.2-2.7). Based on a cohort study of esophageal manometry, we determined the incidence of achalasia in South Australia to be 2.3 to 2.8 per 100,000 persons and to increase with age. South Australia's relative geographic isolation and the population's access to manometry allowed for more accurate identification of cases than hospital code analyses, with a low probability of missed cases. Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

Quantifying Missed Nursing Care Using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey.

PubMed

Orique, Sabrina B; Patty, Christopher M; Sandidge, Alisha; Camarena, Emma; Newsom, Rose

2017-12-01

The aim of this article is to describe the use of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data to measure missed nursing care and construct a missed nursing care metric. Missed nursing care varies widely within and between US hospitals. Missed nursing care can be measured utilizing the HCAHPS data. This cross-sectional study used HCAHPS data to measure missed care. This analysis includes HCAHPS data from 1125 acute care patients discharged between January 2014 and December 2014. A missed care index was computed by dividing the total number of missed care occurrences as reported by the patient into the total number of survey responses that did not indicate missed care. The computed missed care index for the organization was 0.6 with individual unit indices ranging from 0.2 to 1.4. Our methods utilize existing data to quantify missed nursing care. Based on the assessment, nursing leaders can develop interventions to decrease the incidence of missed care. Further data should be gathered to validate the incidence of missed care from HCAHPS reports.

Invasive Cancer Incidence, 2004–2013, and Deaths, 2006–2015, in Nonmetropolitan and Metropolitan Counties — United States

PubMed Central

Anderson, Robert N.; Thomas, Cheryll C.; Massetti, Greta M.; Peaker, Brandy; Richardson, Lisa C.

2017-01-01

Problem/Condition Previous reports have shown that persons living in nonmetropolitan (rural or urban) areas in the United States have higher death rates from all cancers combined than persons living in metropolitan areas. Disparities might vary by cancer type and between occurrence and death from the disease. This report provides a comprehensive assessment of cancer incidence and deaths by cancer type in nonmetropolitan and metropolitan counties. Reporting Period 2004–2015. Description of System Cancer incidence data from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program were used to calculate average annual age-adjusted incidence rates for 2009–2013 and trends in annual age-adjusted incidence rates for 2004–2013. Cancer mortality data from the National Vital Statistics System were used to calculate average annual age-adjusted death rates for 2011–2015 and trends in annual age-adjusted death rates for 2006–2015. For 5-year average annual rates, counties were classified into four categories (nonmetropolitan rural, nonmetropolitan urban, metropolitan with population <1 million, and metropolitan with population ≥1 million). For the trend analysis, which used annual rates, these categories were combined into two categories (nonmetropolitan and metropolitan). Rates by county classification were examined by sex, age, race/ethnicity, U.S. census region, and cancer site. Trends in rates were examined by county classification and cancer site. Results During the most recent 5-year period for which data were available, nonmetropolitan rural areas had lower average annual age-adjusted cancer incidence rates for all anatomic cancer sites combined but higher death rates than metropolitan areas. During 2006–2015, the annual age-adjusted death rates for all cancer sites combined decreased at a slower pace in nonmetropolitan areas (-1.0% per year) than in metropolitan areas (-1.6% per year), increasing the differences in these rates. In contrast, annual age-adjusted incidence rates for all cancer sites combined decreased approximately 1% per year during 2004–2013 both in nonmetropolitan and metropolitan counties. Interpretation This report provides the first comprehensive description of cancer incidence and mortality in nonmetropolitan and metropolitan counties in the United States. Nonmetropolitan rural counties had higher incidence of and deaths from several cancers related to tobacco use and cancers that can be prevented by screening. Differences between nonmetropolitan and metropolitan counties in cancer incidence might reflect differences in risk factors such as cigarette smoking, obesity, and physical inactivity, whereas differences in cancer death rates might reflect disparities in access to health care and timely diagnosis and treatment. Public Health Action Many cancer cases and deaths could be prevented, and public health programs can use evidence-based strategies from the U.S. Preventive Services Task Force and Advisory Committee for Immunization Practices (ACIP) to support cancer prevention and control. The U.S. Preventive Services Task Force recommends population-based screening for colorectal, female breast, and cervical cancers among adults at average risk for these cancers and for lung cancer among adults at high risk; screening adults for tobacco use and excessive alcohol use, offering counseling and interventions as needed; and using low-dose aspirin to prevent colorectal cancer among adults considered to be at high risk for cardiovascular disease based on specific criteria. ACIP recommends vaccination against cancer-related infectious diseases including human papillomavirus and hepatitis B virus. The Guide to Community Preventive Services describes program and policy interventions proven to increase cancer screening and vaccination rates and to prevent tobacco use, excessive alcohol use, obesity, and physical inactivity. PMID:28683054

The prevalence and incidence of systemic lupus erythematosus in children and adults: a population-based study in a mountain community in northern Italy.

PubMed

Tsioni, Vasiliki; Andreoli, Laura; Meini, Antonella; Frassi, Micol; Raffetti, Elena; Airò, Paolo; Allegri, Flavio; Donato, Francesco; Tincani, Angela

2015-01-01

To estimate prevalence and incidence of systemic lupus erythematosus (SLE) in paediatric and adult populations in Italy. The study was carried out in Valtrompia, a valley in northern Italy, where a relatively close community lives, in 2009-2012. The only referral centre for SLE in the area is the Rheumatology Unit of the University Hospital of Brescia. The ascertainment of SLE cases was performed through the integration of three sources: 1) hospital database; 2) database of the Rheumatology laboratory; 3) database of general practitioners and general paediatricians practicing in the area. Each patient was evaluated by a rheumatologist for confirmation of SLE classification based on the presence of at least 4 criteria according to the American College of Rheumatology. Forty-four SLE patients (39 females, 89%) were identified. The prevalence of SLE at 31st December 2012 was 39.2 (95% C.I. 28.5-52.6) cases per 100,000 individuals in all subjects, and 42.3 (30.5-57.2) and 15.3 (1.8-55.1) in adults and children, respectively. Nine new cases of SLE were diagnosed over the 4 years of the study period, with an annual incidence rate of 2.0 (0.9-3.8) per 100,000 individuals. This is the first study estimating the prevalence and incidence of SLE in Italy in both adult and paediatric population. Prevalence and incidence rates in line with those reported in other Mediterranean European countries. The accurate assessment of the SLE frequency is supported by the choice of a well-defined area, the integration of multiple data sources and the revision of each case by a rheumatologist.

Cancer incidence patterns among children and adolescents in Taiwan from 1995 to 2009: a population-based study.

PubMed

Hung, Giun-Yi; Horng, Jiun-Lin; Lee, Yu-Sheng; Yen, Hsiu-Ju; Chen, Chao-Chun; Lee, Chih-Ying

2014-11-15

Currently, little information is available on childhood cancer incidence rates in Eastern Asia. The objective of this study was to report the first population-based cancer surveillance of children and adolescents in Taiwan. Data from the Taiwan Cancer Registry were examined for cancer frequencies and incidence rates among individuals ages birth to 19 years from 1995 to 2009. Types of cancers were grouped according to the International Classification of Childhood Cancer. Rates were compared by sex and age. For further comparisons with other countries, rates were age standardized to the 2000 world standard population in 5-year age groups. Trends in incidence rates also were evaluated. In total, 12,315 individuals were diagnosed with childhood cancers, for an age-standardized incidence rate (ASR) of 132.1 per million person-years from 1995 to 2009. The male-to-female incidence rate ratio was 1.19. Overall, leukemias were the most common cancer (ASR, 39.1 per million person-years), followed by central nervous system neoplasms (15.8 per million person-years), and lymphomas (15.3 per million person-years). During the 15-year study period, the incidence rates increased by 1% annually. Compared with other countries, the rate of hepatic tumors was 2 times greater in Taiwan. The rate of germ cell neoplasms in Taiwan was similar to that in the United States and was 1.3 to 1.9 times greater compared with Canada, Brazil, Israel, and Japan. Based on the current data, the observed increase in overall incidence rates was attributable only marginally to improvements in case ascertainment and diagnostic procedures. The high rates of malignant hepatic tumors and germ cell neoplasms in Taiwan suggest variations in the background risk factors. © 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

[Trends in drug-induced liver injury based on reports of adverse reactions to PMDA in Japan].

PubMed

Sudo, Chie; Maekawa, Keiko; Segawa, Katsunori; Hanatani, Tadaaki; Sai, Kimie; Saito, Yoshiro

2012-01-01

Reports on drug-related adverse reactions from manufacturing/distributing pharmaceutical companies or medical institutions/pharmacies are regulated under the Pharmaceutical Affairs Law of Japan, and this system is important for post-marketing safety measures. Although association between the medicine and the adverse event has not been clearly evaluated, and an incidence may be redundantly reported, this information would be useful to roughly grasp the current status of drug-related adverse reactions. In the present study, we analyzed the incidence of drug-induced liver injury by screening the open-source data publicized by the homepage of Pharmaceutical and Medical Devices Agency from 2005 to 2011 fiscal years. Major drug-classes suspected to cause general drug-induced liver injury were antineoplastics, anti-inflammatory agents/common cold drugs, chemotherapeutics including antituberculous drugs, antidiabetics, antiulcers and antiepileptics. In addition, reported cases for fulminant hepatitis were also summarized. We found that antituberculous isoniazid and antineoplastic tegafur-uracil were the top two suspected drugs. These results might deepen understanding of current situations for the drug-induced liver injury in Japan.

Spatial distribution of tuberculosis in Manaus and its social determinants, 2008-2013.

PubMed

de Castro, D B; Sadahiro, M; Pinto, R C; de Albuquerque, B C; Braga, J U

2018-02-01

Brazil ranks eighteenth worldwide in annual numbers of new tuberculosis (TB) cases. The municipality of Manaus, Amazonas State, has the highest incidence of TB in Brazil. To evaluate the quality of TB epidemiological surveillance, and to describe the spatial distribution pattern of TB incidence in Manaus and its social determinants. An ecological study was performed based on secondary data from TB epidemiological surveillance reports. An index was developed to classify neighborhoods in terms of the quality of surveillance and suspected underreporting. Based on data from neighborhoods with better surveillance performance, we observed that the average number of residents per room, the unemployment rate and the proportion of households connected to a sewage system were significant predictors of TB incidence. Seven neighborhoods in the south and west of the city had clusters of high TB transmission. Our results suggest that the association between TB and social vulnerability is obscured by the poor quality of TB surveillance data. We identified priority areas that require immediate TB control interventions and those where local surveillance efforts should be improved, and generated information useful for formulating more effective actions.

Comprehensive analysis of cutaneous T-cell lymphoma (CTCL) incidence and mortality in Canada reveals changing trends and geographic clustering for this malignancy.

PubMed

Ghazawi, Feras M; Netchiporouk, Elena; Rahme, Elham; Tsang, Matthew; Moreau, Linda; Glassman, Steven; Provost, Nathalie; Gilbert, Martin; Jean, Sara-Elizabeth; Pehr, Kevin; Sasseville, Denis; Litvinov, Ivan V

2017-09-15

Previous reports of geographic clustering of cutaneous T-cell lymphoma (CTCL) in Texas, Pittsburgh, and Sweden as well as the occurrence of CTCL in married couples and family members raise a possibility of the existence of an external and potentially preventable trigger(s) for this rare skin cancer. The authors studied CTCL incidence and mortality in Canada using 3 distinct population-based cancer databases. Data on patients' sex, age at the time of diagnosis, subtype of CTCL malignancy, reporting province, city, and postal code were analyzed. CTCL cases were mapped across Canada using geographic information systems software. In total, 6685 patients with CTCL were identified in Canada during 1992 through 2010 (CTCL incidence rate, 11.32 cases per million individuals per year), of which 58% were males. The mean age at diagnosis was 59.4 ± 21.5 years. Geographic analysis of patients revealed increased CTCL incidence on the provincial and city levels in several eastern provinces and in Manitoba. An analysis according to postal codes (Forward Sortation Area [FSA]) identified select communities in which several high-incidence FSAs were contiguous or adjacent. Several of these FSAs were located in industrial regions of Canadian cities. Conversely, 3 of 8 low-incidence FSAs were clustered in Ottawa, Ontario, which has very little industrial presence. An analysis of CTCL mortality in Canada corroborated the current incidence findings. The current results provide a comprehensive analysis of CTCL burden in Canada and highlight several important areas of geographic case clustering. These findings argue that industrial exposures may play an important role in promoting CTCL pathogenesis. Cancer 2017;123:3550-67. © 2017 American Cancer Society. © 2017 American Cancer Society.

An Estimate of the Incidence of Prostate Cancer in Africa: A Systematic Review and Meta-Analysis

PubMed Central

Aderemi, Adewale Victor; Iseolorunkanmi, Alexander; Oyedokun, Ayo; Ayo, Charles K.

2016-01-01

Background Prostate cancer (PCa) is rated the second most common cancer and sixth leading cause of cancer deaths among men globally. Reports show that African men suffer disproportionately from PCa compared to men from other parts of the world. It is still quite difficult to accurately describe the burden of PCa in Africa due to poor cancer registration systems. We systematically reviewed the literature on prostate cancer in Africa and provided a continent-wide incidence rate of PCa based on available data in the region. Methods A systematic literature search of Medline, EMBASE and Global Health from January 1980 to June 2015 was conducted, with additional search of Google Scholar, International Association of Cancer Registries (IACR), International Agency for Research on Cancer (IARC), and WHO African region websites, for studies that estimated incidence rate of PCa in any African location. Having assessed quality and consistency across selected studies, we extracted incidence rates of PCa and conducted a random effects meta-analysis. Results Our search returned 9766 records, with 40 studies spreading across 16 African countries meeting our selection criteria. We estimated a pooled PCa incidence rate of 22.0 (95% CI: 19.93–23.97) per 100,000 population, and also reported a median incidence rate of 19.5 per 100,000 population. We observed an increasing trend in PCa incidence with advancing age, and over the main years covered. Conclusion Effective cancer registration and extensive research are vital to appropriately quantifying PCa burden in Africa. We hope our findings may further assist at identifying relevant gaps, and contribute to improving knowledge, research, and interventions targeted at prostate cancer in Africa. PMID:27073921

The effectiveness of the error reporting promoting program on the nursing error incidence rate in Korean operating rooms.

PubMed

Kim, Myoung-Soo; Kim, Jung-Soon; Jung, In Sook; Kim, Young Hae; Kim, Ho Jung

2007-03-01

The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.

Under-reporting of road traffic mortality in developing countries: application of a capture-recapture statistical model to refine mortality estimates.

PubMed

Samuel, Jonathan C; Sankhulani, Edward; Qureshi, Javeria S; Baloyi, Paul; Thupi, Charles; Lee, Clara N; Miller, William C; Cairns, Bruce A; Charles, Anthony G

2012-01-01

Road traffic injuries are a major cause of preventable death in sub-Saharan Africa. Accurate epidemiologic data are scarce and under-reporting from primary data sources is common. Our objectives were to estimate the incidence of road traffic deaths in Malawi using capture-recapture statistical analysis and determine what future efforts will best improve upon this estimate. Our capture-recapture model combined primary data from both police and hospital-based registries over a one year period (July 2008 to June 2009). The mortality incidences from the primary data sources were 0.075 and 0.051 deaths/1000 person-years, respectively. Using capture-recapture analysis, the combined incidence of road traffic deaths ranged 0.192-0.209 deaths/1000 person-years. Additionally, police data were more likely to include victims who were male, drivers or pedestrians, and victims from incidents with greater than one vehicle involved. We concluded that capture-recapture analysis is a good tool to estimate the incidence of road traffic deaths, and that capture-recapture analysis overcomes limitations of incomplete data sources. The World Health Organization estimated incidence of road traffic deaths for Malawi utilizing a binomial regression model and survey data and found a similar estimate despite strikingly different methods, suggesting both approaches are valid. Further research should seek to improve capture-recapture data through utilization of more than two data sources and improving accuracy of matches by minimizing missing data, application of geographic information systems, and use of names and civil registration numbers if available.

Under-Reporting of Road Traffic Mortality in Developing Countries: Application of a Capture-Recapture Statistical Model to Refine Mortality Estimates

PubMed Central

Samuel, Jonathan C.; Sankhulani, Edward; Qureshi, Javeria S.; Baloyi, Paul; Thupi, Charles; Lee, Clara N.; Miller, William C.; Cairns, Bruce A.; Charles, Anthony G.

2012-01-01

Road traffic injuries are a major cause of preventable death in sub-Saharan Africa. Accurate epidemiologic data are scarce and under-reporting from primary data sources is common. Our objectives were to estimate the incidence of road traffic deaths in Malawi using capture-recapture statistical analysis and determine what future efforts will best improve upon this estimate. Our capture-recapture model combined primary data from both police and hospital-based registries over a one year period (July 2008 to June 2009). The mortality incidences from the primary data sources were 0.075 and 0.051 deaths/1000 person-years, respectively. Using capture-recapture analysis, the combined incidence of road traffic deaths ranged 0.192–0.209 deaths/1000 person-years. Additionally, police data were more likely to include victims who were male, drivers or pedestrians, and victims from incidents with greater than one vehicle involved. We concluded that capture-recapture analysis is a good tool to estimate the incidence of road traffic deaths, and that capture-recapture analysis overcomes limitations of incomplete data sources. The World Health Organization estimated incidence of road traffic deaths for Malawi utilizing a binomial regression model and survey data and found a similar estimate despite strikingly different methods, suggesting both approaches are valid. Further research should seek to improve capture-recapture data through utilization of more than two data sources and improving accuracy of matches by minimizing missing data, application of geographic information systems, and use of names and civil registration numbers if available. PMID:22355338

When Love Meets Hate: The Relationship Between State Policies on Gay and Lesbian Rights and Hate Crime Incidence

PubMed Central

Levy, Brian L.; Levy, Denise L.

2016-01-01

Do public policies on gay and lesbian rights affect the incidence of hate crimes based on sexual orientation? We propose that legal inequalities increase hate crimes because they provide discursive opportunities for bias, discrimination, and violence. Legal equality, however, will reduce violence. Using annual panel data from 2000 to 2012, a period of substantial policy change, we analyze how three state policies affect reported hate crimes: same-sex partnerships, employment non-discrimination, and hate crime laws. Hate crime and employment non-discrimination laws that include sexual orientation reduce hate crime incidence. Partnership recognition increases reported hate crimes, though it may not increase actual crime incidence. Because incidence is spatially correlated, policy changes in one state yield spillover benefits in other states. These results provide some of the first quantitative evidence that public policies affect hate crimes based on sexual orientation. Findings confirm the roles of institutional heterosexism and discursive opportunities in producing hate crimes. PMID:27886725

When love meets hate: The relationship between state policies on gay and lesbian rights and hate crime incidence.

PubMed

Levy, Brian L; Levy, Denise L

2017-01-01

Do public policies on gay and lesbian rights affect the incidence of hate crimes based on sexual orientation? We propose that legal inequalities increase hate crimes because they provide discursive opportunities for bias, discrimination, and violence. Legal equality, however, will reduce violence. Using annual panel data from 2000 to 2012, a period of substantial policy change, we analyze how three state policies affect reported hate crimes: same-sex partnerships, employment non-discrimination, and hate crime laws. Hate crime and employment non-discrimination laws that include sexual orientation reduce hate crime incidence. Partnership recognition increases reported hate crimes, though it may not increase actual crime incidence. Because incidence is spatially correlated, policy changes in one state yield spillover benefits in other states. These results provide some of the first quantitative evidence that public policies affect hate crimes based on sexual orientation. Findings confirm the roles of institutional heterosexism and discursive opportunities in producing hate crimes. Copyright © 2016 Elsevier Inc. All rights reserved.

