Sample records for safety-related occurrences reported

  1. Packaging- and transportation-related occurrence reports : FY 1994 annual report

    DOT National Transportation Integrated Search

    1995-03-01

    The Oak Ridge National Laboratory, through its support to the Department of Energys Office of Facility Safety Analysis, EH-32, retrieves reports and information pertaining to transportation and : packaging occurrences from the centralized Occurrence ...

  2. Packaging- and transportation-related occurrence reports : FY 1995 annual report

    DOT National Transportation Integrated Search

    1996-03-01

    The Oak Ridge National Laboratory, through its support to the U.S. Department of Energys (DOEs) Office of Facility Safety Analysis, EH-32, retrieves reports and information pertaining to transportation and packaging occurrences from the centralized O...

  3. UMTRA project list of reportable occurrences

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

    Not Available

    1994-04-01

    This UMTRA Project List of Reportable occurrences is provided to facilitate efficient categorization of reportable occurrences. These guidelines have been established in compliance with DOE minimum reporting requirements under DOE Order 5000.3B. Occurrences are arranged into nine groups relating to US Department of Energy (DOE) Uranium Mill Tailings Remedial Action (UMTRA) Project operations for active sites. These nine groupings are provided for reference to determined whether an occurrence meets reporting requirement criteria in accordance with the minimum reporting requirements. Event groups and significance categories that cannot or will not occur, and that do not apply to UMTRA Project operations, aremore » omitted. Occurrence categorization shall be as follows: Group 1. Facility Condition; Group 2. Environmental; Group 3. Personnel Safety; Group 4. Personnel Radiation Protection; Group 5. Safeguards and Security; Group 6. Transportation; Group 7. Value Basis Reporting; Group 8. Facility Status; and Group 9. Cross-Category Items.« less

  4. 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.

  5. 49 CFR 191.23 - Reporting safety-related conditions.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 3 2011-10-01 2011-10-01 false Reporting safety-related conditions. 191.23... HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED...

  6. Report to Congress on abnormal occurrences, October--December 1994. Volume 17, No. 4

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

    NONE

    Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence (AO) as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of public health or safety and requires a quarterly report of such occurrences to be made to Congress. This report provides a description of those incidents and events that have been determined to be AOs during the period of October 1 through December 31, 1994. This report addresses four AOs at NRC-licensed facilities. These occurrences involved the following: a generic concern relating to core shroud cracking in boilingmore » water reactors; recurring incidents of administering higher doses than procedurally allowed for diagnostic imaging at a single facility; one medical teletherapy misadministration; and one medical brachytherapy misadministration. Agreement States submitted four AO reports. These four occurrences involved the following: one major contamination at a commercial facility; two medical brachytherapy misadministrations; and one medical teletherapy misadministration. The report also contains updates of seven AOs previously reported by NRC licensees and four AOs previously reported by the Agreement States. Two ``Other Events of Interest`` are also being reported. These occurrences involved the operability of safety relief valves at a nuclear power plant, and an error in the installation process of a Leksell Gamma KnifeR teletherapy unit that resulted in an operational failure.« less

  7. 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

  8. Electronic clinical safety reporting system: a benefits evaluation.

    PubMed

    Elliott, Pamela; Martin, Desmond; Neville, Doreen

    2014-06-11

    Eastern Health, a large health care organization in Newfoundland and Labrador (NL), started a staged implementation of an electronic occurrence reporting system (used interchangeably with "clinical safety reporting system") in 2008, completing Phase One in 2009. The electronic clinical safety reporting system (CSRS) was designed to replace a paper-based system. The CSRS involves reporting on occurrences such as falls, safety/security issues, medication errors, treatment and procedural mishaps, medical equipment malfunctions, and close calls. The electronic system was purchased from a vendor in the United Kingdom that had implemented the system in the United Kingdom and other places, such as British Columbia. The main objective of the new system was to improve the reporting process with the goal of improving clinical safety. The project was funded jointly by Eastern Health and Canada Health Infoway. The objectives of the evaluation were to: (1) assess the CSRS on achieving its stated objectives (particularly, the benefits realized and lessons learned), and (2) identify contributions, if any, that can be made to the emerging field of electronic clinical safety reporting. The evaluation involved mixed methods, including extensive stakeholder participation, pre/post comparative study design, and triangulation of data where possible. The data were collected from several sources, such as project documentation, occurrence reporting records, stakeholder workshops, surveys, focus groups, and key informant interviews. The findings provided evidence that frontline staff and managers support the CSRS, identifying both benefits and areas for improvement. Many benefits were realized, such as increases in the number of occurrences reported, in occurrences reported within 48 hours, in occurrences reported by staff other than registered nurses, in close calls reported, and improved timelines for notification. There was also user satisfaction with the tool regarding ease of use

  9. 18 CFR 12.10 - Reporting safety-related incidents.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... report of any death or serious injury considered or alleged to be project related must also describe any... be verified in accordance with § 12.13. (3) Accidents that are not project-related may be reported by... COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS AND...

  10. Applied Use of Safety Event Occurrence Control Charts of Harm and Non-Harm Events: A Case Study.

    PubMed

    Robinson, Susan N; Neyens, David M; Diller, Thomas

    Most hospitals use occurrence reporting systems that facilitate identifying serious events that lead to root cause investigations. Thus, the events catalyze improvement efforts to mitigate patient harm. A serious limitation is that only a few of the occurrences are investigated. A challenge is leveraging the data to generate knowledge. The goal is to present a methodology to supplement these incident assessment efforts. The framework affords an enhanced understanding of patient safety through the use of control charts to monitor non-harm and harm incidents simultaneously. This approach can identify harm and non-harm reporting rates and also can facilitate monitoring occurrence trends. This method also can expedite identifying changes in workflow, processes, or safety culture. Although unable to identify root causes, this approach can identify changes in near real time. This approach also supports evaluating safety or policy interventions that may not be observable in annual safety climate surveys.

  11. Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units.

    PubMed

    Xu, Jie; Reale, Carrie; Slagle, Jason M; Anders, Shilo; Shotwell, Matthew S; Dresselhaus, Timothy; Weinger, Matthew B

    Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management-especially medication-related events (MREs)-provides an approach to analyze and improve medication safety and quality. The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs. We conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts. MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts. Most of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.

  12. Occurrence of lead-related symptoms below the current occupational safety and health act allowable blood lead levels.

    PubMed

    Rosenman, Kenneth D; Sims, Amy; Luo, Zhehui; Gardiner, Joseph

    2003-05-01

    To determine the occurrence of symptoms of lead toxicity at levels below the current allowable Occupational Safety and Health Act blood lead level of 50 micrograms/dL, standardized telephone interviews were conducted of individuals reported to a statewide laboratory-based surveillance system. Four hundred and ninety-seven, or 75%, of the eligible participants were interviewed. Gastrointestinal, musculoskeletal, and nervous system symptoms increased with increasing blood lead levels. Nervous, gastrointestinal, and musculoskeletal symptoms all began to be increased in individuals with blood leads between 30-39 micrograms/dL and possibly at levels as low as 25-30 micrograms/dL for nervous system symptoms. The results of this study of increased symptoms are consistent with and provide added weight to previous results showing subclinical changes in the neurologic and renal systems and sperm counts at blood lead levels currently allowed by the Occupational Safety and Health Act.

  13. Screening Electronic Health Record-Related Patient Safety Reports Using Machine Learning.

    PubMed

    Marella, William M; Sparnon, Erin; Finley, Edward

    2017-03-01

    The objective of this study was to develop a semiautomated approach to screening cases that describe hazards associated with the electronic health record (EHR) from a mandatory, population-based patient safety reporting system. Potentially relevant cases were identified through a query of the Pennsylvania Patient Safety Reporting System. A random sample of cases were manually screened for relevance and divided into training, testing, and validation data sets to develop a machine learning model. This model was used to automate screening of remaining potentially relevant cases. Of the 4 algorithms tested, a naive Bayes kernel performed best, with an area under the receiver operating characteristic curve of 0.927 ± 0.023, accuracy of 0.855 ± 0.033, and F score of 0.877 ± 0.027. The machine learning model and text mining approach described here are useful tools for identifying and analyzing adverse event and near-miss reports. Although reporting systems are beginning to incorporate structured fields on health information technology and the EHR, these methods can identify related events that reporters classify in other ways. These methods can facilitate analysis of legacy safety reports by retrieving health information technology-related and EHR-related events from databases without fields and controlled values focused on this subject and distinguishing them from reports in which the EHR is mentioned only in passing. Machine learning and text mining are useful additions to the patient safety toolkit and can be used to semiautomate screening and analysis of unstructured text in safety reports from frontline staff.

  14. Annotated bibliography of safety-related occurrences in boiling-water nuclear power plants as reported in 1976

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

    Scott, R.L.; Gallaher, R.B.

    1977-08-02

    This bibliography contains 100-word abstracts of reports to the U.S. Nuclear Regulatory Commission concerning operational events that occurred at boiling-water reactor nuclear power plants in 1976. The report includes 1,253 abstracts that describe incidents, failures, and design or construction deficiencies that were experienced at the facilities. They are arranged alphabetically by reactor name and then chronologically for each reactor. Key-word and permuted-title indexes are provided to facilitate location of the subjects of interest, and tables that summarize the information contained in the bibliography are provided. The information listed in the tables includes instrument failures, equipment failures, system failures, causes ofmore » failures, deficiencies noted, and the time of occurrence (i.e., during refueling, operation, testing, or construction). Three of the unique events that occurred during the year are reviewed in detail.« less

  15. Annotated bibliography of safety-related occurrences in boiling-water nuclear power plants as reported in 1975

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

    Scott, R.L.; Gallaher, R.B.

    1976-07-01

    The bibliography presented contains 100-word abstracts of reports to the U.S. Nuclear Regulatory Commission concerning operational events that occurred at boiling-water reactor nuclear power plants in 1975. The report includes 1169 abstracts, arranged alphabetically by reactor name and then chronologically for each reactor, that describe incidents, failures, and design or construction deficiencies that were experienced at the facilities. Key-word and permuted-title indexes are provided to facilitate location of the subjects of interest, and tables that summarize the information contained in the bibliography are provided. The information listed in the tables includes instrument failures, equipment failures, system failures, causes of failures,more » deficiencies noted, and the time of occurrence (i.e., during refueling, operation, testing, or construction). Seven of the unique events that occurred during the year are reviewed in detail.« less

  16. Annotated bibliography of safety-related occurrences in pressurized-water nuclear power plants as reported in 1975

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

    Scott, R.L.; Gallaher, R.B.

    1976-07-01

    The bibliography presented contains 100-word abstracts of reports to the U.S. Nuclear Regulatory Commission concerning operational events that occurred at pressurized-water reactor nuclear power plants in 1975. The report includes 1097 abstracts, arranged alphabetically by reactor name and then chronologically for each reactor, that describe incidents, failures, and design or construction deficiencies experienced at the facilities. Key-word and permuted-title indexes are provided to facilitate location of the subjects of interest, and tables summarizing the information contained in the bibliography are presented. The information listed in the tables includes instrument failures, equipment failures, system failures, causes of failures, deficiencies noted, andmore » the time of occurrence (i.e., during refueling, operation, testing, or construction). A few of the unique events that occurred during the year are reviewed in detail.« less

  17. Packaging- and transportation-related occurrence reports : FY 1996 annual report

    DOT National Transportation Integrated Search

    1997-02-01

    The Oak Ridge National Laboratory (ORNL) Packaging and Transportation Safety Program (PATS) has been charged with the responsibility of retrieving reports and information pertaining to transportation and packaging incidents from the centralized ORPS ...

  18. 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.

  19. Factors related to increasing safety belt use in states with safety belt use laws : second annual report to Congress

    DOT National Transportation Integrated Search

    1989-01-01

    This report is the second in a series of four annual reports to the Congress on provisions of state safety belt use laws and other programmatic factors related to increasing safety belt use levels. The first Congressional Report reviewed what was kno...

  20. Annotated bibliography of safety-related occurrences in pressurized-water nuclear power plants as reported in 1976

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

    Scott, R.L.; Gallaher, R.B.

    1977-08-01

    The bibliography contains 100-word abstracts of reports to the U.S. Nuclear Regulatory Commission concerning operational events that occurred at pressurized-water reactor nuclear power plants in 1976. Included are 1264 abstracts that describe incidents, failures, and design construction deficiencies experienced at the facilities. They are arranged alphabetically by reactor name and then chronologically for each reactor. Key-word and permuted-title indexes are provided to facilitate location of the subjects of interest, and tables summarizing the information contained in the bibliography are presented. The information listed in the tables includes instrument failures, equipment failures, system failures, causes of failures, deficiencies noted, and themore » time of occurrence (i.e., during refueling, operation, testing, or construction). A few of the unique events that occurred during the year are reviewed in detail.« less

  1. The Impact of a Patient Safety Program on Medical Error Reporting

    DTIC Science & Technology

    2005-05-01

    307 The Impact of a Patient Safety Program on Medical Error Reporting Donald R. Woolever Abstract Background: In response to the occurrence of...a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety...communication, teamwork, and reporting. Objective: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This

  2. Factors related to increasing safety belt use in states with safety belt use laws : second annual report to Congress, 1988.

    DOT National Transportation Integrated Search

    1989-01-01

    This report. is the second in a series of four annual reports to the : Congress on provisions of state safety belt use laws and other : programmatic factors related to increasing safety belt use levels. : The first Congressional Report reviewed what ...

  3. Report to Congress on abnormal occurrences, October--December 1993. Volume 16, No. 4

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

    Not Available

    1994-04-01

    Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of public health or safety and requires a quarterly report of such events to be made to Congress. This report covers the period from October 1 through December 31, 1993. This report discusses six abnormal occurrences at NRC-licensed facilities. Five involved medical brachytherapy misadministrations, and one involved an overexposure to a nursing infant. Seven abnormal occurrences that were reported by the Agreement States are also discussed, based on informationmore » provided by the Agreement States as of February 28, 1994. Of these events, three involved brachytherapy misadministrations, one involved a teletherapy misadministration, one involved a theft of radioactive material during transport and improper disposal, and two involved lost sources.« less

  4. Nurses' systems thinking competency, medical error reporting, and the occurrence of adverse events: a cross-sectional study.

    PubMed

    Hwang, Jee-In; Park, Hyeoun-Ae

    2017-12-01

    Healthcare professionals' systems thinking is emphasized for patient safety. To report nurses' systems thinking competency, and its relationship with medical error reporting and the occurrence of adverse events. A cross-sectional survey using a previously validated Systems Thinking Scale (STS), was conducted. Nurses from two teaching hospitals were invited to participate in the survey. There were 407 (60.3%) completed surveys. The mean STS score was 54.5 (SD 7.3) out of 80. Nurses with higher STS scores were more likely to report medical errors (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.02-1.08) and were less likely to be involved in the occurrence of adverse events (OR = 0.96; 95% CI = 0.93-0.98). Nurses showed moderate systems thinking competency. Systems thinking was a significant factor associated with patient safety. Impact Statement: The findings of this study highlight the importance of enhancing nurses' systems thinking capacity to promote patient safety.

  5. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1978-01-01

    The study deals with 165 inadvertent operations on or into inappropriate portions of the aircraft areas at controlled airports. Pilot-initiated and controller-initiated incursions are described and discussed. It was found that a majority of the pilot-initiated occurrences involved operation without a clearance; controller-initiated occurrences usually involved failure to maintain assured separation. The factors associated with these occurrences are analyzed. It appears that a major problem in these occurrences is inadequate coordination among the various system participants. Reasons for this, and some possible solutions to various aspects of the problem, are discussed. A sample of reports from pilots and controllers is presented. These relate to undesired occurrences in air transport, general aviation, and air traffic control operations; to ATC coordination problems; and to a recurrent problem in ASRS reports, parachuting operations. A sample of alert bulletins and responses to them is presented.

  6. 21 CFR 1002.20 - Reporting of accidental radiation occurrences.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Reporting of accidental radiation occurrences... SERVICES (CONTINUED) RADIOLOGICAL HEALTH RECORDS AND REPORTS Manufacturers' Reports on Accidental Radiation Occurrences § 1002.20 Reporting of accidental radiation occurrences. (a) Manufacturers of electronic products...

  7. 21 CFR 1002.20 - Reporting of accidental radiation occurrences.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Reporting of accidental radiation occurrences... SERVICES (CONTINUED) RADIOLOGICAL HEALTH RECORDS AND REPORTS Manufacturers' Reports on Accidental Radiation Occurrences § 1002.20 Reporting of accidental radiation occurrences. (a) Manufacturers of electronic products...

  8. 21 CFR 1002.20 - Reporting of accidental radiation occurrences.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Reporting of accidental radiation occurrences... SERVICES (CONTINUED) RADIOLOGICAL HEALTH RECORDS AND REPORTS Manufacturers' Reports on Accidental Radiation Occurrences § 1002.20 Reporting of accidental radiation occurrences. (a) Manufacturers of electronic products...

  9. Effects of safety behaviours with pesticide use on occurrence of acute symptoms in male and female tobacco-growing Malaysian farmers.

    PubMed

    Nordi, Rusli Bin; Araki, Shunichi; Sato, Hajime; Yokoyama, Kazuhito; Wan Muda, Wan Abdul Manan Bin; Win Kyi, Daw

    2002-04-01

    The effects of safety behaviours associated with pesticide use on the occurrence of acute organ symptoms in 395 male and 101 female tobacco-growing farmers in Malaysia were studied. We used a 15-questionnaire checklist on safe pesticide-use behaviours and a 25-questionnaire checklist on acute organ symptoms reported shortly after spraying pesticides. Results of stepwise multiple linear regression analysis indicated that no smoking while spraying, good sprayer-condition, and changing clothes immediately after spraying significantly prevented occurrence of acute symptoms just after pesticide spray in male farmers; in female farmers, only wearing a hat while spraying significantly prevented the symptoms. Safety behaviours in pesticide use in male and female tobacco-growing farmers are discussed in the light of these findings.

  10. 46 CFR 326.4 - Reports of accidents and occurrences.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 46 Shipping 8 2011-10-01 2011-10-01 false Reports of accidents and occurrences. 326.4 Section 326... MARINE PROTECTION AND INDEMNITY INSURANCE UNDER AGREEMENTS WITH AGENTS § 326.4 Reports of accidents and occurrences. The Agent shall report every accident or occurrence of a P&I nature promptly to both the Director...

  11. 46 CFR 326.4 - Reports of accidents and occurrences.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 46 Shipping 8 2010-10-01 2010-10-01 false Reports of accidents and occurrences. 326.4 Section 326... MARINE PROTECTION AND INDEMNITY INSURANCE UNDER AGREEMENTS WITH AGENTS § 326.4 Reports of accidents and occurrences. The Agent shall report every accident or occurrence of a P&I nature promptly to both the Director...

  12. Packaging- and transportation-related occurrence reports : FY 1993 annual report

    DOT National Transportation Integrated Search

    1994-06-01

    This annual report details (1) the methodology that PATS uses to conduct searches of the ORPS for pertinent information, (2) the form of reporting to EH-332, (3) review and examination of trends observed in ORs related to transportation and packaging...

  13. 2012 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    Dumont, Alan G.

    2012-01-01

    This report provides a NASA Range Safety (NRS) overview for current and potential range users. This report contains articles which cover a variety of subject areas, summaries of various NASA Range Safety Program (RSP) activities performed during the past year, links to past reports, and information on several projects that may have a profound impact on the way business will be conducted in the future. Specific topics discussed in the 2012 NASA Range Safety Annual Report include a program overview and 2012 highlights; Range Safety Training; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities.

  14. Two sides of the safety coin?: How patient engagement and safety climate jointly affect error occurrence in hospital units.

    PubMed

    Schiffinger, Michael; Latzke, Markus; Steyrer, Johannes

    2016-01-01

    Safety climate (SC) and more recently patient engagement (PE) have been identified as potential determinants of patient safety, but conceptual and empirical studies combining both are lacking. On the basis of extant theories and concepts in safety research, this study investigates the effect of PE in conjunction with SC on perceived error occurrence (pEO) in hospitals, controlling for various staff-, patient-, and hospital-related variables as well as the amount of stress and (lack of) organizational support experienced by staff. Besides the main effects of PE and SC on error occurrence, their interaction is examined, too. In 66 hospital units, 4,345 patients assessed the degree of PE, and 811 staff assessed SC and pEO. PE was measured with a new instrument, capturing its core elements according to a recent literature review: Information Provision (both active and passive) and Activation and Collaboration. SC and pEO were measured with validated German-language questionnaires. Besides standard regression and correlational analyses, partial least squares analysis was employed to model the main and interaction effects of PE and SC on pEO, also controlling for stress and (lack of) support perceived by staff, various staff and patient attributes, and potential single-source bias. Both PE and SC are associated with lower pEO, to a similar extent. The joint effect of these predictors suggests a substitution rather than mutually reinforcing interaction. Accounting for control variables and/or potential single-source bias slightly attenuates some effects without altering the results. Ignoring PE potentially amounts to forgoing a potential source of additional safety. On the other hand, despite the abovementioned substitution effect and conjectures of SC being inert, PE should not be considered as a replacement for SC.

  15. Work stress and patient safety: observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses.

    PubMed

    Elfering, A; Semmer, N K; Grebner, S

    This study investigates the link between workplace stress and the 'non-singularity' of patient safety-related incidents in the hospital setting. Over a period of 2 working weeks 23 young nurses from 19 hospitals in Switzerland documented 314 daily stressful events using a self-observation method (pocket diaries); 62 events were related to patient safety. Familiarity of safety-related events and probability of recurrence, as indicators of non-singularity, were the dependent variables in multilevel regression analyses. Predictor variables were both situational (self-reported situational control, safety compliance) and chronic variables (job stressors such as time pressure, or concentration demands and job control). Chronic work characteristics were rated by trained observers. The most frequent safety-related stressful events included incomplete or incorrect documentation (40.3%), medication errors (near misses 21%), delays in delivery of patient care (9.7%), and violent patients (9.7%). Familiarity of events and probability of recurrence were significantly predicted by chronic job stressors and low job control in multilevel regression analyses. Job stressors and low job control were shown to be risk factors for patient safety. The results suggest that job redesign to enhance job control and decrease job stressors may be an important intervention to increase patient safety.

  16. 2009 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    2010-01-01

    This year, NASA Range Safety transitioned to a condensed annual report to allow for Secretariat support to the Range Safety Group, Risk Committee. Although much shorter than in previous years, this report contains full-length articles concerning various subject areas, as well as links to past reports. Additionally, summaries from various NASA Range Safety Program activities that took place throughout the year are presented, as well as information on several projects that may have a profound impact on the way business will be done in the future. The sections include a program overview and 2009 highlights; Range Safety Training; Range Safety Policy; Independent Assessments Support to Program Operations at all ranges conducting NASA launch operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities.

  17. 2010 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    Dumont, Alan G.

    2010-01-01

    this report provides a NASA Range Safety overview for current and potential range users. This report contains articles which cover a variety of subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, links to past reports, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed in the 2010 NASA Range Safety Annual Report include a program overview and 2010 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again, the web-based format was used to present the annual report.

  18. Effect of snowboard-related concussion safety education for recognizing possible concussions.

    PubMed

    Koh, J O

    2011-12-01

    The aim of this study was to examine the understanding of snowboard-related concussion and to measure the recognition of possible concussion occurrence after an intervention of snowboard-related concussion safety education in snowboarding. Incidence cohort design. 2008-2009 season Gangwon-do Ski resorts, South Korea. A total of 208 university students (female-72; male-136; age-18 to 32) who registered for a snowboarding class and received credit participated in this project. Snowboard-related concussion safety education class was administered for 30 minutes before the snowboard class began. The knowledge of snowboard-related concussion before and after the safety education was evaluated. Concussion data were collected via a self-report case form at the last day of snowboarding class. The incidence of possible concussion and factors associated with concussions were analyzed by χ2 test. The mean score of snowboard-related concussion knowledge improved from fifteen points to eighteen points out of 20 total points possible. Overall the incidence of concussion was 10 per 100 snowboarder-exposures. χ2 tests showed concussion rates to be significantly different in female snowboarders (P=0.00) and in helmet users (P=0.02). The incidence of possible concussion is high among snowboarding class participants. Emphasis should be given for instituting pre-participation balance training, especially for females to reduce falling in snowboarding. To verify the effects of pre-participation balance training and falling results in a concussion, more research is needed in the future.

  19. A brief review of the occurrence, use, and safety of food-related nanomaterials.

    PubMed

    Magnuson, Bernadene A; Jonaitis, Tomas S; Card, Jeffrey W

    2011-08-01

    Nanotechnology and nanomaterials have tremendous potential to enhance the food supply through novel applications, including nutrient and bioactive absorption and delivery systems; ingredient functionality; improved colors and flavors; microbial, allergen, and contaminant detection and control; and food packaging properties and performance. To determine the current state of knowledge regarding the safety of these potential uses of nanomaterials, an appraisal of the published literature on the safety of food-related nanomaterials was undertaken. A method of assessment of reliability of toxicology studies was developed to conduct this appraisal. The review of the toxicology literature on oral exposure to food-related nanomaterials found that the number of studies is limited. Exposure to nanomaterials in the human food chain may occur not only through intentional uses in food manufacturing, but also via uses in agricultural production and carry over from use in other industries. Although a number of analytical methods are useful in physicochemical characterization of manufactured nanomaterials, new methods may be needed to more fully detect and characterize nanomaterials incorporated into foods and in other media. There is a need for additional toxicology studies of sufficient quality and duration on different types of nanomaterials to further our understanding of the characteristics of nanomaterials that affect safety of oral exposure resulting from use in various food applications. © 2011 Institute of Food Technologists®

  20. Under-reporting of work-related disorders in the workplace: a case study and review of the literature.

    PubMed

    Pransky, G; Snyder, T; Dembe, A; Himmelstein, J

    1999-01-01

    Accurate reporting of work-related conditions is necessary to monitor workplace health and safety, and to identify the interventions that are most needed. Reporting systems may be designed primarily for external agencies (OSHA or workers' compensation) or for the employer's own use. Under-reporting of workplace injuries and illnesses is common due to a variety of causes and influences. Based on previous reports, the authors were especially interested in the role of safety incentive programmes on under-reporting. Safety incentive programmes typically reward supervisors and employees for reducing workplace injury rates, and thus may unintentionally inhibit proper reporting. The authors describe a case study of several industrial facilities in order to illustrate the extent of under-reporting and the reasons for its occurrence. A questionnaire and interview survey was administered to 110 workers performing similar tasks and several managers, health, and safety personnel at each of three industrial facilities. Although less than 5% of workers had officially reported a work-related injury or illness during the past year, over 85% experienced work-related symptoms, 50% had persistent work-related problems, and 30% reported either lost time from work or work restrictions because of their ailment. Workers described several reasons for not reporting their injuries, including fear of reprisal, a belief that pain was an ordinary consequence of work activity or ageing, lack of management responsiveness after prior reports, and a desire not to lose their usual job. Interviews with management representatives revealed administrative and other barriers to reporting, stemming from their desire to attain a goal of no reported injuries, and misconceptions about requirements for recordability. The corporate and facility safety incentives appeared to have an indirect, but significant negative influence on the proper reporting of workplace injuries by workers. A variety of influences

  1. An analysis of electronic health record-related patient safety concerns

    PubMed Central

    Meeks, Derek W; Smith, Michael W; Taylor, Lesley; Sittig, Dean F; Scott, Jean M; Singh, Hardeep

    2014-01-01

    Objective A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system. Methods The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports. Results We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR. Discussion EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA. Conclusions Because EHR-related safety concerns have complex

  2. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    Billings, C. E.; Lauber, J. K.; Funkhouser, H.; Lyman, E. G.; Huff, E. M.

    1976-01-01

    The origins and development of the NASA Aviation Safety Reporting System (ASRS) are briefly reviewed. The results of the first quarter's activity are summarized and discussed. Examples are given of bulletins describing potential air safety hazards, and the disposition of these bulletins. During the first quarter of operation, the ASRS received 1464 reports; 1407 provided data relevant to air safety. All reports are being processed for entry into the ASRS data base. During the reporting period, 130 alert bulletins describing possible problems in the aviation system were generated and disseminated. Responses were received from FAA and others regarding 108 of the alert bulletins. Action was being taken with respect to 70 of the 108 responses received. Further studies are planned of a number of areas, including human factors problems related to automation of the ground and airborne portions of the national aviation system.

  3. 2011 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    Dumont, Alan G.

    2012-01-01

    Welcome to the 2011 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides a NASA Range Safety overview for current and potential range users. As is typical with odd year editions, this is an abbreviated Range Safety Annual Report providing updates and links to full articles from the previous year's report. It also provides more complete articles covering new subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed and updated in the 2011 NASA Range Safety Annual Report include a program overview and 2011 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again the web-based format was used to present the annual report. We continually receive positive feedback on the web-based edition and hope you enjoy this year's product as well. As is the case each year, contributors to this report are too numerous to mention, but we thank individuals from the NASA Centers, the Department of Defense, and civilian organizations for their contributions. In conclusion, it has been a busy and productive year. I'd like to extend a personal Thank You to everyone who contributed to make this year a successful one, and I look forward to working with all of you in the upcoming year.

  4. Parents' Self-Reported Behaviors Related to Health and Safety of Very Young Children.

    ERIC Educational Resources Information Center

    Hendricks, Charlotte M.; Reichert, Ann

    1996-01-01

    Reports a survey that documented the health and safety behaviors of parents of children in Head Start programs. Nearly all parents reported using car seats, teaching handwashing and pedestrian safety, and locking away medicine and alcohol. Sixty percent reported storing guns and bullets safely, possessing working fire extinguishers, and having…

  5. Aerospace Safety Advisory Panel Annual Report for 1999

    NASA Technical Reports Server (NTRS)

    Blomberg, Richard D.

    2000-01-01

    This report covers the activities of the Aerospace Safety Advisory Panel (ASAP) for the calendar year 1999.This was a year of notable achievements and significant frustrations. Both the Space Shuttle and International Space Station (ISS) programs were delayed.The Space Shuttle prudently postponed launches after the occurrence of a wiring short during ascent of the STS-93 mission. The ISS construction schedule slipped as a result of the Space Shuttle delays and problems the Russians experienced in readying the Service Module and its launch vehicle. Each of these setbacks was dealt with in a constructive way. The STS-93 short circuit led to detailed wiring inspections and repairs on all four orbiters as well as analysis of other key subsystems for similar types of hidden damage. The ISS launch delays afforded time for further testing, training, development, and contingency planning. The safety consciousness of the NASA and contractor workforces, from hands-on labor to top management, continues high. Nevertheless, workforce issues remain among the most serious safety concerns of the Panel. Cutbacks and reorganizations over the past several years have resulted in problems related to workforce size, critical skills, and the extent of on-the-job experience. These problems have the potential to impact safety as the Space Shuttle launch rate increases to meet the demands of the ISS and its other customers. As with last year's report, these work- force-related issues were considered of sufficient import to place them first in the material that follows. Some of the same issues of concern for the Space Shuttle and ISS arose in a review of the launch vehicle for the Terra mission that the Panel was asked by NASA to undertake. Other areas the Panel was requested to assess included the readiness of the Inertial Upper Stage for the deployment of the Chandra X-ray Observatory and the possible safety impact of electromagnetic effects on the Space Shuttle. The findings and

  6. Using Active Learning to Identify Health Information Technology Related Patient Safety Events.

    PubMed

    Fong, Allan; Howe, Jessica L; Adams, Katharine T; Ratwani, Raj M

    2017-01-18

    The widespread adoption of health information technology (HIT) has led to new patient safety hazards that are often difficult to identify. Patient safety event reports, which are self-reported descriptions of safety hazards, provide one view of potential HIT-related safety events. However, identifying HIT-related reports can be challenging as they are often categorized under other more predominate clinical categories. This challenge of identifying HIT-related reports is exacerbated by the increasing number and complexity of reports which pose challenges to human annotators that must manually review reports. In this paper, we apply active learning techniques to support classification of patient safety event reports as HIT-related. We evaluated different strategies and demonstrated a 30% increase in average precision of a confirmatory sampling strategy over a baseline no active learning approach after 10 learning iterations.

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

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS AND... providing a copy of a clipping from a newspaper article, if available. (4) For the purposes of this...

  8. 49 CFR 191.23 - Reporting safety-related conditions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., controls, or processes gas or LNG. (4) Any material defect or physical damage that impairs the... strength. (5) Any malfunction or operating error that causes the pressure of a pipeline or LNG facility... structural integrity of an LNG storage tank. (8) Any safety-related condition that could lead to an imminent...

  9. Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.

    PubMed

    Smith, Scott Alan; Yount, Naomi; Sorra, Joann

    2017-02-16

    A number of private and public companies calculate and publish proprietary hospital patient safety scores based on publicly available quality measures initially reported by the U.S. federal government. This study examines whether patient safety culture perceptions of U.S. hospital staff in a large national survey are related to publicly reported patient safety ratings of hospitals. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (Hospital SOPS) assesses provider and staff perceptions of hospital patient safety culture. Consumer Reports (CR), a U.S. based non-profit organization, calculates and shares with its subscribers a Hospital Safety Score calculated annually from patient experience survey data and outcomes data gathered from federal databases. Linking data collected during similar time periods, we analyzed relationships between staff perceptions of patient safety culture composites and the CR Hospital Safety Score and its five components using multiple multivariate linear regressions. We analyzed data from 164 hospitals, with patient safety culture survey responses from 140,316 providers and staff, with an average of 856 completed surveys per hospital and an average response rate per hospital of 56%. Higher overall Hospital SOPS composite average scores were significantly associated with higher overall CR Hospital Safety Scores (β = 0.24, p < 0.05). For 10 of the 12 Hospital SOPS composites, higher patient safety culture scores were associated with higher CR patient experience scores on communication about medications and discharge. This study found a relationship between hospital staff perceptions of patient safety culture and the Consumer Reports Hospital Safety Score, which is a composite of patient experience and outcomes data from federal databases. As hospital managers allocate resources to improve patient safety culture within their organizations, their efforts may also indirectly improve consumer

  10. Annual Report To Congress. Department of Energy Activities Relating to the Defense Nuclear Facilities Safety Board, Calendar Year 2003

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

    None, None

    2004-02-28

    The Department of Energy (Department) submits an Annual Report to Congress each year detailing the Department’s activities relating to the Defense Nuclear Facilities Safety Board (Board), which provides advice and recommendations to the Secretary of Energy (Secretary) regarding public health and safety issues at the Department’s defense nuclear facilities. In 2003, the Department continued ongoing activities to resolve issues identified by the Board in formal recommendations and correspondence, staff issue reports pertaining to Department facilities, and public meetings and briefings. Additionally, the Department is implementing several key safety initiatives to address and prevent safety issues: safety culture and review ofmore » the Columbia accident investigation; risk reduction through stabilization of excess nuclear materials; the Facility Representative Program; independent oversight and performance assurance; the Federal Technical Capability Program (FTCP); executive safety initiatives; and quality assurance activities. The following summarizes the key activities addressed in this Annual Report.« less

  11. Review of safety reports involving electronic flight bags

    DOT National Transportation Integrated Search

    2009-04-27

    Electronic Flight Bags (EFBs) are a relatively new device used by pilots. Even so, 37 safety-related events involving EFBs were identified from the public online Aviation Safety Reporting System (ASRS) database as of June 2008. In addition, two accid...

  12. Motor carrier safety : reincarnating commercial vehicle companies pose safety threat to motoring public; federal safety agency has initiated efforts to prevent future occurrences.

    DOT National Transportation Integrated Search

    2009-07-01

    In 2008, the Federal Motor Carrier Safety Administration (FMCSA) reports that there were about 300 fatalities from bus crashes in the United States. Although bus crashes are relatively rare, they are particularly deadly since many individuals may be ...

  13. 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.

  14. 2013 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    Dumont, Alan G.

    2013-01-01

    Welcome to the 2013 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides an Agency overview for current and potential range users. This report contains articles which cover a variety of subject areas, summaries of various activities performed during the past year, links to past reports, and information on several projects that may have a profound impact on the way business will be conducted in the future. Specific topics discussed in the 2013 NASA Range Safety Annual Report include a program overview and 2013 highlights, Range Safety Training, Independent Assessments, support to Program Operations at all ranges conducting NASA launch/flight operations, a continuing overview of emerging range safety-related technologies, and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. As is the case each year, we had a wide variety of contributors to this report from across our NASA Centers and the national range safety community at large, and I wish to thank them all. On a sad note, we lost one of our close colleagues, Dr. Jim Simpson, due to his sudden passing in December. His work advancing the envelope of autonomous flight safety systems software/hardware development leaves a lasting impression on our community. Such systems are being flight tested today and may one day be considered routine in the range safety business. The NASA family has lost a pioneer in our field, and he will surely be missed. In conclusion, it has been a very busy and productive year, and I look forward to working with all of you in NASA Centers/Programs/Projects and with the national Range Safety community in making Flight/Space activities as safe as they can be in the upcoming year.

  15. Physics of reactor safety. Quarterly report, January--March 1977. [LMFBR

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

    None

    1977-06-01

    This report summarizes work done on reactor safety, Monte Carlo analysis of safety-related critical assembly experiments, and planning of DEMI safety-related critical experiments. Work on reactor core thermal-hydraulics is also included.

  16. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1981-01-01

    Aviation safety reports that relate to loss of control in flight, problems that occur as a result of similar sounding alphanumerics, and pilot incapacitation are presented. Problems related to the go around maneuver in air carrier operations, and bulletins (and FAA responses to them) that pertain to air traffic control systems and procedures are included.

  17. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1980-01-01

    Knowledge of limitations of the Air Traffic Control system in conflict avoidance capabilities is discussed. Assumptions and expectations held by by airmen regarding the capabilities of the system are presented. Limitations related to communication are described and problems associated with visual approaches, airspace configurations, and airport layouts are discussed. A number of pilot and controller reports illustrative of three typical problem types: occurrences involving pilots who have limited experience; reports describing inflight calls for assistance; and flights in which pilots have declined to use available radar services are presented. Examples of Alert Bulletins and the FAA responses to them are included.

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

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.; Reynard, William D.

    1993-01-01

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

  19. 2008 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    Lamoreaux, Richard W.

    2008-01-01

    Welcome to the 2008 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides a NASA Range Safety overview for current and potential range users. This year, along with full length articles concerning various subject areas, we have provided updates to standard subjects with links back to the 2007 original article. Additionally, we present summaries from the various NASA Range Safety Program activities that took place throughout the year, as well as information on several special projects that may have a profound impact on the way we will do business in the future. The sections include a program overview and 2008 highlights of Range Safety Training; Range Safety Policy; Independent Assessments and Common Risk Analysis Tools Development; Support to Program Operations at all ranges conducting NASA launch operations; a continuing overview of emerging Range Safety-related technologies; Special Interests Items that include recent changes in the ELV Payload Safety Program and the VAS explosive siting study; and status reports from all of the NASA Centers that have Range Safety responsibilities. As is the case each year, contributors to this report are too numerous to mention, but we thank individuals from the NASA Centers, the Department of Defense, and civilian organizations for their contributions. We have made a great effort to include the most current information available. We recommend that this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. This is the third year we have utilized this web-based format for the annual report. We continually receive positive feedback on the web-based edition, and we hope you enjoy this year's product as well. It has been a very busy and productive year on many fronts as you will note as you review this report. Thank you to everyone who contributed to make this year a successful one, and I look forward to working with all of you in the

  20. Neighborhood Crime-Related Safety and Its Relation to Children's Physical Activity.

    PubMed

    Kneeshaw-Price, Stephanie H; Saelens, Brian E; Sallis, James F; Frank, Lawrence D; Grembowski, David E; Hannon, Peggy A; Smith, Nicholas L; Chan, K C Gary

    2015-06-01

    Crime is both a societal safety and public health issue. Examining different measures and aspects of crime-related safety and their correlations may provide insight into the unclear relationship between crime and children's physical activity. We evaluated five neighborhood crime-related safety measures to determine how they were interrelated. We then explored which crime-related safety measures were associated with children's total moderate-to-vigorous physical activity (MVPA) and MVPA in their neighborhoods. Significant positive correlations between observed neighborhood incivilities and parents' perceptions of general crime and disorder were found (r = 0.30, p = 0.0002), as were associations between parents' perceptions of general crime and disorder and perceptions of stranger danger (r = 0.30, p = 0.0002). Parent report of prior crime victimization in their neighborhood was associated with observed neighborhood incivilities (r = 0.22, p = 0.007) and their perceptions of both stranger danger (r = 0.24, p = 0.003) and general crime and disorder (r = 0.37, p < 0.0001). After accounting for covariates, police-reported crime within the census block group in which children lived was associated with less physical activity, both total and in their neighborhood (beta = -0.09, p = 0.005, beta = -0.01, p = 0.02, respectively). Neighborhood-active children living in the lowest crime-quartile neighborhoods based on police reports had 40 min more of total MVPA on average compared to neighborhood-active children living in the highest crime-quartile neighborhoods. Findings suggest that police reports of neighborhood crime may be contributing to lower children's physical activity.

  1. Safety and Sex Practices among Nebraska Adolescents. Technical Report 24.

    ERIC Educational Resources Information Center

    Newman, Ian M.; Perry-Hunnicutt, Christina

    This report describes a range of adolescent behaviors related to their safety and the safety of others. The behaviors reported here range from ordinary safety precautions such as only swimming in supervised areas and wearing helmets when riding a motorcycle to less talked about behaviors such as using condoms during sexual intercourse and carrying…

  2. Environment-related and host-related factors affecting the occurrence of lice on rodents in Central Europe.

    PubMed

    Stanko, Michal; Fričová, Jana; Miklisová, Dana; Khokhlova, Irina S; Krasnov, Boris R

    2015-06-01

    We studied the effects of environment- (habitat, season) and host-related (sex, body mass) factors on the occurrence of four species of lice (Insecta:Phthiraptera:Anoplura) on six rodent species (Rodentia:Muridae). We asked how these factors influence the occurrence of lice on an individual host and whether different rodent-louse associations demonstrate consistent trends in these effects. We found significant effects of at least one environment-related and at least one host-related factor on the louse occurrence in five of six host-louse associations. The effect of habitat was significant in two associations with the occurrence of lice being more frequent in lowland than in mountain habitats. The effect of season was significant in five associations with a higher occurrence of infestation during the warm season in four associations and the cold season in one association. Host sex affected significantly the infestation by lice in three associations with a higher frequency of infestation in males. Host body mass affected the occurrence of lice in all five associations, being negative in wood mice and positive in voles. In conclusion, lice were influenced not only by the host- but also by environment-related factors. The effects of the latter could be mediated via life history parameters of a host.

  3. Reported historic asbestos prospects and natural asbestos occurrences in the central United States

    USGS Publications Warehouse

    Van Gosen, Bradley S.

    2006-01-01

    This map and its accompanying dataset provide information for 26 natural asbestos occurrences in the Central United States (U.S.), using descriptions found in the geologic literature. Data on location, mineralogy, geology, and relevant literature for each asbestos site are provided. Using the map and digital data in this report, the user can examine the distribution of previously reported asbestos occurrences and their geological characteristics in the Central U.S. This report is part of an ongoing study by the U.S. Geological Survey to identify and map reported natural asbestos occurrences in the U.S., which began with U.S. Geological Survey Open-File Report 2005-1189 (http://pubs.usgs.gov/of/2005/1189/). These reports are intended to provide State and local government agencies and other stakeholders with geologic information on natural occurrences of asbestos in the U.S.

  4. An analysis of electronic health record-related patient safety incidents.

    PubMed

    Palojoki, Sari; Mäkelä, Matti; Lehtonen, Lasse; Saranto, Kaija

    2017-06-01

    The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.

  5. Barriers to Implementing a Reporting and Learning Patient Safety System: Pediatric Chiropractic Perspective.

    PubMed

    Pohlman, Katherine A; Carroll, Linda; Hartling, Lisa; Tsuyuki, Ross T; Vohra, Sunita

    2016-04-01

    A reporting and learning system is a method of monitoring the occurrence of incidents that affect patient safety. This cross-sectional survey asked pediatric chiropractors about factors that may limit their participation in such a system. The list of potential barriers for participation was developed using a systematic approach. All members of the 2 pediatric councils associated with US national chiropractic organizations were invited to complete the survey (N = 400). The cross-sectional survey was created using an online survey tool (REDCap) and sent directly to member emails addressed by the respective executive committees. Of the 400 potential respondents, 81 responded (20.3%). The most common limitations to participating were identified as time pressure (96%) and patient concerns (81%). Reporting and learning systems have been utilized to increase safety awareness in many high-risk industries. To be successful, future patient safety studies with pediatric chiropractors need to ensure these barriers are understood and addressed. © The Author(s) 2015.

  6. Patient Drug Safety Reporting: Diabetes Patients' Perceptions of Drug Safety and How to Improve Reporting of Adverse Events and Product Complaints.

    PubMed

    Patel, Puja; Spears, David; Eriksen, Betina Østergaard; Lollike, Karsten; Sacco, Michael

    2018-03-01

    Global health care manufacturer Novo Nordisk commissioned research regarding awareness of drug safety department activities and potential to increase patient feedback. Objectives were to examine patients' knowledge of pharmaceutical manufacturers' responsibilities and efforts regarding drug safety, their perceptions and experiences related to these efforts, and how these factors influence their thoughts and behaviors. Data were collected before and after respondents read a description of a drug safety department and its practices. We conducted quantitative survey research across 608 health care consumers receiving treatment for diabetes in the United States, Germany, United Kingdom, and Italy. This research validated initial, exploratory qualitative research (across 40 comparable consumers from the same countries) which served to guide design of the larger study. Before reading a drug safety department description, 55% of respondents were unaware these departments collect safety information on products and patients. After reading the description, 34% reported the department does more than they expected to ensure drug safety, and 56% reported "more confidence" in the industry as a whole. Further, 66% reported themselves more likely to report an adverse event or product complaint, and 60% reported that they were more likely to contact a drug safety department with questions. The most preferred communication methods were websites/online forums (39%), email (27%), and telephone (25%). Learning about drug safety departments elevates consumers' confidence in manufacturers' safety efforts and establishes potential for patients to engage in increased self-monitoring and reporting. Study results reveal potentially actionable insights for the industry across patient and physician programs and communications.

  7. Preventive Effects of Safety Helmets on Traumatic Brain Injury after Work-Related Falls

    PubMed Central

    Kim, Sang Chul; Ro, Young Sun; Shin, Sang Do; Kim, Joo Yeong

    2016-01-01

    Introduction: Work-related traumatic brain injury (TBI) caused by falls is a catastrophic event that leads to disabilities and high socio-medical costs. This study aimed to measure the magnitude of the preventive effect of safety helmets on clinical outcomes and to compare the effect across different heights of fall. Methods: We collected a nationwide, prospective database of work-related injury patients who visited the 10 emergency departments between July 2010 and October 2012. All of the adult patients who experienced work-related fall injuries were eligible, excluding cases with unknown safety helmet use and height of fall. Primary and secondary endpoints were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs) of safety helmet use and height of fall for study outcomes, and adjusted for any potential confounders. Results: A total of 1298 patients who suffered from work-related fall injuries were enrolled. The industrial or construction area was the most common place of fall injury occurrence, and 45.0% were wearing safety helmets at the time of fall injuries. The safety helmet group was less likely to have intracranial injury comparing with the no safety helmet group (the adjusted odds ratios (ORs) (95% confidence interval (CI)): 0.42 (0.24–0.73)), however, there was no statistical difference of in-hospital mortality between two groups (the adjusted ORs (95% CI): 0.83 (0.34–2.03). In the interaction analysis, preventive effects of safety helmet on intracranial injury were significant within 4 m height of fall. Conclusions: A safety helmet is associated with prevention of intracranial injury resulting from work-related fall and the effect is preserved within 4 m height of fall. Therefore, wearing a safety helmet can be an intervention for protecting fall-related intracranial injury in the workplace. PMID:27801877

  8. Preventive Effects of Safety Helmets on Traumatic Brain Injury after Work-Related Falls.

    PubMed

    Kim, Sang Chul; Ro, Young Sun; Shin, Sang Do; Kim, Joo Yeong

    2016-10-29

    Work-related traumatic brain injury (TBI) caused by falls is a catastrophic event that leads to disabilities and high socio-medical costs. This study aimed to measure the magnitude of the preventive effect of safety helmets on clinical outcomes and to compare the effect across different heights of fall. We collected a nationwide, prospective database of work-related injury patients who visited the 10 emergency departments between July 2010 and October 2012. All of the adult patients who experienced work-related fall injuries were eligible, excluding cases with unknown safety helmet use and height of fall. Primary and secondary endpoints were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs) of safety helmet use and height of fall for study outcomes, and adjusted for any potential confounders. A total of 1298 patients who suffered from work-related fall injuries were enrolled. The industrial or construction area was the most common place of fall injury occurrence, and 45.0% were wearing safety helmets at the time of fall injuries. The safety helmet group was less likely to have intracranial injury comparing with the no safety helmet group (the adjusted odds ratios (ORs) (95% confidence interval (CI)): 0.42 (0.24-0.73)), however, there was no statistical difference of in-hospital mortality between two groups (the adjusted ORs (95% CI): 0.83 (0.34-2.03). In the interaction analysis, preventive effects of safety helmet on intracranial injury were significant within 4 m height of fall. A safety helmet is associated with prevention of intracranial injury resulting from work-related fall and the effect is preserved within 4 m height of fall. Therefore, wearing a safety helmet can be an intervention for protecting fall-related intracranial injury in the workplace.

  9. Inroads into Equestrian Safety: Rider-Reported Factors Contributing to Horse-Related Accidents and Near Misses on Australian Roads

    PubMed Central

    Thompson, Kirrilly; Matthews, Chelsea

    2015-01-01

    Simple Summary Riding horses on roads can be dangerous, but little is known about accidents and near misses. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52%) reported having experienced at least one accident or near miss in the 12 months prior to the survey, mostly attributed to speed. Whilst our findings confirmed factors identified overseas, we also identified issues around road rules, hand signals and road rage. This paper suggests strategies for improving the safety of horses, riders and other road users. Abstract Horse riding and horse-related interactions are inherently dangerous. When they occur on public roads, the risk profile of equestrian activities is complicated by interactions with other road users. Research has identified speed, proximity, visibility, conspicuity and mutual misunderstanding as factors contributing to accidents and near misses. However, little is known about their significance or incidence in Australia. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52%) reported having experienced at least one accident or near miss in the 12 months prior to the survey. Whilst our findings confirm the factors identified overseas, we also identified issues around rider misunderstanding of road rules and driver misunderstanding of rider hand signals. Of particular concern, we also found reports of potentially dangerous rider-directed road rage. We identify several areas for potential safety intervention including (1) identifying equestrians as vulnerable road users and horses as sentient decision-making vehicles; (2) harmonising laws regarding passing horses; (3) mandating personal protective equipment; (4) improving road signage; (5) comprehensive data collection; (6) developing mutual understanding amongst road-users; (7) safer road design and alternative riding spaces; and (8) increasing investment

  10. Safety-related requirements for photovoltaic modules and arrays. Final report

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

    Levins, A.

    1984-03-01

    Underwriters Laboratories has conducted a study to identify and develop safety requirements for photovoltaic module and panel designs and configurations for residential, intermediate, and large scale applications. Concepts for safety systems, where each system is a collection of subsystems which together address the total anticipated hazard situation, are described. Descriptions of hardware, and system usefulness and viability are included. This discussion of safety systems recognizes that there is little history on which to base the expected safety related performance of a photovoltaic system. A comparison of these systems, as against the provisions of the 1984 National Electrical Code covering photovoltaicmore » systems is made. A discussion of the UL investigation of the photovoltaic module evaluated to the provisions of the Proposed UL Standard for Flat-Plate Photovoltaic Modules and Panels is included. Grounding systems, their basis and nature, and the advantages and disadvantages of each are described. The meaning of frame grounding, circuit grounding, and the type of circuit ground are covered. The development of the Standard for Flat-Plate Photovoltaic Modules and Panels has continued, and with both industry comment and a product submittal and listing, the Standard has been refined to a viable document allowing an objective safety review of photovoltaic modules and panels. How this document, and other UL documents would cover investigations of certain other photovoltaic system components is described.« less

  11. Final report on the safety assessment of Cocos nucifera (coconut) oil and related ingredients.

    PubMed

    Burnett, Christina L; Bergfeld, Wilma F; Belsito, Donald V; Klaassen, Curtis D; Marks, James G; Shank, Ronald C; Slaga, Thomas J; Snyder, Paul W; Andersen, F Alan

    2011-05-01

    Cocos nucifera (coconut) oil, oil from the dried coconut fruit, is composed of 90% saturated triglycerides. It may function as a fragrance ingredient, hair conditioning agent, or skin-conditioning agent and is reported in 626 cosmetics at concentrations from 0.0001% to 70%. The related ingredients covered in this assessment are fatty acids, and their hydrogenated forms, corresponding fatty alcohols, simple esters, and inorganic and sulfated salts of coconut oil. The salts and esters are expected to have similar toxicological profiles as the oil, its hydrogenated forms, and its constituent fatty acids. Coconut oil and related ingredients are safe as cosmetic ingredients in the practices of use and concentration described in this safety assessment.

