Optimizing Processes to Minimize Risk

NASA Technical Reports Server (NTRS)

Loyd, David

2017-01-01

NASA, like the other hazardous industries, has suffered very catastrophic losses. Human error will likely never be completely eliminated as a factor in our failures. When you can't eliminate risk, focus on mitigating the worst consequences and recovering operations. Bolstering processes to emphasize the role of integration and problem solving is key to success. Building an effective Safety Culture bolsters skill-based performance that minimizes risk and encourages successful engagement.

Ares I-X Range Safety Trajectory Analyses Overview and Independent Validation and Verification

NASA Technical Reports Server (NTRS)

Tarpley, Ashley F.; Starr, Brett R.; Tartabini, Paul V.; Craig, A. Scott; Merry, Carl M.; Brewer, Joan D.; Davis, Jerel G.; Dulski, Matthew B.; Gimenez, Adrian; Barron, M. Kyle

2011-01-01

All Flight Analysis data products were successfully generated and delivered to the 45SW in time to support the launch. The IV&V effort allowed data generators to work through issues early. Data consistency proved through the IV&V process provided confidence that the delivered data was of high quality. Flight plan approval was granted for the launch. The test flight was successful and had no safety related issues. The flight occurred within the predicted flight envelopes. Post flight reconstruction results verified the simulations accurately predicted the FTV trajectory.

Foundations for High Achievement: Safety, Civility, Literacy. K-12 Public Education.

ERIC Educational Resources Information Center

Colorado State Dept. of Education, Denver. Research and Evaluation Unit.

The state of Colorado has set high standards for students based on three fundamental principles: safety, civility, and literacy. How these standards were integrated into the schools is the subject of this report. It opens with an overview of the foundations of academic success and the process involved in implementing standards-based education. The…

Relational approach in managing construction project safety: a social capital perspective.

PubMed

Koh, Tas Yong; Rowlinson, Steve

2012-09-01

Existing initiatives in the management of construction project safety are largely based on normative compliance and error prevention, a risk management approach. Although advantageous, these approaches are not wholly successful in further lowering accident rates. A major limitation lies with the approaches' lack of emphasis on the social and team processes inherent in construction project settings. We advance the enquiry by invoking the concept of social capital and project organisational processes, and their impacts on project safety performance. Because social capital is a primordial concept and affects project participants' interactions, its impact on project safety performance is hypothesised to be indirect, i.e. the impact of social capital on safety performance is mediated by organisational processes in adaptation and cooperation. A questionnaire survey was conducted within Hong Kong construction industry to test the hypotheses. 376 usable responses were received and used for analyses. The results reveal that, while the structural dimension is not significant, the mediational thesis is generally supported with the cognitive and relational dimensions affecting project participants' adaptation and cooperation, and the latter two processes affect safety performance. However, the cognitive dimension also directly affects safety performance. The implications of these results for project safety management are discussed. Copyright © 2011 Elsevier Ltd. All rights reserved.

Development, fabrication and test of a high purity silica heat shield

NASA Technical Reports Server (NTRS)

Rusert, E. L.; Drennan, D. N.; Biggs, M. S.

1978-01-01

A highly reflective hyperpure ( 25 ppm ion impurities) slip cast fused silica heat shield material developed for planetary entry probes was successfully scaled up. Process development activities for slip casting large parts included green strength improvements, casting slip preparation, aggregate casting, strength, reflectance, and subscale fabrication. Successful fabrication of a one-half scale Saturn probe (shape and size) heat shield was accomplished while maintaining the silica high purity and reflectance through the scale-up process. However, stress analysis of this original aggregate slip cast material indicated a small margin of safety (MS. = +4%) using a factor of safety of 1.25. An alternate hyperpure material formulation to increase the strength and toughness for a greater safety margin was evaluated. The alternate material incorporates short hyperpure silica fibers into the casting slip. The best formulation evaluated has a 50% by weight fiber addition resulting in an 80% increase in flexural strength and a 170% increase in toughness over the original aggregate slip cast materials with comparable reflectance.

Exploring the delivery of antiretroviral therapy for symptomatic HIV in Swaziland: threats to the successful treatment and safety of outpatients attending regional and district clinics.

PubMed

Armitage, Gerry; Hodgson, Ian; Wright, John; Bailey, Kerry; Mkhwana, Estel

2011-01-01

To examine the safety and acceptability of providing antiretroviral therapy (ART) in a resource poor setting. Two-stage observational and qualitative study. Rural hospital in Southern Africa. Structured observation using failure modes and effects analysis (FMEA) of the drug supply, dispensing, prescribing and administration processes. The findings from the FMEA were explored further in qualitative interviews with eight health professionals involved in the delivery of ART. To obtain a patient perspective, a stratified sample of 14 patients receiving ART was also interviewed. Key vulnerabilities in the process of ART provision include supply problems, poor packaging and labelling, inadequate knowledge among staff and lack of staff. Key barriers to successful patient adherence include transport inconsistency in supply and personal financial difficulties. There is, however, strong evidence of patient commitment and adherence. IMPLICATIONS AND CONCLUSION: Medication safety is relatively unexplored in the developing world. This study reveals an encouraging resilience in the health system and adherence among patients in the delivery of complex ART. The vulnerabilities identified, however, undermine patient safety and effectiveness of ART. There are implications for drug manufacturers; international aid agencies funding and supplying ART; and local practitioners. FMEA can help identify potential vulnerabilities and inform safety improvement interventions.

The Ergonomic Program Implementation Continuum (EPIC): integration of health and safety--a process evaluation in the healthcare sector.

PubMed

Baumann, Andrea; Holness, D Linn; Norman, Patrica; Idriss-Wheeler, Dina; Boucher, Patricia

2012-07-01

This article presents a health and safety intervention model and the use of process evaluation to assess a participatory ergonomic intervention. The effectiveness of the Ergonomic Program Implementation Continuum (EPIC) was assessed at six healthcare pilot sites in Ontario, Canada. The model provided a framework to demonstrate evaluation findings. Participants reported that EPIC was thorough and identified improvements related to its use. Participants believed the program contributed to advancing an organizational culture of safety (COS). Main barriers to program uptake included resistance to change and need for adequate funding and resources. The dedication of organizational leaders and consultant coaches was identified as essential to the program's success. In terms of impact on industry, findings contribute to the evidence-based knowledge of health and safety interventions and support use of the framework for creating a robust infrastructure to advance organizational COS and link staff safety and wellness with patient safety in healthcare. Copyright © 2012 National Safety Council and Elsevier Ltd. All rights reserved.

Project safety as a sustainable competitive advantage.

PubMed

Rechenthin, David

2004-01-01

To be consistently profitable, a construction company must complete projects in scope, on schedule, and on budget. At the same time, the nature of the often high-risk work performed by construction companies can result in high accident rates. Clients and other stakeholders are placing increasing pressure on companies to decrease those accident rates. Clients routinely demand copies of safety plans and evidence of past results at the "pre-qualification" or "request for proposal" stages of the procurement process. Are high accident rates and the associated costs just a part of business? Companies that deliver on scope, schedule, and budget have a competitive advantage. Is it possible for projects with low accident rates to use it as a competitive advantage? Is the value added by safety just a temporary or parity issue, or does a successful safety program offer significant advantage to the company and the client? This article concludes that in the case of a high-risk industry, such as the construction industry, an organization with a successful safety program can promote safety performance as a sustainable competitive advantage. It is a choice the company can make.

Aerospace Safety Advisory Panel

NASA Technical Reports Server (NTRS)

1999-01-01

This report covers the activities of the Aerospace Safety Advisory Panel (ASAP) for calendar year 1998-a year of sharp contrasts and significant successes at NASA. The year opened with the announcement of large workforce cutbacks. The slip in the schedule for launching the International Space Station (ISS) created a 5-month hiatus in Space Shuttle launches. This slack period ended with the successful and highly publicized launch of the STS-95 mission. As the year closed, ISS assembly began with the successful orbiting and joining of the Functional Cargo Block (FGB), Zarya, from Russia and the Unity Node from the United States. Throughout the year, the Panel maintained its scrutiny of NASAs safety processes. Of particular interest were the potential effects on safety of workforce reductions and the continued transition of functions to the Space Flight Operations Contractor. Attention was also given to the risk management plans of the Aero-Space Technology programs, including the X-33, X-34, and X-38. Overall, the Panel concluded that safety is well served for the present. The picture is not as clear for the future. Cutbacks have limited the depth of talent available. In many cases, technical specialties are "one deep." The extended hiring freeze has resulted in an older workforce that will inevitably suffer significant departures from retirements in the near future. The resulting "brain drain" could represent a future safety risk unless appropriate succession planning is started expeditiously. This and other topics are covered in the section addressing workforce. In the case of the Space Shuttle, beneficial and mandatory safety and operational upgrades are being delayed because of a lack of sufficient present funding. Likewise, the ISS has little flexibility to begin long lead-time items for upgrades or contingency planning.

Incorporating organisational safety culture within ergonomics practice.

PubMed

Bentley, Tim; Tappin, David

2010-10-01

This paper conceptualises organisational safety culture and considers its relevance to ergonomics practice. Issues discussed in the paper include the modest contribution that ergonomists and ergonomics as a discipline have made to this burgeoning field of study and the significance of safety culture to a systems approach. The relevance of safety culture to ergonomics work with regard to the analysis, design, implementation and evaluation process, and implications for participatory ergonomics approaches, are also discussed. A potential user-friendly, qualitative approach to assessing safety culture as part of ergonomics work is presented, based on a recently published conceptual framework that recognises the dynamic and multi-dimensional nature of safety culture. The paper concludes by considering the use of such an approach, where an understanding of different aspects of safety culture within an organisation is seen as important to the success of ergonomics projects. STATEMENT OF RELEVANCE: The relevance of safety culture to ergonomics practice is a key focus of this paper, including its relationship with the systems approach, participatory ergonomics and the ergonomics analysis, design, implementation and evaluation process. An approach to assessing safety culture as part of ergonomics work is presented.

Human factors systems approach to healthcare quality and patient safety

PubMed Central

Carayon, Pascale; Wetterneck, Tosha B.; Rivera-Rodriguez, A. Joy; Hundt, Ann Schoofs; Hoonakker, Peter; Holden, Richard; Gurses, Ayse P.

2013-01-01

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety. PMID:23845724

Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.

PubMed

Burnett, Susan; Benn, Jonathan; Pinto, Anna; Parand, Anam; Iskander, Sandra; Vincent, Charles

2010-08-01

Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding 'readiness' at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.

Safety And Promotion in the Federal Aviation Administration- Enabling Safe and Successful Commercial Space Transportation

NASA Astrophysics Data System (ADS)

Repcheck, Randall J.

2010-09-01

The United States Federal Aviation Administration’s Office of Commercial Space Transportation(AST) authorizes the launch and reentry of expendable and reusable launch vehicles and the operation of launch and reentry sites by United States citizens or within the United States. It authorizes these activities consistent with public health and safety, the safety of property, and the national security and foreign policy interests of the United States. In addition to its safety role, AST has the role to encourage, facilitate, and promote commercial space launches and reentries by the private sector. AST’s promotional role includes, among other things, the development of information of interest to industry, the sharing of information of interest through a variety of methods, and serving as an advocate for Commercial Space Transportation within the United States government. This dual safety and promotion role is viewed by some as conflicting. AST views these two roles as complementary, and important for the current state of commercial space transportation. This paper discusses how maintaining a sound safety decision-making process, maintaining a strong safety culture, and taking steps to avoid complacency can together enable safe and successful commercial space transportation.

Implementing AORN recommended practices for medication safety.

PubMed

Hicks, Rodney W; Wanzer, Linda J; Denholm, Bonnie

2012-12-01

Medication errors in the perioperative setting can result in patient morbidity and mortality. The AORN "Recommended practices for medication safety" provide guidance to perioperative nurses in developing, implementing, and evaluating safe medication use practices. These practices include recognizing risk points in the medication use process, collaborating with pharmacy staff members, conducting preoperative assessments and postoperative evaluations (eg, medication reconciliation), and handling hazardous medications and pharmaceutical waste. Strategies for successful implementation of the recommended practices include promoting a basic understanding of the nurse's role in the medication use process and developing a medication management plan as well as policies and procedures that support medication safety and activities to measure compliance with safe practices. Published by Elsevier Inc.

Doing Knowledge Transfer: Engaging Management and Labor with Research on Employee Health and Safety

ERIC Educational Resources Information Center

Kramer, Desre M.; Cole, Donald C.; Leithwood, Kenneth

2004-01-01

In workplace health interventions, engaging management and union decision makers is considered important for the success of the project, yet little research has described the process of making this happen. A case study of a knowledge-transfer process is presented to describe the practices and processes adopted by a knowledge broker who engaged…

Progress and successes of the Specialty Crop Research Initiative on acrylamide reduction in processed potato products

USDA-ARS?s Scientific Manuscript database

Acrylamide, a suspected human carcinogen, is a Maillard reaction product that forms when carbohydrate-rich foods are cooked at high temperatures. Processed potato products, including French fries and potato chips, make a substantial contribution to total dietary acrylamide. Health safety concerns ra...

Managing patients with behavioral health problems in acute care: balancing safety and financial viability.

PubMed

Rape, Cyndy; Mann, Tammy; Schooley, John; Ramey, Jana

2015-01-01

With a recent decrease in community resources for the mental health population, acute care facilities must seek creative, cost-effective ways to protect and care for these vulnerable individuals. This article describes 1 facility's journey to maintaining patient and staff safety while reducing cost. Success factors of this program include staff engagement, environmental modifications, and a nurse-driven, sitter-reduction process.

Safety and Security Interface Technology Initiative

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

Dr. Michael A. Lehto; Kevin J. Carroll; Dr. Robert Lowrie

Safety and Security Interface Technology Initiative Mr. Kevin J. Carroll Dr. Robert Lowrie, Dr. Micheal Lehto BWXT Y12 NSC Oak Ridge, TN 37831 865-576-2289/865-241-2772 carrollkj@y12.doe.gov Work Objective. Earlier this year, the Energy Facility Contractors Group (EFCOG) was asked to assist in developing options related to acceleration deployment of new security-related technologies to assist meeting design base threat (DBT) needs while also addressing the requirements of 10 CFR 830. NNSA NA-70, one of the working group participants, designated this effort the Safety and Security Interface Technology Initiative (SSIT). Relationship to Workshop Theme. “Supporting Excellence in Operations Through Safety Analysis,” (workshop theme)more » includes security and safety personnel working together to ensure effective and efficient operations. One of the specific workshop elements listed in the call for papers is “Safeguards/Security Integration with Safety.” This paper speaks directly to this theme. Description of Work. The EFCOG Safety Analysis Working Group (SAWG) and the EFCOG Security Working Group formed a core team to develop an integrated process involving both safety basis and security needs allowing achievement of the DBT objectives while ensuring safety is appropriately considered. This effort garnered significant interest, starting with a two day breakout session of 30 experts at the 2006 Safety Basis Workshop. A core team was formed, and a series of meetings were held to develop that process, including safety and security professionals, both contractor and federal personnel. A pilot exercise held at Idaho National Laboratory (INL) in mid-July 2006 was conducted as a feasibility of concept review. Work Results. The SSIT efforts resulted in a topical report transmitted from EFCOG to DOE/NNSA in August 2006. Elements of the report included: Drivers and Endstate, Control Selections Alternative Analysis Process, Terminology Crosswalk, Safety Basis/Security Documentation Integration, Configuration Control, and development of a shared ‘tool box’ of information/successes. Specific Benefits. The expectation or end state resulting from the topical report and associated implementation plan includes: (1) A recommended process for handling the documentation of the security and safety disciplines, including an appropriate change control process and participation by all stakeholders. (2) A means to package security systems with sufficient information to help expedite the flow of that system through the process. In addition, a means to share successes among sites, to include information and safety basis to the extent such information is transportable. (3) Identification of key security systems and associated essential security elements being installed and an arrangement for the sites installing these systems to host an appropriate team to review a specific system and determine what information is exportable. (4) Identification of the security systems’ essential elements and appropriate controls required for testing of these essential elements in the facility. (5) The ability to help refine and improve an agreed to control set at the manufacture stage.« less

Best practice strategies to safeguard drug prescribing and drug administration: an anthology of expert views and opinions.

PubMed

Seidling, Hanna M; Stützle, Marion; Hoppe-Tichy, Torsten; Allenet, Benoît; Bedouch, Pierrick; Bonnabry, Pascal; Coleman, Jamie J; Fernandez-Llimos, Fernando; Lovis, Christian; Rei, Maria Jose; Störzinger, Dominic; Taylor, Lenka A; Pontefract, Sarah K; van den Bemt, Patricia M L A; van der Sijs, Heleen; Haefeli, Walter E

2016-04-01

While evidence on implementation of medication safety strategies is increasing, reasons for selecting and relinquishing distinct strategies and details on implementation are typically not shared in published literature. We aimed to collect and structure expert information resulting from implementing medication safety strategies to provide advice for decision-makers. Medication safety experts with clinical expertise from thirteen hospitals throughout twelve European and North American countries shared their experience in workshop meetings, on-site-visits and remote structured interviews. We performed an expert-based, in-depth assessment of implementation of best-practice strategies to improve drug prescribing and drug administration. Workflow, variability and recommended medication safety strategies in drug prescribing and drug administration processes. According to the experts, institutions chose strategies that targeted process steps known to be particularly error-prone in the respective setting. Often, the selection was channeled by local constraints such as the e-health equipment and critically modulated by national context factors. In our study, the experts favored electronic prescribing with clinical decision support and medication reconciliation as most promising interventions. They agreed that self-assessment and introduction of medication safety boards were crucial to satisfy the setting-specific differences and foster successful implementation. While general evidence for implementation of strategies to improve medication safety exists, successful selection and adaptation of a distinct strategy requires a thorough knowledge of the institute-specific constraints and an ongoing monitoring and adjustment of the implemented measures.

Bioprocessing of plant-derived virus-like particles of Norwalk virus capsid protein under current Good Manufacture Practice regulations

PubMed Central

Lai, Huafang; Chen, Qiang

2012-01-01

Despite the success in expressing a variety of subunit vaccine proteins in plants and the recent stride in improving vaccine accumulation levels by transient expression systems, there is still no plant-derived vaccine that has been licensed for human use. The lack of commercial success of plant-made vaccines lies in several technical and regulatory barriers that remain to be overcome. These challenges include the lack of scalable downstream processing procedures, the uncertainty of regulatory compliance of production processes, and the lack of demonstration of plant-derived products that meet the required standards of regulatory agencies in identity, purity, potency and safety. In this study, we addressed these remaining challenges and successfully demonstrate the ability of using plants to produce a pharmaceutical grade Norwalk virus (NV) vaccine under current Good Manufacture Practice (cGMP) guidelines at multiple gram scales. Our results demonstrate that an efficient and scalable extraction and purification scheme can established for processing virus-like particles (VLP) of NV capsid protein (NVCP). We successfully operated the upstream and downstream NVCP production processes under cGMP regulations. Furthermore, plant-derived NVCP VLP demonstrates the identity, purity, potency and safety that meet the preset release specifications. This material is being tested in a Phase I human clinical trial. This research provides the first report of producing a plant-derived vaccine at scale under cGMP regulations in an academic setting and an important step for plant-produced vaccines to become a commercial reality. PMID:22134876

From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.

PubMed

Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A

2003-02-01

The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1). errors inevitably occur and usually derive from faulty system design, not from negligence; (2). accident prevention should be an ongoing process based on open and full reporting; (3). major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff.

From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care

PubMed Central

Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A

2003-01-01



 The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1) errors inevitably occur and usually derive from faulty system design, not from negligence; (2) accident prevention should be an ongoing process based on open and full reporting; (3) major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff. PMID:12571343

System safety management lessons learned from the US Army acquisition process

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

Piatt, J.A.

1989-05-01

The Assistant Secretary of the Army for Research, Development and Acquisition directed the Army Safety Center to provide an audit of the causes of accidents and safety of use restrictions on recently fielded systems by tracking residual hazards back through the acquisition process. The objective was to develop lessons learned'' that could be applied to the acquisition process to minimize mishaps in fielded systems. System safety management lessons learned are defined as Army practices or policies, derived from past successes and failures, that are expected to be effective in eliminating or reducing specific systemic causes of residual hazards. They aremore » broadly applicable and supportive of the Army structure and acquisition objectives. Pacific Northwest Laboratory (PNL) was given the task of conducting an independent, objective appraisal of the Army's system safety program in the context of the Army materiel acquisition process by focusing on four fielded systems which are products of that process. These systems included the Apache helicopter, the Bradley Fighting Vehicle (BFV), the Tube Launched, Optically Tracked, Wire Guided (TOW) Missile and the High Mobility Multipurpose Wheeled Vehicle (HMMWV). The objective of this study was to develop system safety management lessons learned associated with the acquisition process. The first step was to identify residual hazards associated with the selected systems. Since it was impossible to track all residual hazards through the acquisition process, certain well-known, high visibility hazards were selected for detailed tracking. These residual hazards illustrate a variety of systemic problems. Systemic or process causes were identified for each residual hazard and analyzed to determine why they exist. System safety management lessons learned were developed to address related systemic causal factors. 29 refs., 5 figs.« less

Complying with the Occupational Safety and Health Administration's Bloodborne Pathogens Standard: implementing needleless systems and intravenous safety devices.

PubMed

Marini, Michelle A; Giangregorio, Maeve; Kraskinski, Joanna C

2004-03-01

Preventing the transmission of bloodborne pathogens to healthcare workers has been a mission and a challenge of the healthcare industry for over 20 years. The development of the Occupational Safety and Health Administration Bloodborne Pathogens Standard in 1991 and the passing of the Needlestick Safety Act in 2000 mandated hospitals to develop an Exposure Control Plan to protect workers from these pathogens. Children's Hospital Boston began implementation of a needleless system in 1993. Employees readily accepted these systems into practice, because they were convenient and easy to use. A marked decrease in exposures to bloodborne pathogens naturally followed, which is consistent with the national data. The transition to intravenous (i.v.) safety devices at Children's Hospital began in 2000 and proved to be more of a challenge. First, the clinicians must choose a safety product, which requires developing and implementing a trial plan with potential catheters. This selection process is especially difficult in pediatrics where successful placement of the smallest-gauge catheter, no. 24, is imperative. After choosing an i.v. safety product, successful transition is dependent upon the thoroughness of i.v. safety device training and a commitment by the clinicians to the use of these products. Although the number of needlestick injuries and subsequent transmission of bloodborne pathogens have been further reduced with the use of i.v. safety devices, needlestick injuries still occur. This results from a lack of familiarity with the engineering of the device and therefore poor technique or a failure to activate the safety mechanism. Staff resistance due to loss of expertise with the new device and patient care concerns are additional barriers to the use of these new products. Addressing these obstacles and providing adequate training for all clinicians were required for successful implementation of these i.v. safety devices.

The safety review and approval process for space nuclear power sources

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

Bennett, G.L.

1991-01-01

Over the past 30 yr. the U.S. Government has evolved a process for the safety review and launch approval of nuclear power sources (NPSs) proposed for launch into space. This process, which involves a number of governmental agencies, ensures that the various postulated accident scenarios are considered, that the responses of the NPSs to the accident environments are assessed, and that appropriate elements of the Federal Government are involved in the launch approval. This process has worked very well in the successful launches of 37 radioisotope thermoelectric generators and 1 reactor by the United States since 1961. Particular attention willmore » be focused on the recent launch of the Galileo spacecraft. 19 refs., 12 figs., 4 tabs.« less

Incident management successful practices : a cross-cutting study : improving mobility and saving lives

DOT National Transportation Integrated Search

2000-04-01

Incident management is the process of managing multi-agency, multi-jurisdictional responses to highway traffic disruptions. Efficient and coordinated management of incidents reduces their adverse impacts on public safety, traffic conditions, and the ...

Sex-work harm reduction.

PubMed

Rekart, Michael L

2005-12-17

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.

Product-based Safety Certification for Medical Devices Embedded Software.

PubMed

Neto, José Augusto; Figueiredo Damásio, Jemerson; Monthaler, Paul; Morais, Misael

2015-01-01

Worldwide medical device embedded software certification practices are currently focused on manufacturing best practices. In Brazil, the national regulatory agency does not hold a local certification process for software-intensive medical devices and admits international certification (e.g. FDA and CE) from local and international industry to operate in the Brazilian health care market. We present here a product-based certification process as a candidate process to support the Brazilian regulatory agency ANVISA in medical device software regulation. Center of Strategic Technology for Healthcare (NUTES) medical device embedded software certification is based on a solid safety quality model and has been tested with reasonable success against the Class I risk device Generic Infusion Pump (GIP).

Safety and Mission Assurance: A NASA Perspective

NASA Technical Reports Server (NTRS)

Higginbotham, Scott A.

2016-01-01

Manned spaceflight is an incredibly complex and inherently risky human endeavor. As the result of the lessons learned through years of triumph and tragedy, the National Aeronautics and Space Administration (NASA) has embraced a comprehensive and integrated approach to the challenge of ensuring safety and mission success. This presentation will provide an overview of some of the techniques employed in this effort, with a focus on the processing operations performed at the Kennedy Space Center (KSC).

Elements of Successful Plant Management.

ERIC Educational Resources Information Center

Sweitzer, John H.

The physical plant administrator manages men, money and materials to create the best possible physical environment for the educational processes at his institution. Areas of concern of the plant administrator are administration, building maintenance, janitorial services, traffic, security and safety, utilities, grounds, alterations, and…

Putting the Power of Configuration in the Hands of the Users

NASA Technical Reports Server (NTRS)

Al-Shihabi, Mary-Jo; Brown, Mark; Rigolini, Marianne

2011-01-01

Goal was to reduce the overall cost of human space flight while maintaining the most demanding standards for safety and mission success. In support of this goal, a project team was chartered to replace 18 legacy Space Shuttle nonconformance processes and systems with one fully integrated system Problem Reporting and Corrective Action (PRACA) processes provide a closed-loop system for the identification, disposition, resolution, closure, and reporting of all Space Shuttle hardware/software problems PRACA processes are integrated throughout the Space Shuttle organizational processes and are critical to assuring a safe and successful program Primary Project Objectives Develop a fully integrated system that provides an automated workflow with electronic signatures Support multiple NASA programs and contracts with a single "system" architecture Define standard processes, implement best practices, and minimize process variations

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.

Implementation of Recommendations from the One System Comparative Evaluation of the Hanford Tank Farms and Waste Treatment Plant Safety Bases

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

Garrett, Richard L.; Niemi, Belinda J.; Paik, Ingle K.

2013-11-07

A Comparative Evaluation was conducted for One System Integrated Project Team to compare the safety bases for the Hanford Waste Treatment and Immobilization Plant Project (WTP) and Tank Operations Contract (TOC) (i.e., Tank Farms) by an Expert Review Team. The evaluation had an overarching purpose to facilitate effective integration between WTP and TOC safety bases. It was to provide One System management with an objective evaluation of identified differences in safety basis process requirements, guidance, direction, procedures, and products (including safety controls, key safety basis inputs and assumptions, and consequence calculation methodologies) between WTP and TOC. The evaluation identified 25more » recommendations (Opportunities for Integration). The resolution of these recommendations resulted in 16 implementation plans. The completion of these implementation plans will help ensure consistent safety bases for WTP and TOC along with consistent safety basis processes. procedures, and analyses. and should increase the likelihood of a successful startup of the WTP. This early integration will result in long-term cost savings and significant operational improvements. In addition, the implementation plans lead to the development of eight new safety analysis methodologies that can be used at other U.S. Department of Energy (US DOE) complex sites where URS Corporation is involved.« less

TH-B-12A-01: TG124 “A Guide for Establishing a Credentialing and Privileging Program for Users of Fluoroscopic Equipment in Healthcare Organizations”

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

Moore, M

Fluoroscopy credentialing and privileging programs are being instituted because of recorded patient injuries and the widespread growth in fluoroscopy use by operators whose medical education did not include formal fluoroscopy training. This lack of training is recognized as a patient safety deficiency, and medical physicists and health physicists are finding themselves responsible for helping to establish fluoroscopy credentialing programs. While physicians are very knowledgeable about clinical credentials review and the privileging process, medical physicists and health physicists are not as familiar with the process and associated requirements. To assist the qualified medical physicist (QMP) and the radiation safety officer (RSO)more » with these new responsibilities, TG 124 provides an overview of the credentialing process, guidance for policy development and incorporating trained fluoroscopy users into a facility's established process, as well as recommendations for developing and maintaining a risk-based fluoroscopy safety training program. This lecture will review the major topics addressed in TG124 and relate them to practical situations. Learning Objectives: Understand the difference between credentialing and privileging. Understand the responsibilities, interaction and coordination among key individuals and committees. Understand options for integrating the QMP and/or RSO and Radiation Safety Committee into the credentialing and privileging process. Understand issues related to implementing the fluoroscopy safety training recommendations and with verifying and documenting successful completion.« less

Assuring Ground-Based Detect and Avoid for UAS Operations

NASA Technical Reports Server (NTRS)

Denney, Ewen W.; Pai, Ganeshmadhav Jagadeesh; Berthold, Randall; Fladeland, Matthew; Storms, Bruce; Sumich, Mark

2014-01-01

One of the goals of the Marginal Ice Zones Observations and Processes Experiment (MIZOPEX) NASA Earth science mission was to show the operational capabilities of Unmanned Aircraft Systems (UAS) when deployed on challenging missions, in difficult environments. Given the extreme conditions of the Arctic environment where MIZOPEX measurements were required, the mission opted to use a radar to provide a ground-based detect-and-avoid (GBDAA) capability as an alternate means of compliance (AMOC) with the see-and-avoid federal aviation regulation. This paper describes how GBDAA safety assurance was provided by interpreting and applying the guidelines in the national policy for UAS operational approval. In particular, we describe how we formulated the appropriate safety goals, defined the processes and procedures for system safety, identified and assembled the relevant safety verification evidence, and created an operational safety case in compliance with Federal Aviation Administration (FAA) requirements. To the best of our knowledge, the safety case, which was ultimately approved by the FAA, is the first successful example of non-military UAS operations using GBDAA in the U.S. National Airspace System (NAS), and, therefore, the first nonmilitary application of the safety case concept in this context.

Software safety - A user's practical perspective

NASA Technical Reports Server (NTRS)

Dunn, William R.; Corliss, Lloyd D.

1990-01-01

Software safety assurance philosophy and practices at the NASA Ames are discussed. It is shown that, to be safe, software must be error-free. Software developments on two digital flight control systems and two ground facility systems are examined, including the overall system and software organization and function, the software-safety issues, and their resolution. The effectiveness of safety assurance methods is discussed, including conventional life-cycle practices, verification and validation testing, software safety analysis, and formal design methods. It is concluded (1) that a practical software safety technology does not yet exist, (2) that it is unlikely that a set of general-purpose analytical techniques can be developed for proving that software is safe, and (3) that successful software safety-assurance practices will have to take into account the detailed design processes employed and show that the software will execute correctly under all possible conditions.

Ares Project Overview - Quality in Design

NASA Technical Reports Server (NTRS)

Cianciola, Chris; Crane, Kenneth

2008-01-01

This presentation introduces the audience to the overall goals of the Ares Project, which include providing human access to low-Earth orbit, the Moon, and beyond. The presentation also provides an overview of with the vehicles that will execute those goals and progress made on the vehicles to date. The briefing will provide an introduction to Lean, Six Sigma, and Kaizen practices Ares will use to improve the overall effectiveness and quality of its efforts. Finally, the briefing includes a summary of Safety and Mission Assurance practices being implemented within[Ares to ensure safety and quality early in the design process. Integrating Safety and Mission Assurance in Design: This presentation describes how the Ares Projects are learning from the successes and failures of previous launch systems in order to maximize safety and reliability while maintaining fiscal responsibility. The Ares Projects are integrating Safer T and Mission Assurance into design activities and embracing independent assessments by Quality experts in thorough reviews of designs and processes. Incorporating Lean thinking into the design process, Ares is also streamlining existing processes and future manufacturing flows which will yield savings during production. Understanding the value of early involvement of Quality experts, the Ares Projects are leading launch vehicle development into the 21st century.

Use of encapsulated bacteriophages to enhance farm to fork food safety.

PubMed

Hussain, Malik A; Liu, Huan; Wang, Qi; Zhong, Fang; Guo, Qian; Balamurugan, Sampathkumar

2017-09-02

Bacteriophages have been successfully applied to control the growth of pathogens in foods and to reduce the colonization and shedding of pathogens by food animals. They are set to play a dominant role in food safety in the future. However, many food-processing operations and the microenvironments in food animals' guts inactivate phages and reduce their infectivity. Encapsulation technologies have been used successfully to protect phages against extreme environments, and have been shown to preserve their activity and enable their release in targeted environments. A number of encapsulation technologies have shown potential for use with bacteriophages. This review discusses the current state of knowledge about the use of encapsulation technologies with bacteriophages to control pathogens in foods and food animals.

Benchmarking road safety performance: Identifying a meaningful reference (best-in-class).

PubMed

Chen, Faan; Wu, Jiaorong; Chen, Xiaohong; Wang, Jianjun; Wang, Di

2016-01-01

For road safety improvement, comparing and benchmarking performance are widely advocated as the emerging and preferred approaches. However, there is currently no universally agreed upon approach for the process of road safety benchmarking, and performing the practice successfully is by no means easy. This is especially true for the two core activities of which: (1) developing a set of road safety performance indicators (SPIs) and combining them into a composite index; and (2) identifying a meaningful reference (best-in-class), one which has already obtained outstanding road safety practices. To this end, a scientific technique that can combine the multi-dimensional safety performance indicators (SPIs) into an overall index, and subsequently can identify the 'best-in-class' is urgently required. In this paper, the Entropy-embedded RSR (Rank-sum ratio), an innovative, scientific and systematic methodology is investigated with the aim of conducting the above two core tasks in an integrative and concise procedure, more specifically in a 'one-stop' way. Using a combination of results from other methods (e.g. the SUNflower approach) and other measures (e.g. Human Development Index) as a relevant reference, a given set of European countries are robustly ranked and grouped into several classes based on the composite Road Safety Index. Within each class the 'best-in-class' is then identified. By benchmarking road safety performance, the results serve to promote best practice, encourage the adoption of successful road safety strategies and measures and, more importantly, inspire the kind of political leadership needed to create a road transport system that maximizes safety. Copyright © 2015 Elsevier Ltd. All rights reserved.

Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families.

PubMed

Thornton, Kevin C; Schwarz, Jennifer J; Gross, A Kendall; Anderson, Wendy G; Liu, Kathleen D; Romig, Mark C; Schell-Chaple, Hildy; Pronovost, Peter J; Sapirstein, Adam; Gropper, Michael A; Lipshutz, Angela K M

2017-09-01

Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. Our group determined by consensus which resources would best inform this review. A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

Process Evaluation of Two Participatory Approaches: Implementing Total Worker Health® Interventions in a Correctional Workforce

PubMed Central

Dugan, Alicia G.; Farr, Dana A.; Namazi, Sara; Henning, Robert A.; Wallace, Kelly N.; El Ghaziri, Mazen; Punnett, Laura; Dussetschleger, Jeffrey L.; Cherniack, Martin G.

2018-01-01

Background Correctional Officers (COs) have among the highest injury rates and poorest health of all the public safety occupations. The HITEC-2 (Health Improvement Through Employee Control-2) study uses Participatory Action Research (PAR) to design and implement interventions to improve health and safety of COs. Method HITEC-2 compared two different types of participatory program, a CO-only “Design Team” (DT) and “Kaizen Event Teams” (KET) of COs and supervisors, to determine differences in implementation process and outcomes. The Program Evaluation Rating Sheet (PERS) was developed to document and evaluate program implementation. Results Both programs yielded successful and unsuccessful interventions, dependent upon team-, facility-, organizational, state-, facilitator-, and intervention-level factors. Conclusions PAR in corrections, and possibly other sectors, depends upon factors including participation, leadership, continuity and timing, resilience, and financial circumstances. The new PERS instrument may be useful in other sectors to assist in assessing intervention success. PMID:27378470

Process evaluation of two participatory approaches: Implementing total worker health® interventions in a correctional workforce.

PubMed

Dugan, Alicia G; Farr, Dana A; Namazi, Sara; Henning, Robert A; Wallace, Kelly N; El Ghaziri, Mazen; Punnett, Laura; Dussetschleger, Jeffrey L; Cherniack, Martin G

2016-10-01

Correctional Officers (COs) have among the highest injury rates and poorest health of all the public safety occupations. The HITEC-2 (Health Improvement Through Employee Control-2) study uses Participatory Action Research (PAR) to design and implement interventions to improve health and safety of COs. HITEC-2 compared two different types of participatory program, a CO-only "Design Team" (DT) and "Kaizen Event Teams" (KET) of COs and supervisors, to determine differences in implementation process and outcomes. The Program Evaluation Rating Sheet (PERS) was developed to document and evaluate program implementation. Both programs yielded successful and unsuccessful interventions, dependent upon team-, facility-, organizational, state-, facilitator-, and intervention-level factors. PAR in corrections, and possibly other sectors, depends upon factors including participation, leadership, continuity and timing, resilience, and financial circumstances. The new PERS instrument may be useful in other sectors to assist in assessing intervention success. Am. J. Ind. Med. 59:897-918, 2016. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

System Guidelines for EMC Safety-Critical Circuits: Design, Selection, and Margin Demonstration

NASA Technical Reports Server (NTRS)

Lawton, R. M.

1996-01-01

Demonstration of required safety margins on critical electrical/electronic circuits in large complex systems has become an implementation and cost problem. These margins are the difference between the activation level of the circuit and the electrical noise on the circuit in the actual operating environment. This document discusses the origin of the requirement and gives a detailed process flow for the identification of the system electromagnetic compatibility (EMC) critical circuit list. The process flow discusses the roles of engineering disciplines such as systems engineering, safety, and EMC. Design and analysis guidelines are provided to assist the designer in assuring the system design has a high probability of meeting the margin requirements. Examples of approaches used on actual programs (Skylab and Space Shuttle Solid Rocket Booster) are provided to show how variations of the approach can be used successfully.

Measurement, Standards, and Peer Benchmarking: One Hospital's Journey.

PubMed

Martin, Brian S; Arbore, Mark

2016-04-01

Peer-to-peer benchmarking is an important component of rapid-cycle performance improvement in patient safety and quality-improvement efforts. Institutions should carefully examine critical success factors before engagement in peer-to-peer benchmarking in order to maximize growth and change opportunities. Solutions for Patient Safety has proven to be a high-yield engagement for Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, with measureable improvement in both organizational process and culture. Copyright © 2016 Elsevier Inc. All rights reserved.

Michigan Health & Hospital Association Keystone Obstetrics: a statewide collaborative for perinatal patient safety in Michigan.