Incidence and prognosis of stroke in young adults: a population-based study in Ferrara, Italy.

PubMed

Groppo, Elisabetta; De Gennaro, Riccardo; Granieri, Gino; Fazio, Patrik; Cesnik, Edward; Granieri, Enrico; Casetta, Ilaria

2012-02-01

The reported annual incidence of juvenile stroke ranges from 9 to 47 cases per 100,000 inhabitants. We sought to estimate the incidence of first-ever stroke in young adults through a population-based stroke registry in a well-defined and stable population. We planned to collect all cases of new stroke in people aged 15-44 years in Ferrara, Italy, over the period 2002-2007. During the surveillance period, a first-ever stroke was diagnosed in 39 patients, giving a mean annual crude incidence rate of 12.1 cases per 100,000 person-years (95% CI 8.6-16.5), 9.1 when adjusted to the European population. The overall 30-day case fatality rate was 7.7, 21.4% for hemorrhagic stroke. The incidence rate was in the range of estimates detected in western countries. The case-fatality rate was lower than that reported in less recent studies. The stroke subtype predicted the probability of death and the outcome.

Human Factors in Financial Trading

PubMed Central

Leaver, Meghan; Reader, Tom W.

2016-01-01

Objective This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Background Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors–related issues in operational trading incidents. Method In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Results Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors–related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. Conclusion We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. Application This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. PMID:27142394

Effects of weight changes in the autonomic nervous system: A systematic review and meta-analysis.

PubMed

Costa, João; Moreira, André; Moreira, Pedro; Delgado, Luís; Silva, Diana

2018-01-09

Obesity has been linked to autonomic dysfunction, which is thought to be one of the main contributors for hypertension, cardiac remodelling and death. Exercise and diet-based weight loss are the mainstay therapy for obesity, but there is a paucity of data regarding the effect of weight changes in autonomic nervous system (ANS) activity. To describe the impact of weight changes in autonomic nervous system. A systematic literature search of four biomedical databases was performed evaluating effects of weight changes, thorough diet and/or exercise-based interventions, in the following ANS outcomes: heart rate variability, namely low frequency (LF)/high frequency (HF) ratio (LF/HF ratio), normalized units of LF (LFnu) and HF (HFnu), muscle sympathetic nerve activity (MSNA), noradrenaline spillover rate (NA-SR), standard deviation of normal-to-normal intervals (SDNN), root mean square of successive differences (RMSSD), baroreflex sensitivity and pupillometry. Quality appraisal was performed using the GRADE methodology and, where fitting, studies with comparable outcomes were pooled for meta-analysis. Twenty-seven studies - 7 controlled clinical trials and 20 observational studies - were included. Weight gain was reported in 4 studies and weight loss in all the other studies. Interventions inducing weight changes included: hypocaloric or hypercaloric diets, exercise (strength, endurance or aerobic training) and hypocaloric diet coupled with exercise programs. Most studies which resulted in weight loss reported decreases in LF/HF ratio, LFnu, MSNA burst frequency and incidence, NA-SR, and an increase of baroreflex sensitivity, HF, HFnu and RMSSD, pointing to a parasympathetic nervous system activation. Meta-analysis regarding weight loss interventions showed a significant pooled effect size (95% CI) with a decreased of MSNA burst frequency -5.09 (-8.42, -1.75), MSNA incidence -6.66 (-12.40, -0.62), however this was not significant for SDNN 14.32 (-4.31, 32.96). Weight gain was associated with an increase in LF/HF, LFnu, MSNA burst frequency and incidence. The weight loss effects were potentiated by the association of hypocaloric diet with exercise. Nevertheless, weight changes effects in these outcomes were based in low or very low quality of evidence. Diet and exercise based weight loss appears to increase parasympathetic and decrease sympathetic activity, the opposing effects being observed with weight gain. These findings are not uniformly reported in the literature, possibly due to differences in study design, methodology, characteristics of the participants and techniques used to estimate autonomic nervous activity. Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory cohort study?

PubMed

van Dulmen, Simone A; Tacken, Margot A J B; Staal, J Bart; Gaal, Sander; Wensing, Michel; Nijhuis-van der Sanden, Maria W G

2011-12-01

Research on patient safety in allied healthcare is scarce. Our aim was to document patient safety in primary allied healthcare in the Netherlands and to identify factors associated with incidents. DESIGN AND SUBJECT: A retrospective study of 1000 patient records in a representative sample of 20 allied healthcare practices was combined with a prospective incident-reporting study. All records were reviewed by trained researchers to identify patient safety incidents. The incidents were classified and analyzed, using the Prevention and Recovery Information System for Monitoring and Analysis method. Factors associated with incidents were examined in a logistic regression analysis. In 18 out of 1000 (1.8%; 95% confidence interval: 1.0-2.6) records an incident was detected. The main causes of incidents were related to errors in clinical decisions (89%), communication with other healthcare providers (67%), and monitoring (56%). The probability of incidents was higher if more care providers had been involved and if patient records were incomplete (37% of the records). No incidents were reported in the prospective study. The absolute number of incidents was low, which could imply a low risk of harm in Dutch primary allied healthcare. Nevertheless, incompleteness of the patient records and the fact that incidents were mainly caused through human actions suggest that a focus on clinical reasoning and record keeping is needed to further enhance patient safety. Improvements in record keeping will be necessary before accurate incident reporting will be feasible and valid.

Using Geographical Information Systems to Identify Populations in Need of Improved Accessibility to Antivenom Treatment for Snakebite Envenoming in Costa Rica

PubMed Central

Hansson, Erik; Sasa, Mahmood; Mattisson, Kristoffer; Robles, Arodys; Gutiérrez, José María

2013-01-01

Introduction Snakebite accidents are an important health problem in rural areas of tropical countries worldwide, including Costa Rica, where most bites are caused by the pit-viper Bothrops asper. The treatment of these potentially fatal accidents is based on the timely administration of specific antivenom. In many regions of the world, insufficient health care systems and lack of antivenom in remote and poor areas where snakebites are common, means that efficient treatment is unavailable for many snakebite victims, leading to unnecessary mortality and morbidity. In this study, geographical information systems (GIS) were used to identify populations in Costa Rica with a need of improved access to antivenom treatment: those living in areas with a high risk of snakebites and long time to reach antivenom treatment. Method/Principal Findings Populations living in areas with high risk of snakebites were identified using two approaches: one based on the district-level reported incidence, and another based on mapping environmental factors favoring B. asper presence. Time to reach treatment using ambulance was estimated using cost surface analysis, thereby enabling adjustment of transportation speed by road availability and quality, topography and land use. By mapping populations in high risk of snakebites and the estimated time to treatment, populations with need of improved treatment access were identified. Conclusion/Significance This study demonstrates the usefulness of GIS for improving treatment of snakebites. By mapping reported incidence, risk factors, location of existing treatment resources, and the time estimated to reach these for at-risk populations, rational allocation of treatment resources is facilitated. PMID:23383352

Using geographical information systems to identify populations in need of improved accessibility to antivenom treatment for snakebite envenoming in Costa Rica.

PubMed

Hansson, Erik; Sasa, Mahmood; Mattisson, Kristoffer; Robles, Arodys; Gutiérrez, José María

2013-01-01

Snakebite accidents are an important health problem in rural areas of tropical countries worldwide, including Costa Rica, where most bites are caused by the pit-viper Bothrops asper. The treatment of these potentially fatal accidents is based on the timely administration of specific antivenom. In many regions of the world, insufficient health care systems and lack of antivenom in remote and poor areas where snakebites are common, means that efficient treatment is unavailable for many snakebite victims, leading to unnecessary mortality and morbidity. In this study, geographical information systems (GIS) were used to identify populations in Costa Rica with a need of improved access to antivenom treatment: those living in areas with a high risk of snakebites and long time to reach antivenom treatment. Populations living in areas with high risk of snakebites were identified using two approaches: one based on the district-level reported incidence, and another based on mapping environmental factors favoring B. asper presence. Time to reach treatment using ambulance was estimated using cost surface analysis, thereby enabling adjustment of transportation speed by road availability and quality, topography and land use. By mapping populations in high risk of snakebites and the estimated time to treatment, populations with need of improved treatment access were identified. This study demonstrates the usefulness of GIS for improving treatment of snakebites. By mapping reported incidence, risk factors, location of existing treatment resources, and the time estimated to reach these for at-risk populations, rational allocation of treatment resources is facilitated.

Incidence trends of viral hepatitis A, B, and C seropositivity over eight years of surveillance in Saudi Arabia.

PubMed

Memish, Ziad A; Knawy, Bandar Al; El-Saed, Aiman

2010-02-01

In Saudi Arabia, viral hepatitis ranked the second most common reportable viral disease in 2007, with almost 9000 new cases diagnosed in that year. The objective of this study was to determine the incidence trends of viral hepatitis seropositivity among the population served by the National Guard Health Affairs (NGHA) hospitals in the central, eastern, and western Saudi Arabia regions. The surveillance system at King Abdulaziz Medical City in Riyadh receives weekly reports of laboratory confirmed hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV) cases from all NGHA-served regions. In this study the viral hepatitis surveillance data for the period from January 2000 through December 2007 were analyzed. Between 2000 and 2007, a total of 14 224 seropositive cases of viral hepatitis were reported to the surveillance system. The average annual incidence of seropositivity per 100 000 served population was highest for HBV (104.6), followed by HCV (78.4), and lowest for HAV (13.6). Saudis had higher HBV and HAV incidence, but lower HCV incidence compared to non-Saudis. Over the eight years (2000-2007), the incidence of all three viral hepatitis types showed a 20-30% declining trend. Only HAV incidence followed a clear seasonal cyclic pattern. Despite the declining trend over the eight-year period, viral hepatitis, especially that caused by HBV and HCV, remains a major public health problem in Saudi Arabia, and has probably been underestimated in previous reports. There is a need for more comprehensive prevention strategies. Copyright 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Hepatitis A Surveillance and Vaccine Use in China From 1990 Through 2007

PubMed Central

Cui, Fuqiang; Hadler, Stephen C; Zheng, Hui; Wang, Fuzhen; Zhenhua, Wu; Yuansheng, Hu; Gong, Xiaohong; Chen, Yuansheng; Liang, Xiaofeng

2009-01-01

Background Hepatitis A vaccines have been highly effective in preventing hepatitis A. To investigate the epidemiology of hepatitis A in China after hepatitis A vaccine became available, we reviewed reported cases of hepatitis A and the use of hepatitis A vaccine in China during the period from 1990 through 2007. Methods Data from the National Notifiable Disease Reporting System from 1990 to 2007 and the Emergency Events Reporting System from 2004 to 2007 were reviewed and epidemiologic characteristics analyzed. Hepatitis A vaccine distribution between 1992 and 2007 was also reviewed. Results The incidence of hepatitis A has declined by 90% since 1990, from 56 to 5.9 per 105/year. Declines in age-specific incidence were seen in all age groups, most dramatically among children younger than 10 years. Disease incidence still varies substantially: poorer western provinces have had the highest incidences since 2000. In high-incidence provinces, children younger than 10 years continue to have a high disease incidence. Only 50% of cases were laboratory-confirmed, and only 3% occurred in reported local outbreaks. Over 156 million doses of hepatitis A vaccine have been distributed since 1992, and use has continued to increase since 2003. Conclusions Incidence of hepatitis A has decreased in all age groups, likely due to changing socioeconomic conditions and increasing hepatitis A vaccine use. Nevertheless, western populations remain at high risk, with transmission predominantly occurring among children. The epidemiology of hepatitis A transmission is not well understood. Improved surveillance with better laboratory confirmation is needed to monitor the impact of universal hepatitis A vaccination of young children; this strategy began to be implemented in 2008. PMID:19561383

Incidence of invasive pneumococcal disease in 5-15 year old children with and without comorbidities in Germany after the introduction of PCV13: Implications for vaccinating children with comorbidities.

PubMed

Weinberger, Raphael; Falkenhorst, Gerhard; Bogdan, Christian; van der Linden, Mark; Imöhl, Matthias; von Kries, Rüdiger

2015-11-27

To describe the burden of suffering from IPD in children aged 5-15 years with and without comorbidities up to 5 years after the introduction of PCV13 in Germany and to identify the potential benefit for PCV13 and PPV23 vaccination. The surveillance of IPD for children <16 years was based on two independently reporting sources: active surveillance in pediatric hospitals and a laboratory-based sentinel surveillance system. IPD with cultural detection of pneumococci at a physiologically sterile site in children from 2010 to 2014 in Germany. Incidence was estimated by capture-recapture analysis with stratification by absence/presence of comorbidities. Coverage of the observed serotypes by different vaccines was assessed. 142 (Capture recapture-corrected: 437) cases were reported: 72.5% were healthy children and 27.5% had a comorbidity. The incidence of IPD related to children with comorbidities was 0.2 per 100,000. One third of these cases had serotypes not included in either vaccine. The remaining cases might benefit from pneumococcal vaccination but one third of all cases was not vaccinated. The additional potential benefit of PPV23 compared to PCV13 with respect to coverage was 10%. The incidence of IPD in children with comorbidities in Germany is low. Pneumococcal vaccination uptake in children with comorbidities should be increased, although only about two-thirds of the cases might be preventable by presently available vaccines. Copyright © 2015 Elsevier Ltd. All rights reserved.

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. Copyright © 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

What ASRS incident data tell about flight crew performance during aircraft malfunctions

NASA Technical Reports Server (NTRS)

Sumwalt, Robert L.; Watson, Alan W.

1995-01-01

This research examined 230 reports in NASA's Aviation Safety Reporting System's (ASRS) database to develop a better understanding of factors that can affect flight crew performance when crew are faced with inflight aircraft malfunctions. Each report was placed into one of two categories, based on severity of the malfunction. Report analysis was then conducted to extract information regarding crew procedural issues, crew communications and situational awareness. A comparison of these crew factors across malfunction type was then performed. This comparison revealed a significant difference in ways that crews dealt with serious malfunctions compared to less serious malfunctions. The authors offer recommendations toward improving crew performance when faced with inflight aircraft malfunctions.

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

PubMed

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

2016-05-01

Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically during the documentation of patient positioning and localization of the patient. Incidents were most frequently detected during treatment delivery (30%), and incidents identified at this point also had higher severity scores than other workflow areas (NMRI = 1.6). Incidents identified during on-treatment quality management were also more severe (NMRI = 1.7), and the specific process steps of reviewing portal and CBCT images tended to catch highest-severity incidents. On average, safety barriers caught 46% of all incidents, most frequently at physics chart review, therapist's chart check, and the review of portal images; however, most of the incidents that pass through a particular safety barrier are not designed to be capable of being captured at that barrier. Incident learning systems can be used to assess the most common points of error origination and detection in radiation oncology. This can help tailor safety improvement efforts and target the highest impact portions of the workflow. The most severe near-miss events tend to originate during simulation, with the most severe near-miss events detected at the time of patient treatment. Safety barriers can be improved to allow earlier detection of near-miss events.

A description of medication errors reported by pharmacists in a neonatal intensive care unit.

PubMed

Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila

2017-02-01

Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.

The effects of outsourcing on occupational health and safety: a comparative study of factory-based workers and outworkers in the Australian clothing industry.

PubMed

Mayhew, C; Quinlan, M

1999-01-01

Outsourcing has become increasingly widespread throughout industrialized societies over the past 20 years. Accompanying this has been a renewed growth in home-based work, sometimes using new technologies (telework) but also entailing a re-emergence of old forms, such as clothing outwork, used extensively 100 years ago. A growing body of research indicates that changes to work organization associated with outsourcing adversely affect occupational health and safety (OHS), both for outsourced workers and for those working alongside them. This study assessed the OHS implications of the shift to home-based workers in the Australian clothing industry by systematically comparing the OHS experiences of 100 factory-based workers and 100 outworkers. The level of self-reported injury was over three times higher among outworkers than factory-based workers undertaking similar tasks. The most significant factor explaining this difference was the payment system. All outworkers were paid solely by the piece, whereas factory workers were paid either under a time plus production bonus system or solely on a time basis. While the incidence of injury was far higher among outworkers, factory-based workers paid under an incentive system reported more injuries than those paid solely on a time basis. Increasing injury was correlated with piecework payment systems.

A Case Study in the Identification of Critical Factors Leading to Successful Implementation of the Hospital Incident Command System

DTIC Science & Technology

2015-06-01

California EMSA, National Incident Management System, NIMS, hospital preparedness program, Nursing Home Incident Command System, NHICS, Hospital...The International Journal of Trauma Nursing published an article in 2007 entitled “Organization of a Hospital-based Victim Decontamination Plan...Journal of Trauma Nursing 5, no. 4 (October– November 2007): 119–123. 32 Ellen Lanser May, “Scarred but Smarter: Lessons Learned from Florida’s 2004

Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010

PubMed Central

Buckle, Geoffrey C.; Walker, Christa L. Fischer; Black, Robert E.

2012-01-01

Background Typhoid and paratyphoid fever remain important causes of morbidity worldwide. Accurate disease burden estimates are needed to guide policy decisions and prevention and control strategies. Methods We conducted a systematic literature review of the PubMed and Scopus databases using pre-defined criteria to identify population-based studies with typhoid fever incidence data published between 1980 and 2009. We also abstracted data from annual reports of notifiable diseases in countries with advanced surveillance systems. Typhoid and paratyphoid fever input data were grouped into regions and regional incidence and mortality rates were estimated. Incidence data were extrapolated across regions for those lacking data. Age-specific incidence rates were derived for regions where age-specific data were available. Crude and adjusted estimates of the global typhoid fever burden were calculated. Results Twenty-five studies were identified, all of which contained incidence data on typhoid fever and 12 on paratyphoid fever. Five advanced surveillance systems contributed data on typhoid fever; 2 on paratyphoid fever. Regional typhoid fever incidence rates ranged from <0.1/100 000 cases/y in Central and Eastern Europe and Central Asia to 724.6/100 000 cases/y in Sub-Saharan Africa. Regional paratyphoid incidence rates ranged from 0.8/100 000 cases/y in North Africa/Middle East to 77.4/100 000 cases/y in Sub-Saharan Africa and South Asia. The estimated total number of typhoid fever episodes in 2010 was 13.5 million (interquartile range 9.1–17.8 million). The adjusted estimate accounting for the low sensitivity of blood cultures for isolation of the bacteria was 26.9 million (interquartile range 18.3–35.7 million) episodes. These findings are comparable to the most recent analysis of global typhoid fever morbidity, which reported crude and adjusted estimates of 10.8 million and 21.7 million typhoid fever episodes globally in 2000. Conclusion Typhoid fever remains a significant health burden, especially in low- and middle-income countries. Despite the availability of more recent data on both enteric fevers, additional research is needed in many regions, particularly Africa, Latin America and other developing countries. PMID:23198130

Influenza during pregnancy: Incidence, vaccination coverage and attitudes toward vaccination in the French web-based cohort G-GrippeNet.