  12. NASA Aviation Safety Reporting System (ASRS)

    NASA Technical Reports Server (NTRS)

    Connell, Linda

    2011-01-01

    The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 900,000 reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 5,500 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides de-identified report information through the online ASRS Database at http://asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation \\vill discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

  13. NASA Aviation Safety Reporting System (ASRS)

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.

    2017-01-01

    The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

  14. Overview of Energy Systems` safety analysis report programs. Safety Analysis Report Update Program

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

    Not Available

    1992-03-01

    The primary purpose of an Safety Analysis Report (SAR) is to provide a basis for judging the adequacy of a facility`s safety. The SAR documents the safety analyses that systematically identify the hazards posed by the facility, analyze the consequences and risk of potential accidents, and describe hazard control measures that protect the health and safety of the public and employees. In addition, some SARs document, as Technical Safety Requirements (TSRs, which include Technical Specifications and Operational Safety Requirements), technical and administrative requirements that ensure the facility is operated within prescribed safety limits. SARs also provide conveniently summarized information thatmore » may be used to support procedure development, training, inspections, and other activities necessary to facility operation. This ``Overview of Energy Systems Safety Analysis Report Programs`` Provides an introduction to the programs and processes used in the development and maintenance of the SARs. It also summarizes some of the uses of the SARs within Energy Systems and DOE.« less

  15. The complexity of patient safety reporting systems in UK dentistry.

    PubMed

    Renton, T; Master, S

    2016-10-21

    Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

  16. Safety analysis and review system (SARS) assessment report

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

    Browne, E.T.

    1981-03-01

    Under DOE Order 5481.1, Safety Analysis and Review System for DOE Operations, safety analyses are required for DOE projects in order to ensure that: (1) potential hazards are systematically identified; (2) potential impacts are analyzed; (3) reasonable measures have been taken to eliminate, control, or mitigate the hazards; and (4) there is documented management authorization of the DOE operation based on an objective assessment of the adequacy of the safety analysis. This report is intended to provide the DOE Office of Plans and Technology Assessment (OPTA) with an independent evaluation of the adequacy of the ongoing safety analysis effort. Asmore » part of this effort, a number of site visits and interviews were conducted, and FE SARS documents were reviewed. The latter included SARS Implementation Plans for a number of FE field offices, as well as safety analysis reports completed for certain FE operations. This report summarizes SARS related efforts at the DOE field offices visited and evaluates the extent to which they fulfill the requirements of DOE 5481.1.« less

  17. An assessment of traffic safety culture related to engagement in efforts to improve traffic safety : final report.

    DOT National Transportation Integrated Search

    2016-12-01

    This final report summarizes the methods, results, conclusions, and recommendations derived from a survey conducted to understand values, beliefs, and attitudes regarding engagement in behaviors that impact the traffic safety of others. Results of th...

  18. Inroads into Equestrian Safety: Rider-Reported Factors Contributing to Horse-Related Accidents and Near Misses on Australian Roads.

    PubMed

    Thompson, Kirrilly; Matthews, Chelsea

    2015-07-22

    Horse riding and horse-related interactions are inherently dangerous. When they occur on public roads, the risk profile of equestrian activities is complicated by interactions with other road users. Research has identified speed, proximity, visibility, conspicuity and mutual misunderstanding as factors contributing to accidents and near misses. However, little is known about their significance or incidence in Australia. To explore road safety issues amongst Australian equestrians, we conducted an online survey. More than half of all riders (52%) reported having experienced at least one accident or near miss in the 12 months prior to the survey. Whilst our findings confirm the factors identified overseas, we also identified issues around rider misunderstanding of road rules and driver misunderstanding of rider hand signals. Of particular concern, we also found reports of potentially dangerous rider-directed road rage. We identify several areas for potential safety intervention including (1) identifying equestrians as vulnerable road users and horses as sentient decision-making vehicles (2) harmonising laws regarding passing horses, (3) mandating personal protective equipment, (4) improving road signage, (5) comprehensive data collection, (6) developing mutual understanding amongst road-users, (7) safer road design and alternative riding spaces; and (8) increasing investment in horse-related safety initiatives.

  19. Creating an Oversight Infrastructure for Electronic Health Record-Related Patient Safety Hazards

    PubMed Central

    Singh, Hardeep; Classen, David C.; Sittig, Dean F.

    2013-01-01

    Electronic health records (EHRs) have potential quality and safety benefits. However, reports of EHR-related safety hazards are now emerging. The Office of the National Coordinator (ONC) for Health Information Technology (HIT) recently sponsored an Institute of Medicine committee to evaluate how HIT use affects patient safety. In this paper, we propose the creation of a national EHR oversight program to provide dedicated surveillance of EHR-related safety hazards and to promote learning from identified errors, close calls, and adverse events. The program calls for data gathering, investigation/analysis and regulatory components. The first two functions will depend on institution-level EHR safety committees that will investigate all known EHR-related adverse events and near-misses and report them nationally using standardized methods. These committees should also perform routine safety self-assessments to proactively identify new risks. Nationally, we propose the long-term creation of a centralized, non-partisan board with an appropriate legal and regulatory infrastructure to ensure the safety of EHRs. We discuss the rationale of the proposed oversight program and its potential organizational components and functions. These include mechanisms for robust data collection and analyses of all safety concerns using multiple methods that extend beyond reporting; multidisciplinary investigation of selected high-risk safety events; and enhanced coordination with other national agencies in order to facilitate broad dissemination of hazards information. Implementation of this proposed infrastructure can facilitate identification of EHR-related adverse events and errors and potentially create a safer and more effective EHR-based health care delivery system. PMID:22080284

  20. An exploration of Australian hospital pharmacists' attitudes to patient safety.

    PubMed

    Lalor, Daniel J; Chen, Timothy F; Walpola, Ramesh; George, Rachel A; Ashcroft, Darren M; Fois, Romano A

    2015-02-01

    To explore the attitudes of Australian hospital pharmacists towards patient safety in their work settings. A safety climate questionnaire was administered to all 2347 active members of the Society of Hospital Pharmacists of Australia in 2010. Part of the survey elicited free-text comments about patient safety, error and incident reporting. The comments were subjected to thematic analysis to determine the attitudes held by respondents in relation to patient safety and its quality management in their work settings. Two hundred and ten (210) of 643 survey respondents provided comments on safety and quality issues related to their work settings. The responses contained a number of dominant themes including issues of workforce and working conditions, incident reporting systems, the response when errors occur, the presence or absence of a blame culture, hospital management support for safety initiatives, openness about errors and the value of teamwork. A number of pharmacists described the development of a mature patient-safety culture - one that is open about reporting errors and active in reducing their occurrence. Others described work settings in which a culture of blame persists, stifling error reporting and ultimately compromising patient safety. Australian hospital pharmacists hold a variety of attitudes that reflect diverse workplace cultures towards patient safety, error and incident reporting. This study has provided an insight into these attitudes and the actions that are needed to improve the patient-safety culture within Australian hospital pharmacy work settings. © 2014 Royal Pharmaceutical Society.

  1. Report to NASA Committee on Aircraft Operating Problems Relative to Aviation Safety Engineering and Research Activities

    NASA Technical Reports Server (NTRS)

    1963-01-01

    The following report highlights some of the work accomplished by the Aviation Safety Engineering and Research Division of the Flight Safety Foundations since the last report to the NASA Committee on Aircraft Operating Problems on 22 May 1963. The information presented is in summary form. Additional details may be provided upon request of the reports themselves may be obtained from AvSER.

  2. Does probability of occurrence relate to population dynamics?

    USGS Publications Warehouse

    Thuiller, Wilfried; Münkemüller, Tamara; Schiffers, Katja H.; Georges, Damien; Dullinger, Stefan; Eckhart, Vincent M.; Edwards, Thomas C.; Gravel, Dominique; Kunstler, Georges; Merow, Cory; Moore, Kara; Piedallu, Christian; Vissault, Steve; Zimmermann, Niklaus E.; Zurell, Damaris; Schurr, Frank M.

    2014-01-01

    Hutchinson defined species' realized niche as the set of environmental conditions in which populations can persist in the presence of competitors. In terms of demography, the realized niche corresponds to the environments where the intrinsic growth rate (r) of populations is positive. Observed species occurrences should reflect the realized niche when additional processes like dispersal and local extinction lags do not have overwhelming effects. Despite the foundational nature of these ideas, quantitative assessments of the relationship between range-wide demographic performance and occurrence probability have not been made. This assessment is needed both to improve our conceptual understanding of species' niches and ranges and to develop reliable mechanistic models of species geographic distributions that incorporate demography and species interactions.The objective of this study is to analyse how demographic parameters (intrinsic growth rate r and carrying capacity K ) and population density (N ) relate to occurrence probability (Pocc ). We hypothesized that these relationships vary with species' competitive ability. Demographic parameters, density, and occurrence probability were estimated for 108 tree species from four temperate forest inventory surveys (Québec, western USA, France and Switzerland). We used published information of shade tolerance as indicators of light competition strategy, assuming that high tolerance denotes high competitive capacity in stable forest environments.Interestingly, relationships between demographic parameters and occurrence probability did not vary substantially across degrees of shade tolerance and regions. Although they were influenced by the uncertainty in the estimation of the demographic parameters, we found that r was generally negatively correlated with Pocc, while N, and for most regions K, was generally positively correlated with Pocc. Thus, in temperate forest trees the regions of highest occurrence

  3. Defining and classifying medical error: lessons for patient safety reporting systems.

    PubMed

    Tamuz, M; Thomas, E J; Franchois, K E

    2004-02-01

    It is important for healthcare providers to report safety related events, but little attention has been paid to how the definition and classification of events affects a hospital's ability to learn from its experience. To examine how the definition and classification of safety related events influences key organizational routines for gathering information, allocating incentives, and analyzing event reporting data. In semi-structured interviews, professional staff and administrators in a tertiary care teaching hospital and its pharmacy were asked to describe the existing programs designed to monitor medication safety, including the reporting systems. With a focus primarily on the pharmacy staff, interviews were audio recorded, transcribed, and analyzed using qualitative research methods. Eighty six interviews were conducted, including 36 in the hospital pharmacy. Examples are presented which show that: (1) the definition of an event could lead to under-reporting; (2) the classification of a medication error into alternative categories can influence the perceived incentives and disincentives for incident reporting; (3) event classification can enhance or impede organizational routines for data analysis and learning; and (4) routines that promote organizational learning within the pharmacy can reduce the flow of medication error data to the hospital. These findings from one hospital raise important practical and research questions about how reporting systems are influenced by the definition and classification of safety related events. By understanding more clearly how hospitals define and classify their experience, we may improve our capacity to learn and ultimately improve patient safety.

  4. Are health professionals' perceptions of patient safety related to figures on safety incidents?

    PubMed

    Martijn, Lucie; Harmsen, Mirjam; Gaal, Sander; Mettes, Dirk; van Dulmen, Simone; Wensing, Michel

    2013-10-01

    The study aims to explore whether health care professionals' perceptions of patient safety in their practice were associated with the number of patient safety incidents identified in patient records. Seventy primary care practices of general practice, general dental practice, midwifery practices and allied health care practices were used in the study. A retrospective audit of 50 patient records was performed to identify patient safety incidents in each of the practices and a survey among health professionals to identify their perceptions of patient safety. All health professions felt that 'communication breakdowns inside the practice' as well as 'communication breakdowns outside the practice' and 'reporting of patient safety concerns' were a threat to patient safety in their work setting. We found little association between the perceptions of health professionals and the number of safety incidents. The only item with a significant relation to a higher number of safety incidents referred to the perception of 'communication problems outside the practice' as a threat to patient safety. This study indicates that the assessment of professionals' perceptions may be complementary to observed safety incidents, but not linked to an objective measure of patient safety. © 2012 John Wiley & Sons Ltd.

  5. Administration of the Radiation Control for Health and Safety Act of 1968, Public Law 90-602, (1987 annual report). Report for January-December 1987

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

    Not Available

    This document is an annual report submitted to the President for transmittal to the Congress. The Food and Drug Administration, through its Center for Devices and Radiological Health, is responsible for the day-to-day administration of the Radiation Control for Health and Safety Act of 1968. The report provides a summary of the operations of the Center in carrying out that responsibility for calendar year 1987. In reviewing the operations of the CDRH as reported in the document, it should be kept in mind that the day-to-day administration of the Act is only part of the Center's function. Other responsibilities includemore » the administration and enforcement of the 1976 Medical Device Amendments to the Federal Food, Drug, and Cosmetic Act (not covered in the report). Manufacturers of electronic products are required by 21 CFR 1002.20 to report accidental radiation occurrences to the CDRH. The Center no longer maintains a Radiation Incidents Registry, since accidental radiation occurrences are reported through the Device Experience Network (DEN) and through the requirements of the Medical Device Reporting (MDR) regulations.« less

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

    PubMed

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

    2016-05-01

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

  7. 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.

  8. Impact of Computer Related Posture on the Occurrence of Musculoskeletal Discomfort among Secondary School Students in Lagos, Nigeria.

    PubMed

    Odebiyi, D O; Olawale, O A; Adeniji, Y M

    2013-01-01

    Computers have become an essential part of life particularly in industrially advanced countries of the world. Children now have greater accessibility to computers both at school and at home. Recent studies suggest that with this increased exposure, there are associated musculoskeletal disorders (MSDs) in both school-aged children and adults. To assess the posture assumed by secondary school students during computer use and its impact on the occurrence and severity of reported musculoskeletal discomforts. Posture assumed during normal computer class, occurrence of discomforts, body parts involved and the intensity of discomforts were evaluated in 235 school aged children using Rapid Upper Limb Assessment (RULA) scale, Body Discomfort Chart (BDC) and Visual Analogue Scale (VAS) before and after normal computer class. Inferential statistics of t-test and chi-square were used to determine significance difference between variables, with level of significant set at p < 0.05. None of the participants demonstrated acceptable posture. Computer use produced significant discomforts on the neck, shoulder and low back. There was a significant relationship between participants height and posture assumed. Two hundred and eleven (89.8%) participants reported discomforts/pain during the use of computer. Weight and height were contributory factors to the occurrence of musculoskeletal discomfort/pain (p < 0.05) in some of the body parts studied. Musculoskeletal discomfort was found to be a problem among the school-aged children during computer use. Weight and height were implicated as factors that influenced the form of posture and the nature of the reported discomfort. Creating awareness about the knowledge of ergonomics and safety for promotion of good posture was therefore recommended.

  9. The Effects of Safety Discrimination Training and Frequent Safety Observations on Safety-Related Behavior

    ERIC Educational Resources Information Center

    Taylor, Matthew A.; Alvero, Alicia M.

    2012-01-01

    The intent of the present study was to assess the effects of discrimination training only and in combination with frequent safety observations on five participants' safety-related behavior in a simulated office setting. The study used a multiple-baseline design across safety-related behaviors. Across all participants and behavior, safety improved…

  10. 21 CFR 1002.20 - Reporting of accidental radiation occurrences.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... the Director, Center for Devices and Radiological Health, all accidental radiation occurrences... grounds include, but are not necessarily limited to, professional, scientific, or medical facts or... occurred. (b) Such reports shall be addressed to the Center for Devices and Radiological Health, ATTN...

  11. 21 CFR 1002.20 - Reporting of accidental radiation occurrences.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... the Director, Center for Devices and Radiological Health, all accidental radiation occurrences... grounds include, but are not necessarily limited to, professional, scientific, or medical facts or... occurred. (b) Such reports shall be addressed to Food and Drug Administration, Center for Devices and...

  12. TA-55 Final Safety Analysis Report Comparison Document and DOE Safety Evaluation Report Requirements

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

    Alan Bond

    2001-04-01

    This document provides an overview of changes to the currently approved TA-55 Final Safety Analysis Report (FSAR) that are included in the upgraded FSAR. The DOE Safety Evaluation Report (SER) requirements that are incorporated into the upgraded FSAR are briefly discussed to provide the starting point in the FSAR with respect to the SER requirements.

  13. Inadequate safety reporting in pre-eclampsia trials: a systematic evaluation.

    PubMed

    Duffy, Jmn; Hirsch, M; Pealing, L; Showell, M; Khan, K S; Ziebland, S; McManus, R J

    2018-06-01

    Randomised trials and their syntheses in meta-analyses offer a unique opportunity to assess the frequency and severity of adverse reactions. To assess safety reporting in pre-eclampsia trials. Systematic search using bibliographic databases, including Cochrane Central Register of Controlled Trials, Embase, and MEDLINE, from inception to August 2017. Randomised trials evaluating anticonvulsant or antihypertensive medication for pre-eclampsia. Descriptive statistics appraising the adequacy of adverse reaction and toxicity reporting. We included 60 randomised trials. Six trials (10%) were registered with the International Clinical Trials Registry Platform, two registry records referred to adverse reactions, stating 'safety and toleration' and 'possible side effects' would be collected. Twenty-six trials (43%) stated the frequency of withdrawals within each study arm, and five trials (8%) adequately reported these withdrawals. Adverse reactions were inconsistently reported across eligible trials: 24 (40%) reported no serious adverse reactions and 36 (60%) reported no mild adverse reactions. The methods of definition or measurement of adverse reactions were infrequently reported within published trial reports. Pre-eclampsia trials regularly omit critical information related to safety. Despite the paucity of reporting, randomised trials collect an enormous amount of safety data. Developing and implementing a minimum data set could help to improve safety reporting, permitting a more balanced assessment of interventions by considering the trade-off between the benefits and harms. National Institute for Health Research (DRF-2014-07-051), UK; Maternity Forum, Royal Society of Medicine, UK. Developing @coreoutcomes could help to improve safety reporting in #preeclampsia trials. @NIHR_DC. © 2017 Royal College of Obstetricians and Gynaecologists.

  14. NASA Range Safety Annual Report 2007

    NASA Technical Reports Server (NTRS)

    Dumont, Alan G.

    2007-01-01

    As always, Range Safety has been involved in a number of exciting and challenging activities and events. Throughout the year, we have strived to meet our goal of protecting the public, the workforce, and property during range operations. During the past year, Range Safety was involved in the development, implementation, and support of range safety policy. Range Safety training curriculum development was completed this year and several courses were presented. Tailoring exercises concerning the Constellation Program were undertaken with representatives from the Constellation Program, the 45th Space Wing, and the Launch Constellation Range Safety Panel. Range Safety actively supported the Range Commanders Council and it subgroups and remained involved in updating policy related to flight safety systems and flight safety analysis. In addition, Range Safety supported the Space Shuttle Range Safety Panel and addressed policy concerning unmanned aircraft systems. Launch operations at Kennedy Space Center, the Eastern and Western ranges, Dryden Flight Research Center, and Wallops Flight Facility were addressed. Range Safety was also involved in the evaluation of a number of research and development efforts, including the space-based range (formerly STARS), the autonomous flight safety system, the enhanced flight termination system, and the joint advanced range safety system. Flight safety system challenges were evaluated. Range Safety's role in the Space Florida Customer Assistance Service Program for the Eastern Range was covered along with our support for the Space Florida Educational Balloon Release Program. We hope you have found the web-based format both accessible and easy to use. Anyone having questions or wishing to have an article included in the 2008 Range Safety Annual Report should contact Alan Dumont, the NASA Range Safety Program Manager located at the Kennedy Space Center, or Michael Dook at NASA Headquarters.

  15. Aviation Safety Reporting System: Process and Procedures

    NASA Technical Reports Server (NTRS)

    Connell, Linda J.

    1997-01-01

    The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.

  16. The Interagency Nuclear Safety Review Panel's Galileo safety evaluation report

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

    Nelson, R.C.; Gray, L.B.; Huff, D.A.

    The safety evaluation report (SER) for Galileo was prepared by the Interagency Nuclear Safety Review Panel (INSRP) coordinators in accordance with Presidential directive/National Security Council memorandum 25. The INSRP consists of three coordinators appointed by their respective agencies, the Department of Defense, the Department of Energy (DOE), and the National Aeronautics and Space Administration (NASA). These individuals are independent of the program being evaluated and depend on independent experts drawn from the national technical community to serve on the five INSRP subpanels. The Galileo SER is based on input provided by the NASA Galileo Program Office, review and assessment ofmore » the final safety analysis report prepared by the Office of Special Applications of the DOE under a memorandum of understanding between NASA and the DOE, as well as other related data and analyses. The SER was prepared for use by the agencies and the Office of Science and Technology Policy, Executive Office of the Present for use in their launch decision-making process. Although more than 20 nuclear-powered space missions have been previously reviewed via the INSRP process, the Galileo review constituted the first review of a nuclear power source associated with launch aboard the Space Transportation System.« less

  17. Car manufacturers and global road safety: a word frequency analysis of road safety documents.

    PubMed

    Roberts, I; Wentz, R; Edwards, P

    2006-10-01

    The World Bank believes that the car manufacturers can make a valuable contribution to road safety in poor countries and has established the Global Road Safety Partnership (GRSP) for this purpose. However, some commentators are sceptical. The authors examined road safety policy documents to assess the extent of any bias. Word frequency analyses of road safety policy documents from the World Health Organization (WHO) and the GRSP. The relative occurrence of key road safety terms was quantified by calculating a word prevalence ratio with 95% confidence intervals. Terms for which there was a fourfold difference in prevalence between the documents were tabulated. Compared to WHO's World report on road traffic injury prevention, the GRSP road safety documents were substantially less likely to use the words speed, speed limits, child restraint, pedestrian, public transport, walking, and cycling, but substantially more likely to use the words school, campaign, driver training, and billboard. There are important differences in emphasis in road safety policy documents prepared by WHO and the GRSP. Vigilance is needed to ensure that the road safety interventions that the car industry supports are based on sound evidence of effectiveness.

  18. Canadian Pacific Railway Investigation of Safety-Related Occurrences Protocol considered helpful by both labor and management.

    DOT National Transportation Integrated Search

    2006-09-01

    The Federal Railroad Administration (FRA) Human Factors Research and Development (R&D) Program sponsored an Alternative Safety Measures Program designed to explore alternative methods for evaluating whether safety programs improve safety outcomes and...

  19. An evaluation of safety culture initiatives at BNSF Railway

    DOT National Transportation Integrated Search

    2015-04-01

    Major safety culture (SC) initiatives initiated in the FRA Office of Research, Technology and Development (RT&D), such as Clear Signal for Action (CSA), the Investigation of Safety Related Occurrences Protocol (ISROP), the Participative Safety Rules ...

  20. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1979-01-01

    The human factors frequency considered a cause of or contributor to hazardous events onboard air carriers are examined with emphasis on distractions. Safety reports that have been analyzed, processed, and entered into the aviation safety reporting system data base are discussed. A sampling of alert bulletins and responses to them is also presented.

  1. Reported Back Pain in Army Aircrew in Relation to Airframe, Gender, Age, and Experience.

    PubMed

    Kelley, Amanda M; MacDonnell, Jason; Grigley, Deahndra; Campbell, John; Gaydos, Steven J

    2017-02-01

    Back pain has remained an issue of significance among aircraft crewmembers for decades, occurring in the majority of military helicopter pilots with potential deleterious effects on performance, safety, and operational readiness. This exploratory, correlational survey study was designed to evaluate the presence of patterns and relationships that may require further examination to understand causal factors. The study population consisted of U.S. Army aviation crewmembers. Subjects (467) completed an anonymous survey, including questions regarding demographics, airframes, experience, pain history and severity, ergonomics, mitigation strategies, and duty limitations. Overall, 84.6% of participants reported back pain at some time during their flying career, with 77.8% reporting back pain in the last calendar year. Age was found to significantly correlate with earlier time to pain during flight, higher pain rating after flight, and occurrence of grounding. A stepwise linear regression model was used to explore the relationships between age, flight hours, and years of aviation experience, demonstrating age to be the significant variable accounting for the observed variance. Aircrew reported wear of combat-related survival equipment and poor lumbar support to be the most notable contributors. Back pain rates were consistent with previous studies. The relationship of age to back pain in this study may highlight unique pathophysiological pathways that should be further investigated within an occupational context to better understand the etiologic role. Enhanced seated lumbar support and combat-related survival equipment remain relatively low-cost/high-yield topics worthy of further investigation for exploiting efficient means to improve health, safety, and operational performance.Kelley AM, MacDonnell J, Grigley D, Campbell J, Gaydos SJ. Reported back pain in army aircrew in relation to airframe, gender, age, and experience. Aerosp Med Hum Perform. 2017; 88(2):96-103.

  2. 21 CFR 314.540 - Postmarketing safety reporting.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 5 2010-04-01 2010-04-01 false Postmarketing safety reporting. 314.540 Section... New Drugs for Serious or Life-Threatening Illnesses § 314.540 Postmarketing safety reporting. Drug products approved under this program are subject to the postmarketing recordkeeping and safety reporting...

  3. 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 ...

  4. The aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    Reynard, W. D.

    1984-01-01

    The aviation safety reporting system, an accident reporting system, is presented. The system identifies deficiencies and discrepancies and the data it provides are used for long term identification of problems. Data for planning and policy making are provided. The system offers training in safety education to pilots. Data and information are drawn from the available data bases.

  5. Psychological safety and error reporting within Veterans Health Administration hospitals.

    PubMed

    Derickson, Ryan; Fishman, Jonathan; Osatuke, Katerine; Teclaw, Robert; Ramsel, Dee

    2015-03-01

    In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors. We conducted an ANOVA on psychological safety scores from a VHA employees census survey (n = 185,879), assessing variability of means across racial and supervisory levels. We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Psychological safety increased with supervisory level (P < 0.001, η = 0.03) and was not meaningfully related to race (P < 0.001, η = 0.003). Twelve percent of employees would not report an error; retaliation fear was the most commonly mentioned deterrent. Furthermore, employees at the psychologically unsafe hospital (71% would report, 13% would not) were less willing to report an error than at the psychologically safe hospital (91% would, 0% would not). A substantial minority would not report an error and were willing to admit so in a private interview setting. Their stated reasons as well as higher psychological safety means for supervisory employees both suggest power as an important determinant. Intentions to report were associated with psychological safety, strongly suggesting this climate aspect as instrumental to improving patient safety and reducing costs.

  6. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1977-01-01

    A decline in reports concerning small aircraft was noted; more reports involved transport aircraft, professional pilots, instrument meteorological conditions, and weather problems. A study of 136 reports of operational problems in terminal radar service areas was made. Pilot, controller, and system factors were found to be associated with these occurrences. Information transfer difficulties were prominent. Misunderstandings by pilots, and in some cases by controllers, of the policies and limitations of terminal radar programs were observed.

  7. 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.

  8. [Patient safety: a comparison between handwritten and computerized voluntary incident reporting].

    PubMed

    Capucho, Helaine Carneiro; Arnas, Emilly Rasquini; Cassiani, Silvia Helena De Bortoli

    2013-03-01

    This study's objective was to compare two types of voluntary incident reporting methods that affect patient safety, handwritten (HR) and computerized (CR), in relation to the number of reports, type of incident reported the individual submitting the report, and quality of reports. This was a descriptive, retrospective and cross-sectional study. CR were more frequent than HR (61.2% vs. 38.6%) among the 1,089 reports analyzed and were submitted every day of the month, while HR were submitted only on weekdays. The highest number of reports referred to medication, followed by problems related to medical-hospital material and the professional who most frequently submitted reports were nurses in both cases. Overall CR presented higher quality than HR (86.1% vs. 61.7%); 36.8% of HR were illegible, a problem that was eliminated in CR. Therefore, the use of computerized incident reporting in hospitals favors qualified voluntary reports, increasing patient safety.

  9. Error reporting in transfusion medicine at a tertiary care centre: a patient safety initiative.

    PubMed

    Elhence, Priti; Shenoy, Veena; Verma, Anupam; Sachan, Deepti

    2012-11-01

    Errors in the transfusion process can compromise patient safety. A study was undertaken at our center to identify the errors in the transfusion process and their causes in order to reduce their occurrence by corrective and preventive actions. All near miss, no harm events and adverse events reported in the 'transfusion process' during 1 year study period were recorded, classified and analyzed at a tertiary care teaching hospital in North India. In total, 285 transfusion related events were reported during the study period. Of these, there were four adverse (1.5%), 10 no harm (3.5%) and 271 (95%) near miss events. Incorrect blood component transfusion rate was 1 in 6031 component units. ABO incompatible transfusion rate was one in 15,077 component units issued or one in 26,200 PRBC units issued and acute hemolytic transfusion reaction due to ABO incompatible transfusion was 1 in 60,309 component units issued. Fifty-three percent of the antecedent near miss events were bedside events. Patient sample handling errors were the single largest category of errors (n=94, 33%) followed by errors in labeling and blood component handling and storage in user areas. The actual and near miss event data obtained through this initiative provided us with clear evidence about latent defects and critical points in the transfusion process so that corrective and preventive actions could be taken to reduce errors and improve transfusion safety.

  10. Association between self-reported bruxism activity and occurrence of dental attrition, abfraction, and occlusal pits on natural teeth.

    PubMed

    Tsiggos, Nikolaos; Tortopidis, Dimitrios; Hatzikyriakos, Andreas; Menexes, George

    2008-07-01

    It is unclear whether subjects who report tooth clenching and/or grinding have more noticeable clinical signs of dental attrition, abfractions, and occlusal pits on their natural teeth than subjects who do not report bruxism activity. The purpose of this study was to determine whether there was an association between self-reported (or not reported) bruxism activity and occurrence of dental attrition (anterior, posterior), abfractions, and occlusal pits on natural teeth. One hundred and two volunteer adult Greek subjects (mean age 44.6 +/-5.7 years) were classified into 2 groups (50 self-reported bruxers and 52 nonbruxers) according to 2 inquires regarding grinding and/or clenching of their teeth. Dental attrition (anterior, posterior) was assessed by 2 calibrated experienced examiners on diagnostic casts on a tooth-by-tooth basis, using a previously well established ordinal scale. Abfraction lesions (V-shaped, in the cervical region) and occlusal pits were recorded if these clinical signs were found on at least 2 natural teeth. Statistical comparisons between the 2 groups relative to the distribution of the occurrence of the 4 clinical signs were performed by means of the exact version of the chi-square test. The Fisher's exact test was used for the comparison of percentages. The intra- and interexaminer reliability was assessed by means of the Cohen's kappa coefficient (alpha=.05). The results demonstrated that there was a significant association between self-reported bruxism and occurrence of the 4 clinical signs. Although the 2 groups were significantly different according to the distribution of the 4 clinical signs, the greatest differences occurred for the anterior and posterior attrition signs. In this study, the occurrence of 4 clinical signs (posterior or anterior dental attrition, abfractions, and occlusal pits) was associated with self-reported bruxers. It is suggested that, primarily, signs of dental attrition may differentiate self-reported bruxers from

  11. Review of Safety Reports Involving Electronic Flight Bags.

    DOT National Transportation Integrated Search

    2010-04-01

    Safety events in which Electronic Flight Bags (EFBs) were a factor are reviewed. Relevant reports were obtained from the public Aviation Safety Reporting System (ASRS) database and the National Transportation Safety Board (NTSB) accident report datab...

  12. 10 CFR 72.70 - Safety analysis report updating.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 2 2010-01-01 2010-01-01 false Safety analysis report updating. 72.70 Section 72.70 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF SPENT NUCLEAR FUEL, HIGH-LEVEL RADIOACTIVE WASTE, AND REACTOR-RELATED GREATER THAN CLASS C WASTE Records...

  13. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1977-01-01

    During the third quarter of operation of the Aviation Safety Reporting System (ASRS), 1429 reports concerning aviation safety were received from pilots, air traffic controllers, and others in the national aviation system. Details of the administration and results of the program are discussed. The design and construction of the ASRS data base are briefly presented. Altitude deviations and potential aircraft conflicts associated with misunderstood clearances were studied and the results are discussed. Summary data regarding alert bulletins, examples of alert bulletins and responses to them, and a sample of deidentified ASRS reports are provided.

  14. [Familial occurrence of botulism - a case report].

    PubMed

    AmbroŽová, Helena; DŽupová, Olga; Smíšková, Dita; Roháčová, Hana

    2014-06-01

    Botulism, a life-threatening condition, is very rare in the Czech Republic. Since 1960, a total of 155 cases have been reported; between 2010 and 2012, not a single case was identified. This is a case report of familiar occurrence of botulism following consumption of home-made pork and liver pâté in three family members admitted to the Department of Infectious, Tropical and Parasitic Diseases, Na Bulovce Hospital in Prague in May 2013. The neurological symptoms were dominated by diplopia and dysarthria. After administration of an antitoxin, all patients recovered. Given the poor availability of the antitoxin, a decision was made following this small family epidemic to have an emergency reserve of life-saving anti-infective drugs for the Czech Republic in the Toxicological Information Center in Prague.

  15. 1995 Bicycle and Pedestrian Safety Report

    DOT National Transportation Integrated Search

    1995-03-01

    This report provides a review of the current data on bicycle and pedestrian : safety across the United States, finding that safety and education : programs could significantly improve bicycle and pedestrian safety in the : Dallas-Fort Worth Metropoli...

  16. Reported Historic Asbestos Mines, Historic Asbestos Prospects, and Other Natural Occurrences of Asbestos in Oregon and Washington

    USGS Publications Warehouse

    Van Gosen, Bradley S.

    2010-01-01

    This map and its accompanying dataset provide information for 51 natural occurrences of asbestos in Washington and Oregon, using descriptions found in the geologic literature. Data on location, mineralogy, geology, and relevant literature for each asbestos site are provided. Using the map and digital data in this report, the user can examine the distribution of previously reported asbestos occurrences and their geological characteristics in the Pacific Northwest States of Washington and Oregon. This report is part of an ongoing study by the U.S. Geological Survey to identify and map reported natural asbestos occurrences in the United States, which thus far includes similar maps and datasets of natural asbestos occurrences within the Eastern United States (http://pubs.usgs.gov/of/2005/1189/), the Central United States (http://pubs.usgs.gov/of/2006/1211/), the Rocky Mountain States (http://pubs.usgs.gov/of/2007/1182/), and the Southwestern United States (http://pubs.usgs.gov/of/2008/1095/). These reports are intended to provide State and local government agencies and other stakeholders with geologic information on natural occurrences of asbestos in the United States.

  17. Implications of electronic health record downtime: an analysis of patient safety event reports.

    PubMed

    Larsen, Ethan; Fong, Allan; Wernz, Christian; Ratwani, Raj M

    2018-02-01

    We sought to understand the types of clinical processes, such as image and medication ordering, that are disrupted during electronic health record (EHR) downtime periods by analyzing the narratives of patient safety event report data. From a database of 80 381 event reports, 76 reports were identified as explicitly describing a safety event associated with an EHR downtime period. These reports were analyzed and categorized based on a developed code book to identify the clinical processes that were impacted by downtime. We also examined whether downtime procedures were in place and followed. The reports were coded into categories related to their reported clinical process: Laboratory, Medication, Imaging, Registration, Patient Handoff, Documentation, History Viewing, Delay of Procedure, and General. A majority of reports (48.7%, n = 37) were associated with lab orders and results, followed by medication ordering and administration (14.5%, n = 11). Incidents commonly involved patient identification and communication of clinical information. A majority of reports (46%, n = 35) indicated that downtime procedures either were not followed or were not in place. Only 27.6% of incidents (n = 21) indicated that downtime procedures were successfully executed. Patient safety report data offer a lens into EHR downtime-related safety hazards. Important areas of risk during EHR downtime periods were patient identification and communication of clinical information; these should be a focus of downtime procedure planning to reduce safety hazards. EHR downtime events pose patient safety hazards, and we highlight critical areas for downtime procedure improvement. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

  18. Electrical injury in relation to voltage, "no-let-go" phenomenon, symptoms and perceived safety culture: a survey of Swedish male electricians.

    PubMed

    Rådman, Lisa; Nilsagård, Ylva; Jakobsson, Kristina; Ek, Åsa; Gunnarsson, Lars-Gunnar

    2016-02-01

    Professional electricians are highly subjected to electrical injuries. Previous studies describing symptoms after electrical injury have not included people with less severe initial injuries. The purpose of the present study was to describe symptoms at different time points after electrical injury, the impact of "no-let-go" phenomenon and different electrical potential [high voltage (HV) vs. low voltage (LV)], and the safety culture at the workplace. A retrospective survey was conducted with 523 Swedish electricians. Two questionnaires were issued: the first to identify electricians who had experienced electrical injury and the second to gain information about symptoms and safety culture. Self-reported symptoms were described at different time points following injury. Symptoms for HV and LV accidents were compared. Occurrence or nonoccurrence of "no-let-go" phenomenon was analysed using two-tailed Chi-2. Safety culture was assessed with a validated questionnaire. Nearly all reported having symptoms directly after the injury, mainly paraesthesia and pain. For the first weeks after injury, pain and muscle weakness dominated. The most frequently occurring symptoms at follow-up were pain, muscle weakness and loss of sensation. HV injuries and "no-let go" phenomenon were associated with more sustained symptoms. Deficiencies in the reporting routines were present, as well as shortage of preventive measures. The results indicate that symptoms are reported also long time after an electrical injury and that special attention should be paid to HV injuries and "no-let go" accidents. The workplace routines to reduce the number of work-related electrical injuries for Swedish electricians can be improved.

  19. Predictors of Hospital Nurses' Safety Practices: Work Environment, Workload, Job Satisfaction, and Error Reporting.

    PubMed

    Chiang, Hui-Ying; Hsiao, Ya-Chu; Lee, Huan-Fang

    Nurses' safety practices of medication administration, prevention of falls and unplanned extubations, and handover are essentials to patient safety. This study explored the prediction between such safety practices and work environment factors, workload, job satisfaction, and error-reporting culture of 1429 Taiwanese nurses. Nurses' job satisfaction, error-reporting culture, and one environmental factor of nursing quality were found to be major predictors of safety practices. The other environment factors related to professional development and participation in hospital affairs and nurses' workload had limited predictive effects on the safety practices. Increasing nurses' attention to patient safety by improving these predictors is recommended.

  20. Performance Analysis of Occurrences January 1, 2011-December 31, 2011

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

    Ludwig, M

    2012-03-16

    This report documents the analysis of the occurrences during the period January 1, 2011 through December 31, 2011. The report compares LLNL occurrences by reporting criteria and significance category to see if LLNL is reporting occurrences along similar percentages as other DOE sites. The three-year trends are analyzed. It does not include the analysis of the causes or the lessons learned from the occurrences, as they are analyzed separately. The number and types of occurrences that LLNL reports to DOE varies over time. This variation can be attributed to normally occurring changes in frequency; DOE's or LLNL's heightened interest inmore » a particular subject area; changes in LLNL processes; or emerging problems. Since all of the DOE sites use the same reporting criteria, it is helpful to understand if LLNL is consistent with or diverging from reporting at other sites. This section compares the normalized number of occurrences reported by LLNL and other DOE sites. In order to compare LLNL occurrence reports to occurrence reports from other DOE sites, we normalized (or standardized) the data from the sites. DOE sites vary widely in their budgets, populations, and scope of work and these variations may affect reporting frequency. In addition, reports are required for a wide range of occurrence types, some of which may not be applicable to all DOE sites. For example, one occurrence reporting group is Group 3, Nuclear Safety Basis, and not all sites have nuclear operations. Because limited information is available for all sites, the sites were normalized based on best available information. Site effort hours were extracted from the DOE Computerized Accident Incident Reporting System (CAIRS) and used to normalize (or standardize) the number of occurrences by site. Effort hours are those hours that employees normally work and do not include vacation, holiday hours etc. Sites are responsible for calculating their effort hours and ensuring entry into CAIRS. Out of the

  1. Radiation safety issues related to radiolabeled antibodies. [Contains glossary

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

    Barber, D.E.; Baum, J.W.; Meinhold, C. B.

    1991-03-01

    Techniques related to the use of radiolabeled antibodies in humans are reviewed and evaluated in this report. It is intended as an informational resource for the US Nuclear Regulatory Commission (NRC) and NRC licensees. Descriptions of techniques and health and safety issues are provided. Principal methods for labeling antibodies are summarized to help identify related radiation safety problems in the preparation of dosages for administration to patients. The descriptions are derived from an extensive literature review and consultations with experts in the field. A glossary of terms and acronyms is also included. An assessment was made of the extent ofmore » the involvement of organizations (other than the NRC) with safety issues related to radiolabeled antibodies, in order to identify regulatory issues which require attention. Federal regulations and guides were also reviewed for their relevance. A few (but significant) differences between the use of common radiopharmaceuticals and radiolabeled antibodies were observed. The clearance rate of whole, radiolabeled immunoglobulin is somewhat slower than common radiopharmaceuticals, and new methods of administration are being used. New nuclides are being used or considered (e.g., Re-186 and At-211) for labeling antibodies. Some of these nuclides present new dosimetry, instrument calibration, and patient management problems. Subjects related to radiation safety that require additional research are identified. 149 refs., 3 figs., 20 tabs.« less

  2. Annual report to Congress: Department of Energy activities relating to the Defense Nuclear Facilities Safety Board, Calendar Year 1999

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

    None

    2000-02-01

    This is the tenth Annual Report to the Congress describing Department of Energy activities in response to formal recommendations and other interactions with the Defense Nuclear Facilities Safety Board (Board). The Board, an independent executive-branch agency established in 1988, provides advice and recommendations to the Secretary of Energy regarding public health and safety issues at the Department's defense nuclear facilities. The Board also reviews and evaluates the content and implementation of health and safety standards, as well as other requirements, relating to the design, construction, operation, and decommissioning of the Department's defense nuclear facilities. During 1999, Departmental activities resulted inmore » the closure of nine Board recommendations. In addition, the Department has completed all implementation plan milestones associated with three Board recommendations. One new Board recommendation was received and accepted by the Department in 1999, and a new implementation plan is being developed to address this recommendation. The Department has also made significant progress with a number of broad-based initiatives to improve safety. These include expanded implementation of integrated safety management at field sites, opening of a repository for long-term storage of transuranic wastes, and continued progress on stabilizing excess nuclear materials to achieve significant risk reduction.« less

  3. Transportation Safety Information Report : 1982 Annual Summary

    DOT National Transportation Integrated Search

    1983-01-01

    The "Transportation Safety Information Report" is a compendium of selected national-level transportation safety statistics for all modes of transportation. The report presents and compares data for transportation fatalities, accidents, and injuries f...

  4. Transportation Safety Information Report : 1987 Annual Summary

    DOT National Transportation Integrated Search

    1988-01-01

    The "Transportation Safety Information Report" is a compendium of selected national-level transportation safety statistics for all modes of transportation. The report presents and compares data for transportation fatalities, accidents, and injuries f...

  5. 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.

  6. Error reduction, patient safety and institutional ethics committees.

    PubMed

    Meaney, Mark E

    2004-01-01

    Institutional ethics committees remain largely absent from the literature on error reduction and patient safety. In this paper, the author endeavors to fill the gap. As noted in the Hastings Center's recent report, "Promoting Patient Safety," the occurrence of medical error involves complex web of multiple factors. Human misstep is certainly one such factor, but not the only one. This paper builds on the Hastings Center's report in arguing that institutional ethics committees ought to play an integral role in the transformation of a "culture of blame" to a "culture of safety" in healthcare delivery.

  7. Transportation Safety Information Report : Second Quarter 1984

    DOT National Transportation Integrated Search

    1984-01-01

    The "Transportation Safety Information Report" is a compendium of selected national-level transportation safety statistics for all modes of transportation. The report presents and compares data on a monthly and quarterly basis for transportation fata...

  8. Transportation Safety Information Report : Second Quarter 1985

    DOT National Transportation Integrated Search

    1985-10-01

    The "Transportation Safety Information Report" is a compendium of selected national-level transportation safety statistics for all modes of transportation. The report presents and compares data on a monthly and quarterly basis for transportation fata...

  9. Analysis of Safety-Related Regulatory Actions for New Drugs in Japan by Nature of Identified Risks.

    PubMed

    Fujikawa, Makoto; Ono, Shunsuke

    2017-01-01

    Mechanisms underlying safety events may be heterogeneous and depend on conditions of development and marketing, including the populations studied in clinical trials and the amount of data required for approval, especially under pathways for accelerated access. This study was conducted to investigate possible factors affecting the first post-marketing safety-related regulatory actions (SRRAs) after launch of new drugs in Japan. We studied 338 new molecular entities (NMEs) approved in Japan between 2004 and 2014. We focused on three different types of SRRAs: (1) all-SRRAs (i.e. SRRAs from domestic cases and other countries), (2) domestic-SRRAs (i.e. SRRAs from domestic cases) and (3) domestic unknown-SRRAs (i.e. SRRAs of unknown risks from domestic cases). Occurrences of the three types of SRRAs were analyzed using Kaplan-Meier analysis and Cox-regression. SRRAs tended to occur sooner for NMEs launched in recent years versus those launched towards the beginning of the study period. Risk of SRRA was high for antineoplastics. Drugs for cardiovascular diseases, central nervous system, and diabetes had positive associations with all-SRRAs, but the associations were weaker with domestic-SRRAs. Domestic-SRRAs were more likely for drugs with relatively novel modes of action (MOAs). Longer lag to Japanese launch after first global launch significantly lowered SRRA risks. While most of the variables showed similar associations across the three types of SRRAs, adoption of bridging strategies showed higher risks only for domestic-SRRAs, not for all-SRRAs. FDA safety labeling changes and non-orphan priority review drugs presented higher domestic-SRRA risks. The number of adverse drug reactions (ADRs) from spontaneous reports had positive correlations with the three types of SRRAs, whereas the number from company-led surveillance showed no association. Our results indicated that global clinical development pathways and marketing status should be considered more seriously in

  10. Parental and Adolescent Perceptions of Neighborhood Safety Related to Adolescents’ Physical Activity in Their Neighborhood

    PubMed Central

    Esteban-Cornejo, Irene; Carlson, Jordan A.; Conway, Terry L.; Cain, Kelli L.; Saelens, Brian E.; Frank, Lawrence D.; Glanz, Karen; Roman, Caterina G.; Sallis, James F.

    2017-01-01

    Purpose The purpose of this study was to examine the association between adolescent and parental perceptions of neighborhood safety and adolescents’ physical activity in multiple locations and to investigate the moderating effect of sex within this association. Method This cross-sectional study was conducted with 928 adolescents aged 12 to 16 years old and 1 of their parents. Adolescents and parents reported their perceptions of neighborhood safety (traffic safety, pedestrian safety, crime safety, and stranger danger safety). Adolescents reported how often they were physically active in multiple locations (physical activity in the neighborhood, in parks, and for active transport). Mixed-effects linear regression models were used to investigate these associations while controlling for demographics and the Walkability Index. Results Parent-perceived crime safety was positively associated with adolescents’ physical activity in parks (B = .094, p = .024). Parent-perceived traffic safety was positively associated with adolescents’ reported physical activity in the neighborhood (B = .186, p = .014). Adolescents’ physical activity for active transport was positively associated with parent-perceived traffic safety (B = .179, p = .001), stranger danger safety (B = .110, p = .013), and crime safety (B = .077, p = .035). There were 2 interactions by sex on the relation between adolescent traffic safety perception and parent pedestrian safety perception in the neighborhood and adolescents’ physical activity in parks (i.e., statistically significant only for boys). Conclusions Parents’ perceptions of traffic, stranger danger, and crime safety were all related to adolescents’ active transportation. Multiple safety concerns may be motivating parents to restrict adolescent mobility by walking and bicycling. PMID:27030158

  11. 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.

  12. Analysis of pharmaceutical safety-related regulatory actions in Japan: do tradeoffs exist between safer drugs and launch delay?

    PubMed

    Yamada, Toru; Kusama, Makiko; Hirai, Yuka; Arnold, Frank; Sugiyama, Yuichi; Ono, Shunsuke

    2010-12-01

    Prediction and management of drug safety is a global regulatory issue. Safety-related regulatory actions (SRRAs) are taken mostly when unexpected adverse drug reactions occur. Currently, Japan is reconciled to delayed access to new drugs (ie, launch delay compared to Western countries), but may have been benefiting by free-riding on safety data accumulated in other countries prior to Japanese launch. To identify factors that are significantly associated with SRRAs, and to discuss the challenges that Japan might have to face with increasing access to new drugs. The SRRAs of 135 new drugs approved from January 2000 to December 2005 were analyzed to investigate association with launch lag, company and drug characteristics, market size, submission data, and regulatory status. SRRAs were measured in terms of the number of emergency safety information notifications and official safety instructions issued by the Japanese regulatory agency within 3 years after approval. A negative binomial distribution model was used for regression analysis. Longer launch lags and presence of drugs with similar modes of action were associated with fewer SRRAs. Bridging strategy showed increased SRRAs. No significant association was observed between SRRAs and the subject number in clinical data packages. Occurrence of SRRAs was varied among development strategy, preceding products, and regional regulations. The occurrence of SRRAs was associated with the accumulation of both foreign and domestic postmarketing evidence rather than with clinical trial data upon launch. Considering the paradigm shift to simultaneous global drug development and filing for regulatory approval, this study indicates the importance of intensive data collection in the early postmarketing phase and use of safety information in early markets. However, even if we would be sufficiently cautious about safety risks of new drugs, a population that enjoys first-in-class drugs probably has to bear the risks.

  13. Non-reporting of work injuries and aspects of jobsite safety climate and behavioral-based safety elements among carpenters in Washington State.

    PubMed

    Lipscomb, Hester J; Schoenfisch, Ashley L; Cameron, Wilfrid

    2015-04-01

    Declining work injury rates may reflect safer work conditions as well as under-reporting. Union carpenters were invited to participate in a mailed, cross-sectional survey designed to capture information about injury reporting practices. Prevalence of non-reporting and fear of repercussions for reporting were compared across exposure to behavioral-based safety elements and three domains of the Nordic Safety Climate Questionnaire (NOSACQ-50). The majority (>75%) of the 1,155 participants felt they could report work-related injuries to their supervisor without fear of retribution, and most felt that the majority of injuries on their jobsites got reported. However, nearly half indicated it was best not to report minor injuries, and felt pressures to use their private insurance for work injury care. The prevalence of non-reporting and fear of reporting increased markedly with poorer measures of management safety justice (NOSACQ-50). Formal and informal policies and practices on jobsites likely influence injury reporting. © 2015 Wiley Periodicals, Inc.

  14. 75 FR 16140 - Common Formats for Patient Safety Data Collection and Event Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-03-31

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats for Patient Safety Data Collection and Event Reporting AGENCY: Agency for Healthcare Research and... mandatory reporting system, collaborative/voluntary reporting system, research-related reporting system, or...

  15. Annual report to Congress: Department of Energy activities relating to the Defense Nuclear Facilities Safety Board, calendar year 1998

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

    NONE

    1999-02-01

    This is the ninth Annual Report to the Congress describing Department of Energy (Department) activities in response to formal recommendations and other interactions with the Defense Nuclear Facilities Safety Board (Board). The Board, an independent executive-branch agency established in 1988, provides advice and recommendations to the Secretary of energy regarding public health and safety issues at the Department`s defense nuclear facilities. The Board also reviews and evaluates the content and implementation of health and safety standards, as well as other requirements, relating to the design, construction, operation, and decommissioning of the Department`s defense nuclear facilities. The locations of the majormore » Department facilities are provided. During 1998, Departmental activities resulted in the proposed closure of one Board recommendation. In addition, the Department has completed all implementation plan milestones associated with four other Board recommendations. Two new Board recommendations were received and accepted by the Department in 1998, and two new implementation plans are being developed to address these recommendations. The Department has also made significant progress with a number of broad-based initiatives to improve safety. These include expanded implementation of integrated safety management at field sites, a renewed effort to increase the technical capabilities of the federal workforce, and a revised plan for stabilizing excess nuclear materials to achieve significant risk reduction.« less

  16. Formulating accident occurrence as a survival process.

    PubMed

    Chang, H L; Jovanis, P P

    1990-10-01

    A conceptual framework for accident occurrence is developed based on the principle of the driver as an information processor. The framework underlies the development of a modeling approach that is consistent with the definition of exposure to risk as a repeated trial. Survival theory is proposed as a statistical technique that is consistent with the conceptual structure and allows the exploration of a wide range of factors that contribute to highway operating risk. This survival model of accident occurrence is developed at a disaggregate level, allowing safety researchers to broaden the scope of studies which may be limited by the use of traditional aggregate approaches. An application of the approach to motor carrier safety is discussed as are potential applications to a variety of transportation industries. Lastly, a typology of highway safety research methodologies is developed to compare the properties of four safety methodologies: laboratory experiments, on-the-road studies, multidisciplinary accident investigations, and correlational studies. The survival theory formulation has a mathematical structure that is compatible with each safety methodology, so it may facilitate the integration of findings across methodologies.

  17. Fusion Safety Program annual report, fiscal year 1994

    NASA Astrophysics Data System (ADS)

    Longhurst, Glen R.; Cadwallader, Lee C.; Dolan, Thomas J.; Herring, J. Stephen; McCarthy, Kathryn A.; Merrill, Brad J.; Motloch, Chester C.; Petti, David A.