PubMed

Simpson, Kathleen Rice; Knox, G Eric; Martin, Morgan; George, Chris; Watson, Sam R

2011-12-01

Preventable harm to mothers and infants during labor and birth is a significant patient safety and professional liability issue. A Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Obstetric Collaborative Project involved perinatal teams from 15 Michigan hospitals during an 11-month period in 2009. The purpose of the project was to promote safe care practices during labor and birth using the Comprehensive Unit-based Safety Program (CUSP). Consistent with the CUSP model, this project's components included assessing and promoting a culture of safety; interdisciplinary team building; case review; learning from defects through multiple methods of education; team and individual coaching and peer encouragement; administrative support for the establishment of a fundamental safety infrastructure; and ongoing evaluation of care processes and outcomes. Study measures included 32 components of a perinatal patient infrastructure, 6 care processes during labor and birth, and 4 neonatal outcomes. Significant improvements were found in the safety culture (Safety Attitudes Questionnaire), the perinatal patient safety infrastructure components, and all care processes. Although the project was successful, getting buy-in from all members of the clinical team in each hospital for all of the measures was challenging at times. There was initial resistance to some of the measures and their various expected aspects of care. For example, some of the clinicians were initially reluctant to adopt the recommended standardized oxytocin protocol. Peer encouragement and unit-based feedback on progress in minimizing early elective births proved useful in many hospitals. A CUSP in obstetrics can be beneficial in improving the care of mothers and infants during labor and birth.

Safety Characteristics in System Application of Software for Human Rated Exploration Missions for the 8th IAASS Conference

NASA Technical Reports Server (NTRS)

Mango, Edward J.

2016-01-01

NASA and its industry and international partners are embarking on a bold and inspiring development effort to design and build an exploration class space system. The space system is made up of the Orion system, the Space Launch System (SLS) and the Ground Systems Development and Operations (GSDO) system. All are highly coupled together and dependent on each other for the combined safety of the space system. A key area of system safety focus needs to be in the ground and flight application software system (GFAS). In the development, certification and operations of GFAS, there are a series of safety characteristics that define the approach to ensure mission success. This paper will explore and examine the safety characteristics of the GFAS development. The GFAS system integrates the flight software packages of the Orion and SLS with the ground systems and launch countdown sequencers through the 'agile' software development process. A unique approach is needed to develop the GFAS project capabilities within this agile process. NASA has defined the software development process through a set of standards. The standards were written during the infancy of the so-called industry 'agile development' movement and must be tailored to adapt to the highly integrated environment of human exploration systems. Safety of the space systems and the eventual crew on board is paramount during the preparation of the exploration flight systems. A series of software safety characteristics have been incorporated into the development and certification efforts to ensure readiness for use and compatibility with the space systems. Three underlining factors in the exploration architecture require the GFAS system to be unique in its approach to ensure safety for the space systems, both the flight as well as the ground systems. The first are the missions themselves, which are exploration in nature, and go far beyond the comfort of low Earth orbit operations. The second is the current exploration system will launch only one mission per year even less during its developmental phases. Finally, the third is the partnered approach through the use of many different prime contractors, including commercial and international partners, to design and build the exploration systems. These three factors make the challenges to meet the mission preparations and the safety expectations extremely difficult to implement. As NASA leads a team of partners in the exploration beyond earth's influence, it is a safety imperative that the application software used to test, checkout, prepare and launch the exploration systems put safety of the hardware and mission first. Software safety characteristics are built into the design and development process to enable the human rated systems to begin their missions safely and successfully. Exploration missions beyond Earth are inherently risky, however, with solid safety approaches in both hardware and software, the boldness of these missions can be realized for all on the home planet.

Emergency Management Operations Process Mapping: Public Safety Technical Program Study

DTIC Science & Technology

2011-02-01

Enterprise Architectures in industry, and have been successfully applied to assist companies to optimise interdependencies and relationships between...model for more in-depth analysis of EM processes, and for use in tandem with other studies that apply modeling and simulation to assess EM...for use in tandem with other studies that apply modeling and simulation to assess EM operational effectiveness before and after changing elements

Model Transformation for a System of Systems Dependability Safety Case

NASA Technical Reports Server (NTRS)

Murphy, Judy; Driskell, Stephen B.

2010-01-01

Software plays an increasingly larger role in all aspects of NASA's science missions. This has been extended to the identification, management and control of faults which affect safety-critical functions and by default, the overall success of the mission. Traditionally, the analysis of fault identification, management and control are hardware based. Due to the increasing complexity of system, there has been a corresponding increase in the complexity in fault management software. The NASA Independent Validation & Verification (IV&V) program is creating processes and procedures to identify, and incorporate safety-critical software requirements along with corresponding software faults so that potential hazards may be mitigated. This Specific to Generic ... A Case for Reuse paper describes the phases of a dependability and safety study which identifies a new, process to create a foundation for reusable assets. These assets support the identification and management of specific software faults and, their transformation from specific to generic software faults. This approach also has applications to other systems outside of the NASA environment. This paper addresses how a mission specific dependability and safety case is being transformed to a generic dependability and safety case which can be reused for any type of space mission with an emphasis on software fault conditions.

Quo Vadis Payload Safety?

NASA Technical Reports Server (NTRS)

Fodroci, Michael P.; Schwartz, MaryBeth

2008-01-01

As we complete the preparations for the fourth Hubble Space Telescope (HST) servicing mission, we note an anniversary approaching: it was 30 years ago in July that the first HST payload safety review panel meeting was held. This, in turn, was just over a year after the very first payload safety review, a Phase 0 review for the Tracking and Data Relay Satellite and its Inertial Upper Stage, held in June of 1977. In adapting a process that had been used in the review and certification of earlier Skylab payloads, National Aeronautics and Space Administration (NASA) engineers sought to preserve the lessons learned in the development of technical payload safety requirements, while creating a new process that would serve the very different needs of the new space shuttle program. Their success in this undertaking is substantiated by the fact that this process and these requirements have proven to be remarkably robust, flexible, and adaptable. Furthermore, the payload safety process has, to date, served us well in the critical mission of safeguarding our astronauts, cosmonauts, and spaceflight participants. Both the technical requirements and their interpretation, as well as the associated process requirements have grown, evolved, been streamlined, and have been adapted to fit multiple programs, including the International Space Station (ISS) program, the Shuttle/Mir program, and most recently the United States Constellation program. From its earliest days, it was anticipated that the payload safety process would be international in scope, and so it has been. European Space Agency (ESA), Japan Aerospace Exploration Agency (JAXA), German Space Agency (DLR), Canadian Space Agency (CSA), Russian Space Agency (RSA), and many additional countries have flown payloads on both the space shuttle and on the ISS. Our close cooperation and long-term working relationships have culminated in the franchising of the payload safety review process itself to our partners in ESA, which in turn will serve as a roadmap for extending the franchise to other Partners.

A Framework to Guide the Assessment of Human-Machine Systems.

PubMed

Stowers, Kimberly; Oglesby, James; Sonesh, Shirley; Leyva, Kevin; Iwig, Chelsea; Salas, Eduardo

2017-03-01

We have developed a framework for guiding measurement in human-machine systems. The assessment of safety and performance in human-machine systems often relies on direct measurement, such as tracking reaction time and accidents. However, safety and performance emerge from the combination of several variables. The assessment of precursors to safety and performance are thus an important part of predicting and improving outcomes in human-machine systems. As part of an in-depth literature analysis involving peer-reviewed, empirical articles, we located and classified variables important to human-machine systems, giving a snapshot of the state of science on human-machine system safety and performance. Using this information, we created a framework of safety and performance in human-machine systems. This framework details several inputs and processes that collectively influence safety and performance. Inputs are divided according to human, machine, and environmental inputs. Processes are divided into attitudes, behaviors, and cognitive variables. Each class of inputs influences the processes and, subsequently, outcomes that emerge in human-machine systems. This framework offers a useful starting point for understanding the current state of the science and measuring many of the complex variables relating to safety and performance in human-machine systems. This framework can be applied to the design, development, and implementation of automated machines in spaceflight, military, and health care settings. We present a hypothetical example in our write-up of how it can be used to aid in project success.

The complementary roles of Phase 3 trials and post-licensure surveillance in the evaluation of new vaccines

PubMed Central

Lopalco, Pier Luigi; DeStefano, Frank

2015-01-01

Vaccines have led to significant reductions in morbidity and saved countless lives from many infectious diseases and are one of the most important public health successes of the modern era. Both vaccines' effectiveness and safety are keys for the success of immunisation programmes. The role of post-licensure surveillance has become increasingly recognised by regulatory authorities in the overall vaccine development process. Safety, purity, and effectiveness of vaccines are carefully assessed before licensure, but some safety and effectiveness aspects need continuing monitoring after licensure; Post-marketing activities are a necessary complement to pre-licensure activities for monitoring vaccine quality and to inform public health programmes. In the recent past, the availability of large databases together with data-mining and cross-linkage techniques have significantly improved the potentialities of post-licensure surveillance. The scope of this review is to present challenges and opportunities offered by vaccine post-licensure surveillance. While pre-licensure activities form the foundation for the development of effective and safe vaccines, post-licensure monitoring and assessment, are necessary to assure that vaccines are effective and safe when translated in real world settings. Strong partnerships and collaboration at an international level between different stakeholders is necessary for finding and optimally allocating resources and establishing robust post-licensure processes. PMID:25444788

Perspectives on Home Care Quality

PubMed Central

Kane, Rosalie A.; Kane, Robert L.; Illston, Laurel H.; Eustis, Nancy N.

1994-01-01

Home care quality assurance (QA) must consider features inherent in home care, including: multiple goals, limited provider control, and unique family roles. Successive panels of stakeholders were asked to rate the importance of selected home care outcomes. Most highly rated outcomes were freedom from exploitation, satisfaction with care, physical safety, affordability, and physical functioning. Panelists preferred outcome indicators to process and structure, and all groups emphasized “enabling” criteria. Themes highlighted included: interpersonal components of care; normalizing life for clientele; balancing quality of life with safety; developing flexible, negotiated care plans; mechanisms for accountability and case management. These themes were formulated differently according to the stakeholders' role. Providers preferred intermediate outcomes, akin to process. PMID:10140158

Probabilistic Risk Assessment Procedures Guide for NASA Managers and Practitioners (Second Edition)

NASA Technical Reports Server (NTRS)

Stamatelatos,Michael; Dezfuli, Homayoon; Apostolakis, George; Everline, Chester; Guarro, Sergio; Mathias, Donovan; Mosleh, Ali; Paulos, Todd; Riha, David; Smith, Curtis;

Threads of Mission Success

NASA Technical Reports Server (NTRS)

Gavin, Thomas R.

2006-01-01

This viewgraph presentation reviews the many parts of the JPL mission planning process that the project manager has to work with. Some of them are: NASA & JPL's institutional requirements, the mission systems design requirements, the science interactions, the technical interactions, financial requirements, verification and validation, safety and mission assurance, and independent assessment, review and reporting.

Reflective Learning: Theory and Practice.

ERIC Educational Resources Information Center

Sugerman, Deborah A.; Doherty, Kathryn L.; Garvey, Daniel E.; Gass, Michael A.

An outdoor education leader's job is quite complex--the planning, logistics, preparation, teaching, watching, being aware of safety can be overwhelming. Pulling it all together so that participants can express what they learned from the experience is sometimes overlooked. The reflective process is integral to the success of learning, yet it takes…

Evaluating Injury Prevention Programs: The Oklahoma City Smoke Alarm Project.

ERIC Educational Resources Information Center

Mallonee, Sue

2000-01-01

Illustrates how evaluating the Oklahoma City Smoke Alarm Project increased its success in reducing residential fire-related injuries and deaths. The program distributed and tested smoke alarms in residential dwellings and offered educational materials on fire prevention and safety. Evaluation provided sound data on program processes and outcomes,…

In Defense of DEZ: LC's Perspective.

ERIC Educational Resources Information Center

Welsh, William J.

1987-01-01

The Deputy Librarian of Congress responds to a Library Journal editorial on the Library of Congress' role in the development of the diethyl zinc process in preservation technology. Safety issues, DEZ as prototype, progress and success claims, deciding which books to save, and why DEZ should be used are explained. (EM)

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.

Smart Screening System (S3) In Taconite Processing

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

Daryoush Allaei; Ryan Wartman; David Tarnowski

2006-03-01

The conventional screening machines used in processing plants have had undesirable high noise and vibration levels. They also have had unsatisfactorily low screening efficiency, high energy consumption, high maintenance cost, low productivity, and poor worker safety. These conventional vibrating machines have been used in almost every processing plant. Most of the current material separation technology uses heavy and inefficient electric motors with an unbalanced rotating mass to generate the shaking. In addition to being excessively noisy, inefficient, and high-maintenance, these vibrating machines are often the bottleneck in the entire process. Furthermore, these motors, along with the vibrating machines and supportingmore » structure, shake other machines and structures in the vicinity. The latter increases maintenance costs while reducing worker health and safety. The conventional vibrating fine screens at taconite processing plants have had the same problems as those listed above. This has resulted in lower screening efficiency, higher energy and maintenance cost, and lower productivity and workers safety concerns. The focus of this work is on the design of a high performance screening machine suitable for taconite processing plants. SmartScreens{trademark} technology uses miniaturized motors, based on smart materials, to generate the shaking. The underlying technologies are Energy Flow Control{trademark} and Vibration Control by Confinement{trademark}. These concepts are used to direct energy flow and confine energy efficiently and effectively to the screen function. The SmartScreens{trademark} technology addresses problems related to noise and vibration, screening efficiency, productivity, and maintenance cost and worker safety. Successful development of SmartScreens{trademark} technology will bring drastic changes to the screening and physical separation industry. The final designs for key components of the SmartScreens{trademark} have been developed. The key components include smart motor and associated electronics, resonators, and supporting structural elements. It is shown that the smart motors have an acceptable life and performance. Resonator (or motion amplifier) designs are selected based on the final system requirement and vibration characteristics. All the components for a fully functional prototype are fabricated. The development program is on schedule. The last semi-annual report described the completion of the design refinement phase. This phase resulted in a Smart Screen design that meets performance targets both in the dry condition and with taconite slurry flow using PZT motors. This system was successfully demonstrated for the DOE and partner companies at the Coleraine Mineral Research Laboratory in Coleraine, Minnesota. Since then, the fabrication of the dry application prototype (incorporating an electromagnetic drive mechanism and a new deblinding concept) has been completed and successfully tested at QRDC's lab.« less

Dynamic event tree analysis with the SAS4A/SASSYS-1 safety analysis code

DOE PAGES

Jankovsky, Zachary K.; Denman, Matthew R.; Aldemir, Tunc

2018-02-02

The consequences of a transient in an advanced sodium-cooled fast reactor are difficult to capture with the traditional approach to probabilistic risk assessment (PRA). Numerous safety-relevant systems are passive and may have operational states that cannot be represented by binary success or failure. In addition, the specific order and timing of events may be crucial which necessitates the use of dynamic PRA tools such as ADAPT. The modifications to the SAS4A/SASSYS-1 sodium-cooled fast reactor safety analysis code for linking it to ADAPT to perform a dynamic PRA are described. A test case is used to demonstrate the linking process andmore » to illustrate the type of insights that may be gained with this process. Finally, newly-developed dynamic importance measures are used to assess the significance of reactor parameters/constituents on calculated consequences of initiating events.« less

Dynamic event tree analysis with the SAS4A/SASSYS-1 safety analysis code

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

Jankovsky, Zachary K.; Denman, Matthew R.; Aldemir, Tunc

The consequences of a transient in an advanced sodium-cooled fast reactor are difficult to capture with the traditional approach to probabilistic risk assessment (PRA). Numerous safety-relevant systems are passive and may have operational states that cannot be represented by binary success or failure. In addition, the specific order and timing of events may be crucial which necessitates the use of dynamic PRA tools such as ADAPT. The modifications to the SAS4A/SASSYS-1 sodium-cooled fast reactor safety analysis code for linking it to ADAPT to perform a dynamic PRA are described. A test case is used to demonstrate the linking process andmore » to illustrate the type of insights that may be gained with this process. Finally, newly-developed dynamic importance measures are used to assess the significance of reactor parameters/constituents on calculated consequences of initiating events.« less

The Introduction of "Safety Science" into an Undergraduate Nursing Programme at a Large University in the United Kingdom.

PubMed

White, Nick; Clark, Deborah; Lewis, Robin; Robson, Wayne

2016-04-13

Implementing safety science {a term adopted by the authors which incorporates both patient safety and human factors (Sherwood, G. (2011). Integrating quality and safety science in nursing education and practice. Journal of Research in Nursing, 16(3), 226-240. doi: 10.1177/1744987111400960)} into healthcare programmes is a major challenge facing healthcare educators worldwide (National Advisory Group on the Safety of Patients in England, 2013; World Health Organisation, 2009). Patient safety concerns relating to human factors have been well-documented over the years, and the root cause(s) of as many as 65-80 % of these events are linked to human error (Dunn et al., 2007; Reason, 2005). This paper will describe how safety science education was embedded into a pre-registration nursing programme at a large UK university. The authors argue that the processes described in this paper, may be successfully applied to other pre-registration healthcare programmes in addition to nursing.

Using game technologies to improve the safety of construction plant operations.

PubMed

Guo, Hongling; Li, Heng; Chan, Greg; Skitmore, Martin

2012-09-01

Many accidents occur world-wide in the use of construction plant and equipment, and safety training is considered by many to be one of the best approaches to their prevention. However, current safety training methods/tools are unable to provide trainees with the hands-on practice needed. Game technology-based safety training platforms have the potential to overcome this problem in a virtual environment. One such platform is described in this paper - its characteristics are analysed and its possible contribution to safety training identified. This is developed and tested by means of a case study involving three major pieces of construction plant, which successfully demonstrates that the platform can improve the process and performance of the safety training involved in their operation. This research not only presents a new and useful solution to the safety training of construction operations, but illustrates the potential use of advanced technologies in solving construction industry problems in general. Copyright © 2011 Elsevier Ltd. All rights reserved.

Systems Engineering Technical Authority: A Path to Mission Success

NASA Technical Reports Server (NTRS)

Andary, James F.; So, Maria M.; Breindel, Barry

2008-01-01

The systems engineering of space missions to study planet Earth has been an important focus of the National Aeronautics and Space Administration (NASA) since its inception. But all space missions are becoming increasingly complex and this fact, reinforced by some major mishaps, has caused NASA to reevaluate their approach to achieving safety and mission success. A new approach ensures that there are adequate checks and balances in place to maximize the probability of safety and mission success. To this end the agency created the concept of Technical Authority which identifies a key individual accountable and responsible for the technical integrity of a flight mission as well as a project-independent reporting path. At the Goddard Space Flight Center (GSFC) this responsibility ultimately begins with the Mission Systems Engineer (MSE) for each satellite mission. This paper discusses the Technical Authority process and then describes some unique steps that are being taken at the GSFC to support these MSEs in meeting their responsibilities.

[Learning from errors: applying aviation safety concepts to medicine].

PubMed

Sommer, K-J

2012-11-01

Health care safety levels range below other complex industries. Civil aviation has throughout its history developed methods and concepts that have made the airplane into one of the safest means of mass transport. Key elements are accident investigations that focus on cause instead of blame, human-centered design of machinery and processes, continuous training of all personnel and a shared safety culture. These methods and concepts can basically be applied to medicine which has successfully been achieved in certain areas, however, a comprehensive implementation remains to be completed. This applies particularly to including the topic of safety into relevant curricula. Physicians are obliged by the oath"primum nil nocere" to act, but economic as well as political pressure will eventually confine professional freedom if initiative is not taken soon.

Safety coaches in radiology: decreasing human error and minimizing patient harm.

PubMed

Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

2010-09-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

Optimizing Safety, Fidelity and Usability of an Intelligent Clinical Support Tool (ICST) For Acute Hospital Care: an Australian Case Study Using a Multi-Method Delphi Process.

PubMed

Botti, Mari; Redley, Bernice; Nguyen, Lemai; Coleman, Kimberley; Wickramasinghe, Nilmini

2015-01-01

This research focuses on a major health priority for Australia by addressing existing gaps in the implementation of nursing informatics solutions in healthcare. It serves to inform the successful deployment of IT solutions designed to support patient-centered, frontline acute healthcare delivery by multidisciplinary care teams. The outcomes can guide future evaluations of the contribution of IT solutions to the efficiency, safety and quality of care delivery in acute hospital settings.

Implementing a bar-coded bedside medication administration system.

PubMed

Yates, Cindy

2007-01-01

Hospitals across the nation are struggling with implementing electronic medication administration and reporting (eMAR) systems as part of patient safety programs. St Luke's Hospital in Chesterfield, Mo, initiated their eMAR initiative in June 2003, initiating program start-up in September 2004. This case study documents how the project was approached, its overall success, and what was learned along the way. Also included is a recent update highlighting the expansion of St Luke's patient safety initiative, adapting eMAR to two specialty units: dialysis and laboratory processes.

Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit.

PubMed

Tarrago, Rod; Nowak, Jeffrey E; Leonard, Christopher S; Payne, Nathaniel R

2014-06-01

In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events. The PICU Safety Checklist was implemented in the pediatric ICU (PICU) at Children's Hospitals and Clinics of Minnesota. During a 21-month period, the checklist was used to prompt the care team to address quality and safety items during rounds. The initial checklist was paper, with two subsequent versions being incorporated into the electronic medical record (EMR). The daily safety checklist was successfully implemented in the PICU. Work-flow improvements based on regular multidisciplinary feedback led to more consistent use of the checklist. Improvements on all quality and safety metrics were identified, including invasive device use, medication costs, antibiotic and laboratory test use, and compliance with standards of care. Staff satisfaction rates were > 80% for safety, communication, and collaboration. By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.

Safety policy and requirements for payloads using the Space Transportation System (STS)

NASA Technical Reports Server (NTRS)

1982-01-01

The Space Transportation Operations (STO) safety policy is to minimize STO involvement in the payload and its GSE (ground support equipment) design process while maintaining the assurance of a safe operation. Requirements for assuring payload mission success are the responsibility of the payload organization and are beyond the scope of this document. The intent is to provide the overall safety policies and requirements while allowing for negotiation between the payload organization and the STO operator in the method of implementation of payload safety. This revision provides for a relaxation in the monitoring requirements for inhibits, allows the payload organization to pursue design options and reflects, additionally, some new requirements. As of the issue date of this NHB, payloads which have completed the formal safety assessment reviews of their preliminary design on the basis of the May 1979 issue will be reassessed for compliance with the above changes.

SCAP: a new methodology for safety management based on feedback from credible accident-probabilistic fault tree analysis system.

PubMed

Khan, F I; Iqbal, A; Ramesh, N; Abbasi, S A

2001-10-12

As it is conventionally done, strategies for incorporating accident--prevention measures in any hazardous chemical process industry are developed on the basis of input from risk assessment. However, the two steps-- risk assessment and hazard reduction (or safety) measures--are not linked interactively in the existing methodologies. This prevents a quantitative assessment of the impacts of safety measures on risk control. We have made an attempt to develop a methodology in which risk assessment steps are interactively linked with implementation of safety measures. The resultant system tells us the extent of reduction of risk by each successive safety measure. It also tells based on sophisticated maximum credible accident analysis (MCAA) and probabilistic fault tree analysis (PFTA) whether a given unit can ever be made 'safe'. The application of the methodology has been illustrated with a case study.

Beyond usability: designing effective technology implementation systems to promote patient safety.

PubMed

Karsh, B-T

2004-10-01

Evidence is emerging that certain technologies such as computerized provider order entry may reduce the likelihood of patient harm. However, many technologies that should reduce medical errors have been abandoned because of problems with their design, their impact on workflow, and general dissatisfaction with them by end users. Patient safety researchers have therefore looked to human factors engineering for guidance on how to design technologies to be usable (easy to use) and useful (improving job performance, efficiency, and/or quality). While this is a necessary step towards improving the likelihood of end user satisfaction, it is still not sufficient. Human factors engineering research has shown that the manner in which technologies are implemented also needs to be designed carefully if benefits are to be realized. This paper reviews the theoretical knowledge on what leads to successful technology implementation and how this can be translated into specifically designed processes for successful technology change. The literature on diffusion of innovations, technology acceptance, organisational justice, participative decision making, and organisational change is reviewed and strategies for promoting successful implementation are provided. Given the rapid and ever increasing pace of technology implementation in health care, it is critical for the science of technology implementation to be understood and incorporated into efforts to improve patient safety.

Applying usability heuristics to radiotherapy systems.

PubMed

Chan, Alvita J; Islam, Mohammad K; Rosewall, Tara; Jaffray, David A; Easty, Anthony C; Cafazzo, Joseph A

2012-01-01

Heuristic evaluations have been used to evaluate safety of medical devices by identifying and assessing usability issues. Since radiotherapy treatment delivery systems often consist of multiple complex user-interfaces, a heuristic evaluation was conducted to assess the potential safety issues of such a system. A heuristic evaluation was conducted to evaluate the treatment delivery system at Princess Margaret Hospital (Toronto, Canada). Two independent evaluators identified usability issues with the user-interfaces and rated the severity of each issue. The evaluators identified 75 usability issues in total. Eighteen of them were rated as high severity, indicating the potential to have a major impact on patient safety. A majority of issues were found on the record and verify system, and many were associated with the patient setup process. While the hospital has processes in place to ensure patient safety, recommendations were developed to further mitigate the risks of potential consequences. Heuristic evaluation is an efficient and inexpensive method that can be successfully applied to radiotherapy delivery systems to identify usability issues and improve patient safety. Although this study was conducted only at one site, the findings may have broad implications for the design of these systems. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Preharvest Food Safety Challenges in Beef and Dairy Production.

PubMed

Smith, David R

2016-08-01

Foods of animal origin, including beef and dairy products, are nutritious and important to global food security. However, there are important risks to human health from hazards that are introduced to beef and dairy products on the farm. Food safety hazards may be chemical, biological, or physical in nature. Considerations about protecting the safety of beef and dairy products must begin prior to harvest because some potential food safety hazards introduced at the farm (e.g., chemical residues) cannot be mitigated by subsequent postharvest food processing steps. Also, some people have preferences for consuming food that has not been through postharvest processing even though those foods may be unsafe because of microbiological hazards originating from the farm. Because of human fallibility and complex microbial ecologies, many of the preharvest hazards associated with beef and dairy products cannot entirely be eliminated, but the risk for most can be reduced through systematic interventions taken on the farm. Beef and dairy farms differ widely in production practices because of differences in natural, human, and capital resources. Therefore, the actions necessary to minimize on-farm food safety hazards must be farm-specific and they must address scientific, political, economic, and practical aspects. Notable successes in controlling and preventing on-farm hazards to food safety have occurred through a combination of voluntary and regulatory efforts.

High-School Buildings and Grounds. Bulletin, 1922, No. 23

ERIC Educational Resources Information Center

Bureau of Education, Department of the Interior, 1922

1922-01-01

The success of any high school depends largely upon the planning of its building. The wise planning of a high-school building requires familiarity with school needs and processes, knowledge of the best approved methods of safety, lighting, sanitation, and ventilation, and ability to solve the educational, structural, and architectural problems…

Getting Started with Glass

ERIC Educational Resources Information Center

White, Heather

2007-01-01

The metamorphosis of glass when heated is a magical process to students, yet teachers are often reluctant to try it in class. The biggest challenge in working with glass in the classroom is to simplify procedures just enough to ensure student success while maintaining strict safety practices so no students are injured. Project concepts and safety…

Automated Installation Verification of COMSOL via LiveLink for MATLAB

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

Crowell, Michael W

Verifying that a local software installation performs as the developer intends is a potentially time-consuming but necessary step for nuclear safety-related codes. Automating this process not only saves time, but can increase reliability and scope of verification compared to ‘hand’ comparisons. While COMSOL does not include automatic installation verification as many commercial codes do, it does provide tools such as LiveLink™ for MATLAB® and the COMSOL API for use with Java® through which the user can automate the process. Here we present a successful automated verification example of a local COMSOL 5.0 installation for nuclear safety-related calculations at the Oakmore » Ridge National Laboratory’s High Flux Isotope Reactor (HFIR).« less

Automatic crack detection and classification method for subway tunnel safety monitoring.

PubMed

Zhang, Wenyu; Zhang, Zhenjiang; Qi, Dapeng; Liu, Yun

2014-10-16

Cracks are an important indicator reflecting the safety status of infrastructures. This paper presents an automatic crack detection and classification methodology for subway tunnel safety monitoring. With the application of high-speed complementary metal-oxide-semiconductor (CMOS) industrial cameras, the tunnel surface can be captured and stored in digital images. In a next step, the local dark regions with potential crack defects are segmented from the original gray-scale images by utilizing morphological image processing techniques and thresholding operations. In the feature extraction process, we present a distance histogram based shape descriptor that effectively describes the spatial shape difference between cracks and other irrelevant objects. Along with other features, the classification results successfully remove over 90% misidentified objects. Also, compared with the original gray-scale images, over 90% of the crack length is preserved in the last output binary images. The proposed approach was tested on the safety monitoring for Beijing Subway Line 1. The experimental results revealed the rules of parameter settings and also proved that the proposed approach is effective and efficient for automatic crack detection and classification.

Automatic Crack Detection and Classification Method for Subway Tunnel Safety Monitoring

PubMed Central

Zhang, Wenyu; Zhang, Zhenjiang; Qi, Dapeng; Liu, Yun

2014-01-01

Cracks are an important indicator reflecting the safety status of infrastructures. This paper presents an automatic crack detection and classification methodology for subway tunnel safety monitoring. With the application of high-speed complementary metal-oxide-semiconductor (CMOS) industrial cameras, the tunnel surface can be captured and stored in digital images. In a next step, the local dark regions with potential crack defects are segmented from the original gray-scale images by utilizing morphological image processing techniques and thresholding operations. In the feature extraction process, we present a distance histogram based shape descriptor that effectively describes the spatial shape difference between cracks and other irrelevant objects. Along with other features, the classification results successfully remove over 90% misidentified objects. Also, compared with the original gray-scale images, over 90% of the crack length is preserved in the last output binary images. The proposed approach was tested on the safety monitoring for Beijing Subway Line 1. The experimental results revealed the rules of parameter settings and also proved that the proposed approach is effective and efficient for automatic crack detection and classification. PMID:25325337

Participatory research and service-learning among farmers, health professional students, and experts: an agromedicine approach to farm safety and health.

PubMed

Guin, Susan M; Wheat, John R; Allinder, Russell S; Fanucchi, Gary J; Wiggins, Oscar S; Johnson, Gwendolyn J

2012-01-01

Agromedicine developments in Alabama rest heavily on the interest and support of the farm community. Participatory approaches have been advocated in order to impact the safety and health of farms. The University of Alabama Agromedicine Research Team, working closely with and guided by farmers, places emphasis on identifying areas of farmer concern related to agricultural health and safety and on developing jointly with the farmers plans to address their concerns. Agricultural extension agents were key to developing the trust relationships among farmers, health professionals, and extension personnel required for these successful agricultural safety and health developments. In this article the authors describe how the research team engaged farmers in participatory research to develop service learning activities for graduate students studying Agricultural Safety and Health at The University of Alabama. Accepting farmers' active role in research processes creates an environment that is favorable to change, while providing farmers reassurance that their health and safety is of utmost importance to the researchers.

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

PubMed

West, Priscilla; Sculli, Gary; Fore, Amanda; Okam, Nwoha; Dunlap, Cleveland; Neily, Julia; Mills, Peter

2012-01-01

This project describes the application of the "sterile cockpit rule," a crew resource management (CRM) technique, targeted to improve efficacy and safety for nursing assistants in the performance of patient care duties. Crew resource management techniques have been successfully implemented in the aviation industry to improve flight safety. Application of these techniques can improve patient safety in medical settings. The Veterans Affairs (VA) National Center for Patient Safety conducted a CRM training program in select VA nursing units. One unit developed a novel application of the sterile cockpit rule to create protected time for certified nursing assistants (CNAs) while they collected vital signs and blood glucose data at the beginning of each shift. The typical nursing authority structure was reversed, with senior nurses protecting CNAs from distractions. This process led to improvements in efficiency and communication among nurses, with the added benefit of increased staff morale. Crew resource management techniques can be used to improve efficiency, morale, and patient safety in the healthcare setting.

Improving health care quality and safety: the role of collective learning.

PubMed

Singer, Sara J; Benzer, Justin K; Hamdan, Sami U

2015-01-01

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes.

Improving health care quality and safety: the role of collective learning

PubMed Central

Singer, Sara J; Benzer, Justin K; Hamdan, Sami U

2015-01-01

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes. PMID:29355197

Engineering and Safety Partnership Enhances Safety of the Space Shuttle Program (SSP)

NASA Technical Reports Server (NTRS)

Duarte, Alberto

2007-01-01

Project Management must use the risk assessment documents (RADs) as tools to support their decision making process. Therefore, these documents have to be initiated, developed, and evolved parallel to the life of the project. Technical preparation and safety compliance of these documents require a great deal of resources. Updating these documents after-the-fact not only requires substantial increase in resources - Project Cost -, but this task is also not useful and perhaps an unnecessary expense. Hazard Reports (HRs), Failure Modes and Effects Analysis (FMEAs), Critical Item Lists (CILs), Risk Management process are, among others, within this category. A positive action resulting from a strong partnership between interested parties is one way to get these documents and related processes and requirements, released and updated in useful time. The Space Shuttle Program (SSP) at the Marshall Space Flight Center has implemented a process which is having positive results and gaining acceptance within the Agency. A hybrid Panel, with equal interest and responsibilities for the two larger organizations, Safety and Engineering, is the focal point of this process. Called the Marshall Safety and Engineering Review Panel (MSERP), its charter (Space Shuttle Program Directive 110 F, April 15, 2005), and its Operating Control Plan emphasizes the technical and safety responsibilities over the program risk documents: HRs; FMEA/CILs; Engineering Changes; anomalies/problem resolutions and corrective action implementations, and trend analysis. The MSERP has undertaken its responsibilities with objectivity, assertiveness, dedication, has operated with focus, and has shown significant results and promising perspectives. The MSERP has been deeply involved in propulsion systems and integration, real time technical issues and other relevant reviews, since its conception. These activities have transformed the propulsion MSERP in a truly participative and value added panel, making a difference for the safety of the Space Shuttle Vehicle, its crew, and personnel. Because of the MSERP's valuable contribution to the assessment of safety risk for the SSP, this paper also proposes an enhanced Panel concept that takes this successful partnership concept to a higher level of 'true partnership'. The proposed panel is aimed to be responsible for the review and assessment of all risk relative to Safety for new and future aerospace and related programs.

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.

Airline Safety Improvement Through Experience with Near-Misses: A Cautionary Tale.

PubMed

Madsen, Peter; Dillon, Robin L; Tinsley, Catherine H

2016-05-01

In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes. Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry. Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses-those where the possible dangers are salient. Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses. © 2015 Society for Risk Analysis.

The complementary roles of Phase 3 trials and post-licensure surveillance in the evaluation of new vaccines.

PubMed

Lopalco, Pier Luigi; DeStefano, Frank

2015-03-24

Vaccines have led to significant reductions in morbidity and saved countless lives from many infectious diseases and are one of the most important public health successes of the modern era. Both vaccines' effectiveness and safety are keys for the success of immunisation programmes. The role of post-licensure surveillance has become increasingly recognised by regulatory authorities in the overall vaccine development process. Safety, purity, and effectiveness of vaccines are carefully assessed before licensure, but some safety and effectiveness aspects need continuing monitoring after licensure; Post-marketing activities are a necessary complement to pre-licensure activities for monitoring vaccine quality and to inform public health programmes. In the recent past, the availability of large databases together with data-mining and cross-linkage techniques have significantly improved the potentialities of post-licensure surveillance. The scope of this review is to present challenges and opportunities offered by vaccine post-licensure surveillance. While pre-licensure activities form the foundation for the development of effective and safe vaccines, post-licensure monitoring and assessment, are necessary to assure that vaccines are effective and safe when translated in real world settings. Strong partnerships and collaboration at an international level between different stakeholders is necessary for finding and optimally allocating resources and establishing robust post-licensure processes. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Applying successfully proven measures in roadway safety to reduce harmful collisions in SC.

DOT National Transportation Integrated Search

2017-06-06

The overall goal of this research was to identify proven successful safety programs used in other states and assess the potential for safety improvement if similar programs were implemented in South Carolina. The research team not only sought out eng...

Human factors in safety and business management.

PubMed

Vogt, Joachim; Leonhardt, Jorg; Koper, Birgit; Pennig, Stefan

2010-02-01

Human factors in safety is concerned with all those factors that influence people and their behaviour in safety-critical situations. In aviation these are, for example, environmental factors in the cockpit, organisational factors such as shift work, human characteristics such as ability and motivation of staff. Careful consideration of human factors is necessary to improve health and safety at work by optimising the interaction of humans with their technical and social (team, supervisor) work environment. This provides considerable benefits for business by increasing efficiency and by preventing incidents/accidents. The aim of this paper is to suggest management tools for this purpose. Management tools such as balanced scorecards (BSC) are widespread instruments and also well known in aviation organisations. Only a few aviation organisations utilise management tools for human factors although they are the most important conditions in the safety management systems of aviation organisations. One reason for this is that human factors are difficult to measure and therefore also difficult to manage. Studies in other domains, such as workplace health promotion, indicate that BSC-based tools are useful for human factor management. Their mission is to develop a set of indicators that are sensitive to organisational performance and help identify driving forces as well as bottlenecks. Another tool presented in this paper is the Human Resources Performance Model (HPM). HPM facilitates the integrative assessment of human factors programmes on the basis of a systematic performance analysis of the whole system. Cause-effect relationships between system elements are defined in process models in a first step and validated empirically in a second step. Thus, a specific representation of the performance processes is developed, which ranges from individual behaviour to system performance. HPM is more analytic than BSC-based tools because HPM also asks why a certain factor is facilitating or obstructing success. A significant need for research and development is seen here because human factors are of increasing importance for organisational success. This paper suggests integrating human factors in safety management of aviation businesses - a top-ranking partner of technology and finance - and managing it with professional tools. The tools HPM and BSC were identified as potentially useful for this purpose. They were successfully applied in case studies briefly presented in this paper. In terms of specific safety-steering tools in the aviation industry, further elaboration and empirical study is crucial. Statement of Relevance: The importance of human factors is recognised by operators at the sharp end of aviation, where flights are conducted or coordinated. At the blunt end, measurement tools are needed to manage operational resources.

Defining near misses: towards a sharpened definition based on empirical data about error handling processes.

PubMed

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

2010-05-01

Medical errors in health care still occur frequently. Unfortunately, errors cannot be completely prevented and 100% safety can never be achieved. Therefore, in addition to error reduction strategies, health care organisations could also implement strategies that promote timely error detection and correction. Reporting and analysis of so-called near misses - usually defined as incidents without adverse consequences for patients - are necessary to gather information about successful error recovery mechanisms. This study establishes the need for a clearer and more consistent definition of near misses to enable large-scale reporting and analysis in order to obtain such information. Qualitative incident reports and interviews were collected on four units of two Dutch general hospitals. Analysis of the 143 accompanying error handling processes demonstrated that different incident types each provide unique information about error handling. Specifically, error handling processes underlying incidents that did not reach the patient differed significantly from those of incidents that reached the patient, irrespective of harm, because of successful countermeasures that had been taken after error detection. We put forward two possible definitions of near misses and argue that, from a practical point of view, the optimal definition may be contingent on organisational context. Both proposed definitions could yield large-scale reporting of near misses. Subsequent analysis could enable health care organisations to improve the safety and quality of care proactively by (1) eliminating failure factors before real accidents occur, (2) enhancing their ability to intercept errors in time, and (3) improving their safety culture. Copyright 2010 Elsevier Ltd. All rights reserved.