PubMed

Loubet, Paul; Guerrisi, Caroline; Turbelin, Clément; Blondel, Béatrice; Launay, Odile; Bardou, Marc; Goffinet, François; Colizza, Vittoria; Hanslik, Thomas; Kernéis, Solen

2016-04-29

Pregnancy is a risk factor for severe influenza. However, data on influenza incidence during pregnancy are scarce. Likewise, no data are available on influenza vaccine coverage in France since national recommendation in 2012. We aimed to assess these points using a novel nationwide web-based surveillance system, G-GrippeNet. During the 2014/2015 influenza season, pregnant women living in metropolitan France were enrolled through a web platform (https://www.grippenet.fr/). Throughout the season, participants were asked to report, on a weekly basis, if they had experienced symptoms of influenza-like-illness (ILI). ILI episodes reported were used to calculate incidence density rates based on period of participation from each participant. Vaccination coverage was estimated after weighing on age and education level from national data on pregnant women. Factors associated with higher vaccination coverage were obtained through a logistic regression with Odds Ratio (OR) corrected with the Zhang and Yu method. A total of 153 women were enrolled. ILI incidence density rate was 1.8 per 100 person-week (95% CI, 1.5-2.1). This rate was higher in women older than 40 years (RR = 3.0, 95% CI [1.1-8.3], p = 0.03) and during first/second trimesters compared to third trimester (RR = 4.0, 95% CI [1.4-12.0], p = 0.01). Crude vaccination coverage was 39% (95% CI, 31-47) and weighted vaccination coverage was estimated at 26% (95% CI, 20-34). Health care provider recommendation for vaccination (corrected OR = 7.8; 95% CI [3.0-17.1]) and non-smoking status (cOR = 2.1; 95% CI [1.2-6.9]) were associated with higher vaccine uptake. This original web based longitudinal surveillance study design proved feasible in pregnant women population. First results are of interest and underline that public health policies should emphasize the vaccination promotion through health care providers. Copyright © 2016 Elsevier Ltd. All rights reserved.

Occupational Asthma in Korea

PubMed Central

Kim, Kyoo Sang

2010-01-01

Occupational asthma (OA) is the leading occupational respiratory disease. Cases compensated as OA by the Korea Workers' Compensation and Welfare Service (COMWEL) (218 cases), cases reported by a surveillance system (286 cases), case reports by related scientific journals and cases confirmed by the Occupational Safety and Health Research Institute (OSHRI) over 15 yr from 1992 to 2006 were analyzed. Annual mean incidence rate was 1.6 by compensation and 3.5 by surveillance system, respectively. The trend appeared to increase according to the surveillance system. Incidence was very low compared with other countries. The most frequently reported causative agent was isocyanate followed by reactive dye in dyeing factories. Other chemicals, metals and dust were also found as causative agents. OA was underreported according to compensation and surveillance system data. In conclusion, a more effective surveillance system is needed to evaluate OA causes and distribution, and to effectively prevent newly developing OA. PMID:21258586

Transfusion-Associated Circulatory Overload: Evidence-Based Strategies to Prevent, Identify, and Manage a Serious Adverse Event.

PubMed

Henneman, Elizabeth A; Andrzejewski, Chester; Gawlinski, Anna; McAfee, Kelley; Panaccione, Thomas; Dziel, Kimberly

2017-10-01

Transfusion-associated circulatory overload (TACO) is a potentially life-threatening complication of blood transfusion and is associated with increased morbidity, length of stay (hospital and intensive care unit), and hospital costs. Bedside nurses play a key role in the prevention, identification, and reporting of this complication. A common misperception is that the most frequently encountered serious adverse event during transfusion is a hemolytic reaction in a patient who receives ABO-incompatible blood. In fact, the incidence of TACO-related fatalities is higher than fatalities caused by ABO-related hemolytic reactions. Surveillance and evidence-based strategies such as clinical decision support systems have the potential to reduce the incidence of TACO and mitigate its effects. Practical suggestions for conducting bedside transfusion surveillance and future directions for improving transfusion care are presented. ©2017 American Association of Critical-Care Nurses.

Incidence and Prevalence of Musculoskeletal Injury in Ballet: A Systematic Review.

PubMed

Smith, Preston J; Gerrie, Brayden J; Varner, Kevin E; McCulloch, Patrick C; Lintner, David M; Harris, Joshua D

2015-07-01

Most published studies on injuries in the ballet dancer focus on the lower extremity. The rigors of this activity require special training and care. By understanding prevalence and injury pattern to the musculoskeletal system, targeted prevention and treatment for this population can be developed. To determine the incidence and prevalence of musculoskeletal injuries in ballet. Systematic review; Level of evidence, 4. A systematic review registered with PROSPERO was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Level 1 through 4 evidence studies reporting incidence of musculoskeletal injuries in male and female ballet dancers were included, with the numbers and types of injuries extracted from each. Injury rates were recorded and calculated based on professional status, sex, and nature of injury. Incidence was defined as number of injuries sustained over a specific time. Prevalence was defined as proportion of subjects with an injury at a given point in time. The studies analyzed reported injury incidence or prevalence in more than 1365 amateur and 900 professional dancers. The mean age was 16.2 years among amateur and 27.0 years among professional dancers. The incidence of injury among amateur dancers was 0.99 and 1.09 injuries per 1000 dance hours in males and females, respectively; 75% of injuries were overuse, with similar rates among males and females. In professional dancers, the incidence of injury was 1.06 and 1.46 injuries per 1000 dance hours in males and females, respectively, and 64% of female injuries were overuse, compared with 50% in males (P < .001). Only 3 studies provided prevalence data, including 62% prevalence of lumbosacral pain, 58% painful snapping hip, and 29% patellofemoral pain. Lower extremity injuries comprised 66% to 91% of all injuries, with the foot and ankle accounting for 14% to 57%. The overall incidence of injury among amateur and professional ballet dancers is 0.97 and 1.24 injuries per 1000 dance hours, respectively. The majority are overuse in both amateur and professional dancers, with amateur ballet dancers showing a higher proportion of overuse injuries than professionals (P < .001). Male professional dancers show a higher proportion of traumatic injuries, accounting for half of their injuries (P < .001).

Decision modeling for fire incident analysis

Treesearch

Donald G. MacGregor; Armando González-Cabán

2009-01-01

This paper reports on methods for representing and modeling fire incidents based on concepts and models from the decision and risk sciences. A set of modeling techniques are used to characterize key fire management decision processes and provide a basis for incident analysis. The results of these methods can be used to provide insights into the structure of fire...

Fall incidence in Germany: results of two population-based studies, and comparison of retrospective and prospective falls data collection methods.

PubMed

Rapp, Kilian; Freiberger, Ellen; Todd, Chris; Klenk, Jochen; Becker, Clemens; Denkinger, Michael; Scheidt-Nave, Christa; Fuchs, Judith

2014-09-20

Fall incidence differs considerably between studies and countries. Reasons may be differences between study samples or different assessment methods. The aim was to derive estimates of fall incidence from two population-based studies among older community-living people in Germany and compare retrospective and prospective falls data collection methods. Data were derived from the 2008-11 wave of the German health interview and examination survey for adults (DEGS1), and the Activity and Function of the Elderly in Ulm study (ActiFE-Ulm). Data collection took place in community facilities (DEGS1) or participants' homes (ActiFE-Ulm). Participation rates were 42% (newly recruited) and 64% (panel component) in DEGS1 and 19.8% in ActiFE-Ulm. Self-report retrospective fall data covering the previous 12 month period in DEGS1 and ActiFE-Ulm were collected, but only ActiFE-Ulm used prospective 12 month fall calendars. The incidence of 'any fall' and 'recurrent falls' were calculated for both methods. Fall rates increased with age in men but not women. The ActiFE-Ulm prospectively assessed incidence (95% confidence interval) in women and men aged 65- < 90 years were 38.7 (36.9-40.5) and 29.7 (28.1-31.3) fallers/year and 13.7 (12.5-14.9) and 10.9 (9.9-12.0) recurrent fallers/year, respectively. Retrospective and prospective fall incidence in ActiFE-Ulm did not differ.The retrospectively assessed incidence of 'any fall' among persons 65- < 80 years were significantly lower in DEGS1 than ActiFE-Ulm (women: 25.7% (22.4-29.2) versus 37.4% (34.8-39.9); men: 16.3% (13.6-19.3) versus 28.9% (26.6-31.1). Retrospective incidence estimates of recurrent falls were similar in both studies for women (10.4% (8.3-12.9) versus 10.2% (8.5-11.8)) and men (6.1% (4.3-8.5) versus 8.4% (7.1-9.8)). Both studies were population-based, but retrospective self-reported fall incidence differed between studies. Study design influences retrospective reported fall incidence considerably. Costly collection of prospective data gives similar rates to the cheaper retrospective report method.

Does clinical incident seriousness and receipt of work-based support influence mood experienced by nurses at work? A behavioural diary study.

PubMed

Jones, Martyn C; Johnston, Derek W

2012-08-01

While the relationship between general perceptions of the work environment and negative mood is well detailed, little is known about the effect of specific clinical incident characteristics on the mood experienced at work by nurses. This study examines the effect of incident seriousness and receipt of work-based support in the worst event of a shift from managers and colleagues on the Negative and Positive Affect experienced by nurses at work. We approached the total cohort of medical and surgical nurses in 4 large district general hospitals in England, 17% volunteered. Some 171 nurses filled end of shift and standard entry (every 90 min) computerised behavioural diaries over three consecutive shifts. The diaries measured Incident Seriousness, Receipt of Managerial and Co-worker Support, Negative Affect and Positive Affect. Results were analysed using multilevel modelling (MLwiN 2.19). Following the worst clinical incident of a shift, nurses reported higher Negative Affect (β=1.28, [95%CI: 0.12, 2.45], z=2.17, p<.05) and lower Positive Affect (β=-2.39, [95%CI: -3.96, -0.82], z=2.99, p<.005) which persisted for the remainder of the shift. Most critically, Negative Affect was more elevated after serious incidents (β=0.07, [95%CI: 0.04, 0.10], z=3.5, p<.005). Nurses who reported Receipt of Managerial Support following an incident reported significantly lower levels of Positive Affect compared to those reporting no such contact (β=-5.30, [95%CI: -9.51, -1.09], z=2.47, p<.05). The interaction between Incident and the Receipt of Work-Based Support on NA was not significant (β=2.34 [95%CI: -0.82, 3.95], z=1.45, p>.05). Receipt of Colleague Support had no relationship with Negative Affect or Positive Affect. Free text reports mainly revealed the negative impact of managerial support, although there were instances of contact with managers which were sought following exposure to difficult clinical situations. Serious clinical incidents have enduring effects on Negative Affect and Positive Affect for the remainder of the shift. Nurse Positive Affect was significantly worse following the worst clinical incident of shift when managerial support was received. Further research is required to determine the positive and negative effects of managerial support on the mood experienced by nurses at work. Copyright © 2012 Elsevier Ltd. All rights reserved.

Characteristics of hazardous material spills from reporting systems in California.

PubMed Central

Shaw, G M; Windham, G C; Leonard, A; Neutra, R R

1986-01-01

Data on hazardous material releases that occurred between January 1, 1982 and September 30, 1983 in California were obtained from the California Highway Patrol (CHP) and the US Department of Transportation (DOT). The majority of incidents involved highway transport of hazardous materials, although some information was available on air, rail, and stationary facility releases. Vehicle accidents and failure of or damage to the container were the most frequent causes of releases. Proportionately more hazardous materials incidents occurred in early summer than at other times of the year, during weekdays, and daytime hours. The largest proportions of incidents involved the chemical categories of corrosives and fuels. Reported exposures and injuries to response personnel and other people at the scene were relatively few; no fatalities were reported. Few incidents were reported in both data sources, suggesting that the examination of only one data source would yield a gross underestimate of the total number of hazardous materials incidents in California. The lack of available denominator data limits the interpretation of the findings. Images FIGURE 1 FIGURE 2 FIGURE 3 PMID:3963282

Retrospective study of human cystic echinococcosis over the past decade in France, using a nationwide hospital medical information database.

PubMed

van Cauteren, Dieter; Millon, Laurence; de Valk, Henriette; Grenouillet, Frederic

2016-11-01

No specific surveillance system of cystic echinococcosis infections in humans exists in France. The incidence and trends over time have not been documented since the last decade of the twentieth century. We performed the current analysis to assess human cystic echinococcosis epidemiology over a 10-year period in France (including the island of Corsica but excluding the overseas territories) using a nationwide hospital medical information database. A total number of 2629 patients were identified in this database between 2005 and 2014. The average annual incidence rate was 0.42 hospitalized cases/100,000 inhabitants. It was highest in the Island of Corsica (1.76 cases/100,000) and in the region Provence-Alpes-Côte d'Azur (0.85 cases/100,000). This retrospective analysis of hospital records provides a population-based estimate of cystic echinococcosis incidence and trends over a 10-year period at a national level. It indicates a significant decrease of the incidence between 2005 and 2014 at the national level and in the area that reported the highest incidence. It stresses the fact that in France, cystic echinococcosis is not re-emerging and that the incidence remains low in comparison with similar studies in other Mediterranean countries.

Zika virus infection and microcephaly: Evidence regarding geospatial associations.

PubMed

Vissoci, João Ricardo Nickenig; Rocha, Thiago Augusto Hernandes; Silva, Núbia Cristina da; de Sousa Queiroz, Rejane Christine; Thomaz, Erika Bárbara Abreu Fonseca; Amaral, Pedro Vasconcelos Maia; Lein, Adriana; Branco, Maria Dos Remédios Freitas Carvalho; Aquino, José; Rodrigues, Zulimar Márita Ribeiro; da Silva, Antônio Augusto Moura; Staton, Catherine

2018-04-01

Although the Zika virus (ZIKV) epidemic ceased to be a public health emergency by the end of 2016, studies to improve knowledge about this emerging disease are still needed, especially those investigating a causal relationship between ZIKV in pregnant women and microcephaly in neonates. However, there are still many challenges in describing the relationship between ZIKV and microcephaly. The few studies focusing on the epidemiological profile of ZIKV and its changes over time are largely limited to systematic reviews of case reports and dispersal mapping of ZIKV spread over time without quantitative methods to analyze patterns and their covariates. Since Brazil has been at the epicenter of the ZIKV epidemic, this study examines the geospatial association between ZIKV and microcephaly in Brazil. Our study is categorized as a retrospective, ecological study based on secondary databases. Data were obtained from January to December 2016, from the following data sources: Brazilian System for Epidemiological Surveillance, Disease Notification System, System for Specialized Management Support, and Brazilian Institute of Geography and Statistics. Data were aggregated by municipality. Incidence rates were estimated per 100,000 inhabitants. Analyses consisted of mapping the aggregated incidence rates of ZIKV and microcephaly, followed by a Getis-Ord-Gi spatial cluster analysis and a Bivariate Local Moran's I analysis. The incidence of ZIKV cases is changing the virus's spatial pattern, shifting from Brazil's Northeast region to the Midwest and North regions. The number of municipalities in clusters of microcephaly incidence is also shifting from the Northeast region to the Midwest and North, after a time lag is considered. Our findings suggest an increase in microcephaly incidence in the Midwest and North regions, associated with high levels of ZIKV infection months before. The greatest burden of microcephaly shifted from the Northeast to other Brazilian regions at the beginning of 2016. Brazil's Midwest region experienced an increase in microcephaly incidence associated with ZIKV incidence. This finding highlights an association between an increase in ZIKV infection with a rise in microcephaly cases after approximately three months.

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

PubMed

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

2016-03-14

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. 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. 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. 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. 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). We found the current reported gonorrhoea incidence and sex ratios to be inaccurate due to underestimations of gonorrhoea incidence, especially among women. 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/

Difficult incidents and tutor interventions in problem-based learning tutorials.

PubMed

Kindler, Pawel; Grant, Christopher; Kulla, Steven; Poole, Gary; Godolphin, William

2009-09-01

Tutors report difficult incidents and distressing conflicts that adversely affect learning in their problem-based learning (PBL) groups. Faculty development (training) and peer support should help them to manage this. Yet our understanding of these problems and how to deal with them often seems inadequate to help tutors. The aim of this study was to categorise difficult incidents and the interventions that skilled tutors used in response, and to determine the effectiveness of those responses. Thirty experienced and highly rated tutors in our Year 1 and 2 medical curriculum took part in semi-structured interviews to: identify and describe difficult incidents; describe how they responded, and assess the success of each response. Recorded and transcribed data were analysed thematically to develop typologies of difficult incidents and interventions and compare reported success or failure. The 94 reported difficult incidents belonged to the broad categories 'individual student' or 'group dynamics'. Tutors described 142 interventions in response to these difficult incidents, categorised as: (i) tutor intervenes during tutorial; (ii) tutor gives feedback outside tutorial, or (iii) student or group intervenes. Incidents in the 'individual student' category were addressed relatively unsuccessfully (effective < 50% of the time) by response (i), but with moderate success by response (ii) and successfully (> 75% of the time) by response (iii). None of the interventions worked well when used in response to problems related to 'group dynamics'. Overall, 59% of the difficult incidents were dealt with successfully. Dysfunctional PBL groups can be highly challenging, even for experienced and skilled tutors. Within-tutorial feedback, the treatment that tutors are most frequently advised to apply, was often not effective. Our study suggests that the collective responsibility of the group, rather than of the tutor, to deal with these difficulties should be emphasised.

Cancer patterns, trends, and transitions in Peru: a regional perspective.

PubMed

Piñeros, Marion; Ramos, Willy; Antoni, Sébastien; Abriata, Graciela; Medina, Luis E; Miranda, J Jaime; Payet, Eduardo; Bray, Freddie

2017-10-01

Peru, like several other South American countries, is experiencing remarkable population growth, ageing, and urbanisation, which has given rise to profound changes in its epidemiological profile. Prostate and breast cancer are the most frequent cancers in men and women, respectively, in Lima and Arequipa, the two areas with population-based cancer registries. However, infection-associated cancers (cervix and stomach) are also common, and rank highest in the national cancer mortality profile. Although a foundation of surveillance informs cancer-control initiatives in Peru, improvements in the vital statistics system, and the quality and use of incidence data for the planning and assessment of cancer prevention and control actions, are needed. Existing population-based cancer registries in Lima and Arequipa, and linkages to the established national mandatory cancer reporting system, are crucial for the collection of high-quality data on national cancer incidence. The delivery of effective cancer prevention and control measures requires sustained investment in the collection of high-quality data capable of informing policies and driving research programmes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Dengue incidence in urban and rural Cambodia: results from population-based active fever surveillance, 2006-2008.