    1995-03-01

    This report summarizes the major activities of the Fusion Safety Program in fiscal year 1994. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory and Lockheed Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL, at other DOE laboratories, and at other institutions, including the University of Wisconsin. The technical areas covered in this report include tritium safety, beryllium safety, chemical reactions and activation product release, safety aspects of fusion magnet systems, plasma disruptions, risk assessment failure rate data base development, and thermalhydraulics code development and their application to fusion safety issues. Much of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Also included in the report are summaries of the safety and environmental studies performed by the Fusion Safety Program for the Tokamak Physics Experiment and the Tokamak Fusion Test Reactor and of the technical support for commercial fusion facility conceptual design studies. A major activity this year has been work to develop a DOE Technical Standard for the safety of fusion test facilities.

  18. Cabin Safety Issues Related to Pre-Departure and Inflight Issues

    NASA Technical Reports Server (NTRS)

    Connell, Linda

    2014-01-01

    The Aviation Safety Reporting System (ASRS) in a partnership between the National Aeronautics and Space Administration (NASA), the Federal Aviation Administration (FAA), participating carriers, and labor organizations. It is designed to improve the National Airspace System by collecting and studying reports detailing unsafe conditions and events in the aviation industry. Employees are able to report safety issues or concerns with confidentiality and without fear of discipline. Safety reports highlighting the human element in cabin safety issues and concerns.

  19. Do you see what I see? Effects of national culture on employees' safety-related perceptions and behavior.

    PubMed

    Casey, Tristan W; Riseborough, Karli M; Krauss, Autumn D

    2015-05-01

    Growing international trade and globalization are increasing the cultural diversity of the modern workforce, which often results in migrants working under the management of foreign leadership. This change in work arrangements has important implications for occupational health and safety, as migrant workers have been found to be at an increased risk of injuries compared to their domestic counterparts. While some explanations for this discrepancy have been proposed (e.g., job differences, safety knowledge, and communication difficulties), differences in injury involvement have been found to persist even when these contextual factors are controlled for. We argue that employees' national culture may explain further variance in their safety-related perceptions and safety compliance, and investigate this through comparing the survey responses of 562 Anglo and Southern Asian workers at a multinational oil and gas company. Using structural equation modeling, we firstly established partial measurement invariance of our measures across cultural groups. Estimation of the combined sample structural model revealed that supervisor production pressure was negatively related to willingness to report errors and supervisor support, but did not predict safety compliance behavior. Supervisor safety support was positively related to both willingness to report errors and safety compliance. Next, we uncovered evidence of cultural differences in the relationships between supervisor production pressure, supervisor safety support, and willingness to report errors; of note, among Southern Asian employees the negative relationship between supervisor production pressure and willingness to report errors was stronger, and for supervisor safety support, weaker as compared to the model estimated with Anglo employees. Implications of these findings for safety management in multicultural teams within the oil and gas industry are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.

  20. Patient-Reported Outcome Measures in Safety Event Reporting: PROSPER Consortium guidance.

    PubMed

    Banerjee, Anjan K; Okun, Sally; Edwards, I Ralph; Wicks, Paul; Smith, Meredith Y; Mayall, Stephen J; Flamion, Bruno; Cleeland, Charles; Basch, Ethan

    2013-12-01

    as under-reporting and discordant perspectives between patient reports and clinician perceptions of adverse outcomes. PROSPER seeks to support the wider use of PRO-AEs. The scope of this guidance document, which was completed between July 2011 and March 2013, considered a host of domains related to PRO-AEs, including definitions and suitable taxonomies, the range of datasets that could be used, data collection mechanisms, and suitable analytical methodologies. PROSPER offers an innovative framework to differentiate patient populations. This framework considers populations that are prespecified (such as those in clinical trials, prospective observational studies and some registries) and non-prespecified populations (such as those in claims databases, PRO-enabled online patient networks, and social websites in general). While the main focus of this guidance is on post-approval PRO-AEs from both prespecified and non-prespecified population groups, PROSPER has also considered pre-approval, prespecified populations. The ultimate aim of this guidance is to ensure that the patient 'voice' and perspective feed appropriately into collection of safety data. The guidance also covers a minimum core dataset for use by industry or regulators to structure PRO-AEs (accessible in the online appendix) and how data, once collected, might be evaluated to better inform on the safe and effective use of medicinal products. Structured collection of such patient data can be considered both a means to an end (improving patient safety) as well as an end in itself (expressing the patient viewpoint). The members of the PROSPER Consortium therefore direct this PRO-AE guidance to multiple stakeholders in drug safety, including industry, regulators, prescribers and patients. The use of this document across the entirety of the drug development life cycle will help to better define the benefit-risk profile of new and existing medicines. Because of the clinical relevance of 'real-world' data, PROs

  1. Neonatal Safety Information Reported to the FDA During Drug Development Studies

    PubMed Central

    Avant, Debbie; Baer, Gerri; Moore, Jason; Zheng, Panli; Sorbello, Alfred; Ariagno, Ron; Yao, Lynne; Burckart, Gilbert J.; Wang, Jian

    2017-01-01

    Background Relatively few neonatal drug development studies have been conducted, but an increase is expected with the enactment of the Food and Drug Administration Safety and Innovation Act (FDASIA). Understanding the safety of drugs studied in neonates is complicated by the unique nature of the population and the level of illness. The objective of this study was to examine neonatal safety data submitted to the FDA in studies pursuant to the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA) between 1998 and 2015. Methods FDA databases were searched for BPCA and/or PREA studies that enrolled neonates. Studies that enrolled a minimum of 3 neonates were analyzed for the presence and content of neonatal safety data. Results The analysis identified 40 drugs that were studied in 3 or more neonates. Of the 40 drugs, 36 drugs received a pediatric labeling change as a result of studies between 1998 and 2015, that included information from studies including neonates. Fourteen drugs were approved for use in neonates. Clinical trials for 20 of the drugs reported serious adverse events (SAEs) in neonates. The SAEs primarily involved cardiovascular events such as bradycardia and/or hypotension or laboratory abnormalities such as anemia, neutropenia, and electrolyte disturbances. Deaths were reported during studies of 9 drugs. Conclusions Our analysis revealed that SAEs were reported in studies involving 20 of the 40 drugs evaluated in neonates, with deaths identified in 9 of those studies. Patients enrolled in studies were often critically ill, which complicated determination of whether an adverse event was drug-related. We conclude that the traditional means for collecting safety information in drug development trials needs to be adjusted for neonates and will require the collaboration of regulators, industry, and the clinical and research communities to establish appropriate definitions and reporting strategies for the neonatal

  2. Investigational new drug safety reporting requirements for human drug and biological products and safety reporting requirements for bioavailability and bioequivalence studies in humans. Final rule.

    PubMed

    2010-09-29

    The Food and Drug Administration (FDA) is amending its regulations governing safety reporting requirements for human drug and biological products subject to an investigational new drug application (IND). The final rule codifies the agency's expectations for timely review, evaluation, and submission of relevant and useful safety information and implements internationally harmonized definitions and reporting standards. The revisions will improve the utility of IND safety reports, reduce the number of reports that do not contribute in a meaningful way to the developing safety profile of the drug, expedite FDA's review of critical safety information, better protect human subjects enrolled in clinical trials, subject bioavailability and bioequivalence studies to safety reporting requirements, promote a consistent approach to safety reporting internationally, and enable the agency to better protect and promote public health.

  3. An evaluation of the completeness of safety reporting in reports of complementary and alternative medicine trials

    PubMed Central

    2011-01-01

    Background Adequate reporting of safety in publications of randomized controlled trials (RCTs) is a pre-requisite for accurate and comprehensive profile evaluation of conventional as well as complementary and alternative medicine (CAM) treatments. Clear and concise information on the definition, frequency, and severity of adverse events (AEs) is necessary for assessing the benefit-harm ratio of any intervention. The objectives of this study are to assess the quality of safety reporting in CAM RCTs; to explore the influence of different trial characteristics on the quality of safety reporting. Methods Survey of safety reporting in RCTs published in 2009 across 15 widely used CAM interventions identified from the Cochrane Collaboration's CAM Field specialized register of trials. Primary outcome measures, the adequacy of reporting of AEs; was defined and categorized according to the CONSORT for harms extension; the percentage of words devoted to the reporting of safety in the entire report and in the results section. Results Two-hundred and five trials were included in the review. Of these, 15% (31/205) reported that no harms were observed during the trial period. Of the remaining 174 trials reporting any safety information, only 21% (36/174) had adequate safety reporting. For all trials, the median percentage of words devoted to the reporting of safety in the results section was 2.6. Moreover, 69% (n = 141) of all trials devoted a lesser or equal percentage of words to safety compared to author affiliations. Of the predictor variables used in regression analysis, multicenter trials had more words devoted to safety in the results section than single centre trials (P = 0.045). Conclusions An evaluation of safety reporting in the reports of CAM RCTs across 15 different CAM interventions demonstrated that the reporting of harms was largely inadequate. The quality of reporting safety information in primary reports of CAM randomized trials requires improvement. PMID

  4. Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.

    PubMed

    Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng

    2017-11-03

    Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the

  5. Commercial grade item (CGI) dedication of generators for nuclear safety related applications

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

    Das, R.K.; Hajos, L.G.

    1993-03-01

    The number of nuclear safety related equipment suppliers and the availability of spare and replacement parts designed specifically for nuclear safety related application are shrinking rapidly. These have made it necessary for utilities to apply commercial grade spare and replacement parts in nuclear safety related applications after implementing proper acceptance and dedication process to verify that such items conform with the requirements of their use in nuclear safety related application. The general guidelines for the commercial grade item (CGI) acceptance and dedication are provided in US Nuclear Regulatory Commission (NRC) Generic Letters and Electric Power Research Institute (EPRI) Report NP-5652,more » Guideline for the Utilization of Commercial Grade Items in Nuclear Safety Related Applications. This paper presents an application of these generic guidelines for procurement, acceptance, and dedication of a commercial grade generator for use as a standby generator at Salem Generating Station Units 1 and 2. The paper identifies the critical characteristics of the generator which once verified, will provide reasonable assurance that the generator will perform its intended safety function. The paper also delineates the method of verification of the critical characteristics through tests and provide acceptance criteria for the test results. The methodology presented in this paper may be used as specific guidelines for reliable and cost effective procurement and dedication of commercial grade generators for use as standby generators at nuclear power plants.« less

  6. Perceived crime and traffic safety is related to physical activity among adults in Nigeria.

    PubMed

    Oyeyemi, Adewale L; Adegoke, Babatunde O; Sallis, James F; Oyeyemi, Adetoyeje Y; De Bourdeaudhuij, Ilse

    2012-05-17

    Neighborhood safety is inconsistently related to physical activity, but is seldom studied in developing countries. This study examined associations between perceived neighborhood safety and physical activity among Nigerian adults. In a cross-sectional study, accelerometer-based physical activity (MVPA), reported walking, perceived crime and traffic safety were measured in 219 Nigerian adults. Logistic regression analysis was conducted, and the odds ratio for meeting health guidelines for MVPA and walking was calculated in relation to four safety variables, after adjustment for potential confounders. Sufficient MVPA was related to more perception of safety from traffic to walk (OR=2.28, CI=1.13- 6.25) and more safety from crime at night (OR=1.68, CI=1.07-3.64), but with less perception of safety from crime during the day to walk (OR=0.34, CI=0.06- 0.91). More crime safety during the day and night were associated with more walking. Perceived safety from crime and traffic were associated with physical activity among Nigerian adults. These findings provide preliminary evidence on the need to provide safe traffic and crime environments that will make it easier and more likely for African adults to be physically active.

  7. [The effectiveness of error reporting promoting strategy on nurse's attitude, patient safety culture, intention to report and reporting rate].

    PubMed

    Kim, Myoungsoo

    2010-04-01

    The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses. A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, X(2)-test, t-test, and ANCOVA with the SPSS 12.0 program. After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, p<.001). There was no significant difference in some categories for organizational culture and intention to report. The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.

  8. Implementation and evaluation of a prototype consumer reporting system for patient safety events.

    PubMed

    Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C; Quigley, Denise D; Hunter, Lauren E; Ridgely, M Susan; Schneider, Eric C

    2017-08-01

    No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline. Mixed methods evaluation. The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015. Patients, family members and caregivers associated with two US healthcare systems. A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries. Key informant interviews, measurement of website traffic and analysis of completed reports. Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups. While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

  9. Safety of railroad passenger vehicle dynamics : final summary report

    DOT National Transportation Integrated Search

    2002-07-01

    This report is a summary of all the work done by Foster-Miller on the passenger rail vehicle dynamic safety under the contract awarded by the FRA. The report presents key issues and findings in the safety assessments and a safety assessment methodolo...

  10. Is safety of childhood growth hormone therapy related to dose? Data from a large observational study.

    PubMed

    Sävendahl, Lars; Pournara, Effie; Pedersen, Birgitte Tønnes; Blankenstein, Oliver

    2016-05-01

    Concerns have been raised of increased mortality risk in adulthood in certain patients who received growth hormone treatment during childhood. This study evaluated the safety of growth hormone treatment in childhood in everyday practice. NordiNet(®) International Outcome Study (IOS) is a noninterventional, observational study evaluating safety and effectiveness of Norditropin(®) (somatropin; Novo Nordisk A/S, Bagsvaerd, Denmark). Long-term safety data (1998-2013) were collected on 13 834 growth hormone treated pediatric patients with short stature. Incidence rates (IRs) of adverse events (AEs) defined as adverse drug reactions (ADRs), serious ADRs (SADRs), and serious AEs (SAEs) were calculated by mortality risk group (low/intermediate/high). The effect of growth hormone dose on IRs and the occurrence of cerebrovascular AEs were investigated by the risk group. We found that 61.0% of patients were classified as low-risk, 33.9% intermediate-risk, and 5.1% high-risk. Three hundred and two AEs were reported in 261 (1.9%) patients during a mean (s.d.) treatment duration of 3.9 (2.8) years. IRs were significantly higher in the high- vs the low-risk group (high risk vs low risk-ADR: 9.11 vs 3.14; SAE: 13.66 vs 1.85; SADR: 4.97 vs 0.73 events/1000 patient-years of exposure; P < 0.0001 for all). Except for SAEs in the intermediate-risk group (P = 0.0486) in which an inverse relationship was observed, no association between IRs and growth hormone dose was found. No cerebrovascular events were reported. We conclude that safety data from NordiNet(®) IOS do not reveal any new safety signals and confirm a favorable overall safety profile in accordance with other pediatric observational studies. No association between growth hormone dose and the incidence of AEs during growth hormone treatment in childhood was found. © 2016 European Society of Endocrinology.

  11. Increasing Patient Safety Event Reporting in an Emergency Medicine Residency.

    PubMed

    Steen, Sven; Jaeger, Cassie; Price, Lindsay; Griffen, David

    2017-01-01

    Patient safety event reporting is an important component for fostering a culture of safety. Our tertiary care hospital utilizes a computerized patient safety event reporting system that has been historically underutilized by residents and faculty, despite encouragement of its use. The objective of this quality project was to increase patient safety event reporting within our Emergency Medicine residency program. Knowledge of event reporting was evaluated with a survey. Eighteen residents and five faculty participated in a formal educational session on event reporting followed by feedback every two months on events reported and actions taken. The educational session included description of which events to report and the logistics of accessing the reporting system. Participants received a survey after the educational intervention to assess resident familiarity and comfort with using the system. The total number of events reported was obtained before and after the educational session. After the educational session, residents reported being more confident in knowing what to report as a patient safety event, knowing how to report events, how to access the reporting tool, and how to enter a patient safety event. In the 14 months preceding the educational session, an average of 0.4 events were reported per month from the residency. In the nine months following the educational session, an average of 3.7 events were reported per month by the residency. In addition, the reported events resulted in meaningful actions taken by the hospital to improve patient safety, which were shared with the residents. Improvement efforts including an educational session, feedback to the residency of events reported, and communication of improvements resulting from reported events successfully increased the frequency of safety event reporting in an Emergency Medicine residency.

  12. Occurrence of idiopathic pulmonary fibrosis during immunosuppressive treatment: a case report.

    PubMed

    Cerri, Stefania; Sgalla, Giacomo; Richeldi, Luca; Luppi, Fabrizio

    2016-05-25

    Immunosuppressive therapy has been-until the recent release of new guidelines on diagnosis and management-the recommended treatment for idiopathic pulmonary fibrosis. However, its efficacy in patients with idiopathic pulmonary fibrosis has always been a matter of debate. We report the occurrence of idiopathic pulmonary fibrosis in a white man receiving chronic immunosuppressive treatment following a heart transplant. This case report suggests that the immune mechanisms targeted by azathioprine and cyclosporine do not play a role in the pathogenesis of idiopathic pulmonary fibrosis.

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

    NASA Technical Reports Server (NTRS)

    Enders, J.

    1984-01-01

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

  14. Co-occurrence of substance use related and mental health problems in the Finnish social and health care system.

    PubMed

    Kuussaari, Kristiina; Hirschovits-Gerz, Tanja

    2016-03-01

    Many studies have noted that substance abuse and mental health problems often occur simultaneously. The aim of the work reported here was to study the co-occurrence of mental health problems and problems related to substance use in a sample of clients visiting the Finnish social and health care services for issues related to substance use. We collected background information on the clients and considered the parts of the treatment system in which these clients were treated. Survey data on intoxicant-related cases in the Finnish health care and social services were gathered on a single day in 2011. During the 24 hours of data collection, all intoxicant-related cases were reported and data were obtained for 11,738 intoxicant-related cases. In this analysis we took into account the clients' background variables, mental health variables, information on the treatment type and the main reasons for the client being in treatment. The χ(2) test, Fisher's exact test and binary logistic regression analysis were used. Half of the visiting clients had both substance use related and mental health problems. The strongest factors associated with the co-occurrence of substance use related and mental health problems were female sex, younger age and single marital status. Clients with co-occurring problems were more often treated in the health care services, whereas clients with only substance use related problems were primarily treated in specialized services for the treatment of substance abuse. It is important to identify clients with co-occurring substance use related and mental health problems. In this study, half of the clients presenting to the Finnish social and health care treatment system had both these problems. © 2015 the Nordic Societies of Public Health.

  15. Bisphosphonates and Nonhealing Femoral Fractures: Analysis of the FDA Adverse Event Reporting System (FAERS) and International Safety Efforts

    PubMed Central

    Edwards, Beatrice J.; Bunta, Andrew D.; Lane, Joseph; Odvina, Clarita; Rao, D. Sudhaker; Raisch, Dennis W.; McKoy, June M.; Omar, Imran; Belknap, Steven M.; Garg, Vishvas; Hahr, Allison J.; Samaras, Athena T.; Fisher, Matthew J.; West, Dennis P.; Langman, Craig B.; Stern, Paula H.

    2013-01-01

    Background: In the United States, hip fracture rates have declined by 30% coincident with bisphosphonate use. However, bisphosphonates are associated with sporadic cases of atypical femoral fracture. Atypical femoral fractures are usually atraumatic, may be bilateral, are occasionally preceded by prodromal thigh pain, and may have delayed fracture-healing. This study assessed the occurrence of bisphosphonate-associated nonhealing femoral fractures through a review of data from the U.S. FDA (Food and Drug Administration) Adverse Event Reporting System (FAERS) (1996 to 2011), published case reports, and international safety efforts. Methods: We analyzed the FAERS database with use of the proportional reporting ratio (PRR) and empiric Bayesian geometric mean (EBGM) techniques to assess whether a safety signal existed. Additionally, we conducted a systematic literature review (1990 to February 2012). Results: The analysis of the FAERS database indicated a PRR of 4.51 (95% confidence interval [CI], 3.44 to 5.92) for bisphosphonate use and nonhealing femoral fractures. Most cases (n = 317) were attributed to use of alendronate (PRR = 3.32; 95% CI, 2.71 to 4.17). In 2008, international safety agencies issued warnings and required label changes. In 2010, the FDA issued a safety notification, and the American Society for Bone and Mineral Research (ASBMR) issued recommendations about bisphosphonate-associated atypical femoral fractures. Conclusions: Nonhealing femoral fractures are unusual adverse drug reactions associated with bisphosphonate use, as up to 26% of published cases of atypical femoral fractures exhibited delayed healing or nonhealing. PMID:23426763

  16. Overview of Energy Systems' safety analysis report programs

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

    Not Available

    1992-03-01

    The primary purpose of an Safety Analysis Report (SAR) is to provide a basis for judging the adequacy of a facility's safety. The SAR documents the safety analyses that systematically identify the hazards posed by the facility, analyze the consequences and risk of potential accidents, and describe hazard control measures that protect the health and safety of the public and employees. In addition, some SARs document, as Technical Safety Requirements (TSRs, which include Technical Specifications and Operational Safety Requirements), technical and administrative requirements that ensure the facility is operated within prescribed safety limits. SARs also provide conveniently summarized information thatmore » may be used to support procedure development, training, inspections, and other activities necessary to facility operation. This Overview of Energy Systems Safety Analysis Report Programs'' Provides an introduction to the programs and processes used in the development and maintenance of the SARs. It also summarizes some of the uses of the SARs within Energy Systems and DOE.« less

  17. Perceived crime and traffic safety is related to physical activity among adults in Nigeria

    PubMed Central

    2012-01-01

    Background Neighborhood safety is inconsistently related to physical activity, but is seldom studied in developing countries. This study examined associations between perceived neighborhood safety and physical activity among Nigerian adults. Methods In a cross-sectional study, accelerometer-based physical activity (MVPA), reported walking, perceived crime and traffic safety were measured in 219 Nigerian adults. Logistic regression analysis was conducted, and the odds ratio for meeting health guidelines for MVPA and walking was calculated in relation to four safety variables, after adjustment for potential confounders. Results Sufficient MVPA was related to more perception of safety from traffic to walk (OR=2.28, CI=1.13- 6.25) and more safety from crime at night (OR=1.68, CI=1.07-3.64), but with less perception of safety from crime during the day to walk (OR=0.34, CI=0.06- 0.91). More crime safety during the day and night were associated with more walking. Conclusions Perceived safety from crime and traffic were associated with physical activity among Nigerian adults. These findings provide preliminary evidence on the need to provide safe traffic and crime environments that will make it easier and more likely for African adults to be physically active. PMID:22520066

  18. Reported Historic Asbestos Mines, Historic Asbestos Prospects, and Natural Asbestos Occurrences in the Southwestern United States (Arizona, Nevada, and Utah)

    USGS Publications Warehouse

    Van Gosen, Bradley S.

    2008-01-01

    This map and its accompanying dataset provide information for 113 natural asbestos occurrences in the Southwestern United States (U.S.), using descriptions found in the geologic literature. Data on location, mineralogy, geology, and relevant literature for each asbestos site are provided. Using the map and digital data in this report, the user can examine the distribution of previously reported asbestos occurrences and their geological characteristics in the Southwestern U.S., which includes sites in Arizona, Nevada, and Utah. This report is part of an ongoing study by the U.S. Geological Survey to identify and map reported natural asbestos occurrences in the U.S., which thus far includes similar maps and datasets of natural asbestos occurrences within the Eastern U.S. (http://pubs.usgs.gov/of/2005/1189/), the Central U.S. (http://pubs.usgs.gov/of/2006/1211/), and the Rocky Mountain States (http://pubs.usgs.gov/of/2007/1182/. These reports are intended to provide State and local government agencies and other stakeholders with geologic information on natural occurrences of asbestos in the U.S.

  19. Guideline for the utilization of commercial grade items in nuclear safety related applications: Final report. [Contains Glossary

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

    Tulay, M.P.; Yurich, F.J.; Schremser, F.M. Jr.

    1988-06-01

    This guideline provides direction for the procurement and use of Commercial Grade Items (CGI)in safety-related applications. It is divided into five major sections. A glossary of terms and definitions, an acronym listing, and seven appendices have been included. The glossary defines terms used in this guideline. In certain instances, the definitions may be unique to this guideline. Identification of acronyms utilized in this guideline is also provided. Section 1 provides a background of the commercial grade item issues facing the nuclear industry. It provides a historical perspective of commercial grade item issues. Section 2 discusses the generic process for themore » acceptance of a commercial grade item for safety-related use. Section 3 defines the four distinct methods used to accept commercial grade items for safety-related applications. Section 4 lists specific references that are identified in this guideline. Section 5 is a bibliography of documents that were considered in developed this guideline, but were not directly referenced in the document.« less

  20. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1976-01-01

    During the second quarter of the Aviation Safety Reporting System (ASRS) operation, 1,497 reports were received from pilots, controllers, and others in the national aviation system. Details of the administration and results of the program to date are presented. Examples of alert bulletins disseminated to the aviation community are presented together with responses to those bulletins. Several reports received by ASRS are also presented to illustrate the diversity of topics covered by reports to the system.

  1. Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study

    PubMed Central

    Panagioti, Maria; Blakeman, Thomas; Hann, Mark; Bower, Peter

    2017-01-01

    Background Increasing evidence suggests that patient safety is a serious concern for older patients with long-term conditions. Despite this, there is a lack of research on safety incidents encountered by this patient group. In this study, we sought to examine patient reports of safety incidents and factors associated with reports of safety incidents in older patients with long-term conditions. Methods The baseline cross-sectional data from a longitudinal cohort study were analysed. Older patients (n=3378 aged 65 years and over) with a long-term condition registered in general practices were included in the study. The main outcome was patient-reported safety incidents including availability and appropriateness of medical tests and prescription of wrong types or doses of medication. Binary univariate and multivariate logistic regression analyses were undertaken to examine factors associated with patient-reported safety incidents. Results Safety incidents were reported by 11% of the patients. Four factors were significantly associated with patient-reported safety incidents in multivariate analyses. The experience of multiple long-term conditions (OR=1.09, 95% CI 1.05 to 1.13), a probable diagnosis of depression (OR=1.36, 95% CI 1.06 to 1.74) and greater relational continuity of care (OR=1.28, 95% CI 1.08 to 1.52) were associated with increased odds for patient-reported safety incidents. Perceived greater support and involvement in self-management was associated with lower odds for patient-reported safety incidents (OR=0.95, 95% CI 0.93 to 0.97). Conclusions We found that older patients with multimorbidity and depression are more likely to report experiences of patient safety incidents. Improving perceived support and involvement of patients in their care may help prevent patient-reported safety incidents. PMID:28559454

  2. Assessing the safety effects of cooperative intelligent transport systems: A bowtie analysis approach.

    PubMed

    Ehlers, Ute Christine; Ryeng, Eirin Olaussen; McCormack, Edward; Khan, Faisal; Ehlers, Sören

    2017-02-01

    The safety effects of cooperative intelligent transport systems (C-ITS) are mostly unknown and associated with uncertainties, because these systems represent emerging technology. This study proposes a bowtie analysis as a conceptual framework for evaluating the safety effect of cooperative intelligent transport systems. These seek to prevent road traffic accidents or mitigate their consequences. Under the assumption of the potential occurrence of a particular single vehicle accident, three case studies demonstrate the application of the bowtie analysis approach in road traffic safety. The approach utilizes exemplary expert estimates and knowledge from literature on the probability of the occurrence of accident risk factors and of the success of safety measures. Fuzzy set theory is applied to handle uncertainty in expert knowledge. Based on this approach, a useful tool is developed to estimate the effects of safety-related cooperative intelligent transport systems in terms of the expected change in accident occurrence and consequence probability. Copyright © 2016 Elsevier Ltd. All rights reserved.

  3. Cultivating quality: implementing standardized reporting and safety checklists.

    PubMed

    Stevens, James D; Bader, Mary Kay; Luna, Michele A; Johnson, Linda M

    2011-05-01

    Developing processes to create a culture of safety. It's estimated that as many as 98,000 hospitalized patients lose their lives each year in the United States because of medical errors that could have been prevented. While standardized reporting and safety checklists have been shown to improve communication and patient safety, implementation of these tools in hospitals remains challenging. To implement standardized nurse-to-nurse reporting along with safety checklists at Mission Hospital, a 522-bed facility in Mission Viejo, California, using Lewin's change theory and Knowles's adult learning theory. Nurses were tested to assess their knowledge of the standardized nurse-to-physician reporting method called SBAR (Situation, Background, Assessment, Recommendation), their understanding of the concept of the nurse-to-nurse reporting method called SBAP (Situation, Background, Assessment, Plan), and the use of safety checklists. Then, after viewing a 22-minute educational video, they were retested. A total of 482 nurses completed the pretest and posttest. On the pretest, the nurses' mean score was 15.935 points (SD, 3.529) out of 20. On the posttest, the mean score was 18.94 (SD, 1.53) out of 20. A Wilcoxon matched-pairs signed-rank test was performed; the two-tailed P value was < 0.001. The application of Lewin's change theory and Knowles's adult learning theory was successful in the process of implementing standardized nurse-to-nurse reporting and safety checklists at Mission Hospital.

  4. 30 CFR 250.192 - What reports and statistics must I submit relating to a hurricane, earthquake, or other natural...

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... relating to a hurricane, earthquake, or other natural occurrence? 250.192 Section 250.192 Mineral Resources... Requirements § 250.192 What reports and statistics must I submit relating to a hurricane, earthquake, or other... occurrence, such as a hurricane, a tropical storm, or an earthquake. Statistics include facilities and rigs...

  5. Factors Implicated in Safety-related Firefighter Fatalities.

    PubMed

    Kahn, Steven A; Palmieri, Tina L; Sen, Soman; Woods, Jason; Gunter, Oliver L

    Firefighting is wrought with risk, as 80-100 firefighters (FFs) die on the job each year in the United States. Many of the fatalities have been analyzed by the National Institute for Occupational Safety and Health (NIOSH) to determine contributing factors. The purpose of this study is to determine variables that put FFs at risk for potentially preventable workplace mortality such as use of personal protective equipment (PPE), seat belts, and appropriate training/fitness/clearance for duty. The NIOSH FF Fatality Database reports from 2009 to 2014 were analyzed. Data including age, gender, years on the job, weather, other calls on the same shift, and department type were compared between FFs who employed PPE, seat belts, or wellness/fitness and those who did not. A second group of FFs was determined by NIOSH to have inexperience, lack of training, or inappropriate clearance for duty implicated in their fatalities. Comparisons for the second group were between those whose department used training and safety-related standard operating protocols and those who did not. In 84/176 deaths, PPE/seat belts/fitness was implicated in the fatality. Lack of PPE was more likely on clear days (P = .03) but less likely on cloudy and windy days (P < .001). These FFs dying with lack of PPE had more time on the job in a single department, 18 vs 13 years (P = .03), and more time in a volunteer department, 17 vs 8 years (P < .01). Being deployed on another call during the same shift was associated with lack of PPE-34 vs 16% of those who had not been on another call (P = .005). Lack of training, experience, or medical clearance was implicated in fatalities for 100/176 FFs. FFs who worked in departments that lacked standard operating protocols for respirator fit testing, PPE, fitness testing, rapid intervention, medical clearance, safety/distress alarms, vehicle maintenance, or incident command were statistically more likely to have lack of experience/training/clearance implicated in the

  6. Avation Safety Reporting System (ASRS) 40th Anniversary

    NASA Image and Video Library

    2016-09-28

    Avation Safety Reporting System (ASRS) 40th Anniversary lunch and open house at the Sunnyvale office. Thomas A Edwards, Deputy Center Director NASA Ames (Left), presents a plaque On the anniversary of the aviation safety reporting system, this award is in recognition of 18 years of outstanding leadership as Program Director, resulting in strong program growth, expanded partnership and a widely recognized impact on National and Global transportation safety. Presented to Linda J. Connell, ASRS Program Director (Right)

  7. Folic acid supplementation and the occurrence of congenital heart defects, orofacial clefts, multiple births, and miscarriage.

    PubMed

    Bailey, Lynn B; Berry, Robert J

    2005-05-01

    Key research findings relative to the question of whether maternal use of folic acid before and during pregnancy reduces the chance that offspring will be born with a congenital heart defect or an orofacial cleft are reviewed in this paper. Observational studies in general support an association between maternal use of multivitamins containing folic acid and a reduction in the occurrence of congenital heart defects and orofacial clefts. Results from one randomized controlled trial (RCT) provide the strongest evidence that multivitamins prevent congenital heart defects, but this RCT did not provide evidence that multivitamins prevent orofacial clefts. In addition, most observational and interventional studies are not designed to detect an independent effect from folic acid. Early studies suggested that periconceptional multivitamin use was associated with an increased occurrence of both miscarriages and multiple births, which has resulted in a great deal of controversy about the safety of folic acid use during pregnancy. We also review reports that were designed to answer these questions with more definitive data. When more substantial evidence about the effect of periconceptional folic acid on the occurrence of congenital heart defects and orofacial clefts is reported, we will have additional support for promoting folic acid intervention programs. All women capable of becoming pregnant should continue to consume 400 mug/d of folic acid in addition to a healthy diet as advised.

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

    PubMed

    Ward, Jane K; McEachan, Rosemary R C; Lawton, Rebecca; Armitage, Gerry; Watt, Ian; Wright, John

    2011-05-27

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

  9. 10 CFR 72.248 - Safety analysis report updating.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 2 2010-01-01 2010-01-01 false Safety analysis report updating. 72.248 Section 72.248 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF... Approval of Spent Fuel Storage Casks § 72.248 Safety analysis report updating. (a) Each certificate holder...

  10. Practice-specific risk perceptions and self-reported food safety practices.

    PubMed

    Levy, Alan S; Choinière, Conrad J; Fein, Sara B

    2008-06-01

    The relationship between risk perception and risk avoidance is typically analyzed using self-reported measures. However, in domains such as driving or food handling, the validity of responses about usual behavior is threatened because people think about the situations in which they are self-aware, such as when they encounter a hazard. Indeed, researchers have often noted a divergence between what people say about their behavior and how they actually behave. Thus, in order to draw conclusions about risk perceptions and risk avoidance from survey data, it is important to identify particular cognitive elements, such as those measured by questions about risk and safety knowledge, risk perceptions, or information search behavior, which may be effective antecedents of self-reported safety behavior. It is also important to identify and correct for potential sources of bias that may exist in the data. The authors analyze the Food and Drug Administration's 1998 Food Safety Survey to determine whether there are consistent cognitive antecedents for three types of safe food practices: preparation, eating, and cooling of foods. An assessment of measurement biases shows that endogeneity of food choices affects reports of food preparation. In addition, response bias affects reports of cooling practices as evidenced by its relation to knowledge and information search, a pattern of cognitive effects unique to cooling practices. After correcting for these biases, results show that practice-specific risk perceptions are the primary cognitive antecedents of safe food behavior, which has implications for the design of effective education messages about food safety.

  11. Hospital nurses' working conditions in relation to motivation and patient safety.

    PubMed

    Toode, Kristi; Routasalo, Pirkko; Helminen, Mika; Suominen, Tarja

    2015-03-01

    There is a lack of empirical knowledge about nurses' perceptions of their workplace characteristics and conditions, such as level of autonomy and decision authority, work climate, teamwork, skill exploitation and learning opportunities, and their work motivation in relation to practice outputs such as patient safety. Such knowledge is needed particularly in countries, such as Estonia, where hospital systems for preventing errors and improving patient safety are in the early stages of development. This article reports the findings from a cross-sectional survey of hospital nurses in Estonia that was aimed at determining their perceptions of workplace characteristics, working conditions, work motivation and patient safety, and at exploring the relationship between these. Results suggest that perceptions of personal control over their work can affect nurses' motivation, and that perceptions of work satisfaction might be relevant to patient safety improvement work.

  12. 10 CFR 70.62 - Safety program and integrated safety analysis.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ...; (iv) Potential accident sequences caused by process deviations or other events internal to the... of occurrence of each potential accident sequence identified pursuant to paragraph (c)(1)(iv) of this... have experience in nuclear criticality safety, radiation safety, fire safety, and chemical process...

  13. 10 CFR 70.62 - Safety program and integrated safety analysis.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ...; (iv) Potential accident sequences caused by process deviations or other events internal to the... of occurrence of each potential accident sequence identified pursuant to paragraph (c)(1)(iv) of this... have experience in nuclear criticality safety, radiation safety, fire safety, and chemical process...

  14. 10 CFR 70.62 - Safety program and integrated safety analysis.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ...; (iv) Potential accident sequences caused by process deviations or other events internal to the... of occurrence of each potential accident sequence identified pursuant to paragraph (c)(1)(iv) of this... have experience in nuclear criticality safety, radiation safety, fire safety, and chemical process...

  15. Evaluating North Carolina Food Pantry Food Safety-Related Operating Procedures.

    PubMed

    Chaifetz, Ashley; Chapman, Benjamin

    2015-11-01

    Almost one in seven American households were food insecure in 2012, experiencing difficulty in providing enough food for all family members due to a lack of resources. Food pantries assist a food-insecure population through emergency food provision, but there is a paucity of information on the food safety-related operating procedures used in the pantries. Food pantries operate in a variable regulatory landscape; in some jurisdictions, they are treated equivalent to restaurants, while in others, they operate outside of inspection regimes. By using a mixed methods approach to catalog the standard operating procedures related to food in 105 food pantries from 12 North Carolina counties, we evaluated their potential impact on food safety. Data collected through interviews with pantry managers were supplemented with observed food safety practices scored against a modified version of the North Carolina Food Establishment Inspection Report. Pantries partnered with organized food bank networks were compared with those that operated independently. In this exploratory research, additional comparisons were examined for pantries in metropolitan areas versus nonmetropolitan areas and pantries with managers who had received food safety training versus managers who had not. The results provide a snapshot of how North Carolina food pantries operate and document risk mitigation strategies for foodborne illness for the vulnerable populations they serve. Data analysis reveals gaps in food safety knowledge and practice, indicating that pantries would benefit from more effective food safety training, especially focusing on formalizing risk management strategies. In addition, new tools, procedures, or policy interventions might improve information actualization by food pantry personnel.

  16. Technical Letter Report: Evaluation and Analysis of a Few International Periodic Safety Review Summary Reports

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

    Chopra, Omesh K.; Diercks, Dwight R.; Ma, David Chia-Chiun

    At the request of the United States (U.S.) government, the International Atomic Energy Agency (IAEA) assembled a team of 20 senior safety experts to review the regulatory framework for the safety of operating nuclear power plants in the United States. This review focused on the effectiveness of the regulatory functions implemented by the NRC and on its commitment to nuclear safety and continuous improvement. One suggestion resulting from that review was that the U.S. Nuclear Regulatory Commission (NRC) incorporate lessons learned from periodic safety reviews (PSRs) performed in other countries as an input to the NRC’s assessment processes. In themore » U.S., commercial nuclear power plants (NPPs) are granted an initial 40-year operating license, which may be renewed for additional 20-year periods, subject to complying with regulatory requirements. The NRC has established a framework through its inspection, and operational experience processes to ensure the safe operation of licensed nuclear facilities on an ongoing basis. In contrast, most other countries do not impose a specific time limit on the operating licenses for NPPs, they instead require that the utility operating the plant perform PSRs, typically at approximately 10-year intervals, to assure continued safe operation until the next assessment. The staff contracted with Argonne National Laboratory (Argonne) to perform a pilot review of selected translated PSR assessment reports and related documentation from foreign nuclear regulatory authorities to identify any potential new regulatory insights regarding license renewal-related topics and NPP operating experience (OpE). A total of 14 PSR assessment documents from 9 countries were reviewed. For all of the countries except France, individual reports were provided for each of the plants reviewed. In the case of France, three reports were provided that reviewed the performance assessment of thirty-four 900-MWe reactors of similar design commissioned

  17. 14 CFR 91.25 - Aviation Safety Reporting Program: Prohibition against use of reports for enforcement purposes.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 2 2010-01-01 2010-01-01 false Aviation Safety Reporting Program... GENERAL OPERATING AND FLIGHT RULES General § 91.25 Aviation Safety Reporting Program: Prohibition against... to the National Aeronautics and Space Administration under the Aviation Safety Reporting Program (or...

  18. Pre-Departure Clearance (PDC): An Analysis of Aviation Safety Reporting System Reports Concerning PDC Related Errors

    NASA Technical Reports Server (NTRS)

    Montalyo, Michael L.; Lebacqz, J. Victor (Technical Monitor)

    1994-01-01

    Airlines operating in the United States are required to operate under instrument flight rules (EFR). Typically, a clearance is issued via voice transmission from clearance delivery at the departing airport. In 1990, the Federal Aviation Administration (FAA) began deployment of the Pre-Departure Clearance (PDC) system at 30 U.S. airports. The PDC system utilizes aeronautical datalink and Aircraft Communication and Reporting System (ACARS) to transmit departure clearances directly to the pilot. An objective of the PDC system is to provide an immediate reduction in voice congestion over the clearance delivery frequency. Participating airports report that this objective has been met. However, preliminary analysis of 42 Aviation Safety Reporting System (ASRS) reports has revealed problems in PDC procedures and formatting which have caused errors in the proper execution of the clearance. It must be acknowledged that this technology, along with other advancements on the flightdeck, is adding more responsibility to the crew and increasing the opportunity for error. The present study uses these findings as a basis for further coding and analysis of an additional 82 reports obtained from an ASRS database search. These reports indicate that clearances are often amended or exceptions are added in order to accommodate local ATC facilities. However, the onboard ACARS is limited in its ability to emphasize or highlight these changes which has resulted in altitude and heading deviations along with increases in ATC workload. Furthermore, few participating airports require any type of PDC receipt confirmation. In fact, 35% of all ASRS reports dealing with PDC's include failure to acquire the PDC at all. Consequently, this study examines pilots' suggestions contained in ASRS reports in order to develop recommendations to airlines and ATC facilities to help reduce the amount of incidents that occur.

  19. Inhibition of Fear by Learned Safety Signals: minisymposium review

    PubMed Central

    Fernando, Anushka B. P.; Kazama, Andy M.; Jovanovic, Tanja; Ostroff, Linnaea E.; Sangha, Susan

    2012-01-01

    Safety signals are learned cues that predict the non-occurrence of an aversive event. As such, safety signals are potent inhibitors of fear and stress responses. Investigations of safety signal learning have increased over the last few years due in part to the finding that traumatized persons are unable to utilize safety cues to inhibit fear, making it a clinically relevant phenotype. The goal of this review is to present recent advances relating to the neural and behavioral mechanisms of safety learning and expression in rodents, non-human primates and humans. PMID:23055481

  20. The President's Report on Occupational Safety and Health.

    ERIC Educational Resources Information Center

    Department of Health, Education, and Welfare, Washington, DC.

    This report describes what has been done to implement the Occupational Safety and Health Act of 1970 during its first year of operation. The report examines the responsibilities of the Department of Labor for setting safety and health standards and also explores the activities of the Department of Health, Education, and Welfare in research and…

  1. FY 1991 safety program status report

    NASA Technical Reports Server (NTRS)

    1991-01-01

    In FY 1991, the NASA Safety Division continued efforts to enhance the quality and productivity of its safety oversight function. Recent initiatives set forth in areas such as training, risk management, safety assurance, operational safety, and safety information systems have matured into viable programs contributing to the safety and success of activities throughout the Agency. Efforts continued to develop a centralized intra-agency safety training program with establishment of the NASA Safety Training Center at the Johnson Space Center (JSC). The objective is to provide quality training for NASA employees and contractors on a broad range of safety-related topics. Courses developed by the Training Center will be presented at various NASA locations to minimize travel and reach the greatest number of people at the least cost. In FY 1991, as part of the ongoing efforts to enhance the total quality of NASA's safety work force, the Safety Training Center initiated development of a Certified Safety Professional review course. This course provides a comprehensive review of the skills and knowledge that well-rounded safety professionals must possess to qualify for professional certification. FY 1992 will see the course presented to NASA and contractor employees at all installations via the NASA Video Teleconference System.

  2. A driving simulator investigation of road safety risk mitigation under reduced visibility : final report.

    DOT National Transportation Integrated Search

    2017-06-01

    The effect of low visibility on both crash occurrence and severity is a major concern in the traffic safety field. It is known that crashes tend to be more severe in low visibility conditions than under normal clear conditions. Thus, there is a drast...

  3. UNDERSTANDING OR NURSES' REACTIONS TO ERRORS AND USING THIS UNDERSTANDING TO IMPROVE PATIENT SAFETY.

    PubMed

    Taifoori, Ladan; Valiee, Sina

    2015-09-01

    The operating room can be home to many different types of nursing errors due to the invasiveness of OR procedures. The nurses' reactions towards errors can be a key factor in patient safety. This article is based on a study, with the aim of investigating nurses' reactions toward nursing errors and the various contributing and resulting factors, conducted at Kurdistan University of Medical Sciences in Sanandaj, Iran in 2014. The goal of the study was to determine how OR nurses' reacted to nursing errors with the goal of having this information used to improve patient safety. Research was conducted as a cross-sectional descriptive study. The participants were all nurses employed in the operating rooms of the teaching hospitals of Kurdistan University of Medical Sciences, which was selected by a consensus method (170 persons). The information was gathered through questionnaires that focused on demographic information, error definition, reasons for error occurrence, and emotional reactions for error occurrence, and emotional reactions toward the errors. 153 questionnaires were completed and analyzed by SPSS software version 16.0. "Not following sterile technique" (82.4 percent) was the most reported nursing error, "tiredness" (92.8 percent) was the most reported reason for the error occurrence, "being upset at having harmed the patient" (85.6 percent) was the most reported emotional reaction after error occurrence", with "decision making for a better approach to tasks the next time" (97.7 percent) as the most common goal and "paying more attention to details" (98 percent) was the most reported planned strategy for future improved outcomes. While healthcare facilities are focused on planning for the prevention and elimination of errors it was shown that nurses can also benefit from support after error occurrence. Their reactions, and coping strategies, need guidance and, with both individual and organizational support, can be a factor in improving patient safety.

  4. Development and Validation of Career Development Guidelines by Task/Activity Analysis of Occupational Safety and Health Professions: Industrial Hygiene and Safety Professional. Final Report. Technical Report XII.

    ERIC Educational Resources Information Center

    Vernon, Ralph J.; And Others

    This report summarizes research findings which resulted in development of curricula for occupational safety and health professions based on task/activity analyses and related performance objectives. The first seven chapters focus on the seven objectives. Chapter 1, Literature Review and Selection of Employers, concerns tasks required for…

  5. Patterns in Safety-Related Projects

    NASA Astrophysics Data System (ADS)

    Parsons, Mike; Hunter, Charles

    Within Logica UK, safety-related projects are run in a variety of ways depending on the constraints imposed and how the risks and mitigations are owned and handled. A total of eight different types of project development patterns have been identified and this paper discusses each type. A simple decision tool has been developed based on the patterns which is used as an aid in deciding how to bid a safety project, allowing tradeoffs between risk ownership, development methods and cost to be assessed.

  6. 78 FR 5866 - Pipeline Safety: Annual Reports and Validation

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-28

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket ID PHMSA-2012-0319] Pipeline Safety: Annual Reports and Validation AGENCY: Pipeline and Hazardous Materials... 2012 gas transmission and gathering annual reports, remind pipeline owners and operators to validate...

  7. Meeting Report: 2013 PDA Virus & TSE Safety Forum.

    PubMed

    Willkommen, Hannelore; Blümel, Johannes; Brorson, Kurt; Chen, Dayue; Chen, Qi; Gröner, Albrecht; Hubbard, Brian R; Kreil, Thomas R; Ruffing, Michel; Ruiz, Sol; Scott, Dorothy; Silvester, Glenda

    2014-01-01

    The report provides a summary of the presentations and discussions at the Virus & TSE Safety Forum 2013 organized by the Parenteral Drug Association (PDA) and held in Berlin, Germany, from June 4 to 6, 2013. The conference was accompanied by a workshop, "Virus Spike Preparations and Virus Removal by Filtration: New Trends and Developments". The presentations and the discussion at the workshop are summarized in a separate report that will be published in this issue of the journal as well. As with previous conferences of this series, the PDA Virus & TSE Safety Forum 2013 provided again an excellent opportunity to exchange information and opinions between the industry, research organizations, and regulatory bodies. Updates on regulatory considerations related to virus and transmissible spongiform encephalopathy (TSE) safety of biopharmaceuticals were provided by agencies of the European Union (EU), the United States (US), and Singapore. The epidemiology and detection methods of new emerging pathogens like hepatitis E virus and parvovirus (PARV 4) were exemplified, and the risk of contamination of animal-derived raw materials like trypsin was considered in particular. The benefit of using new sequence-based virus detection methods was discussed. Events of bioreactor contaminations in the past drew the attention to root cause investigations and preventive actions, which were illustrated by several examples. Virus clearance data of specific unit operations were provided; the discussion focused on the mechanism of virus clearance and on the strategic concept of viral clearance integration. As in previous years, the virus safety section was followed by a TSE section that covered recent scientific findings that may influence the risk assessment of blood and cell substrates. These included the realization that interspecies transmission of TSE by blood components in sheep is greater than predicted by assays in transgenic mice. Also, the pathogenesis and possibility of

  8. Natural Occurrence of Nivalenol, Deoxynivalenol, and Deoxynivalenol-3-Glucoside in Polish Winter Wheat

    PubMed Central

    Bryła, Marcin; Ksieniewicz-Woźniak, Edyta; Waśkiewicz, Agnieszka; Szymczyk, Krystyna; Jędrzejczak, Renata

    2018-01-01

    The presence of mycotoxins in cereal grain is a very important food safety factor. The occurrence of “masked” mycotoxins has been intensively investigated in recent years. In this study, the occurrence of nivalenol, deoxynivalenol-3-glucoside, and deoxynivalenol in 92 samples of winter wheat from Polish cultivars was determined. The frequency of the occurrence of deoxynivalenol and nivalenol in the samples was 83% and 70%, respectively. The average content of the analytes was: for deoxynivalenol 140.2 µg/kg (10.5–1265.4 µg/kg), for nivalenol 35.0 µg/kg (5.1–372.5 µg/kg). Deoxynivalenol-3-glucoside, the formation of which is connected with the biotransformation pathway in plants, was present in 27% of tested wheat samples; its average content was 41.9 µg/kg (15.8–137.5 µg/kg). The relative content of deoxynivalenol-3-glucoside (DON-3G) compared to deoxynivalenol (DON) in positive samples was 4–37%. Despite the high frequency of occurrence of these mycotoxins, the quality of wheat from the 2016 season was good. The maximum content of DON, as defined in EU regulations (1250 µg/kg), was exceeded in only one sample. Nevertheless, the presence of a glycosidic derivative of deoxynivalenol can increase the risk to food safety, as it can be hydrolyzed by intestinal microflora. PMID:29438296

  9. School Bus Safety Advisory Committee: 1999 Annual Report.

    ERIC Educational Resources Information Center

    Lazenberry, Dennis; Anderson, Barbara

    This report summarizes the deliberations and recommendations of Minnesota's School Bus Safety Advisory Committee (SBSAC). The committee, which operates under the auspices of the Minnesota Department of Public Safety, is charged to study issues affecting the safety of students on school buses, arrive at consensus on ways to improve student safety…

  10. 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...

  11. Organizational safety culture and medical error reporting by Israeli nurses.

    PubMed

    Kagan, Ilya; Barnoy, Sivia

    2013-09-01

    To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.

  12. Safety management as a foundation for evidence-based aeromedical standards and reporting of medical events.

    PubMed

    Evans, Anthony D; Watson, Dougal B; Evans, Sally A; Hastings, John; Singh, Jarnail; Thibeault, Claude

    2009-06-01

    The different interpretations by States (countries) of the aeromedical standards established by the International Civil Aviation Organization has resulted in a variety of approaches to the development of national aeromedical policy, and consequently a relative lack of harmonization. However, in many areas of aviation, safety management systems have been recently introduced and may represent a way forward. A safety management system can be defined as "A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies, and procedures" (1). There are four main areas where, by applying safety management principles, it may be possible to better use aeromedical data to enhance flight safety. These are: 1) adjustment of the periodicity and content of routine medical examinations to more accurately reflect aeromedical risk; 2) improvement in reporting and analysis of routine medical examination data; 3) improvement in reporting and analysis of in-flight medical events; and 4) support for improved reporting of relevant aeromedical events through the promotion of an appropriate culture by companies and regulatory authorities. This paper explores how the principles of safety management may be applied to aeromedical systems to improve their contribution to safety.

  13. 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.

  14. Transformational leadership and safety performance among nurses: the mediating role of knowledge-related job characteristics.

    PubMed

    Lievens, Ilse; Vlerick, Peter

    2014-03-01

    To report the impact of transformational leadership on two dimensions of nurses' safety performance (i.e. safety compliance and safety participation) and to study the mediating role of knowledge-related job characteristics in this relationship. Safety performance refers to the behaviours that employees exhibit to adhere to safety guidelines and to promote health and safety at their workplace. Nurses' safety performance is a major challenge for healthcare settings, urging the need to identify the key determinants and psychological mechanisms that influence it. A cross-sectional survey study. The study was carried out in September 2010 in a large Belgian hospital. We used self-administered questionnaires; 152 nurses participated. The hypotheses were tested using hierarchical regression analyses. In line with our first hypothesis, the results show that transformational leadership exerted a significant positive impact on both dimensions of nurses' safety performance. This positive relation was mediated by knowledge-related job characteristics, supporting our second hypothesis. Head nurses' transformational leadership can enhance nurses' compliance with and participation in safety. Furthermore, transformational head nurses are able to influence the perception that their nurses have about the kind and amount of knowledge in their job, which can also lead to increases in both dimensions of nurses' safety performance. This study therefore demonstrates the key impact that transformational head nurses have, both directly and indirectly, on the safety performance of their nurses. © 2013 John Wiley & Sons Ltd.