Neural substrates of treatment response to cognitive-behavioral therapy in panic disorder with agoraphobia.

PubMed

Lueken, Ulrike; Straube, Benjamin; Konrad, Carsten; Wittchen, Hans-Ulrich; Ströhle, Andreas; Wittmann, André; Pfleiderer, Bettina; Uhlmann, Christina; Arolt, Volker; Jansen, Andreas; Kircher, Tilo

2013-11-01

Although exposure-based cognitive-behavioral therapy (CBT) is an effective treatment option for panic disorder with agoraphobia, the neural substrates of treatment response remain unknown. Evidence suggests that panic disorder with agoraphobia is characterized by dysfunctional safety signal processing. Using fear conditioning as a neurofunctional probe, the authors investigated neural baseline characteristics and neuroplastic changes after CBT that were associated with treatment outcome in patients with panic disorder with agoraphobia. Neural correlates of fear conditioning and extinction were measured using functional MRI before and after a manualized CBT program focusing on behavioral exposure in 49 medication-free patients with a primary diagnosis of panic disorder with agoraphobia. Treatment response was defined as a reduction exceeding 50% in Hamilton Anxiety Rating Scale scores. At baseline, nonresponders exhibited enhanced activation in the right pregenual anterior cingulate cortex, the hippocampus, and the amygdala in response to a safety signal. While this activation pattern partly resolved in nonresponders after CBT, successful treatment was characterized by increased right hippocampal activation when processing stimulus contingencies. Treatment response was associated with an inhibitory functional coupling between the anterior cingulate cortex and the amygdala that did not change over time. This study identified brain activation patterns associated with treatment response in patients with panic disorder with agoraphobia. Altered safety signal processing and anterior cingulate cortex-amygdala coupling may indicate individual differences among these patients that determine the effectiveness of exposure-based CBT and associated neuroplastic changes. Findings point to brain networks by which successful CBT in this patient population is mediated.

Bromodomains: Are Readers Right for Epigenetic Therapy?

PubMed Central

2012-01-01

There is intense interest in the development of small molecule inhibitors of the acetyl-lysine-reading bromodomain protein module. These inhibitors represent a way of interfering therapeutically in epigenetic processes, and there are currently two bromodomain inhibitors in clinical trials. The success of these compounds rests on safety aspects of epigenetic target modulation being addressed. PMID:24900532

Facilitators: One Key Factor in Implementing Successful Experience-Based Training and Development Programs.

ERIC Educational Resources Information Center

Wagner, Richard J.; Roland, Christopher C.

An increasing number of corporations are using some form of experience-based outdoor training and development. Most of these programs follow a general process that includes: (1) introduction of the activity by the facilitator; (2) the experiential activity (during which the facilitator is observer or safety monitor); and (3) debriefing or…

Precision Landing and Hazard Avoidance (PL&HA) Domain

NASA Technical Reports Server (NTRS)

Robertson, Edward A.; Carson, John M., III

2016-01-01

The Precision Landing and Hazard Avoidance (PL&HA) domain addresses the development, integration, testing, and spaceflight infusion of sensing, processing, and GN&C (Guidance, Navigation and Control) functions critical to the success and safety of future human and robotic exploration missions. PL&HA sensors also have applications to other mission events, such as rendezvous and docking.

Implementation Process of 5S for a Company in Real Life - Problems, Solutions, Successes

NASA Astrophysics Data System (ADS)

Czifra, György

2017-09-01

Developed in Japan, 5S is a system of organizing workplace for efficiency, effectiveness and safety. Is 5s important? The answer is: "YES", because the implementation is about empowering employees to control their work area and create an environment where they want to work every day. It is a program that only works with grass roots level engagement. With commitment to safety, we are equally committed to 5S to ensure a safe place to work. It enabled us to indicate where waste was occurring and thus improve the work area sustainably. We recognized real problems, found solutions and ultimately we were successful in our endeavors. Throughout different companies, various words of similar meaning are used. No matter what specific words are used to identify the steps in 5S, the purpose remains the same: create a clean, organized and efficient work environment.

Additional Risk Minimisation Measures for Medicinal Products in the European Union: A Review of the Implementation and Effectiveness of Measures in the United Kingdom by One Marketing Authorisation Holder.

PubMed

Agyemang, Elaine; Bailey, Lorna; Talbot, John

2017-01-01

Additional risk minimisation measures (aRMMs) for medicinal products are necessary to address specific important safety issues which may not be practically achieved through routine risk management measures alone. The implementation and determination of effectiveness for aRMMs can be a challenge as it involves multiple stakeholders. It is therefore important to have concise objectives to avoid undue burden on patients, healthcare professionals and the healthcare system. The aim of this study was to examine how aRMMs are implemented and how effectiveness is assessed in the European Union (EU) using practical examples from Roche Products Limited in the United Kingdom (UK) (referred to as the 'Company'). Three centrally authorised products were selected from the Company's portfolio, each of which had aRMMs to address important safety concerns; specifically, teratogenicity, medication error and infections. The implementation of EU aRMMs, effectiveness checks and specific UK activities were analysed. Hard copy folders and electronic sites for Company aRMMs were used to assess process indicators. Periodic benefit-risk evaluation reports for specified time intervals and the Company safety database was used in checking safety outcomes for the selected products. For each product, the effectiveness of aRMMs was analysed based on specific process indicators and the subsequent safety outcomes. Literature searches were performed on scientific databases for the purposes of the broader study. The main process indicators in measuring effectiveness of Company aRMMs were distribution metrics for educational materials, assessment of awareness and clinical actions among healthcare professionals (HCPs). Case reports of pregnancy, medication errors and progressive multifocal leukoencephalopathy (PML) were the outcome indicators for Erivedge ® ▼, Kadcyla ® ▼ and MabThera ® (the latter specifically in autoimmune indications: rheumatoid arthritis, granulomatosis with polyangiitis and microscopic polyangiitis) respectively. No pregnancy, one medication error and 10 confirmed PML cases were reported for Erivedge ® ▼, Kadcyla ® ▼ and MabThera ® respectively. For the chosen products, a reasonable awareness of aRMMs amongst HCPs is a positive indicator of success in the use of educational materials. However, low response rates from surveys indicate that voluntary feedback may not always achieve the desired level of response in measuring effectiveness. There is a challenge in determining overall effectiveness of aRMMs due to a lack of defined success thresholds. Further regulatory guidance to outline the elements and desired outcomes of aRMMs will be useful for consistency in achieving successful outcomes.

Can the Aviation Industry be Useful in Teaching Oncology about Safety?

PubMed

Davies, J M; Delaney, G

2017-10-01

Healthcare practitioners have long considered aviation as a domain from which much can be learned about safety. Over the past 30 years, attempts have been made to apply aviation safety-related concepts to healthcare. Although some applications have been successful, a few decades later, many healthcare safety experts have learned that the appeal of the aviation-healthcare analogy is an illusion. Both domains are so basically dissimilar that simple adoption of aviation concepts will not be successful. However, what has succeeded is healthcare's adaptation of specific aviation safety concepts. Three concepts, investment in safety, human factors and safety management systems, are described and examples are given of adapted applications to healthcare/clinical oncology. Finally, there is a need to ensure that these concepts are applied systematically throughout healthcare rather than sporadically and without a centralised mandate, to help ensure success and improved patient and provider safety. Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Safe and effective nursing shift handover with NURSEPASS: An interrupted time series.

PubMed

Smeulers, Marian; Dolman, Christine D; Atema, Danielle; van Dieren, Susan; Maaskant, Jolanda M; Vermeulen, Hester

2016-11-01

Implementation of a locally developed evidence based nursing shift handover blueprint with a bedside-safety-check to determine the effect size on quality of handover. A mixed methods design with: (1) an interrupted time series analysis to determine the effect on handover quality in six domains; (2) descriptive statistics to analyze the intercepted discrepancies by the bedside-safety-check; (3) evaluation sessions to gather experiences with the new handover process. We observed a continued trend of improvement in handover quality and a significant improvement in two domains of handover: organization/efficiency and contents. The bedside-safety-check successfully identified discrepancies on drains, intravenous medications, bandages or general condition and was highly appreciated. Use of the nursing shift handover blueprint showed promising results on effectiveness as well as on feasibility and acceptability. However, to enable long term measurement on effectiveness, evaluation with large scale interrupted times series or statistical process control is needed. Copyright © 2016 Elsevier Inc. All rights reserved.

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

Maintaining space shuttle safety within an environment of change

NASA Astrophysics Data System (ADS)

Greenfield, Michael A.

1999-09-01

In the 10 years since the Challenger accident, NASA has developed a set of stable and capable processes to prepare the Space Shuttle for safe launch and return. Capitalizing on the extensive experience gained from a string of over 50 successful flights, NASA today is changing the way it does business in an effort to reduce cost. A single Shuttle Flight Operations Contractor (SFOC) has been chosen to operate the Shuttle. The Government role will change from direct "oversight" to "insight" gained through understanding and measuring the contractor's processes. This paper describes the program management changes underway and the NASA Safety and Mission Assurance (S&MA) organization's philosophy, role, and methodology for pursuing this new approach. It describes how audit and surveillance will replace direct oversight and how meaningful performance metrics will be implemented.

What Employees Need (and Want) to Hear When Justifying the Suspension of a Regulated Metals Plan for the Processing of Drums Containing Metal Turnings

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

Todd Potts, T.; Hylko, J.M.

2008-07-01

A Regulated Metals Plan (RMP) was implemented for outdoor work activities involving the removal and disposition of approximately 4,000 deteriorated waste drums containing 236 metric tonnes (260 tons) of lead turnings from various, unspecified machine shop facilities at the Paducah Gaseous Diffusion Plant. Until exposure monitoring could prove otherwise, the work area established for processing the drums was conservatively defined as a Lead Regulated Area (LRA) subject to the Occupational Safety and Health Administration's Lead Standard found in Title 29 of the Code of Federal Regulations, Part 1910.1025. The vast majority of the analytical results for the industrial hygiene breathingmore » zone samples collected and tested for arsenic, beryllium, cadmium, chromium, lead, nickel, selenium, silver, and thallium using the National Institute for Occupational Safety and Health's analytical method 7300 were equivalent to the laboratory detection limits for each analyte. All results were less than 6% of their respective Permissible Exposure Limits (PEL), except for one nickel result that was approximately 17% of its PEL. The results provided justification to eventually down-post the LRA to existing employee protection requirements. In addition to removing the deteriorated drums and accompanying debris, the success of this project was quantified in terms of zero recordable injuries. The primary contributor in achieving this success was the sharing and communication of information between management, safety, and the field teams. Specifically, this was what the employees needed (and wanted) to hear when justifying the suspension of the RMP for the processing of drums containing metal turnings. Daily briefings on the status of the project and field monitoring results were just as important as maintaining budget and schedule milestones. Also, the Environmental, Safety and Health organization maintained its presence by continuing to monitor evolving field conditions to ensure the effectiveness of its plans and procedures. (authors)« less

Safety and Mission Assurance Knowledge Management Retention: Managing Knowledge for Successful Mission Operations

NASA Technical Reports Server (NTRS)

Johnson, Teresa A.

2006-01-01

Knowledge Management is a proactive pursuit for the future success of any large organization faced with the imminent possibility that their senior managers/engineers with gained experiences and lessons learned plan to retire in the near term. Safety and Mission Assurance (S&MA) is proactively pursuing unique mechanism to ensure knowledge learned is retained and lessons learned captured and documented. Knowledge Capture Event/Activities/Management helps to provide a gateway between future retirees and our next generation of managers/engineers. S&MA hosted two Knowledge Capture Events during 2005 featuring three of its retiring fellows (Axel Larsen, Dave Whittle and Gary Johnson). The first Knowledge Capture Event February 24, 2005 focused on two Safety and Mission Assurance Safety Panels (Space Shuttle System Safety Review Panel (SSRP); Payload Safety Review Panel (PSRP) and the latter event December 15, 2005 featured lessons learned during Apollo, Skylab, and Space Shuttle which could be applicable in the newly created Crew Exploration Vehicle (CEV)/Constellation development program. Gemini, Apollo, Skylab and the Space Shuttle promised and delivered exciting human advances in space and benefits of space in people s everyday lives on earth. Johnson Space Center's Safety & Mission Assurance team work over the last 20 years has been mostly focused on operations we are now beginning the Exploration development program. S&MA will promote an atmosphere of knowledge sharing in its formal and informal cultures and work processes, and reward the open dissemination and sharing of information; we are asking "Why embrace relearning the "lessons learned" in the past?" On the Exploration program the focus will be on Design, Development, Test, & Evaluation (DDT&E); therefore, it is critical to understand the lessons from these past programs during the DDT&E phase.

Mindful Application of Aviation Practices in Healthcare.

PubMed

Powell-Dunford, Nicole; Brennan, Peter A; Peerally, Mohammad Farhad; Kapur, Narinder; Hynes, Jonny M; Hodkinson, Peter D

2017-12-01

Evidence supports the efficacy of incorporating select recognized aviation practices and procedures into healthcare. Incident analysis, debrief, safety brief, and crew resource management (CRM) have all been assessed for implementation within the UK healthcare system, a world leader in aviation-based patient safety initiatives. Mindful application, in which aviation practices are specifically tailored to the unique healthcare setting, show promise in terms of acceptance and long-term sustainment. In order to establish British healthcare applications of aviation practices, a PubMed search of UK authored manuscripts published between 2005-2016 was undertaken using search terms 'aviation,' 'healthcare,' 'checklist,' and 'CRM.' A convenience sample of UK-authored aviation medical conference presentations and UK-authored patient safety manuscripts were also reviewed. A total of 11 of 94 papers with UK academic affiliations published between 2005-2016 and relevant to aviation modeled healthcare delivery were found. The debrief process, incident analysis, and CRM are the primary practices incorporated into UK healthcare, with success dependent on cultural acceptance and mindful application. CRM training has gained significant acceptance in UK healthcare environments. Aviation modeled incident analysis, debrief, safety brief, and CRM training are increasingly undertaken within the UK healthcare system. Nuanced application, in which the unique aspects of the healthcare setting are addressed as part of a comprehensive safety approach, shows promise for long-term success. The patient safety brief and aviation modeled incident analysis are in earlier phases of implementation, and warrant further analysis.Powell-Dunford N, Brennan PA, Peerally MF, Kapur N, Hynes JM, Hodkinson PD. Mindful application of aviation practices in healthcare. Aerosp Med Hum Perform. 2017; 88(12):1107-1116.

The role of individual diligence in improving safety.

PubMed

Corbett, Angus; Travaglia, Jo; Braithwaite, Jeffrey

2011-01-01

This paper aims to be a theoretical examination of the role of individuals in sponsoring and facilitating effective, systemic change in organisations. Using reports of a number of high-profile initiatives to improve patient safety, it seeks to analyse the role of individual health care professionals in developing and facilitating new systems of care that improve safety and quality. The paper uses recent work in sociology that is concerned with the phenomenon of "sociological citizenship". The authors test whether successful initiators of change in health care can be described as sociological citizens. This notion of sociological citizens is applied to a number of highly successful initiatives to improve safety and quality to extrapolate the factors associated with individual clinician leadership, which may have affected the success of such endeavours. In each of the examples analysed the initiators of change can be characterised as sociological citizens. In reviewing the roles of these charismatic individuals it is evident that they see the relational interdependence between the individuals and organisations and that they use this information to achieve both professional and organisational objectives. The paper uses a case study method to investigate the usefulness of the role of sociological citizenship in interventions that aim to improve patient safety. The paper reviews the key concepts and uses of the concept of sociological citizenship to produce a framework against which the case studies were assessed. The authors suggest that a goal of policy for improving patient safety should be directed to the problem of how hospitals and health care organisations can create the conditions for encouraging the individual diligence and care that is needed to support reliable, safe health care practices. Improving the safety and quality of health care is an important public health initiative. It has also proven to be difficult to achieve sustained reductions in the harm caused by the occurrence of adverse events in health care. The process of linking individual diligence with service outcomes may help to overcome one of the enduring struggles of health care systems around the world: the policy-practice divide. The paper directs attention towards the role of sociological citizenship in health care systems and organisations.

3S (Safeguards, Security, Safety) based pyroprocessing facility safety evaluation plan

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

Ku, J.H.; Choung, W.M.; You, G.S.

The big advantage of pyroprocessing for the management of spent fuels against the conventional reprocessing technologies lies in its proliferation resistance since the pure plutonium cannot be separated from the spent fuel. The extracted materials can be directly used as metal fuel in a fast reactor, and pyroprocessing reduces drastically the volume and heat load of the spent fuel. KAERI has implemented the SBD (Safeguards-By-Design) concept in nuclear fuel cycle facilities. The goal of SBD is to integrate international safeguards into the entire facility design process since the very beginning of the design phase. This paper presents a safety evaluationmore » plan using a conceptual design of a reference pyroprocessing facility, in which 3S (Safeguards, Security, Safety)-By-Design (3SBD) concept is integrated from early conceptual design phase. The purpose of this paper is to establish an advanced pyroprocessing hot cell facility design concept based on 3SBD for the successful realization of pyroprocessing technology with enhanced safety and proliferation resistance.« less

Successful hazard analysis critical control point implementation in the United Kingdom: understanding the barriers through the use of a behavioral adherence model.

PubMed

Gilling, S J; Taylor, E A; Kane, K; Taylor, J Z

2001-05-01

Hazard analysis critical control point (HACCP), a system of risk management designed to control food safety, has emerged over the last decade as the primary approach to securing the safety of the food supply. It is thus an important tool in combatting the worldwide escalation of foodborne disease. Yet despite wide dissemination and scientific support of its principles, successful HACCP implementation has been limited. This report takes a psychological approach to this problem by examining processes and factors that could impede adherence to the internationally accepted HACCP Guidelines and subsequent successful implementation of HACCP. Utilizing knowledge of medical clinical guideline adherence models and practical experience of HACCP implementation problems, the potential advantages of applying a behavioral model to food safety management are highlighted. The models' applicability was investigated using telephone interviews from over 200 businesses in the United Kingdom. Eleven key barriers to HACCP guideline adherence were identified. In-depth narrative interviews with food business proprietors then confirmed these findings and demonstrated the subsequent negative effect(s) on HACCP implementation. A resultant HACCP awareness to adherence model is proposed that demonstrates the complex range of potential knowledge, attitude, and behavior-related barriers involved in failures of HACCP guideline adherence. The model's specificity and detail provide a tool whereby problems can be identified and located and in this way facilitate tailored and constructive intervention. It is suggested that further investigation into the barriers involved and how to overcome them would be of substantial benefit to successful HACCP implementation and thereby contribute to an overall improvement in public health.

The influence of organizational factors on patient safety: Examining successful handoffs in health care.

PubMed

Richter, Jason P; McAlearney, Ann Scheck; Pennell, Michael L

2016-01-01

Although patient handoffs have been extensively studied, they continue to be problematic. Studies have shown poor handoffs are associated with increased costs, morbidity, and mortality. No prior research compared perceptions of management and clinical staff regarding handoffs. Our aims were (a) to determine whether perceptions of organizational factors that can influence patient safety are positively associated with perceptions of successful patient handoffs, (b) to identify organizational factors that have the greatest influence on perceptions of successful handoffs, and (c) to determine whether associations between perceptions of these factors and successful handoffs differ for management and clinical staff. A total of 515,637 respondents from 1,052 hospitals completed the Hospital Survey on Patient Safety Culture that assessed perceptions about organizational factors that influence patient safety. Using weighted least squares multiple regression, we tested seven organizational factors as predictors of successful handoffs. We fit three separate models using data collected from (a) all staff, (b) management only, and (c) clinical staff only. We found that perceived teamwork across units was the most significant predictor of perceived successful handoffs. Perceptions of staffing and management support for safety were also significantly associated with perceived successful handoffs for both management and clinical staff. For management respondents, perceptions of organizational learning or continuous improvement had a significant positive association with perceived successful handoffs, whereas the association was negative for clinical staff. Perceived communication openness had a significant association only among clinical staff. Hospitals should prioritize teamwork across units and strive to improve communication across the organization in efforts to improve handoffs. In addition, hospitals should ensure sufficient staffing and management support for patient safety. Different perceptions between management and clinical staff with respect to the importance of organizational learning are noteworthy and merit additional study.

A combined intervention to reduce interruptions during medication preparation and double-checking: a pilot-study evaluating the impact of staff training and safety vests.

PubMed

Huckels-Baumgart, Saskia; Niederberger, Milena; Manser, Tanja; Meier, Christoph R; Meyer-Massetti, Carla

2017-10-01

The aim was to evaluate the impact of staff training and wearing safety vests as a combined intervention on interruptions during medication preparation and double-checking. Interruptions and errors during the medication process are common and an important issue for patient safety in the hospital setting. We performed a pre- and post-intervention pilot-study using direct structured observation of 26 nurses preparing and double-checking 431 medication doses (225 pre-intervention and 206 post-intervention) for 36 patients (21 pre-intervention and 15 post-intervention). With staff training and the introduction of safety vests, the interruption rate during medication preparation was reduced from 36.8 to 28.3 interruptions per hour and during double-checking from 27.5 to 15 interruptions per hour. This pilot-study showed that the frequency of interruptions decreased during the critical tasks of medication preparation and double-checking after the introduction of staff training and wearing safety vests as part of a quality improvement process. Nursing management should acknowledge interruptions as an important factor potentially influencing medication safety. Unnecessary interruptions can be successfully reduced by considering human and system factors and increasing both staff and nursing managers' awareness of 'interruptive communication practices' and implementing physical barriers. This is the first pilot-study specifically evaluating the impact of staff training and wearing safety vests on the reduction of interruptions during medication preparation and double-checking. © 2017 John Wiley & Sons Ltd.

Controlled Ecological Life Support System: Research and Development Guidelines

NASA Technical Reports Server (NTRS)

Mason, R. M. (Editor); Carden, J. L. (Editor)

1982-01-01

Results of a workshop designed to provide a base for initiating a program of research and development of controlled ecological life support systems (CELSS) are summarized. Included are an evaluation of a ground based manned demonstration as a milestone in CELSS development, and a discussion of development requirements for a successful ground based CELSS demonstration. Research recommendations are presented concerning the following topics: nutrition and food processing, food production, waste processing, systems engineering and modelling, and ecology-systems safety.

Implementation of Programmatic Quality and the Impact on Safety

NASA Technical Reports Server (NTRS)

Huls, Dale Thomas; Meehan, Kevin

2005-01-01

The purpose of this paper is to discuss the implementation of a programmatic quality assurance discipline within the International Space Station Program and the resulting impact on safety. NASA culture has continued to stress safety at the expense of quality when both are extremely important and both can equally influence the success or failure of a Program or Mission. Although safety was heavily criticized in the media after Colimbiaa, strong case can be made that it was the failure of quality processes and quality assurance in all processes that eventually led to the Columbia accident. Consequently, it is possible to have good quality processes without safety, but it is impossible to have good safety processes without quality. The ISS Program quality assurance function was analyzed as representative of the long-term manned missions that are consistent with the President s Vision for Space Exploration. Background topics are as follows: The quality assurance organizational structure within the ISS Program and the interrelationships between various internal and external organizations. ISS Program quality roles and responsibilities with respect to internal Program Offices and other external organizations such as the Shuttle Program, JSC Directorates, NASA Headquarters, NASA Contractors, other NASA Centers, and International Partner/participants will be addressed. A detailed analysis of implemented quality assurance responsibilities and functions with respect to NASA Headquarters, the JSC S&MA Directorate, and the ISS Program will be presented. Discussions topics are as follows: A comparison of quality and safety resources in terms of staffing, training, experience, and certifications. A benchmark assessment of the lessons learned from the Columbia Accident Investigation (CAB) Report (and follow-up reports and assessments), NASA Benchmarking, and traditional quality assurance activities against ISS quality procedures and practices. The lack of a coherent operational and sustaining quality assurance strategy for long-term manned space flight. An analysis of the ISS waiver processes and the Problem Reporting and Corrective Action (PRACA) process implemented as quality functions. Impact of current ISS Program procedures and practices with regards to operational safety and risk A discussion regarding a "defense-in-depth" approach to quality functions will be provided to address the issue of "integration vs independence" with respect to the roles of Programs, NASA Centers, and NASA Headquarters. Generic recommendations are offered to address the inadequacies identified in the implementation of ISS quality assurance. A reassessment by the NASA community regarding the importance of a "quality culture" as a component within a larger "safety culture" will generate a more effective and value-added functionality that will ultimately enhance safety.

Understanding drug targets: no such thing as bad news.

PubMed

Roberts, Ruth A

2018-05-24

How can small-to-medium pharma and biotech companies enhance the chances of running a successful drug project and maximise the return on a limited number of assets? Having a full appreciation of the safety risks associated with proposed drug targets is a crucial element in understanding the unwanted side-effects that might stop a project in its tracks. Having this information is necessary to complement knowledge about the probable efficacy of a future drug. However, the lack of data-rich insight into drug-target safety is one of the major causes of drug-project failure today. Conducting comprehensive target-safety reviews early in the drug discovery process enables project teams to make the right decisions about which drug targets to take forward. Copyright © 2018 Elsevier Ltd. All rights reserved.

Quality and safety aspects of meat products as affected by various physical manipulations of packaging materials.

PubMed

Lee, Keun Taik

2010-09-01

This article explores the effects of physically manipulated packaging materials on the quality and safety of meat products. Recently, innovative measures for improving quality and extending the shelf-life of packaged meat products have been developed, utilizing technologies including barrier film, active packaging, nanotechnology, microperforation, irradiation, plasma and far-infrared ray (FIR) treatments. Despite these developments, each technology has peculiar drawbacks which will need to be addressed by meat scientists in the future. To develop successful meat packaging systems, key product characteristics affecting stability, environmental conditions during storage until consumption, and consumers' packaging expectations must all be taken into consideration. Furthermore, the safety issues related to packaging materials must also be taken into account when processing, packaging and storing meat products.

Developing a Contemporary Dairy Foods Extension Program: A Training and Technical Resource Needs Assessment of Pennsylvania Dairy Foods Processors

ERIC Educational Resources Information Center

Syrko, Joseph; Kaylegian, Kerry E.

2015-01-01

Growth in the dairy industry and the passage of the Food Safety Modernization Act have renewed interest in dairy foods processing extension positions. A needs assessment survey was sent to Pennsylvania dairy processors and raw milk providers to guide priorities for a dairy foods extension program. The successful development and delivery of…

Agricultural health and safety: incorporating the worker perspective.

PubMed

Liebman, Amy K; Augustave, Wilson

2010-07-01

This commentary offers a worker's perspective on agricultural health and safety and describes (1) the historical exemption of agriculture from regulatory oversight and barriers encountered due to lack of regulations and poor enforcement of the existing standards; (2) the effect of immigration status on worker protections; and (3) the basic desire for economic survival and how this impacts worker health and safety. The commentary describes two models to reduce hazards at work that illustrate how workers' perspectives can be incorporated successfully at the policy level and during the intervention development process and puts forth recommendations for employers, researchers, and funding agencies to facilitate the integration of workers' perspectives into occupational health and safety in agriculture. Ultimately, improved worker protection requires systemic policy and regulatory changes as well as strong enforcement of existing regulations. This commentary summarizes the presentation, "Ground View: Perspectives of Hired Workers," at the Agricultural Safety and Health Council of America/National Institute for Occupational Safety and Health conference, "Be Safe, Be Profitable: Protecting Workers in Agriculture," January 27-28, 2010, Dallas/Fort Worth, Texas.

Principles for building public-private partnerships to benefit food safety, nutrition, and health research

PubMed Central

Rowe, Sylvia; Alexander, Nick; Kretser, Alison; Steele, Robert; Kretsch, Molly; Applebaum, Rhona; Clydesdale, Fergus; Cummins, Deborah; Hentges, Eric; Navia, Juan; Jarvis, Ashley; Falci, Ken

2013-01-01

The present article articulates principles for effective public-private partnerships (PPPs) in scientific research. Recognizing that PPPs represent one approach for creating research collaborations and that there are other methods outside the scope of this article, PPPs can be useful in leveraging diverse expertise among government, academic, and industry researchers to address public health needs and questions concerned with nutrition, health, food science, and food and ingredient safety. A three-step process was used to identify the principles proposed herein: step 1) review of existing PPP guidelines, both in the peer-reviewed literature and at 16 disparate non-industry organizations; step 2) analysis of relevant successful or promising PPPs; and step 3) formal background interviews of 27 experienced, senior-level individuals from academia, government, industry, foundations, and non-governmental organizations. This process resulted in the articulation of 12 potential principles for establishing and managing successful research PPPs. The review of existing guidelines showed that guidelines for research partnerships currently reside largely within institutions rather than in the peer-reviewed literature. This article aims to introduce these principles into the literature to serve as a framework for dialogue and for future PPPs. PMID:24117791

Parallel computation safety analysis irradiation targets fission product molybdenum in neutronic aspect using the successive over-relaxation algorithm

NASA Astrophysics Data System (ADS)

Susmikanti, Mike; Dewayatna, Winter; Sulistyo, Yos

2014-09-01

One of the research activities in support of commercial radioisotope production program is a safety research on target FPM (Fission Product Molybdenum) irradiation. FPM targets form a tube made of stainless steel which contains nuclear-grade high-enrichment uranium. The FPM irradiation tube is intended to obtain fission products. Fission materials such as Mo99 used widely the form of kits in the medical world. The neutronics problem is solved using first-order perturbation theory derived from the diffusion equation for four groups. In contrast, Mo isotopes have longer half-lives, about 3 days (66 hours), so the delivery of radioisotopes to consumer centers and storage is possible though still limited. The production of this isotope potentially gives significant economic value. The criticality and flux in multigroup diffusion model was calculated for various irradiation positions and uranium contents. This model involves complex computation, with large and sparse matrix system. Several parallel algorithms have been developed for the sparse and large matrix solution. In this paper, a successive over-relaxation (SOR) algorithm was implemented for the calculation of reactivity coefficients which can be done in parallel. Previous works performed reactivity calculations serially with Gauss-Seidel iteratives. The parallel method can be used to solve multigroup diffusion equation system and calculate the criticality and reactivity coefficients. In this research a computer code was developed to exploit parallel processing to perform reactivity calculations which were to be used in safety analysis. The parallel processing in the multicore computer system allows the calculation to be performed more quickly. This code was applied for the safety limits calculation of irradiated FPM targets containing highly enriched uranium. The results of calculations neutron show that for uranium contents of 1.7676 g and 6.1866 g (× 106 cm-1) in a tube, their delta reactivities are the still within safety limits; however, for 7.9542 g and 8.838 g (× 106 cm-1) the limits were exceeded.

Concise Review: Process Development Considerations for Cell Therapy

PubMed Central

Brieva, Thomas; Raviv, Lior; Rowley, Jon; Niss, Knut; Brandwein, Harvey; Oh, Steve; Karnieli, Ohad

2015-01-01

The development of robust and well-characterized methods of production of cell therapies has become increasingly important as therapies advance through clinical trials toward approval. A successful cell therapy will be a consistent, safe, and effective cell product, regardless of the cell type or application. Process development strategies can be developed to gain efficiency while maintaining or improving safety and quality profiles. This review presents an introduction to the process development challenges of cell therapies and describes some of the tools available to address production issues. This article will provide a summary of what should be considered to efficiently advance a cellular therapy from the research stage through clinical trials and finally toward commercialization. The identification of the basic questions that affect process development is summarized in the target product profile, and considerations for process optimization are discussed. The goal is to identify potential manufacturing concerns early in the process so they may be addressed effectively and thus increase the probability that a therapy will be successful. Significance The present study contributes to the field of cell therapy by providing a resource for those transitioning a potential therapy from the research stage to clinical and commercial applications. It provides the necessary steps that, when followed, can result in successful therapies from both a clinical and commercial perspective. PMID:26315572

Applying Toyota production system techniques for medication delivery: improving hospital safety and efficiency.

PubMed

Newell, Terry L; Steinmetz-Malato, Laura L; Van Dyke, Deborah L

2011-01-01

The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital. © 2010 National Association for Healthcare Quality.

Space-Based Range

NASA Technical Reports Server (NTRS)

2008-01-01

Space-Based Range (SBR), previously known as Space-Based Telemetry and Range Safety (STARS), is a multicenter NASA proof-of-concept project to determine if space-based communications using NASA's Tracking and Data Relay Satellite System (TDRSS) can support the Range Safety functions of acquiring tracking data and generating flight termination signals, while also providing broadband Range User data such as voice, video, and vehicle/payload data. There was a successful test of the Range Safety system at Wallops Flight Facility (WFF) on December 20, 2005, on a two-stage Terrier-Orion spin-stabilized sounding rocket. SBR transmitted GPS tracking data and maintained links with two TDRSS satellites simultaneously during the 10-min flight. The payload section deployed a parachute, landed in the Atlantic Ocean about 90 miles downrange from the launch site, and was successfully recovered. During the Terrier-Orion tests flights, more than 99 percent of all forward commands and more than 95 percent of all return frames were successfully received and processed. The time latency necessary for a command to travel from WFF over landlines to White Sands Complex and then to the vehicle via TDRSS, be processed onboard, and then be sent back to WFF was between 1.0 s and 1.1 s. The forward-link margins for TDRS-10 (TDRS East [TDE]) were 11 dB to 12 dB plus or minus 2 dB, and for TDRS-4 (TDRS Spare [TDS]) were 9 dB to 10 dB plus or minus 1.5 dB. The return-link margins for both TDE and TDS were 6 dB to 8 dB plus or minus 3 dB. There were 11 flights on an F-15B at Dryden Flight Research Center (DFRC) between November 2006 and February 2007. The Range User system tested a 184-element TDRSS Ku-band (15 GHz) phased-array antenna with data rates of 5 Mbps and 10 Mbps. This data was a combination of black-and-white cockpit video, Range Safety tracking and transceiver data, and aircraft and antenna controller data streams. IP data formatting was used.

The FAA's Approach to Quality Assurance in the Flight Safety Analysis of Launch and Reentry Vehicles

NASA Astrophysics Data System (ADS)

Murray, Daniel P.; Weil, Andre

2010-09-01

The U.S. Federal Aviation Administration(FAA) Office of Commercial Space Transportation’s safety mission is to ensure protection of the public, property, and the national security and foreign policy interests of the United States during commercial launch and reentry activities. As part of this mission, the FAA issues licenses to the operators of launch and reentry vehicles who successfully demonstrate compliance with FAA regulations. To meet these regulations, vehicle operators submit an application that contains, among other things, flight safety analyses of their proposed missions. In the process of evaluating these submitted analyses, the FAA often conducts its own independent analyses, using input data from the submitted license application. These analyses are conducted according to approved procedures using industry developed tools. To assist in achieving the highest levels of quality in these independent analyses, the FAA has developed a quality assurance program that consists of multiple levels of review. These reviews rely on the work of multiple teams, as well as additional, independently performed work of support contractors. This paper describes the FAA’s quality assurance process for flight safety analyses. Members of the commercial space industry may find that elements of this process can be easily applied to their own analyses, improving the quality of the material they submit to the FAA in their license applications.

Inherent Conservatism in Deterministic Quasi-Static Structural Analysis

NASA Technical Reports Server (NTRS)

Verderaime, V.

1997-01-01

The cause of the long-suspected excessive conservatism in the prevailing structural deterministic safety factor has been identified as an inherent violation of the error propagation laws when reducing statistical data to deterministic values and then combining them algebraically through successive structural computational processes. These errors are restricted to the applied stress computations, and because mean and variations of the tolerance limit format are added, the errors are positive, serially cumulative, and excessively conservative. Reliability methods circumvent these errors and provide more efficient and uniform safe structures. The document is a tutorial on the deficiencies and nature of the current safety factor and of its improvement and transition to absolute reliability.

OPPE, FPPE, QPS, and why the alphabet soup of physician assessment is essential for safer patient care.

PubMed

Loftus, Michael L

Creating a successful quality and patient safety program requires a multifaceted approach that systematically reviews overall systems and processes, but also creates a standardized framework for evaluating individual practitioner performance on a routine basis. There are two required elements of competency assessment that are typically tied to the hospital credentialing process: ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE). Each of these processes are mandated by the Joint Commission, and form an important cornerstone for ensuring adequate physician performance and knowledge base. Copyright © 2017. Published by Elsevier Inc.

Implementing an Antibiotic Stewardship Information System to Improve Hospital Infection Control: A Co-Design Process.

PubMed

Maia, Mélanie R; Simões, Alexandra; Lapão, Luís V

2018-01-01

HAITooL information system design and implementation was based on Design Science Research Methodology, ensuring full participation, in close collaboration, of researchers and a multidisciplinary team of healthcare professionals. HAITooL enables effective monitoring of antibiotic resistance, antibiotic use and provides an antibiotic prescription decision-supporting system by clinicians, strengthening the patient safety procedures. The design, development and implementation process reveals benefits in organizational and behavior change with significant success. Leadership commitment multidisciplinary team and mainly informaticians engagement was crucial to the implementation process. Participants' motivation and the final product delivery and evolution depends on that.

Green Propellant Landing Demonstration at U.S. Range

NASA Technical Reports Server (NTRS)

Mulkey, Henry W.; Miller, Joseph T.; Bacha, Caitlin E.

2016-01-01

The Green Propellant Loading Demonstration (GPLD) was conducted December 2015 at Wallops Flight Facility (WFF), leveraging work performed over recent years to bring lower toxicity hydrazine replacement green propellants to flight missions. The objective of this collaboration between NASA Goddard Space Flight Center (GSFC), WFF, the Swedish National Space Board (SNSB), and Ecological Advanced Propulsion Systems (ECAPS) was to successfully accept LMP-103S propellant at a U.S. Range, store the propellant, and perform a simulated flight vehicle propellant loading. NASA GSFC Propulsion (Code 597) managed all aspects of the operation, handling logistics, preparing the procedures, and implementing the demonstration. In addition to the partnership described above, Moog Inc. developed an LMP-103S propellant-compatible titanium rolling diaphragm flight development tank and loaned it to GSFC to act as the GPLD flight vessel. The flight development tank offered the GPLD an additional level of flight-like propellant handling process and procedures. Moog Inc. also provided a compatible latching isolation valve for remote propellant expulsion. The GPLD operation, in concert with Moog Inc. executed a flight development tank expulsion efficiency performance test using LMP-103S propellant. As part of the demonstration work, GSFC and WFF documented Range safety analyses and practices including all elements of shipping, storage, handling, operations, decontamination, and disposal. LMP-103S has not been previously handled at a U.S. Launch Range. Requisite for this activity was an LMP-103S Risk Analysis Report and Ground Safety Plan. GSFC and WFF safety offices jointly developed safety documentation for application into the GPLD operation. The GPLD along with the GSFC Propulsion historical hydrazine loading experiences offer direct comparison between handling green propellant versus safety intensive, highly toxic hydrazine propellant. These described motives initiated the GPLD operation in order to investigate the handling and process safety variances in project resources between LMP-103S and typical in-space propellants. The GPLD risk reduction operation proved successful for many reasons including handling the green propellant at a U.S. Range, loading and pressurizing a flight-like tank, expelling the propellant, measuring the tank expulsion efficiency, and most significantly, GSFC propulsion personnel's new insight into the LMP-103S propellant handling details.