PubMed

Vong, Sirenda; Khieu, Virak; Glass, Olivier; Ly, Sowath; Duong, Veasna; Huy, Rekol; Ngan, Chantha; Wichmann, Ole; Letson, G William; Margolis, Harold S; Buchy, Philippe

2010-11-30

Dengue vaccines are now in late-stage development, and evaluation and robust estimates of dengue disease burden are needed to facilitate further development and introduction. In Cambodia, the national dengue case-definition only allows reporting of children less than 16 years of age, and little is known about dengue burden in rural areas and among older persons. To estimate the true burden of dengue in the largest province of Cambodia, Kampong Cham, we conducted community-based active dengue fever surveillance among the 0-to-19-year age group in rural villages and urban areas during 2006-2008. Active surveillance for febrile illness was conducted in 32 villages and 10 urban areas by mothers trained to use digital thermometers combined with weekly home visits to identify persons with fever. An investigation team visited families with febrile persons to obtain informed consent for participation in the follow-up study, which included collection of personal data and blood specimens. Dengue-related febrile illness was defined using molecular and serological testing of paired acute and convalescent blood samples. Over the three years of surveillance, 6,121 fever episodes were identified with 736 laboratory-confirmed dengue virus (DENV) infections for incidences of 13.4-57.8/1,000 person-seasons. Average incidence was highest among children less than 7 years of age (41.1/1,000 person-seasons) and lowest among the 16-to-19-year age group (11.3/1,000 person-seasons). The distribution of dengue was highly focal, with incidence rates in villages and urban areas ranging from 1.5-211.5/1,000 person-seasons (median 36.5). During a DENV-3 outbreak in 2007, rural areas were affected more than urban areas (incidence 71 vs. 17/1,000 person-seasons, p<0.001). The large-scale active surveillance study for dengue fever in Cambodia found a higher disease incidence than reported to the national surveillance system, particularly in preschool children and that disease incidence was high in both rural and urban areas. It also confirmed the previously observed focal nature of dengue virus transmission.

77 FR 14525 - Statement of Organization, Functions, and Delegations of Authority

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-12

... maintains the CDC Computer Security Incident Response Team; (4) performs cyber security incident reporting... systems planning and support; internal security and emergency preparedness; and management analysis and... security; education, training, and workforce development in information and IT disciplines; development and...

Prostate-specific antigen screening in a high-risk population: lessons from the community and how they relate to large-scale population-based studies.

PubMed

Shelton, Jeremy B; Barocas, Daniel A; Conway, Frances; Hart, Kathleen; Nelson, Kinloch; Richstone, Lee; Gonzalez, Ricardo R; Raman, Jay D; Scherr, Douglas S

2005-05-01

To estimate the incidence of prostate cancer among African-American men and Caribbean immigrants to the United States, to assess the applicability of large-scale prostate screening trials to a community screening program, and to recruit unscreened men. African-American and Caribbean-American men were targeted with a community-based prostate cancer screening program in Jamaica, New York. Serum prostate-specific antigen determination and digital rectal examination were used to determine abnormal findings. The incidence of an abnormal screening examination was used to project the incidence of prostate cancer, which was compared with that in other reported trials. The projected incidence of prostate cancer among African-Americans and Caribbean-Americans older than 50 years was 8% and 7%, respectively, similar to that reported in other trials of African-American men. The projected incidence of prostate cancer in Caribbean-American men aged 40 to 49 years was 1%, the same as the high rate reported among Caribbean men. As in other trials, a family history of prostate cancer and age were strong predictors of abnormal findings. Of the recruited men older than 50 years, 58% had never been screened compared with 42% nationally. Large population-based screening trials have identified ethnic groups at high risk of prostate cancer. This trial detected high rates of abnormal screening findings by targeting ethnicity. The incidence of an abnormal examination was high in Caribbean-American men younger than 50 years old. Finally, this trial successfully recruited underscreened men.

Hands-On Experiences in Deploying Cost-Effective Ambient-Assisted Living Systems

PubMed Central

Dasios, Athanasios; Gavalas, Damianos; Pantziou, Grammati; Konstantopoulos, Charalampos

2015-01-01

Older adults’ preferences to remain independent in their own homes along with the high costs of nursing home care have motivated the development of Ambient Assisted Living (AAL) technologies which aim at improving the safety, health conditions and wellness of the elderly. This paper reports hands-on experiences in designing, implementing and operating UbiCare, an AAL based prototype system for elderly home care monitoring. The monitoring is based on the recording of environmental parameters like temperature and light intensity as well as micro-level incidents which allows one to infer daily activities like moving, sitting, sleeping, usage of electrical appliances and plumbing components. The prototype is built upon inexpensive, off-the-shelf hardware (e.g., various sensors, Arduino microcontrollers, ZigBee-compatible wireless communication modules) and license-free software, thereby ensuring low system deployment costs. The network comprises nodes placed in a house’s main rooms or mounted on furniture, one wearable node, one actuator node and a centralized processing element (coordinator). Upon detecting significant deviations from the ordinary activity patterns of individuals and/or sudden falls, the system issues automated alarms which may be forwarded to authorized caregivers via a variety of communication channels. Furthermore, measured environmental parameters and activity incidents may be monitored through standard web interfaces. PMID:26094631

Hands-On Experiences in Deploying Cost-Effective Ambient-Assisted Living Systems.

PubMed

Dasios, Athanasios; Gavalas, Damianos; Pantziou, Grammati; Konstantopoulos, Charalampos

2015-06-18

Older adults' preferences to remain independent in their own homes along with the high costs of nursing home care have motivated the development of Ambient Assisted Living (AAL) technologies which aim at improving the safety, health conditions and wellness of the elderly. This paper reports hands-on experiences in designing, implementing and operating UbiCare, an AAL based prototype system for elderly home care monitoring. The monitoring is based on the recording of environmental parameters like temperature and light intensity as well as micro-level incidents which allows one to infer daily activities like moving, sitting, sleeping, usage of electrical appliances and plumbing components. The prototype is built upon inexpensive, off-the-shelf hardware (e.g., various sensors, Arduino microcontrollers, ZigBee-compatible wireless communication modules) and license-free software, thereby ensuring low system deployment costs. The network comprises nodes placed in a house's main rooms or mounted on furniture, one wearable node, one actuator node and a centralized processing element (coordinator). Upon detecting significant deviations from the ordinary activity patterns of individuals and/or sudden falls, the system issues automated alarms which may be forwarded to authorized caregivers via a variety of communication channels. Furthermore, measured environmental parameters and activity incidents may be monitored through standard web interfaces.

Cancer Among Children With Perinatal Exposure to HIV and Antiretroviral Medications--New Jersey, 1995-2010.

PubMed

Ivy, Wade; Nesheim, Steve R; Paul, Sindy M; Ibrahim, Abdel R; Chan, Miranda; Niu, Xiaoling; Lampe, Margaret A

2015-09-01

Concerns remain regarding the cancer risk associated with perinatal antiretroviral (ARV) exposure among infants. No excessive cancer risk has been found in short-term studies. Children born to HIV-infected women (HIV-exposed) in New Jersey from 1995 to 2008 were identified through the Enhanced HIV/AIDS Reporting System and cross-referenced with data from the New Jersey State Cancer Registry to identify new cases of cancer among children who were perinatally exposed to ARV. Matching of individuals in the Enhanced HIV/AIDS Reporting System to the New Jersey State Cancer Registry was conducted based on name, birth date, Social Security number, residential address, and sex using AutoMatch. Age- and sex-standardized incidence ratio (SIR) and exact 95% confidence intervals (CIs) were calculated using New Jersey (1979-2005) and US (1999-2009) cancer rates. Among 3087 children (29,099 person-years; median follow-up: 9.8 years), 4 were diagnosed with cancer. Cancer incidence among HIV-exposed children who were not exposed to ARV prophylaxis (22.5 per 100,000 person-years) did not differ significantly from the incidence among children who were exposed to any perinatal ARV prophylaxis (14.3 per 100,000 person-years). Furthermore, the number of cases observed among individuals exposed to ARV did not differ significantly from cases expected based on state (SIR = 1.21; 95% CI: 0.25 to 3.54) and national (SIR = 1.27; 95% CI: 0.26 to 3.70) reference rates. Our findings are reassuring that current use of ARV for perinatal HIV prophylaxis does not increase cancer risk. We found no evidence to alter the current federal guidelines of 2014 that recommend ARV prophylaxis of HIV-exposed infants.

Incidence of Parkinson's disease and atypical parkinsonism: Russian population-based study.

PubMed

Winter, Yaroslav; Bezdolnyy, Yury; Katunina, Elena; Avakjan, Gagik; Reese, Jens P; Klotsche, Jens; Oertel, Wolfgang H; Dodel, Richard; Gusev, Eugene

2010-02-15

Data on the incidence of Parkinson's disease (PD) and atypical parkinsonian syndromes (APS) in East European countries and Asia are limited. The objective of this prospective population-based study was to determine the incidence of PD and APS in the Russian population. The study area was a large district of Moscow with a population of 1,237,900 inhabitants. Multiple sources of case ascertainment were used to identify incident cases of PD and APS between July 2006 and December 2008. All incident cases were examined by a specialist and followed up prospectively to confirm the diagnosis. The age-standardized incidence rates per 100,000/year were 9.03 [95% confidence interval (CI) 8.01-10.15] for PD, 0.11 (95% CI 0.03-0.23) for multiple system atrophy, 0.14 (95% CI 0.08-0.21) for progressive supranuclear palsy, and 0.02 (95% CI 0.01-0.12) for corticobasal degeneration. The age-standardized male-to-female ratio of PD was 0.87 for all ages and 1.46 for those aged 60 and older. A high proportion of new cases with PD (34%) and APS (50%) had comorbid depressive symptoms. Given the rapid growth of the elderly population in Eastern Europe and Asia, the epidemiology of PD and APS in these regions should be investigated in greater depth. The incidence of PD in our study was slightly lower than in studies of Western populations and the male-to-female ratio was closer to those reported in studies from Asia. The clinical implication of our study is that it highlights the need for better diagnosis and treatment of depression in early stages of PD. (c) 2010 Movement Disorder Society.

Integrated all-optical logic discriminators based on plasmonic bandgap engineering

PubMed Central

Lu, Cuicui; Hu, Xiaoyong; Yang, Hong; Gong, Qihuang

2013-01-01

Optical computing uses photons as information carriers, opening up the possibility for ultrahigh-speed and ultrawide-band information processing. Integrated all-optical logic devices are indispensible core components of optical computing systems. However, up to now, little experimental progress has been made in nanoscale all-optical logic discriminators, which have the function of discriminating and encoding incident light signals according to wavelength. Here, we report a strategy to realize a nanoscale all-optical logic discriminator based on plasmonic bandgap engineering in a planar plasmonic microstructure. Light signals falling within different operating wavelength ranges are differentiated and endowed with different logic state encodings. Compared with values previously reported, the operating bandwidth is enlarged by one order of magnitude. Also the SPP light source is integrated with the logic device while retaining its ultracompact size. This opens up a way to construct on-chip all-optical information processors and artificial intelligence systems. PMID:24071647

Patient safety in dentistry - state of play as revealed by a national database of errors.

PubMed

Thusu, S; Panesar, S; Bedi, R

2012-08-01

Modern dentistry has become increasingly invasive and sophisticated. Consequently the risk to the patient has increased. The aim of this study is to investigate the types of patient safety incidents (PSIs) that occur in dentistry and the accuracy of the National Patient Safety Agency (NPSA) database in identifying those attributed to dentistry. The database was analysed for all incidents of iatrogenic harm in the speciality of dentistry. A snapshot view using the timeframe January to December 2009 was used. The free text elements from the database were analysed thematically and reclassified according to the nature of the PSI. Descriptive statistics were provided. Two thousand and twelve incident reports were analysed and organised into ten categories. The commonest was due to clerical errors - 36%. Five areas of PSI were further analysed: injury (10%), medical emergency (6%), inhalation/ingestion (4%), adverse reaction (4%) and wrong site extraction (2%). There is generally low reporting of PSIs within the dental specialities. This may be attributed to the voluntary nature of reporting and the reluctance of dental practitioners to disclose incidences for fear of loss of earnings. A significant amount of iatrogenic harm occurs not during treatment but through controllable pre- and post-procedural checks. Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely used. The use of a dental specific reporting system would aid in minimising iatrogenic harm and adhere to the Care Quality Commission (CQC) compliance monitoring system on essential standards of quality and safety in dental practices.

Psychological Trauma in the Workplace: Variation of Incident Severity among Industry Settings and between Recurring vs Isolated Incidents.

PubMed

DeFraia, G S

2015-07-01

Psychologically traumatic workplace events (known as critical incidents) occur within various work environments, with workgroups in certain industries vulnerable to multiple incidents. With the increasing prevalence of incidents in the USA, incident response is a growing practice area within occupational medicine, industrial psychology, occupational social work and other occupational health professions. To analyze a measure of incident severity based on level of disruption to the workplace and explore whether incident severity varied among different industry settings or between workgroups experiencing multiple vs single traumatic incidents. Administrative data mining was employed to examine practice data from a workplace trauma response unit in the USA. Bivariate analyses were conducted to test whether scores from an instrument measuring incident severity level varied among industry settings or between workgroups impacted by multiple vs isolated events. Incident severity level differed among various industry settings. Banks, retail stores and fast food restaurants accounted for the most severe incidents, while industrial and manufacturing sites reported less severe incidents. Workgroups experiencing multiple incidents reported more severe incidents than workgroups experiencing a single incident. Occupational health practitioners should be alert to industry differences in several areas: pre-incident resiliency training, the content of business recovery plans, assessing worker characteristics, strategies to assist continuous operations and assisting workgroups impacted by multiple or severe incidents.

Evaluation of roadside emergency call box technology : a summary report : technical assistance report.

DOT National Transportation Integrated Search

2003-04-01

Introduction Motorist aid call boxes are used to provide motorist assistance, improve safety, and can serve as an incident detection tool. More recently, Intelligent Transportation Systems (ITS) applications have been added to call box systems to enh...

77 FR 58616 - Pipeline Safety: Information Collection Activities, Revision to Gas Transmission and Gathering...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-21

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No. PHMSA-2012-0024] Pipeline Safety: Information Collection Activities, Revision to Gas Transmission and Gathering Pipeline Systems Annual Report, Gas Transmission and Gathering Pipeline Systems Incident Report...

Are cardiovascular risk factors also associated with the incidence of atrial fibrillation? A systematic review and field synopsis of 23 factors in 32 population-based cohorts of 20 million participants.

PubMed

Allan, Victoria; Honarbakhsh, Shohreh; Casas, Juan-Pablo; Wallace, Joshua; Hunter, Ross; Schilling, Richard; Perel, Pablo; Morley, Katherine; Banerjee, Amitava; Hemingway, Harry

2017-05-03

Established primary prevention strategies of cardiovascular diseases are based on understanding of risk factors, but whether the same risk factors are associated with atrial fibrillation (AF) remains unclear. We conducted a systematic review and field synopsis of the associations of 23 cardiovascular risk factors and incident AF, which included 84 reports based on 28 consented and four electronic health record cohorts of 20,420,175 participants and 576,602 AF events. We identified 3-19 reports per risk factor and heterogeneity in AF definition, quality of reporting, and adjustment. We extracted relative risks (RR) and 95 % confidence intervals [CI] and visualised the number of reports with inverse (RR [CI]<1.00), or direct (RR [CI]>1.00) associations. For hypertension (13/17 reports) and obesity (19/19 reports), there were direct associations with incident AF, as there are for coronary heart disease (CHD). There were inverse associations for non-White ethnicity (5/5 reports, with RR from 0.35 to 0.84 [0.82-0.85]), total cholesterol (4/13 reports from 0.76 [0.59-0.98] to 0.94 [0.90-0.97]; 8/13 reports with non-significant inverse associations), and diastolic blood pressure (2/11 reports from 0.87 [0.78-0.96] to 0.92 [0.85-0.99]; 5/11 reports with non-significant inverse associations), and direct associations for taller height (7/10 reports from 1.03 [1.02-1.05] to 1.92 [1.38-2.67]), which are in the opposite direction of known associations with CHD. A systematic evaluation of the available evidence suggests similarities as well as important differences in the risk factors for incidence of AF as compared with other cardiovascular diseases, which has implications for the primary prevention strategies for atrial fibrillation.

Comparative analysis of hydrogen fire and explosion incidents: quarterly report No. 2, December 1, 1977--February 28, 1978

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zalosh, R.G.; Short, T.P.

1978-03-01

Additional hydrogen incident reports compiled during this quarter have increased the size of the computerized data base to a current total of 280 incidents. Listings of 165 incidents that have occurred in industrial and transportation operations since 1968 are presented here. Sample case histories in six different cause categories are provided together with a discussion of common safety problems contributing to these incidents. Some of these problems are inadequate detection measures for hydrogen leaks and fires and ineffective purging with inert gas. A preliminary comparison of losses due to natural gas fires/explosions and hydrogen incidents indicates that hydrogen explosions havemore » been, on the average, four-to-six times as damaging as natural gas explosions. Some tentative explanations for this result are presented but await confirmation from a more sophisticated statistical analysis.« less

Countering imbalanced datasets to improve adverse drug event predictive models in labor and delivery.

PubMed

Taft, L M; Evans, R S; Shyu, C R; Egger, M J; Chawla, N; Mitchell, J A; Thornton, S N; Bray, B; Varner, M

2009-04-01

The IOM report, Preventing Medication Errors, emphasizes the overall lack of knowledge of the incidence of adverse drug events (ADE). Operating rooms, emergency departments and intensive care units are known to have a higher incidence of ADE. Labor and delivery (L&D) is an emergency care unit that could have an increased risk of ADE, where reported rates remain low and under-reporting is suspected. Risk factor identification with electronic pattern recognition techniques could improve ADE detection rates. The objective of the present study is to apply Synthetic Minority Over Sampling Technique (SMOTE) as an enhanced sampling method in a sparse dataset to generate prediction models to identify ADE in women admitted for labor and delivery based on patient risk factors and comorbidities. By creating synthetic cases with the SMOTE algorithm and using a 10-fold cross-validation technique, we demonstrated improved performance of the Naïve Bayes and the decision tree algorithms. The true positive rate (TPR) of 0.32 in the raw dataset increased to 0.67 in the 800% over-sampled dataset. Enhanced performance from classification algorithms can be attained with the use of synthetic minority class oversampling techniques in sparse clinical datasets. Predictive models created in this manner can be used to develop evidence based ADE monitoring systems.

Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.

PubMed

Feigin, Valery L; Lawes, Carlene M M; Bennett, Derrick A; Barker-Collo, Suzanne L; Parag, Varsha

2009-04-01

This systematic review of population-based studies of the incidence and early (21 days to 1 month) case fatality of stroke is based on studies published from 1970 to 2008. Stroke incidence (incident strokes only) and case fatality from 21 days to 1 month post-stroke were analysed by four decades of study, two country income groups (high-income countries and low to middle income countries, in accordance with the World Bank's country classification) and, when possible, by stroke pathological type: ischaemic stroke, primary intracerebral haemorrhage, and subarachnoid haemorrhage. This Review shows a divergent, statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle income countries. In 2000-08, the overall stroke incidence rates in low to middle income countries have, for the first time, exceeded the level of stroke incidence seen in high-income countries, by 20%. The time to decide whether or not stroke is an issue that should be on the governmental agenda in low to middle income countries has now passed. Now is the time for action.

Incidence of amyotrophic lateral sclerosis among American Indians and Alaska natives.