  15. 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.

  16. Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine.

    PubMed

    Martín Delgado, M C; Merino de Cos, P; Sirgo Rodríguez, G; Álvarez Rodríguez, J; Gutiérrez Cía, I; Obón Azuara, B; Alonso Ovies, Á

    2015-01-01

    To explore contributing factors (CF) associated to related critical patients safety incidents. SYREC study pos hoc analysis. A total of 79 Intensive Care Departments were involved. The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

  17. Aerospace Safety Advisory Panel Annual Report February 1996

    NASA Technical Reports Server (NTRS)

    1996-01-01

    The Aerospace Safety Advisory Panel (ASAP) presents its annual report covering February through December 1995. Findings and recommendations include the areas of the Space Shuttle Program, the International Space Station, Aeronautics, and Other. Information to support these findings is included in this report. NASA's response to last year's annual report is included as an appendix. With regards to the Space Shuttle Program, the panel addresses the potential for safety problems due to organizational changes by increasing its scrutiny of Space Shuttle operations and planning.

  18. New Automated System Available for Reporting Safety Concerns | Poster

    Cancer.gov

    A new system has been developed for reporting safety issues in the workplace. The Environment, Health, and Safety’s (EHS’) Safety Inspection and Issue Management System (SIIMS) is an online resource where any employee can report a problem or issue, said Siobhan Tierney, program manager at EHS.

  19. Job demands, job resources and safety outcomes: The roles of emotional exhaustion and safety compliance.

    PubMed

    Li, Feng; Jiang, Li; Yao, Xiang; Li, YongJuan

    2013-03-01

    The aim of this study was to assess the effectiveness of the job demands-resources (JD-R) model in explaining the relationship of job demands and resources with safety outcomes (i.e., workplace injuries and near-misses). We collected self-reported data from 670 crude oil production workers from three sub-companies of a major oilfield company in China. The results of a structural equation analysis indicated that job demands (psychological and physical demands) and job resources (decision latitude, supervisor support and coworker support) could affect emotional exhaustion and safety compliance, and thus influence the occurrence of injuries and near-misses. The implications of the present findings regarding both the JD-R model and occupational safety research were discussed. Copyright © 2012 Elsevier Ltd. All rights reserved.

  20. Patient safety event reporting in critical care: a study of three intensive care units.

    PubMed

    Harris, Carolyn B; Krauss, Melissa J; Coopersmith, Craig M; Avidan, Michael; Nast, Patricia A; Kollef, Marin H; Dunagan, W Claiborne; Fraser, Victoria J

    2007-04-01

    To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. Prospective, single-center, interventional study. A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. Adult patients admitted to these three study ICUs. Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p < .001). This card-based reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These

  1. Technical evaluation of the susceptibility of safety-related systems to flooding caused by the failure of non-Category I systems for Turkey Point Nuclear Power Plant, Units 3 and 4

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

    Collins, E.K.

    1979-08-01

    Three separate reviews of the Turkey Point Units 3 and 4 were conducted by the FPLCO between 1972 and 1975. Initially, at the request of NBC in 1972, the FPLCO reviewed several water systems as sources of flooding. Subsequently, as a result of an abnormal occurrence, the drainage system was reviewed. Finally, the facilities were again reviewed at NRC's request and both the potential sources of flooding and safety-related equipment which could be damaged by flooding were identified. The sources of flooding and the appropriate safety equipment are discussed. An evaluation is presented of measures that were taken by FPLCOmore » to minimize the danger of flooding and to protect safety-related equipment.« less

  2. Transportation Safety Information Report : 1988 annual summary

    DOT National Transportation Integrated Search

    1989-12-01

    The Report is a compendium of selected national-level transportation safety statistics for all modes of transportation and for multimodal transportation of hazardous materials. The report presents and compares data for transportation fatalities, acci...

  3. Annual report to Congress. Department of Energy activities relating to the Defense Nuclear Facilities Safety Board, calendar year 2000

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

    None

    2001-03-01

    This Annual Report to the Congress describes the Department of Energy's activities in response to formal recommendations and other interactions with the Defense Nuclear Facilities Safety Board. During 2000, the Department completed its implementation and proposed closure of one Board recommendation and completed all implementation plan milestones associated with two additional Board recommendations. Also in 2000, the Department formally accepted two new Board recommendations and developed implementation plans in response to those recommendations. The Department also made significant progress with a number of broad-based safety initiatives. These include initial implementation of integrated safety management at field sites and within headquartersmore » program offices, issuance of a nuclear safety rule, and continued progress on stabilizing excess nuclear materials to achieve significant risk reduction.« less

  4. Reporting of meta-analyses of randomized controlled trials with a focus on drug safety: an empirical assessment.

    PubMed

    Hammad, Tarek A; Neyarapally, George A; Pinheiro, Simone P; Iyasu, Solomon; Rochester, George; Dal Pan, Gerald

    2013-01-01

    Due to the sparse nature of serious drug-related adverse events (AEs), meta-analyses combining data from several randomized controlled trials (RCTs) to evaluate drug safety issues are increasingly being conducted and published, influencing clinical and regulatory decision making. Evaluation of meta-analyses involves the assessment of both the individual constituent trials and the approaches used to combine them. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting framework is designed to enhance the reporting of systematic reviews and meta-analyses. However, PRISMA may not cover all critical elements useful in the evaluation of meta-analyses with a focus on drug safety particularly in the regulatory-public health setting. This work was conducted to (1) evaluate the adherence of a sample of published drug safety-focused meta-analyses to the PRISMA reporting framework, (2) identify gaps in this framework based on key aspects pertinent to drug safety, and (3) stimulate the development and validation of a more comprehensive reporting tool that incorporates elements unique to drug safety evaluation. We selected a sample of meta-analyses of RCTs based on review of abstracts from high-impact journals as well as top medical specialty journals between 2009 and 2011. We developed a preliminary reporting framework based on PRISMA with specific additional reporting elements critical for the evaluation of drug safety meta-analyses of RCTs. The reporting of pertinent elements in each meta-analysis was reviewed independently by two authors; discrepancies in the independent evaluations were resolved through discussions between the two authors. A total of 27 meta-analyses, 12 from highest impact journals, 13 from specialty medical journals, and 2 from Cochrane reviews, were identified and evaluated. The great majority (>85%) of PRISMA elements were addressed in more than half of the meta-analyses reviewed. However, the majority of meta

  5. Potash: a global overview of evaporate-related potash resources, including spatial databases of deposits, occurrences, and permissive tracts: Chapter S in Global mineral resource assessment

    USGS Publications Warehouse

    Orris, Greta J.; Cocker, Mark D.; Dunlap, Pamela; Wynn, Jeff C.; Spanski, Gregory T.; Briggs, Deborah A.; Gass, Leila; Bliss, James D.; Bolm, Karen S.; Yang, Chao; Lipin, Bruce R.; Ludington, Stephen; Miller, Robert J.; Słowakiewicz, Mirosław

    2014-01-01

    This report describes a global, evaporite-related potash deposits and occurrences database and a potash tracts database. Chapter 1 summarizes potash resource history and use. Chapter 2 describes a global potash deposits and occurrences database, which contains more than 900 site records. Chapter 3 describes a potash tracts database, which contains 84 tracts with geology permissive for the presence of evaporite-hosted potash resources, including areas with active evaporite-related potash production, areas with known mineralization that has not been quantified or exploited, and areas with potential for undiscovered potash resources. Chapter 4 describes geographic information system (GIS) data files that include (1) potash deposits and occurrences data, (2) potash tract data, (3) reference databases for potash deposit and tract data, and (4) representative graphics of geologic features related to potash tracts and deposits. Summary descriptive models for stratabound potash-bearing salt and halokinetic potash-bearing salt are included in appendixes A and B, respectively. A glossary of salt- and potash-related terms is contained in appendix C and a list of database abbreviations is given in appendix D. Appendix E describes GIS data files, and appendix F is a guide to using the geodatabase.

  6. A cross-sectional study to identify organisational processes associated with nurse-reported quality and patient safety

    PubMed Central

    Tvedt, Christine; Sjetne, Ingeborg Strømseng; Helgeland, Jon; Bukholm, Geir

    2012-01-01

    Objectives The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing. Design This is an observational cross-sectional study using survey methods. Setting Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey. Participants All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses' practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture. Outcome measures Nurses' assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures. Results Quality system, nurse–physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses’ affiliations to medical department and hospital type. Conclusions Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care. PMID:23263021

  7. A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting.

    PubMed

    Burlison, Jonathan D; Quillivan, Rebecca R; Kath, Lisa M; Zhou, Yinmei; Courtney, Sam C; Cheng, Cheng; Hoffman, James M

    2016-11-03

    Patient safety events offer opportunities to improve patient care, but, unfortunately, events often go unreported. Although some barriers to event reporting can be reduced with electronic reporting systems, insight on organizational and cultural factors that influence reporting frequency may help hospitals increase reporting rates and improve patient safety. The purpose of this study was to evaluate the associations between dimensions of patient safety culture and perceived reporting practices of safety events of varying severity. We conducted a cross-sectional survey study using previously collected data from The Agency for Healthcare Research and Quality Hospital Survey of Patient Safety Culture as predictors and outcome variables. The dataset included health-care professionals in U.S. hospitals, and data were analyzed using multilevel modeling techniques. Data from 223,412 individuals, 7816 work areas/units, and 967 hospitals were analyzed. Whether examining near miss, no harm, or potential for harm safety events, the dimension feedback about error accounted for the most unique predictive variance in the outcome frequency of events reported. Other significantly associated variables included organizational learning, nonpunitive response to error, and teamwork within units (all P < 0.001). As the perceived severity of the safety event increased, more culture dimensions became significantly associated with voluntary reporting. To increase the likelihood that a patient safety event will be voluntarily reported, our study suggests placing priority on improving event feedback mechanisms and communication of event-related improvements. Focusing efforts on these aspects may be more efficient than other forms of culture change.

  8. A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships with Perceptions of Voluntary Event Reporting

    PubMed Central

    Burlison, Jonathan D.; Quillivan, Rebecca R.; Kath, Lisa M.; Zhou, Yinmei; Courtney, Sam C.; Cheng, Cheng; Hoffman, James M.

    2016-01-01

    Objectives Patient safety events offer opportunities to improve patient care, but, unfortunately, events often go unreported. Although some barriers to event reporting can be reduced with electronic reporting systems, insight on organizational and cultural factors that influence reporting frequency may help hospitals increase reporting rates and improve patient safety. The purpose of this study was to evaluate the associations between dimensions of patient safety culture and perceived reporting practices of safety events of varying severity. Methods We conducted a cross-sectional survey study using previously collected data from The Agency for Healthcare Research and Quality Hospital Survey of Patient Safety Culture as predictors and outcome variables. The dataset included healthcare professionals in U.S. hospitals, and data were analyzed by using multilevel modeling techniques. Results Data from 223,412 individuals, 7816 work areas/units and 967 hospitals were analyzed. Whether examining Near-miss, No harm, or Potential for harm safety events, the dimension Feedback about error accounted for the most unique predictive variance in the outcome Frequency of events reported. Other significantly associated variables included Organizational learning, Nonpunitive response to error, and Teamwork within units (all p<.001). As the perceived severity of the safety event increased, more culture dimensions became significantly associated with voluntary reporting. Conclusions To increase the likelihood that a patient safety event will be voluntarily reported, our study suggests placing priority on improving event feedback mechanisms and communication of event-related improvements. Focusing efforts on these aspects may be more efficient than other forms of culture change. PMID:27820722

  9. Recommendations for safety planning, data collection, evaluation and reporting during drug, biologic and vaccine development: a report of the safety planning, evaluation, and reporting team.

    PubMed

    Crowe, Brenda J; Xia, H Amy; Berlin, Jesse A; Watson, Douglas J; Shi, Hongliang; Lin, Stephen L; Kuebler, Juergen; Schriver, Robert C; Santanello, Nancy C; Rochester, George; Porter, Jane B; Oster, Manfred; Mehrotra, Devan V; Li, Zhengqing; King, Eileen C; Harpur, Ernest S; Hall, David B

    2009-10-01

    The Safety Planning, Evaluation and Reporting Team (SPERT) was formed in 2006 by the Pharmaceutical Research and Manufacturers of America. SPERT's goal was to propose a pharmaceutical industry standard for safety planning, data collection, evaluation, and reporting, beginning with planning first-in-human studies and continuing through the planning of the post-product-approval period. SPERT's recommendations are based on our review of relevant literature and on consensus reached in our discussions. An important recommendation is that sponsors create a Program Safety Analysis Plan early in development. We also give recommendations for the planning of repeated, cumulative meta-analyses of the safety data obtained from the studies conducted within the development program. These include clear definitions of adverse events of special interest and standardization of many aspects of data collection and study design. We describe a 3-tier system for signal detection and analysis of adverse events and highlight proposals for reducing "false positive" safety findings. We recommend that sponsors review the aggregated safety data on a regular and ongoing basis throughout the development program, rather than waiting until the time of submission. We recognize that there may be other valid approaches. The proactive approach we advocate has the potential to benefit patients and health care providers by providing more comprehensive safety information at the time of new product marketing and beyond.

  10. Safety Management Information Statistics (SAMIS) - 1995 Annual Report

    DOT National Transportation Integrated Search

    1997-04-01

    The Safety Management Information Statistics 1995 Annual Report is a compilation and analysis of transit accident, casualty and crime statistics reported under the Federal Transit Administration's National Transit Database Reporting by transit system...

  11. Precipitation and the occurrence of lyme disease in the Northeastern United States

    USGS Publications Warehouse

    McCabe, G.J.; Bunnell, J.E.

    2004-01-01

    The occurrence of Lyme disease is a growing concern in the United States, and various studies have been performed to understand the factors related to Lyme disease occurrence. In the United States, Lyme disease has occurred most frequently in the northeastern United States. Positive correlations between the number of cases of Lyme disease reported in the northeastern United States during the 1992-2002 period indicate that late spring/early summer precipitation was a significant climate factor affecting the occurrence of Lyme disease. When late spring/early summer precipitation was greater than average, the occurrence of Lyme disease was above average, possibly due to increased tick activity and survival rate during wet conditions. Temperature did not seem to explain the variability in Lyme disease reports for the northeastern United States. ?? Mary Ann Liebert, Inc.

  12. Farm-related injury event, social consequences and injury reporting in the Land Lantbruk newspaper in Sweden: a retrospective study of farm-related injury reporting during 2000-2005.

    PubMed

    Lundälv, Jörgen

    2006-12-01

    The aim of the present study was to detect how a leading news paper, the Land Lantbruk in Stockholm, Sweden, informs the public and specifically the rural sector in Sweden and the Scandinavian countries concerning injury events (farm-related injury event) and the use of injury prevention and control. Injury reporting in the Land Lantbruk has been studied from the point of injury prevention and control. A study of injury prevention and rural health and safety in Australia shows that the newspaper The Land that serves Australia's rural community should 'be an under-utilised vehicle for news and commentary on rural health and safety issues'. The study period was from January 2000 to February 2005. A total of 178 articles were reviewed and analysed. The articles were available on a newspaper database in the Land Lantbruk newspaper. Articles that addressed farm-related injury event and rural health and safety were chosen and organised into subgroups. Tractor and motor vehicle safety (35%) was most common among the injury reporting. Although the newspaper Land Lantbruk provided excellent coverage of the causes of these events, the reports tended to focus on circumstances and did not provide information on injury prevention or the advantages of also coverage of the social and psychosocial long-term consequences of accidents. In the prevention work of reducing farm-related injuries in the rural sector in the Scandinavian countries and decreasing the human suffering represented by this health problem, rural politicians, insurance companies, rural authorities and also handicap organisations should listen more to the injured individuals and their own experiences relative to the difficulty of life after an accident. The reaction of family and relatives, and experiences of the long-term social consequences, have not been included in the media coverage. Journalists at the Land Lantbruk could also share experiences of the Swedish coverage of rural health and safety from

  13. Safety leadership: extending workplace safety climate best practices across health care workforces.

    PubMed

    McCaughey, Deirdre; Halbesleben, Jonathon R B; Savage, Grant T; Simons, Tony; McGhan, Gwen E

    2013-01-01

    Hospitals within the United States consistently have injury rates that are over twice the national employee injury rate. Hospital safety studies typically investigate care providers rather than support service employees. Compounding the lack of evidence for this understudied population is the scant evidence that is available to examine the relationship of support service employees'perceptions of safety and work-related injuries. To examine this phenomenon, the purpose of this study was to investigate support service employees' perceptions of safety leadership and social support as well as the relationship of safety perception to levels of reported injuries. A nonexperimental survey was conducted with the data collected from hospital support service employees (n = 1,272) and examined. (1) relationships between safety leadership (supervisor and organization) and individual and unit safety perceptions; (2) the moderating effect of social support (supervisor and coworker) on individual and unit safety perceptions; and (3) the relationship of safety perception to reported injury rates. The survey items in this study were based on the items from the AHRQ Patient Safety Culture Survey and the U.S. National Health Care Surveys. Safety leadership (supervisor and organization) was found to be positively related to individual safety perceptions and unit safety grade as was supervisor and coworker support. Coworker support was found to positively moderate the following relationships: supervisor safety leadership and safety perceptions, supervisor safety leadership and unit safety grade, and senior management safety leadership and safety perceptions. Positive employee safety perceptions were found to have a significant relationship with lower reported injury rates. These findings suggest that safety leadership from supervisors and senior management as well as coworker support has positive implications for support service employees' perceptions of safety, which, in turn, are

  14. Common raven occurrence in relation to energy transmission line corridors transiting human-altered sagebrush steppe

    USGS Publications Warehouse

    Coates, Peter S.; Howe, Kristy B.; Casazza, Michael L.; Delehanty, David J.

    2014-01-01

    Energy-related infrastructure and other human enterprises within sagebrush steppe of the American West often results in changes that promote common raven (Corvus corax; hereafter, raven) populations. Ravens, a generalist predator capable of behavioral innovation, present a threat to many species of conservation concern. We evaluate the effects of detailed features of an altered landscape on the probability of raven occurrence using extensive raven survey (n= 1045) and mapping data from southern Idaho, USA. We found nonlinear relationships between raven occurrence and distances to transmission lines, roads, and facilities. Most importantly, raven occurrence was greater with presence of transmission lines up to 2.2 km from the corridor.We further explain variation in raven occurrence along anthropogenic features based on the amount of non-native vegetation and cover type edge, such that ravens select fragmented sagebrush stands with patchy, exotic vegetative introgression. Raven occurrence also increased with greater length of edge formed by the contact of big sagebrush (Artemisia tridentate spp.) with non-native vegetation cover types. In consideration of increasing alteration of sagebrush steppe, these findings will be useful for planning energy transmission corridor placement and other management activities where conservation of sagebrush obligate species is a priority.

  15. The Safety of School Children in Arkansas. Special Report.

    ERIC Educational Resources Information Center

    Kelly, Paul D.

    Noting that parents are very concerned about the safety of their children and the impact school violence has on their children's academic success, this report is intended to help parents and others understand how school safety is monitored in Arkansas. The report presents information on what students say about their access to weapons and…

  16. Onboard Monitoring and Reporting for Commercial Motor Vehicle Safety Final Report

    DOT National Transportation Integrated Search

    2008-02-01

    This Final Report describes the process and product from the project, Onboard Monitoring and Reporting for Commercial Motor Vehicle Safety (OBMS), in which a prototypical suite of hardware and software on a class 8 truck was developed and tested. The...

  17. Transit safety retrofit package development : final report.

    DOT National Transportation Integrated Search

    2014-07-01

    This report provides a summary of the Transit Safety Retrofit Package (TRP) Development project and its results. The report documents results of each project phase, and provides recommended next steps as well as a vision for a next generation TRP. Th...

  18. Summary and bibliography of safety-related events at boiling-water nuclear power plants as reported in 1980

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

    McCormack, K.E.; Gallaher, R.B.

    1982-03-01

    This document presents a bibliography that contains 100-word abstracts of event reports submitted to the US Nuclear Regulatory Commission concerning operational events that occurred at boiling-water-reactor nuclear power plants in 1980. The 1547 abstracts included on microfiche in this bibliography describe incidents, failures, and design or construction deficiencies that were experienced at the facilities. These abstracts are arranged alphabetically by reactor name and then chronologically for each reactor. Full-size keyword and permuted-title indexes to facilitate location of individual abstracts are provided following the text. Tables that summarize the information contained in the bibliography are also provided. The information in themore » tables includes a listing of the equipment items involved in the reported events and the associated number of reports for each item. Similar information is given for the various kinds of instrumentation and systems, causes of failures, deficiencies noted, and the time of occurrence (i.e., during refueling, operation, testing, or construction).« less

  19. 30 CFR 250.192 - What reports and statistics must I submit relating to a hurricane, earthquake, or other natural...

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 30 Mineral Resources 2 2010-07-01 2010-07-01 false What reports and statistics must I submit... statistics must I submit relating to a hurricane, earthquake, or other natural occurrence? (a) You must submit evacuation statistics to the Regional Supervisor for a natural occurrence, such as a hurricane, a...

  20. Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices.

    PubMed

    Vernick, J S; O'Brien, M; Hepburn, L M; Johnson, S B; Webster, D W; Hargarten, S W

    2003-12-01

    To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed. Information about all unintentional and undetermined firearm deaths from 1991-98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied. There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0-17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices. Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year.

  1. Safety-Related Improvisation in Led Outdoor Activities: An Exploratory Investigation into Its Occurrence and Influencing Factors

    ERIC Educational Resources Information Center

    Trotter, Margaret J.; Salmon, Paul M.; Lenné, Michael G.

    2014-01-01

    The dynamic nature of led outdoor activities means that, despite activity providers' best efforts, activity leaders can be exposed to unanticipated situations for which no procedures exist. Improvisation, the spontaneous, real-time conception and execution of a novel response, has been identified as a potential means of maintaining safety in…

  2. Safety Management Information Statistics (SAMIS) - 1991 Annual Report

    DOT National Transportation Integrated Search

    1993-02-01

    The Safety Management Information Statistics 1991 Annual Report is a compilation and analysis of mass transit accident and casualty statistics reported by transit systems in the United States during 1991, under FTA's Section 15 reporting system.

  3. Safety Management Information Statistics (SAMIS) - 1994 Annual Report

    DOT National Transportation Integrated Search

    1996-07-01

    The Safety Management Information Statistics 1994 Annual Report is a compilation and analysis of mass transit accident and casualty statistics reported by transit systems in the United States during 1994, reported under the Federal Transit Administra...

  4. Synchronous occurrence of advanced adenocarcinoma with a stromal tumor in the stomach: a case report.

    PubMed

    Salemis, Nikolaos S; Gourgiotis, Stavros; Tsiambas, Evangelos; Karameris, Andreas; Tsohataridis, Efstathios

    2008-06-01

    Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the digestive tract. Synchronous occurrence of a gastrointestinal stromal tumor with a tumor of different histogenesis is very rare and has been documented in the literature mainly in case reports. We present the case of a 78-year old female patient who underwent surgery for an advanced gastric carcinoma during which a gastric stromal tumor was incidentally discovered. A review of the literature is also conducted on the extremely rare synchronous occurrence of malignant tumors of different histogenesis in the stomach.

  5. Relative effects of climatic and local factors on fire occurrence in boreal forest landscapes of northeastern China.

    PubMed

    Wu, Zhiwei; He, Hong S; Yang, Jian; Liu, Zhihua; Liang, Yu

    2014-09-15

    Fire significantly affects species composition, structure, and ecosystem processes in boreal forests. Our study objective was to identify the relative effects of climate, vegetation, topography, and human activity on fire occurrence in Chinese boreal forest landscapes. We used historical fire ignition for 1966-2005 and the statistical method of Kernel Density Estimation to derive fire-occurrence density (number of fires/km(2)). The Random Forest models were used to quantify the relative effects of climate, vegetation, topography, and human activity on fire-occurrence density. Our results showed that fire-occurrence density tended to be spatially clustered. Human-caused fire occurrence was highly clustered at the southern part of the region, where human population density is high (comprising about 75% of the area's population). In the north-central areas where elevations are the highest in the region and less densely populated, lightning-caused fires were clustered. Climate factors (e.g., fine fuel and duff moisture content) were important at both regional and landscape scales. Human activity factors (e.g., distance to nearest settlement and road) were secondary to climate as the primary fire occurrence factors. Predictions of fire regimes often assume a strong linkage between climate and fire but usually with less emphasis placed on the effects of local factors such as human activity. We therefore suggest that accurate forecasting of fire regime should include human influences such as those measured by forest proximity to roads and human settlements. Copyright © 2014 Elsevier B.V. All rights reserved.

  6. Nuclear Reactor Safety--The APS Submits its Report

    ERIC Educational Resources Information Center

    Physics Today, 1975

    1975-01-01

    Presents the summary section of the American Physical Society (APS) report on the safety features of the light-water reactor, reviews the design, construction, and operation of a reactor and outlines the primary engineered safety features. Summarizes the major recommendations of the study group. (GS)

  7. Aviation safety data accessibility study index: a report on the issues related to public interest in aviation safety data

    DOT National Transportation Integrated Search

    1997-01-20

    This paper reviews aviation safety data and measurement issues relevant to the determination of the best means of providing safety information to the public while ensuring the integrity of the aviation safety system. In addition , the paper examines ...

  8. Toward an understanding of the impact of production pressure on safety performance in construction operations.

    PubMed

    Han, Sanguk; Saba, Farzaneh; Lee, Sanghyun; Mohamed, Yasser; Peña-Mora, Feniosky

    2014-07-01

    It is not unusual to observe that actual schedule and quality performances are different from planned performances (e.g., schedule delay and rework) during a construction project. Such differences often result in production pressure (e.g., being pressed to work faster). Previous studies demonstrated that such production pressure negatively affects safety performance. However, the process by which production pressure influences safety performance, and to what extent, has not been fully investigated. As a result, the impact of production pressure has not been incorporated much into safety management in practice. In an effort to address this issue, this paper examines how production pressure relates to safety performance over time by identifying their feedback processes. A conceptual causal loop diagram is created to identify the relationship between schedule and quality performances (e.g., schedule delays and rework) and the components related to a safety program (e.g., workers' perceptions of safety, safety training, safety supervision, and crew size). A case study is then experimentally undertaken to investigate this relationship with accident occurrence with the use of data collected from a construction site; the case study is used to build a System Dynamics (SD) model. The SD model, then, is validated through inequality statistics analysis. Sensitivity analysis and statistical screening techniques further permit an evaluation of the impact of the managerial components on accident occurrence. The results of the case study indicate that schedule delays and rework are the critical factors affecting accident occurrence for the monitored project. Copyright © 2013 Elsevier Ltd. All rights reserved.

  9. From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings.

    PubMed

    Cooper, Elizabeth

    2013-01-01

    Improved patient safety and quality are priority goals for nurses and schools of nursing. This article describes the innovative new role of quality and safety officer (QSO) developed by one university in response to the Quality and Safety Education for Nurses challenge to increase quality and safety education for prelicensure nursing students. The article also describes the results of a study conducted by the QSO, obtaining information from prelicensure nursing students about the use of safety tools and identifying the students' perceptions of safety issues, communication, and safety reporting in the clinical setting. Responses of 145 prelicensure nursing students suggest that it is difficult to get all errors and near-miss events reported. Barriers for nursing students are similar to the barriers nurses and physicians identify in reporting errors and near-miss events. The survey reveals that safety for the patient is the primary concern of the student nurse. Copyright © 2013 Elsevier Inc. All rights reserved.

  10. Experience of safety monitoring in the context of a prospective observational study of artemether-lumefantrine in rural Tanzania: lessons learned for pharmacovigilance reporting.

    PubMed

    Kabanywanyi, Abdunoor M; Mulure, Nathan; Migoha, Christopher; Malila, Aggrey; Lengeler, Christian; Schlienger, Raymond; Genton, Blaise

    2010-07-14

    To identify and implement strategies that help meet safety monitoring requirements in the context of an observational study for artemether-lumefantrine (AL) administered as first-line treatment for uncomplicated malaria in rural Tanzania. Pharmacovigilance procedures were developed through collaboration between the investigating bodies, the relevant regulatory authority and the manufacturer of AL. Training and refresher sessions on the pharmacovigilance system were provided for healthcare workers from local health facilities and field recorders of the Ifakara Health Demographic Surveillance System (IHDSS). Three distinct channels for identification of adverse events (AEs) and serious adverse events (SAEs) were identified and implemented. Passive reporting took place through IHDSS and health care facilities, starting in October 2007. The third channel was through solicited reporting that was included in the context of a survey on AL as part of the ALIVE (Artemether-Lumefantrine In Vulnerable patients: Exploring health impact) study (conducted only in March-April 2008). Training was provided for 40 healthcare providers (with refresher training 18 months later) and for six field recorders. During the period 1st September 2007 to 31st March 2010, 67 AEs were reported including 52 under AL, five under sulphadoxine-pyrimethamine, one under metakelfin, two after antibiotics; the remaining seven were due to anti-pyretic or anti-parasite medications. Twenty patients experienced SAEs; in 16 cases, a relation to AL was suspected. Six of the 20 cases were reported within 24 hours of occurrence. Safety monitoring and reporting is possible even in settings with weak health infrastructure. Reporting can be enhanced by regular and appropriate training of healthcare providers. SMS text alerts provide a practical solution to communication challenges. Experience gained in this setting could help to improve spontaneous reporting of AEs and SAEs to health authorities or marketing

  11. Food safety educational intervention positively influences college students' food safety attitudes, beliefs, knowledge, and self-reported practices.

    PubMed

    Yarrow, Linda; Remig, Valentina M; Higgins, Mary Meck

    2009-01-01

    In this study, the authors evaluated college students' food safety attitudes, beliefs, knowledge, and self-reported practices and explored whether these variables were positively influenced by educational intervention. Students (n=59), were mostly seniors, health or non-health majors, and responsible for meal preparation. Subjects completed a food safety questionnaire (FSQ) prior to educational intervention, which consisted of three interactive modules. Subjects completed module pre-, post-, and post-posttests. The FSQ was also administered after exposure to intervention and five weeks later to determine changes in food safety attitudes, beliefs, knowledge, and self-reported practices. Students' FSQ attitude scores increased from 114 to 122 (p < or = .001); FSQ belief and knowledge scores improved from 86 to 98 (p < or = .001) and from 11 to 13 (p < or = .001), respectively. Food safety knowledge was also measured by module pre- and posttests, and improved significantly after intervention for all students, with health majors having the greatest increase. Intervention resulted in improved food safety self-reported practices for health majors only. The educational intervention appeared effective in improving food safety beliefs and knowledge. For health majors, attitudes and some self-reported practices improved. For all areas, the strongest effects were seen in health majors.

  12. Serious adverse events in randomized psychosocial treatment studies: Safety or Arbitrary Edicts?

    PubMed Central

    Petry, Nancy M.; Roll, John M.; Rounsaville, Bruce J.; Ball, Samuel A.; Stitzer, Maxine; Peirce, Jessica M.; Blaine, Jack; Kirby, Kimberly C.; McCarty, Dennis; Carroll, Kathleen M.

    2009-01-01

    Human subjects protection policies developed for pharmaceutical trials are now being widely applied to psychosocial intervention studies. This study examined occurrences of serious adverse events (SAEs) reported in multicenter psychosocial trials of the National Institute on Drug Abuse Clinical Trials Network. Substance abusing participants (N=1,687) were randomized to standard care or standard care plus either contingency management or motivational enhancement. Twelve percent of participants experienced one or more SAEs during the 27,198 person-weeks of follow-up. Of the 260 SAEs recorded, none were judged by the Data Safety Monitoring Board to be study related, and there were no significant differences between experimental and control conditions in SAE incidence rates. These data underscore the need to reconsider the rationale behind, and appropriate methods for, monitoring safety during psychosocial therapy trials. PMID:19045975

  13. 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.

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

    PubMed

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

    2015-01-01

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

  15. New Entrant Safety Research. Final Report.

    DOT National Transportation Integrated Search

    1998-04-23

    This report documents a study of the safety performance and compliance of motor carriers entering interstate service, i.e., new entrants, and the possible need for a new entrant prequalification and monitoring program. The study was conducted by the ...

  16. Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices

    PubMed Central

    Vernick, J; O'Brien, M; Hepburn, L; Johnson, S; Webster, D; Hargarten, S

    2003-01-01

    Objective: To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed. Design: Information about all unintentional and undetermined firearm deaths from 1991–98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied. Results: There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0–17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices. Conclusion: Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year. PMID:14693889

  17. Home safety practices in an urban low-income population: level of agreement between parental self-report and observed behaviors.

    PubMed

    Lee, Lois K; Walia, Taranjeev; Forbes, Peter W; Osganian, Stavroula K; Samuels, Ronald; Cox, Joanne E; Mooney, David P

    2012-12-01

    Home-related injuries are overrepresented in children from low-income households. The objectives of this study were to determine frequencies of home safety behaviors and the level of agreement between parental self-report and observed safety practices in low-income homes. In a prospective, interventional home injury prevention study of 49 low-income families with children <5 years old, a trained home visitor administered baseline parental home safety behavior questionnaires and assessments. There was high agreement between caregiver self-report and home visitor observation for lack of cabinet latch (99%, 95% confidence interval [CI] = 88%-99%) and stair gate use (100%, 95% CI = 88-100%). There was lower agreement for the safe storage of cleaning supplies (62%, 95% CI = 46%-75%), sharps (74%, 95% CI = 59%-85%), and medicines/vitamins (83%, 95% CI = 69%-92%) because of the overreporting of safe practices. Self-reports of some home safety behaviors are relatively accurate, but certain practices may need to be verified by direct assessment.

  18. Using naturalistic driving data to explore the association between traffic safety-related events and crash risk at driver level.

    PubMed

    Wu, Kun-Feng; Aguero-Valverde, Jonathan; Jovanis, Paul P

    2014-11-01

    There has been considerable research conducted over the last 40 years using traffic safety-related events to support road safety analyses. Dating back to traffic conflict studies from the 1960s these observational studies of driver behavior have been criticized due to: poor quality data; lack of available and useful exposure measures linked to the observations; the incomparability of self-reported safety-related events; and, the difficulty in assessing culpability for safety-related events. This study seeks to explore the relationships between driver characteristics and traffic safety-related events, and between traffic safety-related events and crash involvement while mitigating some of those limitations. The Virginia Tech Transportation Institute 100-Car Naturalistic Driving Study dataset, in which the participants' vehicles were instrumented with various cameras and sensors during the study period, was used for this study. The study data set includes 90 drivers observed for 12-13 months driving. This study focuses on single vehicle run-off-road safety-related events only, including 14 crashes and 182 safety-related events (30 near crashes, and 152 crash-relevant incidents). Among the findings are: (1) drivers under age 25 are significantly more likely to be involved in safety-related events and crashes; and (2) significantly positive correlations exist between crashes, near crashes, and crash-relevant incidents. Although there is still much to learn about the factors affecting the positive correlation between safety-related events and crashes, a Bayesian multivariate Poisson log-normal model is shown to be useful to quantify the associations between safety-related events and crash risk while controlling for driver characteristics. Copyright © 2014 Elsevier Ltd. All rights reserved.

  19. Self-reported risk factors related to the most frequent musculoskeletal complaints among Czech dentists.

    PubMed

    Hodacova, Lenka; Sustova, Zdenka; Cermakova, Eva; Kapitan, Martin; Smejkalova, Jindra

    2015-01-01

    The purpose of the study was to describe the occurrence of the most common complaints related to MSDs in Czech dentists and to assess the risk factors affecting them. A questionnaire survey of 581 Czech dentists (the response rate 72.6%) was conducted in 2011. The questionnaire ascertained general information about the respondents, their work habits and environment along with the occurrence of musculoskeletal disorders. The respondents filled out the questionnaires during the educational events organized by the Czech Dental Chamber. At least mild difficulties associated with the motoric system were reported by 96.9% of the respondents, with 66.3% of respondents reporting moderate or major difficulties. Back and neck pain followed by shoulder pain and headache were the most common complaints in our sample. According to our data: age, gender, length of practice, a history of serious MSDs, the occurrence of MSDs in blood relatives, the perception of work as psychologically demanding, and especially a perceived moderate/bad general health were significantly associated with the four most common musculoskeletal complaints. Some of the factors were found as protective. This study suggests that MSDs represent a significant burden for Czech dentists and further research is needed to elucidate this issue.

  20. 76 FR 5494 - Pipeline Safety: Mechanical Fitting Failure Reporting Requirements

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-01

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration 49 CFR Part... Safety: Mechanical Fitting Failure Reporting Requirements AGENCY: Pipeline and Hazardous Materials Safety... tightening. A widely accepted industry guidance document, Gas Pipeline Technical Committee (GPTC) Guide, does...

  1. Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events.

    PubMed

    Schneider, Eric C; Ridgely, M Susan; Quigley, Denise D; Hunter, Lauren E; Leuschner, Kristin J; Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C

    2017-06-01

    This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.

  2. Urban and suburban arterial safety performance functions : final report.

    DOT National Transportation Integrated Search

    2016-06-30

    This report documents findings from a comprehensive set of safety performance functions developed for the entire urban-suburban : arterial road segment system on the state highway system in Washington. Conventional urban suburban safety performance :...

  3. An assessment of traffic safety culture related to engagement efforts to improve traffic safety : research programs.

    DOT National Transportation Integrated Search

    2016-12-01

    The Center for Health and Safety Culture at Montana State University developed a survey to investigate the traffic safety culture related to engagement in traffic safety citizenship behaviors. The development of the survey was based on an augmented f...

  4. Mine safety assessment using gray relational analysis and bow tie model

    PubMed Central

    2018-01-01

    Mine safety assessment is a precondition for ensuring orderly and safety in production. The main purpose of this study was to prevent mine accidents more effectively by proposing a composite risk analysis model. First, the weights of the assessment indicators were determined by the revised integrated weight method, in which the objective weights were determined by a variation coefficient method and the subjective weights determined by the Delphi method. A new formula was then adopted to calculate the integrated weights based on the subjective and objective weights. Second, after the assessment indicator weights were determined, gray relational analysis was used to evaluate the safety of mine enterprises. Mine enterprise safety was ranked according to the gray relational degree, and weak links of mine safety practices identified based on gray relational analysis. Third, to validate the revised integrated weight method adopted in the process of gray relational analysis, the fuzzy evaluation method was used to the safety assessment of mine enterprises. Fourth, for first time, bow tie model was adopted to identify the causes and consequences of weak links and allow corresponding safety measures to be taken to guarantee the mine’s safe production. A case study of mine safety assessment was presented to demonstrate the effectiveness and rationality of the proposed composite risk analysis model, which can be applied to other related industries for safety evaluation. PMID:29561875

  5. Preliminary report on near-surface lignite occurrences, Cleveland County, Arkansas

    USGS Publications Warehouse

    Heermann, Stephen E.

    1983-01-01

    Four cross sections were constructed from lithologic descriptions of 43 drill holes in Cleveland County, Ark., in order to illustrate the occurrence of lignite and to relate the lignite beds to the regional stratigraphic framework. Of 43 holes drilled, 8 contained beds of lignite, but only two had beds greater than 30 in. thick. These beds are apparently lenticular and are restricted to the upper 60 ft. of the Cockfield Formation of the Claiborne Group of Middle Eocene age. The Cockfield Formation is at or near the surface west of the Saline River.

  6. Special report. Revising your fire safety plans.

    PubMed

    1993-12-01

    Every hospital has a fire safety plan, although some fail to update their plans when circumstances change, such as when the facility is refurbished or new fire protection equipment is added, or when new wings bring in additional patients and staff. Others may fail to develop new education programs to heighten staff awareness of what is expected of them during a fire and to train employees to meet those expectations. In this report, we'll examine the new fire safety plans at two Massachusetts hospitals and the revisions they made to address these issues. We'll offer suggestions for effectively evaluating and revising your own fire safety plans.

  7. Safety analysis report for the Waste Storage Facility. Revision 2

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

    Bengston, S.J.

    1994-05-01

    This safety analysis report outlines the safety concerns associated with the Waste Storage Facility located in the Radioactive Waste Management Complex at the Idaho National Engineering Laboratory. The three main objectives of the report are: define and document a safety basis for the Waste Storage Facility activities; demonstrate how the activities will be carried out to adequately protect the workers, public, and environment; and provide a basis for review and acceptance of the identified risk that the managers, operators, and owners will assume.

  8. Hysterosalpingo-foam sonography (HyFoSy): Tolerability, safety and the occurrence of pregnancy post-procedure.

    PubMed

    Tanaka, Keisuke; Chua, Jackie; Cincotta, Robert; Ballard, Emma L; Duncombe, Gregory

    2018-02-01

    Fallopian tube patency testing is an essential part of infertility evaluation. Hysterosalpingo-contrast sonography (HyCoSy) has been described as reliable, well tolerated and safe compared to other modalities such as laparoscopy and a dye test or hysterosalpingography. Limited availability of the previously used contrast has led to the introduction of a foam contrast agent as an alternative. To assess the tolerability, safety and occurrence of pregnancy post-procedure of hysterosalpingo-foam sonography (HyFoSy). A retrospective cohort study of women who had a HyFoSy at Queensland Ultrasound for Women from March 2013 to February 2015. A questionnaire was sent to their referring doctor to identify any complications or subsequent pregnancies with or without artificial reproductive technology (ART) within six months of the HyFoSy. Of 200 women, four cases were abandoned due to difficulty introducing the intracervical catheter, severe discomfort or a vasovagal episode. Response from referring doctors for 155 women reported no post-procedural complication. One hundred and eleven women were followed up for at least six months. Twenty-four out of 59 women (40.7%) who had ART and 24 out of 52 women (46.2%) who did not have ART conceived. Fifty percent of women who were nulligravida at the time of investigation, found to have at least one patent fallopian tube, whose partner had a normal semen analysis, spontaneously conceived within the time of follow up. HyFoSy is well tolerated and safe. A preponderance of pregnancies in the first month after HyFoSy suggests that a therapeutic effect may exist. © 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

  9. Reporting of methodological features in observational studies of pre-harvest food safety.

    PubMed

    Sargeant, Jan M; O'Connor, Annette M; Renter, David G; Kelton, David F; Snedeker, Kate; Wisener, Lee V; Leonard, Erin K; Guthrie, Alessia D; Faires, Meredith

    2011-02-01

    Observational studies in pre-harvest food safety may be useful for identifying risk factors and for evaluating potential mitigation strategies to reduce foodborne pathogens. However, there are no structured reporting guidelines for these types of study designs in livestock species. Our objective was to evaluate the reporting of observational studies in the pre-harvest food safety literature using guidelines modified from the human healthcare literature. We identified 100 pre-harvest food safety studies published between 1999 and 2009. Each study was evaluated independently by two reviewers using a structured checklist. Of the 38 studies that explicitly stated the observational study design, 27 were described as cross-sectional studies, eight as case-control studies, and three as cohort studies. Study features reported in over 75% of the selected studies included: description of the geographic location of the studies, definitions and sources of data for outcomes, organizational level and source of data for independent variables, description of statistical methods and results, number of herds enrolled in the study and included in the analysis, and sources of study funding. However, other features were not consistently reported, including details related to eligibility criteria for groups (such as barn, room, or pen) and individuals, numbers of groups and individuals included in various stages of the study, identification of primary outcomes, the distinction between putative risk factors and confounding variables, the identification of a primary exposure variable, the referent level for evaluation of categorical variable associations, methods of controlling confounding variables and missing variables, model fit, details of subset analysis, demographic information at the sampling unit level, and generalizability of the study results. Improvement in reporting of observational studies of pre-harvest food safety will aid research readers and reviewers in interpreting and

  10. Occurrence of carbapenemase-producing bacteria in coastal recreational waters.

    PubMed

    Montezzi, Lara Feital; Campana, Eloiza Helena; Corrêa, Laís Lisboa; Justo, Livia Helena; Paschoal, Raphael Paiva; da Silva, Isabel Lemos Vieira Dias; Souza, Maria do Carmo Maciel; Drolshagen, Marcia; Picão, Renata Cristina

    2015-02-01

    The spread of carbapenemase-producing Gram-negative rods is an emerging global problem. Although most infections due to carbapenemase producers are limited to healthcare institutions, reports of the occurrence of clinically relevant carbapenemase producers in sewage and polluted rivers are increasingly frequent. Polluted rivers flowing to oceans may contaminate coastal waters with multidrug-resistant bacteria, potentially threatening the safety of recreational activities in these locations. Here we assessed the occurrence of carbapenemase producers in water from touristic beaches located in Rio de Janeiro, Brazil, showing distinct pollution patterns. The presence of enterobacteria was noted, including the predominantly environmental genus Kluyvera spp., producing either Klebsiella pneumoniae carbapenemase (KPC) or Guyana extended-spectrum (GES)-type carbapenemases and often associated with quinolone resistance determinants. An Aeromonas sp. harbouring blaKPC and qnrS was also observed. These findings strengthen the role of aquatic matrices as reservoirs and vectors of clinically relevant antimicrobial-resistant bacteria, with potential to favour the spread of these resistance threats throughout the community. Copyright © 2014 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

  11. Mapping the Relative Probability of Common Toad Occurrence in Terrestrial Lowland Farm Habitat in the United Kingdom.

    PubMed

    Salazar, Rosie D; Montgomery, Robert A; Thresher, Sarah E; Macdonald, David W

    2016-01-01

    The common toad (Bufo bufo) is of increasing conservation concern in the United Kingdom (UK) due to dramatic population declines occurring in the past century. Many of these population declines coincided with reductions in both terrestrial and aquatic habitat availability and quality and have been primarily attributed to the effect of agricultural land conversion (of natural and semi-natural habitats to arable and pasture fields) and pond drainage. However, there is little evidence available to link habitat availability with common toad population declines, especially when examined at a broad landscape scale. Assessing such patterns of population declines at the landscape scale, for instance, require an understanding of how this species uses terrestrial habitat. We intensively studied the terrestrial resource selection of a large population of common toads in Oxfordshire, England, UK. Adult common toads were fitted with passive integrated transponder (PIT) tags to allow detection in the terrestrial environment using a portable PIT antenna once toads left the pond and before going into hibernation (April/May-October 2012 and 2013). We developed a population-level resource selection function (RSF) to assess the relative probability of toad occurrence in the terrestrial environment by collecting location data for 90 recaptured toads. The predicted relative probability of toad occurrence for this population was greatest in wooded habitat near to water bodies; relative probability of occurrence declined dramatically > 50 m from these habitats. Toads also tended to select habitat near to their breeding pond and toad occurrence was negatively related to urban environments.

  12. Factors related to occurrence and distribution of selected bacterial and protozoan pathogens in Pennsylvania streams

    USGS Publications Warehouse

    Duris, Joseph W.; Reif, Andrew G.; Donna A. Crouse,; Isaacs, Natasha M.

    2013-01-01

    The occurrence and distribution of fecal indicator bacteria (FIB) and bacterial and protozoan pathogens are controlled by diverse factors. To investigate these factors in Pennsylvania streams, 217 samples were collected quarterly from a 27-station water-quality monitoring network from July 2007 through August 2009. Samples were analyzed for concentrations of Escherichia coli (EC) and enterococci (ENT) indicator bacteria, concentrations of Cryptosporidium oocysts and Giardia cysts, and the presence of four genes related to pathogenic types of EC (eaeA, stx2, stx1, rfbO157) plus three microbial source tracking (MST) gene markers that are also associated with pathogenic ENT and EC (esp, LTIIa, STII). Water samples were concurrently analyzed for basic water chemistry, physical measures of water quality, nutrients, metals, and a suite of 79 organic compounds that included hormones, pharmaceuticals, and antibiotics. For each sample location, stream discharge was measured by using standardized methods at the time of sample collection, and ancillary sample site information, such as land use and geological characteristics, was compiled. Samples exceeding recreational water quality criteria were more likely to contain all measured pathogen genes but notCryptosporidium or Giardia (oo)cysts. FIB and Giardia density and frequency of eaeA gene occurrence were significantly related to season. When discharge at a sampling location was high (>75th percentile of daily mean discharge), there were greater densities of FIB and Giardia, and the stx2, rfbO157, STII, and esp genes were found more frequently than at other discharge conditions. Giardia occurrence was likely related to nonpoint sources, which are highly influential during seasonal overland transport resulting from snowmelt and elevated precipitation in late winter and spring in Pennsylvania. When MST markers of human, swine, or bovine origin were present, samples more frequently carried the eaeA, stx2

  13. 14 CFR 91.25 - Aviation Safety Reporting Program: Prohibition against use of reports for enforcement purposes.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 14 Aeronautics and Space 2 2011-01-01 2011-01-01 false Aviation Safety Reporting Program... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIR TRAFFIC AND GENERAL OPERATING RULES GENERAL OPERATING AND FLIGHT RULES General § 91.25 Aviation Safety Reporting Program: Prohibition against...

  14. 14 CFR 91.25 - Aviation Safety Reporting Program: Prohibition against use of reports for enforcement purposes.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 14 Aeronautics and Space 2 2012-01-01 2012-01-01 false Aviation Safety Reporting Program... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIR TRAFFIC AND GENERAL OPERATING RULES GENERAL OPERATING AND FLIGHT RULES General § 91.25 Aviation Safety Reporting Program: Prohibition against...

  15. 14 CFR 91.25 - Aviation Safety Reporting Program: Prohibition against use of reports for enforcement purposes.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 2 2014-01-01 2014-01-01 false Aviation Safety Reporting Program... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIR TRAFFIC AND GENERAL OPERATING RULES GENERAL OPERATING AND FLIGHT RULES General § 91.25 Aviation Safety Reporting Program: Prohibition against...

  16. 14 CFR 91.25 - Aviation Safety Reporting Program: Prohibition against use of reports for enforcement purposes.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 2 2013-01-01 2013-01-01 false Aviation Safety Reporting Program... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIR TRAFFIC AND GENERAL OPERATING RULES GENERAL OPERATING AND FLIGHT RULES General § 91.25 Aviation Safety Reporting Program: Prohibition against...

  17. MedWatch, the FDA Safety Information and Adverse Event Reporting Program

    MedlinePlus

    ... Information and Adverse Event Reporting Program MedWatch: The FDA Safety Information and Adverse Event Reporting Program Share ... use. [Posted 06/01/2018] More What's New FDA Approved Safety Information DailyMed (National Library of Medicine) ...

  18. 77 FR 71561 - Health and Safety Data Reporting; Addition of Certain Chemicals

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-12-03

    ... be, incorporated into consumer products to report certain unpublished health and safety studies to... the submission of TSCA section 8(d) health and safety studies from processors and distributors of... be, incorporated into consumer products to report certain unpublished health and safety studies to...

  19. Creating the Web-based Intensive Care Unit Safety Reporting System

    PubMed Central

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

    2005-01-01

    In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter. PMID:15561794

  20. 21 CFR 312.32 - IND safety reporting.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... testing. The sponsor must report any findings from animal or in vitro testing, whether or not conducted by... 21 Food and Drugs 5 2014-04-01 2014-04-01 false IND safety reporting. 312.32 Section 312.32 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR...

  1. Safety. Unit 8: A Core Curriculum of Related Instruction for Apprentices.

    ERIC Educational Resources Information Center

    New York State Education Dept., Albany. Bureau of Occupational and Career Curriculum Development.

    The safety education unit is presented to assist apprentices to acquire a general knowledge of procedures for insuring safety on the job. The unit consists of 10 modules: (1) the Occupational Safety and Health Act: safety and health bill of rights for workers; (2) accident prevention; (3) first aid; (4) accident reports; importance, use, and how…

  2. A randomized, controlled intervention of machine guarding and related safety programs in small metal-fabrication businesses.

    PubMed

    Parker, David L; Brosseau, Lisa M; Samant, Yogindra; Xi, Min; Pan, Wei; Haugan, David

    2009-01-01

    Metal fabrication employs an estimated 3.1 million workers in the United States. The absence of machine guarding and related programs such as lockout/tagout may result in serious injury or death. The purpose of this study was to improve machine-related safety in small metal-fabrication businesses. We used a randomized trial with two groups: management only and management-employee. We evaluated businesses for the adequacy of machine guarding (machine scorecard) and related safety programs (safety audit). We provided all businesses with a report outlining deficiencies and prioritizing their remediation. In addition, the management-employee group received four one-hour interactive training sessions from a peer educator. We evaluated 40 metal-fabrication businesses at baseline and 37 (93%) one year later. Of the three nonparticipants, two had gone out of business. More than 40% of devices required for adequate guarding were missing or inadequate, and 35% of required safety programs and practices were absent at baseline. Both measures improved significantly during the course of the intervention. No significant differences in changes occurred between the two intervention groups. Machine-guarding practices and programs improved by up to 13% and safety audit scores by up to 23%. Businesses that added safety committees or those that started with the lowest baseline measures showed the greatest improvements. Simple and easy-to-use assessment tools allowed businesses to significantly improve their safety practices, and safety committees facilitated this process.