Green Propellant Loading Demonstration at U.S. Range

NASA Technical Reports Server (NTRS)

Mulkey, Henry W.; Miller, Joseph T.; Bacha, Caitlin E.

2016-01-01

The Green Propellant Loading Demonstration (GPLD) was conducted December 2015 at Wallops Flight Facility (WFF), leveraging work performed over recent years to bring lower toxicity hydrazine replacement green propellants to flight missions. The objective of this collaboration between NASA Goddard Space Flight Center (GSFC), WFF, the Swedish National Space Board (SNSB), and Ecological Advanced Propulsion Systems (ECAPS) was to successfully accept LMP-103S propellant at a U.S. Range, store the propellant, and perform a simulated flight vehicle propellant loading. NASA GSFC Propulsion (Code 597) managed all aspects of the operation, handling logistics, preparing the procedures, and implementing the demonstration. In addition to the partnership described above, Moog Inc. developed an LMP-103S propellant-compatible titanium rolling diaphragm flight development tank and loaned it to GSFC to act as the GPLD flight vessel. The flight development tank offered the GPLD an additional level of flight-like propellant handling process and procedures. Moog Inc. also provided a compatible latching isolation valve for remote propellant expulsion. The GPLD operation, in concert with Moog Inc. executed a flight development tank expulsion efficiency performance test using LMP-103S propellant. As part of the demonstration work, GSFC and WFF documented Range safety analyses and practices including all elements of shipping, storage, handling, operations, decontamination, and disposal. LMP-103S has not been previously handled at a U.S. Launch Range. Requisite for this activity was an LMP-103S Risk Analysis Report and Ground Safety Plan. GSFC and WFF safety offices jointly developed safety documentation for application into the GPLD operation. The GPLD along with the GSFC Propulsion historical hydrazine loading experiences offer direct comparison between handling green propellant versus safety intensive, highly toxic hydrazine propellant. These described motives initiated the GPLD operation in order to investigate the handling and process safety variances in project resources between LMP-103S and typical in-space propellants. The GPLD risk reduction operation proved successful for many reasons including handling the green propellant at a U.S. Range, loading and pressurizing a flight-like tank, expelling the propellant, measuring the tank expulsion efficiency, and most significantly, GSFC propulsion personnel's new insight into the LMP-103S propellant handling details.

Theory of sampling: four critical success factors before analysis.

PubMed

Wagner, Claas; Esbensen, Kim H

2015-01-01

Food and feed materials characterization, risk assessment, and safety evaluations can only be ensured if QC measures are based on valid analytical data, stemming from representative samples. The Theory of Sampling (TOS) is the only comprehensive theoretical framework that fully defines all requirements to ensure sampling correctness and representativity, and to provide the guiding principles for sampling in practice. TOS also defines the concept of material heterogeneity and its impact on the sampling process, including the effects from all potential sampling errors. TOS's primary task is to eliminate bias-generating errors and to minimize sampling variability. Quantitative measures are provided to characterize material heterogeneity, on which an optimal sampling strategy should be based. Four critical success factors preceding analysis to ensure a representative sampling process are presented here.

Fermented Nut-Based Vegan Food: Characterization of a Home made Product and Scale-Up to an Industrial Pilot-Scale Production.

PubMed

Tabanelli, Giulia; Pasini, Federica; Riciputi, Ylenia; Vannini, Lucia; Gozzi, Giorgia; Balestra, Federica; Caboni, Maria Fiorenza; Gardini, Fausto; Montanari, Chiara

2018-03-01

Because of the impossibility to consume food of animal origin, vegan consumers are looking for substitutes that could enrich their diet. Among many substitutes, fermented nut products are made from different nut types and obtained after soaking, grinding, and fermentation. Although other fermented vegetable products have been deeply investigated, there are few data about the fermentative processes of nut-based products and the microbial consortia able to colonize these products are not yet studied. This study characterized a hand-made vegan product obtained from cashew nut. Lactic acid bacteria responsible for fermentation were identified, revealing a succession of hetero- and homo-fermentative species during process. Successively, some lactic acid bacteria isolates from the home-made vegan product were used for a pilot-scale fermentation. The products obtained were characterized and showed features similar to the home-made one, although the microbiological hazards have been prevented through proper and rapid acidification, enhancing their safety features. Spontaneous fermented products are valuable sources of microorganisms that can be used in many food processes as starter cultures. The lactic acid bacteria isolated in this research can be exploited by industries to develop new foods and therefore to enter new markets. The use of selected starter cultures guarantees good organoleptic characteristics and food safety (no growth of pathogens). © 2018 Institute of Food Technologists®.

Transforming Systems Engineering through Model-Centric Engineering

DTIC Science & Technology

2018-02-28

intelligence (e.g., Artificial Intelligence , etc.), because they provide a means for representing knowledge. We see these capabilities coming to use in both...level, including:  Performance is measured by degree of success of a mission  Artificial Intelligence (AI) is applied to counterparties so that they...Modeling, Artificial Intelligence , Simulation and Modeling, 1989. [140] SAE ARP4761. Guidelines and Methods for Conducting the Safety Assessment Process

Space Shuttle Program Legacy Report

NASA Technical Reports Server (NTRS)

Johnson, Scott

2012-01-01

Share lessons learned on Space Shuttle Safety and Mission Assurance (S&MA) culture, processes, and products that can guide future enterprises to improve mission success and minimize the risk of catastrophic failures. Present the chronology of the Johnson Space Center (JSC) S&MA organization over the 40-year history of the Space Shuttle Program (SSP) and identify key factors and environments which contributed to positive and negative performance.

The impact of assay technology as applied to safety assessment in reducing compound attrition in drug discovery.

PubMed

Thomas, Craig E; Will, Yvonne

2012-02-01

Attrition in the drug industry due to safety findings remains high and requires a shift in the current safety testing paradigm. Many companies are now positioning safety assessment at each stage of the drug development process, including discovery, where an early perspective on potential safety issues is sought, often at chemical scaffold level, using a variety of emerging technologies. Given the lengthy development time frames of drugs in the pharmaceutical industry, the authors believe that the impact of new technologies on attrition is best measured as a function of the quality and timeliness of candidate compounds entering development. The authors provide an overview of in silico and in vitro models, as well as more complex approaches such as 'omics,' and where they are best positioned within the drug discovery process. It is important to take away that not all technologies should be applied to all projects. Technologies vary widely in their validation state, throughput and cost. A thoughtful combination of validated and emerging technologies is crucial in identifying the most promising candidates to move to proof-of-concept testing in humans. In spite of the challenges inherent in applying new technologies to drug discovery, the successes and recognition that we cannot continue to rely on safety assessment practices used for decades have led to rather dramatic strategy shifts and fostered partnerships across government agencies and industry. We are optimistic that these efforts will ultimately benefit patients by delivering effective and safe medications in a timely fashion.

Relationship between ethical leadership and organisational commitment of nurses with perception of patient safety culture.

PubMed

Lotfi, Zahra; Atashzadeh-Shoorideh, Foroozan; Mohtashami, Jamileh; Nasiri, Maliheh

2018-03-12

To determine the relationship between ethical leadership, organisational commitment of nurses and their perception of patient safety culture. Patient safety, organisational commitment and ethical leadership styles are very important for improving the quality of nursing care. In this descriptive-correlational study, 340 nurses were selected using random sampling from the hospitals in Tehran in 2016. Data were analysed using descriptive and inferential statistics in SPSS v.20. There was a significant positive relationship between the ethical leadership of nursing managers, perception of patient safety culture and organisational commitment. The regression analysis showed that nursing managers' ethical leadership and nurses' organisational commitment is a predictor of patient safety culture and confirms the relationship between the variables. Regarding the relationship between the nurses' safety performance, ethical leadership and organisational commitment, it seems that the optimisation of the organisational commitment and adherence to ethical leadership by administrators and managers in hospitals could improve the nurses' performance in terms of patient safety. Implementing ethical leadership seems to be one feasible strategy to improve nurses' organisational commitment and perception of patient safety culture. Efforts by nurse managers to develop ethical leadership reinforce organisational commitment to improve patient outcomes. Nurse managers' engagement and performance in this process is vital for a successful result. © 2018 John Wiley & Sons Ltd.

How do the top 12 pharmaceutical companies operate safety pharmacology?

PubMed

Ewart, Lorna; Gallacher, David J; Gintant, Gary; Guillon, Jean-Michel; Leishman, Derek; Levesque, Paul; McMahon, Nick; Mylecraine, Lou; Sanders, Martin; Suter, Willi; Wallis, Rob; Valentin, Jean-Pierre

2012-09-01

How does safety pharmacology operate in large pharmaceutical companies today? By understanding our current position, can we prepare safety pharmacology to successfully navigate the complex process of drug discovery and development? A short anonymous survey was conducted, by invitation, to safety pharmacology representatives of the top 12 pharmaceutical companies, as defined by 2009 revenue figures. A series of multiple choice questions was designed to explore group size, accountabilities, roles and responsibilities of group members, outsourcing policy and publication record. A 92% response rate was obtained. Six out of 11 companies have 10 to 30 full time equivalents in safety pharmacology, who hold similar roles and responsibilities; although the majority of members are not qualified at PhD level or equivalent. Accountabilities were similar across companies and all groups have accountability for core battery in vivo studies and problem solving activities but differences do exist for example with in vitro safety screening and pharmacodynamic/pharmokinetic modeling (PK/PD). The majority of companies outsource less than 25% of studies, with in vitro profiling being the most commonly outsourced activity. Finally, safety pharmacology groups are publishing 1 to 4 articles each year. This short survey has highlighted areas of similarity and differences in the way large pharmaceutical companies operate safety pharmacology. Copyright © 2012 Elsevier Inc. All rights reserved.

International Cooperation in the Field of International Space Station (ISS) Payload Safety

NASA Astrophysics Data System (ADS)

Grayson, C.; Sgobba, T.; Larsen, A.; Rose, S.; Heimann, T.; Ciancone, M.; Mulhern, V.

2005-12-01

In the frame of the International Space Station (ISS) Program cooperation, in 1998 the European Space Agency (ESA) approached the National Aeronautics and Space Administration (NASA) with the unique concept of a Payload Safety Review Panel (PSRP) "franchise" based at the European Space Technology Center (ESTEC), where the panel would be capable of autonomously reviewing flight hardware for safety. This paper will recount the course of an ambitious idea as it progressed into a fully functional reality. It will show how a panel initially conceived at NASA to serve a national programme has evolved into an international safety cooperation asset. The PSRP established at NASA began reviewing ISS payloads approximately in late 1994 or early 1995 as an expansion of the pre- existing Shuttle Program PSRP. This paper briefly describes the fundamental Shuttle safety process and the establishment of the safety requirements for payloads intending to use the Space Transportation System and ISS. The paper will also offer some historical statistics about the experiments that completed the payload safety process for Shuttle and ISS. The paper then presents the background of ISS agreements and international treaties that had to be considered when establishing the ESA PSRP. The paper will expound upon the detailed franchising model, followed by an outline of the cooperation charter approved by the NASA Associate Administrator, Office of Space Flight, and ESA Director of Manned Spaceflight and Microgravity. The paper will then address the resulting ESA PSRP implementation and its success statistics to date. Additionally, the paper presents ongoing developments with the Japan Aerospace Exploration Agency (JAXA). The discussion will conclude with ideas for future developments, such to achieve a fully integrated international system of payload safety panels for ISS.

International Cooperation in the Field of International Space Station (ISS) Payload Safety

NASA Technical Reports Server (NTRS)

Heimann, Timothy; Larsen, Axel M.; Rose, Summer; Sgobba, Tommaso

2005-01-01

In the frame of the International Space Station (ISS) Program cooperation, in 1998, the European Space Agency (ESA) approached the National Aeronautics and Space Administration (NASA) with the unique concept of a Payload Safety Review Panel (PSRP) "franchise" based at the European Space Technology Center (ESTEC), where the panel would be capable of autonomously reviewing flight hardware for safety. This paper will recount the course of an ambitious idea as it progressed into a fully functional reality. It will show how a panel initially conceived at NASA to serve a national programme has evolved into an international safety cooperation asset. The PSRP established at NASA began reviewing ISS payloads approximately in late 1994 or early 1995 as an expansion of the pre-existing Shuttle Program PSRP. This paper briefly describes the fundamental Shuttle safety process and the establishment of the safety requirements for payloads intending to use the Space Transportation System and International Space Station (ISS). The paper will also offer some historical statistics about the experiments that completed the payload safety process for Shuttle and ISS. The paper 1 then presents the background of ISS agreements and international treaties that had to be taken into account when establishing the ESA PSRP. The detailed franchising model will be expounded upon, followed by an outline of the cooperation charter approved by the NASA Associate Administrator, Office of Space Flight, and ESA Director of Manned Spaceflight and Microgravity. The resulting ESA PSRP implementation and its success statistics to date will then be addressed. Additionally the paper presents the ongoing developments with the Japan Aerospace Exploration Agency. The discussion will conclude with ideas for future developments, such to achieve a fully integrated international system of payload safety panels for ISS.

The changing paradigm in surgery is system integration: How do we respond?

PubMed

Zenilman, Michael E; Freischlag, Julie-Ann

2017-12-08

With expansion of health care systems across the country, close relationships need to be developed between academic medical centers and their affiliated community hospitals. This creates opportunity to integrate surgical programs across different hospitals. Herein we describe a model of surgical integration at the system level of five large hospitals. We discuss utilizing advantages that both the academic and community hospital bring to the model. A close relationship between an interdisciplinary team, which includes the academic surgical chair, a regional director liaison who was embedded in the community, individual hospital leadership, and practice plan leaders was created. Three pillars as a foundation to success were physician leadership, the use of system infrastructure and development of new processes. This resulted in development of trust, leading to successful recruitments, models of employment and expansion into novel areas of patient safety. Once created, new opportunities for programming for surgical safety across the health care were identified. Copyright © 2017 Elsevier Inc. All rights reserved.

Corporate incentives for promoting safety belt use : rationale, guidelines, and examples

DOT National Transportation Integrated Search

1982-10-01

This manual was designed to teach the corporate executive successful strategies for implementing and evaluating a successful industry-based program to motivate employee safety belt use. A rationale is given for the general approach; and specific guid...

Experience with soluble neutron poisons for criticality control at ICPP

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

Wilson, R.E.; Mortimer, S.R.

1978-01-01

Soluble neutron poisons assure criticality control in two of the headend fuel reprocessing systems at the Idaho Chemical Processing Plant. Soluble poisons have been used successfully since 1964 and will be employed in the projected new headend processes. The use of soluble poisons (1) greatly increases the process output (2) allows versatility in the size of fuel assemblies processed and (3) allows the practical reprocessing of some fuels. The safety limit for all fluids entering the U-Zr alloy dissolver is 3.6 g/liter boron. To allow for possible deviations in the measurement systems and drift between analytical sampling periods, the standardmore » practice is to use 3.85 g/liter boron as the lower limit. This dissolver has had 4000 successful hours of operation using soluble poisons. The electrolytic dissolution process depends on soluble gadolinium for criticality safety. This system is used to process high enriched uranium clad in stainless steel. Electrolytic dissolution takes advantage of the anodic corrosion that occurs when a large electrical current is passed through the fuel elements in a corrosive environment. Three control methods are used on each headend system. First, the poison is mixed according to standard operating procedures and the measurements are affirmed by the operator's supervisor. Second, the poisoned solution is stirred, sampled, analyzed, and the analysis reported while still in the mix tank. Finally, a Nuclear Poison Detection System (NPDS) must show an acceptable poison concentration before the solution can be transferred. The major disadvantage of using soluble poisons is the need for very sophisticated control systems and procedures, which require extensive checkout. The need for a poisoned primary heating and cooling system means a secondary system is needed as well. Experience has shown, however, that production enhancement more than makes up for the problems.« less

New health and safety initiatives at the Department of Energy (DOE)

NASA Technical Reports Server (NTRS)

Ziemer, Paul L.

1993-01-01

This document touches on some of the more important lessons learned and the more noteworthy initiatives DOE has put into motion in the last three years to protect the health and safety of our contractor employees. What we have learned in the process should come as no surprise to those of you who have been working in the field: (1) that management commitment to safety and health is critical to a successful program; (2) that meaningful employee participation in all aspects of the program enhances its effectiveness at every level; and (3) that the dedication and expertise of medical and occupational safety and health professionals are needed if the challenging problems presented by the complex and technologically advanced environment at DOE facilities are to be overcome. I believe that we have made a good beginning in the long and arduous task of building an Occupational Safety and Health Program that will serve as a model for others, and I can assure you that we intend to continue our efforts to protect every worker within the complex from occupational injury and disease.

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

Farren Hunt

Idaho National Laboratory (INL) performed an Annual Effectiveness Review of the Integrated Safety Management System (ISMS), per 48 Code of Federal Regulations (CFR) 970.5223 1, “Integration of Environment, Safety and Health into Work Planning and Execution.” The annual review assessed Integrated Safety Management (ISM) effectiveness, provided feedback to maintain system integrity, and identified target areas for focused improvements and assessments for fiscal year (FY) 2013. Results of the FY 2012 annual effectiveness review demonstrated that the INL’s ISMS program was significantly strengthened. Actions implemented by the INL demonstrate that the overall Integrated Safety Management System is sound and ensures safemore » and successful performance of work while protecting workers, the public, and environment. This report also provides several opportunities for improvement that will help further strengthen the ISM Program and the pursuit of safety excellence. Demonstrated leadership and commitment, continued surveillance, and dedicated resources have been instrumental in maturing a sound ISMS program. Based upon interviews with personnel, reviews of assurance activities, and analysis of ISMS process implementation, this effectiveness review concludes that ISM is institutionalized and is “Effective”.« less

Enhancing Food Processing by Pulsed and High Voltage Electric Fields: Principles and Applications.

PubMed

Wang, Qijun; Li, Yifei; Sun, Da-Wen; Zhu, Zhiwei

2018-02-02

Improvements in living standards result in a growing demand for food with high quality attributes including freshness, nutrition and safety. However, current industrial processing methods rely on traditional thermal and chemical methods, such as sterilization and solvent extraction, which could induce negative effects on food quality and safety. The electric fields (EFs) involving pulsed electric fields (PEFs) and high voltage electric fields (HVEFs) have been studied and developed for assisting and enhancing various food processes. In this review, the principles and applications of pulsed and high voltage electric fields are described in details for a range of food processes, including microbial inactivation, component extraction, and winemaking, thawing and drying, freezing and enzymatic inactivation. Moreover, the advantages and limitations of electric field related technologies are discussed to foresee future developments in the food industry. This review demonstrates that electric field technology has a great potential to enhance food processing by supplementing or replacing the conventional methods employed in different food manufacturing processes. Successful industrial applications of electric field treatments have been achieved in some areas such as microbial inactivation and extraction. However, investigations of HVEFs are still in an early stage and translating the technology into industrial applications need further research efforts.

Criticality safety strategy and analysis summary for the fuel cycle facility electrorefiner at Argonne National Laboratory West

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

Mariani, R.D.; Benedict, R.W.; Lell, R.M.

1996-05-01

As part of the termination activities of Experimental Breeder Reactor II (EBR-II) at Argonne National Laboratory (ANL) West, the spent metallic fuel from EBR-II will be treated in the fuel cycle facility (FCF). A key component of the spent-fuel treatment process in the FCF is the electrorefiner (ER) in which the actinide metals are separated from the active metal fission products and the reactive bond sodium. In the electrorefining process, the metal fuel is anodically dissolved into a high-temperature molten salt, and refined uranium or uranium/plutonium products are deposited at cathodes. The criticality safety strategy and analysis for the ANLmore » West FCF ER is summarized. The FCF ER operations and processes formed the basis for evaluating criticality safety and control during actinide metal fuel refining. To show criticality safety for the FCF ER, the reference operating conditions for the ER had to be defined. Normal operating envelopes (NOEs) were then defined to bracket the important operating conditions. To keep the operating conditions within their NOEs, process controls were identified that can be used to regulate the actinide forms and content within the ER. A series of operational checks were developed for each operation that will verify the extent or success of an operation. The criticality analysis considered the ER operating conditions at their NOE values as the point of departure for credible and incredible failure modes. As a result of the analysis, FCF ER operations were found to be safe with respect to criticality.« less

Facilitators and barriers for the adoption, implementation and monitoring of child safety interventions: a multinational qualitative analysis.

PubMed

Scholtes, Beatrice; Schröder-Bäck, Peter; MacKay, J Morag; Vincenten, Joanne; Förster, Katharina; Brand, Helmut

2017-06-01

The efficiency and effectiveness of child safety interventions are determined by the quality of the implementation process. This multinational European study aimed to identify facilitators and barriers for the three phases of implementation: adoption, implementation and monitoring (AIM process). Twenty-seven participants from across the WHO European Region were invited to provide case studies of child safety interventions from their country. Cases were selected by the authors to ensure broad coverage of injury issues, age groups and governance level of implementation (eg, national, regional or local). Each participant presented their case and provided a written account according to a standardised template. Presentations and question and answer sessions were recorded. The presentation slides, written accounts and the notes taken during the workshops were analysed using thematic content analysis to elicit facilitators and barriers. Twenty-six cases (from 26 different countries) were presented and analysed. Facilitators and barriers were identified within eight general themes, applicable across the AIM process: management and collaboration; resources; leadership; nature of the intervention; political, social and cultural environment; visibility; nature of the injury problem and analysis and interpretation. The importance of the quality of the implementation process for intervention effectiveness, coupled with limited resources for child safety makes it more difficult to achieve successful actions. The findings of this study, divided by phase of the AIM process, provide practitioners with practical suggestions, where proactive planning might help increase the likelihood of effective implementation. 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/.

Climbing the Extravehicular Activity (EVA) Wall - Safely

NASA Technical Reports Server (NTRS)

Fuentes, Jose; Greene, Stacie

2010-01-01

The success of the EVA team, that includes the EVA project office, Crew Office, Mission Operations, Engineering and Safety, is assured by the full integration of all necessary disciplines. Safety participation in all activities from hardware development concepts, certification and crew training, provides for a strong partnership within the team. Early involvement of Safety on the EVA team has mitigated risk and produced a high degree of mission success.

Role of champions in the implementation of patient safety practice change.

PubMed

Soo, Stephanie; Berta, Whitney; Baker, G Ross

2009-01-01

Practitioners of patient safety practice change agree that champions are central to the success of implementation. The clinical champion role is a concept that has been widely promoted yet empirically underdeveloped in health services literature. Questions remain as to who these champions are, what roles they play in patient safety practice change and what contexts serve to facilitate their efforts. This investigation used a multiple-case study design to critically examine the role of champions in the implementation of rapid response teams (RRTs), an innovative complex patient safety intervention, in two large urban acute care facilities. An analysis of interviews with key individuals involved in the RRT implementation process revealed a typology of the patient safety practice champion that extended beyond clinical personnel to include managerial and executive staff. Champions engaged to a varying extent in a number of core activities, including education, advocacy, relationship building and boundary spanning. Individuals became champions both through informal emergence and a combination of formal appointment and informal emergence. By identifying and elaborating upon specific features of the champion role, this study aims to expand the dialogue about champions for patient safety practice change.

Reducing workplace accidents through the use of leadership interventions: A quasi-experimental field study.

PubMed

Clarke, Sharon; Taylor, Ian

2018-05-15

There is increasing evidence to suggest that leaders need to use a combination of leader behaviors to successfully improve safety, including both transformational and transactional styles, but there has been limited testing of this idea. We developed a leadership intervention, based on supervisor training in both transformational and active transactional behaviors, and implemented it with supervisors at a UK-based chemical processing company. The study found that the supervisory training intervention led to significant improvements in perceived employee safety climate, over an eight-week period, relative to the comparison group. Although we found no change in the frequency of leader behaviors, the intervention was effective in helping supervisors to apply active transactional leader behaviors in a safety-critical context. The results indicated that transformational leader behaviors were already at a high level and effectively linked to safety. Our findings suggest not only that employees may be receptive to safety-related active transactional behaviors within high-risk situations, but furthermore, leaders can be trained to adjust their behaviors to focus more on active transactional behaviors in safety-critical contexts. Copyright © 2018 Elsevier Ltd. All rights reserved.

Evidence-Based and Value-Based Decision Making About Healthcare Design: An Economic Evaluation of the Safety and Quality Outcomes.

PubMed

Zadeh, Rana; Sadatsafavi, Hessam; Xue, Ryan

2015-01-01

This study describes a vision and framework that can facilitate the implementation of evidence-based design (EBD), scientific knowledge base into the process of the design, construction, and operation of healthcare facilities and clarify the related safety and quality outcomes for the stakeholders. The proposed framework pairs EBD with value-driven decision making and aims to improve communication among stakeholders by providing a common analytical language. Recent EBD research indicates that the design and operation of healthcare facilities contribute to an organization's operational success by improving safety, quality, and efficiency. However, because little information is available about the financial returns of evidence-based investments, such investments are readily eliminated during the capital-investment decision-making process. To model the proposed framework, we used engineering economy tools to evaluate the return on investments in six successful cases, identified by a literature review, in which facility design and operation interventions resulted in reductions in hospital-acquired infections, patient falls, staff injuries, and patient anxiety. In the evidence-based cases, calculated net present values, internal rates of return, and payback periods indicated that the long-term benefits of interventions substantially outweighed the intervention costs. This article explained a framework to develop a research-based and value-based communication language on specific interventions along the planning, design and construction, operation, and evaluation stages. Evidence-based and value-based design frameworks can be applied to communicate the life-cycle costs and savings of EBD interventions to stakeholders, thereby contributing to more informed decision makings and the optimization of healthcare infrastructures. © The Author(s) 2015.

Managing the Mars Science Laboratory Thermal Vacuum Test for Safety and Success

NASA Technical Reports Server (NTRS)

Evans, Jordan P.

2010-01-01

The Mars Science Laboratory is a NASA/JPL mission to send the next generation of rover to Mars. Originally slated for launch in 2009, development problems led to a delay in the project until the next launch opportunity in 2011. Amidst the delay process, the Launch/Cruise Solar Thermal Vacuum Test was undertaken as risk reduction for the project. With varying maturity and capabilities of the flight and ground systems, undertaking the test in a safe manner presented many challenges. This paper describes the technical and management challenges and the actions undertaken that led to the ultimate safe and successful execution of the test.

Exploitation of molecular profiling techniques for GM food safety assessment.

PubMed

Kuiper, Harry A; Kok, Esther J; Engel, Karl-Heinz

2003-04-01

Several strategies have been developed to identify unintended alterations in the composition of genetically modified (GM) food crops that may occur as a result of the genetic modification process. These include comparative chemical analysis of single compounds in GM food crops and their conventional non-GM counterparts, and profiling methods such as DNA/RNA microarray technologies, proteomics and metabolite profiling. The potential of profiling methods is obvious, but further exploration of specificity, sensitivity and validation is needed. Moreover, the successful application of profiling techniques to the safety evaluation of GM foods will require linked databases to be built that contain information on variations in profiles associated with differences in developmental stages and environmental conditions.

Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

PubMed

Kuo, Calvin C; Robb, William J

2013-06-01

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

PNNL Supports Hanford Waste Treatment

ScienceCinema

None

2018-04-16

For more than 40 years, technical assistance from PNNL has supported the operations and processing of Hanford tank waste. Our expertise in tank waste chemistry, fluid dynamics and scaling, waste forms, and safety bases has helped to shape the site’s waste treatment baseline and solve operational challenges. The historical knowledge and unique scientific and technical expertise at PNNL are essential to the success of the Hanford mission.

Perceived neighborhood safety, recovery capital, and successful outcomes among mothers 10 years after substance abuse treatment

PubMed Central

Evans, E.; Li, L.; Buoncristiani, S.; Hser, Y.I.

2014-01-01

This study examines perceived neighborhood characteristics associated with successful outcome among mothers 10 years after being treated for substance use disorders. Data were obtained from 713 mothers first studied at admission to drug treatment in California in 2000-2002 and followed-up in 2009-2011. At follow-up, 53.6% of mothers had a successful outcome (i.e., no use of illicit drugs and not involved with the criminal justice system). Perceived neighborhood safety almost doubled the odds of success. Perceived neighborhood safety interacted with social involvement, decreasing the odds of success among mothers who reported more versus less neighborhood social involvement. Perceived neighborhood climate is associated with long-term outcomes among mothers with substance use disorders independent of individual-level characteristics, underscoring the need for further efforts to understand its interaction with recovery capital in ways that promote and impede health. PMID:24832914

Perceived neighborhood safety, recovery capital, and successful outcomes among mothers 10 years after substance abuse treatment.

PubMed

Evans, Elizabeth; Li, Libo; Buoncristiani, Samantha; Hser, Yih-Ing

2014-09-01

This study examines perceived neighborhood characteristics associated with successful outcome among mothers 10 years after being treated for substance use disorders. Data were obtained from 713 mothers first studied at admission to drug treatment in California in 2000-2002 and followed up in 2009-2011. At follow-up, 53.6% of mothers had a successful outcome (i.e., no use of illicit drugs and not involved with the criminal justice system). Perceived neighborhood safety almost doubled the odds of success. Perceived neighborhood safety interacted with social involvement, decreasing the odds of success among mothers who reported more versus less neighborhood social involvement. Perceived neighborhood climate is associated with long-term outcomes among mothers with substance use disorders independent of individual-level characteristics, underscoring the need for further efforts to understand its interaction with recovery capital in ways that promote and impede health.

Accomplishing much in a short time: use of a rapid improvement event to redesign the assessment and treatment of patients with alcohol withdrawal.

PubMed

Sankoff, Jeffrey; Taub, Julie; Mintzer, David

2013-01-01

The use of Lean tools for quality improvement and process refinement is gaining acceptance in many health care institutions. Traditionally, these tools are used to apply incremental changes to established processes in order to reduce waste and improve quality. In this article, the authors describe a novel Lean methodology, the Rapid Improvement Event (RIE), used in a unique way to develop a new treatment protocol for a specific medical condition: alcohol withdrawal. The RIE allowed for the collaboration of a multidisciplinary group of providers invested in the success of a new protocol for alcohol withdrawal that spans areas from the emergency department to the inpatient ward at an inner-city safety net hospital. It also allowed for the definition of measures for its success once it is implemented.

Structural design/margin assessment

NASA Technical Reports Server (NTRS)

Ryan, R. S.

1993-01-01

Determining structural design inputs and the structural margins following design completion is one of the major activities in space exploration. The end result is a statement of these margins as stability, safety factors on ultimate and yield stresses, fracture limits (fracture control), fatigue lifetime, reuse criteria, operational criteria and procedures, stability factors, deflections, clearance, handling criteria, etc. The process is normally called a load cycle and is time consuming, very complex, and involves much more than structures. The key to successful structural design is the proper implementation of the process. It depends on many factors: leadership and management of the process, adequate analysis and testing tools, data basing, communications, people skills, and training. This process and the various factors involved are discussed.

Blending technology and teamwork for successful management of product recalls.

PubMed

Frush, Karen; Pleasants, Jane; Shulby, Gail; Hendrix, Barbara; Berson, Brooke; Gordon, Cynthia; Cuffe, Michael S

2009-12-01

Patient safety programs have been developed in many hospitals to reduce the risk of harm to patients. Proactive, real-time, and retrospective risk-reduction strategies should be implemented in hospitals, but patient safety leaders should also be cognizant of the risks associated with thousands of products that enter the hospital through the supply chain. A growing number of recalls and alerts related to these products are received by health care facilities each year, through a recall process that is fraught with challenges. Despite the best efforts of health care providers, weaknesses and gaps in the process lead to delays, fragmentation, and disruptions, thus extending the number of days patients may be at risk from potentially faulty or misused products. To address these concerns, Duke Medicine, which comprises an academic medical center, two community hospitals, outlying clinics, physicians' offices, and home health and hospice, implemented a Web-based recall management system. Within three months, the time required to receive, deliver, and close alerts decreased from 43 days to 2.74 days. To maximize the effectiveness of the recall management process, a team of senior Duke Medicine leaders was established to evaluate the impact of product recalls and alerts on patient safety, to evaluate response action plans, and to provide oversight of patient and provider communication strategies. Alerts are now communicated more effectively and responded to in a more consistent and global manner. This comprehensive approach to product recalls is a critical component of a broader Duke Medicine strategy to improve patient safety.

A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates.

PubMed

Hubble, Michael W; Brown, Lawrence; Wilfong, Denise A; Hertelendy, Attila; Benner, Randall W; Richards, Michael E

2010-01-01

Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking. We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature. We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression. Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%-89.4%); OETI for non-cardiac arrest patients: 69.8% (50.9%-83.8%); DFI 86.8% (80.2%-91.4%); and RSI 96.7% (94.7%-98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%-95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%-83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year. We provide pooled estimates of placement success rates for prehospital airway interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure.

Resilient Practices in Maintaining Safety of Health Information Technologies

PubMed Central

Ash, Joan S.; Sittig, Dean F.; Singh, Hardeep

2014-01-01

Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management. PMID:25866492

How Can Eastern/Southern Mediterranean Countries Resolve Quality and Safety Issues in Transfusion Medicine?

PubMed Central

Haddad, Antoine; Bou Assi, Tarek; Garraud, Olivier

2018-01-01

Unlike their Western counterparts, some of the Eastern/Southern Mediterranean countries lack centralized coordinated blood transfusion services leading to an unequal blood safety level. This was recently highlighted by a recent World Health Organization (WHO) regional committee report in which WHO urges these countries to establish and implement a national blood system with well-coordinated blood transfusion activities and to make attempts to reach 100% voluntary non-remunerated blood donation. The objective is thus to meet the same levels or standards as Western countries in term of self-sufficiency and blood safety. This raises the question whether these countries can either comply with Western countries’ guidelines and experiences or develop their own safety scheme based on proper sociopolitical and economic features. Another option is to identify efficient and cost-effective strategies setup successfully in neighbor countries sharing cultural and economic features. To address this issue—and make an attempt to achieve this goal—we designed a number of surveys specifically addressed to Mediterranean countries, which were sent out to the national authorities; so far, five surveys aim at covering all aspects in blood collection, processing, testing, inventory and distribution, as well as patient immune-hematological testing and follow-up (including surveillance and vigilances). It is anticipated that such practice can help identifying and then sharing the more successful and cost-effective experiences, and be really focused on Mediterranean areas while not necessarily copying and pasting experiences designed for Western/Northern areas with significantly distinct situations. PMID:29536009

Quick Response codes for surgical safety: a prospective pilot study.

PubMed

Dixon, Jennifer L; Smythe, William Roy; Momsen, Lara S; Jupiter, Daniel; Papaconstantinou, Harry T

2013-09-01

Surgical safety programs have been shown to reduce patient harm; however, there is variable compliance. The purpose of this study is to determine if innovative technology such as Quick Response (QR) codes can facilitate surgical safety initiatives. We prospectively evaluated the use of QR codes during the surgical time-out for 40 operations. Feasibility and accuracy were assessed. Perceptions of the current time-out process and the QR code application were evaluated through surveys using a 5-point Likert scale and binomial yes or no questions. At baseline (n = 53), survey results from the surgical team agreed or strongly agreed that the current time-out process was efficient (64%), easy to use (77%), and provided clear information (89%). However, 65% of surgeons felt that process improvements were needed. Thirty-seven of 40 (92.5%) QR codes scanned successfully, of which 100% were accurate. Three scan failures resulted from excessive curvature or wrinkling of the QR code label on the body. Follow-up survey results (n = 33) showed that the surgical team agreed or strongly agreed that the QR program was clearer (70%), easier to use (57%), and more accurate (84%). Seventy-four percent preferred the QR system to the current time-out process. QR codes accurately transmit patient information during the time-out procedure and are preferred to the current process by surgical team members. The novel application of this technology may improve compliance, accuracy, and outcomes. Copyright © 2013 Elsevier Inc. All rights reserved.

Motivation of employers to encourage their employees to use safety belts (phase 2).

DOT National Transportation Integrated Search

1983-08-01

An employer manual is developed which offers guidelines for the elements of a successful safety bell program. The guidelines are based upon the model developed as a result of site visits to successful programs and synthesis of expert opinion. A needs...

Building Collaboration: A Scoping Review of Cultural Competency and Safety Education and Training for Healthcare Students and Professionals in Canada.

PubMed

Guerra, Olivia; Kurtz, Donna

2017-01-01

Phenomenon: This scoping literature review summarizes current Canadian health science education and training aimed to lessen health gaps between Aboriginal and non-Aboriginal peoples. Keyword searches of peer-reviewed and gray literature databases, websites, and resources recommended by local Aboriginal community members identified 1,754 resources. Using specific inclusion and exclusion criteria, 26 resources relevant to education and training of healthcare professionals and students in Canada were selected. Information included self-assessment for cultural competency/safety skills, advocacy within Canadian healthcare, and descriptions of current programs and training approaches. In spite of increasing awareness and use of cultural competency and safety concepts, few programs have been successfully implemented. Insights: A concerted effort among health science education and training bodies to develop integrated and effective programs could result in comprehensive processes that hasten the Canadian culturally safe healthcare provision, thus reducing the gaps among populations.

Symbolic solutions for deadly dilemmas: an analysis of federal coal mine health and safety legislation.

PubMed

Curran, D J

1984-01-01

Numerous studies of coal mine laws have argued that the passage of all significant health and safety legislation can be attributed to a succession of catastrophic disasters which heightened awareness and propelled lawmakers into action. This paper takes issue with this "disaster-law" argument because it obscures the intricacies of law creation by focusing on a single factor. More accurately, mining disasters represent one dimension of a process aimed at resolving conflicts occurring within a specific social context. Historically, legislation has been utilized to avert economic crises by addressing the demands of protesting miners. Unfortunately, while the "written law" assured improvements, the "law in action" did not meet these guarantees and the deaths in the mines continued. A case study of the Coal Mine Health and Safety Act of 1969 demonstrates how a law with apparently progressive standards can fail to effect change because of its dualistic nature and incomplete implementation.

Surgical robotics for patient safety in the perioperative environment: realizing the promise.

PubMed

Fuji Lai; Louw, Deon

2007-06-01

Surgery is at a crossroads of complexity. However, there is a potential path toward patient safety. One such course is to leverage computer and robotic assist techniques in the reduction and interception of error in the perioperative environment. This white paper attempts to facilitate the road toward realizing that promise by outlining a research agenda. The paper will briefly review the current status of surgical robotics and summarize any conclusions that can be reached to date based on existing research. It will then lay out a roadmap for future research to determine how surgical robots should be optimally designed and integrated into the perioperative workflow and process. Successful movement down this path would involve focused efforts and multiagency collaboration to address the research priorities outlined, thereby realizing the full potential of surgical robotics to augment human capabilities, enhance task performance, extend the reach of surgical care, improve health care quality, and ultimately enhance patient safety.