PubMed

Gordon, Paul H; Mehal, Jason M; Holman, Robert C; Rowland, Lewis P; Rowland, Andrew S; Cheek, James E

2013-04-01

More thorough evaluation of amyotrophic lateral sclerosis (ALS) and motor neuron disease in unique populations could provide clues to etiologies for these idiopathic conditions, and educational programs for American Indian and Alaska Native (AI/AN) people and health care professionals on reservations could improve awareness, understanding, diagnosis, and treatment. In the ongoing search for susceptibility genes, studying particular racial groups, such as AI/ANs,might facilitate the identification of new mutations. To provide better understanding of ALS and secondarily of motor neuron disease among AI/AN people by estimating the incidence and prevalence among AI/ANs served by the Indian Health Service health care system. Analysis of electronic records for AI/ANs with ALS and with motor neuron disease separately for the calendar years 2002-2009 using inpatient and outpatient visit data from the Indian Health Service, which provides health care to eligible AI/ANs nationwide. Cases were defined by at least 2 inpatient or outpatient visits with the diagnosis. Crude and age-adjusted incidence and prevalence rates were calculated. Seventy-one AI/ANs were diagnosed with ALS, yielding an average annual crude incidence rate of 0.63 cases per 100 000 and an age-adjusted incidence of 0.92. The median age at onset was 56.0 years and was higher among women than men (62.0 vs 55.0 years; P=.06). Age-specific incidence increased to 70 to 74 years. The crude and age-adjusted point prevalence rates were 2.00 and 4.12, respectively. The crude and age-adjusted incidence rates for motor neuron disease were 1.08 and 1.50, respectively. The annual rates were unchanged across the study period. The incidence of ALS among AI/ANs appears to be lower than that reported for white populations, a finding congruent with reports of other minority populations. Community-based studies are important to confirm these findings and to examine reasons for the low rate of ALS among AI/ANs.

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

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pappas, D; Reis, S; Ali, A

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 seemore » 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.« less

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.

Computer-based training (CBT) intervention reduces workplace violence and harassment for homecare workers.

PubMed

Glass, Nancy; Hanson, Ginger C; Anger, W Kent; Laharnar, Naima; Campbell, Jacquelyn C; Weinstein, Marc; Perrin, Nancy

2017-07-01

The study examines the effectiveness of a workplace violence and harassment prevention and response program with female homecare workers in a consumer driven model of care. Homecare workers were randomized to either; computer based training (CBT only) or computer-based training with homecare worker peer facilitation (CBT + peer). Participants completed measures on confidence, incidents of violence, and harassment, health and work outcomes at baseline, 3, 6 months post-baseline. Homecare workers reported improved confidence to prevent and respond to workplace violence and harassment and a reduction in incidents of workplace violence and harassment in both groups at 6-month follow-up. A decrease in negative health and work outcomes associated with violence and harassment were not reported in the groups. CBT alone or with trained peer facilitation with homecare workers can increase confidence and reduce incidents of workplace violence and harassment in a consumer-driven model of care. © 2017 Wiley Periodicals, Inc.

Incidence of diseases primarily affecting the skin by age group: population-based epidemiologic study in Olmsted County, Minnesota, and comparison with age-specific incidence rates worldwide.

PubMed

Wessman, Laurel L; Andersen, Louise K; Davis, Mark D P

2018-01-29

Understanding the effects of age on the epidemiology of diseases primarily affecting the skin is important to the practice of dermatology, both for proper allocation of resources and for optimal patient-centered care. To fully appreciate the effect that age may have on the population-based calculations of incidence of diseases primarily affecting the skin in Olmsted County, Minnesota, and worldwide, we performed a review of all relevant Rochester Epidemiology Project-published data and compared them to similar reports in the worldwide English literature. Using the Rochester Epidemiology Project, population-based epidemiologic studies have been performed to estimate the incidence of specific skin diseases over the past 50 years. In older persons (>65 years), nonmelanoma skin cancer, lentigo maligna, herpes zoster, delusional infestation, venous stasis syndrome, venous ulcer, and burning mouth syndrome were more commonly diagnosed. In those younger than 65 years, atypical nevi, psoriatic arthritis, pityriasis rosea, herpes progenitalis, genital warts, alopecia areata, hidradenitis suppurativa, infantile hemangioma, Behçet's disease, and sarcoidosis (isolated cutaneous, with sarcoidosis-specific cutaneous lesions and with erythema nodosum) had a higher incidence. Many of the incidence rates by age group of diseases primarily affecting the skin derived from the Rochester Epidemiology Project were similar to those reported elsewhere. © 2018 The International Society of Dermatology.

The effect of case management and vector-control interventions on space-time patterns of malaria incidence in Uganda.

PubMed

Ssempiira, Julius; Kissa, John; Nambuusi, Betty; Kyozira, Carol; Rutazaana, Damian; Mukooyo, Eddie; Opigo, Jimmy; Makumbi, Fredrick; Kasasa, Simon; Vounatsou, Penelope

2018-04-12

Electronic reporting of routine health facility data in Uganda began with the adoption of the District Health Information Software System version 2 (DHIS2) in 2011. This has improved health facility reporting and overall data quality. In this study, the effects of case management with artemisinin-based combination therapy (ACT) and vector control interventions on space-time patterns of disease incidence were determined using DHIS2 data reported during 2013-2016. Bayesian spatio-temporal negative binomial models were fitted on district-aggregated monthly malaria cases, reported by two age groups, defined by a cut-off age of 5 years. The effects of interventions were adjusted for socio-economic and climatic factors. Spatial and temporal correlations were taken into account by assuming a conditional autoregressive and a first-order autoregressive AR(1) process on district and monthly specific random effects, respectively. Fourier trigonometric functions were incorporated in the models to take into account seasonal fluctuations in malaria transmission. The temporal variation in incidence was similar in both age groups and depicted a steady decline up to February 2014, followed by an increase from March 2015 onwards. The trends were characterized by a strong bi-annual seasonal pattern with two peaks during May-July and September-December. Average monthly incidence in children < 5 years declined from 74.7 cases (95% CI 72.4-77.1) in 2013 to 49.4 (95% CI 42.9-55.8) per 1000 in 2015 and followed by an increase in 2016 of up to 51.3 (95% CI 42.9-55.8). In individuals ≥ 5 years, a decline in incidence from 2013 to 2015 was followed by an increase in 2016. A 100% increase in insecticide-treated nets (ITN) coverage was associated with a decline in incidence by 44% (95% BCI 28-59%). Similarly, a 100% increase in ACT coverage reduces incidence by 28% (95% BCI 11-45%) and 25% (95% BCI 20-28%) in children < 5 years and individuals ≥ 5 years, respectively. The ITN effect was not statistically important in older individuals. The space-time patterns of malaria incidence in children < 5 are similar to those of parasitaemia risk predicted from the malaria indicator survey of 2014-15. The decline in malaria incidence highlights the effectiveness of vector-control interventions and case management with ACT in Uganda. This calls for optimizing and sustaining interventions to achieve universal coverage and curb reverses in malaria decline.

Evaluation of adverse drug event information in US manufacturer labels.

PubMed

Harrington, Catherine A; Garcia, Angela S; Sircar-Ramsewak, Feroza

2011-02-01

Pharmaceutical manufacturer labels are an important source of adverse drug event (ADE) information. The study objective was to determine the sufficiency of ADE reporting in US drug labels. A sample of 50 labels was evaluated from the top 200 drugs dispensed in the US. Electronic copies of labels were obtained and reviewed by 2 pharmacists for ADE incidence and discontinuation data. ADE incidence data were provided in 86% of labels. However, discontinuation rates due to ADEs and ADE incidence by dose were only reported in 60%. ADE incidence reporting by age (46%) or gender (18%) was also low. ADEs that occurred in less than 2% of the population were rarely reported. Incidence rates were based on small populations (median of 794) and short term studies (median of 84 days for chronic conditions). Labels for 19 drugs used chronically had no long term study data. Methods for collecting ADE data were stated in only 12% of labels. Adverse drug event and drug discontinuation data is under-reported in US labels. More information on adverse events causing discontinuation (especially serious events) and those related to dose, age, and gender is needed in labels to ensure safe prescribing and dispensing of drugs.

Questionnaire-based study to assess the association between management practices and mastitis within tie-stall and free-stall dairy housing systems in Switzerland

PubMed Central

2013-01-01

Background Prophylactic measures are key components of dairy herd mastitis control programs, but some are only relevant in specific housing systems. To assess the association between management practices and mastitis incidence, data collected in 2011 by a survey among 979 randomly selected Swiss dairy farms, and information from the regular test day recordings from 680 of these farms was analyzed. Results The median incidence of farmer-reported clinical mastitis (ICM) was 11.6 (mean 14.7) cases per 100 cows per year. The median annual proportion of milk samples with a composite somatic cell count (PSCC) above 200,000 cells/ml was 16.1 (mean 17.3) %. A multivariable negative binomial regression model was fitted for each of the mastitis indicators for farms with tie-stall and free-stall housing systems separately to study the effect of other (than housing system) management practices on the ICM and PSCC events (above 200,000 cells/ml). The results differed substantially by housing system and outcome. In tie-stall systems, clinical mastitis incidence was mainly affected by region (mountainous production zone; incidence rate ratio (IRR) = 0.73), the dairy herd replacement system (1.27) and farmers age (0.81). The proportion of high SCC was mainly associated with dry cow udder controls (IRR = 0.67), clean bedding material at calving (IRR = 1.72), using total merit values to select bulls (IRR = 1.57) and body condition scoring (IRR = 0.74). In free-stall systems, the IRR for clinical mastitis was mainly associated with stall climate/temperature (IRR = 1.65), comfort mats as resting surface (IRR = 0.75) and when no feed analysis was carried out (IRR = 1.18). The proportion of high SSC was only associated with hand and arm cleaning after calving (IRR = 0.81) and beef producing value to select bulls (IRR = 0.66). Conclusions There were substantial differences in identified risk factors in the four models. Some of the factors were in agreement with the reported literature while others were not. This highlights the multifactorial nature of the disease and the differences in the risks for both mastitis manifestations. Attempting to understand these multifactorial associations for mastitis within larger management groups continues to play an important role in mastitis control programs. PMID:24107254

Questionnaire-based study to assess the association between management practices and mastitis within tie-stall and free-stall dairy housing systems in Switzerland.

PubMed

Gordon, Paz F; van den Borne, Bart H P; Reist, Martin; Kohler, Samuel; Doherr, Marcus G

2013-10-09

Prophylactic measures are key components of dairy herd mastitis control programs, but some are only relevant in specific housing systems. To assess the association between management practices and mastitis incidence, data collected in 2011 by a survey among 979 randomly selected Swiss dairy farms, and information from the regular test day recordings from 680 of these farms was analyzed. The median incidence of farmer-reported clinical mastitis (ICM) was 11.6 (mean 14.7) cases per 100 cows per year. The median annual proportion of milk samples with a composite somatic cell count (PSCC) above 200,000 cells/ml was 16.1 (mean 17.3) %. A multivariable negative binomial regression model was fitted for each of the mastitis indicators for farms with tie-stall and free-stall housing systems separately to study the effect of other (than housing system) management practices on the ICM and PSCC events (above 200,000 cells/ml). The results differed substantially by housing system and outcome. In tie-stall systems, clinical mastitis incidence was mainly affected by region (mountainous production zone; incidence rate ratio (IRR) = 0.73), the dairy herd replacement system (1.27) and farmers age (0.81). The proportion of high SCC was mainly associated with dry cow udder controls (IRR = 0.67), clean bedding material at calving (IRR = 1.72), using total merit values to select bulls (IRR = 1.57) and body condition scoring (IRR = 0.74). In free-stall systems, the IRR for clinical mastitis was mainly associated with stall climate/temperature (IRR = 1.65), comfort mats as resting surface (IRR = 0.75) and when no feed analysis was carried out (IRR = 1.18). The proportion of high SSC was only associated with hand and arm cleaning after calving (IRR = 0.81) and beef producing value to select bulls (IRR = 0.66). There were substantial differences in identified risk factors in the four models. Some of the factors were in agreement with the reported literature while others were not. This highlights the multifactorial nature of the disease and the differences in the risks for both mastitis manifestations. Attempting to understand these multifactorial associations for mastitis within larger management groups continues to play an important role in mastitis control programs.

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country.

PubMed

Abbasi, Shemila; Khan, Fauzia Anis; Khan, Sobia

2018-01-01

The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

Optimized mirror shape tuning using beam weightings based on distance, angle of incidence, reflectivity, and power.

PubMed

Goldberg, Kenneth A; Yashchuk, Valeriy V

2016-05-01

For glancing-incidence optical systems, such as short-wavelength optics used for nano-focusing, incorporating physical factors in the calculations used for shape optimization can improve performance. Wavefront metrology, including the measurement of a mirror's shape or slope, is routinely used as input for mirror figure optimization on mirrors that can be bent, actuated, positioned, or aligned. Modeling shows that when the incident power distribution, distance from focus, angle of incidence, and the spatially varying reflectivity are included in the optimization, higher Strehl ratios can be achieved. Following the works of Maréchal and Mahajan, optimization of the Strehl ratio (for peak intensity with a coherently illuminated system) occurs when the expectation value of the phase error's variance is minimized. We describe an optimization procedure based on regression analysis that incorporates these physical parameters. This approach is suitable for coherently illuminated systems of nearly diffraction-limited quality. Mathematically, this work is an enhancement of the methods commonly applied for ex situ alignment based on uniform weighting of all points on the surface (or a sub-region of the surface). It follows a similar approach to the optimization of apodized and non-uniformly illuminated optical systems. Significantly, it reaches a different conclusion than a more recent approach based on minimization of focal plane ray errors.

Review of NJ point system.

DOT National Transportation Integrated Search

2013-03-01

The purpose of this study is to investigate the comparative effectiveness of point-based versus incident-based : negligent driver monitoring systems and to explore how certain changes to the existing point-based system used in : New Jersey might impr...

Suicide notes.

PubMed

O'Donnell, I; Farmer, R; Catalan, J

1993-07-01

Detailed case reports of incidents of suicide and attempted suicide on the London Underground railway system between 1985 and 1989 were examined for the presence of suicide notes. The incidence of note-leaving was 15%. Notes provided little insight into the causes of suicide as subjectively perceived, or strategies for suicide prevention.

Concept of operations and policy implications for unmanned aircraft systems use for traffic incident management (UAS-TIM) : final report.

DOT National Transportation Integrated Search

2017-03-01

Texas freeways experience considerable traffic congestionsome from high traffic volumes and some from traffic incidents, both minor (e.g., crashes, stalls, and road debris) and major (e.g., vehicle rollovers, chemical spills, flooding, and hurrica...

Potential immediate hypersensitivity reactions following immunization in preschool aged children in Victoria, Australia.

PubMed

Baxter, C-M; Clothier, H J; Perrett, K P

2018-04-06

Immediate hypersensitivity reactions (IHR) are rare but potentially serious adverse events following immunization (AEFI). Surveillance of Adverse Events following Vaccination in the Community (SAEFVIC) is an enhanced passive surveillance system that collects, analyses and reports information about AEFI in Victoria, Australia. We describe the incidence, timing and type of potential IHR following vaccination in preschool children reported over an 8-year period. A total of 2110 AEFI were reported in 1620 children, of which 23.5% (496) were classified as potential IHR. Of these, 37.1% (184) were suspected to be IgE-mediated, (including anaphylaxis, angioedema and/or urticaria) and 83.5% (414) occurred within 15 minutes of vaccination. The incidence of potential IHR was 5.4 per 100,000 doses, with that of suspected IgE-mediated IHR being 2.0 per 100,000 doses. The incidence of anaphylaxis was extremely low (0.13 per 100,000 doses) and is consistent with other published studies. Potential IHR following immunization should be reported to appropriate local pharmacovigilance systems and patients reviewed by specialists able to evaluate, investigate and manage future vaccinations.

Analysis of accidents in nine Iranian gas refineries: 2007-2011.

PubMed

Mehrdad, R; Bolouri, A; Shakibmanesh, A R

2013-10-01

Occupational accidents are one of the major health hazards in industries and associated with high mortality, morbidity, spiritual damage and economic losses in the world. To determine the incidence of occupational accidents in 9 Iranian gas refineries between March 2007 and February 2011. Data on all occupational accidents occurred between March 2007 and February 2011, as well as other possible associated variables including time of accident, whether the accident was due to a personal or systemic fault, type of accident and its outcomes, age and gender of the victim, the injured parts of the body, job experience, and type of employment, were extracted from HSE reports and notes of health care services. Based on these data, we calculated the incidence rate of accidents and assessed the associated factors. During the 5 studied years, 1129 accidents have been recorded. The incidence of fatal accidents was 1.64 per 100 000 and of nonfatal accidents was 1857 per 100 000 workers per year. 99.4% of injured workers were male. The mean±SD age of injured people was 29.6±7.3 years. Almost 70% of injured workers aged under 30 years. The mean±SD job experience was 5.3±5.3 years. Accidents occurred more commonly around 10:00. More than 60% of accidents happened between 8:00 and 15:00. July had the highest incidence rate. The most common type of accident was being struck by an object (48%). More than 94% of accidents are caused by personal rather than systemic faults. Hands and wrists were the most common injured parts and involved in more than one-third of accidents. 70% of injured workers needed medical treatment and returned to work after primary treatment. The pattern of occupational accidents in Iranian gas refineries is similar to other previous reports in many ways. The incidence did not change significantly over the study period. Establishment of an online network for precise registration, notification and meticulous data collection seems necessary.

Causal Factors and Adverse Events of Aviation Accidents and Incidents Related to Integrated Vehicle Health Management

NASA Technical Reports Server (NTRS)

Reveley, Mary S.; Briggs, Jeffrey L.; Evans, Joni K.; Jones, Sharon M.; Kurtoglu, Tolga; Leone, Karen M.; Sandifer, Carl E.

2011-01-01

Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.

Incidence of solitary pulmonary nodules in Northeastern France: a population-based study in five regions.

PubMed

Marrer, Émilie; Jolly, Damien; Arveux, Patrick; Lejeune, Catherine; Woronoff-Lemsi, Marie-Christine; Jégu, Jérémie; Guillemin, Francis; Velten, Michel

2017-01-11

The discovery of a solitary pulmonary nodule (SPN) on a chest imaging exam is of major clinical concern. However, the incidence rates of SPNs in a general population have not been estimated. The objective of this study was to provide incidence estimates of SPNs in a general population in 5 northeastern regions of France. This population-based study was undertaken in 5 regions of northeastern France in May 2002-March 2003 and May 2004-June 2005. SPNs were identified by chest CT reports collected from all radiology centres in the study area by trained readers using a standardised procedure. All reports for patients at least 18 years old, without a previous history of cancer and showing an SPN between 1 and 3 cm, were included. A total of 11,705 and 20,075 chest CT reports were collected for the 2002-2003 and 2004-2005 periods, respectively. Among them, 154 and 297 reports showing a SPN were included, respectively for each period. The age-standardised incidence rate (IR) was 10.2 per 100,000 person-years (95% confidence interval 8.5-11.9) for 2002-2003 and 12.6 (11.0-14.2) for 2004-2005. From 2002 to 2005, the age-standardised IR evolved for men from 16.4 (13.2-19.6) to 17.7 (15.0-20.4) and for women from 4.9 (3.2-6.6) to 8.2 (6.4-10.0). In multivariate Poisson regression analysis, gender, age, region and period were significantly associated with incidence variation. This study provides reference incidence rates of SPN in France. Incidence was higher for men than women, increased with age for both gender and with time for women. Trends in smoking prevalence and improvement in radiological equipment may be related to incidence variations.

The incidence and aetiology of acute pancreatitis across Europe.