  3. Safe RESIDential Environments? A longitudinal analysis of the influence of crime-related safety on walking.

    PubMed

    Foster, Sarah; Hooper, Paula; Knuiman, Matthew; Christian, Hayley; Bull, Fiona; Giles-Corti, Billie

    2016-02-16

    Numerous cross-sectional studies have investigated the premise that the perception of crime will cause residents to constrain their walking; however the findings to date are inconclusive. In contrast, few longitudinal or prospective studies have examined the impact of crime-related safety on residents walking behaviours. This study used longitudinal data to test whether there is a causal relationship between crime-related safety and walking in the local neighbourhood. Participants in the RESIDential Environments Project (RESIDE) in Perth, Australia, completed a questionnaire before moving to their new neighbourhood (n = 1813) and again approximately one (n = 1467), three (n = 1230) and seven years (n = 531) after relocating. Self-report measures included neighbourhood perceptions (modified NEWS items) and walking inside the neighbourhood (min/week). Objective built environmental measures were generated for each participant's 1600 m neighbourhood at each time-point, and the count of crimes reported to police were generated at the suburb-level for the first three time-points only. The impact of crime-related safety on walking was examined in SAS using the Proc Mixed procedure (marginal repeated measures model with unrestricted variance pattern). Initial models controlled for demographics, time and self-selection, and subsequent models progressively adjusted for other built and social environment factors based on a social ecological model. For every increase of one level on a five-point Likert scale in perceived safety from crime, total walking within the local neighbourhood increased by 18.0 min/week (p = 0.000). This relationship attenuated to an increase of 10.5 min/week after accounting for other built and social environment factors, but remained significant (p = 0.008). Further analyses examined transport and recreational walking separately. In the fully adjusted models, each increase in safety from crime was associated with a 7.0

  4. The effects of power, leadership and psychological safety on resident event reporting.

    PubMed

    Appelbaum, Nital P; Dow, Alan; Mazmanian, Paul E; Jundt, Dustin K; Appelbaum, Eric N

    2016-03-01

    Although the reporting of adverse events is a necessary first step in identifying and addressing lapses in patient safety, such events are under-reported, especially by frontline providers such as resident physicians. This study describes and tests relationships between power distance and leader inclusiveness on psychological safety and the willingness of residents to report adverse events. A total of 106 resident physicians from the departments of neurosurgery, orthopaedic surgery, emergency medicine, otolaryngology, neurology, obstetrics and gynaecology, paediatrics and general surgery in a mid-Atlantic teaching hospital were asked to complete a survey on psychological safety, perceived power distance, leader inclusiveness and intention to report adverse events. Perceived power distance (β = -0.26, standard error [SE] 0.06, 95% confidence interval [CI] -0.37 to 0.15; p < 0.001) and leader inclusiveness (β = 0.51; SE 0.07, 95% CI 0.38-0.65; p < 0.001) both significantly predicted psychological safety, which, in turn, significantly predicted intention to report adverse events (β = 0.34; SE 0.08, 95% CI 0.18-0.49; p < 0.001). Psychological safety significantly mediated the direct relationship between power distance and intention to report adverse events (indirect effect: -0.09; SE 0.02, 95% CI -0.13 to 0.04; p < 0.001). Psychological safety also significantly mediated the direct relationship between leader inclusiveness and intention to report adverse events (indirect effect: 0.17; SE 0.02, 95% CI 0.08-0.27; p = 0.001). Psychological safety was found to be a predictor of intention to report adverse events. Perceived power distance and leader inclusiveness both influenced the reporting of adverse events through the concept of psychological safety. Because adverse event reporting is shaped by relationships and culture external to the individual, it should be viewed as an organisational as much as a personal function. Supervisors and other leaders in health care

  5. President's Child Safety Partnership. Final Report.

    ERIC Educational Resources Information Center

    President's Commission on Child Safety Partnership, Washington, DC.

    This report presents the findings and recommendations from the President's Child Safety Partnership, a group of citizens representing business, private nonprofit groups, the government, and private individuals appointed by President Reagan to gather accurate information about the nature and extent of violence against children and to identify…

  6. Methyl tert-butyl ether occurrence and related factors in public and private wells in southeast New Hampshire.

    PubMed

    Ayotte, Joseph D; Argue, Denise M; McGarry, Frederick J

    2005-01-01

    The occurrence of methyl tert-butyl ether (MTBE) in water from public wells in New Hampshire has increased steadily over the past several years. Using a laboratory reporting level of 0.2 microg/L, 40% of samples from public wells and 21% from private wells in southeast New Hampshire have measurable concentrations of MTBE. The rate of occurrence of MTBE varied significantly for public wells by establishmenttype; for example, 63% of public wells serving residential properties have MTBE concentrations above 0.2 microg/L, whereas lower rates were found for schools (21%). MTBE concentrations correlate strongly with urban factors, such as population density. Surprisingly, MTBE was correlated positively with well depth for public supply wells. Well depth is inversely related to yield in New Hampshire bedrock wells, which may mean that there is less opportunity for dilution of MTBE captured by deep wells. Another possibility is that the source(s) of water to low-yield wells may be dominated by leakage from potentially contaminated shallow groundwater through near-surface fractures or along the well casing. These wells may also have relatively large contributing areas (due to low recharge at the bedrock surface) and therefore have a greater chance of intersecting MTBE sources. This finding is significant because deep bedrock wells are often considered to be less vulnerable to contamination than shallow wells, and in southeast New Hampshire, wells are being drilled deeper in search of increased supply.

  7. 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

  8. Delaware highway safety annual report : FY 2009

    DOT National Transportation Integrated Search

    2009-01-01

    The Fiscal Year 2009 Annual Evaluation Report reflects our major : accomplishments in impacting our priority areas, and highlights the : programming initiatives undertaken to increase public awareness about : highway safety. Throughout the coming yea...

  9. Adverse Event Reporting: Harnessing Residents to Improve Patient Safety.

    PubMed

    Tevis, Sarah E; Schmocker, Ryan K; Wetterneck, Tosha B

    2017-10-13

    Reporting of adverse and near miss events are essential to identify system level targets to improve patient safety. Resident physicians historically report few events despite their role as front-line patient care providers. We sought to evaluate barriers to adverse event reporting in an effort to improve reporting. Our main outcomes were as follows: resident attitudes about event reporting and the frequency of event reporting before and after interventions to address reporting barriers. We surveyed first year residents regarding barriers to adverse event reporting and used this input to construct a fishbone diagram listing barriers to reporting. Barriers were addressed, and resident event reporting was compared before and after efforts were made to reduce obstacles to reporting. First year residents (97%) recognized the importance of submitting event reports; however, the majority (85%) had not submitted an event report in the first 6 months of residency. Only 7% of residents specified that they had not witnessed an adverse event in 6 months, whereas one third had witnessed 10 or more events. The main barriers were as follows: lack of knowledge about how to submit events (38%) and lack of time to submit reports (35%). After improving resident education around event reporting and simplifying the reporting process, resident event reporting increased 230% (68 to 154 annual reports, P = 0.025). We were able to significantly increase resident event reporting by educating residents about adverse events and near misses and addressing the primary barriers to event reporting. Moving forward, we will continue annual resident education about patient safety, focus on improving feedback to residents who submit reports, and empower senior residents to act as role models to junior residents in patient safety initiatives.

  10. An observational survey of safety belt and child safety seat use in Virginia : final report : the 1990 update.

    DOT National Transportation Integrated Search

    1992-01-01

    This report was prepared in response to a request from the Transportation Safety Administration of the Virginia Department ofMotor Vehicles for data concerning the use of safety belts and child safety seats by the occupants of vehicles bearing Virgin...

  11. Senior charge nurses' leadership behaviours in relation to hospital ward safety: a mixed method study.

    PubMed

    Agnew, Cakil; Flin, Rhona

    2014-05-01

    High standards of quality and patient safety in hospital wards cannot be achieved without the active role of the nursing leaders that manage these units. Previous studies tended to focus on the leadership behaviours of nurses in relation to staff job satisfaction and other organizational outcomes. Less is known about the leadership skills of senior charge nurses that are effective for ensuring safety for patients and staff in their wards. The aim of the two studies was to identify the leadership behaviours of senior charge nurses that are (a) typically used and, (b) that relate to safety outcomes. In study one, semi-structured interviews were conducted with 15 senior charge nurses at an acute NHS hospital. Transcribed interviews were coded using Yukl's Managerial Practices Survey (MPS) framework. In study two, self ratings of leadership (using the MPS) from 15 senior charge nurses (SCN) and upward ratings from 82 staff nurses reporting to them were used to investigate associations between SCNs' leadership behaviours and worker and patient-related safety outcomes. The interviews in study one demonstrated the relevance of the MPS leadership framework for nurses at hospital ward level. The SCNs mainly engaged in relations-oriented (n=370, 49%), and task-oriented (n=342, 45%) behaviours, with fewer change-oriented (n=25, 3%), and lead by example behaviours (n=26, 3%). In demanding situations, more task-oriented behaviours were reported. In study two, staff nurses' ratings of their SCNs' behaviours (Monitoring and Recognizing) were related to staff compliance with rules and patient injuries (medium severity), while the self ratings of SCNs indicated that Supporting behaviours were linked to lower infection rates and Envisioning change behaviours were linked to lower infection and other safety indicators for both patients and staff. This study provides preliminary data on the usability of a standard leadership taxonomy (Yukl et al., 2002), and the related MPS

  12. NASA Aviation Safety Reporting System

    NASA Technical Reports Server (NTRS)

    1980-01-01

    Problems in briefing of relief by air traffic controllers are discussed, including problems that arise when duty positions are changed by controllers. Altimeter reading and setting errors as factors in aviation safety are discussed, including problems associated with altitude-including instruments. A sample of reports from pilots and controllers is included, covering the topics of ATIS broadcasts an clearance readback problems. A selection of Alert Bulletins, with their responses, is included.

  13. Social media for arthritis-related comparative effectiveness and safety research and the impact of direct-to-consumer advertising.

    PubMed

    Curtis, Jeffrey R; Chen, Lang; Higginbotham, Phillip; Nowell, W Benjamin; Gal-Levy, Ronit; Willig, James; Safford, Monika; Coe, Joseph; O'Hara, Kaitlin; Sa'adon, Roee

    2017-03-07

    Social media may complement traditional data sources to answer comparative effectiveness/safety questions after medication licensure. The Treato platform was used to analyze all publicly available social media data including Facebook, blogs, and discussion boards for posts mentioning inflammatory arthritis (e.g. rheumatoid, psoriatic). Safety events were self-reported by patients and mapped to medical ontologies, resolving synonyms. Disease and symptom-related treatment indications were manually redacted. The units of analysis were unique terms in posts. Pre-specified conditions (e.g. herpes zoster (HZ)) were selected based upon safety signals from clinical trials and reported as pairwise odds ratios (ORs); drugs were compared with Fisher's exact test. Empirically identified events were analyzed using disproportionality analysis and reported as relative reporting ratios (RRRs). The accuracy of a natural language processing (NLP) classifier to identify cases of shingles associated with arthritis medications was assessed. As of October 2015, there were 785,656 arthritis-related posts. Posts were predominantly US posts (75%) from patient authors (87%) under 40 years of age (61%). For HZ posts (n = 1815), ORs were significantly increased with tofacitinib versus other rheumatoid arthritis therapies. ORs for mentions of perforated bowel (n = 13) were higher with tocilizumab versus other therapies. RRRs associated with tofacitinib were highest in conditions related to baldness and hair regrowth, infections and cancer. The NLP classifier had a positive predictive value of 91% to identify HZ. There was a threefold increase in posts following television direct-to-consumer advertisement (p = 0.04); posts expressing medication safety concerns were significantly more frequent than favorable posts. Social media is a challenging yet promising data source that may complement traditional approaches for comparative effectiveness research for new medications.

  14. Safety monitoring in the Vaccine Adverse Event Reporting System (VAERS)

    PubMed Central

    Shimabukuro, Tom T.; Nguyen, Michael; Martin, David; DeStefano, Frank

    2015-01-01

    The Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) conduct post-licensure vaccine safety monitoring using the Vaccine Adverse Event Reporting System (VAERS), a spontaneous (or passive) reporting system. This means that after a vaccine is approved, CDC and FDA continue to monitor safety while it is distributed in the marketplace for use by collecting and analyzing spontaneous reports of adverse events that occur in persons following vaccination. Various methods and statistical techniques are used to analyze VAERS data, which CDC and FDA use to guide further safety evaluations and inform decisions around vaccine recommendations and regulatory action. VAERS data must be interpreted with caution due to the inherent limitations of passive surveillance. VAERS is primarily a safety signal detection and hypothesis generating system. Generally, VAERS data cannot be used to determine if a vaccine caused an adverse event. VAERS data interpreted alone or out of context can lead to erroneous conclusions about cause and effect as well as the risk of adverse events occurring following vaccination. CDC makes VAERS data available to the public and readily accessible online. We describe fundamental vaccine safety concepts, provide an overview of VAERS for healthcare professionals who provide vaccinations and might want to report or better understand a vaccine adverse event, and explain how CDC and FDA analyze VAERS data. We also describe strengths and limitations, and address common misconceptions about VAERS. Information in this review will be helpful for healthcare professionals counseling patients, parents, and others on vaccine safety and benefit-risk balance of vaccination. PMID:26209838

  15. An examination of safety reports involving electronic flight bags and portable electronic devices

    DOT National Transportation Integrated Search

    2014-06-01

    The purpose of this research was to develop a better understanding of safety considerations with the use of Electronic Flight Bags (EFBs) and Portable Electronic Devices (PEDs) by examining safety reports from Aviation Safety Reporting System (ASRS),...

  16. Food safety. [chemical contaminants and human toxic diseases

    NASA Technical Reports Server (NTRS)

    Pier, S. M.; Valentine, J. L.

    1975-01-01

    Illness induced by unsafe food is a problem of great public health significance. This study relates exclusively to the occurrence of chemical agents which will result in food unsafe for human consumption since the matter of food safety is of paramount importance in the mission and operation of the manned spacecraft program of the National Aeronautics and Space Administration.

  17. Propulsion Health Monitoring for Enhanced Safety

    NASA Technical Reports Server (NTRS)

    Butz, Mark G.; Rodriguez, Hector M.

    2003-01-01

    This report presents the results of the NASA contract Propulsion System Health Management for Enhanced Safety performed by General Electric Aircraft Engines (GE AE), General Electric Global Research (GE GR), and Pennsylvania State University Applied Research Laboratory (PSU ARL) under the NASA Aviation Safety Program. This activity supports the overall goal of enhanced civil aviation safety through a reduction in the occurrence of safety-significant propulsion system malfunctions. Specific objectives are to develop and demonstrate vibration diagnostics techniques for the on-line detection of turbine rotor disk cracks, and model-based fault tolerant control techniques for the prevention and mitigation of in-flight engine shutdown, surge/stall, and flameout events. The disk crack detection work was performed by GE GR which focused on a radial-mode vibration monitoring technique, and PSU ARL which focused on a torsional-mode vibration monitoring technique. GE AE performed the Model-Based Fault Tolerant Control work which focused on the development of analytical techniques for detecting, isolating, and accommodating gas-path faults.

  18. Management of radioactive material safety programs at medical facilities. Final report

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

    Camper, L.W.; Schlueter, J.; Woods, S.

    A Task Force, comprising eight US Nuclear Regulatory Commission and two Agreement State program staff members, developed the guidance contained in this report. This report describes a systematic approach for effectively managing radiation safety programs at medical facilities. This is accomplished by defining and emphasizing the roles of an institution`s executive management, radiation safety committee, and radiation safety officer. Various aspects of program management are discussed and guidance is offered on selecting the radiation safety officer, determining adequate resources for the program, using such contractual services as consultants and service companies, conducting audits, and establishing the roles of authorized usersmore » and supervised individuals; NRC`s reporting and notification requirements are discussed, and a general description is given of how NRC`s licensing, inspection and enforcement programs work.« less

  19. 14 CFR Appendix J to Part 417 - Ground Safety Analysis Report

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... information required by this appendix. J417.3Ground safety analysis report chapters (a) Introduction. A ground... analysis report must include a chapter that provides detailed safety information about each launch vehicle... data. A hazard analysis form must contain or reference all information necessary to understand the...

  20. 14 CFR Appendix J to Part 417 - Ground Safety Analysis Report

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... information required by this appendix. J417.3Ground safety analysis report chapters (a) Introduction. A ground... analysis report must include a chapter that provides detailed safety information about each launch vehicle... data. A hazard analysis form must contain or reference all information necessary to understand the...

  1. 14 CFR Appendix J to Part 417 - Ground Safety Analysis Report

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... information required by this appendix. J417.3Ground safety analysis report chapters (a) Introduction. A ground... analysis report must include a chapter that provides detailed safety information about each launch vehicle... data. A hazard analysis form must contain or reference all information necessary to understand the...

  2. 14 CFR Appendix J to Part 417 - Ground Safety Analysis Report

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... information required by this appendix. J417.3Ground safety analysis report chapters (a) Introduction. A ground... analysis report must include a chapter that provides detailed safety information about each launch vehicle... data. A hazard analysis form must contain or reference all information necessary to understand the...

  3. 14 CFR Appendix J to Part 417 - Ground Safety Analysis Report

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... information required by this appendix. J417.3Ground safety analysis report chapters (a) Introduction. A ground... analysis report must include a chapter that provides detailed safety information about each launch vehicle... data. A hazard analysis form must contain or reference all information necessary to understand the...

  4. Unstoppable The Gap Between Public Safety and Traffic Safety in the Age of Driverless Cars

    DTIC Science & Technology

    2017-03-01

    themselves, what will the increase in traffic safety cost society in terms of public safety? • What can public safety and homeland security...industry. Safer products are more marketable products, and companies that work with law enforcement for the benefit of public safety may have an...secondary public safety benefit of crime suppression. Reasonable suspicion to stop a vehicle would be an infrequent occurrence, and the legal authority

  5. Electronic health records and patient safety: co-occurrence of early EHR implementation with patient safety practices in primary care settings.

    PubMed

    Tanner, C; Gans, D; White, J; Nath, R; Pohl, J

    2015-01-01

    The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. Data from 209 primary care practices responding between 2006-2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.

  6. Idaho National Laboratory Quarterly Occurrence Analysis

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

    Mitchell, Lisbeth Ann

    This report is published quarterly by the Idaho National Laboratory (INL) Quality and Performance Management Organization. The Department of Energy (DOE) Occurrence Reporting and Processing System (ORPS), as prescribed in DOE Order 232.2, “Occurrence Reporting and Processing of Operations Information,” requires a quarterly analysis of events, both reportable and not reportable, for the previous 12 months. This report is the analysis of 85 reportable events (18 from the 4th Qtr FY-15 and 67 from the prior three reporting quarters), as well as 25 other issue reports (including events found to be not reportable and Significant Category A and B conditions)more » identified at INL during the past 12 months (8 from this quarter and 17 from the prior three quarters).« less

  7. 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.

  8. 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/.

  9. Safety analysis report for packaging (onsite) steel drum

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

    McCormick, W.A.

    This Safety Analysis Report for Packaging (SARP) provides the analyses and evaluations necessary to demonstrate that the steel drum packaging system meets the transportation safety requirements of HNF-PRO-154, Responsibilities and Procedures for all Hazardous Material Shipments, for an onsite packaging containing Type B quantities of solid and liquid radioactive materials. The basic component of the steel drum packaging system is the 208 L (55-gal) steel drum.

  10. Application of Natural Language Processing and Network Analysis Techniques to Post-market Reports for the Evaluation of Dose-related Anti-Thymocyte Globulin Safety Patterns.

    PubMed

    Botsis, Taxiarchis; Foster, Matthew; Arya, Nina; Kreimeyer, Kory; Pandey, Abhishek; Arya, Deepa

    2017-04-26

    To evaluate the feasibility of automated dose and adverse event information retrieval in supporting the identification of safety patterns. We extracted all rabbit Anti-Thymocyte Globulin (rATG) reports submitted to the United States Food and Drug Administration Adverse Event Reporting System (FAERS) from the product's initial licensure in April 16, 1984 through February 8, 2016. We processed the narratives using the Medication Extraction (MedEx) and the Event-based Text-mining of Health Electronic Records (ETHER) systems and retrieved the appropriate medication, clinical, and temporal information. When necessary, the extracted information was manually curated. This process resulted in a high quality dataset that was analyzed with the Pattern-based and Advanced Network Analyzer for Clinical Evaluation and Assessment (PANACEA) to explore the association of rATG dosing with post-transplant lymphoproliferative disorder (PTLD). Although manual curation was necessary to improve the data quality, MedEx and ETHER supported the extraction of the appropriate information. We created a final dataset of 1,380 cases with complete information for rATG dosing and date of administration. Analysis in PANACEA found that PTLD was associated with cumulative doses of rATG >8 mg/kg, even in periods where most of the submissions to FAERS reported low doses of rATG. We demonstrated the feasibility of investigating a dose-related safety pattern for a particular product in FAERS using a set of automated tools.

  11. Administration of the Radiation Control for Health and Safety Act of 1968, Public Law 90-602, April 1, 1985 (1984 annual report). Report for 1 January-31 December 1984

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

    Not Available

    The Secretary of Health and Human Services is required by Subpart 3, Part F of Title III of the Public Health Service Act; 42 USC 263b et seq. (Public Law 90-602) to submit an annual report to the President for transmittal to the Congress on or before April 1 on the administration of the Radiation Control for Health and Safety Act. The detailed information required to be included in the report is outlined in Section 360D of the Public Health Service Act. The Food and Drug Administration, through its Center for Devices and Radiological Health, is responsible for the day-to-daymore » administration of the Act. The report covers the detailed operation of the Agency in carrying out that responsibility for calendar year 1984. Manufacturers of electronic products are required by 21 CFR 1002.20 to report accidental radiation occurrences to the CDRH, FDA. During the calendar year 1984, the Radiation Incidents Registry received 11 reports alleging injury involving 235 persons.« less

  12. Reported Historic Asbestos Mines, Historic Asbestos Prospects, and Natural Asbestos Occurrences in the Rocky Mountain States of the United States (Colorado, Idaho, Montana, New Mexico, and Wyoming)

    USGS Publications Warehouse

    Van Gosen, Bradley S.

    2007-01-01

    This map and its accompanying dataset provide information for 48 natural asbestos occurrences in the Rocky Mountain States of the United States (U.S.), using descriptions found in the geologic literature. Data on location, mineralogy, geology, and relevant literature for each asbestos site are provided. Using the map and digital data in this report, the user can examine the distribution of previously reported asbestos occurrences and their geological characteristics in the Rocky Mountain States. This report is part of an ongoing study by the U.S. Geological Survey to identify and map reported natural asbestos occurrences in the U.S., which thus far includes similar maps and datasets of natural asbestos occurrences within the Eastern U.S. (http://pubs.usgs.gov/of/2005/1189/) and the Central U.S. (http://pubs.usgs.gov/of/2006/1211/). These reports are intended to provide State and local government agencies and other stakeholders with geologic information on natural occurrences of asbestos in the U.S.

  13. Work-related injury factors and safety climate perception in truck drivers.

    PubMed

    Anderson, Naomi J; Smith, Caroline K; Byrd, Jesse L

    2017-08-01

    The trucking industry has a high burden of work-related injuries. This study examined factors, such as safety climate perceptions, that may impact injury risk. A random sample of 9800 commercial driver's license holders (CDL) were sent surveys, only 4360 were eligible truck drivers. Descriptive statistics and logistic regression models were developed to describe the population and identify variables associated with work-related injury. 2189 drivers completed the pertinent interview questions. Driving less-than-truckload, daytime sleepiness, pressure to work faster, and having a poor composite score for safety perceptions were all associated with increased likelihood of work-related injury. Positive safety perception score was protective for odds of work-related injury, and increased claim filing when injured. Positive psychological safety climate is associated with decreased likelihood of work-related injury and increased likelihood that a driver injured on the job files a workers' compensation claim. © 2017 Wiley Periodicals, Inc.

  14. Evaluation of US 119 Pine Mountain safety improvements : interim report.

    DOT National Transportation Integrated Search

    2003-10-01

    The safety improvement project for a section of US 119 across Pine Mountain in Letcher County was initiated as an interim effort to address safety issues related t o roadway geometrics and specific problems related to truck traffic. : Specific object...

  15. Safety climate and attitude toward medication error reporting after hospital accreditation in South Korea.

    PubMed

    Lee, Eunjoo

    2016-09-01

    This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. This study employed a longitudinal, descriptive design. Data were collected using questionnaires. A tertiary acute hospital in South Korea undergoing a hospital accreditation program. Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively. Hospital accreditation program. Perceived safety climate and attitude toward medication error reporting. The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants' perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program. Improving hospitals' safety climate increased nurses' medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses' fear of penalties. Administration and managers should support nurses who report their own errors. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  16. Hydrogen Safety Issues Compared to Safety Issues with Methane and Propane

    NASA Astrophysics Data System (ADS)

    Green, M. A.

    2006-04-01

    The hydrogen economy is not possible if the safety standards currently applied to liquid hydrogen and hydrogen gas by many laboratories are applied to devices that use either liquid or gaseous hydrogen. Methane and propane are commonly used by ordinary people without the special training. This report asks, "How is hydrogen different from flammable gasses that are commonly being used all over the world?" This report compares the properties of hydrogen, methane and propane and how these properties may relate to safety when they are used in both the liquid and gaseous state. Through such an analysis, sensible safety standards for the large-scale (or even small-scale) use of liquid and gaseous hydrogen systems can be developed. This paper is meant to promote discussion of issues related to hydrogen safety so that engineers designing equipment can factor sensible safety standards into their designs.

  17. Hydrogen Safety Issues Compared to Safety Issues with Methane andPropane

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

    Green, Michael A.

    The hydrogen economy is not possible if the safety standards currently applied to liquid hydrogen and hydrogen gas by many laboratories are applied to devices that use either liquid or gaseous hydrogen. Methane and propane are commonly used by ordinary people without the special training. This report asks, 'How is hydrogen different from flammable gasses that are commonly being used all over the world?' This report compares the properties of hydrogen, methane and propane and how these properties may relate to safety when they are used in both the liquid and gaseous state. Through such an analysis, sensible safety standardsmore » for the large-scale (or even small-scale) use of liquid and gaseous hydrogen systems can be developed. This paper is meant to promote discussion of issues related to hydrogen safety so that engineers designing equipment can factor sensible safety standards into their designs.« less

  18. Estimating the Prevalence of Heat-Related Symptoms and Sun Safety-Related Behavior among Latino Farmworkers in Eastern North Carolina.

    PubMed

    Kearney, Gregory D; Hu, Hui; Xu, Xiaohui; Hall, Marla B; Balanay, Jo Anne G

    2016-01-01

    In hot weather, thermal heat generated by the body, combined with environmental heat from the sun, can lead outdoor workers to experience heat-related stress, severe illness, or even death. The aims of this study were to estimate the prevalence of heat-related symptoms and potential risk factors associated with sun safety-related behavior among Latino farmworkers. Data from interviewer-administered questionnaires were collected from a cross-sectional survey among farmworkers (N = 158) from August to September 2013. Data analysis assessed associations between work activities, sun safety behavior, and the prevalence of heat-related illness (HRI) symptoms among workers. Nearly two thirds (72%) of farmworkers experienced at least one HRI symptom and lacked proper cooling methods when working outdoors. Most workers reported wearing long-sleeved shirts (85%), long pants (98%), and baseball caps (93%). The prevalence of having one HRI symptom was 72% and 27% among workers having three or more HRI symptoms. The majority of farmworkers experience symptoms of HRI and are not provided with proper shade protection when working outdoors. Increased emphasis on administrative controls, particularly educating field supervisors and workers on how to avoid and recognize HRI, should be a priority.

  19. Liver-related safety assessment of green tea extracts in humans: a systematic review of randomized controlled trials

    PubMed Central

    Isomura, T; Suzuki, S; Origasa, H; Hosono, A; Suzuki, M; Sawada, T; Terao, S; Muto, Y; Koga, T

    2016-01-01

    There remain liver-related safety concerns, regarding potential hepatotoxicity in humans, induced by green tea intake, despite being supposedly beneficial. Although many randomized controlled trials (RCTs) of green tea extracts have been reported in the literature, the systematic reviews published to date were only based on subjective assessment of case reports. To more objectively examine the liver-related safety of green tea intake, we conducted a systematic review of published RCTs. A systematic literature search was conducted using three databases (PubMed, EMBASE and Cochrane Central Register of Controlled Trials) in December 2013 to identify RCTs of green tea extracts. Data on liver-related adverse events, including laboratory test abnormalities, were abstracted from the identified articles. Methodological quality of RCTs was assessed. After excluding duplicates, 561 titles and abstracts and 119 full-text articles were screened, and finally 34 trials were identified. Of these, liver-related adverse events were reported in four trials; these adverse events involved seven subjects (eight events) in the green tea intervention group and one subject (one event) in the control group. The summary odds ratio, estimated using a meta-analysis method for sparse event data, for intervention compared with placebo was 2.1 (95% confidence interval: 0.5–9.8). The few events reported in both groups were elevations of liver enzymes. Most were mild, and no serious liver-related adverse events were reported. Results of this review, although not conclusive, suggest that liver-related adverse events after intake of green tea extracts are expected to be rare. PMID:27188915

  20. Safety and Efficacy of Ziagen (Abacavir Sulfate) in HIV-Infected Korean Patients.

    PubMed

    Ann, Heawon; Kim, Ki Hyon; Choi, Hyun Young; Chang, Hyun Ha; Han, Sang Hoon; Kim, Kye Hyung; Lee, Jin Soo; Kim, Yeon Sook; Park, Kyung Hwa; Kim, Young Keun; Sohn, Jang Wook; Yun, Na Ra; Lee, Chang Seop; Choi, Young Wha; Lee, Yil Seob; Kim, Shin Woo

    2017-09-01

    Abacavir is a widely-used nucleoside reverse transcriptase inhibitor for the treatment of human immunodeficiency virus (HIV) infection. Mandatory postmarketing surveillance was conducted in Korea to monitor the safety and evaluate the effectiveness of Ziagen® (abacavir sulfate 300 mg; ViiV Healthcare, Middlesex, UK). An open-label, multi-center, non-interventional postmarketing surveillance study was conducted from June 2010 to June 2016 to monitor the safety and effectiveness of Ziagen across 12 hospitals in Korea. Subjects older than 18 years taking Ziagen according to prescribing information were enrolled. The primary outcome was defined as the occurrence of any adverse events after Ziagen administration. Secondary outcomes included the occurrence of adverse drug reactions, occurrence of serious adverse events, and effectiveness of Ziagen administration. A total of 669 patients were enrolled in this study, with a total observation period of 1047.8 person-years. Of these, 90.7% of patients were male. The mean age of patients was 45.8±11.9 years. One-hundred ninety-six (29.3%) patients reported 315 adverse events, and four patients reported seven serious adverse events, without any fatal events. There was one potential case of an abacavir hypersensitivity reaction. Among the 97 adverse drug reactions that were reported from 75 patients, the most frequent adverse drug reactions included diarrhea (12 events), dyspepsia (10 events), and rash (9 events). No ischemic heart disease was observed. In the effectiveness analysis, 91% of patients achieved HIV-1 RNA under 50 copies/mL after 24 months of observation with abacavir administration. Our data showed the safety and effectiveness of Ziagen in a real-world setting. During the study period, Ziagen was well-tolerated, with one incident of a clinically suspected abacavir hypersensitivity reaction. The postmarketing surveillance of Ziagen did not highlight any new safety information. These data may be helpful in

  1. 30 CFR 250.192 - What reports and statistics must I submit relating to a hurricane, earthquake, or other natural...

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... relating to a hurricane, earthquake, or other natural occurrence? 250.192 Section 250.192 Mineral Resources... What reports and statistics must I submit relating to a hurricane, earthquake, or other natural..., such as a hurricane, a tropical storm, or an earthquake. Statistics include facilities and rigs...

  2. 30 CFR 250.192 - What reports and statistics must I submit relating to a hurricane, earthquake, or other natural...

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... relating to a hurricane, earthquake, or other natural occurrence? 250.192 Section 250.192 Mineral Resources... What reports and statistics must I submit relating to a hurricane, earthquake, or other natural..., such as a hurricane, a tropical storm, or an earthquake. Statistics include facilities and rigs...

  3. 30 CFR 250.192 - What reports and statistics must I submit relating to a hurricane, earthquake, or other natural...

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... relating to a hurricane, earthquake, or other natural occurrence? 250.192 Section 250.192 Mineral Resources... What reports and statistics must I submit relating to a hurricane, earthquake, or other natural..., such as a hurricane, a tropical storm, or an earthquake. Statistics include facilities and rigs...

  4. Effect of Surgical Safety checklist implementation on the occurrence of postoperative complications in orthopedic patients.

    PubMed

    Boaz, Mona; Bermant, Alexander; Ezri, Tiberiu; Lakstein, Dror; Berlovitz, Yitzhak; Laniado, Iris; Feldbrin, Zeev

    2014-01-01

    Surgical adverse events are errors that emerge during perioperative patient care. The World Health Organization recently published "Guidelines for Safe Surgery." To estimate the effect of implementation of a safety checklist in an orthopedic surgical department. We conducted a single-center cross-sectional study to compare the incidence of complications prior to and following implementation of the Guidelines for Safe Surgery checklist. The medical records of all consecutive adult patients admitted to the orthopedics department at Wolfson Medical Center during the period 1 July 2008 to 1 January 2009 (control group) and from 1 January 2009 to 1 July 2009 (study group) were reviewed. The occurrences of all complications were compared between the two groups. The records of 760 patients (380 in each group) hospitalized during this 12 month period were analyzed. Postoperative fever occurred in 5.3% versus 10.6% of patients with and without the checklist respectively (P = 0.008). Significantly more patients received only postoperative prophylactic antibiotics rather than both pre-and postoperative antibiotic treatment prior to implementation of the checklist (3.2% versus 0%, P = 0.004). In addition, a statistically non-significant 34% decrease in the rate of surgical wound infection was also detected in the checklist group. In a logistic regression model of postoperative fever, the checklist emerged as a significant independent predictor of this outcome: odds ratio 0.53, 95% confidence interval 0.29-0.96, P = 0.037. A significant reduction in postoperative fever after the implementation of the surgical safety checklist occurred. It is possible that the improved usage of preoperative prophylactic antibiotics may explain the reduction in postoperative fever.

  5. Bus safety study : a report to Congress.

    DOT National Transportation Integrated Search

    2013-11-01

    Section 20021(b) of the Moving Ahead for Progress for the 21st Century (MAP-21) legislation requires the Secretary of Transportation : to submit a report of the results of a Bus Safety Study to the Committee on Banking, Housing, and Urban Affai...

  6. The safety profile of parecoxib for the treatment of postoperative pain: a pooled analysis of 28 randomized, double-blind, placebo-controlled clinical trials and a review of over 10 years of postauthorization data

    PubMed Central

    Schug, Stephan A; Parsons, Bruce; Li, Chunming; Xia, Feng

    2017-01-01

    Background Nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 (COX-2) inhibitors are associated with safety issues including cardiovascular, renal, and gastrointestinal (GI) events. Objective To examine the safety of parecoxib, a COX-2 inhibitor, for the management of postoperative pain. Design Pooled analysis of 28 placebo-controlled trials of parecoxib and review of postauthorization safety data. Main outcome measures Prespecified safety events commonly associated with COX-2 inhibitors and/or NSAIDs. In the clinical trial analysis, the frequency of each event was compared between treatment groups using a chi-square test. In the postauthorization review, the number of confirmed cases, along with outcome, was presented for each event. Results In the clinical trial analysis, GI-related events occurred in ~0.2% of patients in the parecoxib and placebo groups. Renal failure and impairment was similar between parecoxib (1.0%) and placebo (0.9%). The occurrence of arterial (parecoxib=0.3%; placebo=0.2%) and venous (parecoxib=0.2%; placebo=0.1%) cardiovascular embolic and thrombotic events was similar between groups. Hypersensitivity reactions including anaphylactic reactions (parecoxib=8.7%; placebo=8.6%), hypotension (parecoxib=2.6%; placebo=2.1%), angioedema (parecoxib=2.5%; placebo=2.8%), and severe cutaneous adverse reactions (0% in both groups) were similar between groups. Incision site or other skin/tissue infections occurred in <0.1% of patients in both groups. The occurrence of these events (total reports/serious reports) in the postauthorization database, based on 69,567,300 units of parecoxib, was as follows: GI ulceration-related events (35/35), renal failure and impairment (77/68), cardiovascular embolic and thrombotic events (66/64), hypersensitivity reactions including hypotension-related events (32/25) and severe cutaneous adverse events (17/17), and masking signs of inflammation (18/18). A majority of reported

  7. The safety profile of parecoxib for the treatment of postoperative pain: a pooled analysis of 28 randomized, double-blind, placebo-controlled clinical trials and a review of over 10 years of postauthorization data.

    PubMed

    Schug, Stephan A; Parsons, Bruce; Li, Chunming; Xia, Feng

    2017-01-01

    Nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 (COX-2) inhibitors are associated with safety issues including cardiovascular, renal, and gastrointestinal (GI) events. To examine the safety of parecoxib, a COX-2 inhibitor, for the management of postoperative pain. Pooled analysis of 28 placebo-controlled trials of parecoxib and review of postauthorization safety data. Prespecified safety events commonly associated with COX-2 inhibitors and/or NSAIDs. In the clinical trial analysis, the frequency of each event was compared between treatment groups using a chi-square test. In the postauthorization review, the number of confirmed cases, along with outcome, was presented for each event. In the clinical trial analysis, GI-related events occurred in ~0.2% of patients in the parecoxib and placebo groups. Renal failure and impairment was similar between parecoxib (1.0%) and placebo (0.9%). The occurrence of arterial (parecoxib=0.3%; placebo=0.2%) and venous (parecoxib=0.2%; placebo=0.1%) cardiovascular embolic and thrombotic events was similar between groups. Hypersensitivity reactions including anaphylactic reactions (parecoxib=8.7%; placebo=8.6%), hypotension (parecoxib=2.6%; placebo=2.1%), angioedema (parecoxib=2.5%; placebo=2.8%), and severe cutaneous adverse reactions (0% in both groups) were similar between groups. Incision site or other skin/tissue infections occurred in <0.1% of patients in both groups. The occurrence of these events (total reports/serious reports) in the postauthorization database, based on 69,567,300 units of parecoxib, was as follows: GI ulceration-related events (35/35), renal failure and impairment (77/68), cardiovascular embolic and thrombotic events (66/64), hypersensitivity reactions including hypotension-related events (32/25) and severe cutaneous adverse events (17/17), and masking signs of inflammation (18/18). A majority of reported outcomes were classified as recovered or recovering

  8. SER assistant: An expert system for safety evaluation reports

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

    DeChaine, M.D.; Levine, S.H.; Feltus, M.A.

    1993-01-01

    The SER Assistant is an expert system that assists engineers to write safety evaluation reports (SERs). Section 50.59 of the Code of Federal Regulations allows modifications to be made to nuclear power plants without prior US Nuclear Regulatory Commission approval if two conditions are satisfied. First, the change must not affect the technical specifications of the plant. Second, the modification must not affect a part of the plant described in the final safety analysis report, or if it does, it must not create an unreviewed safety question. The purpose of an SER is to ensure that these conditions are satisfiedmore » for the proposed modification. The SER Assistant aids this process by providing relevant, but directed, questions and information as well as giving engineers an organized environment to document their thought processes.« less

  9. 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.

  10. Hospital safety climate and safety behavior: A social exchange perspective.

    PubMed

    Ancarani, Alessandro; Di Mauro, Carmela; Giammanco, Maria D

    Safety climate is considered beneficial to the improvement of hospital safety outcomes. Nevertheless, the relations between two of its key constituents, namely those stemming from leader-subordinate relations and coworker support for safety, are still to be fully ascertained. This article uses the theoretical lens of Social Exchange Theory to study the joint impact of leader-member exchange in the safety sphere and coworker support for safety on safety-related behavior at the hospital ward level. Social exchange constructs are further related to the existence of a shame-/blame-free environment, seen as a potential antecedent of safety behavior. A cross-sectional study including 166 inpatients in hospital wards belonging to 10 public hospitals in Italy was undertaken to test the hypotheses developed. Hypothesized relations have been analyzed through a fully mediated multilevel structural equation model. This methodology allows studying behavior at the individual level, while keeping into account the heterogeneity among hospital specialties. Results suggest that the linkage between leader support for safety and individual safety behavior is mediated by coworker support on safety issues and by the creation of a shame-free environment. These findings call for the creation of a safety climate in which managerial efforts should be directed not only to the provision of new safety resources and the enforcement of safety rules but also to the encouragement of teamwork and freedom to report errors as ways to foster the capacity of the staff to communicate, share, and learn from each other.

  11. Comparison of food safety cognitions and self-reported food-handling behaviors with observed food safety behaviors of young adults.

    PubMed

    Abbot, J M; Byrd-Bredbenner, C; Schaffner, D; Bruhn, C M; Blalock, L

    2009-04-01

    Developing tailored and effective food safety education for young adults is critical given their future roles as caregivers likely to be preparing food for populations who may be at greater risk for foodborne disease (FBD). The objective of this study was to examine the relationship between food safety self-reported food-handling behaviors and cognitions of young adults to observed food-handling behaviors. Participants were 153 young adults (mean age 20.74+/-1.30 s.d.) attending a major American university. Each prepared a meal under observation in a controlled laboratory setting, permitted researchers to observe their home kitchen and completed an online survey assessing food safety knowledge, behavior and psychosocial measures. Descriptive statistics were generated for participants' self-reported food-handling behaviors, psychosocial characteristics, knowledge, food preparation observations and home kitchen observations. Determinants of compliance with safe food-handling procedures while preparing a meal and home food storage/rotation practices were identified using backward regression models. Participants engaged in less than half of the recommended safe food-handling practices evaluated and correctly answered only two-thirds of the food safety knowledge items. They reported positive food safety beliefs and high food safety self-efficacy. Self-reported compliance with cross-contamination prevention, disinfection procedures and knowledge of groups at greatest risk for FBD were the best measures for predicting compliance with established safe food-handling practices. Food safety education directed toward young adults should focus on increasing awareness of FBD and knowledge of proper cross-contamination prevention procedures to help promote better compliance with actual safe food handling.

  12. Safety concerns related to modular/prefabricated building construction.

    PubMed

    Fard, Maryam Mirhadi; Terouhid, Seyyed Amin; Kibert, Charles J; Hakim, Hamed

    2017-03-01

    The US construction industry annually experiences a relatively high rate of fatalities and injuries; therefore, improving safety practices should be considered a top priority for this industry. Modular/prefabricated building construction is a construction strategy that involves manufacturing of the whole building or some of its components off-site. This research focuses on the safety performance of the modular/prefabricated building construction sector during both manufacturing and on-site processes. This safety evaluation can serve as the starting point for improving the safety performance of this sector. Research was conducted based on Occupational Safety and Health Administration investigated accidents. The study found 125 accidents related to modular/prefabricated building construction. The details of each accident were closely examined to identify the types of injury and underlying causes. Out of 125 accidents, there were 48 fatalities (38.4%), 63 hospitalized injuries (50.4%), and 14 non-hospitalized injuries (11.2%). It was found that, the most common type of injury in modular/prefabricated construction was 'fracture', and the most common cause of accidents was 'fall'. The most frequent cause of cause (underlying and root cause) was 'unstable structure'. In this research, the accidents were also examined in terms of corresponding location, occupation, equipment as well as activities during which the accidents occurred. For improving safety records of the modular/prefabricated construction sector, this study recommends that future research be conducted on stabilizing structures during their lifting, storing, and permanent installation, securing fall protection systems during on-site assembly of components while working from heights, and developing training programmes and standards focused on modular/prefabricated construction.

  13. Why System Safety Professionals Should Read Accident Reports

    NASA Technical Reports Server (NTRS)

    Holloway, C. M.; Johnson, C. W.

    2006-01-01

    System safety professionals, both researchers and practitioners, who regularly read accident reports reap important benefits. These benefits include an improved ability to separate myths from reality, including both myths about specific accidents and ones concerning accidents in general; an increased understanding of the consequences of unlikely events, which can help inform future designs; a greater recognition of the limits of mathematical models; and guidance on potentially relevant research directions that may contribute to safety improvements in future systems.

  14. Final report on the safety assessment of sodium cetearyl sulfate and related alkyl sulfates as used in cosmetics.

    PubMed

    Fiume, Monice; Bergfeld, Wilma F; Belsito, Donald V; Klaassen, Curtis D; Marks, James G; Shank, Ronald C; Slaga, Thomas J; Snyder, Paul W; Alan Andersen, F

    2010-05-01

    Sodium cetearyl sulfate is the sodium salt of a mixture of cetyl and stearyl sulfate. The other ingredients in this safety assessment are also alkyl salts, including ammonium coco-sulfate, ammonium myristyl sulfate, magnesium coco-sulfate, sodium cetyl sulfate, sodium coco/hydrogenated tallow sulfate, sodium coco-sulfate, sodium decyl sulfate, sodium ethylhexyl sulfate, sodium myristyl sulfate, sodium oleyl sulfate, sodium stearyl sulfate, sodium tallow sulfate, sodium tridecyl sulfate, and zinc coco-sulfate. These ingredients are surfactants used at concentrations from 0.1% to 29%, primarily in soaps and shampoos. Many of these ingredients are not in current use. The Cosmetic Ingredient Review (CIR) Expert Panel previously completed a safety assessment of sodium and ammonium lauryl sulfate. The data available for sodium lauryl sulfate and ammonium lauryl sulfate provide sufficient basis for concluding that sodium cetearyl sulfate and related alkyl sulfates are safe in the practices of use and concentration described in the safety assessment.

  15. Meeting Report: 2015 PDA Virus & TSE Safety Forum.

    PubMed

    Willkommen, Hannelore; Blümel, Johannes; Brorson, Kurt; Chen, Dayue; Chen, Qi; Gröner, Albrecht; Kreil, Thomas R; Ruffing, Michel; Ruiz, Sol; Scott, Dorothy; Silvester, Glenda

    2016-01-01

    The report provides a summary of the presentations at the Virus & TSE Safety Forum 2015 organized by the Parenteral Drug Association (PDA) and held in Cascais, Portugal, from 9 to 11 June, 2015. As with previous conferences of this series, the PDA Virus & TSE Safety Forum 2015 provided an excellent forum for the exchange of information and opinions between the industry, research organizations, and regulatory bodies. Regulatory updates on virus and TSE safety aspects illustrating current topics of discussion at regulatory agencies in Europe and the United States were provided; the conference covered emerging viruses and new virus detection systems that may be used for the investigation of human pathogenic viruses as well as the virus safety of cell substrates and of raw material of ovine/caprine or human origin. Progress of development and use of next-generation sequencing methods was shown by several examples. Virus clearance data illustrating the effectiveness of inactivation or removal methods were presented and data provided giving insight into the mechanism of action of these technologies. In the transmissible spongiform encephalopathy (TSE) part of the conference, the epidemiology of variant Creutzfeldt-Jakob disease was reviewed and an overview about diagnostic tests provided; current thinking about the spread and propagation of prions was presented and the inactivation of prions by disinfection (equipment) and in production of bovine-derived reagents (heparin) shown. The current report provides an overview about the outcomes of the 2015 PDA Virus & TSE Safety Forum, a unique event in this field. © PDA, Inc. 2016.

  16. Lessons learnt from Dental Patient Safety Case Reports

    PubMed Central

    Obadan, Enihomo M.; Ramoni, Rachel B.; Kalenderian, Elsbeth

    2015-01-01

    Background Errors are commonplace in dentistry, it is therefore our imperative as dental professionals to intercept them before they lead to an adverse event, and/or mitigate their effects when an adverse event occurs. This requires a systematic approach at both the profession-level, encapsulated in the Agency for Healthcare Research and Quality’s Patient Safety Initiative structure, as well as at the practice-level, where Crew Resource Management is a tested paradigm. Supporting patient safety at both the dental practice and profession levels relies on understanding the types and causes of errors, an area in which little is known. Methods A retrospective review of dental adverse events reported in the literature was performed. Electronic bibliographic databases were searched and data were extracted on background characteristics, incident description, case characteristics, clinic setting where adverse event originated, phase of patient care that adverse event was detected, proximal cause, type of patient harm, degree of harm and recovery actions. Results 182 publications (containing 270 cases) were identified through our search. Delayed and unnecessary treatment/disease progression after misdiagnosis was the largest type of harm reported. 24.4% of reviewed cases were reported to have experienced permanent harm. One of every ten case reports reviewed (11.1%) reported that the adverse event resulted in the death of the affected patient. Conclusions Published case reports provide a window into understanding the nature and extent of dental adverse events, but for as much as the findings revealed about adverse events, they also identified the need for more broad-based contributions to our collective body of knowledge about adverse events in the dental office and their causes. Practical Implications Siloed and incomplete contributions to our understanding of adverse events in the dental office are threats to dental patients’ safety. PMID:25925524

  17. Relationships between psychological safety climate facets and safety behavior in the rail industry: a dominance analysis.

    PubMed

    Morrow, Stephanie L; McGonagle, Alyssa K; Dove-Steinkamp, Megan L; Walker, Curtis T; Marmet, Matthew; Barnes-Farrell, Janet L

    2010-09-01

    The goals of this study were twofold: (1) to confirm a relationship between employee perceptions of psychological safety climate and safety behavior for a sample of workers in the rail industry and (2) to explore the relative strengths of relationships between specific facets of safety climate and safety behavior. Non-management rail maintenance workers employed by a large North American railroad completed a survey (n=421) regarding workplace safety perceptions and behaviors. Three facets of safety climate (management safety, coworker safety, and work-safety tension) were assessed as relating to individual workers' reported safety behavior. All three facets were significantly associated with safety behavior. Dominance analysis was used to assess the relative importance of each facet as related to the outcome, and work-safety tension evidenced the strongest relationship with safety behavior. Published by Elsevier Ltd.

  18. Basic Program Elements for Federal employee Occupational Safety and Health Programs and related matters; Subpart I for Recordkeeping and Reporting Requirements. Final rule.

    PubMed

    2013-08-05

    OSHA is issuing a final rule amending the Basic Program Elements to require Federal agencies to submit their occupational injury and illness recordkeeping information to the Bureau of Labor Statistics (BLS) and OSHA on an annual basis. The information, which is already required to be created and maintained by Federal agencies, will be used by BLS to aggregate injury and illness information throughout the Federal government. OSHA will use the information to identify Federal establishments with high incidence rates for targeted inspection, and assist in determining the most effective safety and health training for Federal employees. The final rule also interprets several existing basic program elements in our regulations to clarify requirements applicable to Federal agencies, amends the date when Federal agencies must submit to the Secretary of Labor their annual report on occupational safety and health programs, amends the date when the Secretary of Labor must submit to the President the annual report on Federal agency safety and health, and clarifies that Federal agencies must include uncompensated volunteers when reporting and recording occupational injuries and illnesses.

  19. Tectonic implications of Archean anorthosite occurrences

    NASA Technical Reports Server (NTRS)

    Phinney, W. C.; Morrison, D. A.; Maczuga, D. E.

    1988-01-01

    The occurrences of megacrystic anorthosite and basalt in a variety of geologic settings were reviewed and it was found that these rock types occur in a variety of tectonic settings. Anorthosites and megacrystic basalts are petrogenetically related and are found in oceanic volcanic crust, cratons, and shelf environments. Although megacrystic basalts are most common in Archean terranes, similar occurrences are observed in rocks of early Proterozoic age, and even in young terranes such as the Galapagos hotspot. Based on inferences from experimental petrology, all of the occurrences are apparently associated with similar parental melts that are relatively Fe-rich tholeiites. The megacrystic rocks exhibit a two- (or more)-stage development of plagioclase, with the megacrysts having relatively uniform composition produced under nearly isothermal and isochemical conditions over substantial periods of time. The anorthosites appear to have intruded various crustal levels from very deep to very shallow. The petrogenetic indicators, however, suggest that conditions of formation of the Precambrian examples were different from Phanerozoic occurrences.

  20. Individual, school-related and family characteristics distinguish co-occurrence of drinking and depressive symptoms in very young adolescents.

    PubMed

    Salom, Caroline L; Kelly, Adrian B; Alati, Rosa; Williams, Gail M; Patton, George C; Williams, Joanne W

    2016-07-01

    Alcohol misuse and depressed mood are common during early adolescence, and comorbidity of these conditions in adulthood is associated with poorer health and social outcomes, yet little research has examined the co-occurrence of these problems at early adolescence. This study assessed risky and protective characteristics of pre-teens with concurrent depressed mood/early alcohol use in a large school-based sample. School children aged 10-14 years (n = 7289) from late primary and early secondary school classes in government, Catholic and independent sectors participated with parental consent in the cross-sectional Healthy Neighbourhoods Study. Key measures included depressed mood, recent alcohol use, school mobility, family relationship quality, school engagement and coping style. Multinomial logistic regression analyses were used to identify school and family-related factors that distinguished those with co-occurring drinking and depressive symptoms from those with either single condition. Gender and school-level interactions for each factor were evaluated. Co-occurring conditions were reported by 5.7% of students [confidence interval (CI)95 5.19, 6.19]. Recent drinkers were more likely than non-drinkers to have symptoms consistent with depression (odds ratio 1.80; CI95 1.58, 2.03). Low school commitment was associated with co-occurring drinking/depressive symptoms (odds ratio 2.86; CI95 2.25, 3.65 compared with null condition). This association appeared to be weaker in the presence of adaptive stress-coping skills (odds ratio 0.18; CI95 0.14, 0.23). We have identified factors that distinguish pre-teens with very early co-occurrence of drinking and depressed mood, and protective factors with potential utility for school-based prevention programmes targeting these conditions. [Salom CL, Kelly AB, Alati R, Williams GM, Patton GC, Williams JW. Individual, school-related and family characteristics distinguish co-occurrence of drinking and depressive symptoms in very

  1. 21 CFR 312.32 - IND safety reports.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... safety reports. (a) Definitions. The following definitions of terms apply to this section:- Associated... intervention to prevent one of the outcomes listed in this definition. Examples of such medical events include... example, under this definition, hepatic necrosis would be unexpected (by virtue of greater severity) if...