The Role for Community-Based Participatory Research in Formulating Policy Initiatives: Promoting Safety and Health for In-Home Care Workers and Their Consumers

PubMed Central

Gong, Fang; Ayala, Linda; Stock, Laura; McDevitt, Susannah; Heaney, Cathy

2009-01-01

Although community-based participatory research (CBPR) can be effective in influencing policy, the process of formulating policy initiatives through CBPR is understudied. We describe a case study to illustrate how alliances among various community partners could be united to formulate policy directions. In collaboration with partners, the National Institute for Occupational Safety and Health initiated a project aimed at improving health and safety for low-income elderly and disabled persons and their in-home care workers. Community partners and stakeholders participated in focus groups, stakeholder interviews, and meetings; they played multiple roles including identifying organizational policy changes the partners could initiate immediately, as well as broader public policy goals. Results indicated that a strong community partnership, participation, and shared values contributed to successful formulation of policy initiatives. PMID:19890153

Use of evidential reasoning and AHP to assess regional industrial safety

PubMed Central

Chen, Zhichao; Chen, Tao; Qu, Zhuohua; Ji, Xuewei; Zhou, Yi; Zhang, Hui

2018-01-01

China’s fast economic growth contributes to the rapid development of its urbanization process, and also renders a series of industrial accidents, which often cause loss of life, damage to property and environment, thus requiring the associated risk analysis and safety control measures to be implemented in advance. However, incompleteness of historical failure data before the occurrence of accidents makes it difficult to use traditional risk analysis approaches such as probabilistic risk analysis in many cases. This paper aims to develop a new methodology capable of assessing regional industrial safety (RIS) in an uncertain environment. A hierarchical structure for modelling the risks influencing RIS is first constructed. The hybrid of evidential reasoning (ER) and Analytical Hierarchy Process (AHP) is then used to assess the risks in a complementary way, in which AHP is hired to evaluate the weight of each risk factor and ER is employed to synthesise the safety evaluations of the investigated region(s) against the risk factors from the bottom to the top level in the hierarchy. The successful application of the hybrid approach in a real case analysis of RIS in several major districts of Beijing (capital of China) demonstrates its feasibility as well as provides risk analysts and safety engineers with useful insights on effective solutions to comprehensive risk assessment of RIS in metropolitan cities. The contribution of this paper is made by the findings on the comparison of risk levels of RIS at different regions against various risk factors so that best practices from the good performer(s) can be used to improve the safety of the others. PMID:29795593

Use of evidential reasoning and AHP to assess regional industrial safety.

PubMed

Chen, Zhichao; Chen, Tao; Qu, Zhuohua; Yang, Zaili; Ji, Xuewei; Zhou, Yi; Zhang, Hui

2018-01-01

China's fast economic growth contributes to the rapid development of its urbanization process, and also renders a series of industrial accidents, which often cause loss of life, damage to property and environment, thus requiring the associated risk analysis and safety control measures to be implemented in advance. However, incompleteness of historical failure data before the occurrence of accidents makes it difficult to use traditional risk analysis approaches such as probabilistic risk analysis in many cases. This paper aims to develop a new methodology capable of assessing regional industrial safety (RIS) in an uncertain environment. A hierarchical structure for modelling the risks influencing RIS is first constructed. The hybrid of evidential reasoning (ER) and Analytical Hierarchy Process (AHP) is then used to assess the risks in a complementary way, in which AHP is hired to evaluate the weight of each risk factor and ER is employed to synthesise the safety evaluations of the investigated region(s) against the risk factors from the bottom to the top level in the hierarchy. The successful application of the hybrid approach in a real case analysis of RIS in several major districts of Beijing (capital of China) demonstrates its feasibility as well as provides risk analysts and safety engineers with useful insights on effective solutions to comprehensive risk assessment of RIS in metropolitan cities. The contribution of this paper is made by the findings on the comparison of risk levels of RIS at different regions against various risk factors so that best practices from the good performer(s) can be used to improve the safety of the others.

Modeling and simulation: A key to future defense technology

NASA Technical Reports Server (NTRS)

Muccio, Anthony B.

1993-01-01

The purpose of this paper is to express the rationale for continued technological and scientific development of the modeling and simulation process for the defense industry. The defense industry, along with a variety of other industries, is currently being forced into making sacrifices in response to the current economic hardships. These sacrifices, which may not compromise the safety of our nation, nor jeopardize our current standing as the world peace officer, must be concentrated in areas which will withstand the needs of the changing world. Therefore, the need for cost effective alternatives of defense issues must be examined. This paper provides support that the modeling and simulation process is an economically feasible process which will ensure our nation's safety as well as provide and keep up with the future technological developments and demands required by the defense industry. The outline of this paper is as follows: introduction, which defines and describes the modeling and simulation process; discussion, which details the purpose and benefits of modeling and simulation and provides specific examples of how the process has been successful; and conclusion, which summarizes the specifics of modeling and simulation of defense issues and lends the support for its continued use in the defense arena.

Defensive efficacy interim design: Dynamic benefit/risk ratio view using probability of success.

PubMed

Tang, Zhongwen

2017-01-01

Traditional efficacy interim design is based on alpha spending which does not have intuitive interpretation and hence is difficult to communicate with non-statistician colleagues. The alpha-spending approach is based on efficacy alone and hence does not have the flexibility to incorporate newly emerged safety signal. Newly emerged safety signal may nullify the originally set efficacy boundary. In contrast, the probability of success (POS) concept has intuitive interpretation and hence can facilitate our communication with non-statistician colleagues and help to obtain health authority (HA) buying. The success criteria of POS are not restricted to statistical significance. Hence, POS has the capability to incorporate both efficacy and safety information. We propose to use POS and its credible interval to design efficacy interim. In the proposed method, the efficacy boundary is adjustable to offset newly emerged safety signal.

Launching the dialogue: Safety and innovation as partners for success in advanced manufacturing.

PubMed

Geraci, C L; Tinkle, S S; Brenner, S A; Hodson, L L; Pomeroy-Carter, C A; Neu-Baker, N

2018-06-01

Emerging and novel technologies, materials, and information integrated into increasingly automated and networked manufacturing processes or into traditional manufacturing settings are enhancing the efficiency and productivity of manufacturing. Globally, there is a move toward a new era in manufacturing that is characterized by: (1) the ability to create and deliver more complex designs of products; (2) the creation and use of materials with new properties that meet a design need; (3) the employment of new technologies, such as additive and digital techniques that improve on conventional manufacturing processes; and (4) a compression of the time from initial design concept to the creation of a final product. Globally, this movement has many names, but "advanced manufacturing" has become the shorthand for this complex integration of material and technology elements that enable new ways to manufacture existing products, as well as new products emerging from new technologies and new design methods. As the breadth of activities associated with advanced manufacturing suggests, there is no single advanced manufacturing industry. Instead, aspects of advanced manufacturing can be identified across a diverse set of business sectors that use manufacturing technologies, ranging from the semiconductors and electronics to the automotive and pharmaceutical industries. The breadth and diversity of advanced manufacturing may change the occupational and environmental risk profile, challenge the basic elements of comprehensive health and safety (material, process, worker, environment, product, and general public health and safety), and provide an opportunity for development and dissemination of occupational and environmental health and safety (OEHS) guidance and best practices. It is unknown how much the risk profile of different elements of OEHS will change, thus requiring an evolution of health and safety practices. These changes may be accomplished most effectively through multi-disciplinary, multi-sector, public-private dialogue that identifies issues and offers solutions.

Improving staff perception of a safety climate with crew resource management training.

PubMed

Kuy, SreyRam; Romero, Ramon A L

2017-06-01

Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate. Published by Elsevier Inc.

Consensus-based Recommendations for Research Priorities Related to Interventions to Safeguard Patient Safety in the Crowded Emergency Department

PubMed Central

Fee, Christopher; Hall, Kendall; Morrison, J. Bradley; Stephens, Robert; Cosby, Karen; Fairbanks, Rollin (Terry) J.; Youngberg, Barbara; Lenehan, Gail; Abualenain, Jameel; O’Connor, Kevin; Wears, Robert

2012-01-01

This article describes the results of the Interventions to Safeguard Safety breakout session of the 2011 Academic Emergency Medicine (AEM) consensus conference entitled “Interventions to Assure Quality in the Crowded Emergency Department.” Using a multistep nominal group technique, experts in emergency department (ED) crowding, patient safety, and systems engineering defined knowledge gaps and priority research questions related to the maintenance of safety in the crowded ED. Consensus was reached for seven research priorities related to interventions to maintain safety in the setting of a crowded ED. Included among these are: 1) How do routine corrective processes and compensating mechanism change during crowding? 2) What metrics should be used to determine ED safety? 3) How can checklists ensure safer care and what factors contribute to their success or failure? 4) What constitutes safe staffing levels / ratios? 5) How can we align emergency medicine (EM)-specific patient safety issues with national patient safety issues? 6) How can we develop metrics and skills to recognize when an ED is getting close to catastrophic overload conditions? and 7) What can EM learn from experts and modeling from fields outside of medicine to develop innovative solutions? These priorities have the potential to inform future clinical and human factors research and extramural funding decisions related to this important topic. PMID:22168192

Using the Donabedian framework to examine the quality and safety of nursing service innovation.

PubMed

Gardner, Glenn; Gardner, Anne; O'Connell, Jane

2014-01-01

To evaluate the safety and quality of nurse practitioner service using the audit framework of Structure, Process and Outcome. Health service and workforce reform are on the agenda of governments and other service providers seeking to contain healthcare costs whilst providing safe and effective health care to communities. The nurse practitioner service is one health workforce innovation that has been adopted globally to improve timely access to clinical care, but there is scant literature reporting evaluation of the quality of this service innovation. A mixed-methods design within the Donabedian evaluation framework was used. The Donabedian framework was used to evaluate the Structure, Process and Outcome of nurse practitioner service. A range of data collection approaches was used, including stakeholder survey (n = 36), in-depth interviews (11 patients and 13 nurse practitioners) and health records data on service processes. The study identified that adequate and detailed preparation of Structure and Process is essential for the successful implementation of a service innovation. The multidisciplinary team was accepting of the addition of nurse practitioner service, and nurse practitioner clinical care was shown to be effective, satisfactory and safe from the perspective of the clinician stakeholders and patients. This study demonstrated that the Donabedian framework of Structure, Process and Outcome evaluation is a valuable and validated approach to examine the safety and quality of a service innovation. Furthermore, in this study, specific Structure elements were shown to influence the quality of service processes further validating the framework and the interdependence of the Structure, Process and Outcome components. Understanding the Structure and Process requirements for establishing nursing service innovation lays the foundation for safe, effective and patient-centred clinical care. © 2013 John Wiley & Sons Ltd.

Daily Management System of the Henry Ford Production System: QTIPS to Focus Continuous Improvements at the Level of the Work.

PubMed

Zarbo, Richard J; Varney, Ruan C; Copeland, Jacqueline R; D'Angelo, Rita; Sharma, Gaurav

2015-07-01

To support our Lean culture of continuous improvement, we implemented a daily management system designed so critical metrics of operational success were the focus of local teams to drive improvements. We innovated a standardized visual daily management board composed of metric categories of Quality, Time, Inventory, Productivity, and Safety (QTIPS); frequency trending; root cause analysis; corrective/preventive actions; and resulting process improvements. In 1 year (June 2013 to July 2014), eight laboratory sections at Henry Ford Hospital employed 64 unique daily metrics. Most assessed long-term (>6 months), monitored process stability, while short-term metrics (1-6 months) were retired after successful targeted problem resolution. Daily monitoring resulted in 42 process improvements. Daily management is the key business accountability subsystem that enabled our culture of continuous improvement to function more efficiently at the managerial level in a visible manner by reviewing and acting based on data and root cause analysis. Copyright© by the American Society for Clinical Pathology.

Small Column Ion Exchange Design and Safety Strategy

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

Huff, T.; Rios-Armstrong, M.; Edwards, R.

2011-02-07

Small Column Ion Exchange (SCIX) is a transformational technology originally developed by the Department of Energy (DOE) Environmental Management (EM-30) office and is now being deployed at the Savannah River Site (SRS) to significantly increase overall salt processing capacity and accelerate the Liquid Waste System life-cycle. The process combines strontium and actinide removal using Monosodium Titanate (MST), Rotary Microfiltration, and cesium removal using Crystalline Silicotitanate (CST, specifically UOP IONSIV{reg_sign}IE-911 ion exchanger) to create a low level waste stream to be disposed in grout and a high level waste stream to be vitrified. The process also includes preparation of the streamsmore » for disposal, e.g., grinding of the loaded CST material. These waste processing components are technically mature and flowsheet integration studies are being performed including glass formulations studies, application specific thermal modeling, and mixing studies. The deployment program includes design and fabrication of the Rotary Microfilter (RMF) assembly, ion-exchange columns (IXCs), and grinder module, utilizing an integrated system safety design approach. The design concept is to install the process inside an existing waste tank, Tank 41H. The process consists of a feed pump with a set of four RMFs, two IXCs, a media grinder, three Submersible Mixer Pumps (SMPs), and all supporting infrastructure including media receipt and preparation facilities. The design addresses MST mixing to achieve the required strontium and actinide removal and to prevent future retrieval problems. CST achieves very high cesium loadings (up to 1,100 curies per gallon (Ci/gal) bed volume). The design addresses the hazards associated with this material including heat management (in column and in-tank), as detailed in the thermal modeling. The CST must be size reduced for compatibility with downstream processes. The design addresses material transport into and out of the grinder and includes provisions for equipment maintenance including remote handling. The design includes a robust set of nuclear safety controls compliant with DOE Standard (STD)-1189, Integration of Safety into the Design Process. The controls cover explosions, spills, boiling, aerosolization, and criticality. Natural Phenomena Hazards (NPH) including seismic event, tornado/high wind, and wildland fire are considered. In addition, the SCIX process equipment was evaluated for impact to existing facility safety equipment including the waste tank itself. SCIX is an innovative program which leverages DOE's technology development capabilities to provide a basis for a successful field deployment.« less

The End-To-End Safety Verification Process Implemented to Ensure Safe Operations of the Columbus Research Module

NASA Astrophysics Data System (ADS)

Arndt, J.; Kreimer, J.

2010-09-01

The European Space Laboratory COLUMBUS was launched in February 2008 with NASA Space Shuttle Atlantis. Since successful docking and activation this manned laboratory forms part of the International Space Station(ISS). Depending on the objectives of the Mission Increments the on-orbit configuration of the COLUMBUS Module varies with each increment. This paper describes the end-to-end verification which has been implemented to ensure safe operations under the condition of a changing on-orbit configuration. That verification process has to cover not only the configuration changes as foreseen by the Mission Increment planning but also those configuration changes on short notice which become necessary due to near real-time requests initiated by crew or Flight Control, and changes - most challenging since unpredictable - due to on-orbit anomalies. Subject of the safety verification is on one hand the on orbit configuration itself including the hardware and software products, on the other hand the related Ground facilities needed for commanding of and communication to the on-orbit System. But also the operational products, e.g. the procedures prepared for crew and ground control in accordance to increment planning, are subject of the overall safety verification. In order to analyse the on-orbit configuration for potential hazards and to verify the implementation of the related Safety required hazard controls, a hierarchical approach is applied. The key element of the analytical safety integration of the whole COLUMBUS Payload Complement including hardware owned by International Partners is the Integrated Experiment Hazard Assessment(IEHA). The IEHA especially identifies those hazardous scenarios which could potentially arise through physical and operational interaction of experiments. A major challenge is the implementation of a Safety process which owns quite some rigidity in order to provide reliable verification of on-board Safety and which likewise provides enough flexibility which is desired by manned space operations with scientific objectives. In the period of COLUMBUS operations since launch already a number of lessons learnt could be implemented especially in the IEHA that allow to improve the flexibility of on-board operations without degradation of Safety.

Metal Cutting Theory and Friction Stir Welding Tool Design

NASA Technical Reports Server (NTRS)

Payton, Lewis N.

2003-01-01

Friction Stir Welding (FSW) is a relatively new industrial process that was invented at The Weld Institute (TWI, United Kingdom) and patented in 1992 under research funded by in part by the National Aeronautics and Space Administration (NASA). Often quoted advantages of the process include good strength and ductility along with minimization of residual stress and distortion. Less well advertised are the beneficial effects of this solid state welding process in the field of occupational and environmental safety. It produces superior weld products in difficult to weld materials without producing any toxic fumes or solid waste that must be controlled as hazardous waste. In fact, it reduces noise pollution in the workspace as well. In the early days of FSW, most welding was performed on modified machine tools, in particular on milling machines with modified milling cutters. In spite of the obvious milling heritage of the process, the techniques and lessons learned from almost 250 years of successful metalworking with milling machines have not been applied in the field of modern Friction Stir Welding. The goal of the current research was to study currently successful FSW tools and parameterize the process in such a way that the design of new tools for new materials could be accelerated. Along the way, several successful new tooling designs were developed for current issues at the Marshall Space Flight Center with accompanying patent disclosures

Space Tethers: Design Criteria

NASA Technical Reports Server (NTRS)

Tomlin, D. D.; Faile, G. C.; Hayashida, K. B.; Frost, C. L.; Wagner, C. Y.; Mitchell, M. L.; Vaughn, J. A.; Galuska, M. J.

1997-01-01

This document is prepared to provide a systematic process for the selection of tethers for space applications. Criteria arc provided for determining the strength requirement for tether missions and for mission success from tether severing due to micrometeoroids and orbital debris particle impacts. Background information of materials for use in space tethers is provided, including electricity-conducting tethers. Dynamic considerations for tether selection is also provided. Safety, quality, and reliability considerations are provided for a tether project.

Development and implementation of a navigator-facilitated care coordination algorithm to improve clinical outcomes of underserved Latino patients with uncontrolled diabetes.

PubMed

Congdon, Heather Brennan; Eldridge, Barbara Hoffman; Truong, Hoai-An

2013-11-01

Development and implementation of an interprofessional navigator-facilitated care coordination algorithm (NAVCOM) for low-income, uninsured patients with uncontrolled diabetes at a safety-net clinic resulted in improvement of disease control as evidenced by improvement in hemoglobin A1C. This report describes the process and lessons learned from the development and implementation of NAVCOM and patient success stories.

Smart Screening System (S3) In Taconite Processing

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

Daryoush Allaei; Angus Morison; David Tarnowski

2005-09-01

The conventional screening machines used in processing plants have had undesirable high noise and vibration levels. They also have had unsatisfactorily low screening efficiency, high energy consumption, high maintenance cost, low productivity, and poor worker safety. These conventional vibrating machines have been used in almost every processing plant. Most of the current material separation technology uses heavy and inefficient electric motors with an unbalanced rotating mass to generate the shaking. In addition to being excessively noisy, inefficient, and high-maintenance, these vibrating machines are often the bottleneck in the entire process. Furthermore, these motors, along with the vibrating machines and supportingmore » structure, shake other machines and structures in the vicinity. The latter increases maintenance costs while reducing worker health and safety. The conventional vibrating fine screens at taconite processing plants have had the same problems as those listed above. This has resulted in lower screening efficiency, higher energy and maintenance cost, and lower productivity and workers safety concerns. The focus of this work is on the design of a high performance screening machine suitable for taconite processing plants. SmartScreens{trademark} technology uses miniaturized motors, based on smart materials, to generate the shaking. The underlying technologies are Energy Flow Control{trademark} and Vibration Control by Confinement{trademark}. These concepts are used to direct energy flow and confine energy efficiently and effectively to the screen function. The SmartScreens{trademark} technology addresses problems related to noise and vibration, screening efficiency, productivity, and maintenance cost and worker safety. Successful development of SmartScreens{trademark} technology will bring drastic changes to the screening and physical separation industry. The final designs for key components of the SmartScreens{trademark} have been developed. The key components include smart motor and associated electronics, resonators, and supporting structural elements. It is shown that the smart motors have an acceptable life and performance. Resonator (or motion amplifier) designs are selected based on the final system requirement and vibration characteristics. All the components for a fully functional prototype are fabricated. The development program is on schedule. The last semi-annual report described the process of FE model validation and correlation with experimental data in terms of dynamic performance and predicted stresses. It also detailed efforts into making the supporting structure less important to system performance. Finally, an introduction into the dry application concept was presented. Since then, the design refinement phase was completed. This has resulted in a Smart Screen design that meets performance targets both in the dry condition and with taconite slurry flow using PZT motors. Furthermore, this system was successfully demonstrated for the DOE and partner companies at the Coleraine Mineral Research Laboratory in Coleraine, Minnesota.« less

Development of a Chlorine Dosing Strategy for Fresh Produce Washing Process to Maintain Microbial Food Safety and Minimize Residual Chlorine.

PubMed

Chen, Xi; Hung, Yen-Con

2018-06-01

The residual free chlorine level in fresh produce wash solution is closely correlated to the chemical and microbial safety of produce. Excess amount of free chlorine can quickly react with organic matters to form hazardous disinfection by-products (DBPs) above EPA-permitted levels, whereas deficiency of residual chlorine in produce wash solution may result in incompletely removing pathogens on produce. The purpose of this study was to develop a chlorine dosing strategy to optimize the chlorine dosage during produce washing process without impacting the microbial safety of fresh produce. Prediction equations were developed to estimate free chlorine needed to reach targeted residual chlorine at various sanitizer pH and organic loads, and then validated using fresh-cut iceberg lettuce and whole strawberries in an automated produce washer. Validation results showed that equations successfully predicted the initial chlorine concentration needed to achieve residual chlorine at 10, 30, 60, and 90 mg/L for both lettuce and strawberry washing processes, with the root mean squared error at 4.45 mg/L. The Escherichia coli O157:H7 reductions only slightly increased on iceberg lettuce and strawberries with residual chlorine increasing from 10 to 90 mg/L, indicating that lowering residual chlorine to 10 mg/L would not compromise the antimicrobial efficacy of chlorine-based sanitizer. Based on the prediction equations and E. coli O157:H7 reduction results, a chlorine dosing strategy was developed to help the produce industry to maintain microbial inactivation efficacy without adding excess amount of free chlorine. The chlorine dosing strategy can be used for fresh produce washing process to enhance the microbial food safety and minimize the DBPs formation potential. © 2018 Institute of Food Technologists®.

Making Human Spaceflight as Safe as Possible

NASA Technical Reports Server (NTRS)

Gregory, Frederick D.

2005-01-01

We articulated the safety hierarchy a little over two years ago, as part of our quest to be the nation s leader in safety and occupational health, and in the safety of the products and services we provide. The safety hierarchy stresses that we are all accountable for assuring that our programs, projects, and operations do not impact safety or health for the public, astronauts and pilots, employees on the ground, and high-value equipment and property. When people are thinking about doing things safely, they re also thinking about doing things right. And for the past couple of years, we ve had some pretty good results. In the time since the failures of the Mars 98 missions that occurred in late 1999, every NASA spacecraft launch has met the success objectives, and every Space Shuttle mission has safely and successfully met all mission objectives. Now I can t say that NASA s safety program is solely responsible for these achievements, but, as we like to say, "mission success starts with safety." In the future, looking forward, we will continue to make spaceflight even safer. That is NASA s vision. That is NASA s duty to both those who will travel into space and the American people who will make the journey possible.

The impact of a medical procedure service on patient safety, procedure quality and resident training opportunities.

PubMed

Tukey, Melissa H; Wiener, Renda Soylemez

2014-03-01

At some academic hospitals, medical procedure services are being developed to provide supervision for residents performing bedside procedures in hopes of improving patient safety and resident education. There is limited knowledge of the impact of such services on procedural complication rates and resident procedural training opportunities. To determine the impact of a medical procedure service (MPS) on patient safety and resident procedural training opportunities. Retrospective cohort analysis comparing characteristics and outcomes of procedures performed by the MPS versus the primary medical service. Consecutive adults admitted to internal medicine services at a large academic hospital who underwent a bedside medical procedure (central venous catheterization, thoracentesis, paracentesis, lumbar puncture) between 1 July 2010 and 31 December 2011. The primary outcome was a composite rate of major complications. Secondary outcomes included resident participation in bedside procedures and use of "best practice" safety process measures. We evaluated 1,707 bedside procedures (548 by the MPS, 1,159 by the primary services). There were no differences in the composite rate of major complications (1.6 % vs. 1.9 %, p = 0.71) or resident participation in bedside procedures (57.0 % vs. 54.3 %, p = 0.31) between the MPS and the primary services. Procedures performed by the MPS were more likely to be successfully completed (95.8 % vs. 92.8 %, p = 0.02) and to use best practice safety process measures, including use of ultrasound guidance when appropriate (96.8 % vs. 90.0 %, p = 0.0004), avoidance of femoral venous catheterization (89.5 vs. 82.7 %, p = 0.02) and involvement of attending physicians (99.3 % vs. 57.0 %, p < 0.0001). Although use of a MPS did not significantly affect the rate of major complications or resident opportunities for training in bedside procedures, it was associated with increased use of best practice safety process measures.

Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses’ Medication Administration Processes and Systems (the MAPS Study)

PubMed Central

McLeod, Monsey; Barber, Nicholas; Franklin, Bryony Dean

2015-01-01

Context Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety. Aim To identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions. Methods We used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures. Findings Overall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses’ inherent behaviour; we grouped these behaviours into ‘task focused’, and ‘patient-interaction focused’. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a ‘double-checker’. Conclusions We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals. PMID:26098106

The other side of the safety coin. [aerospace operations

NASA Technical Reports Server (NTRS)

Roth, Gilbert L.

1986-01-01

The development, inspection and testing requirements for successful production and launch and safe operation of spaceflight hardware are discussed. Emphasis is placed on paying acute attention to malfunctions, which could be caused by contaminants (particles in docking rings), insufficiently durable materials (Orbiter brakes), etc. Generic and specific problems which occur in propulsion, avionics, mechanical and computer systems and in configuration management, manufacturing and process control efforts are explored. Case histories of deficiencies found in LOX fuel lines, contaminated hydraulic control systems, the Solar Maximum Mission thermal insulation grommets, are summarized. Thorough inspection and testing procedures and design change recording during manufacture of spacecraft components are identified as requisites for successful space missions.

Probabilistic modeling of the fate of Listeria monocytogenes in diced bacon during the manufacturing process.

PubMed

Billoir, Elise; Denis, Jean-Baptiste; Cammeau, Natalie; Cornu, Marie; Zuliani, Veronique

2011-02-01

To assess the impact of the manufacturing process on the fate of Listeria monocytogenes, we built a generic probabilistic model intended to simulate the successive steps in the process. Contamination evolution was modeled in the appropriate units (breasts, dice, and then packaging units through the successive steps in the process). To calibrate the model, parameter values were estimated from industrial data, from the literature, and based on expert opinion. By means of simulations, the model was explored using a baseline calibration and alternative scenarios, in order to assess the impact of changes in the process and of accidental events. The results are reported as contamination distributions and as the probability that the product will be acceptable with regards to the European regulatory safety criterion. Our results are consistent with data provided by industrial partners and highlight that tumbling is a key step for the distribution of the contamination at the end of the process. Process chain models could provide an important added value for risk assessment models that basically consider only the outputs of the process in their risk mitigation strategies. Moreover, a model calibrated to correspond to a specific plant could be used to optimize surveillance. © 2010 Society for Risk Analysis.

Dietitians employed by health care facilities preferred a HACCP system over irradiation or chemical rinses for reducing risk of foodborne disease.

PubMed

Giamalva, J N; Redfern, M; Bailey, W C

1998-08-01

To survey dietitians in health care facilities about the acceptability of alternative meat and poultry processing methods designed to reduce the risk of foodborne disease and their willingness to pay for these processes. A geographically representative sample of 600 members of The American Dietetic Association who work in health care facilities. The response rate was 250 completed questionnaires from 592 eligible subjects (42%). A mail survey was used to gather information on the acceptability of a Hazard Analysis and Critical Control Point (HACCP) system, chemical rinses, and irradiation for increasing the safety of food. Discrete choice contingent valuation was used to determine the acceptability at current prices and at 5, 10, and 25 cents per pound above current prices. Logistic regression was used to estimate mean willingness to pay (the maximum amount respondents are willing to pay) for each process. A simultaneous equations regression model was used to estimate the effects of other variables on acceptability. Respondents expressed a high level of concern for food safety in health care facilities. The estimated mean willingness to pay was highest for a HACCP system and lowest for chemical rinses. The successful adoption of alternative methods to increase food safety depends on their acceptance by foodservice professionals. The professionals sampled were most accepting of a HACCP system, somewhat less accepting of irradiation, and least accepting of new chemical rinses. Poultry and beef processors and government agencies concerned with food safety may want to take into account the attitudes of foodservice professionals.

Barcode identification for transfusion safety.

PubMed

Murphy, M F; Kay, J D S

2004-09-01

Errors related to blood transfusion in hospitals may produce catastrophic consequences. This review addresses potential solutions to prevent patient misidentification including the use of new technology, such as barcoding. A small number of studies using new technology for the transfusion process in hospitals have shown promising results in preventing errors. The studies demonstrated improved transfusion safety and staff preference for new technology such as bedside handheld scanners to carry out pretransfusion bedside checking. They also highlighted the need for considerable efforts in the training of staff in the new procedures before their successful implementation. Improvements in hospital transfusion safety are a top priority for transfusion medicine, and will depend on a combined approach including a better understanding of the causes of errors, a reduction in the complexity of routine procedures taking advantage of new technology, improved staff training, and regular monitoring of practice. The use of new technology to improve the safety of transfusion is very promising. Further development of the systems is needed to enable staff to carry out bedside transfusion procedures quickly and accurately, and to increase their functionality to justify the cost of their wider implementation.

Implementation of a patient safety program at a tertiary health system: A longitudinal analysis of interventions and serious safety events.

PubMed

Cropper, Douglas P; Harb, Nidal H; Said, Patricia A; Lemke, Jon H; Shammas, Nicolas W

2018-04-01

We hypothesize that implementation of a safety program based on high reliability organization principles will reduce serious safety events (SSE). The safety program focused on 7 essential elements: (a) safety rounding, (b) safety oversight teams, (c) safety huddles, (d) safety coaches, (e) good catches/safety heroes, (f) safety education, and (g) red rule. An educational curriculum was implemented focusing on changing high-risk behaviors and implementing critical safety policies. All unusual occurrences were captured in the Midas system and investigated by risk specialists, the safety officer, and the chief medical officer. A multidepartmental committee evaluated these events, and a root cause analysis (RCA) was performed. Events were tabulated and serious safety event (SSE) recorded and plotted over time. Safety success stories (SSSs) were also evaluated over time. A steady drop in SSEs was seen over 9 years. Also a rise in SSSs was evident, reflecting on staff engagement in the program. The parallel change in SSEs, SSSs, and the implementation of various safety interventions highly suggest that the program was successful in achieving its goals. A safety program based on high-reliability organization principles and made a core value of the institution can have a significant positive impact on reducing SSEs. © 2018 American Society for Healthcare Risk Management of the American Hospital Association.

Motor vehicle safety : comprehensive state programs offer best opportunity for increasing use of safety belts

DOT National Transportation Integrated Search

1996-01-01

This report describes the nation's progress in achieving goals for the use of safety belts in motor vehicles, assesses the strategies used most successfully by some states to increase the use of safety belts, and identifies federal strategies that co...

Mechanisms of food processing and storage-related stress tolerance in Clostridium botulinum.

PubMed

Dahlsten, Elias; Lindström, Miia; Korkeala, Hannu

2015-05-01

Vegetative cultures of Clostridium botulinum produce the extremely potent botulinum neurotoxin, and may jeopardize the safety of foods unless sufficient measures to prevent growth are applied. Minimal food processing relies on combinations of mild treatments, primarily to avoid deterioration of the sensory qualities of the food. Tolerance of C. botulinum to minimal food processing is well characterized. However, data on effects of successive treatments on robustness towards further processing is lacking. Developments in genetic manipulation tools and the availability of annotated genomes have allowed identification of genetic mechanisms involved in stress tolerance of C. botulinum. Most studies focused on low temperature, and the importance of various regulatory mechanisms in cold tolerance of C. botulinum has been demonstrated. Furthermore, novel roles in cold tolerance were shown for metabolic pathways under the control of these regulators. A role for secondary oxidative stress in tolerance to extreme temperatures has been proposed. Additionally, genetic mechanisms related to tolerance to heat, low pH, and high salinity have been characterized. Data on genetic stress-related mechanisms of psychrotrophic Group II C. botulinum strains are scarce; these mechanisms are of interest for food safety research and should thus be investigated. This minireview encompasses the importance of C. botulinum as a food safety hazard and its central physiological characteristics related to food-processing and storage-related stress. Special attention is given to recent findings considering genetic mechanisms C. botulinum utilizes in detecting and countering these adverse conditions. Copyright © 2014 Institut Pasteur. Published by Elsevier Masson SAS. All rights reserved.

Successful development of recombinant DNA-derived pharmaceuticals.

PubMed

Werner, R G; Pommer, C H

1990-11-01

Successful development of recombinant DNA-derived pharmaceuticals, a new class of therapeutic agents, is determined by a variety of factors affecting the selection and positioning of the compound under development. For an efficient development it is of utmost importance that the mechanism of action of the compound selected be understood on a molecular level. The compound's potential therapeutical profile and a strong patent position are key positioning considerations, as well as vital elements in shortening the development phase and protecting innovation. Installation of an interdisciplinary project management team, along with a clear definition of team members' responsibilities, is required to avoid delays and improve communication during development. Selection of the organism to be used in production must take into consideration both the structure of the protein and the quality and safety of the final product. New technologies require a considerable investment in new manufacturing facilities and equipment. Often, the decision for such an investment must be made early and with a high degree of uncertainty. Desired product yield, expected dosage, and estimated market potential are the most important considerations in this decision. Following public disclosure of the plan to develop recombinant DNA-derived products, approval of the production plant and expansion or adaptation to the new process and technology may be delayed. For this reason, they should be considered as a critical step in the overall development phase. Recruitment of qualified staff is a time-consuming and critical element of the production process. Its impact on the product timeline should not be underestimated, especially if such technologies are new to the company. The entire production process must be validated in respect to identity, purity, and safety of the product to guarantee constant product quality, as well as for safety aspects in the environment. Adequate in-process and final product controls have to be established and specifications determined for release or rejection of batches for preclinical and clinical studies as well as for marketing. Preclinical testing is limited because recombinant DNA-derived proteins cannot be differentiated from naturally occurring human proteins, and because some proteins are species-specific.

Integrated information systems for electronic chemotherapy medication administration.

PubMed

Levy, Mia A; Giuse, Dario A; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K

2011-07-01

Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations.

The successful evolution of a voluntary vessel safety program in the USA.

PubMed

Hughes, Leslie

2006-01-01

The North Pacific Fishing Vessel Owners' Association (NPFVOA) is a non-profit association dedicated to safety education and training for commercial fishermen and other mariners. Funding is provided primarily through member contributions and also through tuition fees and sales of materials. Members are primarily fishing vessel owners and fishing-related companies, from small salmon boats with single operators to large processing ships with crews of 150 or more. The Association also works together with insurance underwriters and brokers, maritime attorneys and fishing industry support businesses. It works closely with the United States Coast Guard, the Occupational Safety and Health Administration (OSHA) of the United States Department of Labor, the National Institute for Occupational Safety and Health (NIOSH), and many state agencies. There are three primary components of the NPFVOA Vessel Safety Program--a comprehensive safety manual, a series of safety and survival at sea videotapes, and a crew training program. The vessel safety manual includes 300 pages of text and illustrations covering subjects ranging from vessel familiarity for deckhands to stability for the owner and skipper. It is based on the experience of those who have fished the Bering Sea and the North Pacific. The manual calls for vessel owners and skippers to adopt safety practices specific to the vessel's characteristics and service, the waters fished, the season fished and the experience of the crew. The safety and survival videotape series is designed to complement hands-on training classes. The crew training program uses hands-on practice to dramatize and enliven the information presented in the manual and on the videotapes. Courses are designed to be portable and conducted in numerous ports and states. The NPFVOA also publishes a quarterly newsletter covering its safety program, other relevant safety information and reports of lessons learned from serious fishing vessel accidents.

An overview of safety assessment, regulation, and control of hazardous material use at NREL

NASA Astrophysics Data System (ADS)

Nelson, B. P.; Crandall, R. S.; Moskowitz, P. D.; Fthenakis, V. M.

1992-12-01

This paper summarizes the methodology we use to ensure the safe use of hazardous materials at the National Renewable Energy Laboratory (NREL). First, we analyze the processes and the materials used in those processes to identify the hazards presented. Then we study federal, state, and local regulations and apply the relevant requirements to our operations. When necessary, we generate internal safety documents to consolidate this information. We design research operations and support systems to conform to these requirements. Before we construct the systems, we perform a semiquantitative risk analysis on likely accident scenarios. All scenarios presenting an unacceptable risk require system or procedural modifications to reduce the risk. Following these modifications, we repeat the risk analysis to ensure that the respective accident scenarios present an acceptable risk. Once all risks are acceptable, we conduct an operational readiness review (ORR). A management-appointed panel performs the ORR ensuring compliance with all relevant requirements. After successful completion of the ORR, operations can begin.

Moving research to practice through partnership: a case study in Asphalt Paving.

PubMed

Chang, Charlotte; Nixon, Laura; Baker, Robin

2015-08-01

Multi-stakeholder partnerships play a critical role in dissemination and implementation in health and safety. To better document and understand construction partnerships that have successfully scaled up effective interventions to protect workers, this case study focused on the collaborative processes of the Asphalt Paving Partnership. In the 1990s, this partnership developed, evaluated, disseminated, and achieved near universal, voluntary adoption of paver engineering controls to reduce exposure to asphalt fumes. We used in-depth interviews (n = 15) and document review in the case study. We describe contextual factors that both facilitated and challenged the formation of the collaboration, central themes and group processes, and research to practice (r2p) outcomes. The Asphalt Paving Partnership offers insight into how multi-stakeholder partnerships in construction can draw upon the strengths of diverse members to improve the dissemination and adoption of health and safety innovations and build a collaborative infrastructure to sustain momentum over time. © 2015 Wiley Periodicals, Inc.

Video capture of clinical care to enhance patient safety

PubMed Central

Weinger, M; Gonzales, D; Slagle, J; Syeed, M

2004-01-01



 Experience from other domains suggests that videotaping and analyzing actual clinical care can provide valuable insights for enhancing patient safety through improvements in the process of care. Methods are described for the videotaping and analysis of clinical care using a high quality portable multi-angle digital video system that enables simultaneous capture of vital signs and time code synchronization of all data streams. An observer can conduct clinician performance assessment (such as workload measurements or behavioral task analysis) either in real time (during videotaping) or while viewing previously recorded videotapes. Supplemental data are synchronized with the video record and stored electronically in a hierarchical database. The video records are transferred to DVD, resulting in a small, cheap, and accessible archive. A number of technical and logistical issues are discussed, including consent of patients and clinicians, maintaining subject privacy and confidentiality, and data security. Using anesthesiology as a test environment, over 270 clinical cases (872 hours) have been successfully videotaped and processed using the system. PMID:15069222

The Role of Space Medicine in Management of Risk in Spaceflight

NASA Technical Reports Server (NTRS)

Clark, Jonathan B.