PubMed

Roberts, Stephen E; Morrison-Rees, Sian; John, Ann; Williams, John G; Brown, Tim H; Samuel, David G

Acute pancreatitis is increasingly one of the most important acute gastrointestinal conditions throughout much of the world, although incidence and aetiology varies across countries and regions. This study investigated regional and national patterns in the incidence and aetiology of acute pancreatitis, demographic patterns in incidence and trends over time in incidence across Europe. A structured review of acute pancreatitis incidence and aetiology from studies of hospitalised patient case series, cohort studies or other population based studies from 1989 to 2015 and a review of trends in incidence from 1970 to 2015 across all 51 European states. The incidence of acute pancreatitis was reported from 17 countries across Europe and ranged from 4.6 to 100 per 100 000 population. Incidence was usually highest in eastern or northern Europe, although reported rates often varied according to case ascertainment criteria. Of 20 studies that reported on trends in incidence, all but three show percentage increases over time (overall median increase = 3.4% per annum; range = -0.4%-73%). The highest ratios of gallstone to alcohol aetiologies were identified in southern Europe (Greece, Turkey, Italy and Croatia) with lowest ratios mainly in eastern Europe (Latvia, Finland, Romania, Hungary, Russia and Lithuania). The incidence of acute pancreatitis varies across Europe. Gallstone is the dominant aetiology in southern Europe and alcohol in eastern Europe with intermediate ratios in northern and western Europe. Acute pancreatitis continues to increase throughout most of Europe. Copyright © 2017. Published by Elsevier B.V.

16 CFR 1000.26 - Directorate for Epidemiology.

Code of Federal Regulations, 2010 CFR

2010-01-01

... things, incidents associated with consumer products, based on news clips, medical examiner reports, hotline reports, Internet complaints, and referrals. The Hazard Analysis Division conducts statistical...

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2015-05-01

A constructive safety culture is essential for the successful implementation of patient safety improvements. To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture. A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands. The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires. The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups. Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety. © British Journal of General Practice 2015.

Incidence and prevalence of idiopathic inflammatory myopathies among commercially insured, Medicare supplemental insured, and Medicaid enrolled populations: an administrative claims analysis

PubMed Central

2012-01-01

Background Idiopathic inflammatory myopathies (IIMs) are a rare group of autoimmune syndromes characterized by chronic muscle inflammation and muscle weakness with no known cause. Little is known about their incidence and prevalence. This study reports the incidence and prevalence of IIMs among commercially insured and Medicare and Medicaid enrolled populations in the US. Methods We retrospectively examined medical claims with an IIM diagnosis (ICD-9-CM 710.3 [dermatomyositis (DM)], 710.4 [polymyositis (PM)], 728.81[interstitial myositis]) in the MarketScan® databases to identify age- and gender-adjusted annual IIM incidence and prevalence for 2004–2008. Sensitivity analysis was performed for evidence of a specialist visit (rheumatologist/ neurologist/dermatologist), systemic corticosteroid or immunosuppressant use, or muscle biopsy. Results We identified 2,990 incident patients between 2004 and 2008 (67% female, 17% Medicaid enrollees, 27% aged ≥65 years). Overall adjusted IIM incidence for 2004–2008 for commercial and Medicare supplemental groups combined were 4.27 cases (95% CI, 4.09-4.44) and for Medicaid, 5.23 (95% CI 4.74-5.72) per 100,000 person-years (py). Disease sub-type incidence rates per 100,000-py were 1.52 (95% CI 1.42-1.63) and 1.70 (1.42-1.97) for DM, 2.46 (2.33-2.59) and 3.53 (3.13-3.94) for PM, and 0.73 (0.66-0.81) and 0.78 (0.58-0.97) for interstitial myositis for the commercial/Medicare and Medicaid cohorts respectively. Annual incidence fluctuated over time with the base MarketScan populations. There were 7,155 prevalent patients, with annual prevalence ranging from 20.62 to 25.32 per 100,000 for commercial/Medicare (83% of prevalent cases) and from 15.35 to 32.74 for Medicaid. Conclusions We found higher IIM incidence than historically reported. Employer turnover, miscoding and misdiagnosing, care seeking behavior, and fluctuations in database membership over time can influence the results. Further studies are needed to confirm the incidence and prevalence of IIM. PMID:22703603

Three-parameter error analysis method based on rotating coordinates in rotating birefringent polarizer system

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cao, Junjie; Jia, Hongzhi, E-mail: hzjia@usst.edu.cn

2015-11-15

We propose error analysis using a rotating coordinate system with three parameters of linearly polarized light—incidence angle, azimuth angle on the front surface, and angle between the incidence and vibration planes—and demonstrate the method on a rotating birefringent prism system. The transmittance and angles are calculated plane-by-plane using a birefringence ellipsoid model and the final transmitted intensity equation is deduced. The effects of oblique incidence, light interference, beam convergence, and misalignment of the rotation and prism axes are discussed. We simulate the entire error model using MATLAB and conduct experiments based on a built polarimeter. The simulation and experimental resultsmore » are consistent and demonstrate the rationality and validity of this method.« less

DOE Office of Scientific and Technical Information (OSTI.GOV)

Elnahal, Shereef M., E-mail: selnaha1@jhmi.edu; Blackford, Amanda; Smith, Koren

Purpose: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. Methods and Materials: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause. A control group of patients without events was generated for comparison. Summary statistics, likelihood ratios, and mixed-effect logistic regression models were used for group comparisons. Results:more » The incident and control groups comprised 794 and 499 patients, respectively. Common root causes included documentation errors (26.5%), communication (22.5%), technical treatment planning (37.5%), and technical treatment delivery (13.5%). Incidents were more frequently reported in minors (age <18 years) than in adult patients (37.7% vs 0.4%, P<.001). Patients with head and neck (16% vs 8%, P<.001) and breast (20% vs 15%, P=.03) primaries more frequently had incidents, whereas brain (18% vs 24%, P=.008) primaries were less frequent. Larger tumors (17% vs 10% had T4 lesions, P=.02), and cases on protocol (9% vs 5%, P=.005) or with intensity modulated radiation therapy/image guided intensity modulated radiation therapy (52% vs 43%, P=.001) were more likely to have incidents. Conclusions: We found several treatment- and patient-specific variables associated with incidents. These factors should be considered by treatment teams at the time of peer review to identify patients at higher risk. Larger datasets are required to recommend changes in care process standards, to minimize safety risks.« less

78 FR 53736 - Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-30

...: Title, Associated Form and OMB Number: Defense Industrial Base Cyber Security/Information Assurance (DIB CS/IA) Cyber Incident Reporting; OMB Control Number 0704-0489. Type of Request: Reinstatement without.... The requested information supports the collaborative cyber threat information sharing and incident...

Is it possible to eliminate patient identification errors in medical imaging?

PubMed

Danaher, Luke A; Howells, Joan; Holmes, Penny; Scally, Peter

2011-08-01

The aim of this article is to review a system that validates and documents the process of ensuring the correct patient, correct site and side, and correct procedure (commonly referred to as the 3 C's) within medical imaging. A 4-step patient identification and procedure matching process was developed using health care and aviation models. The process was established in medical imaging departments after a successful interventional radiology pilot program. The success of the project was evaluated using compliance audit data, incident reporting data before and after the implementation of the process, and a staff satisfaction survey. There was 95% to 100% verification of site and side and 100% verification of correct patient, procedure, and consent. Correct patient data and side markers were present in 82% to 95% of cases. The number of incidents before and after the implementation of the 3 C's was difficult to assess because of a change in reporting systems and incident underreporting. More incidents are being reported, particularly "near misses." All near misses were related to incorrect patient identification stickers being placed on request forms. The majority of staff members surveyed found the process easy (55.8%), quick (47.7%), relevant (51.7%), and useful (60.9%). Although identification error is difficult to eliminate, practical initiatives can engender significant systems improvement in complex health care environments. Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.

Treating Multiple Incident Post-Traumatic Stress Disorder (PTSD) in an Inner City London Prison: The Need for an Evidence Base.

PubMed

Campbell, Catherine A; Albert, Idit; Jarrett, Manuela; Byrne, Majella; Roberts, Anna; Phillip, Patricia; Huddy, Vyv; Valmaggia, Lucia

2016-01-01

Mental health problems have been found to be more prevalent in prison populations, and higher rates of post-traumatic stress disorder (PTSD) have been found in sentenced populations compared to the general population. Evidence-based treatment in the general population however has not been transferred and empirically supported into the prison system. The aim of this manuscript is to illustrate how trauma focused work can be applied in a prison setting. This report describes a two-phased approach to treating PTSD, starting with stabilization, followed by an integration of culturally appropriate ideas from narrative exposure therapy (NET), given that the traumas were during war and conflict, and trauma-focused cognitive behavioural therapy (TF-CBT). PTSD and scores on paranoia scales improved between start and end of treatment; these improvements were maintained at a 6-month follow-up. This case report 1 illustrates successful treatment of multiple incident PTSD in a prison setting using adaptations to TF-CBT during a window of opportunity when individuals are more likely to be free from substances and live in relative stability. Current service provision and evidence-based practice for PTSD is urgently required in UK prisons to allow individuals to engage in opportunities to reduce re-offending, free from mental health symptoms.

Causes and types of health effects during the use of crop protection chemicals: data from a survey of over 6,300 smallholder applicators in 24 different countries.

PubMed

Tomenson, John A; Matthews, Graham A

2009-08-01

The present investigation looks in detail at the causes and types of health incidents reported by 6,300 mainly smallholder agrochemical users in 24 countries during 2005 and 2006. The investigation is based on a questionnaire survey of knowledge, attitude and practice that concentrated on the sequence of events from purchasing the pesticide to disposal. Information was also collected about health problems experienced while using agrochemicals. The survey targeted mainly smallholder knapsack spray operators who were expected to be at a highest risk of exposure. In the 12 months prior to interview, 1.2% of users reported an agrochemical-related incident that required hospital treatment, 5.8% reported an incident requiring at least trained medical treatment but not hospitalisation and 19.8% reported only a minor sign or symptom. Users who had experienced an incident involving agricultural equipment were 3.38 (95% CI 2.29-4.99) times more likely to experience an agrochemical-related health incident, but confident users who felt that their use of personal protective equipment while spraying was best practice were 0.60 (95% CI 0.44-0.84) times less likely to experience such an incident. Over 80% of product-related incidents were caused by insecticides and the incidence rate per spraying time for incidents linked to insecticides was significantly higher than that for fungicides or herbicides. Headache/dizziness and nausea/vomiting, often smell related, were the most common symptoms reported by users who listed agrochemical products that had caused them health problems (52 and 38% of product mentions, respectively). In most countries, the incidence of serious health effects was low; however, there was a high incidence of minor signs and symptoms in a few countries, especially in Africa. A disproportionate number of incidents occurred during insecticide use relative to the time that they were sprayed. Failure to exercise caution as indicated by whether users had incidents involving agricultural equipment or livestock, and lack of confidence in their practices were the most important predictors of agrochemical-related incidents.

[Compulsory reporting of accidents and injuries in somatic hospitals. Is the existing system adequate for quality assurance?].

PubMed

Molven, O

1992-10-10

Doctors in Norway are obliged by law to submit reports to central authorities about injuries and risk of injury arising from medical equipment and drugs. Deaths following health care procedures must be reported to the police, and major injuries to the County Medical Officer. Most hospitals have their own rules requiring health care providers to report all incidents resulting in injury or risk of injury. The author contends that fewer than 5% of the injuries are reported. Neither the law, nor the hospital rules, require that the incidents in general are evaluated, with feed-back to the care providers. Most incidents do not seem to be evaluated. There is much left to do, both in building a set of regulations and in implementing better hospital practice, by using records of injuries and mishaps to identify and prevent further mishaps.

Altitude deviations: Breakdowns of an error-tolerant system

NASA Technical Reports Server (NTRS)

Palmer, Everett A.; Hutchins, Edwin L.; Ritter, Richard D.; Vancleemput, Inge

1993-01-01

Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.

QCloud: A cloud-based quality control system for mass spectrometry-based proteomics laboratories

PubMed Central

Chiva, Cristina; Olivella, Roger; Borràs, Eva; Espadas, Guadalupe; Pastor, Olga; Solé, Amanda

2018-01-01

The increasing number of biomedical and translational applications in mass spectrometry-based proteomics poses new analytical challenges and raises the need for automated quality control systems. Despite previous efforts to set standard file formats, data processing workflows and key evaluation parameters for quality control, automated quality control systems are not yet widespread among proteomics laboratories, which limits the acquisition of high-quality results, inter-laboratory comparisons and the assessment of variability of instrumental platforms. Here we present QCloud, a cloud-based system to support proteomics laboratories in daily quality assessment using a user-friendly interface, easy setup, automated data processing and archiving, and unbiased instrument evaluation. QCloud supports the most common targeted and untargeted proteomics workflows, it accepts data formats from different vendors and it enables the annotation of acquired data and reporting incidences. A complete version of the QCloud system has successfully been developed and it is now open to the proteomics community (http://qcloud.crg.eu). QCloud system is an open source project, publicly available under a Creative Commons License Attribution-ShareAlike 4.0. PMID:29324744

[Detection and classification of medication errors at Joan XXIII University Hospital].

PubMed

Jornet Montaña, S; Canadell Vilarrasa, L; Calabuig Mũoz, M; Riera Sendra, G; Vuelta Arce, M; Bardají Ruiz, A; Gallart Mora, M J

2004-01-01

Medication errors are multifactorial and multidisciplinary, and may originate in processes such as drug prescription, transcription, dispensation, preparation and administration. The goal of this work was to measure the incidence of detectable medication errors that arise within a unit dose drug distribution and control system, from drug prescription to drug administration, by means of an observational method confined to the Pharmacy Department, as well as a voluntary, anonymous report system. The acceptance of this voluntary report system's implementation was also assessed. A prospective descriptive study was conducted. Data collection was performed at the Pharmacy Department from a review of prescribed medical orders, a review of pharmaceutical transcriptions, a review of dispensed medication and a review of medication returned in unit dose medication carts. A voluntary, anonymous report system centralized in the Pharmacy Department was also set up to detect medication errors. Prescription errors were the most frequent (1.12%), closely followed by dispensation errors (1.04%). Transcription errors (0.42%) and administration errors (0.69%) had the lowest overall incidence. Voluntary report involved only 4.25% of all detected errors, whereas unit dose medication cart review contributed the most to error detection. Recognizing the incidence and types of medication errors that occur in a health-care setting allows us to analyze their causes and effect changes in different stages of the process in order to ensure maximal patient safety.

[Mandatory reporting of antimicrobial-resistant pathogens. What should, what can be achieved? : assessment related to the particular facility seems crucial].

PubMed

Heudorf, Ursel; Gottschalk, R; Exner, M

2014-11-01

Antimicrobial-resistant organisms are regarded as a particular threat to the public health of the European population. In Germany the requirement for a national rollout reporting of positive laboratory test results for methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures was implemented in 2009. This was followed in 2011 by the introduction of a laboratory-based, rollout reporting system for the detection of gram-negative bacteria with acquired carbapenem-resistance (carbapenem-resistant organisms, CRO) in the federal state of Hessen. This article will present the experience gained in Frankfurt am Main with the existing reporting system. Blood or cerebrospinal fluid cultures positive for MRSA were reported from all Frankfurt clinics between 2010 and 2013. The objective of preventing nosocomial infections by introducing a mandatory reporting for MRSA in blood cultures was only partially achieved by the reporting procedure on a population scale. Instead, reporting on a clinic-based scale, i.e., incidence per 1,000 patient days should be used. Moreover, mandatory reporting of clusters of nosocomial colonizations with MRSA could be an appropriate measure for the timely prevention of nosocomial infections with these organisms. CROs were reported from nearly all clinics as well as the ambulatory setting. Different reporting criteria have resulted not only in a greatly varying workload for the institutions and the health authorities but also in vastly different numbers of reported events. Regarding the importance of CRO, mandatory reporting seems reasonable. Criteria of reporting should be simple and easily comprehensible, i.e., all 4MRGN (gram-negative bacteria with resistance against four antibiotic groups such as acylureidopenicillins, third- and fourth-generation cephalosporins, fluorchinolones, and carbapenems) according to the German Commission on Hospital Hygiene and Infection Prevention (KRINKO) should be considered. Reporting and evaluation of multidrug-resistant organisms (MDRO) in a population-based system does not seem to be sufficient regarding these organisms with high importance for hospital hygiene; mandatory reporting on an anonymous clinic-based scale should be used.

Embedding learning from adverse incidents: a UK case study.

PubMed

Eshareturi, Cyril; Serrant, Laura

2017-04-18

Purpose This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. The purpose of this paper is to review the incident investigation methodology used in identifying strengths or weaknesses and explore the use of a database as a tool to embed learning. Design/methodology/approach Documentary examination was conducted of all adverse incidents reported between 1 June 2011 and 30 June 2012 by three UK National Health Service hospitals. One root cause analysis report per adverse incident for each individual hospital was sent to an advisory group for a review. Using terms of reference supplied, the advisory group feedback was analysed using an inductive thematic approach. The emergent themes led to the generation of questions which informed seven in-depth semi-structured interviews. Findings "Time" and "work pressures" were identified as barriers to using adverse incident investigations as tools for quality enhancement. Methodologically, a weakness in approach was that no criteria influenced the techniques which were used in investigating adverse incidents. Regarding the sharing of learning, the use of a database as a tool to embed learning across the region was not supported. Practical implications Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum. Originality/value The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.

Ground Taxi Navigation Problems and Training Solutions

NASA Technical Reports Server (NTRS)

Quinn, Cheryl; Walter, Kim E.; Rosekind, Mark (Technical Monitor)

1997-01-01

Adverse weather conditions can put considerable strain on the National Airspace System. Even small decreases in visibility on the airport surface can create delays, hinder safe movement and lead to errors. Studies of Aviation Safety Reporting System (ASRS) surface movement incidents support the need for technologies and procedures to improve ground operations in low-visibility conditions. This study examined 139 ASRS reports of low-visibility surface movement incidents at 10 major U.S. airports. Errors were characterized in terms of incident type, contributing factors and consequences. The incidents in the present sample were comprised of runway transgressions, taxiway excursions and ground conflicts. The primary contributing factors were Airport Layout and Markings, Communication and Distraction. In half the incidents the controller issued a new clearance or the flight crew took an evasive action and in the remaining half, no recovery attempt was made because the error was detected after the fact. By gaining a better understanding the factors that affect crew navigation in low visibility and the types of errors that are likely to occur, it will be possible to develop more robust technologies to aid pilots in the ground taxi task. Implications for crew training and procedure development for low-visibility ground taxi are also discussed.

Adverse drug events and the Freedom of Information Act: an apple in Eden.

PubMed

Stang, P E; Fox, J L

1992-02-01

To review some of the abuses and proper uses of the Food and Drug Administration's (FDA's) spontaneous adverse-reaction reporting system, as a way of educating the reader to its strengths and limitations. Published literature and reports based on information obtained from the FDA's database of spontaneous adverse drug-event reports. The Freedom of Information Act has increased public access to the FDA's database of spontaneous adverse drug reaction reports. As these reports are voluntarily received and reported to the FDA, their use for comparisons of drug safety is severely limited. Despite these limitations and the FDA's caveats for use of these data, consumer advocacy groups, researchers, and various pharmaceutical marketing groups have used this source to project the incidence of adverse drug reactions. The FDA's spontaneous adverse-event reporting system is designed to generate signals of unexpected adverse drug events. Use of the data gathered by this system to make drug safety comparisons is beyond their credible scope because many factors influence the reporting of adverse events. Researchers and peer reviewers should place these data in the proper perspective and support sound research into questions of drug safety.