  2. Advanced Test Reactor Safety Basis Upgrade Lessons Learned Relative to Design Basis Verification and Safety Basis Management

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

    G. L. Sharp; R. T. McCracken

    The Advanced Test Reactor (ATR) is a pressurized light-water reactor with a design thermal power of 250 MW. The principal function of the ATR is to provide a high neutron flux for testing reactor fuels and other materials. The reactor also provides other irradiation services such as radioisotope production. The ATR and its support facilities are located at the Test Reactor Area of the Idaho National Engineering and Environmental Laboratory (INEEL). An audit conducted by the Department of Energy's Office of Independent Oversight and Performance Assurance (DOE OA) raised concerns that design conditions at the ATR were not adequately analyzedmore » in the safety analysis and that legacy design basis management practices had the potential to further impact safe operation of the facility.1 The concerns identified by the audit team, and issues raised during additional reviews performed by ATR safety analysts, were evaluated through the unreviewed safety question process resulting in shutdown of the ATR for more than three months while these concerns were resolved. Past management of the ATR safety basis, relative to facility design basis management and change control, led to concerns that discrepancies in the safety basis may have developed. Although not required by DOE orders or regulations, not performing design basis verification in conjunction with development of the 10 CFR 830 Subpart B upgraded safety basis allowed these potential weaknesses to be carried forward. Configuration management and a clear definition of the existing facility design basis have a direct relation to developing and maintaining a high quality safety basis which properly identifies and mitigates all hazards and postulated accident conditions. These relations and the impact of past safety basis management practices have been reviewed in order to identify lessons learned from the safety basis upgrade process and appropriate actions to resolve possible concerns with respect to the current ATR

  3. FAA National Aviation Safety Inspection Program. Annual Report FY90

    DOT National Transportation Integrated Search

    1991-06-01

    This report was undertaken to document, analyze, and place : into national perspective the findings from the 1990 National : Aviation Safety Inspection Program (NASIP). This report is the : fifth in a series of annual reports covering the results of ...

  4. Associations of Organizational Safety Practices and Culture With Physical Workload, Perceptions About Work, and Work-Related Injury and Symptoms Among Hospital Nurses.

    PubMed

    Lee, Soo-Jeong; Lee, Joung Hee

    The study aim was to examine the relationships of organizational safety practices with nurses' perceptions about job and risk and experiences of work-related injury and symptoms. Nursing professions report high rates of work-related injuries. Organizational safety practices have been linked to workers' safety outcomes and perceptions about work. This study analyzed data from a random sample of 280 California RNs in a cross-sectional statewide survey. Data were collected by both postal and online surveys. Higher perceptions of organizational safety practices (safety climate, ergonomic practices, people-oriented culture) were significantly associated with lower physical workload, lower job strain, higher job satisfaction, lower risk perception, and lower work-related injury and symptom experiences. Ergonomic practices and people-oriented culture were associated with less intention of leaving job. Organizational safety practices may play a pivotal role in improving positive perceptions about jobs, reducing injury risks, and promoting nurse retention.

  5. Annotated Bibliography of Rail Transit Safety, 1975-1980, with Emphasis on Safety Research and Development.

    DOT National Transportation Integrated Search

    1981-09-01

    The bibliography provides a comprehensive review of published literature concerning rail transit safety and includes 186 annotated entries. The report covers domestic and foreign material on rail transit safety and related safety research and develop...

  6. Clinical Trial Electronic Portals for Expedited Safety Reporting: Recommendations from the Clinical Trials Transformation Initiative Investigational New Drug Safety Advancement Project.

    PubMed

    Perez, Raymond P; Finnigan, Shanda; Patel, Krupa; Whitney, Shanell; Forrest, Annemarie

    2016-12-15

    Use of electronic clinical trial portals has increased in recent years to assist with sponsor-investigator communication, safety reporting, and clinical trial management. Electronic portals can help reduce time and costs associated with processing paperwork and add security measures; however, there is a lack of information on clinical trial investigative staff's perceived challenges and benefits of using portals. The Clinical Trials Transformation Initiative (CTTI) sought to (1) identify challenges to investigator receipt and management of investigational new drug (IND) safety reports at oncologic investigative sites and coordinating centers and (2) facilitate adoption of best practices for communicating and managing IND safety reports using electronic portals. CTTI, a public-private partnership to improve the conduct of clinical trials, distributed surveys and conducted interviews in an opinion-gathering effort to record investigator and research staff views on electronic portals in the context of the new safety reporting requirements described in the US Food and Drug Administration's final rule (Code of Federal Regulations Title 21 Section 312). The project focused on receipt, management, and review of safety reports as opposed to the reporting of adverse events. The top challenge investigators and staff identified in using individual sponsor portals was remembering several complex individual passwords to access each site. Also, certain tasks are time-consuming (eg, downloading reports) due to slow sites or difficulties associated with particular operating systems or software. To improve user experiences, respondents suggested that portals function independently of browsers and operating systems, have intuitive interfaces with easy navigation, and incorporate additional features that would allow users to filter, search, and batch safety reports. Results indicate that an ideal system for sharing expedited IND safety information is through a central portal used by

  7. 75 FR 36615 - Pipeline Safety: Information Collection Gas Distribution Annual Report Form

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-28

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration 49 CFR Part 192 [Docket No. PHMSA-RSPA-2004-19854] Pipeline Safety: Information Collection Gas Distribution Annual Report Form AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA), DOT. ACTION: Request...

  8. 21 CFR 601.93 - Postmarketing safety reporting.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 21 Food and Drugs 7 2013-04-01 2013-04-01 false Postmarketing safety reporting. 601.93 Section 601.93 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible...

  9. 21 CFR 314.630 - Postmarketing safety reporting.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 314.630 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.630 Postmarketing safety reporting. Drug...

  10. 21 CFR 601.93 - Postmarketing safety reporting.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 7 2012-04-01 2012-04-01 false Postmarketing safety reporting. 601.93 Section 601.93 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible...

  11. 21 CFR 314.630 - Postmarketing safety reporting.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 314.630 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.630 Postmarketing safety reporting. Drug...

  12. 21 CFR 601.93 - Postmarketing safety reporting.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 7 2010-04-01 2010-04-01 false Postmarketing safety reporting. 601.93 Section 601.93 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible...

  13. 21 CFR 314.630 - Postmarketing safety reporting.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 314.630 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.630 Postmarketing safety reporting. Drug...

  14. 21 CFR 314.630 - Postmarketing safety reporting.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 314.630 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.630 Postmarketing safety reporting. Drug...

  15. 21 CFR 314.630 - Postmarketing safety reporting.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 314.630 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.630 Postmarketing safety reporting. Drug...

  16. 21 CFR 601.93 - Postmarketing safety reporting.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 21 Food and Drugs 7 2011-04-01 2010-04-01 true Postmarketing safety reporting. 601.93 Section 601.93 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible...

  17. 21 CFR 601.93 - Postmarketing safety reporting.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 21 Food and Drugs 7 2014-04-01 2014-04-01 false Postmarketing safety reporting. 601.93 Section 601.93 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible...

  18. Safety Management Information Statistics (SAMIS) - 1993 Annual Report

    DOT National Transportation Integrated Search

    1995-05-01

    The 1993 Safety Management Information Statistics (SAMIS) report, now in its fourth year of publication, is a compilation and analysis of transit accident and casualty statistics uniformly collected from approximately 400 transit agencies throughout ...

  19. Independent evaluation of the transit retrofit package safety applications : final report.

    DOT National Transportation Integrated Search

    2015-02-01

    This report presents the methodology and results of the independent evaluation of retrofit safety packages installed on transit vehicles in the : Safety Pilot Model Deploymentpart of the United States Department of Transportations Intelligent T...

  20. A Preliminary Report on the CO2 Laser for Lumbar Fusion: Safety, Efficacy and Technical Considerations.

    PubMed

    Villavicencio, Alan T; Burneikiene, Sigita; Babuska, Jason M; Nelson, Ewell L; Mason, Alexander; Rajpal, Sharad

    2015-04-01

    The purpose of this study was to evaluate potential technical advantages of the CO2 laser technology in mini-open transforaminal lumbar interbody fusion (TLIF) surgeries and report our preliminary clinical data on the safety and clinical outcomes. There is currently no literature discussing the recently redeveloped CO2 laser technology application for lumbar fusion. Safety and clinical outcomes were compared between two groups: 24 patients that underwent CO2 laser-assisted one-level TLIF surgeries and 30 patients that underwent standard one-level TLIF surgeries without the laser. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. At a mean follow-up of 17.4 months, significantly reduced lower back pain scores (P=0.013) were reported in the laser-assisted patient group compared to a standard fusion patient group. Lower extremity radicular pain intensity scores were similar in both groups. Laser-assisted TLIF surgeries showed a tendency (P = 0.07) of shorter operative times that was not statistically significant. Based on this preliminary clinical report, the safety of the CO2 laser device for lumbar fusion surgeries was assessed. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. Further investigation of CO2 laser-assisted lumbar fusion procedures is warranted in order to evaluate its effect on clinical outcomes.

  1. Global occurrence of infant botulism, 1976-2006.

    PubMed

    Koepke, Ruth; Sobel, Jeremy; Arnon, Stephen S

    2008-07-01

    To summarize the worldwide occurrence of reported infant (intestinal toxemia) botulism cases since first recognition of the disease in 1976. We collected information on infant botulism cases by active and passive surveillance, by provision of therapeutic Human Botulism Immune Globulin to suspected cases, and by searching the medical literature. We defined a case as laboratory-confirmed botulism that occurred in an infant reported the occurrence of at least 1 case of infant botulism among their residents. The United States, Argentina, Australia, Canada, Italy, and Japan, in this order, reported the largest number of cases. A history of honey exposure was significantly more common among case subjects hospitalized outside of the United States than among those who were recently hospitalized in California. Most countries have not yet reported cases of infant botulism. This limited reporting of the disease to date contrasts with the known global occurrence of Clostridium botulinum spores in soils and dust and suggests that infant botulism may be under-recognized, underreported, or both. When bulbar palsies, hypotonia, and weakness are present, physicians should consider the possibility of infant botulism even if the patient has not been fed honey. Publication of additional case reports and surveillance summaries will enhance understanding of the occurrence and extent of this under-recognized disease.

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

    NASA Technical Reports Server (NTRS)

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

    2010-01-01

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

  3. Certification of highly complex safety-related systems.

    PubMed

    Reinert, D; Schaefer, M

    1999-01-01

    The BIA has now 15 years of experience with the certification of complex electronic systems for safety-related applications in the machinery sector. Using the example of machining centres this presentation will show the systematic procedure for verifying and validating control systems using Application Specific Integrated Circuits (ASICs) and microcomputers for safety functions. One section will describe the control structure of machining centres with control systems using "integrated safety." A diverse redundant architecture combined with crossmonitoring and forced dynamization is explained. In the main section the steps of the systematic certification procedure are explained showing some results of the certification of drilling machines. Specification reviews, design reviews with test case specification, statistical analysis, and walk-throughs are the analytical measures in the testing process. Systematic tests based on the test case specification, Electro Magnetic Interference (EMI), and environmental testing, and site acceptance tests on the machines are the testing measures for validation. A complex software driven system is always undergoing modification. Most of the changes are not safety-relevant but this has to be proven. A systematic procedure for certifying software modifications is presented in the last section of the paper.

  4. Safety huddles to proactively identify and address electronic health record safety

    PubMed Central

    Menon, Shailaja; Singh, Hardeep; Giardina, Traber D; Rayburn, William L; Davis, Brenda P; Russo, Elise M

    2017-01-01

    Objective: Methods to identify and study safety risks of electronic health records (EHRs) are underdeveloped and largely depend on limited end-user reports. “Safety huddles” have been found useful in creating a sense of collective situational awareness that increases an organization’s capacity to respond to safety concerns. We explored the use of safety huddles for identifying and learning about EHR-related safety concerns. Design: Data were obtained from daily safety huddle briefing notes recorded at a single midsized tertiary-care hospital in the United States over 1 year. Huddles were attended by key administrative, clinical, and information technology staff. We conducted a content analysis of huddle notes to identify what EHR-related safety concerns were discussed. We expanded a previously developed EHR-related error taxonomy to categorize types of EHR-related safety concerns recorded in the notes. Results: On review of daily huddle notes spanning 249 days, we identified 245 EHR-related safety concerns. For our analysis, we defined EHR technology to include a specific EHR functionality, an entire clinical software application, or the hardware system. Most concerns (41.6%) involved “EHR technology working incorrectly,” followed by 25.7% involving “EHR technology not working at all.” Concerns related to “EHR technology missing or absent” accounted for 16.7%, whereas 15.9% were linked to “user errors.” Conclusions: Safety huddles promoted discussion of several technology-related issues at the organization level and can serve as a promising technique to identify and address EHR-related safety concerns. Based on our findings, we recommend that health care organizations consider huddles as a strategy to promote understanding and improvement of EHR safety. PMID:28031286

  5. 78 FR 54493 - Report to Congress on Abnormal Occurrences: Fiscal Year 2012, Revision 1; Dissemination of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-04

    ... health or safety. The Federal Reports Elimination and Sunset Act of 1995 (Pub. L. 104-68) requires that... maintenance and inspections performed by the manufacturer. State--The Texas Department of State Health... manner that provides for adequate protection of public health and safety. On February 26, 2013, the NRC...

  6. Occurrence of human respiratory syncytial virus in summer in Japan.

    PubMed

    Shobugawa, Y; Takeuchi, T; Hibino, A; Hassan, M R; Yagami, R; Kondo, H; Odagiri, T; Saito, R

    2017-01-01

    In temperate zones, human respiratory syncytial virus (HRSV) outbreaks typically occur in cold weather, i.e. in late autumn and winter. However, recent outbreaks in Japan have tended to start during summer and autumn. This study examined associations of meteorological conditions with the numbers of HRSV cases reported in summer in Japan. Using data from the HRSV national surveillance system and national meteorological data for summer during the period 2007-2014, we utilized negative binomial logistic regression analysis to identify associations between meteorological conditions and reported cases of HRSV. HRSV cases increased when summer temperatures rose and when relative humidity increased. Consideration of the interaction term temperature × relative humidity enabled us to show synergistic effects of high temperature with HRSV occurrence. In particular, HRSV cases synergistically increased when relative humidity increased while the temperature was ⩾28·2 °C. Seasonal-trend decomposition analysis using the HRSV national surveillance data divided by 11 climate divisions showed that summer HRSV cases occurred in South Japan (Okinawa Island), Kyushu, and Nankai climate divisions, which are located in southwest Japan. Higher temperature and higher relative humidity were necessary conditions for HRSV occurrence in summer in Japan. Paediatricians in temperate zones should be mindful of possible HRSV cases in summer, when suitable conditions are present.

  7. Environmental health and safety independent investigation of the in situ vitrification melt expulsion at the Oak Ridge National Laboratory, Oak Ridge, Tennessee

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

    NONE

    At about 6:12 pm, EDT on April 21, 1996, steam and molten material were expelled from Pit 1 in situ vitrification (ISV) project at the Oak Ridge National Laboratory (ORNL). At the request of the director of the Environmental Restoration (ER) Division, Department of Energy Oak Ridge Operations (DOE ORO), an independent investigation team was established on April 26, 1996. This team was tasked to determine the facts related to the ORNL Pit 1 melt expulsion event (MEE) in the areas of environment safety and health concerns such as the adequacy of the ISV safety systems; operational control restrictions; emergencymore » response planning/execution; and readiness review, and report the investigation team findings within 45 days from the date of incident. These requirements were stated in the letter of appointment presented in Appendix A of this report. This investigation did not address the physical causes of the MEE. A separate investigation was conducted by ISV project personnel to determine the causes of the melt expulsion and the extent of the effects of this phenomenon. In response to this event, occurrence report ORO-LMES-X10ENVRES-1996-0006 (Appendix B) was filed. The investigation team did not address the occurrence reporting or event notification process. The project personnel (project team) examined the physical evidence at Pit 1 ISV site (e.g., the ejected melt material and the ISV hood), reviewed documents such as the site- specific health and safety plan (HASP), and interviewed personnel involved in the event and/or the project. A listing of the personnel interviewed and evidence reviewed is provided in Appendix C.« less

  8. [Field epidemiological study on news reports that related to public health emergencies].

    PubMed

    Zhang, Shun-xiang; Li, Xue-mei; Luo, Nian-ci; Mei, Shu-jiang; Jiang, Li-juan

    2013-12-01

    All news reports (NR) that were related to public health emergency (PHE) were collected from the Southern Metropolis Daily (SMD) to explore the characteristics of epidemiology in the fields. Based on the theory of communication that including both case and text analysis, qualitative analysis on all the NR regarding PHE published in SMD from the years of 2008 to 2012, was carried out and input to database using the EpiData. Numbers of articles as indicators were compared to show the yearly change of different types of events. Various features of the NR including coverage, source of information, location of the incident, style and size of news, with or without editorials etc. were statistically analyzed by SPSS version 18.0. Among all the 998 reports related to PHE, higher proportion was found in the events of Infectious diseases (35.3%) and food safety (34.1%)respectively. Events on vaccines and drugs used for disease prevention and control (8.9%), environmental pollution caused incidents (8.0%)appeared to be less frequent. Events related to occupational disease, poisoning, bioterrorism and biochemical events were rare. Looking at the monthly distribution of reports, we noticed that the peaks occurred in 2008 and in 2009, which were caused by the Melamine-contamination events and the 2009 H1N1 pandemic. Between 2010 and 2012, figures of monthly reports were smooth, including some critical events from the interests of the media. Most events took place in Guangdong province (34.3%) and other provinces (50.9%), with some were from Hong Kong, Macao and Taiwan regions (9.5%). However, international events (5.2%)were less seen. Extensive coverage accounted for 17.6% of all of reports, and 11.5% allotted the editorials or other forms of in-depth reports. Most of the source of reports on infectious diseases and food safety were from the official release, however. The main sources of occupational diseases and poisoning, vaccines and drug incidents, environmental pollution

  9. A survey of the occurrence of motion sickness amongst passengers at sea.

    PubMed

    Lawther, A; Griffin, M J

    1988-05-01

    A questionnaire survey of motion sickness occurrence on board passenger ferries has been conducted. Data were collected from 20,029 passengers on 114 voyages on 9 vessels: 6 ships, 2 hovercraft, and 1 jetfoil. Information was obtained about feelings of illness, the occurrence of vomiting, the taking of anti-seasickness tablets, the consumption of alcoholic drinks, regularity of travel by sea, age, and sex. Overall, 7% of passengers reported vomiting at some time during the journey, 21% said they felt "slightly unwell," 4% felt "quite ill," and a further 4% felt "absolutely dreadful." Both vomiting incidence and illness rating were greater in females than in males, and there was a slight decrease in sickness occurrence with increasing age. The incidence of vomiting was related to the taking of tablets and the drinking of alcohol; there were also some interaction effects with other variables. Anecdotal information from passengers is reported and consideration is given to the effects of environmental variables.

  10. Development and application of the Safe Performance Index as a risk-based methodology for identifying major hazard-related safety issues in underground coal mines

    NASA Astrophysics Data System (ADS)

    Kinilakodi, Harisha

    medium-sized mines. The accident rates (NDL IR, NFDL IR, SM/100) of very small and small mines in 2008 and 2009 were less than those of medium and large mines. The data indicates a heavy occurrence of very severe injuries in a number of very small and small mines. In another application which is a part of this research, the six normalized safety measures and the SPI are used to evaluate the risk that existed at mines in the two years preceding the occurrence of a fatality. This mine safety performance tracking method could have been helpful to the companies, state agency, or MSHA in recognizing and addressing emerging problems with actions that may have been able to prevent high-risk conditions, the fatality, and/or other serious injuries. The approach would have given scrutiny to the risk of mines that encompassed 74% of the fatalities during 2007-2010. In order to assess the SPI as a comparable risk measurement tool, a traditional risk approach is also developed using data embracing frequency and severity in the final equation to analyze the relative risk for all underground coal mines for the years 2007--2010. Then, the SPI is compared with this traditional risk analysis method to demonstrate that the results attained by either method provide the relative safety-related risk of underground coal mines regarding injuries and citations for violations of regulations. The comparison reveals that the SPI does emulate a traditional approach to risk analysis. A correlation coefficient of --0.89 or more was observed between the results of these two methodologies and either can be used to assist companies, the Mine Safety and Health Administration (MSHA), or state agencies in target-ing mines with high risk for serious injuries and elevated citations for remediation of their injury and/or violation experience. The SPI, however, provides a more understandable approach for mine operators to apply using measures compatible with MSHA's enforcement tools. These methodologies form an

  11. Alcohol and highway safety : a bibliography

    DOT National Transportation Integrated Search

    1976-05-15

    This bibliography represents literature acquired since the establishment of the National Highway Traffic Safety Administration (NHTSA) in 1967, as related to alcohol and highway safety. It is comprised of NHTSA contract reports, reports of other orga...

  12. 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.

  13. THE OCCURRENCE OF DISINFECTION BY-PRODUCTS OF HEALTH CONCERN IN DRINKING WATER: RESULTS OF A NATIONWIDE DBP OCCURRENCE STUDY

    EPA Science Inventory

    The motivation for this Nationwide Disinfection By-product (DBP) Occurrence Study was two-fold: First, more than 500 DBPs have been reported in the literature, yet there is almost no quantitative occurrence information for most. As a result, there is significant uncertainty ove...

  14. Suspected adverse drug reactions in elderly patients reported to the Committee on Safety of Medicines.

    PubMed

    Castleden, C M; Pickles, H

    1988-10-01

    1. Spontaneous reports of suspected adverse drug reactions (ADRs) reported to the Committee on Safety of Medicines (CSM) have been studied in relation to patient age. 2. The proportion of reports received for the elderly increased between 1965 and 1983. 3. There was a correlation between the use of drugs and the number of ADR reports. Thus age-related prescription figures for two non-steroidal anti-inflammatory drugs (NSAI) and co-trimoxazole matched ADR reports for each drug in each age group. 4. The reported ADR was more likely to be serious or fatal in the elderly. 5. The commonest ADRs reported for the elderly affected the gastrointestinal (GIT) and haemopoietic systems, where more reports were received than would be expected from prescription figures. 6. The drug suspected of causing a GIT reaction was a NSAI in 75% of the reports. 7. Ninety-one per cent of fatal reports of GIT bleeds and perforations associated with NSAI drugs were in patients over 60 years of age.

  15. Allelic Variation of Risk for Anxiety Symptoms Moderates the Relation Between Adolescent Safety Behaviors and Social Anxiety Symptoms

    PubMed Central

    Thomas, Sarah A.; Weeks, Justin W.; Dougherty, Lea R.; Lipton, Melanie F.; Daruwala, Samantha E.; Kline, Kathryn

    2015-01-01

    Social anxiety often develops in adolescence, and precedes the onset of depression and substance use disorders. The link between social anxiety and use of behaviors to minimize distress in social situations (i.e., safety behaviors) is strong and for some patients, this link poses difficulty for engaging in, and benefiting from, exposure-based treatment. Yet, little is known about whether individual differences may moderate links between social anxiety and safety behaviors, namely variations in genetic alleles germane to anxiety. We examined the relation between adolescent social anxiety and expressions of safety behaviors, and whether allelic variation for anxiety moderates this relation. Adolescents (n=75; ages 14–17) were recruited from two larger studies investigating measurement of family relationships or adolescent social anxiety. Adolescents completed self-report measures about social anxiety symptoms and use of safety behaviors. They also provided saliva samples to assess allelic variations for anxiety from two genetic polymorphisms (BDNF rs6265; TAQ1A rs1800497). Controlling for adolescent age and gender, we observed a significant interaction between social anxiety symptoms and allelic variation (β=0.37, t=2.41, p=.02). Specifically, adolescents carrying allelic variations for anxiety evidenced a statistically significant and relatively strong positive relation between social anxiety symptoms and safety behaviors (β=0.73), whereas adolescents not carrying allelic variation evidenced a statistically non-significant and relatively weak relation (β=0.22). These findings have important implications for treating adolescent social anxiety, in that we identified an individual difference variable that can be used to identify people who evidence a particularly strong link between use of safety behaviors and expressing social anxiety. PMID:26692635

  16. State Safety Oversight Program : annual report for 2003

    DOT National Transportation Integrated Search

    2004-10-01

    The Federal Transit Administration (FTA) State Safety Oversight Rule (49 CFR Part 659) requires oversight of all rail transit agencies in revenue operation after January 1, 1997. This report summarizes activities performed to implement the State Safe...

  17. State safety oversight program : annual report for 1999

    DOT National Transportation Integrated Search

    2000-09-01

    The Federal Transit Administration (FTA) State Safety Oversight Rule (49 CFR Part 659) requires oversight for all rail transit agencies in revenue operation after January 1, 1997. This report summarizes activities performed to implement the State Saf...

  18. Transit safety & security statistics & analysis 2003 annual report (formerly SAMIS)

    DOT National Transportation Integrated Search

    2005-12-01

    The Transit Safety & Security Statistics & Analysis 2003 Annual Report (formerly SAMIS) is a compilation and analysis of mass transit accident, casualty, and crime statistics reported under the Federal Transit Administrations (FTAs) National Tr...

  19. Transit safety & security statistics & analysis 2002 annual report (formerly SAMIS)

    DOT National Transportation Integrated Search

    2004-12-01

    The Transit Safety & Security Statistics & Analysis 2002 Annual Report (formerly SAMIS) is a compilation and analysis of mass transit accident, casualty, and crime statistics reported under the Federal Transit Administrations (FTAs) National Tr...

  20. Occurrence of Autoimmune Diseases Related to the Vaccine against Yellow Fever

    PubMed Central

    Oliveira, Ana Cristina Vanderley; Maria Henrique da Mota, Licia; dos Santos-Neto, Leopoldo Luiz; De Carvalho, Jozélio Freire; Caldas, Iramaya Rodrigues; Martins Filho, Olindo Assis; Tauil, Pedro Luis

    2014-01-01

    Yellow fever is an infectious disease, endemic in South America and Africa. This is a potentially serious illness, with lethality between 5 and 40% of cases. The most effective preventive vaccine is constituted by the attenuated virus strain 17D, developed in 1937. It is considered safe and effective, conferring protection in more than 90% in 10 years. Adverse effects are known as mild reactions (allergies, transaminases transient elevation, fever, headache) and severe (visceral and neurotropic disease related to vaccine). However, little is known about its potential to induce autoimmune responses. This systematic review aims to identify the occurrence of autoinflammatory diseases related to 17D vaccine administration. Six studies were identified describing 13 possible cases. The diseases were Guillain-Barré syndrome, multiple sclerosis, multiple points evanescent syndrome, acute disseminated encephalomyelitis, autoimmune hepatitis, and Kawasaki disease. The data suggest that 17D vaccination may play a role in the mechanism of loss of self-tolerance. PMID:25405025

  1. Training Course for Compliance Safety and Health Officers. Final Report.

    ERIC Educational Resources Information Center

    McKnight, A. James; And Others

    The report describes revision of the Compliance Safety and Health Officers (CSHO) course for the Department of Labor, Occupational Safety and Health Administration (OSHA). The CSHO's job was analyzed in depth, in accord with OSHA standards, policies, and procedures. A listing of over 1,700 violations of OSHA standards was prepared, and specialists…

  2. Vision and commercial motor vehicle driver safety : vol. 1 : evidence report

    DOT National Transportation Integrated Search

    2008-06-06

    The purpose of this evidence report is to address several key questions posed by the Federal Motor Carrier Safety Administration (FMCSA) that pertain to vision and commercial motor vehicle (CMV) driver safety. Each of these key questions was develope...

  3. Patient-Reported Safety Information: A Renaissance of Pharmacovigilance?

    PubMed

    Härmark, Linda; Raine, June; Leufkens, Hubert; Edwards, I Ralph; Moretti, Ugo; Sarinic, Viola Macolic; Kant, Agnes

    2016-10-01

    The role of patients as key contributors in pharmacovigilance was acknowledged in the new EU pharmacovigilance legislation. This contains several efforts to increase the involvement of the general public, including making patient adverse drug reaction (ADR) reporting systems mandatory. Three years have passed since the legislation was introduced and the key question is: does pharmacovigilance yet make optimal use of patient-reported safety information? Independent research has shown beyond doubt that patients make an important contribution to pharmacovigilance signal detection. Patient reports provide first-hand information about the suspected ADR and the circumstances under which it occurred, including medication errors, quality failures, and 'near misses'. Patient-reported safety information leads to a better understanding of the patient's experiences of the ADR. Patients are better at explaining the nature, personal significance and consequences of ADRs than healthcare professionals' reports on similar associations and they give more detailed information regarding quality of life including psychological effects and effects on everyday tasks. Current methods used in pharmacovigilance need to optimise use of the information reported from patients. To make the most of information from patients, the systems we use for collecting, coding and recording patient-reported information and the methodologies applied for signal detection and assessment need to be further developed, such as a patient-specific form, development of a severity grading and evolution of the database structure and the signal detection methods applied. It is time for a renaissance of pharmacovigilance.

  4. Avation Safety Reporting System (ASRS) 40th Anniversary.

    NASA Image and Video Library

    2016-09-28

    Avation Safety Reporting System (ASRS) 40th Anniversary lunch and open house at the Sunnyvale office. Linda J. Connell, ASRS Program Director (left); Dr. John Lauber, Resident Scientist and early pioneer of the ASRS at Ames, 1972-1985 (Right).

  5. 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.

  6. 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

  7. Automated enforcement and highway safety : final report.

    DOT National Transportation Integrated Search

    2013-11-01

    The objectives of the Automated Enforcement and Highway Safety Research study were to conduct a : literature review of national research related to the effectiveness of Red Light Camera (RLC) programs : in changing crash frequency, crash severity, cr...

  8. Zero Tolerance: A Stage Adaptation of an Investigative Report on School Safety

    ERIC Educational Resources Information Center

    Goldstein, Tara; Wickett, Jocelyn

    2009-01-01

    In May 2007, 15-year-old Jordan Manners was shot and killed in the hallway of his Toronto school. In June 2007, the Toronto District School Board commissioned an investigation into school safety, which resulted in a report entitled "The Road to Health: A Final Report on School Safety." In February 2008, in an attempt to provoke…

  9. Patient safety in out-of-hours primary care: a review of patient records.

    PubMed

    Smits, Marleen; Huibers, Linda; Kerssemeijer, Brian; de Feijter, Eimert; Wensing, Michel; Giesen, Paul

    2010-12-10

    Most patients receive healthcare in primary care settings, but relatively little is known about patient safety. Out-of-hours contacts are of particular importance to patient safety. Our aim was to examine the incidence, types, causes, and consequences of patient safety incidents at general practice cooperatives for out-of-hours primary care and to examine which factors were associated with the occurrence of patient safety incidents. A retrospective study of 1,145 medical records concerning patient contacts with four general practice cooperatives. Reviewers identified records with evidence of a potential patient safety incident; a physician panel determined whether a patient safety incident had indeed occurred. In addition, the panel determined the type, causes, and consequences of the incidents. Factors associated with incidents were examined in a random coefficient logistic regression analysis. In 1,145 patient records, 27 patient safety incidents were identified, an incident rate of 2.4% (95% CI: 1.5% to 3.2%). The most frequent incident type was treatment (56%). All incidents had at least partly been caused by failures in clinical reasoning. The majority of incidents did not result in patient harm (70%). Eight incidents had consequences for the patient, such as additional interventions or hospitalisation. The panel assessed that most incidents were unlikely to result in patient harm in the long term (89%). Logistic regression analysis showed that age was significantly related to incident occurrence: the likelihood of an incident increased with 1.03 for each year increase in age (95% CI: 1.01 to 1.04). Patient safety incidents occur in out-of-hours primary care, but most do not result in harm to patients. As clinical reasoning played an important part in these incidents, a better understanding of clinical reasoning and guideline adherence at GP cooperatives could contribute to patient safety.

  10. Administration of the Radiation Control for Health and Safety Act of 1968, Public Law 90-602, April 1, 1987 (1986 annual report). Report for January-December 1986

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

    Not Available

    This report provides a summary of the operations of the Center for Devices and Radiological Health in carrying out that responsibility for calendar year 1986. Manufactureres of electronic products are required by 21 CFR 1002.20 to report accidental radiation occurrences to the CDRH. The Center no longer maintains a Radiation Incidents Registry, since accidental radiation occurrences are reported through the Device Experience Network (DEN) and through the requirements of the Medical Device Reporting (MDR) regulations.

  11. Fire Safety Tests for Spherical Resorcinol Formaldehyde Resin: Data Summary Report

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

    Kim, Dong-Sang; Peterson, Reid A.; Schweiger, Michael J.

    2012-07-30

    A draft safety evaluation of the scenario for spherical resorcinol-formaldehyde (SRF) resin fire inside the ion exchange column was performed by the Hanford Tank Waste Treatment and Immobilization Plant (WTP) Fire Safety organization. The result of this draft evaluation suggested a potential change of the fire safety classification for the Cesium Ion Exchange Process System (CXP) emergency elution vessels, equipment, and piping, which may be overly bounding based on the fire performance data from the manufacturer of the ion exchange resin selected for use at the WTP. To resolve this question, the fire properties of the SRF resin were measuredmore » by Southwest Research Institute (SwRI), following the American Society for Testing and Materials (ASTM) standard procedures, through a subcontract managed by Pacific Northwest National Laboratory (PNNL). For some tests, the ASTM standard procedures were not entirely appropriate or practical for the SRF resin material, so the procedures were modified and deviations from the ASTM standard procedures were noted. This report summarizes the results of fire safety tests performed and reported by SwRI. The efforts by PNNL were limited to summarizing the test results provided by SwRI into one consolidated data report. All as-received SwRI reports are attached to this report in the Appendix. Where applicable, the precision and bias of each test method, as given by each ASTM standard procedure, are included and compared with the SwRI test results of the SRF resin.« less

  12. Exploring the Influence of Nurse Work Environment and Patient Safety Culture on Attitudes Toward Incident Reporting.

    PubMed

    Yoo, Moon Sook; Kim, Kyoung Ja

    2017-09-01

    The aim of this study was to explore the influence of nurse work environments and patient safety culture on attitudes toward incident reporting. Patient safety culture had been known as a factor of incident reporting by nurses. Positive work environment could be an important influencing factor for the safety behavior of nurses. A cross-sectional survey design was used. The structured questionnaire was administered to 191 nurses working at a tertiary university hospital in South Korea. Nurses' perception of work environment and patient safety culture were positively correlated with attitudes toward incident reporting. A regression model with clinical career, work area and nurse work environment, and patient safety culture against attitudes toward incident reporting was statistically significant. The model explained approximately 50.7% of attitudes toward incident reporting. Improving nurses' attitudes toward incident reporting can be achieved with a broad approach that includes improvements in work environment and patient safety culture.

  13. Effect of occupational safety and health education received during schooling on the incidence of workplace injuries in the first 2 years of occupational life: a prospective study

    PubMed Central

    Boini, Stephanie; Colin, Regis; Grzebyk, Michel

    2017-01-01

    Objectives This study aimed to determine the effect of occupational safety and health (OSH) education during formal schooling on the incidence of workplace injuries (WIs) in young people starting their careers. We hypothesised that young people who had received OSH education during their schooling would have fewer WIs than those who received no OSH education. Secondary objectives focused on the effect of ‘first aid at work’ training during schooling and the conditions encountered on arrival in the company (occupational hazard information, safety training and job task training) on WI occurrence. Design Prospective cohort study. Participants From 2009 to 2012, French apprentices and students at the end of their schooling and starting their careers were included. Outcomes Occurrence of WIs. Methods At the time of inclusion, information about school courses and personal characteristics were collected, and subsequent half-yearly contacts gathered information relating to work and personal data. During the 2-year follow-up, WIs were directly reported by participants and were identified by searching the French National Health Insurance Funds’ databases listing compulsory WI declarations. Results 755 participants reported holding 1290 jobs. During follow-up, 158 WIs were identified, corresponding to an incident rate of 0.12 (0.10 to 0.14) WIs per full-time worker. Subjects who reported having received OSH education at school had two times less WIs than those declaring not having received OSH education (incidence rate ratio (IRR) 0.51, 0.00 to 0.98). A lower WI risk was observed for participants who received the ‘first aid at work’ training (IRR=0.68, 0.00 to 0.98). The conditions on arrival in company were not associated with WIs occurrence. Conclusion In France, the OSH education provided to apprentices and students is mostly broader than the specific risks related to future jobs. Our results highlight the advantages of reinforcing this approach. PMID:28720614

  14. Using a quantitative risk register to promote learning from a patient safety reporting system.

    PubMed

    Mansfield, James G; Caplan, Robert A; Campos, John S; Dreis, David F; Furman, Cathie

    2015-02-01

    Patient safety reporting systems are now used in most health care delivery organizations. These systems, such as the one in use at Virginia Mason (Seattle) since 2002, can provide valuable reports of risk and harm from the front lines of patient care. In response to the challenge of how to quantify and prioritize safety opportunities, a risk register system was developed and implemented. Basic risk register concepts were refined to provide a systematic way to understand risks reported by staff. The risk register uses a comprehensive taxonomy of patient risk and algorithmically assigns each patient safety report to 1 of 27 risk categories in three major domains (Evaluation, Treatment, and Critical Interactions). For each category, a composite score was calculated on the basis of event rate, harm, and cost. The composite scores were used to identify the "top five" risk categories, and patient safety reports in these categories were analyzed in greater depth to find recurrent patterns of risk and associated opportunities for improvement. The top five categories of risk were easy to identify and had distinctive "profiles" of rate, harm, and cost. The ability to categorize and rank risks across multiple dimensions yielded insights not previously available. These results were shared with leadership and served as input for planning quality and safety initiatives. This approach provided actionable input for the strategic planning process, while at the same time strengthening the Virginia Mason culture of safety. The quantitative patient safety risk register serves as one solution to the challenge of extracting valuable safety lessons from large numbers of incident reports and could profitably be adopted by other organizations.

  15. Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

    PubMed

    Martinez, William; Lehmann, Lisa Soleymani; Thomas, Eric J; Etchegaray, Jason M; Shelburne, Julia T; Hickson, Gerald B; Brady, Donald W; Schleyer, Anneliese M; Best, Jennifer A; May, Natalie B; Bell, Sigall K

    2017-11-01

    Open communication between healthcare professionals about care concerns, also known as 'speaking up', is essential to patient safety. Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats. Anonymous, cross-sectional survey. Six US academic medical centres, 2013-2014. 1800 medical and surgical interns and residents (47% responded). Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales. Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50). Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient

  16. Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "good catch" awards.

    PubMed

    Herzer, Kurt R; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A; Mark, Lynette J

    2012-08-01

    Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them. A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time. Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail. A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.

  17. Barriers to Safety Event Reporting in an Academic Radiology Department: Authority Gradients and Other Human Factors.

    PubMed

    Siewert, Bettina; Swedeen, Suzanne; Brook, Olga R; Eisenberg, Ronald L; Hochman, Mary

    2018-05-15

    Purpose To investigate barriers to reporting safety concerns in an academic radiology department and to evaluate the role of human factors, including authority gradients, as potential barriers to safety concern reporting. Materials and Methods In this institutional review board-approved, HIPAA-compliant retrospective study, an online questionnaire link was emailed four times to all radiology department staff members (n = 648) at a tertiary care institution. Survey questions included frequency of speaking up about safety concerns, perceived barriers to speaking up, and the annual number of safety concerns that respondents were unsuccessful in reporting. Respondents' sex, role in the department, and length of employment were recorded. Statistical analysis was performed with the Fisher exact test. Results The survey was completed by 363 of the 648 employees (56%). Of those 363 employees, 182 (50%) reported always speaking up about safety concerns, 134 (37%) reported speaking up most of the time, 36 (10%) reported speaking up sometimes, seven (2%) reported rarely speaking up, and four (1%) reported never speaking up. Thus, 50% of employees spoke up about safety concerns less than 100% of the time. The most frequently reported barriers to speaking up included high reporting threshold (69%), reluctance to challenge someone in authority (67%), fear of disrespect (53%), and lack of listening (52%). Conclusion Of employees in a large academic radiology department, 50% do not attain 100% reporting of safety events. The most common human barriers to speaking up are high reporting threshold, reluctance to challenge authority, fear of disrespect, and lack of listening, which suggests that existing authority gradients interfere with full reporting of safety concerns. © RSNA, 2018.

  18. Increased variability of tornado occurrence in the United States.

    PubMed

    Brooks, Harold E; Carbin, Gregory W; Marsh, Patrick T

    2014-10-17

    Whether or not climate change has had an impact on the occurrence of tornadoes in the United States has become a question of high public and scientific interest, but changes in how tornadoes are reported have made it difficult to answer it convincingly. We show that, excluding the weakest tornadoes, the mean annual number of tornadoes has remained relatively constant, but their variability of occurrence has increased since the 1970s. This is due to a decrease in the number of days per year with tornadoes combined with an increase in days with many tornadoes, leading to greater variability on annual and monthly time scales and changes in the timing of the start of the tornado season. Copyright © 2014, American Association for the Advancement of Science.

  19. 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.

  20. Relation of Cloud Occurrence Frequency, Overlap, and Effective Thickness Derived from CALIPSO and CloudSat Merged Cloud Vertical Profiles

    NASA Technical Reports Server (NTRS)

    Kato, Seiji; Sun-Mack, Sunny; Miller, Walter F.; Rose, Fred G.; Chen, Yan; Minnis, Patrick; Wielicki, Bruce A.

    2009-01-01

    A cloud frequency of occurrence matrix is generated using merged cloud vertical profile derived from Cloud-Aerosol Lidar with Orthogonal Polarization (CALIOP) and Cloud Profiling Radar (CPR). The matrix contains vertical profiles of cloud occurrence frequency as a function of the uppermost cloud top. It is shown that the cloud fraction and uppermost cloud top vertical pro les can be related by a set of equations when the correlation distance of cloud occurrence, which is interpreted as an effective cloud thickness, is introduced. The underlying assumption in establishing the above relation is that cloud overlap approaches the random overlap with increasing distance separating cloud layers and that the probability of deviating from the random overlap decreases exponentially with distance. One month of CALIPSO and CloudSat data support these assumptions. However, the correlation distance sometimes becomes large, which might be an indication of precipitation. The cloud correlation distance is equivalent to the de-correlation distance introduced by Hogan and Illingworth [2000] when cloud fractions of both layers in a two-cloud layer system are the same.

  1. The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

    PubMed

    Panesar, Sukhmeet S; Netuveli, Gopalakrishnan; Carson-Stevens, Andrew; Javad, Sundas; Patel, Bhavesh; Parry, Gareth; Donaldson, Liam J; Sheikh, Aziz

    2013-11-21

    The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery. Cross-sectional study (retrospective analysis of records in a database). The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties. We extracted all orthopaedic error reports from the system over 1 year (2009-2010). The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention. 155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively. The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.

  2. Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining the role of ease of reporting, unit norms of openness, and participative leadership.

    PubMed

    Zaheer, Shahram; Ginsburg, Liane; Chuang, You-Ta; Grace, Sherry L

    2015-01-01

    Increased awareness regarding the importance of patient safety issues has led to the proliferation of theoretical conceptualizations, frameworks, and articles that apply safety experiences from high-reliability industries to medical settings. However, empirical research on patient safety and patient safety climate in medical settings still lags far behind the theoretical literature on these topics. The broader organizational literature suggests that ease of reporting, unit norms of openness, and participative leadership might be important variables for improving patient safety. The aim of this empirical study is to examine in detail how these three variables influence frontline staff perceptions of patient safety climate within health care organizations. A cross-sectional study design was used. Data were collected using a questionnaire composed of previously validated scales. The results of the study show that ease of reporting, unit norms of openness, and participative leadership are positively related to staff perceptions of patient safety climate. Health care management needs to involve frontline staff during the development and implementation stages of an error reporting system to ensure staff perceive error reporting to be easy and efficient. Senior and supervisory leaders at health care organizations must be provided with learning opportunities to improve their participative leadership skills so they can better integrate frontline staff ideas and concerns while making safety-related decisions. Finally, health care management must ensure that frontline staff are able to freely communicate safety concerns without fear of being punished or ridiculed by others.

  3. 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.

  4. Pilot-controller communication errors : an analysis of Aviation Safety Reporting System (ASRS) reports

    DOT National Transportation Integrated Search

    1998-08-01

    The purpose of this study was to identify the factors that contribute to pilot-controller communication errors. Resports submitted to the Aviation Safety Reporting System (ASRS) offer detailed accounts of specific types of errors and a great deal of ...

  5. School Safety Study: Phase I.

    ERIC Educational Resources Information Center

    Arora, Alka

    This report summarizes findings from a study concerned with Arizona school safety. The survey component highlights safety-related policy information across 300 schools; the interview component highlights school-safety perceptions of 64 staff across 16 schools. Various policies and programs that respond to internal and external threats to school…

  6. Suspected adverse drug reactions in elderly patients reported to the Committee on Safety of Medicines.

    PubMed Central

    Castleden, C M; Pickles, H

    1988-01-01

    1. Spontaneous reports of suspected adverse drug reactions (ADRs) reported to the Committee on Safety of Medicines (CSM) have been studied in relation to patient age. 2. The proportion of reports received for the elderly increased between 1965 and 1983. 3. There was a correlation between the use of drugs and the number of ADR reports. Thus age-related prescription figures for two non-steroidal anti-inflammatory drugs (NSAI) and co-trimoxazole matched ADR reports for each drug in each age group. 4. The reported ADR was more likely to be serious or fatal in the elderly. 5. The commonest ADRs reported for the elderly affected the gastrointestinal (GIT) and haemopoietic systems, where more reports were received than would be expected from prescription figures. 6. The drug suspected of causing a GIT reaction was a NSAI in 75% of the reports. 7. Ninety-one per cent of fatal reports of GIT bleeds and perforations associated with NSAI drugs were in patients over 60 years of age. PMID:3263875

  7. Safety analysis report for packaging (onsite) multicanister overpack cask

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

    Edwards, W.S.

    1997-07-14

    This safety analysis report for packaging (SARP) documents the safety of shipments of irradiated fuel elements in the MUlticanister Overpack (MCO) and MCO Cask for a highway route controlled quantity, Type B fissile package. This SARP evaluates the package during transfers of (1) water-filled MCOs from the K Basins to the Cold Vacuum Drying Facility (CVDF) and (2) sealed and cold vacuum dried MCOs from the CVDF in the 100 K Area to the Canister Storage Building in the 200 East Area.

  8. Software for analysis of chemical mixtures--composition, occurrence, distribution, and possible toxicity

    USGS Publications Warehouse

    Scott, Jonathon C.; Skach, Kenneth A.; Toccalino, Patricia L.

    2013-01-01

    The composition, occurrence, distribution, and possible toxicity of chemical mixtures in the environment are research concerns of the U.S. Geological Survey and others. The presence of specific chemical mixtures may serve as indicators of natural phenomena or human-caused events. Chemical mixtures may also have ecological, industrial, geochemical, or toxicological effects. Chemical-mixture occurrences vary by analyte composition and concentration. Four related computer programs have been developed by the National Water-Quality Assessment Program of the U.S. Geological Survey for research of chemical-mixture compositions, occurrences, distributions, and possible toxicities. The compositions and occurrences are identified for the user-supplied data, and therefore the resultant counts are constrained by the user’s choices for the selection of chemicals, reporting limits for the analytical methods, spatial coverage, and time span for the data supplied. The distribution of chemical mixtures may be spatial, temporal, and (or) related to some other variable, such as chemical usage. Possible toxicities optionally are estimated from user-supplied benchmark data. The software for the analysis of chemical mixtures described in this report is designed to work with chemical-analysis data files retrieved from the U.S. Geological Survey National Water Information System but can also be used with appropriately formatted data from other sources. Installation and usage of the mixture software are documented. This mixture software was designed to function with minimal changes on a variety of computer-operating systems. To obtain the software described herein and other U.S. Geological Survey software, visit http://water.usgs.gov/software/.

  9. Wheelbarrow tire explosion causing trauma to the forearm and hand: a case report

    PubMed Central

    2009-01-01

    Introduction Tire explosion injuries are rare, but they may result in a severe injury pattern. Case reports and statistics from injuries caused by exploded truck tires during servicing are established, but trauma from exploded small tires seems to be unknown. Case presentation A 47-year-old german man inflated a wheelbarrow tire. The tire exploded during inflation and caused an open, multiple forearm and hand injury. Conclusion Even small tires can cause severe injury patterns in the case of an explosion. High inflating pressures and low safety distances are the main factors responsible for this occurrence. Broad safety information and suitable filling devices are indispensable for preventing these occurrences. PMID:19946543

  10. Avation Safety Reporting System (ASRS) 40th Anniversary.

    NASA Image and Video Library

    2016-09-28

    Avation Safety Reporting System (ASRS) 40th Anniversary lunch and open house at the Sunnyvale office. Linda J. Connell, ASRS Program Director (Left); Thomas A Edwards, Deputy Center Director NASA Ames; Dr. John Lauber, Resident Scientist and pioneer of the ASRS at Ames from 1972-1985 (Right).

  11. 77 FR 75439 - Guidances for Industry and Investigators on Safety Reporting Requirements for Investigational New...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-12-20

    ... Reporting Requirements for INDs and BA/BE Studies'' and ``Safety Reporting Requirements for INDs and BA/BE...) and bioavailability (BA) and bioequivalence (BE) studies. DATES: Submit either electronic or written... Reporting Requirements for INDs and BA/BE Studies'' and ``Safety Reporting Requirements for INDs and BA/BE...

  12. 49 CFR 195.56 - Filing safety-related condition reports.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... operator. (2) Date of report. (3) Name, job title, and business telephone number of person submitting the report. (4) Name, job title, and business telephone number of person who determined that the condition... planned follow-up or future corrective action, including the anticipated schedule for starting and...

  13. 49 CFR 195.55 - Reporting safety-related conditions.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... hazardous liquid could reasonably be expected to pollute any stream, river, lake, reservoir, or other body of water; (2) Is an accident that is required to be reported under § 195.50 or results in such an...

  14. 49 CFR 195.55 - Reporting safety-related conditions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... hazardous liquid could reasonably be expected to pollute any stream, river, lake, reservoir, or other body of water; (2) Is an accident that is required to be reported under § 195.50 or results in such an...

  15. Basic Safety II. Apprentice Related Training Module.

    ERIC Educational Resources Information Center

    Rice, Eric; Spetz, Sally H.

    One in a series of core instructional materials for apprentices to use during the first or second years of apprentice-related subjects training, this booklet deals with basic safety. The first section consists of an outline of the content and scope of the core materials as well as a self-assessment pretest. Covered in the four instructional…

  16. Co-occurrence of chancroid and gonorrhea.

    PubMed

    Nawaf, Al-Mutairi; Joshi, Arun; Tayeh, Mohammad

    2006-01-01

    Gonorrhea and chancroid are common sexually transmitted infections in many parts of the world. Still, co-occurrence of these two conditions is uncommonly reported. We present here a patient who presented with painful genital ulcers and urethral discharge simultaneously acquired from a single exposure, which turned out to be chancroid and gonorrhea, respectively. Both conditions responded well to a single intramuscular dose of ceftriaxone 250 mg. This report describes the uncommon occurrence of gonorrhea and chancroid in a patient. Clinical features, relevant investigations, treatment options of these two sexually transmitted infections, and possible implications in view of the human immunodeficiency virus (HIV) pandemic are briefly discussed.

  17. The safety and effectiveness profile of eldecalcitol in a prospective, post-marketing observational study in Japanese patients with osteoporosis: interim report.