2001-01-01

The purpose of Space Medicine is to ensure mission success by providing quality and comprehensive health care throughout all mission phases to optimize crew health and performance and to prevent negative long-term health consequences. Space flight presents additional hazards and associated risks to crew health, performance, and safety. With an extended human presence in space it is expected that illness and injury will occur on orbit, which may present a significant threat to crew health and performance and to mission success. Maintaining crew health, safety and performance and preventing illness and injury are high priorities necessary for mission success and agency goals. Space flight health care should meet the standards of practice of evidence based clinical medicine. The function of Space Medicine is expected to meet the agency goals as stated in the 1998 NASA Strategic Plan and the priorities established by the Critical Path Roadmap Project. The Critical Path Roadmap Project is an integrated NASA cross-disciplinary strategy to assess, understand, mitigate, and manage the risks associated with long-term exposure to the space flight environment. The evidence based approach to space medicine should be standardized, objective process yielding expected results and establishing clinical practice standards while balancing individual risk with mission (programmatic) risk. The ability to methodically apply available knowledge and expertise to individual and mission health issues will ensure appropriate priorities are assigned and resources are allocated. NASA Space Medicine risk management process is a combined clinical and engineering approach. Competition for weight, power, volume, cost, and crew time must be balanced in making decisions about the care of individual crew with competing agency resources.

Integrating team resource management program into staff training improves staff's perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan.

PubMed

Hsu, Ya-Chi; Jerng, Jih-Shuin; Chang, Ching-Wen; Chen, Li-Chin; Hsieh, Ming-Yuan; Huang, Szu-Fen; Liu, Yueh-Ping; Hung, Kuan-Yu

2014-08-11

The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.

Integrating team resource management program into staff training improves staff’s perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan

PubMed Central

2014-01-01

Background The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. Methods We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. Results During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Conclusion Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation. PMID:25115403

Conceptual Frameworks for the Workplace Change Adoption Process: Elements Integration from Decision Making and Learning Cycle Process.

PubMed

Radin Umar, Radin Zaid; Sommerich, Carolyn M; Lavender, Steve A; Sanders, Elizabeth; Evans, Kevin D

2018-05-14

Sound workplace ergonomics and safety-related interventions may be resisted by employees, and this may be detrimental to multiple stakeholders. Understanding fundamental aspects of decision making, behavioral change, and learning cycles may provide insights into pathways influencing employees' acceptance of interventions. This manuscript reviews published literature on thinking processes and other topics relevant to decision making and incorporates the findings into two new conceptual frameworks of the workplace change adoption process. Such frameworks are useful for thinking about adoption in different ways and testing changes to traditional intervention implementation processes. Moving forward, it is recommended that future research focuses on systematic exploration of implementation process activities that integrate principles from the research literature on sensemaking, decision making, and learning processes. Such exploration may provide the groundwork for development of specific implementation strategies that are theoretically grounded and provide a revised understanding of how successful intervention adoption processes work.

What has change management in industry got to do with improving patient safety?

PubMed

Noble, Douglas J; Lemer, Claire; Stanton, Emma

2011-05-01

Healthcare is often in a constant state of change - for political, technological, patient related, and scientific reasons. Yet, for a business where change is the norm, too little time is spent thinking theoretically about how change occurs. One area where change is still needed is in patient safety. Presented is an analysis of the literature on change to suggest how this may inform patient safety. No one change approach guarantees success in patient safety. Success very much depends on selecting the best fit change framework and adapting it to local context. Well regarded change models, like that of Kotter, are not well tested within a healthcare context. Those that are, such as Pettigrew, do not specifically address all the issues associated with patient safety. Kotter's phases of change may be applied in a healthcare context to enhance patient safety. Kotter's model is well studied in non-healthcare contexts and has potential to be adapted for improving patient safety.

Ball driven type MEMS SAD for artillery fuse

NASA Astrophysics Data System (ADS)

Seok, Jin Oh; Jeong, Ji-hun; Eom, Junseong; Lee, Seung S.; Lee, Chun Jae; Ryu, Sung Moon; Oh, Jong Soo

2017-01-01

The SAD (safety and arming device) is an indispensable fuse component that ensures safe and reliable performance during the use of ammunition. Because the application of electronic devices for smart munitions is increasing, miniaturization of the SAD has become one of the key issues for next-generation artillery fuses. Based on MEMS technology, various types of miniaturized SADs have been proposed and fabricated. However, none of them have been reported to have been used in actual munitions due to their lack of high impact endurance and complicated explosive train arrangements. In this research, a new MEMS SAD using a ball driven mechanism, is successfully demonstrated based on a UV LIGA (lithography, electroplating and molding) process. Unlike other MEMS SADs, both high impact endurance and simple structure were achieved by using a ball driven mechanism. The simple structural design also simplified the fabrication process and increased the processing yield. The ball driven type MEMS SAD performed successfully under the desired safe and arming conditions of a spin test and showed fine agreement with the FEM simulation result, conducted prior to its fabrication. A field test was also performed with a grenade launcher to evaluate the SAD performance in the firing environment. All 30 of the grenade samples equipped with the proposed MEMS SAD operated successfully under the high-G setback condition.

Aerospace Safety Advisory Panel

NASA Technical Reports Server (NTRS)

2002-01-01

This report presents the results of the Aerospace Safety Advisory Panel (ASAP) activities during 2002. The format of the report has been modified to capture a long-term perspective. Section II is new and highlights the Panel's view of NASA's safety progress during the year. Section III contains the pivotal safety issues facing NASA in the coming year. Section IV includes the program area findings and recommendations. The Panel has been asked by the Administrator to perform several special studies this year, and the resulting white papers appear in Appendix C. The year has been filled with significant achievements for NASA in both successful Space Shuttle operations and International Space Station (ISS) construction. Throughout the year, safety has been first and foremost in spite of many changes throughout the Agency. The relocation of the Orbiter Major Modifications (OMMs) from California to Kennedy Space Center (KSC) appears very successful. The transition of responsibilities for program management of the Space Shuttle and ISS programs from Johnson Space Center (JSC) to NASA Headquarters went smoothly. The decision to extend the life of the Space Shuttle as the primary NASA vehicle for access to space is viewed by the Panel as a prudent one. With the appropriate investments in safety improvements, in maintenance, in preserving appropriate inventories of spare parts, and in infrastructure, the Space Shuttle can provide safe and reliable support for the ISS for the foreseeable future. Indications of an aging Space Shuttle fleet occurred on more than one occasion this year. Several flaws went undetected in the early prelaunch tests and inspections. In all but one case, the problems were found prior to launch. These incidents were all handled properly and with safety as the guiding principle. Indeed, launches were postponed until the problems were fully understood and mitigating action could be taken. These incidents do, however, indicate the need to analyze the Space Shuttle certification criteria closely. Based on this analysis, NASA can determine the need to receritfy the vehicles and to incorporate more stringent inspections throughout the process to minimize launch schedule impact. A highly skilled and experience workforce will be increasingly important for safe and reliable operations as the Space Shuttle vehicles and infrastructure continue to age.

Health information technology and hospital patient safety: a conceptual model to guide research.

PubMed

Paez, Kathryn; Roper, Rebecca A; Andrews, Roxanne M

2013-09-01

The literature indicates that health information technology (IT) use may lead to some gains in the quality and safety of care in some situations but provides little insight into this variability in the results that has been found. The inconsistent findings point to the need for a conceptual model that will guide research in sorting out the complex relationships between health IT and the quality and safety of care. A conceptual model was developed that describes how specific health IT functions could affect different types of inpatient safety errors and that include contextual factors that influence successful health IT implementation. The model was applied to a readily available patient safety measure and nationwide data (2009 AHA Annual Survey Information Technology Supplement and 2009 Healthcare Cost and Utilization Project State Inpatient Databases). The model was difficult to operationalize because (1) available health IT adoption data did not characterize health IT features and extent of usage, and (2) patient safety measures did not elucidate the process failures leading to safety-related outcomes. The sample patient safety measure--Postoperative Physiologic and Metabolic Derangement Rate--was not significantly related to self-reported health IT capabilities when adjusted for hospital structural characteristics. These findings illustrate the critical need for collecting data that are germane to health IT and the possible mechanisms by which health IT may affect inpatient safety. Well-defined and sufficiently granular measures of provider's correct use of health IT functions, the contextual factors surrounding health IT use, and patient safety errors leading to health care-associated conditions are needed to illuminate the impact of health IT on patient safety.

Implementation of a Surgical Safety Checklist: Impact on Surgical Team Perspectives

PubMed Central

Papaconstantinou, Harry T.; Jo, ChanHee; Reznik, Scott I.; Smythe, W. Roy; Wehbe-Janek, Hania

2013-01-01

Background The World Health Organization (WHO) surgical safety checklist has been shown to decrease mortality and complications and has been adopted worldwide. However, system flaws and human errors persist. Identifying provider perspectives of patient safety initiatives may identify strategies for improvement. The purpose of this study was to determine provider perspectives of surgical safety checklist implementation in an effort to improve initiatives that enhance surgical patients' safety. Methods In September 2010, a WHO-adapted surgical safety checklist was implemented at our institution. Surgical teams were invited to complete a checklist-focused questionnaire 1 month before and 1 year after implementation. Baseline and follow-up results were compared. Results A total of 437 surgical care providers responded to the survey: 45% of providers responded at baseline and 64% of providers responded at follow-up. Of the total respondents, 153 (35%) were nurses, 104 (24%) were anesthesia providers, and 180 (41%) were surgeons. Overall, we found an improvement in the awareness of patient safety and quality of care, with significant improvements in the perception of the value of and participation in the time-out process, in surgical team communication, and in the establishment and clarity of patient care needs. Some discordance was noted between surgeons and other surgical team members, indicating that barriers in communication still exist. Overall, approximately 65% of respondents perceived that the checklist improved patient safety and patient care; however, we found a strong negative perception of operating room efficiency. Conclusion Implementation of a surgical safety checklist improves perceptions of surgical safety. Barriers to implementation exist, but staff feedback may be used to enhance the sustainability and success of patient safety initiatives. PMID:24052757

Investigating Change in Adolescent Self-Efficacy of Food Safety through Educational Interventions

ERIC Educational Resources Information Center

Beavers, Amy S.; Murphy, Lindsay; Richards, Jennifer K.

2015-01-01

A successfully targeted intervention can influence food safety knowledge, attitudes, and behaviors, as well as encourage participants to recognize their own responsibility for safe food handling. This acknowledgement of an individual's responsibility and capacity to address food safety can be understood as self-efficacy of food safety (SEFS). This…

Smart home technology for safety and functional independence: the UK experience.

PubMed

Dewsbury, Guy; Linskell, Jeremy

2011-01-01

This paper proposes that people with neurological conditions can be successfully supported by smart homes only when their needs and aspirations of the technological interventions are fully understood and integrated in the design. A neurological condition can and does provide a clue to the finished technological design but this alone fails to personalise the system and stands to be rejected by the person who requires the technology. This paper explores the underlying issues of the complexity of this design process when designing for people with neurological conditions, and advances a matrix to facilitate the assessment process to maintain a person-centred design of any system.

Latent error detection: A golden two hours for detection.

PubMed

Saward, Justin R E; Stanton, Neville A

2017-03-01

Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

Use of System Safety Risk Assessments for the Space Shuttle Reusable Solid Rocket Motor (RSRM)

NASA Technical Reports Server (NTRS)

Greenhalgh, Phillip O.; McCool, Alex (Technical Monitor)

2001-01-01

This paper discusses the System Safety approach used to assess risk for the Space Shuttle Reusable Solid Rocket Motor (RSRM). Previous to the first RSRM flight in the fall of 1988, all systems were analyzed extensively to assure that hazards were identified, assessed and that the baseline risk was understood and appropriately communicated. Since the original RSRM baseline was established, Thiokol and NASA have implemented a number of initiatives that have further improved the RSRM. The robust design, completion of rigorous testing and flight success of the RSRM has resulted in a wise reluctance to make changes. One of the primary assessments required to accompany the documentation of each proposed change and aid in the decision making process is a risk assessment. Documentation supporting proposed changes, including the risk assessments from System Safety, are reviewed and assessed by Thiokol and NASA technical management. After thorough consideration, approved changes are implemented adding improvements to and reducing risk of the Space Shuttle RSRM.

Researching Reflexively With Patients and Families: Two Studies Using Video-Reflexive Ethnography to Collaborate With Patients and Families in Patient Safety Research.

PubMed

Collier, Aileen; Wyer, Mary

2016-06-01

Patient safety research has to date offered few opportunities for patients and families to be actively involved in the research process. This article describes our collaboration with patients and families in two separate studies, involving end-of-life care and infection control in acute care. We used the collaborative methodology of video-reflexive ethnography, which has been primarily used with clinicians, to involve patients and families as active participants and collaborators in our research. The purpose of this article is to share our experiences and findings that iterative researcher reflexivity in the field was critical to the progress and success of each study. We present and analyze the complexities of reflexivity-in-the-field through a framework of multilayered reflexivity. We share our lessons here for other researchers seeking to actively involve patients and families in patient safety research using collaborative visual methods. © The Author(s) 2015.

NASA's Approach to Software Assurance

NASA Technical Reports Server (NTRS)

Wetherholt, Martha

2015-01-01

NASA defines software assurance as: the planned and systematic set of activities that ensure conformance of software life cycle processes and products to requirements, standards, and procedures via quality, safety, reliability, and independent verification and validation. NASA's implementation of this approach to the quality, safety, reliability, security and verification and validation of software is brought together in one discipline, software assurance. Organizationally, NASA has software assurance at each NASA center, a Software Assurance Manager at NASA Headquarters, a Software Assurance Technical Fellow (currently the same person as the SA Manager), and an Independent Verification and Validation Organization with its own facility. An umbrella risk mitigation strategy for safety and mission success assurance of NASA's software, software assurance covers a wide area and is better structured to address the dynamic changes in how software is developed, used, and managed, as well as it's increasingly complex functionality. Being flexible, risk based, and prepared for challenges in software at NASA is essential, especially as much of our software is unique for each mission.

Total Quality Management and the System Safety Secretary

NASA Technical Reports Server (NTRS)

Elliott, Suzan E.

1993-01-01

The system safety secretary is a valuable member of the system safety team. As downsizing occurs to meet economic constraints, the Total Quality Management (TQM) approach is frequently adopted as a formula for success and, in some cases, for survival.

Space-Based Telemetry and Range Safety Project Ku-Band and Ka-Band Phased Array Antenna

NASA Technical Reports Server (NTRS)

Whiteman, Donald E.; Valencia, Lisa M.; Birr, Richard B.

2005-01-01

The National Aeronautics and Space Administration Space-Based Telemetry and Range Safety study is a multiphase project to increase data rates and flexibility and decrease costs by using space-based communications assets for telemetry during launches and landings. Phase 1 used standard S-band antennas with the Tracking and Data Relay Satellite System to obtain a baseline performance. The selection process and available resources for Phase 2 resulted in a Ku-band phased array antenna system. Several development efforts are under way for a Ka-band phased array antenna system for Phase 3. Each phase includes test flights to demonstrate performance and capabilities. Successful completion of this project will result in a set of communications requirements for the next generation of launch vehicles.

Ku- and Ka-Band Phased Array Antenna for the Space-Based Telemetry and Range Safety Project

NASA Technical Reports Server (NTRS)

Whiteman, Donald E.; Valencia, Lisa M.; Birr, Richard B.

2005-01-01

The National Aeronautics and Space Administration Space-Based Telemetry and Range Safety study is a multiphase project to increase data rates and flexibility and decrease costs by using space-based communications assets for telemetry during launches and landings. Phase 1 used standard S-band antennas with the Tracking and Data Relay Satellite System to obtain a baseline performance. The selection process and available resources for Phase 2 resulted in a Ku-band phased array antenna system. Several development efforts are under way for a Ka-band phased array antenna system for Phase 3. Each phase includes test flights to demonstrate performance and capabilities. Successful completion of this project will result in a set of communications requirements for the next generation of launch vehicles.

Using a Theory-Driven Approach to Manage the Relocation of an Intensive Care Unit: An Exemplar.

PubMed

Lin, Frances; Marshall, Andrea; Hervey, Lucy; Foster, Michelle; Hancock, Jane; Chaboyer, Wendy

Proactive planning and managing moving from old to newly built hospitals, and the relocation process of patients for complex specialized units such as intensive care units, are necessary for both patient safety and staff well-being. This article provides an exemplar for how theory can be used to facilitate a positive relocation experience. Using change management theory, a systematic approach to cocreate implementation strategy among researchers and clinicians was critical to the success of this project.

TANK OPERATIONS CONTRACT CONSTRUCTION MANAGEMENT METHODOLOGY UTILIZING THE AGENCY METHOD OF CONSTRUCTION MANAGEMENT

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

LESKO KF; BERRIOCHOA MV

2010-02-26

Washington River Protection Solutions, LLC (WRPS) has faced significant project management challenges in managing Davis-Bacon construction work that meets contractually required small business goals. The unique challenge is to provide contracting opportunities to multiple small business constructioin subcontractors while performing high hazard work in a safe and productive manner. Previous to the WRPS contract, construction work at the Hanford Tank Farms was contracted to large companies, while current Department of Energy (DOE) Contracts typically emphasize small business awards. As an integral part of Nuclear Project Management at Hanford Tank Farms, construction involves removal of old equipment and structures and installationmore » of new infrastructure to support waste retrieval and waste feed delivery to the Waste Treatment Plant. Utilizing the optimum construction approach ensures that the contractors responsible for this work are successful in meeting safety, quality, cost and schedule objectives while working in a very hazardous environment. This paper descirbes the successful transition from a traditional project delivery method that utilized a large business general contractor and subcontractors to a new project construction management model that is more oriented to small businesses. Construction has selected the Agency Construction Management Method (John E Schaufelberger, Len Holm, "Management of Construction Projects, A Constructor's Perspective", University of Washington, Prentice Hall 2002). This method was implemented in the first quarter of Fiscal Year 2009 (FY2009), where Construction Management is performed by substantially home office resources from the URS Northwest Office in Richland, Washington. The Agency Method has allowed WRPS to provide proven Construction Managers and Field Leads to mentor and direct small business contractors, thus providing expertise and assurance of a successful project. Construction execution contracts are subcontracted directly by WRPS to small or disadvantaged contractors that are mentored and supported by URS personnel. Each small contractor is mentored and supported utilizing the principles of the Construction Industry Institute (CII) Partnering process. Some of the key mentoring and partnering areas that are explored in this paper are, internal and external safety professional support, subcontractor safety teams and the interface with project and site safety teams, quality assurance program support to facilitate compliance with NQA-1, construction, team roles and responsibilities, work definition for successful fixed price contracts, scheduling and interface with project schedules and cost projection/accruals. The practical application of the CII Partnering principles, with the Construction Management expertise of URS, has led to a highly successful construction model that also meets small business contracting goals.« less

TANK OPERATIONS CONTRACT CONSTRUCTION MANAGEMENT METHODOLOGY UTILIZING THE AGENCY METHOD OF CONSTRUCTION MANAGEMENT TO SAFELY AND EFFECTIVELY COMPLETE NUCLEAR CONSTRUCTION WORK

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

LESO KF; HAMILTON HM; FARNER M

Washington River Protection Solutions, LLC (WRPS) has faced significant project management challenges in managing Davis-Bacon construction work that meets contractually required small business goals. The unique challenge is to provide contracting opportunities to multiple small business construction subcontractors while performing high hazard work in a safe and productive manner. Previous to the Washington River Protection Solutions, LLC contract, Construction work at the Hanford Tank Farms was contracted to large companies, while current Department of Energy (DOE) Contracts typically emphasize small business awards. As an integral part of Nuclear Project Management at Hanford Tank Farms, construction involves removal of old equipmentmore » and structures and installation of new infrastructure to support waste retrieval and waste feed delivery to the Waste Treatment Plant. Utilizing the optimum construction approach ensures that the contractors responsible for this work are successful in meeting safety, quality, cost and schedule objectives while working in a very hazardous environment. This paper describes the successful transition from a traditional project delivery method that utilized a large business general contractor and subcontractors to a new project construction management model that is more oriented to small businesses. Construction has selected the Agency Construction Management Method. This method was implemented in the first quarter of Fiscal Year (FY) 2009, where Construction Management is performed by substantially home office resources from the URS Northwest Office in Richland, Washington. The Agency Method has allowed WRPS to provide proven Construction Managers and Field Leads to mentor and direct small business contractors, thus providing expertise and assurance of a successful project. Construction execution contracts are subcontracted directly by WRPS to small or disadvantaged contractors that are mentored and supported by DRS personnel. Each small contractor is mentored and supported utilizing the principles of the Construction Industry Institute (CII) Partnering process. Some of the key mentoring and partnering areas that are explored in this paper are, internal and external safety professional support, subcontractor safety teams and the interface with project and site safety teams, quality assurance program support to facilitate compliance with NQA-1, construction, team roles and responsibilities, work definition for successful fixed price contracts, scheduling and interface with project schedules and cost projection/accruals. The practical application of the CII Partnering principles, with the Construction Management expertise of URS, has led to a highly successful construction model that also meets small business contracting goals.« less

Aerospace Safety Advisory Panel

NASA Technical Reports Server (NTRS)

1999-01-01

This report covers the activities of the Aerospace Safety Advisory Panel (ASAP) for calendar year 1998-a year of sharp contrasts and significant successes at NASA. The year opened with the announcement of large workforce cutbacks. The slip in the schedule for launching the International Space Station (ISS) created a five-month hiatus in Space Shuttle launches. This slack period ended with the successful and highly publicized launch of the STS-95 mission. As the year closed, ISS assembly began with the successful orbiting and joining of the Functional Cargo Block (FGB), Zarya, from Russia and the Unity Node from the United States. Throughout the year, the Panel maintained its scrutiny of NASA's safety processes. Of particular interest were the potential effects on safety of workforce reductions and the continued transition of functions to the Space Flight Operations Contractor. Attention was also given to the risk management plans of the Aero-Space Technology programs, including the X-33, X-34, and X-38. Overall, the Panel concluded that safety is well served for the present. The picture is not as clear for the future. Cutbacks have limited the depth of talent available. In many cases, technical specialties are 'one deep.' The extended hiring freeze has resulted in an older workforce that will inevitably suffer significant departures from retirements in the near future. The resulting 'brain drain' could represent a future safety risk unless appropriate succession planning is started expeditiously. This and other topics are covered in the section addressing workforce. The major NASA programs are also limited in their ability to plan property for the future. This is of particular concern for the Space Shuttle and ISS because these programs are scheduled to operate well into the next century. In the case of the Space Shuttle, beneficial and mandatory safety and operational upgrades are being delayed because of a lack of sufficient present funding. Likewise, the ISS has little flexibility to begin long lead-time items for upgrades or contingency planning. For example, the section on computer hardware and software contains specific findings related to required longer range safety-related actions. NASA can be proud of its accomplishments this past year, but must remain ever vigilant, particularly as ISS assembly begins to accelerate. The Panel will continue to focus on both the short- and long-term aspects of risk management and safety planning. This task continues to be made manageable and productive by the excellent cooperation the Panel receives from both NASA and its contractors. Particular emphasis will continue to be directed to longer term workforce and program planning issues as well as the immediate risks associated with ISS assembly and the initial flights of the X-33 and X-34. Section 2 of this report presents specific findings and recommendations generated by ASAP activities during 1998. Section 3 contains more detailed information in support of these findings and recommendations. Appendix A is a current roster of Panel members, consultants, and staff. Appendix B contains NASA's response to the findings and recommendations from the 1997 ASAP Annual Report. Appendix C details the fact-finding activities of the Panel in 1998. During the year, Mr. Richard D. Blomberg was elected chair of the Panel and Vice Admiral (VADM) Robert F Dunn was elected deputy chair. VADM Bernard M. Kauderer moved from consultant to member. Mr. Charles J. Donlan retired from the Panel after many years of meritorious service. Ms. Shirley C. McCarty and Mr. Robert L. ('Hoot') Gibson joined the Panel as consultants.

Principles of operating room organization.

PubMed

Watkins, W D

1997-01-01

The importance of the changing health care climate has triggered important changes in the management of high-cost components of acute care facilities. By integrating and better managing various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. The leadership that physicians can provide is crucial to the success of this undertaking (1). The importance of the use of primary data related to patient throughput and related resources should be strongly emphasized, for only when such data are converted to INFORMATION of functional value can participating healthcare personnel be reasonably expected to anticipate and respond to varying clinical demands with ever-limited resources. Despite the claims of specific commercial vendors, no single product will likely be sufficient to significantly change the perioperative process to the degree or for the duration demanded by healthcare reform. The most effective approach to achieving safety, cost-effectiveness, and predictable process in the realm of Surgical Services will occur by appropriate application of the "best of breed" contributions of: (a) medical/patient safety practice/oversight; (b) information technology; (c) contemporary management; and (d) innovative and functional cost-accounting methodology. S "modified activity-based cost accounting method" can serve as the basis for acquiring true direct-cost information related to the perioperative process. The proposed overall management strategy emphasizes process and feedback, rather than specific product, and although imposing initial demands and change on the traditional hospital setting, can advance the strongest competitive position in perioperative services. This comprehensive approach comprises a functional basis for important bench-marking activities among multiple surgical services. An active, comparative process of this type is of paramount importance in emphasizing patient care and safety as the highest priority while changing the process and cost of perioperative care. Additionally, this approach objectively defines the surgical process in terms by which the impact of new treatments, drugs, devices and process changes can be assessed rationally.

Tenderizing Meat with Explosives

NASA Astrophysics Data System (ADS)

Gustavson, Paul K.; Lee, Richard J.; Chambers, George P.; Solomon, Morse B.; Berry, Brad W.

2001-06-01

Investigators at the Food Technology and Safety Laboratory have had success tenderizing meat by explosively shock loading samples submerged in water. This technique, referred to as the Hydrodynamic Pressure (HDP) Process, is being developed to improve the efficiency and reproducibility of the beef tenderization processing over conventional aging techniques. Once optimized, the process should overcome variability in tenderization currently plaguing the beef industry. Additional benefits include marketing lower quality grades of meat, which have not been commercially viable due to a low propensity to tenderization. The simplest and most successful arrangement of these tests has meat samples (50 to 75 mm thick) placed on a steel plate at the bottom of a plastic water vessel. Reported here are tests which were instrumented by Indian Head investigators. Carbon-composite resistor-gauges were used to quantify the shock profile delivered to the surface of the meat. PVDF and resistor gauges (used later in lieu of PVDF) provided data on the pressure-time history at the meat/steel interface. Resulting changes in tenderization were correlated with increasing shock duration, which were provided by various explosives.

A new leadership role for pharmacists: a prescription for change.

PubMed

Burgess, L Hayley; Cohen, Michael R; Denham, Charles R

2010-03-01

Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharmacists can take to create a visible and sustainable safe medication management structure and system in the health care environment. An evidence-based literature search was performed to determine what actions successful pharmacist leaders have taken to improve patient safety. There is a growing number of quality and patient safety standards, as well as measures that focus specifically on medication use and education. Health care organizations must be made aware of the valuable resources that pharmacists provide and of the complexity of medication management. There are steps that pharmacist leaders can take to achieve these goals. The 10 steps that pharmacist leaders can take to create a visible and sustainable safe medication management structure and system are the following: 1. Identify and mitigate medication management risks and hazards to reduce preventable patient harm. 2. Establish pharmacy leadership structures and systems to ensure organizational awareness of medication safety gaps. 3. Support an organizational culture of safe medication use. 4. Ensure evidence-based medication regimens for all patients. 5. Have daily check-in calls/meetings, with the primary focus on significant safety or quality issues. 6. Establish a medication safety committee. 7. Perform medication safety walk-rounds to evaluate medication processes, and request front-line staff ’s input about medication safe practices. 8. Ensure that pharmacy staff engage in teamwork, skill building, and communication training. 9. Engage in readiness planning for implementation of health information technology (HIT). 10. Include medication history-taking and reviews upon entry into the organization; medication counseling and training during the discharge process; and follow-up after the transition to home.

Safety Verification of a Fault Tolerant Reconfigurable Autonomous Goal-Based Robotic Control System

NASA Technical Reports Server (NTRS)

Braman, Julia M. B.; Murray, Richard M; Wagner, David A.

2007-01-01

Fault tolerance and safety verification of control systems are essential for the success of autonomous robotic systems. A control architecture called Mission Data System (MDS), developed at the Jet Propulsion Laboratory, takes a goal-based control approach. In this paper, a method for converting goal network control programs into linear hybrid systems is developed. The linear hybrid system can then be verified for safety in the presence of failures using existing symbolic model checkers. An example task is simulated in MDS and successfully verified using HyTech, a symbolic model checking software for linear hybrid systems.

Criticality safety strategy for the Fuel Cycle Facility electrorefiner at Argonne National Laboratory, West

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

Mariani, R.D.; Benedict, R.W.; Lell, R.M.

1993-09-01

The Integral Fast Reactor being developed by Argonne National Laboratory (ANL) combines the advantages of metal-fueled, liquid-metal-cooled reactors and a closed fuel cycle. Presently, the Fuel Cycle Facility (FCF) at ANL-West in Idaho Falls, Idaho is being modified to recycle spent metallic fuel from Experimental Breeder Reactor II as part of a demonstration project sponsored by the Department of Energy. A key component of the FCF is the electrorefiner (ER) in which the actinides are separated from the fission products. In the electrorefining process, the metal fuel is anodically dissolved into a high-temperature molten salt and refined uranium or uranium/plutoniummore » products are deposited at cathodes. In this report, the criticality safety strategy for the FCF ER is summarized. FCF ER operations and processes formed the basis for evaluating criticality safety and control during actinide metal fuel refining. In order to show criticality safety for the FCF ER, the reference operating conditions for the ER had to be defined. Normal operating envelopes (NOES) were then defined to bracket the important operating conditions. To keep the operating conditions within their NOES, process controls were identified that can be used to regulate the actinide forms and content within the ER. A series of operational checks were developed for each operation that wig verify the extent or success of an operation. The criticality analysis considered the ER operating conditions at their NOE values as the point of departure for credible and incredible failure modes. As a result of the analysis, FCF ER operations were found to be safe with respect to criticality.« less

Dancing the two-step: Collaborating with intermediary organizations as research partners to help implement workplace health and safety interventions.

PubMed

Kramer, Desre M; Wells, Richard P; Bigelow, Phillip L; Carlan, Niki A; Cole, Donald C; Hepburn, C Gail

2010-01-01

To evaluate the effect of the involvement of intermediaries who were research partners on three intervention studies. The projects crossed four sectors: manufacturing, transportation, service sector, and electrical-utilities sectors. The interventions were participative ergonomic programs. The study attempts to further our understanding of collaborative workplace-based research between researchers and intermediary organizations; to analyze this collaboration in terms of knowledge transfer; and to further our understanding of the successes and challenges with such a process. The intermediary organizations were provincial health and safety associations (HSAs). They have workplaces as their clients and acted as direct links between the researchers and workplaces. Data was collected from observations, emails, research-meeting minutes, and 36 qualitative interviews. Interviewees were managers, and consultants from the collaborating associations, 17 company representatives and seven researchers. The article describes how the collaborations were created, the structure of the partnerships, the difficulties, the benefits, and challenges to both the researchers and intermediaries. The evidence of knowledge utilization between the researchers and HSAs was tracked as a proxy-measure of impact of this collaborative method, also called Mode 2 research. Despite the difficulties, both the researchers and the health and safety specialists agreed that the results of the research made the process worthwhile.

[Establishment of Quality Control System of Nucleic Acid Detection for Ebola Virus in Sierra Leone-China Friendship Biological Safety Laboratory].

PubMed

Wang, Qin; Zhang, Yong; Nie, Kai; Wang, Huanyu; Du, Haijun; Song, Jingdong; Xiao, Kang; Lei, Wenwen; Guo, Jianqiang; Wei, Hejiang; Cai, Kun; Wang, Yanhai; Wu, Jiang; Gerald, Bangura; Kamara, Idrissa Laybohr; Liang, Mifang; Wu, Guizhen; Dong, Xiaoping

2016-03-01

The quality control process throughout the Ebola virus nucleic acid detection in Sierra Leone-China Friendship Biological Safety Laboratory (SLE-CHN Biosafety Lab) was described in detail, in order to comprehensively display the scientific, rigorous, accurate and efficient practice in detection of Ebola virus of first batch detection team in SLE-CHN Biosafety Lab. Firstly, the key points of laboratory quality control system was described, including the managements and organizing, quality control documents and information management, instrument, reagents and supplies, assessment, facilities design and space allocation, laboratory maintenance and biosecurity. Secondly, the application of quality control methods in the whole process of the Ebola virus detection, including before the test, during the test and after the test, was analyzed. The excellent and professional laboratory staffs, the implementation of humanized management are the cornerstone of the success; High-level biological safety protection is the premise for effective quality control and completion of Ebola virus detection tasks. And professional logistics is prerequisite for launching the laboratory diagnosis of Ebola virus. The establishment and running of SLE-CHN Biosafety Lab has landmark significance for the friendship between Sierra Leone and China, and the lab becomes the most important base for Ebola virus laboratory testing in Sierra Leone.

Process safety improvement--quality and target zero.

PubMed

Van Scyoc, Karl

2008-11-15

Process safety practitioners have adopted quality management principles in design of process safety management systems with positive effect, yet achieving safety objectives sometimes remain a distant target. Companies regularly apply tools and methods which have roots in quality and productivity improvement. The "plan, do, check, act" improvement loop, statistical analysis of incidents (non-conformities), and performance trending popularized by Dr. Deming are now commonly used in the context of process safety. Significant advancements in HSE performance are reported after applying methods viewed as fundamental for quality management. In pursuit of continual process safety improvement, the paper examines various quality improvement methods, and explores how methods intended for product quality can be additionally applied to continual improvement of process safety. Methods such as Kaizen, Poke yoke, and TRIZ, while long established for quality improvement, are quite unfamiliar in the process safety arena. These methods are discussed for application in improving both process safety leadership and field work team performance. Practical ways to advance process safety, based on the methods, are given.

The image-guided surgery toolkit IGSTK: an open source C++ software toolkit.

PubMed

Enquobahrie, Andinet; Cheng, Patrick; Gary, Kevin; Ibanez, Luis; Gobbi, David; Lindseth, Frank; Yaniv, Ziv; Aylward, Stephen; Jomier, Julien; Cleary, Kevin

2007-11-01

This paper presents an overview of the image-guided surgery toolkit (IGSTK). IGSTK is an open source C++ software library that provides the basic components needed to develop image-guided surgery applications. It is intended for fast prototyping and development of image-guided surgery applications. The toolkit was developed through a collaboration between academic and industry partners. Because IGSTK was designed for safety-critical applications, the development team has adopted lightweight software processes that emphasizes safety and robustness while, at the same time, supporting geographically separated developers. A software process that is philosophically similar to agile software methods was adopted emphasizing iterative, incremental, and test-driven development principles. The guiding principle in the architecture design of IGSTK is patient safety. The IGSTK team implemented a component-based architecture and used state machine software design methodologies to improve the reliability and safety of the components. Every IGSTK component has a well-defined set of features that are governed by state machines. The state machine ensures that the component is always in a valid state and that all state transitions are valid and meaningful. Realizing that the continued success and viability of an open source toolkit depends on a strong user community, the IGSTK team is following several key strategies to build an active user community. These include maintaining a users and developers' mailing list, providing documentation (application programming interface reference document and book), presenting demonstration applications, and delivering tutorial sessions at relevant scientific conferences.

Application of Six Sigma towards improving surgical outcomes.

PubMed

Shukla, P J; Barreto, S G; Nadkarni, M S

2008-01-01

Six Sigma is a 'process excellence' tool targeting continuous improvement achieved by providing a methodology for improving key steps of a process. It is ripe for application into health care since almost all health care processes require a near-zero tolerance for mistakes. The aim of this study is to apply the Six Sigma methodology into a clinical surgical process and to assess the improvement (if any) in the outcomes and patient care. The guiding principles of Six Sigma, namely DMAIC (Define, Measure, Analyze, Improve, Control), were used to analyze the impact of double stapling technique (DST) towards improving sphincter preservation rates for rectal cancer. The analysis using the Six Sigma methodology revealed a Sigma score of 2.10 in relation to successful sphincter preservation. This score demonstrates an improvement over the previous technique (73% over previous 54%). This study represents one of the first clinical applications of Six Sigma in the surgical field. By understanding, accepting, and applying the principles of Six Sigma, we have an opportunity to transfer a very successful management philosophy to facilitate the identification of key steps that can improve outcomes and ultimately patient safety and the quality of surgical care provided.

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

PubMed

2017-01-01

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

Exploring how ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process evaluation

PubMed Central

Sheard, Laura; Marsh, Claire; O’Hara, Jane; Armitage, Gerry; Wright, John; Lawton, Rebecca

2017-01-01

Objectives A patient safety intervention was tested in a 33-ward randomised controlled trial. No statistically significant difference between intervention and control wards was found. We conducted a process evaluation of the trial and our aim in this paper is to understand staff engagement across the 17 intervention wards. Design Large qualitative process evaluation of the implementation of a patient safety intervention. Setting and participants National Health Service staff based on 17 acute hospital wards located at five hospital sites in the North of England. Data We concentrate on three sources here: (1) analysis of taped discussion between ward staff during action planning meetings; (2) facilitators’ field notes and (3) follow-up telephone interviews with staff focusing on whether action plans had been achieved. The analysis involved the use of pen portraits and adaptive theory. Findings First, there were palpable differences in the ways that the 17 ward teams engaged with the key components of the intervention. Five main engagement typologies were evident across the life course of the study: consistent, partial, increasing, decreasing and disengaged. Second, the intensity of support for the intervention at the level of the organisation does not predict the strength of engagement at the level of the individual ward team. Third, the standardisation of facilitative processes provided by the research team does not ensure that implementation standardisation of the intervention occurs by ward staff. Conclusions A dilution of the intervention occurred during the trial because wards engaged with Patient Reporting and Action for a Safe Environment (PRASE) in divergent ways, despite the standardisation of key components. Facilitative processes were not sufficiently adequate to enable intervention wards to successfully engage with PRASE components. PMID:28710206

Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely.

PubMed

Young, John Q; Wachter, Robert M

2009-09-01

Health care organizations have increasingly embraced industrial methods, such as the Toyota Production System (TPS), to improve quality, safety, timeliness, and efficiency. However, the use of such methods in psychiatric hospitals has been limited. A psychiatric hospital applied TPS principles to patient transfers to the outpatient medication management clinics (MMCs) from all other inpatient and outpatient services within the hospital's system. Sources of error and delay were identified, and a new process was designed to improve timely access (measured by elapsed time from request for transfer to scheduling of an appointment and to the actual visit) and patient safety by decreasing communication errors (measured by number of failed transfers). Complexity was substantially reduced, with one streamlined pathway replacing five distinct and more complicated pathways. To assess sustainability, the postintervention period was divided into Period 1 (first 12 months) and Period 2 (next 24 months). Time required to process the transfer and schedule the first appointment was reduced by 74.1% in Period 1 (p < .001) and by an additional 52.7% in Period 2 (p < .0001) for an overall reduction of 87% (p < .0001). Similarly, time to the actual appointment was reduced 31.2% in Period 1 (p < .0001), but was stable in Period 2 (p = .48). The number of transfers per month successfully processed and scheduled increased 95% in the postintervention period compared with the pre-implementation period (p = .015). Finally, data for failed transfers were only available for the postintervention period, and the rate decreased 89% in Period 2 compared with Period 1 (p = .017). The application of TPS principles enhanced access and safety through marked and sustained improvements in the transfer process's timeliness and reliability. Almost all transfer processes have now been standardized.