Association between Landscape Factors and Spatial Patterns of Plasmodium knowlesi Infections in Sabah, Malaysia

PubMed Central

Abidin, Tommy Rowel; Alexander, Neal; Brock, Paddy; Grigg, Matthew J.; Murphy, Amanda; William, Timothy; Menon, Jayaram; Drakeley, Chris J.; Cox, Jonathan

2016-01-01

The zoonotic malaria species Plasmodium knowlesi has become the main cause of human malaria in Malaysian Borneo. Deforestation and associated environmental and population changes have been hypothesized as main drivers of this apparent emergence. We gathered village-level data for P. knowlesi incidence for the districts of Kudat and Kota Marudu in Sabah state, Malaysia, for 2008–2012. We adjusted malaria records from routine reporting systems to reflect the diagnostic uncertainty of microscopy for P. knowlesi. We also developed negative binomial spatial autoregressive models to assess potential associations between P. knowlesi incidence and environmental variables derived from satellite-based remote-sensing data. Marked spatial heterogeneity in P. knowlesi incidence was observed, and village-level numbers of P. knowlesi cases were positively associated with forest cover and historical forest loss in surrounding areas. These results suggest the likelihood that deforestation and associated environmental changes are key drivers in P. knowlesi transmission in these areas. PMID:26812373

Using Natural Language Processing to Improve Efficiency of Manual Chart Abstraction in Research: The Case of Breast Cancer Recurrence

PubMed Central

Carrell, David S.; Halgrim, Scott; Tran, Diem-Thy; Buist, Diana S. M.; Chubak, Jessica; Chapman, Wendy W.; Savova, Guergana

2014-01-01

The increasing availability of electronic health records (EHRs) creates opportunities for automated extraction of information from clinical text. We hypothesized that natural language processing (NLP) could substantially reduce the burden of manual abstraction in studies examining outcomes, like cancer recurrence, that are documented in unstructured clinical text, such as progress notes, radiology reports, and pathology reports. We developed an NLP-based system using open-source software to process electronic clinical notes from 1995 to 2012 for women with early-stage incident breast cancers to identify whether and when recurrences were diagnosed. We developed and evaluated the system using clinical notes from 1,472 patients receiving EHR-documented care in an integrated health care system in the Pacific Northwest. A separate study provided the patient-level reference standard for recurrence status and date. The NLP-based system correctly identified 92% of recurrences and estimated diagnosis dates within 30 days for 88% of these. Specificity was 96%. The NLP-based system overlooked 5 of 65 recurrences, 4 because electronic documents were unavailable. The NLP-based system identified 5 other recurrences incorrectly classified as nonrecurrent in the reference standard. If used in similar cohorts, NLP could reduce by 90% the number of EHR charts abstracted to identify confirmed breast cancer recurrence cases at a rate comparable to traditional abstraction. PMID:24488511

Incidence of rheumatoid arthritis in Sweden: a nationwide population-based assessment of incidence, its determinants, and treatment penetration.

PubMed

Eriksson, Jonas K; Neovius, Martin; Ernestam, Sofia; Lindblad, Staffan; Simard, Julia F; Askling, Johan

2013-06-01

To estimate the nationwide incidence of rheumatoid arthritis (RA) in Sweden, including its variation across age, sex, geography, and demography, and to describe the sensitivity of register-based incidence estimates to different RA case definitions. Incident RA patients were identified using the Swedish National Patient Register. In the base case, incident RA was defined as first-ever inpatient or nonprimary outpatient care visit listing an RA diagnosis in 2006-2008, with a second visit listing RA within 1 year. Patients prescribed disease-modifying antirheumatic drugs more than 6 months prior to the first visit listing RA were not regarded as incident. The robustness of this definition was evaluated by more liberal and strict criteria, and by penetration of antirheumatic treatment. Between 2006 and 2008, 8,826 individuals were identified as incident RA patients. The overall incidence was 41 per 100,000 (56 for women, 25 for men). The incidence increased with age and peaked in the 70-79 years age group for both women and men. The age- and sex-standardized incidences were lower in densely populated areas and in individuals with high educational level. No geographic trends were noted. More liberal and strict definitions of RA only altered the observed incidence by approximately 14%. The overall nationwide register-based incidence of RA was robust across different case definitions. In a country with universal access to care, RA displayed demographic and socioeconomic, but no geographic, variations in incidence, and peaks at an older age than most commonly reported, with no difference in peak age at RA onset between sexes. Copyright © 2013 by the American College of Rheumatology.

Comparing population and incident data for optimal air ambulance base locations in Norway.

PubMed

Røislien, Jo; van den Berg, Pieter L; Lindner, Thomas; Zakariassen, Erik; Uleberg, Oddvar; Aardal, Karen; van Essen, J Theresia

2018-05-24

Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data. We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5-95 percentile) of 4675 (940-36,264) inhabitants and 10 (2-38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure. The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was -0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts. Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data.

Development of the Parkland-UT Southwestern Colonoscopy Reporting System (CoRS) for evidence-based colon cancer surveillance recommendations

PubMed Central

Gupta, Samir; Halm, Ethan A; Wright, Shaun; McCallister, Katharine; Bishop, Wendy; Santini, Noel; Mayorga, Christian; Agrawal, Deepak; Moran, Brett; Sanders, Joanne M; Singal, Amit G

2016-01-01

Objective Through colonoscopy, polyps can be identified and removed to reduce colorectal cancer incidence and mortality. Appropriate use of surveillance colonoscopy, post polypectomy, is a focus of healthcare reform. Materials and Methods The authors developed and implemented the first electronic medical record–based colonoscopy reporting system (CoRS) that matches endoscopic findings with guideline-consistent surveillance recommendations and generates tailored results and recommendation letters for patients and providers. Results In its first year, CoRS was used in 98.6% of indicated cases. Via a survey, colonoscopists agreed/strongly agreed it is easy to use (83%), provides guideline-based recommendations (89%), improves quality of Spanish letters (94%), they would recommend it for other institutions (78%), and it made their work easier (61%), and led to improved practice (56%). Discussion CoRS’ widespread adoption and acceptance likely resulted from stakeholder engagement throughout the development and implementation process. Conclusion CoRS is well-accepted by clinicians and provides guideline-based recommendations and results communications to patients and providers. PMID:26254481

Integrating an incident management system within a continuity of operations programme: case study of the Bank of Canada.

PubMed

Loop, Carole

2013-01-01

Carrying out critical business functions without interruption requires a resilient and robust business continuity framework. By embedding an industry-standard incident management system within its business continuity structure, the Bank of Canada strengthened its response plan by enabling timely response to incidents while maintaining a strong focus on business continuity. A total programme approach, integrating the two disciplines, provided for enhanced recovery capabilities. While the value of an effective and efficient response organisation is clear, as demonstrated by emergency events around the world, incident response structures based on normal operating hierarchy can experience unique challenges. The internationally-recognised Incident Command System (ICS) model addresses these issues and reflects the five primary incident management functions, each contributing to the overall strength and effectiveness of the response organisation. The paper focuses on the Bank of Canada's successful implementation of the ICS model as its incident management and continuity of operations programmes evolved to reflect current best practices.

Incidence of rubella in a state in North-western Nigeria: a call for action.

PubMed

Omoleke, Semeeh Akinwale; Udenenwu, Henry Chukwuebuka

2016-01-01

Rubella cases are often under-reported, especially in many developing countries, owing to inadequate attention and weak funding of elimination strategies, despite being an epidemic-prone disease. Based on available data, this paper, therefore, seeks to bring the attention of public health practitioners, researchers and policy makers to threats of rubella in our environment, and also recommend measures to mitigate the threats. The authors conducted a retrospective cross-sectional study in which the laboratory results of febrile-rash-illness cases in Kebbi State, Northwest Nigeria, from January 1, 2014 to December 31, 2015 were analysed, using descriptive statistics and chi-square test. We obtained the data set through the routine Integrated Disease Surveillance System and Response being conducted in Nigeria. A total of 413 febrile-rash-illness cases were reported and investigated in Kebbi State from 2014 to 2015, 5 (3.5%) tested positive for rubella IgM in 2014 while 7(2.6%) tested positive in 2015. There was no statistically significant difference in the incidence of rubella between 2014 and 2015 (p> 0.05). Rubella infection was mainly found in children less than 5 years of age with peak incidence period during the hot season (between February and April). There was no significant sex bias in this study. However, our practice experiences in this environment suggest a systematic under-reporting and under-diagnosis of febrile- rash-illnesses. There was no statistically significant difference in the incidence of rubella in children in our setting for the 2-years studied. However, there is a potential for increase in the transmission of the disease due to non-availability of routine childhood vaccination against rubella and the systematic under-reporting of suspected cases and weak laboratory support. In order to better appreciate the burden of rubella infection, there may be a need to undertake a prevalence survey, and simultaneously, strengthening case-based surveillance in Northwestern Nigeria. Further, WHO should support national government in accelerating the introduction of rubella-containing vaccine to stem the potential spread of this infectious disease.

Incidence of rubella in a state in North-western Nigeria: a call for action

PubMed Central

Omoleke, Semeeh Akinwale; Udenenwu, Henry Chukwuebuka

2016-01-01

Introduction Rubella cases are often under-reported, especially in many developing countries, owing to inadequate attention and weak funding of elimination strategies, despite being an epidemic-prone disease. Based on available data, this paper, therefore, seeks to bring the attention of public health practitioners, researchers and policy makers to threats of rubella in our environment, and also recommend measures to mitigate the threats. Methods The authors conducted a retrospective cross-sectional study in which the laboratory results of febrile-rash-illness cases in Kebbi State, Northwest Nigeria, from January 1, 2014 to December 31, 2015 were analysed, using descriptive statistics and chi-square test. We obtained the data set through the routine Integrated Disease Surveillance System and Response being conducted in Nigeria. Results A total of 413 febrile-rash-illness cases were reported and investigated in Kebbi State from 2014 to 2015, 5 (3.5%) tested positive for rubella IgM in 2014 while 7(2.6%) tested positive in 2015. There was no statistically significant difference in the incidence of rubella between 2014 and 2015 (p> 0.05). Rubella infection was mainly found in children less than 5 years of age with peak incidence period during the hot season (between February and April). There was no significant sex bias in this study. However, our practice experiences in this environment suggest a systematic under-reporting and under-diagnosis of febrile- rash-illnesses. Conclusion There was no statistically significant difference in the incidence of rubella in children in our setting for the 2-years studied. However, there is a potential for increase in the transmission of the disease due to non-availability of routine childhood vaccination against rubella and the systematic under-reporting of suspected cases and weak laboratory support. In order to better appreciate the burden of rubella infection, there may be a need to undertake a prevalence survey, and simultaneously, strengthening case-based surveillance in Northwestern Nigeria. Further, WHO should support national government in accelerating the introduction of rubella-containing vaccine to stem the potential spread of this infectious disease. PMID:28250873

Retrospective review of adverse incidents involving passengers seated in wheeled mobility devices while traveling in large accessible transit vehicles.

PubMed

Frost, Karen L; Bertocci, Gina

2010-04-01

Characterize wheeled mobility device (WhMD) adverse incidents on large accessible transit vehicles (LATVs) based on vehicle motion, WhMD activity during incident, incident scenario and injury. Retrospective records review. WhMD passengers traveling on LATVs while remaining seated in their. Adverse incidents characterized based on vehicle motion, WhMD activity during incident, and incident scenario. Injury characterized based on outcome, medical attention sought, vehicle activity, WhMD activity and incident scenario. 115 WhMD-related incident reports for years 2000-2005 were analyzed. Most incidents occurred when the LATV was stopped (73.9%), during ingress/egress (42.6%), and at the securement station (33.9%) when the LATV was moving. The combination of WhMD tipping and passenger falling (43.4%) occurred most frequently, and was 1.8 times more likely to occur during ingress/egress than at the securement station. One-third (33.6%) of all incidents resulted in injury, and injuries were equally distributed between ingress/egress (43.6%) and at the securement station (43.6%). WhMD users have a greater chance of incurring injury during ingress/egress than during transit. Research is needed to objectively assess real world transportation experiences of WhMD passengers, and to assess the adequacy of existing federal legislation/guidelines for accessible ramps used in public transportation. Copyright 2009 IPEM. Published by Elsevier Ltd. All rights reserved.

Advanced myopia, prevalence and incidence analysis.

PubMed

Greene, Peter R; Greene, Judith M

2018-04-01

Various high-percentage high-incidence medical conditions, acute or chronic, start at a particular age of onset t1 (years), accumulate or progress rapidly, with a system time constant t0 (years), typically from 1 week to 5 years, and then level off at a plateau level [Formula: see text], ultimately affecting 10-95% of the population. This report investigates the prevalence and incidence functions for myopia and high myopia as a function of age. Fundamental prevalence versus time and incidence versus time results allow continuous prediction of myopia and high myopia population fractions as a function of age. This is a retrospective study. Nine reports are calculated with N = 444,600 subjects. There were no interventions other than usual regular eye examinations and subsequent indicated refraction change. The main result is continuous prediction of myopia prevalence-time data along with incidence rate data (%/year), age of onset (years), system plateau level, and system time constant (years). These parameters apply to progressive myopia and high myopia (R < -6 D), useful over several decades. The primary finding of this research is that the prevalence ratio of high myopes (R < -6.0 D) to common myopes is expected to increase from 15% entering college to 45% or more after college and graduate school. These statistics are particularly relevant to the many years of study required by M.D., Ph.D., and M.D./Ph.D. programs.

Prevalence and Incidence of Hypoglycaemia in 532,542 People with Type 2 Diabetes on Oral Therapies and Insulin: A Systematic Review and Meta-Analysis of Population Based Studies

PubMed Central

Edridge, Chloe L.; Dunkley, Alison J.; Bodicoat, Danielle H.; Rose, Tanith C.; Gray, Laura J.; Davies, Melanie J.; Khunti, Kamlesh

2015-01-01

Objective To collate and evaluate the current literature reporting the prevalence and incidence of hypoglycaemia in population based studies of type 2 diabetes. Research Design and Methods Medline, Embase and Cochrane were searched up to February 2014 to identify population based studies reporting the proportion of people with type 2 diabetes experiencing hypoglycaemia or rate of events experienced. Two reviewers independently screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were carried out to calculate the prevalence and incidence of hypoglycaemia. Results 46 studies (n = 532,542) met the inclusion criteria. Prevalence of hypoglycaemia was 45% (95%CI 0.34,0.57) for mild/moderate and 6% (95%CI, 0.05,0.07) for severe. Incidence of hypoglycaemic episodes per person-year for mild/moderate and for severe was 19 (95%CI 0.00, 51.08) and 0.80 (95%CI 0.00,2.15), respectively. Hypoglycaemia was prevalent amongst those on insulin; for mild/moderate episodes the prevalence was 50% and incidence 23 events per person-year, and for severe episodes the prevalence was 21% and incidence 1 event per person-year. For treatment regimes that included a sulphonylurea, mild/moderate prevalence was 30% and incidence 2 events per person-year, and severe prevalence was 5% and incidence 0.01 events per person-year. A similar prevalence of 5% was found for treatment regimes that did not include sulphonylureas. Conclusions Current evidence shows hypoglycaemia is considerably prevalent amongst people with type 2 diabetes, particularly for those on insulin, yet still fairly common for other treatment regimens. This highlights the subsequent need for educational interventions and individualisation of therapies to reduce the risk of hypoglycaemia. PMID:26061690

[Assessing incident cardiovascular and metabolic diseases in epidemiological cohort studies in Germany].

PubMed

Herrmann, Wolfram J; Weikert, Cornelia; Bergmann, Manuela; Boeing, Heiner; Katzke, Verena A; Kaaks, Rudolf; Tiller, Daniel; Greiser, Karin Halina; Heier, Margit; Meisinger, Christa; Schmidt, Carsten Oliver; Neuhauser, Hannelore; Heidemann, Christin; Jünger, Claus; Wild, Philipp S; Schramm, Sara Helena; Jöckel, Karl-Heinz; Dörr, Marcus; Pischon, Tobias

2018-04-01

Cardiovascular and metabolic diseases are a major cause of mortality and loss of quality of life in Germany. Research into risk factors of these diseases requires large population-based cohort studies. Complete and accurate assessment of the incidence of cardiovascular and metabolic diseases is a key element for valid interpretation of the results from such studies. Our aim was to identify population-based cohort studies with incidence of cardiovascular and metabolic diseases in Germany and to summarize their methods for assessment and classification of disease endpoints, including myocardial infarction, type 2 diabetes, stroke, heart failure, and arterial hypertension. Within the framework of a workshop, representatives of the ascertained population-based cohort studies in Germany with incidence of cardiovascular or metabolic diseases were invited to present and to systematically provide information on their methods of endpoint identification. We identified eight studies from different regions in Germany with a total of 100,571 participants, aged 18-83 years at baseline. Self-reporting by study participants is the major source for further inquiries to assess disease endpoints in these studies. Most studies use additional data sources to verify the incidence of diseases, such as documents provided by the treating physician or hospital. Our results highlight the central role of self-reporting and the efforts associated with identification and verification of disease endpoints in cohort studies. They also provide a basis for future population-based studies that aim for standardized assessment of the incidence of cardiovascular and metabolic diseases.

Systematic review of the incidence and prevalence of genital warts

PubMed Central

2013-01-01

Background Anogenital warts (AGWs) are a common, highly infectious disease caused by the human papillomavirus (HPV), whose high recurrence rates contribute to direct medical costs, productivity loss and increased psychosocial impact. Because of the lack of a systematic review of the epidemiology of AGWs in the literature, this study reviewed the published medical literature on the incidence and prevalence of AGWs. Methods A comprehensive literature search was performed on the worldwide incidence and prevalence of AGWs between 2001 and 2012 using the PubMed and EMBASE databases. An additional screening of abstracts from relevant sexual health and infectious disease conferences from 2009 to 2011 was also conducted. Only original studies with general adult populations (i.e., at least including ages 20 through 40 years) were included. Results The overall (females and males combined) reported annual incidence of any AGWs (including new and recurrent) ranged from 160 to 289 per 100,000, with a median of 194.5 per 100,000. New AGW incidence rates among males ranged from 103 to 168 per 100,000, with a median of 137 per 100,000 and among females from 76 to 191 per 100,000, with a median of 120.5 per 100,000 per annum. The reported incidence of recurrent AGWs was as high as 110 per 100,000 among females and 163 per 100,000 among males. Incidence peaked before 24 years of age in females and between 25 and 29 years of age among males. The overall prevalence of AGWs based on retrospective administrative databases or medical chart reviews or prospectively collected physician reports ranged from 0.13% to 0.56%, whereas it ranged from 0.2% to 5.1% based on genital examinations. Conclusions The literature suggests that AGWs are widespread and the prevalence depends on study methodology as suggested by higher rates reported from routine genital examinations versus those from treatment records. However, there remains a need for more population-based studies from certain regions including Africa, Latin America and Southern Asia to further elucidate the global epidemiology of this disease. PMID:23347441

Better Incident Response with SCOT

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bruner, Todd

2015-04-01

SCOT is an incident response management system and knowledge base designed for incident responders by incident responders. SCOT increases the effectiveness of the team without adding undue burdens. Focused on reducing the friction between analysts and their tools, SCOT enables analysts to document and share their research and response efforts in near real time. Automatically identifying indicators and correlating those indicators, SCOT helps analysts discover and respond to advanced threats.