    PubMed

    Saito, Hitoshi; Kakihata, Hiroyuki; Nishida, Yosuke; Yatomi, Sawako; Nihojima, Shigeru; Kobayashi, Yumiko; Tabata, Hidehiro; Nomura, Makoto

    2017-07-01

    This large-scale post-marketing surveillance study was conducted to assess the safety and effectiveness of eldecalcitol treatment in patients with osteoporosis in a Japanese clinical setting. A total of 3567 patients with osteoporosis were enrolled and received eldecalcitol 0.75 μg/day for 12 months. For this interim report, 3285 patients were eligible for analysis. Mean age was 74.9 ± 8.7 years; 86.8 % (2854/3285) were women. There were 142 reported adverse drug reactions (ADRs) in 129 patients (3.92 % of the total 3285 patients): the most common were hypercalcemia and increased blood calcium (0.88 %), renal impairment (0.27 %), abdominal discomfort (0.24 %), constipation (0.24 %), and pruritus (0.24 %). The incidence of ADRs was 5.10 % in men and 3.74 % in women. Although 10 serious ADRs were reported in 9 patients (0.27 %), no clinically significant safety issues were identified. Incidence of hypercalcemia or increased blood calcium was 8.47 % in patients with renal impairment and only 0.74 % in patients without renal impairment. At last observation, the incidence of new vertebral and nonvertebral fractures was 2.44 % and 1.70 %, respectively. There was a significant increase in bone mineral density at the lumbar spine and distal radius. The bone turnover markers BAP, serum NTX, urinary NTX, and TRACP-5b were suppressed by eldecalcitol treatment in both sexes. In conclusion, consistent with the findings of the phase III pivotal clinical trial, eldecalcitol was shown to have a favorable safety profile and effectiveness in Japanese patients with osteoporosis. However, periodic measurements of serum calcium were required to prevent occurrence of hypercalcemia during eldecalcitol treatment, especially in patients with renal impairment.

  18. Safety surrogate histograms (SSH): A novel real-time safety assessment of dilemma zone related conflicts at signalized intersections.

    PubMed

    Ghanipoor Machiani, Sahar; Abbas, Montasir

    2016-11-01

    Drivers' indecisiveness in dilemma zones (DZ) could result in crash-prone situations at signalized intersections. DZ is to the area ahead of an intersection in which drivers encounter a dilemma regarding whether to stop or proceed through the intersection when the signal turns yellow. An improper decision to stop by the leading driver, combined with the following driver deciding to go, can result in a rear-end collision, unless the following driver recognizes a collision is imminent and adjusts his or her behavior at or shortly after the onset of yellow. Considering the significance of DZ-related crashes, a comprehensive safety measure is needed to characterize the level of safety at signalized intersections. In this study, a novel safety surrogate measure was developed utilizing real-time radar field data. This new measure, called safety surrogate histogram (SSH), captures the degree and frequency of DZ-related conflicts at each intersection approach. SSH includes detailed information regarding the possibility of crashes, because it is calculated based on the vehicles conflicts. An example illustrating the application of the new methodology at two study sites in Virginia is presented and discussed, and a comparison is provided between SSH and other DZ-related safety surrogate measures mentioned in the literature. The results of the study reveal the efficacy of the SSH as complementary to existing surrogate measures. Copyright © 2015 Elsevier Ltd. All rights reserved.

  19. 49 CFR 191.25 - Filing safety-related condition reports.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... information: (1) Name and principal address of operator. (2) Date of report. (3) Name, job title, and business telephone number of person submitting the report. (4) Name, job title, and business telephone number of... the anticipated schedule for starting and concluding such action. [Amdt. 191-6, 53 FR 24949, July 1...

  20. The Washington State Task Force on Student Transportation Safety. Final Report.

    ERIC Educational Resources Information Center

    Washington State Legislature, Olympia.

    Findings of a study conducted by the Washington State Task Force on Student Transportation Safety are presented in this report. The data-collection process involved four phases: meetings with experts in student transportation and pedestrian safety; public meetings, informational work sessions, and tours of problems areas; task force meetings; and…

  1. Aviation Trends Related to Atmospheric Environment Safety Technologies Project Technical Challenges

    NASA Technical Reports Server (NTRS)

    Reveley, Mary S.; Withrow, Colleen A.; Barr, Lawrence C.; Evans, Joni K.; Leone, Karen M.; Jones, Sharon M.

    2014-01-01

    Current and future aviation safety trends related to the National Aeronautics and Space Administration's Atmospheric Environment Safety Technologies Project's three technical challenges (engine icing characterization and simulation capability; airframe icing simulation and engineering tool capability; and atmospheric hazard sensing and mitigation technology capability) were assessed by examining the National Transportation Safety Board (NTSB) accident database (1989 to 2008), incidents from the Federal Aviation Administration (FAA) accident/incident database (1989 to 2006), and literature from various industry and government sources. The accident and incident data were examined for events involving fixed-wing airplanes operating under Federal Aviation Regulation (FAR) Parts 121, 135, and 91 for atmospheric conditions related to airframe icing, ice-crystal engine icing, turbulence, clear air turbulence, wake vortex, lightning, and low visibility (fog, low ceiling, clouds, precipitation, and low lighting). Five future aviation safety risk areas associated with the three AEST technical challenges were identified after an exhaustive survey of a variety of sources and include: approach and landing accident reduction, icing/ice detection, loss of control in flight, super density operations, and runway safety.

  2. Role of the law in ensuring work related road safety.

    PubMed

    Griffith, Richard; Tengnah, Cassam

    2007-12-01

    Some 150 deaths and serious injuries are caused each week by people who were driving in the course of their work. The police, health and safety executive and government are seeking to improve this startling statistic by ensuring that organizations, including NHS Trusts, comply with health and safety law and fulfil their duty to carry out an assessment of risks associated with work related driving and implement a policy to minimize those risks. Failing to comply could result in prosecution by the police and health and safety executive.

  3. Predicting the Occurrence of Oxygenation Impairment in Patients with Type-B Acute Aortic Dissection

    PubMed Central

    Tomita, Kazunori; Hata, Noritake; Kobayashi, Nobuaki; Shinada, Takuro; Shirakabe, Akihiro

    2014-01-01

    Complicated respiratory failure requiring mechanical ventilation in patients with type-B acute aortic dissection (AAD) has been previously reported, and inflammatory reactions have been found to be associated with the occurrence of oxygenation impairment (OI). However, the possibility of predicting the occurrence of OI in patients with type-B AAD has not yet been evaluated. This study was performed to investigate the possibility of predicting the occurrence of OI in type-B AAD. In this study, 79 type-B AAD patients were enrolled to investigate the possibility of predicting the occurrence of OI. OI was defined as Po 2/Fio 2 ≤ 200. Patient characteristics, type of AAD, vital signs on admission, and the presence of inflammatory reactions obtained on admission day were evaluated. OI occurred in 39 patients (49%) on hospital day 2.5 ± 1.4 on average. Younger age, male gender, nonslender frame (body mass index ≥ 22 kg/m2), a relatively high maximum body temperature on the admission day (≥ 36.5°C), DeBakey IIIb type, patent false lumen, and lower Po 2/Fio 2 on admission were found to be associated with the occurrence of OI. Multivariate analysis revealed that nonslender frame, relatively high body temperature on the admission day, and lower Po 2/Fio 2 on admission were reliable for predicting the occurrence of oxygen impairment. The occurrence of OI in type-B AAD can be predicted in the clinical setting. PMID:24627618

  4. A consideration of lithium cell safety

    NASA Astrophysics Data System (ADS)

    Tobishima, Shin-ichi; Yamaki, Jun-ichi

    The safety characteristics of commercial lithium ion cells are examined in relation to their use as batteries for cellular phones. This report describes a theoretical approach to an understanding of cell safety, example results of safety tests that we performed on lithium ion cells, and also presents our views regarding cell safety.

  5. 77 FR 32146 - Safety Evaluation Report, International Isotopes Fluorine Products, Inc., Fluorine Extraction...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-31

    ... NUCLEAR REGULATORY COMMISSION [Docket No. 40-9086; NRC-2010-0143] Safety Evaluation Report... Deconversion Plant (FEP/DUP) and will be located in Lea County, New Mexico. The NRC has prepared a Safety..., Deconversion and Enrichment Branch, Division of Fuel Cycle Safety and Safeguards, Office of Nuclear Material...

  6. Safety evaluation of laninamivir octanoate hydrate through analysis of adverse events reported during early post-marketing phase vigilance.

    PubMed

    Nakano, Takashi; Okumura, Akihisa; Tanabe, Takuya; Niwa, Shimpei; Fukushima, Masato; Yonemochi, Rie; Eda, Hisano; Tsutsumi, Hiroyuki

    2013-06-01

    Abnormal behavior and delirium are common in children with influenza. While abnormal behavior and delirium are considered to be associated with influenza encephalopathy, an increased risk of such neuropsychiatric symptoms in patients receiving neuraminidase inhibitor treatment is suspected. Laninamivir octanoate hydrate, recently approved in Japan, is a long-acting neuraminidase inhibitor. It is important to establish a safety profile for laninamivir early, based on post-marketing experiences. Spontaneous safety reports collected in the early post-marketing phase vigilance were analyzed. Adverse events of interest such as abnormal behavior/delirium, dizziness/vertigo, respiratory disorders, shock/syncope, and any other serious events were intensively reviewed by the Safety Evaluation Committee. Abnormal behavior/delirium was a frequently reported event. Almost all the reported cases were considered to be due to influenza and not laninamivir. There were 32 cases of abnormal behavior/delirium that could lead to dangerous accidents, and these were observed more frequently in males and teenagers. Syncope probably related to the act of inhalation per se of laninamivir was reported during this survey. This safety review revealed that the safety profile of laninamivir for abnormal behavior/delirium and syncope was similar to that of other neuraminidase inhibitors. As stated in the labeling, teenage patients inhaling laninamivir should remain under constant parental supervision for at least 2 days and should be closely monitored for behavioral changes to prevent serious accidents associated with abnormal behavior/delirium. Furthermore, to avoid syncope because of inhalation, patients should be instructed to inhale in a relaxed sitting position.

  7. Toward an Application Guide for Safety Integrity Level Allocation in Railway Systems.

    PubMed

    Ouedraogo, Kiswendsida Abel; Beugin, Julie; El-Koursi, El-Miloudi; Clarhaut, Joffrey; Renaux, Dominique; Lisiecki, Frederic

    2018-02-02

    The work in the article presents the development of an application guide based on feedback and comments stemming from various railway actors on their practices of SIL allocation to railway safety-related functions. The initial generic methodology for SIL allocation has been updated to be applied to railway rolling stock safety-related functions in order to solve the SIL concept application issues. Various actors dealing with railway SIL allocation problems are the intended target of the methodology; its principles will be summarized in this article with a focus on modifications and precisions made in order to establish a practical guide for railway safety authorities. The methodology is based on the flowchart formalism used in CSM (common safety method) European regulation. It starts with the use of quantitative safety requirements, particularly tolerable hazard rates (THR). THR apportioning rules are applied. On the one hand, the rules are related to classical logical combinations of safety-related functions preventing hazard occurrence. On the other hand, to take into account technical conditions (last safety weak link, functional dependencies, technological complexity, etc.), specific rules implicitly used in existing practices are defined for readjusting some THR values. SIL allocation process based on apportioned and validated THR values is finally illustrated through the example of "emergency brake" subsystems. Some specific SIL allocation rules are also defined and illustrated. © 2018 Society for Risk Analysis.

  8. Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.

    PubMed

    Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R

    2017-01-30

    Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P < 0.0001). This increase in resident error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.

  9. Relatives in end-of-life care--part 2: a theory for enabling safety.

    PubMed

    Ohlén, Joakim; Andershed, Birgitta; Berg, Christina; Frid, Ingvar; Palm, Carl-Axel; Ternestedt, Britt-Marie; Segesten, Kerstin

    2007-02-01

    To develop a goal-oriented praxis theory for enabling safety for relatives when an adult or older patient is close to end-of-life. This is the second part of a project focusing on the situation and needs of relatives in end-of-life care. Our interpretation of the existing corpus of knowledge pertaining to the needs of close relatives in this situation showed the significance of relatives' need for safety. The theory was developed step-by-step, through triangulation of critical review of empirical research in the field, our own clinical experiences from end-of-life care, renewed literature searches and theoretical reasoning. The foundation for the theory is taken from the ethical intention of the philosopher Paul Ricoeur. From this, the theory focuses on relatives in the context of end-of-life care with the goal of enabling safety. This is proposed by four aphorisms functioning as safety enablers and these are directed towards the professional's approach and attitude, the relative's concern for the patient, the specific situation for the relative and the patient's end-of-life period as a period in the life of the relative. Implications for end-of-life practice are considered and include aspects for promotion of just institutions in end-of-life care, the significance of negotiated partnership in end-of-life care, enabling safety for relatives living in existential and practical uncertainty in connection with end-of-life care and diversity of relatives' preferences as they live through this particular period.

  10. Evolving Models of Rehabilitation-Related Patient Safety and Quality: PIECES.

    PubMed

    Gans, Bruce M

    2018-06-01

    A conceptual framework for measuring and reporting safety and quality in medical rehabilitation is described in this special communication. Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

  11. 75 FR 60129 - Draft Guidance for Industry and Investigators on Safety Reporting Requirements for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-29

    ... with the new requirements in the final rule entitled ``Investigational New Drug Safety Reporting...] Draft Guidance for Industry and Investigators on Safety Reporting Requirements for Investigational New... the agency considers your comment on this draft guidance before it begins work on the final version of...

  12. Patient Reporting of Safety experiences in Organisational Care Transfers (PRoSOCT): a feasibility study of a patient reporting tool as a proactive approach to identifying latent conditions within healthcare systems

    PubMed Central

    Scott, Jason; Waring, Justin; Heavey, Emily; Dawson, Pamela

    2014-01-01

    Background It is increasingly recognised that patients can play a role in reporting safety incidents. Studies have tended to focus on patients within hospital settings, and on the reporting of patient safety incidents as defined within a medical model of safety. This study aims to determine the feasibility of collecting and using patient experiences of safety as a proactive approach to identifying latent conditions of safety as patients undergo organisational care transfers. Methods and analysis The study comprises three components: (1) patients’ experiences of safety relating to a care transfer, (2) patients’ receptiveness to reporting experiences of safety, (3) quality improvement using patient experiences of safety. (1) A safety survey and evaluation form will be distributed to patients discharged from 15 wards across four clinical areas (cardiac, care of older people, orthopaedics and stroke) over 1 year. Healthcare professionals involved in the care transfer will be provided with a regular summary of patient feedback. (2) Patients (n=36) who return an evaluation form will be sampled representatively based on the four clinical areas and interviewed about their experiences of healthcare and safety and completing the survey. (3) Healthcare professionals (n=75) will be invited to participate in semistructured interviews and focus groups to discuss their experiences with and perceptions of receiving and using patient feedback. Data analysis will explore the relationship between patient experiences of safety and other indicators and measures of quality and safety. Interview and focus group data will be thematically analysed and triangulated with all other data sources using a convergence coding matrix. Ethics and dissemination The study has been granted National Health Service (NHS) Research Ethics Committee approval. Patient experiences of safety will be disseminated to healthcare teams for the purpose of organisational development and quality improvement

  13. Novel approaches to improving the chemical safety of the meat chain towards toxicants.

    PubMed

    Engel, E; Ratel, J; Bouhlel, J; Planche, C; Meurillon, M

    2015-11-01

    In addition to microbiological issues, meat chemical safety is a growing concern for the public authorities, chain stakeholders and consumers. Meat may be contaminated by various chemical toxicants originating from the environment, treatments of agricultural production or food processing. Generally found at trace levels in meat, these toxicants may harm human health during chronic exposure. This paper overviews the key issues to be considered to ensure better control of their occurrence in meat and assessment of the related health risk. We first describe potential contaminants of meat products. Strategies to move towards a more efficient and systematic control of meat chemical safety are then presented in a second part, with a focus on emerging approaches based on toxicogenomics. The third part presents mitigation strategies to limit the impact of process-induced toxicants in meat. Finally, the last part introduces methodological advances to refine chemical risk assessment related to the occurrence of toxicants in meat by quantifying the influence of digestion on the fraction of food contaminants that may be assimilated by the human body. Copyright © 2015 Elsevier Ltd. All rights reserved.

  14. [Use of complementary tests in emergencies and their relation with patient safety incidents].

    PubMed

    Alcaraz-Martínez, J; Aranaz-Andrés, J M; Cantero-Sandoval, A; Piñera-Salmerón, P; Mas-Luzón, J; Serrano-Martínez, J A; González Garro, E

    To analyse the use of complementary tests and their relationship with safety incidents in hospital emergency departments. An analysis was performed on 935 patients seen in the 9 hospital emergency departments. The source of data used for the detection of incidents were: emergency department clinical record and reports, together with face-to-face observation in the department, plus a telephone survey of the patient or family member at one week after the care. Statistical tests used: The Student t test for quantitative variables, Chi squared test for qualitative variables, and the ANOVA test. A peripheral venous catheter was used in 397 patients (42.4% (95% CI; 39.3-45.5%)), with a variability with significant differences between hospitals (P<.01), with a range of use from 37% to 81.8%. It was also observed that in 23.4% (95% CI; 19.2-27.6%) of the cases, the catheter was not used after the first blood draw. Radiological tests were requested for 351 patients, 37.7% (95% CI; 34.6-40.8%), also with significant differences between hospitals (P<.01), ranging from 24.6 to 65, 1%. Incidents were detected in 95 (10.2%) patients (95% CI; 8.3-12.1%) in the all the study centres. A higher proportion of safety incidents have been observed in patients where peripheral venous catheter has been used (12.8%) than in those in whom they had not been used (8.5%) (P=.03), as well as in patients on whom an x-ray was requested (12.8%) compared to those who did not (8.64%) (P=.04). A longer stay was also observed in cases with an incident (mean 248.9minutes) than in those where there were none (mean 164.1minutes) (P<.001). No statistically significant differences were found in the other parameters studied. A relationship was observed between the use of a peripheral venous catheter (many of them without use) and radiological tests and the occurrence of safety incidents in the Emergency Departments. Copyright © 2018 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

  15. Flight deck party line issues : an Aviation Safety Reporting System analysis

    DOT National Transportation Integrated Search

    1995-06-01

    This document describes an analysis of the Aviation Safety Reporting System : (ASRS) database with regards to human factors aspects concerning the : implementation of Data Link into the flightdeck. The ASRS database contains : thousands of reports co...

  16. Women's Experience of Orgasm During Intercourse: Question Semantics Affect Women's Reports and Men's Estimates of Orgasm Occurrence.

    PubMed

    Shirazi, Talia; Renfro, Kaytlin J; Lloyd, Elisabeth; Wallen, Kim

    2018-04-01

    Most women report reliably experiencing orgasm from masturbation, but a smaller proportion of women report regularly experiencing orgasm from intercourse. Research suggests that concurrent clitoral stimulation during intercourse increases the likelihood of orgasm, yet most surveys of orgasm during intercourse leave unspecified whether vaginal intercourse does or does not include concurrent clitoral stimulation (assisted intercourse or unassisted intercourse, respectively). Using an online sample of 1569 men and 1478 women, we tested whether phrasing of questions about the occurrence of orgasm in intercourse modulates women's reported frequency and men's estimates of women's frequency of orgasm in intercourse. Participants provided estimates of orgasm when asked explicitly about intercourse with stimulation unspecified, assisted intercourse, and unassisted intercourse. Women's reports of orgasm occurrence were highest in response to assisted intercourse (51-60%), second highest in response to intercourse with clitoral stimulation unspecified (31-40%), and lowest in response to unassisted intercourse (21-30%). Men's estimates of women's orgasms were highest in response to assisted intercourse (61-70%), and lowest in response to unassisted intercourse (41-50%); in both conditions, men's estimates were significantly higher than women's reports. When clitoral stimulation was unspecified, women interpreted "orgasm in intercourse" in three ways: as from intercourse alone, as including concurrent clitoral stimulation though it was unspecified, or as an average of assisted and unassisted intercourse. Taken together, these results demonstrate that the phrasing of questions about women's orgasm produces markedly different orgasm estimates, and suggest that concurrent clitoral stimulation increases the likelihood of women experiencing orgasm in intercourse.

  17. Comparative Safety and Tolerability of Anti-VEGF therapy in Age-Related Macular Degeneration

    PubMed Central

    Modi, Yasha S.; Tanchon, Carley; Ehlers, Justis P

    2015-01-01

    Neovascular age-related macular degeneration (NVAMD) is one of the leading causes of blindness. Over the last decade, the treatment of NVAMD has been revolutionized by the development intravitreal anti-vascular endothelial growth factor (VEGF) therapies. Several anti-VEGF medications are used for the treatment of NVAMD. The safety and tolerability of these medications deserve review given the high prevalence of NVAMD and the significant utilization of these medications. Numerous large randomized clinical trials have not shown any definitive differential safety relative to ocular or systemic safety of these medications. Intravitreal anti-VEGF therapy does appear to impact systemic VEGF levels, but the implications of these changes remain unclear. One unique safety concern relates drug compounding and the potential risks of contamination, specifically for bevacizumab. Continued surveillance for systemic safety concerns, particularly for rare events is merited. Overall these medications are well tolerated and effective in the treatment of NVAMD. PMID:25700714

  18. Writing Seveso II safety reports: new EU guidance reflecting 5 years' experience with the Directive.

    PubMed

    Wood, Maureen Heraty; Fabbri, Luciano; Struckl, Michael

    2008-09-15

    Since the coming into force of the Seveso II Directive, considerable experience has been acquired in regard to preparation of safety reports for establishments that fall under the requirements of this Directive. In light of this experience, the Amendment of the Seveso II Directive adopted by the European Parliament and the Council on 16 December 2003, gave the European Commission the mandate "to review by 31 December 2006 in close cooperation with the Member States, the existing Guidance on the Preparation of a safety report (EUR 17690)". As a result, a technical working group of Member States representing the Seveso competent authorities and the European Commission's Major Accident Hazards Bureau was established to review and re-examine the guidance. The new guidance maintains the high-level and overarching character of the older version, but improves the document through better definition of conceptual elements of the safety report and greater alignment with Annex II of the Directive, which describes the essential elements of the safety report. This paper describes the new guidance in terms of its contribution to developing a harmonized conceptual framework for preparing and reviewing safety reports within the context of Seveso II implementation. Overall, the aim of the guidance is to provide concrete advice to operators and competent authorities on the logic and expectations underlying the safety report, so as to make both preparation and review of the report a more efficient and useful exercise for all parties involved.

  19. 78 FR 34703 - Pipeline Safety: Information Collection Activities, Revision to Gas Distribution Annual Report

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-10

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No. PHMSA-2013-0004] Pipeline Safety: Information Collection Activities, Revision to Gas Distribution Annual Report AGENCY: Pipeline and Hazardous Materials Safety Administration, DOT. ACTION: Notice and request...

  20. Rowers' Self-Reported Behaviors, Attitudes, and Safety Concerns Related to Exercise, Training, and Competition During Pregnancy.

    PubMed

    Franklin, Ashley; Mishtal, Joanna; Johnson, Teresa; Simms-Cendan, Judith

    2017-08-01

    Background The American College of Obstetrics and Gynecology notes that pregnant athletes require more supervision due to their involvement in strenuous training schedules throughout pregnancy. Currently, rowing is not mentioned in the guidelines despite its increasing popularity, high cardiovascular demands, and risk for abdominal trauma. Methods This study aimed to elicit information from competitive female rowers regarding exercise, training, and competition during pregnancy. We administered a survey consisting of 122 items to female Masters rowers in the United States, aged 21 to 49 years, from June to December 2013. Results A total of 224 recreational and elite rowers met the inclusion criteria. Pregnant rowers self-reported high levels of exercise engagement: 85.2% (n/N = 98/115) exercised during any past pregnancy; exercise adherence decreased throughout pregnancy with 51.3%, 42.4%, and 15.7% meeting and/or exceeding national guidelines during the first, second, and third trimesters, respectively. Rowers were significantly (p < 0.001) more likely to state that an activity at a specified intensity and trimester was unsafe if they were younger, had less rowing experience, or were nulliparous. Decreased perceived rowing safety was associated with on-water training, higher intensity exercise, competition, and increasing gestational age. Primary safety concerns were the risk of oar-induced abdominal trauma and physiological effects due to high intensities required by the sport. Novel barriers to exercise in pregnancy included guilt towards the team and a mental barrier due to decreased performance. Healthcare providers are the number one information source for rowers regarding exercise during pregnancy. Conclusion Pregnant rowers are a relevant obstetrics population and have barriers and sport-specific safety concerns not previously identified in the literature. Rowers consider exercising in pregnancy to be important and struggle to meet exercise guidelines

  1. Rowers’ Self-Reported Behaviors, Attitudes, and Safety Concerns Related to Exercise, Training, and Competition During Pregnancy

    PubMed Central

    Mishtal, Joanna; Johnson, Teresa; Simms-Cendan, Judith

    2017-01-01

    Background The American College of Obstetrics and Gynecology notes that pregnant athletes require more supervision due to their involvement in strenuous training schedules throughout pregnancy. Currently, rowing is not mentioned in the guidelines despite its increasing popularity, high cardiovascular demands, and risk for abdominal trauma. Methods This study aimed to elicit information from competitive female rowers regarding exercise, training, and competition during pregnancy. We administered a survey consisting of 122 items to female Masters rowers in the United States, aged 21 to 49 years, from June to December 2013. Results A total of 224 recreational and elite rowers met the inclusion criteria. Pregnant rowers self-reported high levels of exercise engagement: 85.2% (n/N = 98/115) exercised during any past pregnancy; exercise adherence decreased throughout pregnancy with 51.3%, 42.4%, and 15.7% meeting and/or exceeding national guidelines during the first, second, and third trimesters, respectively. Rowers were significantly (p < 0.001) more likely to state that an activity at a specified intensity and trimester was unsafe if they were younger, had less rowing experience, or were nulliparous. Decreased perceived rowing safety was associated with on-water training, higher intensity exercise, competition, and increasing gestational age. Primary safety concerns were the risk of oar-induced abdominal trauma and physiological effects due to high intensities required by the sport. Novel barriers to exercise in pregnancy included guilt towards the team and a mental barrier due to decreased performance. Healthcare providers are the number one information source for rowers regarding exercise during pregnancy. Conclusion Pregnant rowers are a relevant obstetrics population and have barriers and sport-specific safety concerns not previously identified in the literature. Rowers consider exercising in pregnancy to be important and struggle to meet exercise guidelines

  2. Lead isotope database of unpublished results from sulfide mineral occurrences-California, Idaho, Oregon, and Washington

    USGS Publications Warehouse

    Church, S.E.

    2010-01-01

    The Pb isotope database for sulfide deposits and occurrences in the Western United States was funded by the Mineral Resources Program, U.S. Geological Survey (USGS). Reports on Pb isotope data from Alaska were published in Church and others (1987a) and Gaccetta and Church (1989). The primary objectives of the project were three-fold: * To utilize Pb isotope signatures, in conjunction with the regional mapping, to assess the relative ages and to categorize the types of deposits studied, * To relate the Pb isotope and trace-element geochemical signatures of specific deposits and occurrences to ore-forming processes, and * To use the Pb isotope data to correlate lithotectonic terranes within the northern Cordillera. The report by Church and others (1987b) shows how this fingerprinting methodology can be applied to trace the offset of lithostratigraphic terranes

  3. 78 FR 25488 - Qualification Tests for Safety-Related Actuators in Nuclear Power Plants

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-01

    ... NUCLEAR REGULATORY COMMISSION [NRC-2013-0079] Qualification Tests for Safety-Related Actuators in... regulatory guide (DG), DG-1235, ``Qualification Tests for Safety-Related Actuators in Nuclear Power Plants...-251- 7495, email: [email protected] . Both of the Office of Nuclear Regulatory Research, U.S. Nuclear...

  4. Frontline worker perceptions of medication safety in India

    PubMed Central

    Sharma, Sangeeta; Tabassum, Fauzia; Khurana, Sarbjeet; Kapoor, Kaveri

    2016-01-01

    Background: To explore interprofessionals’ perceptions about patient safety, particularly medication safety and associated factors and barriers. Methods: A total of 389 respondents were recruited using convenience sample in the cross sectional survey. Results: Medication safety was perceived as somewhat safe (60%). One-third of respondents witnessed 3–4 or more medication errors (MEs) within the past 1 year. Out of that, one quarter were reportedly, sentinel events. More sentinel events were witnessed in public hospitals and solo practice clinics compared with corporate hospitals and nursing homes (p < 0.02). No difference was observed in the occurrence of sentinel events in accredited and nonaccredited facilities (p = 0.30). Younger respondents witnessed more MEs, whereas accredited hospitals (mostly corporate hospitals) witnessed significantly fewer MEs and graded overall safety as ‘better’. However, most MEs go unreported particularly in solo practice clinics (88%) followed by nursing homes (67%), public hospitals (54%), and corporate hospitals (42%). Error identification and subsequent disclosure was inhibited by several system factors: fear of punitive action and lack of reporting systems. General surgical (46%), medical (42%), and paediatric units (36%), were the most error-prone places. Documentation diverted all healthcare workers from direct patient care. Many doctors and pharmacists from nursing homes, solo clinics and public hospitals reported working overtime. Staff shortages and poor training were overwhelming concerns to all healthcare workers and in public hospitals. Solo clinics and nursing homes perceived more barriers; lack of reporting systems, standard protocol, and resources for patient safety and unfamiliarity with prescribed medications was their overwhelming concern. Other factors threatening MEs were a lack of team approach and openness in interdisciplinary communications, illegible medical orders, and medicines prescribed by brand

  5. Fire Safety Tests for Cesium-Loaded Spherical Resorcinol Formaldehyde Resin: Data Summary Report

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

    Kim, Dong-Sang; Schweiger, Michael J.; Peterson, Reid A.

    2012-09-01

    A draft safety evaluation of the scenario for spherical resorcinol formaldehyde (SRF) resin fire inside the ion exchange column was performed by the Hanford Tank Waste Treatment and Immobilization Plant (WTP) Fire Safety organization. The result of this draft evaluation suggested a potential change of the fire safety classification for the Cesium Ion Exchange Process System (CXP) emergency elution vessels, equipment, and piping. To resolve this question, the fire properties of the SRF resin were measured by Southwest Research Institute (SwRI) through a subcontract managed by Pacific Northwest National Laboratory (PNNL). The results of initial fire safety tests on themore » SRF resin were documented in a previous report (WTP-RPT-218). The present report summarizes the results of additional tests performed by SwRI on the cesium-loaded SRF resin. The efforts by PNNL were limited to summarizing the test results provided by SwRI into one consolidated data report. The as-received SwRI report is attached to this report in the Appendix A. Where applicable, the precision and bias of each test method, as given by each American Society for Testing and Materials (ASTM) standard procedure, are included and compared with the SwRI test results of the cesium-loaded SRF resin.« less

  6. 77 FR 34457 - Pipeline Safety: Mechanical Fitting Failure Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-11

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... notice provides clarification to owners and operators of gas distribution pipeline facilities when... of a gas distribution pipeline facility to file a written report for any mechanical fitting failure...

  7. Comprehensive School Safety Initiative Report

    ERIC Educational Resources Information Center

    National Institute of Justice, 2014

    2014-01-01

    The National Institute of Justice (NIJ) developed the Comprehensive School Safety Initiative in consultation with federal partners and Congress. It is a research-focused initiative designed to increase the safety of schools nationwide through the development of knowledge regarding the most effective and sustainable school safety interventions and…

  8. Sponsors' and investigative staffs' perceptions of the current investigational new drug safety reporting process in oncology trials.

    PubMed

    Perez, Raymond; Archdeacon, Patrick; Roach, Nancy; Goodwin, Robert; Jarow, Jonathan; Stuccio, Nina; Forrest, Annemarie

    2017-06-01

    The Food and Drug Administration's final rule on investigational new drug application safety reporting, effective from 28 March 2011, clarified the reporting requirements for serious and unexpected suspected adverse reactions occurring in clinical trials. The Clinical Trials Transformation Initiative released recommendations in 2013 to assist implementation of the final rule; however, anecdotal reports and data from a Food and Drug Administration audit indicated that a majority of reports being submitted were still uninformative and did not result in actionable changes. Clinical Trials Transformation Initiative investigated remaining barriers and potential solutions to full implementation of the final rule by polling and interviewing investigators, clinical research staff, and sponsors. In an opinion-gathering effort, two discrete online surveys designed to assess challenges and motivations related to management of expedited (7- to 15-day) investigational new drug safety reporting processes in oncology trials were developed and distributed to two populations: investigators/clinical research staff and sponsors. Data were collected for approximately 1 year. Twenty-hour-long interviews were also conducted with Clinical Trials Transformation Initiative-nominated interview participants who were considered as having extensive knowledge of and experience with the topic. Interviewees included 13 principal investigators/study managers/research team members and 7 directors/vice presidents of pharmacovigilance operations from 5 large global pharmaceutical companies. The investigative site's responses indicate that too many individual reports are still being submitted, which are time-consuming to process and provide little value for patient safety assessments or for informing actionable changes. Fewer but higher quality reports would be more useful, and the investigator and staff would benefit from sponsors'"filtering" of reports and increased sponsor communication. Sponsors

  9. Sponsors’ and investigative staffs' perceptions of the current investigational new drug safety reporting process in oncology trials

    PubMed Central

    Perez, Raymond; Archdeacon, Patrick; Roach, Nancy; Goodwin, Robert; Jarow, Jonathan; Stuccio, Nina; Forrest, Annemarie

    2017-01-01

    Background/aims: The Food and Drug Administration’s final rule on investigational new drug application safety reporting, effective from 28 March 2011, clarified the reporting requirements for serious and unexpected suspected adverse reactions occurring in clinical trials. The Clinical Trials Transformation Initiative released recommendations in 2013 to assist implementation of the final rule; however, anecdotal reports and data from a Food and Drug Administration audit indicated that a majority of reports being submitted were still uninformative and did not result in actionable changes. Clinical Trials Transformation Initiative investigated remaining barriers and potential solutions to full implementation of the final rule by polling and interviewing investigators, clinical research staff, and sponsors. Methods: In an opinion-gathering effort, two discrete online surveys designed to assess challenges and motivations related to management of expedited (7- to 15-day) investigational new drug safety reporting processes in oncology trials were developed and distributed to two populations: investigators/clinical research staff and sponsors. Data were collected for approximately 1 year. Twenty-hour-long interviews were also conducted with Clinical Trials Transformation Initiative–nominated interview participants who were considered as having extensive knowledge of and experience with the topic. Interviewees included 13 principal investigators/study managers/research team members and 7 directors/vice presidents of pharmacovigilance operations from 5 large global pharmaceutical companies. Results: The investigative site’s responses indicate that too many individual reports are still being submitted, which are time-consuming to process and provide little value for patient safety assessments or for informing actionable changes. Fewer but higher quality reports would be more useful, and the investigator and staff would benefit from sponsors’“filtering” of

  10. 75 FR 37310 - Health and Safety Data Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-29

    ... ENVIRONMENTAL PROTECTION AGENCY 40 CFR Part 716 Health and Safety Data Reporting CFR Correction In Title 40 of the Code of Federal Regulations, Parts 700 to 789, revised as of July 1, 2009, make the following corrections: 1. At the bottom of page 86, in Sec. 716.20, paragraph (a) introductory text, in the...

  11. A red-flag-based approach to risk management of EHR-related safety concerns.

    PubMed

    Sittig, Dean F; Singh, Hardeep

    2013-01-01

    Although electronic health records (EHRs) have a significant potential to improve patient safety, EHR-related safety concerns have begun to emerge. Based on 369 responses to a survey sent to the memberships of the American Society for Healthcare Risk Management and the American Health Lawyers Association and supplemented by our previous work in EHR-related patient safety, we identified the following common EHR-related safety concerns: (1) incorrect patient identification; (2) extended EHR unavailability (either planned or unplanned); (3) failure to heed a computer-generated warning or alert; (4) system-to-system interface errors; (5) failure to identify, find, or use the most recent patient data; (6) misunderstandings about time; (7) incorrect item selected from a list of items; and (8) open or incomplete orders. In this article, we present a "red-flag"-based approach that can be used by risk managers to identify potential EHR safety concerns in their institutions. An organization that routinely conducts EHR-related surveillance activities, such as the ones proposed here, can significantly reduce risks associated with EHR implementation and use. © 2013 American Society for Healthcare Risk Management of the American Hospital Association.

  12. 78 FR 67206 - Qualification Tests for Safety-Related Actuators in Nuclear Power Plants

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-08

    ... NUCLEAR REGULATORY COMMISSION [NRC-2013-0079] Qualification Tests for Safety-Related Actuators in..., ``Qualification Tests for Safety-Related Actuators in Nuclear Power Plants.'' This RG is being revised to provide... power plants. This RG is proposed Revision 1 of RG 1.73, ``Qualification Tests of Electric Valve...

  13. A preliminary analysis of incident investigation reports of an integrated steel plant: some reflection.

    PubMed

    Verma, A; Maiti, J; Gaikwad, V N

    2018-06-01

    Large integrated steel plants employ an effective safety management system and gather a significant amount of safety-related data. This research intends to explore and visualize the rich database to find out the key factors responsible for the occurrences of incidents. The study was carried out on the data in the form of investigation reports collected from a steel plant in India. The data were processed and analysed using some of the quality management tools like Pareto chart, control chart, Ishikawa diagram, etc. Analyses showed that causes of incidents differ depending on the activities performed in a department. For example, fire/explosion and process-related incidents are more common in the departments associated with coke-making and blast furnace. Similar kind of factors were obtained, and recommendations were provided for their mitigation. Finally, the limitations of the study were discussed, and the scope of the research works was identified.

  14. 2006 NASA Range Safety Annual Report

    NASA Technical Reports Server (NTRS)

    TenHaken, Ron; Daniels, B.; Becker, M.; Barnes, Zack; Donovan, Shawn; Manley, Brenda

    2007-01-01

    Throughout 2006, Range Safety was involved in a number of exciting and challenging activities and events, from developing, implementing, and supporting Range Safety policies and procedures-such as the Space Shuttle Launch and Landing Plans, the Range Safety Variance Process, and the Expendable Launch Vehicle Safety Program procedures-to evaluating new technologies. Range Safety training development is almost complete with the last course scheduled to go on line in mid-2007. Range Safety representatives took part in a number of panels and councils, including the newly formed Launch Constellation Range Safety Panel, the Range Commanders Council and its subgroups, the Space Shuttle Range Safety Panel, and the unmanned aircraft systems working group. Space based range safety demonstration and certification (formerly STARS) and the autonomous flight safety system were successfully tested. The enhanced flight termination system will be tested in early 2007 and the joint advanced range safety system mission analysis software tool is nearing operational status. New technologies being evaluated included a processor for real-time compensation in long range imaging, automated range surveillance using radio interferometry, and a space based range command and telemetry processor. Next year holds great promise as we continue ensuring safety while pursuing our quest beyond the Moon to Mars.

  15. Relation Between Magnetospheric State Parameters and the Occurrence of Plasma Depletion Events in the Nighttime Midlatitude F Region

    NASA Technical Reports Server (NTRS)

    Seker, Ilgin; Fung, Shing F.; Mathews, John D.

    2011-01-01

    Studies using all-sky imagers have revealed the presence of various ionospheric irregularities in the nighttime midlatitude F region. The most prevalent and well known of these are the medium-scale traveling ionospheric disturbances (MSTIDs) that usually occur when the geomagnetic activity is low and midlatitude spread F plumes that are often observed when the geomagnetic activity is high. The inverse and direct relations between geomagnetic activity and the occurrence rate of MSTIDs and midlatitude plumes, respectively, have been observed by several studies using different instruments; however, most of them focus on MSTIDs only and use only Kp to characterize geomagnetic activity. In order to understand the underlying causes of these two relations and to distinguish between MSTIDs and plumes, it is illuminating to better characterize the occurrence of MSTIDs and plumes using multiple magnetospheric state parameters. Here we statistically compare multiple geomagnetic driver and response parameters (such as Kp, AE, Dst, and solar wind parameters) with the occurrence rates of nighttime MSTIDs and plumes observed using an all ]sky imager at Arecibo Observatory (AO) between 2003 and 2008. We also present seasonal and annual variations of MSTIDs and plumes at AO. The results not only allow us to better distinguish MSTIDs and plumes, but also to shed further light on the generation mechanism and electrodynamics of these two different phenomena occurring at nighttime in the midlatitude F region.

  16. Final safety analysis report for the Galileo Mission: Volume 2: Book 1, Accident model document

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

    Not Available

    The Accident Model Document (AMD) is the second volume of the three volume Final Safety Analysis Report (FSAR) for the Galileo outer planetary space science mission. This mission employs Radioisotope Thermoelectric Generators (RTGs) as the prime electrical power sources for the spacecraft. Galileo will be launched into Earth orbit using the Space Shuttle and will use the Inertial Upper Stage (IUS) booster to place the spacecraft into an Earth escape trajectory. The RTG's employ silicon-germanium thermoelectric couples to produce electricity from the heat energy that results from the decay of the radioisotope fuel, Plutonium-238, used in the RTG heat source.more » The heat source configuration used in the RTG's is termed General Purpose Heat Source (GPHS), and the RTG's are designated GPHS-RTGs. The use of radioactive material in these missions necessitates evaluations of the radiological risks that may be encountered by launch complex personnel as well as by the Earth's general population resulting from postulated malfunctions or failures occurring in the mission operations. The FSAR presents the results of a rigorous safety assessment, including substantial analyses and testing, of the launch and deployment of the RTGs for the Galileo mission. This AMD is a summary of the potential accident and failure sequences which might result in fuel release, the analysis and testing methods employed, and the predicted source terms. Each source term consists of a quantity of fuel released, the location of release and the physical characteristics of the fuel released. Each source term has an associated probability of occurrence. 27 figs., 11 tabs.« less

  17. The occurrence of paraesthesia of the maxillary division of the trigeminal nerve after dental local anaesthetic use: a case report.

    PubMed

    Moorthy, Advan; Stassen, Leo F A

    2015-01-01

    Paraesthesia can be a complication of surgical intervention. Its occurrence after dental local anaesthetic use is a rare event in general dental practice. Reported cases have mainly described its presentation for the mandibular division of the trigeminal nerve with very few reports for the maxillary division of this nerve. This report describes a case of paraesthesia in the maxillary region following local anaesthetic use prior to removal of an upper molar tooth.

  18. Integrated care: an Information Model for Patient Safety and Vigilance Reporting Systems.

    PubMed

    Rodrigues, Jean-Marie; Schulz, Stefan; Souvignet, Julien

    2015-01-01

    Quality management information systems for safety as a whole or for specific vigilances share the same information types but are not interoperable. An international initiative tries to develop an integrated information model for patient safety and vigilance reporting to support a global approach of heath care quality.

  19. Indicators of safety compromise in gastrointestinal endoscopy.

    PubMed

    Borgaonkar, Mark Ram; Hookey, Lawrence; Hollingworth, Roger; Kuipers, Ernst J; Forster, Alan; Armstrong, David; Barkun, Alan; Bridges, Ron; Carter, Rose; de Gara, Chris; Dube, Catherine; Enns, Robert; Macintosh, Donald; Forget, Sylviane; Leontiadis, Grigorios; Meddings, Jonathan; Cotton, Peter; Valori, Roland

    2012-02-01

    The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs. To identify key indicators of safety compromise in gastrointestinal endoscopy. The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance. A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related - the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm⁄bronchospasm; procedure-related early - perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed - death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider

  20. Road safety in the Eastern Mediterranean Region--findings from the Global Road Safety Status Report.

    PubMed

    Soori, H; Hussain, S J; Razzak, J A

    2011-10-01

    A secondary data analysis using the Global Status Report on Road Safety (GSRRS) was carried out to assess the epidemiology of road traffic injuries (RTIs) and preventive strategies in the Eastern Mediterranean egion (EMR). EMR countries ranked equal first in the world for the highest number of fatalities due to RTIs (32.2 per 100 000 population). The region had about 4% of the world's vehicles with 0.097 registered vehicles per person. The number of injured cases in EMR was 210.1 per 100 000 population. Only 15% of EMR countries had a funded, independent, multisectoral body for road safety. Only 25% had mandatory seat-belt laws for both front-seat and rear-seat passengers, 60% had mandatory helmet laws for both drivers and passengers of motorized two-wheelers and 10% had child restraint laws. Road safety in EMR countries needs more attention and consideration.

  1. Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

    PubMed Central

    Herzer, Kurt R.; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A.; Mark, Lynette J.

    2014-01-01

    Background Since 1999, hospitals have made substantial commitments to healthcare quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. Cohesive quality and safety approaches have become comprehensive programs to identify and mitigate hazards that could harm patients. This article moves to the next level with an intense refocusing of attention on one of the individual components of a comprehensive program--the patient safety reporting system—with a goal of maximized usefulness of the reports and long-term sustainability of quality improvements arising from them. Methods A six-phase framework was developed to deal with patient safety hazards: identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with “Good Catch” awards, and follow up to determine if quality improvements were sustained over time. Results To date, 29 patient safety hazards have gone through this process with “Good Catch” awards being granted at our institution. These awards were presented at various times over the past 4 years since the process began in 2008. Follow-up revealed that 86% of the associated quality improvements have been sustained over time since the awards were given. We present the details of two of these “Good Catch” awards: vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control. Conclusion A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting system, positive

  2. Social Media Listening for Routine Post-Marketing Safety Surveillance.

    PubMed

    Powell, Gregory E; Seifert, Harry A; Reblin, Tjark; Burstein, Phil J; Blowers, James; Menius, J Alan; Painter, Jeffery L; Thomas, Michele; Pierce, Carrie E; Rodriguez, Harold W; Brownstein, John S; Freifeld, Clark C; Bell, Heidi G; Dasgupta, Nabarun

    2016-05-01

    Post-marketing safety surveillance primarily relies on data from spontaneous adverse event reports, medical literature, and observational databases. Limitations of these data sources include potential under-reporting, lack of geographic diversity, and time lag between event occurrence and discovery. There is growing interest in exploring the use of social media ('social listening') to supplement established approaches for pharmacovigilance. Although social listening is commonly used for commercial purposes, there are only anecdotal reports of its use in pharmacovigilance. Health information posted online by patients is often publicly available, representing an untapped source of post-marketing safety data that could supplement data from existing sources. The objective of this paper is to describe one methodology that could help unlock the potential of social media for safety surveillance. A third-party vendor acquired 24 months of publicly available Facebook and Twitter data, then processed the data by standardizing drug names and vernacular symptoms, removing duplicates and noise, masking personally identifiable information, and adding supplemental data to facilitate the review process. The resulting dataset was analyzed for safety and benefit information. In Twitter, a total of 6,441,679 Medical Dictionary for Regulatory Activities (MedDRA(®)) Preferred Terms (PTs) representing 702 individual PTs were discussed in the same post as a drug compared with 15,650,108 total PTs representing 946 individual PTs in Facebook. Further analysis revealed that 26 % of posts also contained benefit information. Social media listening is an important tool to augment post-marketing safety surveillance. Much work remains to determine best practices for using this rapidly evolving data source.

  3. The elements of a commercial human spaceflight safety reporting system

    NASA Astrophysics Data System (ADS)

    Christensen, Ian

    2017-10-01

    In its report on the SpaceShipTwo accident the National Transportation Safety Board (NTSB) included in its recommendations that the Federal Aviation Administration (FAA) ;in collaboration with the commercial spaceflight industry, continue work to implement a database of lessons learned from commercial space mishap investigations and encourage commercial space industry members to voluntarily submit lessons learned.; In its official response to the NTSB the FAA supported this recommendation and indicated it has initiated an iterative process to put into place a framework for a cooperative safety data sharing process including the sharing of lessons learned, and trends analysis. Such a framework is an important element of an overall commercial human spaceflight safety system.

  4. Understanding safety climate in small automobile collision repair shops.

    PubMed

    Parker, David L; Brosseau, Lisa M; Bejan, Anca; Skan, Maryellen; Xi, Min

    2014-01-01

    In the United States, approximately 236,000 people work in 37,600 auto collision-repair businesses. Workers in the collision-repair industry may be exposed to a wide range of physical and chemical hazards. This manuscript examines the relationship of safety climate as reported by collision repair shop workers and owners to: (1) an independent business safety assessment, and (2) employee self-reported work practices. The study was conducted in the Twin Cities metropolitan area. A total of 199 workers from 49 collision shops completed a survey of self-reported work practices and safety climate. Surveys were completed by an owner or manager in all but three shops. In general, self-reported work practices were poor. Workers' scores on safety climate were uniformly lower than those of owners. For workers, there was no correlation between how well the business scored on an independent audit of business safety practices and the safety climate measures they reported. For owners, however, there was a positive correlation between safety climate scores and the business safety assessment. For workers, safety rules and procedures were associated with improved work practices for those engaged in both painting-related and body technician-related activities. The enforcement of safety rules and procedures emerged as a strong factor positively affecting self-reported work practices. These findings identify a simple, cost effective path to reducing hazards in small workplaces. © 2013 Wiley Periodicals, Inc.

  5. The role of attitudes about vaccine safety, efficacy, and value in explaining parents' reported vaccination behavior.

    PubMed

    Lavail, Katherine Hart; Kennedy, Allison Michelle

    2013-10-01

    To explain vaccine confidence as it related to parents' decisions to vaccinate their children with recommended vaccines, and to develop a confidence measure to efficiently and effectively predict parents' self-reported vaccine behaviors. A sample of parents with at least one child younger than 6 years (n = 376) was analyzed using data from the HealthStyles 2010 survey. Questions were grouped into block variables to create three confidence constructs: value, safety, and efficacy. Regression equations controlling for demographic characteristics were used to identify the confidence construct(s) that best predicted parents' self-reported vaccination decisions (accept all, some, or none of the recommended childhood vaccines). Among the three constructs evaluated, confidence in the value of vaccines, that is the belief that vaccines are important and vaccinating one's children is the right thing to do, was the best predictor of parents' vaccine decisions, F(2, 351) = 119.199, p < .001. When combined into a block variable for analysis, two survey items measuring confidence in the value of vaccines accounted for 40% of the variance in parents' self-reported vaccine decisions. Confidence in the safety or efficacy of vaccines failed to account for additional significant variance in parent-reported vaccination behavior. Confidence in the value of vaccines is a helpful predictor of parent-reported vaccination behavior. Attitudinal constructs of confidence in the safety and efficacy of vaccines failed to account for additional significant variance in parents' vaccination behaviors. Future research should assess the role of vaccine knowledge and tangible barriers, such as access and cost, to further explain parents' vaccination behaviors.

  6. 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

  7. 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.

  8. Assessment of occupational health and safety hazard exposures among working college students.

    PubMed

    Balanay, Jo Anne G; Adesina, Adepeju; Kearney, Gregory D; Richards, Stephanie L

    2014-01-01

    Adolescents and young adults have higher injury rates than their adult counterparts in similar jobs. This study used the working college student population to assess health and safety hazards in the workplace, characterize related occupational diseases and injuries, and describe worker health/safety activities provided by employers. College students (≥17 years old) were assessed via online surveys about work history, workplace exposure to hazards, occupational diseases/injuries, and workplace health/safety activities. Approximately half (51%) of participants (n = 1,147) were currently employed at the time of the survey or had been employed while enrolled in college. Restaurants (other than fast food) were the most frequently reported work setting. The most reported workplace hazards included noise exposure and contact with hot liquids/surfaces. Twenty percent of working students experienced injury at work; some injuries were severe enough to limit students' normal activities for >3 days (30%) or require medical attention (44%). Men had significantly higher prevalence of injuries (P = 0.05) and near-misses (P < 0.01) at work than women. Injury occurrence was associated with near-misses (AOR = 5.08, P < 0.01) and co-worker injuries (AOR = 3.19, P < 0.01) after gender and age adjustments. Most (77%) received worker safety training and half were given personal protective equipment (PPE) by their employers. Risk reduction from workplace injuries and illnesses among working college students may be achieved by implementing occupational health and safety (OHS) strategies including incorporation of OHS in the college curriculum, promotion of OHS by university/college student health services, and improving awareness of OHS online resources among college students, employers, and educators. © 2013 Wiley Periodicals, Inc.

  9. 78 FR 38803 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ... Reports for Gas Pipeline Operators AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... (OMB) Control No. 2137-0522, titled ``Incident and Annual Reports for Gas Pipeline Operators.'' PHMSA...

  10. Use of portable ladders - field observations and self-reported safety performance in the cable TV industry.

    PubMed

    Chang, Wen-Ruey; Huang, Yueng-Hsiang; Brunette, Christopher; Lee, Jin

    2017-11-01

    Portable ladders incidents remain a major cause of falls from heights. This study reported field observations of environments, work conditions and safety behaviour involving portable ladders and their correlations with self-reported safety performance. Seventy-five professional installers of a company in the cable and other pay TV industry were observed for 320 ladder usages at their worksites. The participants also filled out a questionnaire to measure self-reported safety performance. Proper setup on slippery surfaces, correct method for ladder inclination setup and ladder secured at the bottom had the lowest compliance with best practices and training guidelines. The observation compliance score was found to have significant correlation with straight ladder inclined angle (Pearson's r = 0.23, p < 0.0002) and employees' self-reported safety participation (r = 0.29, p < 0.01). The results provide a broad perspective on employees' safety compliance and identify areas for improving safety behaviours. Practitioner Summary: A checklist was used while observing professional installers of a cable company for portable ladder usage at their worksites. Items that had the lowest compliance with best practices and training guidelines were identified. The results provide a broad perspective on employees' safety compliance and identify areas for improving safety behaviours.

  11. An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program.

    PubMed

    Hicks, Rodney W; Becker, Shawn C

    2006-01-01

    Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.