Kilogram-scale prexasertib monolactate monohydrate synthesis under continuous-flow CGMP conditions.

PubMed

Cole, Kevin P; Groh, Jennifer McClary; Johnson, Martin D; Burcham, Christopher L; Campbell, Bradley M; Diseroad, William D; Heller, Michael R; Howell, John R; Kallman, Neil J; Koenig, Thomas M; May, Scott A; Miller, Richard D; Mitchell, David; Myers, David P; Myers, Steven S; Phillips, Joseph L; Polster, Christopher S; White, Timothy D; Cashman, Jim; Hurley, Declan; Moylan, Robert; Sheehan, Paul; Spencer, Richard D; Desmond, Kenneth; Desmond, Paul; Gowran, Olivia

2017-06-16

Advances in drug potency and tailored therapeutics are promoting pharmaceutical manufacturing to transition from a traditional batch paradigm to more flexible continuous processing. Here we report the development of a multistep continuous-flow CGMP (current good manufacturing practices) process that produced 24 kilograms of prexasertib monolactate monohydrate suitable for use in human clinical trials. Eight continuous unit operations were conducted to produce the target at roughly 3 kilograms per day using small continuous reactors, extractors, evaporators, crystallizers, and filters in laboratory fume hoods. Success was enabled by advances in chemistry, engineering, analytical science, process modeling, and equipment design. Substantial technical and business drivers were identified, which merited the continuous process. The continuous process afforded improved performance and safety relative to batch processes and also improved containment of a highly potent compound. Copyright © 2017, American Association for the Advancement of Science.

Educating for Safety.

ERIC Educational Resources Information Center

Rothe, J. Peter

1991-01-01

To enhance the chance for success in educating young drivers, there should be a balance between the content, structure, and goals of traffic safety programs and the normative rules governing young people's lives. Presents recommendations for safety education based on the notion of complementarity and using a multiperspective approach. (AF)

A framework for the development of patient safety education and training guidelines.

PubMed

Zikos, Dimitrios; Diomidous, Marianna; Mantas, John

2010-01-01

Patient Safety (PS) is a major concern that involves a wide range of roles in healthcare, including those who are directly and indirectly involved, and patients as well. In order to succeed into developing a safety culture among healthcare providers, carers and patients, there should be given great attention into building appropriate education and training tools, especially addressing those who plan patient safety activities. The framework described in this policy paper is based on the results of the European Network for Patient Safety (EUNetPaS) project and analyses the principles and elements of the guidance that should be provided to those who design and implement Patient Safety Education and training activities. The main principles that it should be based on and the core teaching objectives-expected outcomes are addressed. Once the main context and considerations are properly set, the guidance should define the general schema of the content that should be included in the Education and Training activities, as well as how these activities would be delivered. It is also important that the different roles of the recipients are clearly distinguished and linked to their role-specific methods, proper delivery platforms and success stories. Setting these principles into practice when planning and implementing interventions, primarily aims to enlighten and support those who are enrolled to design and implement Patient Safety education and training teaching activities. This is achieved by providing them with a framework to build upon, succeeding to build a collaborative, safety conscious and competent environment, in terms of PS. A guidelines web platform has been developed to support this process.

The quest to standardize hemodialysis care.

PubMed

Hegbrant, Jörgen; Gentile, Giorgio; Strippoli, Giovanni F M

2011-01-01

A large global dialysis provider's core activities include providing dialysis care with excellent quality, ensuring a low variability across the clinic network and ensuring strong focus on patient safety. In this article, we summarize the pertinent components of the quality assurance and safety program of the Diaverum Renal Services Group. Concerning medical performance, the key components of a successful quality program are setting treatment targets; implementing evidence-based guidelines and clinical protocols; consistently, regularly, prospectively and accurately collecting data from all clinics in the network; processing collected data to provide feedback to clinics in a timely manner, incorporating information on interclinic and intercountry variations; and revising targets, guidelines and clinical protocols based on sound scientific data. The key activities for ensuring patient safety include a standardized approach to education, i.e. a uniform education program including control of theoretical knowledge and clinical competencies; implementation of clinical policies and procedures in the organization in order to reduce variability and potential defects in clinic practice; and auditing of clinical practice on a regular basis. By applying a standardized and systematic continuous quality improvement approach throughout the entire organization, it has been possible for Diaverum to progressively improve medical performance and ensure patient safety. Copyright © 2011 S. Karger AG, Basel.

Identifying facilitators and barriers for implementation of interprofessional education: Perspectives from medical educators in the Netherlands.

PubMed

de Vries-Erich, Joy; Reuchlin, Kirsten; de Maaijer, Paul; van de Ridder, J M Monica

2017-03-01

Patient care and patient safety can be compromised by the lack of interprofessional collaboration and communication between healthcare providers. Interprofessional education (IPE) should therefore start during medical training and not be postponed until after graduation. This case study explored the current situation in the Dutch context and interviewed experts within medical education and with pioneers of successful best practices to learn more about their experiences with IPE. Data analysis started while new data were still collected, resulting in an iterative, constant comparative process. Using a strengths, weaknesses, opportunities, and threats (SWOT) analysis framework, we identified barriers and facilitators such as lack of a collective professional language, insufficient time or budget, stakeholders' resistance, and hierarchy. Opportunities and strengths identified were developing a collective vision, more attention for patient safety, and commitment of teachers. The facilitators and barriers relate to the organisational level of IPE and the educational content and practice. In particular, communication, cohesiveness, and support are influenced by these facilitators. An adequate identification of the SWOT elements in the current situation could prove beneficial for a successful implementation of IPE within the healthcare educational system.

Case Studies in Crewed Spacecraft Environmental Control and Life Support System Process Compatibility and Cabin Environmental Impact

NASA Technical Reports Server (NTRS)

Perry, J. L.

2017-01-01

Contamination of a crewed spacecraft's cabin environment leading to environmental control and life support system (ECLSS) functional capability and operational margin degradation or loss can have an adverse effect on NASA's space exploration mission figures of merit-safety, mission success, effectiveness, and affordability. The role of evaluating the ECLSS's compatibility and cabin environmental impact as a key component of pass trace contaminant control is presented and the technical approach is described in the context of implementing NASA's safety and mission success objectives. Assessment examples are presented for a variety of chemicals used in vehicle systems and experiment hardware for the International Space Station program. The ECLSS compatibility and cabin environmental impact assessment approach, which can be applied to any crewed spacecraft development and operational effort, can provide guidance to crewed spacecraft system and payload developers relative to design criteria assigned ECLSS compatibility and cabin environmental impact ratings can be used by payload and system developers as criteria for ensuring adequate physical and operational containment. In additional to serving as an aid for guiding containment design, the assessments can guide flight rule and procedure development toward protecting the ECLSS as well as approaches for contamination event remediation.

Isolation, amplification and characterization of foodborne pathogen disease bacteria gene for rapid kit test development

NASA Astrophysics Data System (ADS)

Nurjayadi, M.; Santoso, I.; Kartika, I. R.; Kurniadewi, F.; Saamia, V.; Sofihan, W.; Nurkhasanah, D.

2017-07-01

There is a lot of public concern over food safety. Food-safety cases recently, including many food poisoning cases in both the developed and developing countries, considered to be the national security threats which involved police investigation. Quick and accurate detection methods are needed to handle the food poisoning cases with a big number of sufferers at the same time. Therefore, the research is aimed to develop a specific, sensitive, and rapid result molecular detection tool for foodborne pathogen bacteria. We, thus, propose genomic level approach with Polymerase Chain Reaction. The research has successfully produced a specific primer to perform amplification to fim-C S. typhi, E. coli, and pef Salmonella typhimurium genes. The electrophoresis result shows that amplification products are 95 base pairs, 121 base pairs, and 139 base pairs; and all three genes are in accordance with the size of the in silico to third genes bacteria. In conclusion, the research has been successfully designed a specific detection tool to three foodborne pathogen bacteria genes. Further stages test and the uses of Real-time PCR in the detection are still in the trial process for better detection method.

Systemic safety project selection tool.

DOT National Transportation Integrated Search

2013-07-01

"The Systemic Safety Project Selection Tool presents a process for incorporating systemic safety planning into traditional safety management processes. The Systemic Tool provides a step-by-step process for conducting systemic safety analysis; conside...

Indigenous Bacteria and Fungi Drive Traditional Kimoto Sake Fermentations

PubMed Central

Bokulich, Nicholas A.; Ohta, Moe; Lee, Morgan

2014-01-01

Sake (Japanese rice wine) production is a complex, multistage process in which fermentation is performed by a succession of mixed fungi and bacteria. This study employed high-throughput rRNA marker gene sequencing, quantitative PCR, and terminal restriction fragment length polymorphism to characterize the bacterial and fungal communities of spontaneous sake production from koji to product as well as brewery equipment surfaces. Results demonstrate a dynamic microbial succession, with koji and early moto fermentations dominated by Bacillus, Staphylococcus, and Aspergillus flavus var. oryzae, succeeded by Lactobacillus spp. and Saccharomyces cerevisiae later in the fermentations. The microbiota driving these fermentations were also prevalent in the production environment, illustrating the reservoirs and routes for microbial contact in this traditional food fermentation. Interrogating the microbial consortia of production environments in parallel with food products is a valuable approach for understanding the complete ecology of food production systems and can be applied to any food system, leading to enlightened perspectives for process control and food safety. PMID:24973064

Indigenous bacteria and fungi drive traditional kimoto sake fermentations.

PubMed

Bokulich, Nicholas A; Ohta, Moe; Lee, Morgan; Mills, David A

2014-09-01

Sake (Japanese rice wine) production is a complex, multistage process in which fermentation is performed by a succession of mixed fungi and bacteria. This study employed high-throughput rRNA marker gene sequencing, quantitative PCR, and terminal restriction fragment length polymorphism to characterize the bacterial and fungal communities of spontaneous sake production from koji to product as well as brewery equipment surfaces. Results demonstrate a dynamic microbial succession, with koji and early moto fermentations dominated by Bacillus, Staphylococcus, and Aspergillus flavus var. oryzae, succeeded by Lactobacillus spp. and Saccharomyces cerevisiae later in the fermentations. The microbiota driving these fermentations were also prevalent in the production environment, illustrating the reservoirs and routes for microbial contact in this traditional food fermentation. Interrogating the microbial consortia of production environments in parallel with food products is a valuable approach for understanding the complete ecology of food production systems and can be applied to any food system, leading to enlightened perspectives for process control and food safety. Copyright © 2014, American Society for Microbiology. All Rights Reserved.

Current medical staff governance and physician sensemaking: a formula for resistance to high reliability.

PubMed

Flitter, Marc A; Riesenmy, Kelly Rouse; van Stralen, Daved

2012-01-01

To offer a theoretical explanation for observed physician resistance and rejection of high reliability patient safety initiatives. A grounded theoretical qualitative approach, utilizing the organizational theory of sensemaking, provided the foundation for inductive and deductive reasoning employed to analyze medical staff rejection of two successfully performing high reliability programs at separate hospitals. Physician behaviors resistant to patient-centric high reliability processes were traced to provider-centric physician sensemaking. Research, conducted with the advantage that prospective studies have over the limitations of this retrospective investigation, is needed to evaluate the potential for overcoming physician resistance to innovation implementation, employing strategies based upon these findings and sensemaking theory in general. If hospitals are to emulate high reliability industries that do successfully manage environments of extreme hazard, physicians must be fully integrated into the complex teams required to accomplish this goal. Reforming health care, through high reliability organizing, with its attendant continuous focus on patient-centric processes, offers a distinct alternative to efforts directed primarily at reforming health care insurance. It is by changing how health care is provided that true cost efficiencies can be achieved. Technology and the insights of organizational science present the opportunity of replacing the current emphasis on privileged information with collective tools capable of providing quality and safety in health care. The fictions that have sustained a provider-centric health care system have been challenged. The benefits of patient-centric care should be obtainable.

Integrated Information Systems for Electronic Chemotherapy Medication Administration

PubMed Central

Levy, Mia A.; Giuse, Dario A.; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K.

2011-01-01

Introduction: Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. Methods: We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. Results: We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Conclusion: Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations. PMID:22043185

The likelihood of achieving quantified road safety targets: a binary logistic regression model for possible factors.

PubMed

Sze, N N; Wong, S C; Lee, C Y

2014-12-01

In past several decades, many countries have set quantified road safety targets to motivate transport authorities to develop systematic road safety strategies and measures and facilitate the achievement of continuous road safety improvement. Studies have been conducted to evaluate the association between the setting of quantified road safety targets and road fatality reduction, in both the short and long run, by comparing road fatalities before and after the implementation of a quantified road safety target. However, not much work has been done to evaluate whether the quantified road safety targets are actually achieved. In this study, we used a binary logistic regression model to examine the factors - including vehicle ownership, fatality rate, and national income, in addition to level of ambition and duration of target - that contribute to a target's success. We analyzed 55 quantified road safety targets set by 29 countries from 1981 to 2009, and the results indicate that targets that are in progress and with lower level of ambitions had a higher likelihood of eventually being achieved. Moreover, possible interaction effects on the association between level of ambition and the likelihood of success are also revealed. Copyright © 2014 Elsevier Ltd. All rights reserved.

Impact of biomarker development on drug safety assessment

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

Marrer, Estelle, E-mail: estelle.marrer@novartis.co; Dieterle, Frank

2010-03-01

Drug safety has always been a key aspect of drug development. Recently, the Vioxx case and several cases of serious adverse events being linked to high-profile products have increased the importance of drug safety, especially in the eyes of drug development companies and global regulatory agencies. Safety biomarkers are increasingly being seen as helping to provide the clarity, predictability, and certainty needed to gain confidence in decision making: early-stage projects can be stopped quicker, late-stage projects become less risky. Public and private organizations are investing heavily in terms of time, money and manpower on safety biomarker development. An illustrative andmore » 'door opening' safety biomarker success story is the recent recognition of kidney safety biomarkers for pre-clinical and limited translational contexts by FDA and EMEA. This milestone achieved for kidney biomarkers and the 'know how' acquired is being transferred to other organ toxicities, namely liver, heart, vascular system. New technologies and molecular-based approaches, i.e., molecular pathology as a complement to the classical toolbox, allow promising discoveries in the safety biomarker field. This review will focus on the utility and use of safety biomarkers all along drug development, highlighting the present gaps and opportunities identified in organ toxicity monitoring. A last part will be dedicated to safety biomarker development in general, from identification to diagnostic tests, using the kidney safety biomarkers success as an illustrative example.« less

Making Homes Healthy: International Code Council Processes and Patterns.

PubMed

Coyle, Edward C; Isett, Kimberley R; Rondone, Joseph; Harris, Rebecca; Howell, M Claire Batten; Brandus, Katherine; Hughes, Gwendolyn; Kerfoot, Richard; Hicks, Diana

2016-01-01

Americans spend more than 90% of their time indoors, so it is important that homes are healthy environments. Yet many homes contribute to preventable illnesses via poor air quality, pests, safety hazards, and others. Efforts have been made to promote healthy housing through code changes, but results have been mixed. In support of such efforts, we analyzed International Code Council's (ICC) building code change process to uncover patterns of content and context that may contribute to successful adoptions of model codes. Discover patterns of facilitators and barriers to code amendments proposals. Mixed methods study of ICC records of past code change proposals. N = 2660. N/A. N/A. There were 4 possible outcomes for each code proposal studied: accepted as submitted, accepted as modified, accepted as modified by public comment, and denied. We found numerous correlates for final adoption of model codes proposed to the ICC. The number of proponents listed on a proposal was inversely correlated with success. Organizations that submitted more than 15 proposals had a higher chance of success than those that submitted fewer than 15. Proposals submitted by federal agencies correlated with a higher chance of success. Public comments in favor of a proposal correlated with an increased chance of success, while negative public comment had an even stronger negative correlation. To increase the chance of success, public health officials should submit their code changes through internal ICC committees or a federal agency, limit the number of cosponsors of the proposal, work with (or become) an active proposal submitter, and encourage public comment in favor of passage through their broader coalition.

Technology and Tool Development to Support Safety and Mission Assurance

NASA Technical Reports Server (NTRS)

Denney, Ewen; Pai, Ganesh

2017-01-01

The Assurance Case approach is being adopted in a number of safety-mission-critical application domains in the U.S., e.g., medical devices, defense aviation, automotive systems, and, lately, civil aviation. This paradigm refocuses traditional, process-based approaches to assurance on demonstrating explicitly stated assurance goals, emphasizing the use of structured rationale, and concrete product-based evidence as the means for providing justified confidence that systems and software are fit for purpose in safely achieving mission objectives. NASA has also been embracing assurance cases through the concepts of Risk Informed Safety Cases (RISCs), as documented in the NASA System Safety Handbook, and Objective Hierarchies (OHs) as put forth by the Agency's Office of Safety and Mission Assurance (OSMA). This talk will give an overview of the work being performed by the SGT team located at NASA Ames Research Center, in developing technologies and tools to engineer and apply assurance cases in customer projects pertaining to aviation safety. We elaborate how our Assurance Case Automation Toolset (AdvoCATE) has not only extended the state-of-the-art in assurance case research, but also demonstrated its practical utility. We have successfully developed safety assurance cases for a number of Unmanned Aircraft Systems (UAS) operations, which underwent, and passed, scrutiny both by the aviation regulator, i.e., the FAA, as well as the applicable NASA boards for airworthiness and flight safety, flight readiness, and mission readiness. We discuss our efforts in expanding AdvoCATE capabilities to support RISCs and OHs under a project recently funded by OSMA under its Software Assurance Research Program. Finally, we speculate on the applicability of our innovations beyond aviation safety to such endeavors as robotic, and human spaceflight.

Controlled versus automatic processes: which is dominant to safety? The moderating effect of inhibitory control.

PubMed

Xu, Yaoshan; Li, Yongjuan; Ding, Weidong; Lu, Fan

2014-01-01

This study explores the precursors of employees' safety behaviors based on a dual-process model, which suggests that human behaviors are determined by both controlled and automatic cognitive processes. Employees' responses to a self-reported survey on safety attitudes capture their controlled cognitive process, while the automatic association concerning safety measured by an Implicit Association Test (IAT) reflects employees' automatic cognitive processes about safety. In addition, this study investigates the moderating effects of inhibition on the relationship between self-reported safety attitude and safety behavior, and that between automatic associations towards safety and safety behavior. The results suggest significant main effects of self-reported safety attitude and automatic association on safety behaviors. Further, the interaction between self-reported safety attitude and inhibition and that between automatic association and inhibition each predict unique variances in safety behavior. Specifically, the safety behaviors of employees with lower level of inhibitory control are influenced more by automatic association, whereas those of employees with higher level of inhibitory control are guided more by self-reported safety attitudes. These results suggest that safety behavior is the joint outcome of both controlled and automatic cognitive processes, and the relative importance of these cognitive processes depends on employees' individual differences in inhibitory control. The implications of these findings for theoretical and practical issues are discussed at the end.

Controlled versus Automatic Processes: Which Is Dominant to Safety? The Moderating Effect of Inhibitory Control

PubMed Central

Xu, Yaoshan; Li, Yongjuan; Ding, Weidong; Lu, Fan

2014-01-01

This study explores the precursors of employees' safety behaviors based on a dual-process model, which suggests that human behaviors are determined by both controlled and automatic cognitive processes. Employees' responses to a self-reported survey on safety attitudes capture their controlled cognitive process, while the automatic association concerning safety measured by an Implicit Association Test (IAT) reflects employees' automatic cognitive processes about safety. In addition, this study investigates the moderating effects of inhibition on the relationship between self-reported safety attitude and safety behavior, and that between automatic associations towards safety and safety behavior. The results suggest significant main effects of self-reported safety attitude and automatic association on safety behaviors. Further, the interaction between self-reported safety attitude and inhibition and that between automatic association and inhibition each predict unique variances in safety behavior. Specifically, the safety behaviors of employees with lower level of inhibitory control are influenced more by automatic association, whereas those of employees with higher level of inhibitory control are guided more by self-reported safety attitudes. These results suggest that safety behavior is the joint outcome of both controlled and automatic cognitive processes, and the relative importance of these cognitive processes depends on employees' individual differences in inhibitory control. The implications of these findings for theoretical and practical issues are discussed at the end. PMID:24520338

10 CFR 50.36 - Technical specifications.

Code of Federal Regulations, 2010 CFR

2010-01-01

..., or component that is part of the primary success path and which functions or actuates to mitigate a... significant safety functions. Where a limiting safety system setting is specified for a variable on which a... the automatic safety system does not function as required, the licensee shall take appropriate action...

Tobacco Industry Efforts to Defeat the Occupational Safety and Health Administration Indoor Air Quality Rule

PubMed Central

Bryan-Jones, Katherine; Bero, Lisa A.

2003-01-01

Objectives. We describe tobacco industry strategies to defeat the Occupational Safety and Health Administration (OSHA) Indoor Air Quality rule and the implementation of those strategies. Methods. We analyzed tobacco industry documents, public commentary on, and media coverage of the OSHA rule. Results. The tobacco industry had 5 strategies: (1) maintain scientific debate about the basis of the rule, (2) delay deliberation on the rule, (3) redefine the scope of the rule, (4) recruit and assist labor and business organizations in opposing the rule, and (5) increase media coverage of the tobacco industry position. The tobacco industry successfully implemented all 5 strategies. Conclusions. Our findings suggest that regulatory authorities must take into account the source, motivation, and validity of arguments used in the regulatory process in order to make accurately informed decisions. PMID:12660202

Blood transfusion: patient identification and empowerment.

PubMed

Stout, Lynn; Joseph, Sundari

Positive patient identification is pivotal to several steps of the transfusion process; it is integral to ensuring that the correct blood is given to the correct patient. If patient misidentification occurs, this has potentially fatal consequences for patients. Historically patient involvement in healthcare has focused on clinical decision making, where the patient, having been provided with medical information, is encouraged to become involved in the decisions related to their individualised treatment. This article explores the aspects of patient contribution to patient safety relating to positive patient identification in transfusion. When involving patients in their care, however, clinicians must recognise the diversity of patients and the capacity of the patient to be involved. It must not be assumed that all patients will be willing or indeed able to participate. Additionally, clinicians' attitudes to patient involvement in patient safety can determine whether cultural change is successful.

Launch Commit Criteria Monitoring Agent

NASA Technical Reports Server (NTRS)

Semmel, Glenn S.; Davis, Steven R.; Leucht, Kurt W.; Rowe, Dan A.; Kelly, Andrew O.; Boeloeni, Ladislau

2005-01-01

The Spaceport Processing Systems Branch at NASA Kennedy Space Center has developed and deployed a software agent to monitor the Space Shuttle's ground processing telemetry stream. The application, the Launch Commit Criteria Monitoring Agent, increases situational awareness for system and hardware engineers during Shuttle launch countdown. The agent provides autonomous monitoring of the telemetry stream, automatically alerts system engineers when predefined criteria have been met, identifies limit warnings and violations of launch commit criteria, aids Shuttle engineers through troubleshooting procedures, and provides additional insight to verify appropriate troubleshooting of problems by contractors. The agent has successfully detected launch commit criteria warnings and violations on a simulated playback data stream. Efficiency and safety are improved through increased automation.

Fabrication of highly oriented nanoporous fibers via airflow bubble-spinning

NASA Astrophysics Data System (ADS)

Liu, Fujuan; Li, Shaokai; Fang, Yue; Zheng, Fangfang; Li, Junhua; He, Jihuan

2017-11-01

Highly oriented Poly(lactic acid) (PLA) nanofibers with nanoporous structures has been successfully fabricated via airflow bubble-spinning without electrostatic hazard. In this work, the volatile solvent was necessary for preparing the nanoporous fiber, which was attributed to the competition between phase separation and solvent evaporation. The interconnected porous structures were affected by the processing variables of solution concentration, airflow temperature, collecting distance and relative humidity (RH). Besides, the rheological properties of solutions were studied and the highly oriented PLA nanofibers with nanoporous structure were also completely characterized using scanning electron microscope (SEM). This study provided a novel technique that successfully gets rid of the potential safety hazards caused by unexpected static to prepare highly oriented nanoporous fibers, which would demonstrate an impressive prospect for the fields of adsorption and filtration.

Implementing Software Safety in the NASA Environment

NASA Technical Reports Server (NTRS)

Wetherholt, Martha S.; Radley, Charles F.

1994-01-01

Until recently, NASA did not consider allowing computers total control of flight systems. Human operators, via hardware, have constituted the ultimate safety control. In an attempt to reduce costs, NASA has come to rely more and more heavily on computers and software to control space missions. (For example. software is now planned to control most of the operational functions of the International Space Station.) Thus the need for systematic software safety programs has become crucial for mission success. Concurrent engineering principles dictate that safety should be designed into software up front, not tested into the software after the fact. 'Cost of Quality' studies have statistics and metrics to prove the value of building quality and safety into the development cycle. Unfortunately, most software engineers are not familiar with designing for safety, and most safety engineers are not software experts. Software written to specifications which have not been safety analyzed is a major source of computer related accidents. Safer software is achieved step by step throughout the system and software life cycle. It is a process that includes requirements definition, hazard analyses, formal software inspections, safety analyses, testing, and maintenance. The greatest emphasis is placed on clearly and completely defining system and software requirements, including safety and reliability requirements. Unfortunately, development and review of requirements are the weakest link in the process. While some of the more academic methods, e.g. mathematical models, may help bring about safer software, this paper proposes the use of currently approved software methodologies, and sound software and assurance practices to show how, to a large degree, safety can be designed into software from the start. NASA's approach today is to first conduct a preliminary system hazard analysis (PHA) during the concept and planning phase of a project. This determines the overall hazard potential of the system to be built. Shortly thereafter, as the system requirements are being defined, the second iteration of hazard analyses takes place, the systems hazard analysis (SHA). During the systems requirements phase, decisions are made as to what functions of the system will be the responsibility of software. This is the most critical time to affect the safety of the software. From this point, software safety analyses as well as software engineering practices are the main focus for assuring safe software. While many of the steps proposed in this paper seem like just sound engineering practices, they are the best technical and most cost effective means to assure safe software within a safe system.

A qualitative evaluation of fire safety education programs for older adults.

PubMed

Diekman, Shane T; Stewart, Tamara A; Teh, S Leesia; Ballesteros, Michael F

2010-03-01

This article presents a qualitative evaluation of six fire safety education programs for older adults delivered by public fire educators. Our main aims were to explore how these programs are implemented and to determine important factors that may lead to program success, from the perspectives of the public fire educators and the older adults. For each program, we interviewed the public fire educator(s), observed the program in action, and conducted focus groups with older adults attending the program. Analysis revealed three factors that were believed to facilitate program success (established relationships with the older adult community, rapport with older adult audiences, and presentation relevance) as well as three challenges (lack of a standardized curriculum and program implementation strategies, attendance difficulties, and physical limitations due to age). More fire safety education should be developed for older adult populations. For successful programs, public fire educators should address the specific needs of their local older adult community.

Defining Desirable Central Nervous System Drug Space through the Alignment of Molecular Properties, in Vitro ADME, and Safety Attributes

PubMed Central

2010-01-01

As part of our effort to increase survival of drug candidates and to move our medicinal chemistry design to higher probability space for success in the Neuroscience therapeutic area, we embarked on a detailed study of the property space for a collection of central nervous system (CNS) molecules. We carried out a thorough analysis of properties for 119 marketed CNS drugs and a set of 108 Pfizer CNS candidates. In particular, we focused on understanding the relationships between physicochemical properties, in vitro ADME (absorption, distribution, metabolism, and elimination) attributes, primary pharmacology binding efficiencies, and in vitro safety data for these two sets of compounds. This scholarship provides guidance for the design of CNS molecules in a property space with increased probability of success and may lead to the identification of druglike candidates with favorable safety profiles that can successfully test hypotheses in the clinic. PMID:22778836

NAVIGATING A QUALITY ROUTE TO A NATIONAL SAFETY AWARD

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

PREVETTE SS

Deming quality methodologies applied to safety are recognized with the National Safety Council's annual Robert W. Campbell Award. Over the last ten years, the implementation of Statistical Process Control and quality methodologies at the U.S. Department of Energy's Hanford Site have contributed to improved safety. Improvements attributed to Statistical Process Control are evidenced in Occupational Safety and Health records and documented through several articles in Quality Progress and the American Society of Safety Engineers publication, Professional Safety. Statistical trending of safety, quality, and occurrence data continues to playa key role in improving safety and quality at what has been calledmore » the world's largest environmental cleanup project. DOE's Hanford Site played a pivotal role in the nation's defense beginning in the 1940s, when it was established as part of the Manhattan Project. After more than 50 years of producing material for nuclear weapons, Hanford, which covers 586 square miles in southeastern Washington state, is now focused on three outcomes: (1) Restoring the Columbia River corridor for multiple uses; (2) Transitioning the central plateau to support long-term waste management; and (3) Putting DOE assets to work for the future. The current environmental cleanup mission faces challenges of overlapping technical, political, regulatory, environmental, and cultural interests. From Oct. 1, 1996 through Sept. 30, 2008, Fluor Hanford was a prime contractor to the Department of Energy's Richland Operations Office. In this role, Fluor Hanford managed several major cleanup activities that included dismantling former nuclear-processing facilities, cleaning up the Site's contaminated groundwater, retrieving and processing transuranic waste for shipment and disposal off-site, maintaining the Site's infrastructure, providing security and fire protection, and operating the Volpentest HAMMER Training and Education Center. On October 1,2008, a transition occurred that changed Fluor's role at Hanford. Fluor's work at Hanford was split in two with the technical scope being assumed by the CH2M HILL Plateau Remediation Company (CHPRC) CHPRC is now spearheading much of the cleanup work associated with former nuclear-processing facilities, contaminated groundwater, and transuranic waste. Fluor is an integrated subcontractor to CH PRC in this effort. In addition, at the time of this writing, while the final outcome is being determined for the new Mission Support Contract, Fluor Hanford has had its contract extended to provide site-wide services that include security, fire protection, infrastructure, and operating the HAMMER facility. The emphasis has to be on doing work safely, delivering quality work, controlling costs, and meeting deadlines. Statistical support is provided by Fluor to the PRC, within Fluor Hanford, and to a third contractor, Washington Closure Hanford, which is tasked with cleaning up approximately 210 square miles designated as the Columbia River corridor along the outer edge of the Hanford Site. The closing months of Fluor Hanford's 12 year contract were busy, characterized by special events that capped its work as a prime cleanup contractor, transitions of work scope and personnel, and the completion numerous activities. At this time, Fluor's work and approach to safety were featured in state and national forums. A 'Blockbuster' presentation at the Washington State Governor's Industrial Safety Conference in September 2008 featured Fluor Hanford's Chief Operating Officer, a company Safety Representative, and me. Simultaneously, an award ceremony in Anaheim, Calif. recognized Fluor Hanford as the winner of the 2008 Robert W. Campbell Award. The Robert W. Campbell Award is co-sponsored by Exxon Mobil Corporation and the National Safety Council. Named after a pioneer of industrial safety, the Campbell Award recognizes organizations that demonstrate how integration of environmental, health and safety (EHS) management into business operations is a cornerstone of their corporate success. Fluor Hanford received the award for corporations with more than 1,000 employees. Campbell Award winners undergo rigorous assessments that include site visits and comprehensive evaluations of their commitment to, and implementation of, EHS practices. Award winners work with an international partnership of 21 organizations to develop case studies that illustrate their superior EHS programs and best practices, for use by top business and engineering schools worldwide. Quality methodologies in place at Fluor Hanford played a key role in the award process. Fluor Hanford's integrated use of Statistical Process Control and Pareto Charts for analyzing and displaying EHS performance were viewed favorably by the award judges.« less

Review article: practical current issues in perioperative patient safety.

PubMed

Eichhorn, John H

2013-02-01

This brief review provides an overview and, importantly, a context perspective of relevant current practical issues in perioperative patient safety. The dramatic improvement in anesthesia patient safety over the last 30 years was not initiated by electronic monitors but, rather, largely by a set of behaviours known as "safety monitoring" that were then made decidedly more effective by extending the human senses through electronic monitoring, for example, capnography and pulse oximetry. In the highly developed world, this current success is threatened by complacency and production pressure. In some areas of the developing/underdeveloped world, the challenge is implementing the components of anesthesia practice that will bring safety improvements to parallel the overall current success, for instance, applying the World Federation of Societies of Anaesthesiologists (WFSA) "International Standards for A Safe Practice of Anaesthesia". Generally, expanding the current success in safety involves many practical issues. System issues involve research, effective reporting mechanisms and analysis/broadcasting of results, perioperative communication (including "speaking up to power"), and checklists. Monitoring issues involve enforcing existing published monitoring standards and also recognizing the risk of danger to the patient from hypoventilation during procedural sedation and from postoperative intravenous pain medications. Issues of clinical care include medication errors in the operating room, cerebral hypoperfusion (especially in the head-up position), dangers of airway management, postoperative residual weakness from muscle relaxants, operating room fires, and risks specific in obstetric anesthesia. Recognition of the issues outlined here and empowerment of all anesthesia professionals, from the most senior professors and administrators to the newest practitioners, should help maintain, solidify, and expand the improvements in anesthesia and perioperative patient safety.

KSC-06pd1420

NASA Image and Video Library

2006-07-04

KENNEDY SPACE CENTER, FLA. - In Firing Room 4 of the Launch Control Center, Shuttle Launch Director Mike Leinbach (foreground) cheers over the successful liftoff of Space Shuttle Discovery, watching it rocket through the sky on mission STS-121 -- the first ever Independence Day launch of a space shuttle. At far left is Stephanie Stilson, NASA flow director in the Process Integration Branch of the Shuttle Processing Directorate, who began conducting Discovery's processing operations in December 2000. Liftoff was on-time at 2:38 p.m. EDT. During the 12-day mission, the STS-121 crew of seven will test new equipment and procedures to improve shuttle safety, as well as deliver supplies and make repairs to the International Space Station. Landing is scheduled for July 16 or 17 at Kennedy's Shuttle Landing Facility. Photo credit: NASA/Kim Shiflett

Envisioning successful teamwork: An exploratory qualitative study of team processes used by nursing teams in a paediatric hospital unit.

PubMed

Whitehair, Leeann; Hurley, John; Provost, Steve

2018-06-12

To explore how team processes support nursing teams in hospital units during every day work. Due to their close proximity to patients, nurses are central to the process of maintaining patient safety. Globally, changes in models of care delivery by nurses, inclusive of team nursing are being considered. This qualitative study used purposive sampling in a single hospital and participants were nurses employed to work on a paediatric unit. Data was collected using non-participant observation. Thematic analysis was used to analyse and code data to create themes. Three clear themes emerged. Theme 1:"We are a close knit team"; Behaviours building a successful team"- outlines expectations regarding how members are to behave when establishing, nurturing and managing a team. Theme 2: "Onto it"; Ways of interacting with each other" - Identifies the expected pattern of relating within the team which contribute to shared understanding and actions. Theme 3: "No point in second guessing"; Maintaining a global view of the unit" - focuses on the processes for monitoring and reporting signals that team performance is on course or breaking down and includes accepting responsibility to lead the team and team members having a widespread sensitivity to what needs to happen. Essential to successful teamwork is the interplay and mutuality of team members and team leaders. Leadership behaviours exhibited in this study provide useful insights to how informal and shared or distributed leadership of teams may be achieved. Without buy-in from team members, teams may not achieve successful desired outcomes. It is not sufficient for teams to rely on current successful outcomes, as they need to be on the look-out for new ways to ensure that they can anticipate possible risks or threats to the team before harm is done. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Barriers to, and facilitators of, the prevention of unintentional injury in children in the home: a systematic review and synthesis of qualitative research.

PubMed

Smithson, Janet; Garside, Ruth; Pearson, Mark

2011-04-01

This review considers barriers to, and facilitators of, success for interventions to reduce unintentional injury to children in the home through supply and/or installation of home safety equipment, and looks at risk assessments. A systematic review of qualitative research. Bibliographic databases were searched for studies on interventions to reduce unintentional child injury in the home, or on related attitudes and behaviours. Studies were quality appraised, findings extracted, and a conceptual framework was developed to assess factors affecting the success of interventions. Nine peer-reviewed journal articles were included. Barriers and facilitators were highlighted at organisational, environmental and personal levels. Effective provision of safety equipment involves ongoing support with installation and maintenance. Take up and success of interventions depends on adjusting interventions according to practical limitations and parents' cultural expectations. A particular barrier was parents' inability to modify rented or shared accommodation. The review highlights ways in which health inequalities affect the take up and success of home safety interventions, and how health workers can use this knowledge to facilitate future interventions.

Vaccine safety monitoring systems in developing countries: an example of the Vietnam model.

PubMed

Ali, Mohammad; Rath, Barbara; Thiem, Vu Dinh

2015-01-01

Only few health intervention programs have been as successful as vaccination programs with respect to preventing morbidity and mortality in developing countries. However, the success of a vaccination program is threatened by rumors and misunderstanding about the risks of vaccines. It is short-sighted to plan the introduction of vaccines into developing countries unless effective vaccine safety monitoring systems are in place. Such systems that track adverse events following immunization (AEFI) is currently lacking in most developing countries. Therefore, any rumor may affect the entire vaccination program. Public health authorities should implement the safety monitoring system of vaccines, and disseminate safety issues in a proactive mode. Effective safety surveillance systems should allow for the conduct of both traditional and alternative epidemiologic studies through the use of prospective data sets. The vaccine safety data link implemented in Vietnam in mid-2002 indicates that it is feasible to establish a vaccine safety monitoring system for the communication of vaccine safety in developing countries. The data link provided the investigators an opportunity to evaluate AEFI related to measles vaccine. Implementing such vaccine safety monitoring system is useful in all developing countries. The system should be able to make objective and clear communication regarding safety issues of vaccines, and the data should be reported to the public on a regular basis for maintaining their confidence in vaccination programs.

Process-Based Mission Assurance- Knowledge Management System

NASA Astrophysics Data System (ADS)

Kantzes, Zachary S.; Wander, Stephen; Otero, Suzanne; Vantine, William; Stuart, Richard

2005-12-01

The Process-Based Mission Assurance - Knowledge Management System (PBMA-KMS) implemented at the National Aeronautics and Space Administration (NASA) focuses on the practical application of the knowledge management (KM) theory and is based on a systems engineering management approach coupled to a continual improvement and risk management philosophy. Not to be confused with an Agency mandate, an intense focus has been placed on grassroots input to the future of the product. By providing emphasis to both Agency safety and mission success objectives and individual users' needs, the PBMA-KMS team has been able to be both reactive to Agency requirements and proactive to the needs of the community.PBMA-KMS is an excellent case study on how to use new approaches to facilitate and integrate safety into the culture of an organization. Principle discussion topics include: • Overarching themes,• Tactical approaches,• Highlights of key functionalities, and• Agency KM approach of managed Darwinism.PBMA-KMS can show how, by providing top-level guidance along with the necessary tools and support, the organization not only receives immediate value, but the long-ranging benefits of a more experienced, effective, and engaged workforce.