Age/race differences in HER2 testing and in incidence rates for breast cancer triple subtypes: a population-based study and first report.

PubMed

Lund, Mary Jo; Butler, Ebonee N; Hair, Brionna Y; Ward, Kevin C; Andrews, Judy H; Oprea-Ilies, Gabriella; Bayakly, A Rana; O'Regan, Ruth M; Vertino, Paula M; Eley, J William

2010-06-01

Although US year 2000 guidelines recommended characterizing breast cancers by human epidermal growth factor receptor 2 (HER2), national cancer registries do not collect HER2, rendering a population-based understanding of HER2 and clinical "triple subtypes" (estrogen receptor [ER] / progesterone receptor [PR] / HER2) largely unknown. We document the population-based prevalence of HER2 testing / status, triple subtypes and present the first report of subtype incidence rates. Medical records were searched for HER2 on 1842 metropolitan Atlanta females diagnosed with breast cancer during 2003-2004. HER2 testing/status and triple subtypes were analyzed by age, race/ethnicity, tumor factors, socioeconomic status, and treatment. Age-adjusted incidence rates were calculated. Over 90% of cases received HER2 testing: 12.6% were positive, 71.7% negative, and 15.7% unknown. HER2 testing compliance was significantly better for women who were younger, of Caucasian or African-American descent, or diagnosed with early stage disease. Incidence rates (per 100,000) were 21.1 for HER2+ tumors and 27.8 for triple-negative tumors, the latter differing by race (36.3 and 19.4 for black and white women, respectively). HER2 recommendations are not uniformly adhered to. Incidence rates for breast cancer triple subtypes differ by age/race. As biologic knowledge is translated into the clinical setting eg, HER2 as a biomarker, it will be incumbent upon national cancer registries to report this information. Incidence rates cautiously extrapolate to an annual burden of 3000 and 17,000 HER2+ tumors for black and white women, respectively, and triple-negative tumors among 5000 and 16,000 respectively. Testing, rate, and burden variations warrant population-based in-depth exploration and clinical translation. (c) 2010 American Cancer Society.

Outcomes of a pilot hand hygiene randomized cluster trial to reduce communicable infections among US office-based employees.

PubMed

Stedman-Smith, Maggie; DuBois, Cathy L Z; Grey, Scott F; Kingsbury, Diana M; Shakya, Sunita; Scofield, Jennifer; Slenkovich, Ken

2015-04-01

To determine the effectiveness of an office-based multimodal hand hygiene improvement intervention in reducing self-reported communicable infections and work-related absence. A randomized cluster trial including an electronic training video, hand sanitizer, and educational posters (n = 131, intervention; n = 193, control). Primary outcomes include (1) self-reported acute respiratory infections (ARIs)/influenza-like illness (ILI) and/or gastrointestinal (GI) infections during the prior 30 days; and (2) related lost work days. Incidence rate ratios calculated using generalized linear mixed models with a Poisson distribution, adjusted for confounders and random cluster effects. A 31% relative reduction in self-reported combined ARI-ILI/GI infections (incidence rate ratio: 0.69; 95% confidence interval, 0.49 to 0.98). A 21% nonsignificant relative reduction in lost work days. An office-based multimodal hand hygiene improvement intervention demonstrated a substantive reduction in self-reported combined ARI-ILI/GI infections.

Rating the Relevance of QUORUM-Selected ASRS Incident Narratives to a "Controlled Flight into Terrain" Accident

NASA Technical Reports Server (NTRS)

McGreevy, Michael W.; Statler, Irving C.

1998-01-01

An exploratory study was conducted to identify commercial aviation incidents that are relevant to a "controlled flight into terrain" (CFIT) accident using a NASA-developed text processing method. The QUORUM method was used to rate 67820 incident narratives, virtually all of the narratives in the Aviation Safety Reporting System (ASRS) database, according to their relevance to two official reports on the crash of American Airlines Flight 965 near Cali, Colombia in December 1995. For comparison with QUORUM's ratings, three experienced ASRS analysts read the reports of the crash and independently rated the relevance of the 100 narratives that were most highly rated by QUORUM, as well as 100 narratives randomly selected from the database. Eighty-four of 100 QUORUM-selected narratives were rated as relevant to the Cali accident by one or more of the analysts. The relevant incidents involved a variety of factors, including, over-reliance on automation, confusion and changes during descent/approach, terrain avoidance, and operations in foreign airspace. In addition, the QUORUM collection of incidents was found to be significantly more relevant than the random collection.

The Rising Incidence of Intentional Ingestion of Ethanol-Containing Hand Sanitizers

PubMed Central

Gormley, Nicole J.; Bronstein, Alvin C.; Rasimas, Joseph J.; Pao, Maryland; T.Wratney, Angela; Sun, Junfeng; Austin, Howard A.; Suffredini, Anthony F.

2012-01-01

Objective To describe a case of intentional ingestion of hand sanitizer in our hospital and to review published cases and those reported to the American Association of Poison Control Centers’ National Poison Data System (NPDS). Design A case report, a literature review of published cases, and a query of the National Poison Data System (NPDS). Measurements Incidence and outcome of reported cases of unintentional and intentional ethanol containing-hand sanitizer ingestion in the United States from 2005 through 2009. Main Results A literature search found 14 detailed case-reports of intentional alcohol-based hand sanitizer ingestions with one death. From 2005 to 2009, NPDS received reports of 68,712 exposures to 96 ethanol-based hand sanitizers. The number of new cases increased by an average of 1894 (95% CI: 1266, 2521) cases per year (p = 0.002). In 2005, the rate of exposures, per year, per million U.S residents was 33.7 (95% CI: 28.4, 39.1); from 2005 to 2009, this rate increased on average by 5.87 per year (95%CI: 3.70, 8.04; p=0.003). In 2005, the rate of intentional exposures, per year, per million U.S residents, was 0.68 (95%CI: 0.17-1.20); from 2005 to 2009, this rate increased on average by 0.32 per year (95%CI: 0.11,0.53; p=0.02). Conclusions The number of new cases per year of intentional hand sanitizer ingestion significantly increased during this five - year period. While the majority of cases of hand sanitizer ingestion have a favorable outcome, 288 moderate and 12 major medical complications were reported in this NPDS cohort. Increased awareness of the risks associated with intentional ingestion is warranted, particularly among healthcare providers caring for persons with a history of substance abuse, risk-taking behavior or suicidal ideation. PMID:21926580

Using interrupted time series design to analyze changes in hand, foot, and mouth disease incidence during the declining incidence periods of 2008-2010 in China.

PubMed

Yu, Shi Cheng; Hao, Yuan Tao; Zhang, Jing; Xiao, Ge Xin; Liu, Zhuang; Zhu, Qi; Ma, Jia Qi; Wang, Yu

2012-12-01

To identify patterns of hand, foot and mouth disease (HFMD) incidence in China during declining incidence periods of 2008, 2009, and 2010. Reported HFMD cases over a period of 25 months were extracted from the National Disease Reporting System (NDRS) and analyzed. An interrupted time series (ITS) technique was used to detect changes in HFMD incidence rates in terms of level and slope between declining incidence periods of the three years. Over 3.58 million HFMD cases younger than 5 years were reported to the NDRS between May 1, 2008, and May 31, 2011. Males comprised 63.4% of the cases. ITS analyses demonstrated a significant increase in incidence rate level (P<0.0001) when comparing the current period with the previous period. There were significant changes in declining slopes when comparing 2010 to 2009, and 2010 to 2008 (all P<0.005), but not 2009 to 2008. Incremental changes in incidence rate level during the declining incidence periods of 2009 and 2010 can potentially be attributed to a few factors. The more steeply declining slope in 2010 compared with previous years could be ascribed to the implementation of more effective interventions and preventive strategies in 2010. Further investigation is required to examine this possibility. Copyright © 2012 The Editorial Board of Biomedical and Environmental Sciences. Published by Elsevier B.V. All rights reserved.

Epidemiology of Cholera in the Philippines

PubMed Central

Lopez, Anna Lena; Macasaet, Lino Y.; Ylade, Michelle; Tayag, Enrique A.; Ali, Mohammad

2015-01-01

Background Despite being a cholera-endemic country, data on cholera in the Philippines remain sparse. Knowing the areas where cholera is known to occur and the factors that lead to its occurrence will assist in planning preventive measures and disaster mitigation. Methods Using sentinel surveillance data, PubMed and ProMED searches covering information from 2008–2013 and event-based surveillance reports from 2010–2013, we assessed the epidemiology of cholera in the Philippines. Using spatial log regression, we assessed the role of water, sanitation and population density on the incidence of cholera. Results and Discussion We identified 12 articles from ProMED and none from PubMed that reported on cholera in the Philippines from 2008 to 2013. Data from ProMed and surveillance revealed 42,071 suspected and confirmed cholera cases reported from 2008 to 2013, among which only 5,006 were confirmed. 38 (47%) of 81 provinces and metropolitan regions reported at least one confirmed case of cholera and 32 (40%) reported at least one suspected case. The overall case fatality ratio in sentinel sites was 0.62%, but was 2% in outbreaks. All age groups were affected. Using both confirmed and suspected cholera cases, the average annual incidence in 2010–2013 was 9.1 per 100,000 population. Poor access to improved sanitation was consistently associated with higher cholera incidence. Paradoxically, access to improved water sources was associated with higher cholera incidence using both suspected and confirmed cholera data sources. This finding may have been due to the breakdown in the infrastructure and non-chlorination of water supplies, emphasizing the need to maintain public water systems. Conclusion Our findings confirm that cholera affects a large proportion of the provinces in the country. Identifying areas most at risk for cholera will support the development and implementation of policies to minimize the morbidity and mortality due to this disease. PMID:25569505

Joint Improved Explosive Device Defeat Organization. Annual Report FY 2009

DTIC Science & Technology

2009-01-01

incident, IEDs were 14 percent more effective in FY 2009 over FY 2008. Coupled with the significant corresponding increase in IED incidents, this...Testing and Evaluation (RDT&E), procurement, and sustainment of 69 systems. Detect Air Detect Air systems enable the warfighter to detect insurgent...oriented centers of excellence (COE): the Army COE at Fort Irwin; the Navy COE at Indian Head, Maryland; the Air Force COE at Lackland Air Force

An investigation of reports of Controlled Flight Toward Terrain (CFTT)

NASA Technical Reports Server (NTRS)

Porter, R. F.; Loomis, J. P.

1981-01-01

Some 258 reports from more than 23,000 documents in the files of the Aviation Safety Reporting System (ASRS) were found to be to the hazard of flight into terrain with no prior awareness by the crew of impending disaster. Examination of the reports indicate that human error was a casual factor in 64% of the incidents in which some threat of terrain conflict was experienced. Approximately two-thirds of the human errors were attributed to controllers, the most common discrepancy being a radar vector below the Minimum Vector Altitude (MVA). Errors by pilots were of a much diverse nature and include a few instances of gross deviations from their assigned altitudes. The ground proximity warning system and the minimum safe altitude warning equipment were the initial recovery factor in some 18 serious incidents and were apparently the sole warning in six reported instances which otherwise would most probably have ended in disaster.

Health effects of Halon 1301 exposure

DOE Office of Scientific and Technical Information (OSTI.GOV)

Holness, D.L.; House, R.A.

1992-07-01

An accidental discharge of a Halon 1301 system is reported. Thirty-one workers were assessed, 22 who were present at the time of the discharge, and 9 who worked the next shift. The incident was complicated by a small Freon-22 leak several hours later. Throat, eye, and nasal irritation and lightheadedness were reported by the majority of workers. Workers present during the halon discharge reported significantly more lightheadedness, headache, voice change, cough, and a fast heartbeat than did those who worked the later shift. These differences were significant even after correcting for confounding factors such as age, sex, and sense ofmore » anxiety at the time of the incident. The possible causes for the irritant symptoms include breakdown products of Halon 1301 and Freon-22 or contaminants from the halon discharge system. Although these irritant effects may not be an effect of Halon 1301 alone, they may occur in these discharge situations, and workers should be advised of this possibility. The possible cardiac and central nervous system effects also should be considered. The importance of a clear-cut protocol to deal with such incidents as well as worker education are discussed.« less

ILD-NSCLC-GAP index scoring and staging system for patients with non-small cell lung cancer and interstitial lung disease.

PubMed

Kobayashi, Haruki; Naito, Tateaki; Omae, Katsuhiro; Omori, Shota; Nakashima, Kazuhisa; Wakuda, Kazushige; Ono, Akira; Kenmotsu, Hirotsugu; Murakami, Haruyasu; Endo, Masahiro; Takahashi, Toshiaki

2018-07-01

Patients with advanced non-small cell lung cancer (NSCLC) and interstitial lung disease (ILD) are commonly excluded from most clinical trials because of acute exacerbation (AE) of ILD triggered by chemotherapy. Data on the efficacy and feasibility of chemotherapy are limited in this patient population. Recently, the ILD-GAP index and staging system was reported as a clinical prognostic factor associated with mortality in patients with ILD. Therefore, we evaluated the incidence of ILD-AE during the surveillance term in this study and the prognosis in patients with NSCLC and ILD using a modified ILD-GAP (ILD-NSCLC-GAP) index scoring system. The medical records of patients with NSCLC and ILD who underwent a pulmonary function test before initiation of platinum-based chemotherapy as first-line treatment at the Shizuoka Cancer Center between September 2002 and December 2014 were reviewed retrospectively. Among these patients, we compared the incidence of ILD-AE, one-year survival rate, and overall survival (OS) between the ILD-NSCLC-GAP index scores and stages. Of the 78 patients included, 21 (27%; 95% confidence interval [CI], 18%-38%) had ILD-AE during the surveillance term in this study. The one-year survival and median OS rates were 49% and 11.3 months, respectively. The incidence of ILD-AE increased gradually and the one-year survival and median OS rates decreased gradually with increasing ILD-NSCLC-GAP index scores and stages. The ILD-NSCLC-GAP index scoring and staging system may be a useful tool to calculate a prediction of the incidence of ILD-AE and its prognosis for patients with NSCLC and ILD. Copyright © 2018 Elsevier B.V. All rights reserved.

[Hierarchical regionalization for spatial epidemiology: a case study of thyroid cancer incidence in Yiwu, Zhejiang].

PubMed

Teng, Shizhu; Jia, Qiaojuan; Huang, Yijian; Chen, Liangcao; Fei, Xufeng; Wu, Jiaping

2015-10-01

Sporadic cases occurring in mall geographic unit could lead to extreme value of incidence due to the small population bases, which would influence the analysis of actual incidence. This study introduced a method of hierarchy clustering and partitioning regionalization, which integrates areas with small population into larger areas with enough population by using Geographic Information System (GIS) based on the principles of spatial continuity and geographical similarity (homogeneity test). This method was applied in spatial epidemiology by using a data set of thyroid cancer incidence in Yiwu, Zhejiang province, between 2010 and 2013. Thyroid cancer incidence data were more reliable and stable in the new regionalized areas. Hotspot analysis (Getis-Ord) on the incidence in new areas indicated that there was obvious case clustering in the central area of Yiwu. This method can effectively solve the problem of small population base in small geographic units in spatial epidemiological analysis of thyroid cancer incidence and can be used for other diseases and in other areas.

Epidemiology of amyotrophic lateral sclerosis in Minnesota: a year-long population based study.

PubMed

Harper, Caitlin J; Sorenson, Eric J; Mandrekar, Jay

2015-01-01

This is the largest population based study of ALS in the U.S., encompassing the population of Minnesota (> 5.4 million people) from July 2013 to July 2014. Data on gender, age at diagnosis, and residential county were collected for all Minnesota residents who registered with the Minnesota/North Dakota/South Dakota chapter of the ALS Association from July 2013 to July 2014. Incidence rates were calculated as the number of new cases of ALS per 100,000 people per year. The standardized incidence rates for the 2013 U.S. population and the 2013 European standard population were also reported. Results showed that the crude incidence rate of ALS was 2.2 cases per 100,000 person-years. Incidence increased with age, peaking at 70-79 years (8.3 per 100,000) with mean age at diagnosis 64 years, and was greater in males (2.4 per 100,000) than in females (1.5 per 100,000). Standardized incidence rates for the 2013 U.S. and European standard population were 2.2 and 2.39 cases per 100,000 person-years, respectively. In conclusion, the overall incidence and age and gender patterns of ALS in Minnesota are comparable to those reported by European studies ( 1-5 ).

Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.

PubMed

Hoffmann, B; Müller, V; Rochon, J; Gondan, M; Müller, B; Albay, Z; Weppler, K; Leifermann, M; Mießner, C; Güthlin, C; Parker, D; Hofinger, G; Gerlach, F M

2014-01-01

The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations. In this study we assessed the effects of FraTrix on safety culture in general practice. We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12 months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. During the team sessions, practice teams reflected on their safety culture and decided on about 10 actions per practice to improve it. After 12 months, no significant differences were found between intervention and control groups in terms of error management (competing probability=0.48, 95% CI 0.34 to 0.63, p=0.823), 11 further patient safety culture indicators and safety climate scales. Intervention practices showed better reporting of patient safety incidents, reflected in a higher number of incident reports (mean (SD) 4.85 (4.94) vs 3.10 (5.42), p=0.045) and incident reports of higher quality (scoring 2.27 (1.93) vs 1.49 (1.67), p=0.038) than control practices. Applied as a team-based instrument to assess safety culture, FraTrix did not lead to measurable improvements in error management. Comparable studies with more positive results had less robust study designs. In future research, validated combined methods to measure safety culture will be required. In addition, more attention should be paid to evaluation of process parameters. Implemented actions and incident reporting may be more appropriate target endpoints. German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) No. DRKS00000145.

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real‐time record review may all have a place

PubMed Central

Olsen, Sisse; Neale, Graham; Schwab, Kat; Psaila, Beth; Patel, Tejal; Chapman, E Jane; Vincent, Charles

2007-01-01

Background Over the past five years, in most hospitals in England and Wales, incident reporting has become well established but it remains unclear how well reports match clinical adverse events. International epidemiological studies of adverse events are based on retrospective, multi‐hospital case record review. In this paper the authors describe the use of incident reporting, pharmacist surveillance and local real‐time record review for the recognition of clinical risks associated with hospital inpatient care. Methodology Data on adverse events were collected prospectively on 288 patients discharged from adult acute medical and surgical units in an NHS district general hospital using incident reports, active surveillance of prescription charts by pharmacists and record review at time of discharge. Results Record review detected 26 adverse events (AEs) and 40 potential adverse events (PAEs) occurring during the index admission. In contrast, in the same patient group, incident reporting detected 11 PAEs and no AEs. Pharmacy surveillance found 10 medication errors all of which were PAEs. There was little overlap in the nature of events detected by the three methods. Conclusion The findings suggest that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection. Structured record review, carried out by clinicians, provides an important component of an integrated approach to identifying risk in the context of developing a safety and quality improvement programme. PMID:17301203