  12. Preoperative Safety Briefing Project

    PubMed Central

    DeFontes, James; Surbida, Stephanie

    2004-01-01

    Context: Increased media attention on surgical procedures that were performed on the wrong anatomic site or wrong patient has prompted the health care industry to identify and address human factors that lead to medical errors. Objective: To increase patient safety in the perioperative setting, our objective was to create a climate of improved communication, collaboration, team-work, and situational awareness while the surgical team reviewed pertinent information about the patient and the pending procedure. Methods: A team of doctors, nurses, and technicians used human factors principles to develop the Preoperative Safety Briefing for use by surgical teams, a briefing similar to the preflight checklist used by the airline industry. A six-month pilot of the briefing began in the Kaiser Permanente (KP) Anaheim Medical Center in February 2002. Four indicators of safety culture were used to measure success of the pilot: occurrence of wrong-site/wrong procedures, attitudinal survey data, near-miss reports, and nursing personnel turnover data. Results: Wrong-site surgeries decreased from 3 to 0 (300%) per year; employee satisfaction increased 19%; nursing personnel turnover decreased 16%; and perception of the safety climate in the operating room improved from “good” to “outstanding.” Operating suite personnel perception of teamwork quality improved substantially. Operating suite personnel perception of patient safety as a priority, of personnel communication, of their taking responsibility for patient safety, of nurse input being well received, of overall morale, and of medical errors being handled appropriately also improved substantially. Conclusions: Team members who work together and communicate well can quickly detect and more easily avoid errors. The Preoperative Safety Briefing is now standard in many operating suites in the KP Orange County Service Area. The concepts and design of this project are transferable, and similar projects are underway in the

  13. Global status report on road safety : time for action

    DOT National Transportation Integrated Search

    2009-01-01

    The Global status report on road safety reaffirms our understanding of road traffic injuries as a global health and development problem. More than 1.2 million people die on the world's road every year, and as many as 50 million others are injured. Ov...

  14. Occurrence of Toxigenic Fungi and Aflatoxin Potential of Aspergillus spp. Strains Associated with Subsistence Farmed Crops in Haiti.

    PubMed

    Aristil, Junior; Venturini, Giovanni; Spada, Alberto

    2017-04-01

    Subsistence farming and poor storage facilities favor toxigenic fungal contamination and mycotoxin accumulation in staple foods from tropical countries such as Haiti. The present preliminary study was designed to evaluate the occurrence of toxigenic fungi in Haitian foodstuffs to define the mycotoxin risk associated with Haitian crops. The objectives of this research were to determine the distribution of toxigenic fungi in the Haitian crops maize, moringa, and peanut seeds and to screen Aspergillus section Flavi (ASF) isolates for production of aflatoxins B 1 and G 1 in vitro. Maize, moringa, and peanut samples were contaminated by potential toxigenic fungal taxa, mainly ASF and Fusarium spp. The isolation frequency of Aspergillus spp. and Fusarium spp. was influenced by locality and thus by farming systems, storage systems, and weather conditions. Particularly for ASF in peanut and maize samples, isolation frequencies were directly related to the growing season length. The present study represents the first report of contamination by toxigenic fungi and aflatoxin in moringa seeds, posing concerns about the safety of these seeds, which people in Haiti commonly consume. Most (80%) of the Haitian ASF strains were capable of producing aflatoxins, indicating that Haitian conditions clearly favor the colonization of toxigenic ASF strains over atoxigenic strains. ASF strains producing both aflatoxins B 1 and G 1 were found. Understanding the distribution of toxigenic ASF in Haitian crops and foodstuffs is important for determining accurate toxicological risks because the toxic profile of ASF is species specific. The occurrence of toxigenic fungi and the profiles of the ASF found in various crops highlight the need to prevent formation of aflatoxins in Haitian crops. This study provides relevant preliminary baseline data for guiding the development of legislation regulating the quality and safety of crops in this low-income country.

  15. Patient Safety Competence of Nursing Students in Saudi Arabia: A Self-Reported Survey

    PubMed Central

    Colet, Paolo C.; Cruz, Jonas P.; Cruz, Charlie P.; Al-otaibi, Jazi; Qubeilat, Hikmet; Alquwez, Nahed

    2015-01-01

    Objective With the growing recognition of the significance of patient safety (PS) in educational institutions and health organizations, it is essential to understand the perspective of nursing students on their own PS competence. This study analyzed the self-reported PS competence of nursing students at a government university in Saudi Arabia. Methodology A cross-sectional self-reported survey of 191 respondents, using the Health Professional Education in Patient Safety Survey (H-PEPSS) was conducted. The survey tool reflected 6 key socio-cultural dimensions assessing competence in classroom and clinical setting. Results Female nursing students reported higher PS competence in both the classroom and clinical settings along the dimensions ‘working in teams’ and ‘communicating effectively’ while males reported higher competence in both settings as to the ‘managing safety risks’ and ‘understanding human and environmental factors’ dimensions. The respondents’ academic level and self–reported PS competence have weak negative correlation in the classroom while a strong negative correlation between the 2 variables existed in the clinical setting. Self-reported PS competence for the dimensions ‘working in teams’, ‘recognize and respond to remove immediate risks of harm’, and ‘culture of safety’ is significantly higher in classroom than in the clinical setting. Conclusion Generally, the Saudi nursing students reported varying levels of competence in the six dimensions of patient safety. Significant gap between the perceived PS competence was observed between learning settings. Educational and training interventions are suggested for implementation to bridge this gap. PMID:26715921

  16. Aggregate analysis of regulatory authority assessors' comments to improve the quality of periodic safety update reports.

    PubMed

    Jullian, Sandra; Jaskiewicz, Lukasz; Pfannkuche, Hans-Jürgen; Parker, Jeremy; Lalande-Luesink, Isabelle; Lewis, David J; Close, Philippe

    2015-09-01

    Marketing authorization holders (MAHs) are expected to provide high-quality periodic safety update reports (PSURs) on their pharmaceutical products to health authorities (HAs). We present a novel instrument aiming at improving quality of PSURs based on standardized analysis of PSUR assessment reports (ARs) received from the European Union HAs across products and therapeutic areas. All HA comments were classified into one of three categories: "Request for regulatory actions," "Request for medical and scientific information," or "Data deficiencies." The comments were graded according to their impact on patients' safety, the drug's benefit-risk profile, and the MAH's pharmacovigilance system. A total of 476 comments were identified through the analysis of 63 PSUR HA ARs received in 2013 and 2014; 47 (10%) were classified as "Requests for regulatory actions," 309 (65%) as "Requests for medical and scientific information," and 118 (25%) comments were related to "Data deficiencies." The most frequent comments were requests for labeling changes (35 HA comments in 19 ARs). The aggregate analysis revealed commonly raised issues and prompted changes of the MAH's procedures related to the preparation of PSURs. The authors believe that this novel instrument based on the evaluation of PSUR HA ARs serves as a valuable mechanism to enhance the quality of PSURs and decisions about optimization of the use of the products and, therefore, contributes to improve further the MAH's pharmacovigilance system and patient safety. Copyright © 2015 John Wiley & Sons, Ltd.

  17. DON occurrence in cereal grains: A North American perspective

    USDA-ARS?s Scientific Manuscript database

    The occurrence of deoxynivalenol (DON) in agricultural commodities has been reported all over the world, with levels varying amongst grain type and years of production. However, a systematic review of the current situation regarding this mycotoxin, its occurrence, and its management in North America...

  18. Associations between safety climate and safety management practices in the construction industry.

    PubMed

    Marín, Luz S; Lipscomb, Hester; Cifuentes, Manuel; Punnett, Laura

    2017-06-01

    Safety climate, a group-level measure of workers' perceptions regarding management's safety priorities, has been suggested as a key predictor of safety outcomes. However, its relationship with actual injury rates is inconsistent. We posit that safety climate may instead be a parallel outcome of workplace safety practices, rather than a determinant of workers' safety behaviors or outcomes. Using a sample of 25 commercial construction companies in Colombia, selected by injury rate stratum (high, medium, low), we examined the relationship between workers' safety climate perceptions and safety management practices (SMPs) reported by safety officers. Workers' perceptions of safety climate were independent of their own company's implementation of SMPs, as measured here, and its injury rates. However, injury rates were negatively related to the implementation of SMPs. Safety management practices may be more important than workers' perceptions of safety climate as direct predictors of injury rates. © 2017 Wiley Periodicals, Inc.

  19. Thermal overload protection for electric motors on safety-related motor-operated valves: Generic Issue II. E. 6. 1

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

    Rothberg, O.

    1988-06-01

    NRC regulatory positions, as stated in Regulatory Guide 1.106, Revision 1, have been identified by the Office for Analysis and Evaluation of Operational Data (AEOD) as potential contributors to valve motor burnout. AEOD is particularly concerned about the allowed policy of bypassing thermal overload devices during normal or accident conditions. Regulatory Guide 1.106 favors compromising the function of thermal overload devices in favor of completing the safety-related action of valves. The purpose of this study was to determine if the guidance contained in Regulatory Guide 1.106 is appropriate and, if not, to recommend the necessary changes. This report describes thermalmore » overload devices commonly used to protect safety-related valve operator motors. The regulatory guidelines stated in Regulatory Guide 1.106 along with the limitations of thermal overload protection are discussed. Supplements and alternatives to thermal overload protection are also described. Findings and conclusions of several AEOD reports are discussed. Information obtained from the standard review plan, standard technical specifications, technical specifications from representative plants, and several papers are cited.« less

  20. 78 FR 71033 - Pipeline Safety: Information Collection Activities, Revisions to Incident and Annual Reports for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-27

    ... Reports for Gas Pipeline Operators AGENCY: Pipeline and Hazardous Materials Safety Administration, DOT... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... Pipeline Systems; PHMSA F 7100.2-1 Annual Report for Calendar Year 20xx Natural and Other Gas Transmission...

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

    PubMed

    Vallejo-Gutiérrez, Paula; Bañeres-Amella, Joaquim; Sierra, Eduardo; Casal, Jesús; Agra, Yolanda

    2014-01-01

    To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test. Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system. The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.

  2. Relation between diabetes, metformin treatment and the occurrence of malignancies in a Belgian primary care setting.

    PubMed

    Geraldine, Ngwana; Marc, Aerts; Carla, Truyers; Chantal, Mathieu; Stefaan, Bartholomeeusen; Welcome, Wami; Frank, Buntinx

    2012-08-01

    Associations between type 2 diabetic patients and a higher risk of developing cancer have been reported worldwide. Recently, a protective effect of metformin has been described. To examine in the Belgian primary care population the relation between presence of type 2 diabetes with and without metformin treatment and the occurrence of malignancies. Retrospective cohort study, based on the Intego database, an ongoing Belgian general practice-based morbidity registry, covering 90 general practitioners and including about 1.5 million patient-years between 1994 and 2008. Cox proportional hazard analysis comparing emergence of malignancy in patients with and without type 2 diabetes, and among patients with diabetes comparing emergence of malignancy in those treated with various antidiabetic drugs. Malignancies occurred more in type 2 diabetic patients compared to non-diabetic controls (HR=1.84; 95% CI=1.51-2.24), adjusted for age, gender and weight. Treatment with both metformin and 'other' antidiabetic agents was related to decreased cancer risk (HR=0.24 and 0.22) compared to diet only in men but not in women. In this Belgian primary care setting, diabetic patients have higher cancer prevalences than non-diabetic patients. Moreover, in diabetic men, not only metformin but also other antidiabetic agents were associated with lower cancer risks. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  3. 77 FR 75699 - Pipeline Safety: Reporting of Exceedances of Maximum Allowable Operating Pressure

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-12-21

    ... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration [Docket No... AGENCY: Pipeline and Hazardous Materials Safety Administration (PHMSA); DOT. ACTION: Notice; Issuance of... occurs. This reporting requirement is applicable to all gas transmission pipeline facility owners and...

  4. The advancement of a new human factors report--'The Unique Report'--facilitating flight crew auditing of performance/operations as part of an airline's safety management system.

    PubMed

    Leva, M C; Cahill, J; Kay, A M; Losa, G; McDonald, N

    2010-02-01

    This paper presents the findings of research relating to the specification of a new human factors report, conducted as part of the work requirements for the Human Integration into the Lifecycle of Aviation Systems project, sponsored by the European Commission. Specifically, it describes the proposed concept for a unique report, which will form the basis for all operational and safety reports completed by flight crew. This includes all mandatory and optional reports. Critically, this form is central to the advancement of improved processes and technology tools, supporting airline performance management, safety management, organisational learning and knowledge integration/information-sharing activities. Specifically, this paper describes the background to the development of this reporting form, the logic and contents of this form and how reporting data will be made use of by airline personnel. This includes a description of the proposed intelligent planning process and the associated intelligent flight plan concept, which makes use of airline operational and safety analyses information. Primarily, this new reporting form has been developed in collaboration with a major Spanish airline. In addition, it has involved research with five other airlines. Overall, this has involved extensive field research, collaborative prototyping and evaluation of new reports/flight plan concepts and a number of evaluation activities. Participants have included both operational and management personnel, across different airline flight operations processes. Statement of Relevance: This paper presents the development of a reporting concept outlined through field research and collaborative prototyping within an airline. The resulting reporting function, embedded in the journey log compiled at the end of each flight, aims at enabling employees to audit the operations of the company they work for.

  5. 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.

  6. The occurrence of N-nitrosamines, residual nitrite and biogenic amines in commercial dry fermented sausages and evaluation of their occasional relation.

    PubMed

    De Mey, Eveline; De Klerck, Katrijn; De Maere, Hannelore; Dewulf, Lore; Derdelinckx, Guy; Peeters, Marie-Christine; Fraeye, Ilse; Vander Heyden, Yvan; Paelinck, Hubert

    2014-02-01

    Regarding food borne intoxications, the accumulation of biogenic amines must be avoided in all kinds of food products. Moreover, biogenic amines can function as precursors for the formation of carcinogenic N-nitrosamines when nitrite is present. To estimate the food safety of the dry fermented sausages available on the Belgian market, a screening of the residual sodium nitrite and nitrate contents, biogenic amines and volatile N-nitrosamine concentrations was performed on 101 samples. The median concentrations of residual NaNO2 and NaNO3 were each individually lower than 20mg/kg. In general, the biogenic amine accumulation remained low at the end of shelf life. Only in one product the amounts of cadaverine and putrescine reached intoxicating levels. Concerning the occurrence of N-nitrosamines, only N-nitrosopiperidine and N-nitrosomorpholine were detected in a high number of samples (resp. 22% and 28%). No correlation between the presence of N-nitrosamines and the biogenic amines content was observed. Although the N-nitrosamines could not been linked to specific product categories, the occurrence of N-nitrosopiperidine could probably be attributed to the use of pepper. © 2013.

  7. Analysis of human factors effects on the safety of transporting radioactive waste materials: Technical report

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

    Abkowitz, M.D.; Abkowitz, S.B.; Lepofsky, M.

    1989-04-01

    This report examines the extent of human factors effects on the safety of transporting radioactive waste materials. It is seen principally as a scoping effort, to establish whether there is a need for DOE to undertake a more formal approach to studying human factors in radioactive waste transport, and if so, logical directions for that program to follow. Human factors effects are evaluated on driving and loading/transfer operations only. Particular emphasis is placed on the driving function, examining the relationship between human error and safety as it relates to the impairment of driver performance. Although multi-modal in focus, the widespreadmore » availability of data and previous literature on truck operations resulted in a primary study focus on the trucking mode from the standpoint of policy development. In addition to the analysis of human factors accident statistics, the report provides relevant background material on several policies that have been instituted or are under consideration, directed at improving human reliability in the transport sector. On the basis of reported findings, preliminary policy areas are identified. 71 refs., 26 figs., 5 tabs.« less

  8. Identification of priorities for medication safety in neonatal intensive care.

    PubMed

    Kunac, Desireé L; Reith, David M

    2005-01-01

    Although neonates are reported to be at greater risk of medication error than infants and older children, little is known about the causes and characteristics of error in this patient group. Failure mode and effects analysis (FMEA) is a technique used in industry to evaluate system safety and identify potential hazards in advance. The aim of this study was to identify and prioritize potential failures in the neonatal intensive care unit (NICU) medication use process through application of FMEA. Using the FMEA framework and a systems-based approach, an eight-member multidisciplinary panel worked as a team to create a flow diagram of the neonatal unit medication use process. Then by brainstorming, the panel identified all potential failures, their causes and their effects at each step in the process. Each panel member independently rated failures based on occurrence, severity and likelihood of detection to allow calculation of a risk priority score (RPS). The panel identified 72 failures, with 193 associated causes and effects. Vulnerabilities were found to be distributed across the entire process, but multiple failures and associated causes were possible when prescribing the medication and when preparing the drug for administration. The top ranking issue was a perceived lack of awareness of medication safety issues (RPS score 273), due to a lack of medication safety training. The next highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Perceived causes were multiple, but were largely associated with unsafe systems for medication preparation and storage in the unit, variable staff skill level and lack of computerised technology. Interventions to decrease medication-related adverse events in the NICU should aim to increase staff awareness of medication safety issues and focus on medication administration processes.

  9. Mixed-Methods Evaluation of Real-Time Safety Reporting by Hospitalized Patients and Their Care Partners: The MySafeCare Application.

    PubMed

    Collins, Sarah A; Couture, Brittany; Smith, Ann DeBord; Gershanik, Esteban; Lilley, Elizabeth; Chang, Frank; Yoon, Cathy; Lipsitz, Stuart; Sheikh, Aziz; Benneyan, James; Bates, David W

    2018-04-27

    The aims of the study were to evaluate the amount and content of data patients and care partners reported using a real-time electronic safety tool compared with other reporting mechanisms and to understand their perspectives on safety concerns and reporting in the hospital. This study used mixed methods including 20-month preimplementation and postimplementation trial evaluating MySafeCare, a web-based application, which allows hospitalized patients/care partners to report safety concerns in real time. The study compared MySafeCare submission rates for three hospital units (oncology acute care, vascular intermediate care, medical intensive care) with submissions rates of Patient Family Relations (PFR) Department, a hospital service to address patient/family concerns. The study used triangulation of quantitative data with thematic analysis of safety concern submissions and patient/care partner interviews to understand submission content and perspectives on safety reporting. Thirty-two MySafeCare submissions were received with an average rate of 1.7 submissions per 1000 patient-days and a range of 0.3 to 4.8 submissions per 1000 patient-days across all units, indicating notable variation between units. MySafeCare submission rates were significantly higher than PFR submission rates during the postintervention period on the vascular unit (4.3 [95% confidence interval = 2.8-6.5] versus 1.5 [95% confidence interval = 0.7-3.1], Poisson) (P = 0.01). Overall trends indicated a decrease in PFR submissions after MySafeCare implementation. Triangulated data indicated patients preferred to report anonymously and did not want concerns submitted directly to their care team. MySafeCare evaluation confirmed the potential value of providing an electronic, anonymous reporting tool in the hospital to capture safety concerns in real time. Such applications should be tested further as part of patient safety programs.This is an open-access article distributed under the terms of the

  10. Safety Issues at the Defense Production Reactors. A Report to the U.S. Department of Energy.

    ERIC Educational Resources Information Center

    National Academy of Sciences - National Research Council, Washington, DC. Commission on Physical Sciences, Mathematics, and Resources.

    This report provides an assessment of safety management, safety review, and safety methodology employed by the Department of Energy (DOE) and private contractors. Chapter 1, "The DOE Safety Framework," examines safety objectives for production reactors and processes to implement the objectives. Chapter 2, "Technical Issues,"…

  11. First report on the occurrence of Theileria sp. OT3 in China.

    PubMed

    Tian, Zhancheng; Liu, Guangyuan; Yin, Hong; Xie, Junren; Wang, Suyan; Yuan, Xiaosong; Wang, Fangfang; Luo, Jin

    2014-04-01

    Theileria sp. OT3 was firstly detected and identified from clinically healthy sheep in Xinjiang Uygur Autonomous Region of China (XUAR) through comparing the complete 18S rDNA gene sequences available in GenBank database and the phylogenetic status based on the internal transcribed spacers (ITS1, ITS2) as well as the intervening 5.8S coding region of the rRNA gene by the methods of a partitioned multi-locus analysis in BEAST and Maximum likelihood analysis in PhyML. Moreover, the findings were confirmed by the species-specific PCR for Theileria sp. OT3 and the prevalence of Theileria sp. OT3 was 14.9% in the north of XUAR. This study is the first report on the occurrence of Theileria sp. OT3 in China. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  12. Guide for the Development of Safety Assessment Report (SAR)

    DTIC Science & Technology

    1987-08-01

    Di ’:t ib ityioe I A,;!i~abiiity Codes Dist SpdIt ora bloe INSia OEapy r TABLE OF CONTENTS PAGE III SAFETY ASSESSMENT REPORT...above. Potential hazards associated with the maintenance of the turbine engine (i.e., use of cleaning agents ) are not addressed .in the accompanying

  13. Safety analysis report for the SR-101 inert reservoir package

    DOT National Transportation Integrated Search

    1998-11-01

    Department of Energy (DOE) AL Weapons Surety Division (WSD) requires the SR-101 Inert Reservoir Package to : meet applicable hazardous material transportation requirements. This Safety Analysis Report (SAR) is based on : requirements in place at the ...

  14. Greater sage-grouse: General use and roost site occurrence with pellet counts as a measure of relative abundance: Chapter 5

    USGS Publications Warehouse

    2011-01-01

    Greater sage-grouse (Centrocercus urophasianus) have been declining both spatially and numerically throughout their range because of anthropogenic disturbance and loss and fragmentation of sagebrush (Artemisia spp.) habitats. Understanding how sage-grouse respond to these habitat alterations and disturbances, particularly the types of disturbances and extent at which they respond, is critical to designing management actions and prioritizing areas of conservation. To address these needs, we developed statistical models of the relationships between occurrence and abundance of greater sage-grouse and multi-scaled measures of vegetation, abiotic, and disturbance in the Wyoming Basins Ecoregional Assessment (WBEA) area. Sage-grouse occurrence was strongly related to the amount of sagebrush within 1 km for both roost site and general use locations. Roost sites were identified by presence of sage-grouse fecal pellet groups whereas general use locations had single pellets. Proximity to anthropogenic disturbance including energy development, power lines, and major roads was negatively associated with sage-grouse occurrence. Models of sage-grouse occurrence correctly predicted active lek locations with >75% accuracy. Our spatially explicit models identified areas of high occurrence probability in the WBEA area that can be used to delineate areas for conservation and refine existing conservation plans. These models can also facilitate identification of pathways and corridors important for maintenance of sage-grouse population connectivity.

  15. Mechanisms of slow-pitch softball injuries reported to the HQ Air Force Safety Center a 10-year descriptive study, 1993-2002.

    PubMed

    Burnham, Bruce R; Copley, G Bruce; Shim, Matthew J; Kemp, Philip A; Jones, Bruce H

    2010-01-01

    Softball is a popular sport in civilian and military populations and results in a large number of lost-workday injuries. The purpose of this study is to describe the mechanisms associated with softball injuries occurring among active duty U.S. Air Force (USAF) personnel to better identify potentially effective countermeasures. Data derived from safety reports were obtained from the USAF Ground Safety Automated System in 2003. Softball injuries for the years 1993-2002 that resulted in at least one lost workday were included in the study. Narrative data were systematically reviewed and coded in order to categorize and summarize mechanisms associated with these injuries. This report documents a total of 1181 softball-related mishap reports, involving 1171 active duty USAF members who sustained one lost-workday injury while playing softball. Eight independent mechanisms were identified. Three specific scenarios (sliding, being hit by a ball, and colliding with a player) accounted for 60% of reported softball injuries. Mechanisms of injury for activities such as playing softball, necessary for prevention planning, can be identified using the detailed information found in safety reports. This information should also be used to develop better sports injury coding systems. Within the USAF and U.S. softball community, interventions to reduce injuries related to the most common mechanisms (sliding, being hit by a ball, and colliding with a player) should be developed, implemented, and evaluated. Published by Elsevier Inc.

  16. Food safety knowledge, attitudes and self-reported practices among Ontario high school students.

    PubMed

    Majowicz, Shannon E; Diplock, Kenneth J; Leatherdale, Scott T; Bredin, Chad T; Rebellato, Steven; Hammond, David; Jones-Bitton, Andria; Dubin, Joel A

    2016-03-16

    To measure the food safety knowledge, attitudes and self-reported practices of high school students in Ontario. We administered a school-wide paper survey to the student body (n = 2,860) of four Ontario high schools. We developed the survey by selecting questions from existing, validated questionnaires, prioritizing questions that aligned with the Canadian Partnership for Consumer Food Safety Education's educational messages and the food safety objectives from the 2013 Ontario High School Curriculum. One in five students reported currently handling food in commercial or public-serving venues; of these, 45.1% had ever taken a course that taught them how to prepare food (e.g., food and nutrition classes, food handler certification). Food safety knowledge among respondents was low. For example, 17.3% knew that the best way to determine whether hamburgers were cooked enough to eat was to measure the temperature with a food thermometer. Despite low knowledge, most respondents (72.7%) reported being confident that they could cook safe, healthy meals for themselves and their families. Safe food handling practices were frequently self-reported. Most students (86.5%) agreed that being able to cook safe, healthy meals was an important life skill, although their interest in learning about safe food handling and concern about foodborne disease were less pronounced. Our findings suggest that food safety knowledge is low, yet confidence in preparing safe, healthy meals is high, among high school students. Because work and volunteer opportunities put students in contact with both the public and food, this group is important to target for increased education about safe food handling.

  17. The association between EMS workplace safety culture and safety outcomes.

    PubMed

    Weaver, Matthew D; Wang, Henry E; Fairbanks, Rollin J; Patterson, Daniel

    2012-01-01

    Prior studies have highlighted wide variation in emergency medical services (EMS) workplace safety culture across agencies. To determine the association between EMS workplace safety culture scores and patient or provider safety outcomes. We administered a cross-sectional survey to EMS workers affiliated with a convenience sample of agencies. We recruited these agencies from a national EMS management organization. We used the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure workplace safety culture and the EMS Safety Inventory (EMS-SI), a tool developed to capture self-reported safety outcomes from EMS workers. The EMS-SAQ provides reliable and valid measures of six domains: safety climate, teamwork climate, perceptions of management, working conditions, stress recognition, and job satisfaction. A panel of medical directors, emergency medical technicians and paramedics, and occupational epidemiologists developed the EMS-SI to measure self-reported injury, medical errors and adverse events, and safety-compromising behaviors. We used hierarchical linear models to evaluate the association between EMS-SAQ scores and EMS-SI safety outcome measures. Sixteen percent of all respondents reported experiencing an injury in the past three months, four of every 10 respondents reported an error or adverse event (AE), and 89% reported safety-compromising behaviors. Respondents reporting injury scored lower on five of the six domains of safety culture. Respondents reporting an error or AE scored lower for four of the six domains, while respondents reporting safety-compromising behavior had lower safety culture scores for five of the six domains. Individual EMS worker perceptions of workplace safety culture are associated with composite measures of patient and provider safety outcomes. This study is preliminary evidence of the association between safety culture and patient or provider safety outcomes.

  18. Effect of occupational safety and health education received during schooling on the incidence of workplace injuries in the first 2 years of occupational life: a prospective study.

    PubMed

    Boini, Stephanie; Colin, Regis; Grzebyk, Michel

    2017-07-18

    This study aimed to determine the effect of occupational safety and health (OSH) education during formal schooling on the incidence of workplace injuries (WIs) in young people starting their careers. We hypothesised that young people who had received OSH education during their schooling would have fewer WIs than those who received no OSH education. Secondary objectives focused on the effect of 'first aid at work' training during schooling and the conditions encountered on arrival in the company (occupational hazard information, safety training and job task training) on WI occurrence. Prospective cohort study. From 2009 to 2012, French apprentices and students at the end of their schooling and starting their careers were included. Occurrence of WIs. At the time of inclusion, information about school courses and personal characteristics were collected, and subsequent half-yearly contacts gathered information relating to work and personal data. During the 2-year follow-up, WIs were directly reported by participants and were identified by searching the French National Health Insurance Funds' databases listing compulsory WI declarations. 755 participants reported holding 1290 jobs. During follow-up, 158 WIs were identified, corresponding to an incident rate of 0.12 (0.10 to 0.14) WIs per full-time worker. Subjects who reported having received OSH education at school had two times less WIs than those declaring not having received OSH education (incidence rate ratio (IRR) 0.51, 0.00 to 0.98). A lower WI risk was observed for participants who received the 'first aid at work' training (IRR=0.68, 0.00 to 0.98). The conditions on arrival in company were not associated with WIs occurrence. In France, the OSH education provided to apprentices and students is mostly broader than the specific risks related to future jobs. Our results highlight the advantages of reinforcing this approach. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article

  19. Thinking critically about the occurrence of widespread participation in poor nursing care.

    PubMed

    Roberts, Marc; Ion, Robin

    2015-04-01

    A discussion of how Arendt's work can be productively re-contextualized to provide a critical analysis of the occurrence of widespread participation in poor nursing care and what the implications of this are for the providers of nursing education. While the recent participation of nurses in healthcare failings, such as that detailed in the Francis report, has been universally condemned, there has been an absence of critical analyses in the literature that attempt to understand the occurrence of such widespread participation in poor nursing care. This is a significant omission in so far as such analyses will form an integral part of the strategy to limit the occurrence of such widespread participation of nurses in future healthcare failings. Discussion paper. Arendt's 'Eichmann in Jerusalem: A Report on the Banality of Evil' and 'Thinking and Moral Considerations: A Lecture'. In addition, a literature search was conducted and articles published in English relating to the terms care, compassion, ethics, judgement and thinking between 2004-2014 were included. It is anticipated that this discussion will stimulate further critical debate about the role of Arendt's work for an understanding of the occurrence of poor nursing care, and encouraging additional detailed analyses of the widespread participation of nurses in healthcare failings more generally. This article provides a challenging analysis of the widespread participation of nurses in poor care and discusses the opportunities confronting the providers of nursing education in limiting future healthcare failings. © 2014 John Wiley & Sons Ltd.

  20. Levels of salivary thiocyanate and its relation with occurrence of micronuclei using exfoliative cytology in smokers and nonsmokers.

    PubMed

    Baldawa, Prachi Shrigopal; Kulkarni, Venkatesh V; Koshy, Ajit V; Shaikh, Sabeer S; Varu, Rucha; Srivastava, Garima

    2016-01-01

    To evaluate the levels of salivary thiocyanate and its relation with the occurrence of micronuclei (MN) using exfoliative cytology in smokers and nonsmokers. One hundred and twenty patients were divided into 3 groups: nonsmoker group 1 (control), smokers group 2, and smokers group 3. Their saliva was collected and analyzed for thiocyanate levels, and exfoliative cytology was evaluated for the presence of MN. Fisher's exact test and ANOVA test were used. It was seen that as the grade of smoking increased, the levels of salivary thiocyanate and occurrence of MN increased. Detection and quantification of "biomarkers" such as salivary thiocyanate and MN in noninvasive and painless procedures such as oral exfoliative cytology can be an upcoming research domain in the field of cancer prevention and therapeutics.

  1. Taste and Safety: Is the Exceptional Cuisine Offered by High End Restaurants Paralleled by High Standards of Food Safety?

    PubMed Central

    Kanagarajah, Sanch; Mook, Piers; Crook, Paul; Awofisayo-Okuyelu, Adedoyin; McCarthy, Noel

    2016-01-01

    Introduction: Restaurant guides such as the Good Food Guide Top 50 create a hierarchy focussing on taste and sophistication. Safety is not explicitly included. We used restaurant associated outbreaks to assess evidence for safety. Methods: All foodborne disease outbreaks in England reported to the national database from 2000 to 2014 were used to compare the Top 50 restaurants (2015) to other registered food businesses using the Public Health England (PHE) outbreak database. Health Protection Teams were also contacted to identify any outbreaks not reported to the national database. Among Good Food Guide Top 50 restaurants, regression analysis estimated the association between outbreak occurrence and position on the list. Results: Four outbreaks were reported to the PHE national outbreak database among the Top 50 giving a rate 39 times higher (95% CI 14.5–103.2) than other registered food businesses. Eight outbreaks among the 44 English restaurants in the Top 50 were identified by direct contact with local Health Protection Teams. For every ten places higher ranked, Top 50 restaurants were 66% more likely to have an outbreak (Odds Ratio 1.66, 95% CI 0.89–3.13). Discussion: Top 50 restaurants were substantially more likely to have had reported outbreaks from 2000-2014 than other food premises, and there was a trend for higher rating position to be associated with higher probability of reported outbreaks. Our findings, that eating at some of these restaurants may pose an increased risk to health compared to other dining out, raises the question of whether food guides should consider aspects of food safety alongside the clearly important complementary focus on taste and other aspects of the dining experience. PMID:27617168

  2. Gendered role of appraisals of safety in psychological outcome in relation to trauma.

    PubMed

    Padmanabhanunni, Anita; Campbell, Jerome; Pretorius, Tyrone B

    2017-09-01

    This study investigated gender differences in the role of appraisals of safety in the relationship between exposure to violence and trauma-related symptoms among South African adolescents living in low socioeconomic settings. Limited research exists in developing contexts on the role of cognitive appraisals in mitigating outcome following exposure to violence. Given the prevalence of violence in South Africa and the vulnerability of youth, this type of research is valuable in identifying adolescents at risk of negative psychological outcome following exposure, and in informing intervention efforts. Adolescents (N = 498) completed an adapted version of the Harvard Trauma Questionnaire (Mollica et al., 1992) and the Safety Index (Ward, Flisher, Zissis, Muller, & Lombard, 2001). The results indicate a significant positive relationship between all violence subscales and trauma-related symptoms, whereas a significant negative relationship was found between sense of safety and trauma-related symptoms. Important gender differences were identified in the role of appraisals of safety, with more effects noted for women than men. For men, the obtained results only demonstrated a health-sustaining role. For women, the results indicated a health-sustaining role, an indirect effect, and a stress-reducing role. These findings stress the necessity of gender-specific interventions. Assessment of psychological trauma, particularly among female adolescents, needs to include measures of cognitive appraisals related to safety. Therapeutic techniques that may be particularly beneficial to adolescent girls are those focusing on promoting sense of safety and targeting dysfunctional threat appraisals. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

  3. Clinical Evaluation of a Safety-device to Prevent Urinary Catheter Inflation Related Injuries.

    PubMed

    Davis, Niall F; Cunnane, Eoghan M; Mooney, Rory O'C; Forde, James C; Walsh, Michael T

    2018-05-01

    To evaluate the feasibility of a novel "safety-valve" device for preventing catheter related urethral trauma during urethral catheterization (UC). To assess the opinions of clinicians on the performance of the safety-valve device. A validated prototype "safety-valve" device for preventing catheter balloon inflation related urethral injuries was prospectively piloted in male patients requiring UC in a tertiary referral teaching hospital (n = 100). The device allows fluid in the catheter system to decant through an activated safety threshold pressure valve if the catheter anchoring balloon is misplaced. Users evaluated the "safety-valve" with an anonymous questionnaire. The primary outcome measurement was prevention of anchoring balloon inflation in the urethra. Secondary outcome measurement was successful inflation of urinary catheter anchoring balloon in the bladder. Patient age was 76 ± 12 years and American Society of Anaesthesiologists grade was 3 ± 1.4. The "safety-valve" was utilized by 34 clinicians and activated in 7% (n = 7/100) patients during attempted UC, indicating that the catheter anchoring balloon was incorrectly positioned in the patient's urethra. In these 7 cases, the catheter was successfully manipulated into the urinary bladder and inflated. 31 of 34 (91%) clinicians completed the questionnaire. Ten percent (n = 3/31) of respondents had previously inflated a urinary catheter anchoring balloon in the urethra and 100% (n = 31) felt that a safety mechanism for preventing balloon inflation in the urethra should be compulsory for all UCs. The safety-valve device piloted in this clinical study offers an effective solution for preventing catheter balloon inflation related urethral injuries. Copyright © 2018 Elsevier Inc. All rights reserved.

  4. Does despotic behavior or food search explain the occurrence of problem brown bears in Europe?

    PubMed Central

    Elfström, Marcus; Zedrosser, Andreas; Jerina, Klemen; Støen, Ole-Gunnar; Kindberg, Jonas; Budic, Lara; Jonozovič, Marko; Swenson, Jon E

    2014-01-01

    Bears foraging near human developments are often presumed to be responding to food shortage, but this explanation ignores social factors, in particular despotism in bears. We analyzed the age distribution and body condition index (BCI) of shot brown bears in relation to densities of bears and people, and whether the shot bears were killed by managers (i.e., problem bears; n = 149), in self-defense (n = 51), or were hunter-killed nonproblem bears (n = 1,896) during 1990–2010. We compared patterns between areas with (Slovenia) and without supplemental feeding (Sweden) of bears relative to 2 hypotheses. The food-search/food-competition hypothesis predicts that problem bears should have a higher BCI (e.g., exploiting easily accessible and/or nutritious human-derived foods) or lower BCI (e.g., because of food shortage) than nonproblem bears, that BCI and human density should have a positive correlation, and problem bear occurrence and seasonal mean BCI of nonproblem bears should have a negative correlation (i.e., more problem bears during years of low food availability). Food competition among bears additionally predicts an inverse relationship between BCI and bear density. The safety-search/naivety hypothesis (i.e., avoiding other bears or lack of human experience) predicts no relationship between BCI and human density, provided no dietary differences due to spatiotemporal habitat use among bears, no relationship between problem bear occurrence and seasonal mean BCI of nonproblem bears, and does not necessarily predict a difference between BCI for problem/nonproblem bears. If food competition or predation avoidance explained bear occurrence near settlements, we predicted younger problem than nonproblem bears and a negative correlation between age and human density. However, if only food search explained bear occurrence near settlements, we predicted no relation between age and problem or nonproblem bear status, or between age and human density. We found

  5. Implementation of the Generic Safety Analysis Report - Lessons Learned

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

    Blanchard, A.

    1999-06-02

    The Savannah River Site has completed the development, review and approval process for the Generic Safety Analysis Report (GSAR) and implemented this information in facility SARs and BIOs. This includes the yearly revision of the GSAR and the facility-specific SARs. The process has provided us with several lessons learned.

  6. Final safety analysis report for the Galileo Mission: Volume 1, Reference design document

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

    Not Available

    The Galileo mission uses nuclear power sources called Radioisotope Thermoelectric Generators (RTGs) to provide the spacecraft's primary electrical power. Because these generators contain nuclear material, a Safety Analysis Report (SAR) is required. A preliminary SAR and an updated SAR were previously issued that provided an evolving status report on the safety analysis. As a result of the Challenger accident, the launch dates for both Galileo and Ulysses missions were later rescheduled for November 1989 and October 1990, respectively. The decision was made by agreement between the DOE and the NASA to have a revised safety evaluation and report (FSAR) preparedmore » on the basis of these revised vehicle accidents and environments. The results of this latest revised safety evaluation are presented in this document (Galileo FSAR). Volume I, this document, provides the background design information required to understand the analyses presented in Volumes II and III. It contains descriptions of the RTGs, the Galileo spacecraft, the Space Shuttle, the Inertial Upper Stage (IUS), the trajectory and flight characteristics including flight contingency modes, and the launch site. There are two appendices in Volume I which provide detailed material properties for the RTG.« less

  7. Canister Storage Building (CSB) Hazard Analysis Report

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

    POWERS, T.B.

    2000-03-16

    This report describes the methodology used in conducting the Canister Storage Building (CSB) Hazard Analysis to support the final CSB Safety Analysis Report and documents the results. This report describes the methodology used in conducting the Canister Storage Building (CSB) hazard analysis to support the CSB final safety analysis report (FSAR) and documents the results. The hazard analysis process identified hazardous conditions and material-at-risk, determined causes for potential accidents, identified preventive and mitigative features, and qualitatively estimated the frequencies and consequences of specific occurrences. The hazard analysis was performed by a team of cognizant CSB operations and design personnel, safetymore » analysts familiar with the CSB, and technical experts in specialty areas. The material included in this report documents the final state of a nearly two-year long process. Attachment A provides two lists of hazard analysis team members and describes the background and experience of each. The first list is a complete list of the hazard analysis team members that have been involved over the two-year long process. The second list is a subset of the first list and consists of those hazard analysis team members that reviewed and agreed to the final hazard analysis documentation. The material included in this report documents the final state of a nearly two-year long process involving formal facilitated group sessions and independent hazard and accident analysis work. The hazard analysis process led to the selection of candidate accidents for further quantitative analysis. New information relative to the hazards, discovered during the accident analysis, was incorporated into the hazard analysis data in order to compile a complete profile of facility hazards. Through this process, the results of the hazard and accident analyses led directly to the identification of safety structures, systems, and components, technical safety requirements, and

  8. 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...

  9. NASA aviation safety reporting system

    NASA Technical Reports Server (NTRS)

    1978-01-01

    A sample of reports relating to operations during winter weather is presented. Several reports involving problems of judgment and decisionmaking have been selected from the numerous reports representative of this area. Problems related to aeronautical charts are discussed in a number of reports. An analytic study of reports involving potential conflicts in the immediate vicinity of uncontrolled airports was performed; the results are discussed in this report. It was found that in three-fourths of 127 such conflicts, neither pilot, or only one of the pilots, was communicating position and intentions on the appropriate frequency. The importance of providing aural transfer of information, as a backup to the visual see and avoid mode of information transfer is discussed. It was also found that a large fraction of pilots involved in potential conflicts on final approach had executed straight-in approaches, rather than the recommended traffic pattern entries, prior to the conflicts. A selection of alert bulletins and responses to them by various segments of the aviation community is presented.

  10. Moving forward with safety culture.

    PubMed

    Weber, Michael

    2012-04-01

    Radiation safety and protection of people are shared goals of the Health Physics Society (HPS) and the U.S. Nuclear Regulatory Commission (NRC). A positive safety culture contributes to achieving radiation safety and protection of people, which are important to both the HPS and the NRC. Through unprecedented collaboration and engagement with diverse stakeholders, the NRC and the stakeholders developed a Safety Culture Policy Statement. The policy statement defines safety culture and describes the traits of a positive safety culture. Consideration of both safety and security issues and the interface of safety and security are underlying principles that support the policy. Examination of significant events, both within the nuclear industry and in society at large, illustrates how weaknesses in these traits can contribute to the occurrence and consequences of safety incidents, including serious injury and loss of life. With the policy statement in place, the NRC is moving forward with outreach and education about safety culture. Health physicists and other radiation safety specialists play an essential role in enhancing safety culture.

  11. Reporting natural health product related adverse drug reactions: is it the pharmacist's responsibility?

    PubMed

    Walji, Rishma; Boon, Heather; Barnes, Joanne; Welsh, Sandy; Austin, Zubin; Baker, G Ross

    2011-12-01

    Herbal medicines and other natural health products (NHPs) are sold in Canadian pharmacies as over-the-counter products, yet there is limited information on their safety and adverse effect profile. Signals of safety concerns associated with medicines can arise through analysis of reports of suspected adverse drug reactions (ADRs) submitted to national pharmacovigilance centres by health professionals, including pharmacists and the public. However, typically such systems experience substantial under-reporting for NHPs. The objective of this paper is to explore pharmacists' experiences with and responses to receiving or identifying reports of suspected ADRs associated with NHPs from pharmacy customers. A qualitative study in which in-depth, semi-structured interviews were conducted with 12 community pharmacists in Toronto, Canada. Pharmacists generally did not submit reports of adverse events associated with NHPs to the national ADR reporting system and cited several barriers, including lack of time, complexity of the reporting process and lack of knowledge about NHPs. Pharmacists who accepted responsibility for adverse event reporting appeared to have different perceptions of their professional role: they saw themselves as 'knowledge generators', contributing to overall healthcare knowledge. Reporting behaviour for suspected ADRs associated with NHPs may be explained by a pharmacist's perception of his/her professional role and perceptions of the relative importance of generating knowledge to share in the wider system of health care. © 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society.

  12. Occurrence and distribution of Indian primates

    USGS Publications Warehouse

    Karanth, K.K.; Nichols, J.D.; Hines, J.E.

    2010-01-01

    Global and regional species conservation efforts are hindered by poor distribution data and range maps. Many Indian primates face extinction, but assessments of population status are hindered by lack of reliable distribution data. We estimated the current occurrence and distribution of 15 Indian primates by applying occupancy models to field data from a country-wide survey of local experts. We modeled species occurrence in relation to ecological and social covariates (protected areas, landscape characteristics, and human influences), which we believe are critical to determining species occurrence in India. We found evidence that protected areas positively influence occurrence of seven species and for some species are their only refuge. We found evergreen forests to be more critical for some primates along with temperate and deciduous forests. Elevation negatively influenced occurrence of three species. Lower human population density was positively associated with occurrence of five species, and higher cultural tolerance was positively associated with occurrence of three species. We find that 11 primates occupy less than 15% of the total land area of India. Vulnerable primates with restricted ranges are Golden langur, Arunachal macaque, Pig-tailed macaque, stump-tailed macaque, Phayre's leaf monkey, Nilgiri langur and Lion-tailed macaque. Only Hanuman langur and rhesus macaque are widely distributed. We find occupancy modeling to be useful in determining species ranges, and in agreement with current species ranking and IUCN status. In landscapes where monitoring efforts require optimizing cost, effort and time, we used ecological and social covariates to reliably estimate species occurrence and focus species conservation efforts. ?? Elsevier Ltd.

  13. 78 FR 20926 - Draft Guidance for Industry on Providing Postmarket Periodic Safety Reports in the International...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-08

    ...The Food and Drug Administration (FDA) is announcing the availability of a draft guidance for industry entitled ``Providing Postmarket Periodic Safety Reports in the ICH E2C(R2) Format (Periodic Benefit-Risk Evaluation Report).'' This guidance is intended to inform applicants of the conditions under which FDA will exercise its waiver authority to permit applicants to submit an International Conference on Harmonisation (ICH) E2C(R2) Periodic Benefit-Risk Evaluation Report (PBRER) in place of the ICH E2C(R1) Periodic Safety Update Report (PSUR), U.S. periodic adverse drug experience report (PADER), or U.S. periodic adverse experience report (PAER), to satisfy the periodic safety reporting requirements in FDA regulations. The guidance describes the steps applicants can take to submit the PBRER, and discusses the format, content, submission deadline, and frequency of reporting for the PBRER.

  14. The association between EMS workplace safety culture and safety outcomes

    PubMed Central

    Weaver, Matthew D.; Wang, Henry E.; Fairbanks, Rollin J.; Patterson, Daniel

    2012-01-01

    Objective Prior studies have highlighted wide variation in EMS workplace safety culture across agencies. We sought to determine the association between EMS workplace safety culture scores and patient or provider safety outcomes. Methods We administered a cross-sectional survey to EMS workers affiliated with a convenience sample of agencies. We recruited these agencies from a national EMS management organization. We used the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure workplace safety culture and the EMS Safety Inventory (EMS-SI), a tool developed to capture self-reported safety outcomes from EMS workers. The EMS-SAQ provides reliable and valid measures of six domains: safety climate, teamwork climate, perceptions of management, perceptions of working conditions, stress recognition, and job satisfaction. A panel of medical directors, paramedics, and occupational epidemiologists developed the EMS-SI to measure self-reported injury, medical errors and adverse events, and safety-compromising behaviors. We used hierarchical linear models to evaluate the association between EMS-SAQ scores and EMS-SI safety outcome measures. Results Sixteen percent of all respondents reported experiencing an injury in the past 3 months, four of every 10 respondents reported an error or adverse event (AE), and 90% reported safety-compromising behaviors. Respondents reporting injury scored lower on 5 of the 6 domains of safety culture. Respondents reporting an error or AE scored lower for 4 of the 6 domains, while respondents reporting safety-compromising behavior had lower safety culture scores for 5 of 6 domains. Conclusions Individual EMS worker perceptions of workplace safety culture are associated with composite measures of patient and provider safety outcomes. This study is preliminary evidence of the association between safety culture and patient or provider safety outcomes. PMID:21950463

  15. Pavement markings and safety : tech transfer summary.

    DOT National Transportation Integrated Search

    2010-11-01

    Objective: This study explores the statistical relationship between crash occurrence probability and longitudinal pavement marking retroreflectivity. : Problem Statement: Previous research on pavement markings, from a safety perspective, tackled vari...

  16. Evidence report : diabetes and commercial motor vehicle driver safety (expedited review) : September 8, 2006.

    DOT National Transportation Integrated Search

    2006-09-08

    This report is comprised of research conducted to analyze the impact of Diabetes on Commercial Motor Vehicle Driver Safety. Federal Motor Carrier Safety Administration considers evidence, expert recommendations, and other data, however, all proposed ...

  17. Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members: Experiences, Expectations, Tolerance, Reporting, and Recommendations.

    PubMed

    Copeland, Darcy; Henry, Melissa

    Workplace violence (WPV) is a widely recognized problem in emergency departments (EDs). The majority of WPV studies do not include nonclinical staff and do not address expectations of violence, tolerance to violence, or perceptions of safety. Among a multidisciplinary sample of ED staff members, specific study aims were to (a) describe exposure to WPV; (b) describe perceptions of safety, tolerance to violence, and expectation of violence; (c) describe reporting behaviors and perceived barriers to reporting violence; (d) examine relationships between demographic variables, experiences of violence, tolerance to violence, perceptions of safety, and reporting behaviors; and (e) identify perceptions of viable interventions to improve workplace safety. A cross-sectional design was used to survey ED staff members in a Level 1 Shock Trauma center. Eleven disciplines were represented in 147 completed surveys; 88% of respondents reported exposure to WPV in the previous 6 months. Members of every discipline reported exposure to WPV; 98% of the sample felt safe at work and 64% felt violence was an expected part of the job. Most violence was not reported, primarily because "nobody was hurt." Emergency department staff members expected and experienced violence; nevertheless, there was a widespread perception of safety. Perceptions of safety and reasons for not reporting did not mirror previous findings. The WPV exposure is not isolated to clinical staff members and occurs even when prevention strategies are in place. The definition of WPV and the individual's interpretation of the event might preclude reporting.

  18. Review: Occurrence of the pathogenic amoeba Naegleria fowleri in groundwater

    NASA Astrophysics Data System (ADS)

    Bright, Kelly R.; Gerba, Charles P.

    2017-06-01

    Naegleria fowleri is a thermophilic free-living amoeba found worldwide in soils and warm freshwater. It is the causative agent of primary amebic meningoencephalitis, a nearly always fatal disease afflicting mainly children and young adults. Humans are exposed to the organism via swimming, bathing, or other recreational activity during which water is forcefully inhaled into the upper nasal passages. Although many studies have looked at the occurrence of N. fowleri in surface waters, limited information is available regarding its occurrence in groundwater and geothermally heated natural waters such as hot springs. This paper reviews the current literature related to the occurrence of N. fowleri in these waters and the methods employed for its detection. Case reports of potential groundwater exposures are also included. Despite increased interest in N. fowleri in recent years due to well-publicized cases linked to drinking water, many questions still remain unanswered. For instance, why the organism persists in some water sources and not in others is not well understood. The role of biofilms in groundwater wells and plumbing in individual buildings, and the potential for warming due to climate change to expand the occurrence of the organism into new regions, are still unclear. Additional research is needed to address these questions in order to better understand the ecology of N. fowleri and the conditions that result in greater risks to bathers.

  19. Smooth handling: the lack of safety-related consumer information in car advertisements.

    PubMed

    Wilson, Nick; Maher, Anthony; Thomson, George; Keall, Michael

    2007-10-01

    To examine the content and trends of safety-related consumer information in magazine vehicle advertisements, as a case study within the worldwide marketing of vehicles. Content analysis of popular current affairs magazines in New Zealand for the 5-year period 2001-2005 was undertaken (n = 514 advertisements), supplemented with vehicle data from official websites. Safety information in advertisements for light passenger vehicles was relatively uncommon with only 27% mentioning one or more of nine key safety features examined (average: 1.7 out of nine features in this 27%). Also included were potentially hazardous features of: speed imagery (in 29% of advertisements), power references (14%), and acceleration data (4%). The speed and power aspects became relatively more common over the 5-year period (p < 0.05 for trend). To enhance informed consumer choice and improve injury prevention, governments should consider regulating the content of vehicle advertisements and vehicle marketing - as already occurs with many other consumer products.

  20. Return to driving after arthroscopic rotator cuff repair: patient-reported safety and maneuverability.

    PubMed

    Gholson, J Joseph; Lin, Albert; McGlaston, Timothy; DeAngelis, Joseph; Ramappa, Arun

    2015-01-01

    This survey investigated patients' return to driving after rotator cuff surgery, to determine whether pain, weakness, sling use, and narcotics correlate with self-assessed safety and maneuvering. Fifty-four patients (80.6% of those eligible) were surveyed 4 months after surgery. Return to driving ranged widely from same day to 4 months, with two not driving at 4 months; 12% reported narcotics use and 33% reported sling use. Drivers reporting weakness were more likely to feel unsafe (p = .02) and more likely to report difficulty maneuvering (p <.01). Drivers reporting pain were more likely to feel unsafe (p < .01) and more likely to report difficulty maneuvering their vehicle (p < .01). Patient-reported return to driving does not correspond to perceived safety; pain and weakness correspond with feeling unsafe and difficulty maneuvering. Although subjective, clinicians may find these self-assessments predictive when counseling patients on return to driving.

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