[Statement: Requirements for the assessment of surgical innovations].

PubMed

Seidel, Dörthe; Pieper, Dawid; Neugebauer, Edmund

2015-01-01

The term "innovation" refers to new products, but also to the process of developing and distributing new products and procedures. The operative disciplines are often associated with innovations because of their continuous, stepwise adaptation of daily practice to established procedures. Medical devices play a significant role in integrating surgical technology with surgical experience. The success of a surgical innovation and other invasive treatments does not only depend on the surgical procedure, but also on the context of the whole treatment process including the pre- and postoperative phase, the interaction of the surgical team and the setting. High standards have been set for the assessment of surgical innovations in terms of patient safety, efficacy and patient benefit, which will be discussed in the present paper. A stepwise approach to evaluation will be used, split into preclinical development, clinical development (feasibility and safety), evaluation phase (efficacy and patient benefit) and longtime surveillance. Our paper is based on the expert-based consented IDEAL approach as well as the consented recommendations of the European Association of Endoscopic Surgery (EAES). (As supplied by publisher). Copyright © 2015. Published by Elsevier GmbH.

Establishing a proactive safety and health risk management system in the fire service.

PubMed

Poplin, Gerald S; Pollack, Keshia M; Griffin, Stephanie; Day-Nash, Virginia; Peate, Wayne F; Nied, Ed; Gulotta, John; Burgess, Jefferey L

2015-04-19

Formalized risk management (RM) is an internationally accepted process for reducing hazards in the workplace, with defined steps including hazard scoping, risk assessment, and implementation of controls, all within an iterative process. While required for all industry in the European Union and widely used elsewhere, the United States maintains a compliance-based regulatory structure, rather than one based on systematic, risk-based methodologies. Firefighting is a hazardous profession, with high injury, illness, and fatality rates compared with other occupations, and implementation of RM programs has the potential to greatly improve firefighter safety and health; however, no descriptions of RM implementation are in the peer-reviewed literature for the North American fire service. In this paper we describe the steps used to design and implement the RM process in a moderately-sized fire department, with particular focus on prioritizing and managing injury hazards during patient transport, fireground, and physical exercise procedures. Hazard scoping and formalized risk assessments are described, in addition to the identification of participatory-led injury control strategies. Process evaluation methods were conducted to primarily assess the feasibility of voluntarily instituting the RM approach within the fire service setting. The RM process was well accepted by the fire department and led to development of 45 hazard specific-interventions. Qualitative data documenting the implementation of the RM process revealed that participants emphasized the: value of the RM process, especially the participatory bottom-up approach; usefulness of the RM process for breaking down tasks to identify potential risks; and potential of RM for reducing firefighter injury. As implemented, this risk-based approach used to identify and manage occupational hazards and risks was successful and is deemed feasible for U.S. (and other) fire services. While several barriers and challenges do exist in the implementation of any intervention such as this, recommendations for adopting the process are provided. Additional work will be performed to determine the effectiveness of select controls strategies that were implemented; however participants throughout the organizational structure perceived the RM process to be of high utility while researchers also found the process improved the awareness and engagement in actively enhancing worker safety and health.

The Implementation and Maintenance of a Behavioral Safety Process in a Petroleum Refinery

ERIC Educational Resources Information Center

Myers, Wanda V.; McSween, Terry E.; Medina, Rixio E.; Rost, Kristen; Alvero, Alicia M.

2010-01-01

A values-centered and team-based behavioral safety process was implemented in a petroleum oil refinery. Employee teams defined the refinery's safety values and related practices, which were used to guide the process design and implementation. The process included (a) a safety assessment; (b) the clarification of safety-related values and related…

A formative evaluation of the implementation of a medication safety data collection tool in English healthcare settings: A qualitative interview study using normalisation process theory.

PubMed

Rostami, Paryaneh; Ashcroft, Darren M; Tully, Mary P

2018-01-01

Reducing medication-related harm is a global priority; however, impetus for improvement is impeded as routine medication safety data are seldom available. Therefore, the Medication Safety Thermometer was developed within England's National Health Service. This study aimed to explore the implementation of the tool into routine practice from users' perspectives. Fifteen semi-structured interviews were conducted with purposely sampled National Health Service staff from primary and secondary care settings. Interview data were analysed using an initial thematic analysis, and subsequent analysis using Normalisation Process Theory. Secondary care staff understood that the Medication Safety Thermometer's purpose was to measure medication safety and improvement. However, other uses were reported, such as pinpointing poor practice. Confusion about its purpose existed in primary care, despite further training, suggesting unsuitability of the tool. Decreased engagement was displayed by staff less involved with medication use, who displayed less ownership. Nonetheless, these advocates often lacked support from management and frontline levels, leading to an overall lack of engagement. Many participants reported efforts to drive scale-up of the use of the tool, for example, by securing funding, despite uncertainty around how to use data. Successful improvement was often at ward-level and went unrecognised within the wider organisation. There was mixed feedback regarding the value of the tool, often due to a perceived lack of "capacity". However, participants demonstrated interest in learning how to use their data and unexpected applications of data were reported. Routine medication safety data collection is complex, but achievable and facilitates improvements. However, collected data must be analysed, understood and used for further work to achieve improvement, which often does not happen. The national roll-out of the tool has accelerated shared learning; however, a number of difficulties still exist, particularly in primary care settings, where a different approach is likely to be required.

A formative evaluation of the implementation of a medication safety data collection tool in English healthcare settings: A qualitative interview study using normalisation process theory

PubMed Central

Ashcroft, Darren M.; Tully, Mary P.

2018-01-01

Background Reducing medication-related harm is a global priority; however, impetus for improvement is impeded as routine medication safety data are seldom available. Therefore, the Medication Safety Thermometer was developed within England’s National Health Service. This study aimed to explore the implementation of the tool into routine practice from users’ perspectives. Method Fifteen semi-structured interviews were conducted with purposely sampled National Health Service staff from primary and secondary care settings. Interview data were analysed using an initial thematic analysis, and subsequent analysis using Normalisation Process Theory. Results Secondary care staff understood that the Medication Safety Thermometer’s purpose was to measure medication safety and improvement. However, other uses were reported, such as pinpointing poor practice. Confusion about its purpose existed in primary care, despite further training, suggesting unsuitability of the tool. Decreased engagement was displayed by staff less involved with medication use, who displayed less ownership. Nonetheless, these advocates often lacked support from management and frontline levels, leading to an overall lack of engagement. Many participants reported efforts to drive scale-up of the use of the tool, for example, by securing funding, despite uncertainty around how to use data. Successful improvement was often at ward-level and went unrecognised within the wider organisation. There was mixed feedback regarding the value of the tool, often due to a perceived lack of “capacity”. However, participants demonstrated interest in learning how to use their data and unexpected applications of data were reported. Conclusion Routine medication safety data collection is complex, but achievable and facilitates improvements. However, collected data must be analysed, understood and used for further work to achieve improvement, which often does not happen. The national roll-out of the tool has accelerated shared learning; however, a number of difficulties still exist, particularly in primary care settings, where a different approach is likely to be required. PMID:29489842

Making Stronger Twine With Matched Strands

NASA Technical Reports Server (NTRS)

Kirkland, W. L.

1985-01-01

Higher tensil strength achieved with same production equipment. Strong twine made by using spools in one of two-step manufacturing process. Three primary strands twisted together in opposite direction to form threeply twine. Technique used successfully in manufacture of safety netting with 600- to 700-lb (2,700-to 3,100-N) tensil strength and 60-ton (54 x 10 to third power kg) tuna seine with area of 86 acres (3.5 x 10 to fifth power m2). Increase in tensil strength of completed twine found experimentally 10 to 12 percent.

Supporting Command and Control (C2) of an Embarked Commander: Tunneling SIPRNet Data Across an UNCLAS Wireless LAN

DTIC Science & Technology

2011-09-01

that you did to help me through this process. Your efforts and guidance truly made this a success. To SPAWAR SCTD expert Stephanie Koontz , your...ty%20and%20Safety%20Services/05– 500%20Security%20Services/5510.36A.pdf [accessed June 19, 2011]. [28] S. Koontz . “Secret client tunneling...devices - KOV-26 talon user procedures.” Unpublished survey, SPAWAR, Point Loma, CA. [29] S. Koontz . “Secret client tunneling devices - KIV-54 user

Advanced reliability modeling of fault-tolerant computer-based systems

NASA Technical Reports Server (NTRS)

Bavuso, S. J.

1982-01-01

Two methodologies for the reliability assessment of fault tolerant digital computer based systems are discussed. The computer-aided reliability estimation 3 (CARE 3) and gate logic software simulation (GLOSS) are assessment technologies that were developed to mitigate a serious weakness in the design and evaluation process of ultrareliable digital systems. The weak link is based on the unavailability of a sufficiently powerful modeling technique for comparing the stochastic attributes of one system against others. Some of the more interesting attributes are reliability, system survival, safety, and mission success.

Lessons from a Successful Implementation of a Computerized Provider Order Entry System

PubMed Central

Jacobs, Brian R.; Hallstrom, Craig K.; Hart, Kim Ward; Mahoney, Daniela; Lykowski, Gayle

2007-01-01

OBJECTIVES The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS. METHODS Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included. RESULTS Nine distinct challenges were identified: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician. CONCLUSIONS Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success. PMID:23055847

49 CFR 180.511 - Acceptable results of inspections and tests.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) Safety system inspection. A tank car successfully passes the safety system inspection when each thermal..., distortion, excessive permanent expansion, or other evidence of weakness that might render the tank car...

Implementing local agency safety management

DOT National Transportation Integrated Search

2003-12-17

For local agencies to mount a successful effort toward reducing motor vehicle collisions and their costs, an effective systematic approach must be taken. A Safety Management System (SMS) has two basic components: a collaborative information exchange ...

January, 2018 Mission Success is in Our Hands.

NASA Image and Video Library

2018-01-18

Vernon "Bill" Wessel, former associate director of NASA's Glenn Research Center from 2006-2011, addresses team members at NASA's Marshall Space Flight Center Jan. 19 as part of the "Mission Success in in Our Hands" Shared Experiences forum. Wessel, currently senior vice president of Ares Corp. and deputy of the Huntsville-based company's Space & Defense Division, spoke about his 30-year NASA career and the importance of workplace safety. "Keep in your head every day and in every way that safety is number one," he said. "When you meet people, ask them, 'How are you doing today? How's the job? How are you staying safe?' These are the things that are important." The bimonthly Shared Experiences forum, a Marshall safety initiative to promote and strengthen mission assurance and flight safety, is sponsored by NASA partner Jacobs Engineering of Huntsville.

Promoting Automobile Safety Belt Use by Young Children.

ERIC Educational Resources Information Center

Sowers-Hoag, Karen M.; And Others

1987-01-01

A program of behavioral practice, assertiveness training, and social and contrived reinforcers was successful in establishing and maintaining automobile safety belt use by 16 children (ages 4-7) who never used them during a five-day preobservation period. Safety belt use occurred during 76%-90% of follow-up observations after two-three months.…

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…

Calculations of reliability predictions for the Apollo spacecraft

NASA Technical Reports Server (NTRS)

Amstadter, B. L.

1966-01-01

A new method of reliability prediction for complex systems is defined. Calculation of both upper and lower bounds are involved, and a procedure for combining the two to yield an approximately true prediction value is presented. Both mission success and crew safety predictions can be calculated, and success probabilities can be obtained for individual mission phases or subsystems. Primary consideration is given to evaluating cases involving zero or one failure per subsystem, and the results of these evaluations are then used for analyzing multiple failure cases. Extensive development is provided for the overall mission success and crew safety equations for both the upper and lower bounds.

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

PubMed

McNab, Duncan; Bowie, Paul; Morrison, Jill; Ross, Alastair

2016-11-01

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.

Stennis Space Center observes 2009 Safety and Health Day

NASA Technical Reports Server (NTRS)

2009-01-01

Sue Smith, a medical clinic employee at NASA's John C. Stennis Space Center, takes the temperature of colleague Karen Badon during 2009 Safety and Health Day activities Oct. 22. Safety Day activities included speakers, informational sessions and a number of displays on safety and health issues. Astronaut Dominic Gorie also visited the south Mississippi rocket engine testing facility during the day to address employees and present several Silver Snoopy awards for outstanding contributions to flight safety and mission success. The activities were part of an ongoing safety and health emphasis at Stennis.

IGIV: contents, properties, and methods of industrial production--evolving closer to a more physiologic product.

PubMed

Martin, Turf D

2006-04-01

Is the process the product? Immune globulin intravenous (IGIV) is not manufactured, but is purified (fractionated) from human plasma. Machines can only damage what Mother Nature makes; they cannot improve it. Therefore, fractionators of biologic molecules must strive to ensure what is taken from a human body is exactly the same when it is returned to the human body for optimal tolerability and safety. The processes of purification have the potential to adversely affect the product. Four primary purification processes exist for commercial IGIV. The Cohn-Oncley process is 1940s technology, which has been modified through the decades, but the basic process remains unchanged. The Kistler-Nitschmann process was developed in the 1950s by the Central Laboratory of the Swiss Red Cross (ZLB, today known as ZLB-Behring, a subsidiary of CSL Limited). Various attempts have been made to utilize chromatography as the sole separation technology without much success. Most recently, Bayer HealthCare (Talecris Biotherapeutics acquired the contributed assets of the worldwide plasma business of Bayer Biological Products and became operational April 1, 2005; all plasma-based products, including Gamunex, Prolastin, the hyperimmune line (Fraction II), Plasbumin (Bayer Albumin), Koate DVI, and Thrombate III were included) introduced a new product into the United States and Canada that utilizes caprylate and chromatography for high purity, better yields, and integration of safety and efficacy. This is the first new IGIV purification technology in over 20 years.

Using signals associated with safety in avoidance learning: computational model of sex differences

PubMed Central

Beck, Kevin D.; Pang, Kevin C.H.; Myers, Catherine E.

2015-01-01

Avoidance behavior involves learning responses that prevent upcoming aversive events; these responses typically extinguish when the aversive events stop materializing. Stimuli that signal safety from aversive events can paradoxically inhibit extinction of avoidance behavior. In animals, males and females process safety signals differently. These differences help explain why women are more likely to be diagnosed with an anxiety disorder and exhibit differences in symptom presentation and course compared to men. In the current study, we extend an existing model of strain differences in avoidance behavior to simulate sex differences in rats. The model successfully replicates data showing that the omission of a signal associated with a period of safety can facilitate extinction in females, but not males, and makes novel predictions that this effect should depend on the duration of the period, the duration of the signal itself, and its occurrence within that period. Non-reinforced responses during the safe period were also found to be important in the expression of these patterns. The model also allowed us to explore underlying mechanisms for the observed sex effects, such as whether safety signals serve as occasion setters for aversive events, to determine why removing them can facilitate extinction of avoidance. The simulation results argue against this account, and instead suggest the signal may serve as a conditioned reinforcer of avoidance behavior. PMID:26213650

The challenges for global harmonisation of food safety norms and regulations: issues for India.

PubMed

Prakash, Jamuna

2014-08-01

Safe and adequate food is a human right, safety being a prime quality attribute without which food is unfit for consumption. Food safety regulations are framed to exercise control over all types of food produced, processed and sold so that the customer is assured that the food consumed will not cause any harm. From the Indian perspective, global harmonisation of food regulations is needed to improve food and nutrition security, the food trade and delivery of safe ready-to-eat (RTE) foods at all places and at all times. The Millennium Development Goals (MDGs) put forward to transform developing societies incorporate many food safety issues. The success of the MDGs, including that of poverty reduction, will in part depend on an effective reduction of food-borne diseases, particularly among the vulnerable group, which includes women and children. Food- and water-borne illnesses can be a serious health hazard, being responsible for high incidences of morbidity and mortality across all age groups of people. Global harmonisation of food regulations would assist in facilitating food trade within and outside India through better compliance, ensuring the safety of RTE catered foods, as well as addressing issues related to the environment. At the same time, regulations need to be optimum, as overregulation may have undue negative effects on the food trade. © 2013 Society of Chemical Industry.

Comprehensibility of traffic signs among urban drivers in Turkey.

PubMed

Kirmizioglu, Erkut; Tuydes-Yaman, Hediye

2012-03-01

Traffic signs are commonly used traffic safety tools, mainly developed to provide crucial information in a short time to support safe drive; but the success depends on their comprehensibility by the drivers. Also, a sudden change in the traditionally used and accepted signs can cause significant safety problem, as in the case of cancellation of red oblique bars in 2004 as a part of the European Union Harmonization Process of Turkey. Having a severe traffic safety problem in Turkey, a need to assess both the comprehensibility of internationally accepted traffic signs and current level of driver education, was the main motivation behind this study. A paper-based survey study in 2009 that reached a sample of 1478 urban drivers in the City of Ankara, focused on the determination of comprehensibility of 30 selected traffic signs, which are commonly used and critical for safety, including two recently changed signs. The meaning of each sign is sought using an open-ended question format to capture different levels and types of comprehensions, which enabled the detection of "opposite" and "partially correct" answers besides "wrong" and "correct" ones. High comprehensibility of 9 control group signs shows the validity of the study. The recently changed signs are among the oppositely associated ones proving the increased risk in traffic safety and need for more aggressive campaigning to publicize them. Copyright © 2011 Elsevier Ltd. All rights reserved.

The management of ultrasound equipment at Sheffield Teaching Hospitals NHS Foundation Trust

PubMed Central

Peacock, M

2013-01-01

Management of ultrasound equipment at Sheffield Teaching Hospitals NHS Foundation Trust is described. The organisation and input of various stakeholders and their involvement with ultrasound equipment management and scientific ultrasound is discussed. Two important stakeholders are the Medical Equipment Management Group and the Radiation Safety Steering Committee. The Medical Equipment Management Group has a specific sub-group, the Ultrasound sub-group, and its role is to coordinate the purchase, replacement and quality assurance of ultrasound equipment in the Trust. The Radiation Safety Steering Committee has a non-ionising radiation representative and the role of this committee is to provide corporate assurance that any health and safety issues arising from the use of radiation to either patients, members of the public or staff within the Trust are being effectively managed. The Ultrasound sub-group of the Medical Equipment Management Group has successfully brought together management of all ultrasound equipment within the Trust and is in the process of fulfilling the quality assurance and training milestones set out by the Medical Equipment Management Group. Advice from the Radiation Safety Steering Committee has helped to increase awareness of ultrasound safety and good scanning practice, especially in the case of neonatal ultrasound imaging, within the Trust. In addition, the RSSC has given advice on clinical pathways for patients undergoing ionising radiation imaging while being treated by extra-corporeal shockwave lithotripsy. PMID:27433195

[The INSuLa Project: the survey of training needs in the SPSAL(Service for Prevention and Safety in the Work Environment)].

PubMed

Martini, Agnese; Iavicoli, Sergio; Bonafede, Michela; Corso, Luca; Iosuel, Michela; Isolani, Lucia; Di Leone, Giorgio; Di Marzio, Davide; Bertazzi, Pier Alberto

2014-01-01

According to Italian Legislative Decree 81/2008 and subsequent modifications the Regions and Autonomous Provinces have a innovative and complex role: 1) to regulate and coordinate the total prevention system and 2) to develop interventions/initiatives through regional/local occupational safety and health (OSH) department using not only inspections and controls but education, training and support. Recommendations also include consolidating the role of actors involved in preventing risks to occupational health throughout occupational safety and health education and training, keys for a successful process to improve prevention system. As result of changing world of work and OSH legislation the INSuLa project has creating a national survey involving of all Italian prevention system actors, in order to evaluate implementation and impact of the actual regulations. According to overall objective of the INSuLA project, for the first time in Italy, we studied about operators in regional/local OSH department. The purpose of this paper is to show and recognize the individual learning paths, the perception of adequacy education degree, the exploring criticalities andthe training needs.

Nursing Information Systems Requirements: A Milestone for Patient Outcome and Patient Safety Improvement.

PubMed

Farzandipour, Mehrdad; Meidani, Zahra; Riazi, Hossein; Sadeqi Jabali, Monireh

2016-12-01

Considering the integral role of understanding users' requirements in information system success, this research aimed to determine functional requirements of nursing information systems through a national survey. Delphi technique method was applied to conduct this study through three phases: focus group method modified Delphi technique and classic Delphi technique. A cross-sectional study was conducted to evaluate the proposed requirements within 15 general hospitals in Iran. Forty-three of 76 approved requirements were clinical, and 33 were administrative ones. Nurses' mean agreements for clinical requirements were higher than those of administrative requirements; minimum and maximum means of clinical requirements were 3.3 and 3.88, respectively. Minimum and maximum means of administrative requirements were 3.1 and 3.47, respectively. Research findings indicated that those information system requirements that support nurses in doing tasks including direct care, medicine prescription, patient treatment management, and patient safety have been the target of special attention. As nurses' requirements deal directly with patient outcome and patient safety, nursing information systems requirements should not only address automation but also nurses' tasks and work processes based on work analysis.

Patient Safety Movement: History and Future Directions.

PubMed

Lark, Meghan E; Kirkpatrick, Kay; Chung, Kevin C

2018-02-01

Despite progress within the past 15 years, improving patient safety in health care remains an important public health issue. The history of safety policies, research, and development has revealed that this issue is more complex than initially perceived and is pertinent to all health care settings. Solutions, therefore, must be approached at the systems level and supplemented with a change in safety culture, especially in higher risk fields such as surgery. To do so, health care agents at all levels have started to prioritize the improvement of nontechnical skills such as teamwork, communication, and accountability, as reflected by the development of various checklists and safety campaigns. This progress may be sustained by adopting teamwork training programs that have proven successful in other high-risk industries, such as crew resource management in aviation. These techniques can be readily implemented among surgical teams; however, successful application depends heavily on the strong leadership and vigilance of individual surgeons. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Implementation of clinical governance in hospitals: challenges and the keys for success.

PubMed

Mousavi, Seyed Mohammad Hadi; Agharahimi, Zahra; Daryabeigi, Maede; Rezaei, Nima

2014-01-01

There is a number of models and strategies for improving the quality of care such as total quality management, continuous quality improvement and clinical governance. The policy of clinical governance is part of the governments overall strategy for monitoring, assuring and improving in the national health services organization. Clinical governance has been introduced as a bridge between managerial and clinical approaches to quality. For successful implementing of clinical governance, it is necessary to pay attention to firm foundations of the structure, including equipment, staffing arrangement, supporting specialties, and staff training. Therefore, as clinical governance improves safety and quality in health care services, the current situation in hospitals should be evaluated before any intervention while barriers and blocks on structure and process should be determined to select a method for changing them. Considering these points could guarantee success in implementation of clinical governance; otherwise there would be a little chance to achieve the desired results despite consumption of plenty of time and huge paper works.

Memorial Hermann: high reliability from board to bedside.

PubMed

Shabot, M Michael; Monroe, Douglas; Inurria, Juan; Garbade, Debbi; France, Anne-Claire

2013-06-01

In 2006 the Memorial Hermann Health System (MHHS), which includes 12 hospitals, began applying principles embraced by high reliability organizations (HROs). Three factors support its HRO journey: (1) aligned organizational structure with transparent management systems and compressed reporting processes; (2) Robust Process Improvement (RPI) with high-reliability interventions; and (3) cultural establishment, sustainment, and evolution. The Quality and Safety strategic plan contains three domains, each with a specific set of measures that provide goals for performance: (1) "Clinical Excellence;" (2) "Do No Harm;" and (3) "Saving Lives," as measured by the Serious Safety Event rate. MHHS uses a uniform approach to performance improvement--RPI, which includes Six Sigma, Lean, and change management, to solve difficult safety and quality problems. The 9 acute care hospitals provide multiple opportunities to integrate high-reliability interventions and best practices across MHHS. For example, MHHS partnered with the Joint Commission Center for Transforming Healthcare in its inaugural project to establish reliable hand hygiene behaviors, which improved MHHS's average hand hygiene compliance rate from 44% to 92% currently. Soon after compliance exceeded 85% at all 12 hospitals, the average rate of central line-associated bloodstream and ventilator-associated pneumonias decreased to essentially zero. MHHS's size and diversity require a disciplined approach to performance improvement and systemwide achievement of measurable success. The most significant cultural change at MHHS has been the expectation for 100% compliance with evidence-based quality measures and 0% incidence of patient harm.

[CIRRNET® - learning from errors, a success story].

PubMed

Frank, O; Hochreutener, M; Wiederkehr, P; Staender, S

2012-06-01

CIRRNET® is the network of local error-reporting systems of the Swiss Patient Safety Foundation. The network has been running since 2006 together with the Swiss Society for Anaesthesiology and Resuscitation (SGAR), and network participants currently include 39 healthcare institutions from all four different language regions of Switzerland. Further institutions can join at any time. Local error reports in CIRRNET® are bundled at a supraregional level, categorised in accordance with the WHO classification, and analysed by medical experts. The CIRRNET® database offers a solid pool of data with error reports from a wide range of medical specialist's areas and provides the basis for identifying relevant problem areas in patient safety. These problem areas are then processed in cooperation with specialists with extremely varied areas of expertise, and recommendations for avoiding these errors are developed by changing care processes (Quick-Alerts®). Having been approved by medical associations and professional medical societies, Quick-Alerts® are widely supported and well accepted in professional circles. The CIRRNET® database also enables any affiliated CIRRNET® participant to access all error reports in the 'closed user area' of the CIRRNET® homepage and to use these error reports for in-house training. A healthcare institution does not have to make every mistake itself - it can learn from the errors of others, compare notes with other healthcare institutions, and use existing knowledge to advance its own patient safety.

Evolving safety practices in the setting of modern complex operating room: role of nurses.

PubMed

Niu, L; Li, H Y; Tang, W; Gong, S; Zhang, L J

2017-01-01

Operating room (OR) nursing previously referred to patient care provided during the intra-operative phase and the service provided within the OR itself. With the expansion of responsibilities of nurses, OR nursing now includes pre-operative and post-operative periods, therefore peri-operative nursing is accepted as a nursing process in OR in the contemporary medical literature. Peri-operative nurses provide care to the surgical patients during the entire process of surgery. They have several roles including those of manager or a director, clinical practitioner (scrub nurse, circulating nurse and nurse anesthetist), educator as well as researcher. Although, utmost priority is placed on insuring patient safety and well-being, they are also expected to participate in professional organization, continuing medical education programs and participating in research activities. A Surgical Patient Safety Checklist formulated by the World Health Organization serves as a major guideline to all activities in OR, and peri-operative nurses are key personnel in its implementation. Communication among the various players of a procedure in OR is key to successful patient outcome, and peri-operative nurses have a central role in making it happen. Setting up of OR in military conflict zones or places that suffering a widespread natural disaster poses a unique challenge to nursing. This review discusses all aspects of peri-operative nursing and suggests points of improvement in patient care.

10 CFR 830.203 - Unreviewed safety question process.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 10 Energy 4 2010-01-01 2010-01-01 false Unreviewed safety question process. 830.203 Section 830.203 Energy DEPARTMENT OF ENERGY NUCLEAR SAFETY MANAGEMENT Safety Basis Requirements § 830.203 Unreviewed safety question process. (a) The contractor responsible for a hazard category 1, 2, or 3 DOE...

Low-enriched uranium high-density target project. Compendium report

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

Vandegrift, George; Brown, M. Alex; Jerden, James L.

2016-09-01

At present, most 99Mo is produced in research, test, or isotope production reactors by irradiation of highly enriched uranium targets. To achieve the denser form of uranium needed for switching from high to low enriched uranium (LEU), targets in the form of a metal foil (~125-150 µm thick) are being developed. The LEU High Density Target Project successfully demonstrated several iterations of an LEU-fission-based Mo-99 technology that has the potential to provide the world’s supply of Mo-99, should major producers choose to utilize the technology. Over 50 annular high density targets have been successfully tested, and the assembly and disassemblymore » of targets have been improved and optimized. Two target front-end processes (acidic and electrochemical) have been scaled up and demonstrated to allow for the high-density target technology to mate up to the existing producer technology for target processing. In the event that a new target processing line is started, the chemical processing of the targets is greatly simplified. Extensive modeling and safety analysis has been conducted, and the target has been qualified to be inserted into the High Flux Isotope Reactor, which is considered above and beyond the requirements for the typical use of this target due to high fluence and irradiation duration.« less

Proposal for Ground Safety Review Coordination at ISS Launch Sites

NASA Technical Reports Server (NTRS)

Kirkpatrick, Paul D.

2010-01-01

As the transportation of ISS payloads and cargo shifts from KSC to other launch sites, close coordination of ground safety review processes would be of benefit to all parties. The benefit would have the launch sites receiving consistent data that would require less effort to review while still meeting their needs. Until recently, ground safety focus for the ISS program has been almost exclusively for prelaunch processing at KSC/post-landing processing at KSC/DFRC Each launch site, used by the ISS Program, has a ground safety review process. Ground safety viewed as local prerogative. Up till now, ground processing has consisted of low risk/low hazard items; but this will not always be the case. Recent coordination issues associated with the ground safety review of ORU's to be processed at Tanegashima for HTV-2, illustrate that IP ground safety review processes are not well understood by the ISS community at large. Confusion for data providers (US only?). Lack of internal review process for data being submitted to launch sites can lead to inconsistent submittals. NCRs/HRs. Majority of IP ground safety requirements are based upon old KHB 1700.7 (now KNPR 8715.3, Chapter 20). Proposals include: Establish a ground safety working group as part of the MS&MAP. Search for efficiencies in requirements and data submittal processes. Document processes in NSTS 13830/SSP 30599. Each launch site report out its payload ground safety status at the F2F (Monthly's as required). Completions/due dates/NCRs/issues/changes. Establish internal processes for review of ground safety submittals.

Applying NASA's explosive seam welding

NASA Technical Reports Server (NTRS)

Bement, Laurence J.

1991-01-01

The status of an explosive seam welding process, which was developed and evaluated for a wide range of metal joining opportunities, is summarized. The process employs very small quantities of explosive in a ribbon configuration to accelerate a long-length, narrow area of sheet stock into a high-velocity, angular impact against a second sheet. At impact, the oxide films of both surface are broken up and ejected by the closing angle to allow atoms to bond through the sharing of valence electrons. This cold-working process produces joints having parent metal properties, allowing a variety of joints to be fabricated that achieve full strength of the metals employed. Successful joining was accomplished in all aluminum alloys, a wide variety of iron and steel alloys, copper, brass, titanium, tantalum, zirconium, niobium, telerium, and columbium. Safety issues were addressed and are as manageable as many currently accepted joining processes.

A Model for Integrating Ambulatory Surgery Centers Into an Academic Health System Using a Novel Ambulatory Surgery Coordinating Council.

PubMed

Ishii, Lisa; Pronovost, Peter J; Demski, Renee; Wylie, Gill; Zenilman, Michael

2016-06-01

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations. Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs. Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies. The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.

Unitizing worker expertise and maximizing the brain reward centers

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

Martinez, Anthony Bert

People are experts when it comes to the work they do; unfortunately their expertise is not utilized as frequently as it could be. More opportunities need to be provided that allow people to participate in the design of their work including: accident investigations, job planning, and process improvements. Many employers use some form of job hazard analysis process to identify and document hazards and controls, but the front line worker is rarely involved. This presentation will show the core principles supporting employee involvement, provide examples where workers had brilliant ideas but no one listened, and provide examples where workers weremore » given the opportunity to use their expertise to improve occupational safety. According to Abraham Maslow's Hierarch of Needs model, one essential human need is to be innovative and solve problems. Advances in brain science have proven, through functional magnetic resonance imaging (fMRI) studies, the brain reward pathway is activated when people are recognized for their intellectual contributions. As people contribute their expertise to improve occupational safety more frequently they will feel a sense of gratification. In addition, safety professionals will have more time to spend on strategic planning of emerging occupational safety issues. One effect of the current global recession is that SH&E professionals are asked to do more with less. Therefore, to be successful it is essential that SH&E professionals incorporate worker expertise in job planning. This will be illustrated in the presentation through an example where a worker had the answer to a difficult decision on appropriate personal protective equipment for a job but no one asked the worker for his idea during the job planning phase. Fortunately the worker was eventually consulted and his recommendation for the appropriate personal protective equipment for the job was implemented before work began. The goal of this presentation is to expand the awareness and knowledge of SH&E professionals on the benefits and opportunities for leveraging brain science. This will include an overview of the components of the brain reward pathway and the biological mechanisms that make workers feel a sense of gratification when they contribute their ideas toward improving occupational safety. On-the-job examples where it is hypothesized that the brain reward pathway was activated in workers will be provided. Finally, the presentation will include a model illustrating the importance of empowering workers to participate in occupational safety programs. SH&E professionals can use this model to maintain a robust safety and health program with limited resources. The model will also help SH&E professionals prepare for challenges in the SH&E fields by showing them how to allocate more time for strategic planning of emerging issues. Many recent best selling business books such as Wikinomics, Crowdsourcing, and Sway, illustrate how the benefit of harnessing the collective knowledge of employees is a key to company success. Companies like Google and Pixar have mastered the ability to capture empFoyee knowledge in terms of technology. Why should occupational safety be any different? Workers know how to improve safety in their workplace. SH&E professionals can harness this collective safety knowledge just as top companies do with technology, and workers will feel grateful for contributing.« less

Preparing Safety Cases for Operating Outside Prescriptive Fatigue Risk Management Regulations.

PubMed

Gander, Philippa; Mangie, Jim; Wu, Lora; van den Berg, Margo; Signal, Leigh; Phillips, Adrienne

2017-07-01

Transport operators seeking to operate outside prescriptive fatigue management regulations are typically required to present a safety case justifying how they will manage the associated risk. This paper details a method for constructing a successful safety case. The method includes four elements: 1) scope (prescriptive rules and operations affected); 2) risk assessment; 3) risk mitigation strategies; and 4) monitoring ongoing risk. A successful safety case illustrates this method. It enables landing pilots in 3-pilot crews to choose the second or third in-flight rest break, rather than the regulatory requirement to take the third break. Scope was defined using a month of scheduled flights that would be covered (N = 4151). These were analyzed in the risk assessment using existing literature on factors affecting fatigue to estimate the maximum time awake at top of descent and sleep opportunities in each break. Additionally, limited data collected before the new regulations showed that pilots flying at landing chose the third break on only 6% of flights. A prospective survey comparing subjective reports (N = 280) of sleep in the second vs. third break and fatigue and sleepiness ratings at top of descent confirmed that the third break is not consistently superior. The safety case also summarized established systems for fatigue monitoring, risk assessment and hazard identification, and multiple fatigue mitigation strategies that are in place. Other successful safety cases have used this method. The evidence required depends on the expected level of risk and should evolve as experience with fatigue risk management systems builds.Gander P, Mangie J, Wu L, van den Berg M, Signal L, Phillips A. Preparing safety cases for operating outside prescriptive fatigue risk management regulations. Aerosp Med Hum Perform. 2017; 88(7):688-696.

A safety rule approach to surveillance and eradication of biological invasions

Treesearch

Denys Yemshanov; Robert G. Haight; Frank H. Koch; Robert Venette; Kala Studens; Ronald E. Fournier; Tom Swystun; Jean J. Turgeon; Yulin Gao

2017-01-01

Uncertainty about future spread of invasive organisms hinders planning of effective response measures. We present a two-stage scenario optimization model that accounts for uncertainty about the spread of an invader, and determines survey and eradication strategies that minimize the expected program cost subject to a safety rule for eradication success. The safety rule...

2014 Summer Series - Kristin Yvonne Rozier - No More Helicopter Parenting: Intelligent Autonomous Unmanned Aerial Vehicle

NASA Image and Video Library

2014-06-10

Safety is NASA's top priority! The search for innovative new ways to validate and verify is vital for the development of safety-critical systems. Such techniques have been successfully used to assure systems for air traffic control, airplane separation assurance, autopilots, logic designs, medical devices, and other functions that ensure human safety.

The science of laboratory and project management in regulated bioanalysis.

PubMed

Unger, Steve; Lloyd, Thomas; Tan, Melvin; Hou, Jingguo; Wells, Edward

2014-05-01

Pharmaceutical drug development is a complex and lengthy process, requiring excellent project and laboratory management skills. Bioanalysis anchors drug safety and efficacy with systemic and site of action exposures. Development of scientific talent and a willingness to innovate or adopt new technology is essential. Taking unnecessary risks, however, should be avoided. Scientists must strategically assess all risks and find means to minimize or negate them. Laboratory Managers must keep abreast of ever-changing technology. Investments in instrumentation and laboratory design are critical catalysts to efficiency and safety. Matrix management requires regular communication between Project Managers and Laboratory Managers. When properly executed, it aligns the best resources at the right times for a successful outcome. Attention to detail is a critical aspect that separates excellent laboratories. Each assay is unique and requires attention in its development, validation and execution. Methods, training and facilities are the foundation of a bioanalytical laboratory.

Water safety plans: bridges and barriers to implementation in North Carolina.

PubMed

Amjad, Urooj Quezon; Luh, Jeanne; Baum, Rachel; Bartram, Jamie

2016-10-01

First developed by the World Health Organization, and now used in several countries, water safety plans (WSPs) are a multi-step, preventive process for managing drinking water hazards. While the beneficial impacts of WSPs have been documented in diverse countries, how to successfully implement WSPs in the United States remains a challenge. We examine the willingness and ability of water utility leaders to implement WSPs in the US state of North Carolina. Our findings show that water utilities have more of a reactive than preventive organizational culture, that implementation requires prioritization of time and resources, perceived comparative advantage to other hazard management plans, leadership in implementation, and identification of how WSPs can be embedded in existing work practices. Future research could focus on whether WSP implementation provides benefits such as decreases in operational costs, and improved organization of records and communication.

Methodologies for sustaining barcode medication administration compliance. A multi-disciplinary approach.

PubMed

McNulty, Judy; Donnelly, Eileen; Iorio, Kris

2009-01-01

Numerous recent studies have looked at how nursing workarounds and technology failures can undermine the patient safety benefits of barcode medication administration (BCMA) systems. This article will discuss how Solaris Health System in Edison, NJ, methodically addressed these challenges to achieve and sustain 95 percent compliance with BCMA, one of two major initiatives of the non-profit Solaris Patient Safety Institute, which was established to research best practices that could be shared with other organizations. Through meetings and interviews with frontline nurses and their managers, a multidisciplinary team (pharmacy, IT, nursing) identified 12 educational, technological and process-oriented issues, then developed concrete action plans to address each one (e.g., one-on-one software and device training, additional wireless access points, a "hard stop" to require scanning the patient's wristband). Key success factors included demonstrating executive dedication, creating a culture of ownership by engaging frontline nurses in solution design and providing a strong support system.

[The risk of direct current countershock].

PubMed

Gajek, J; Zyśko, D

2001-07-01

Direct current cardioversion (DCC) is a procedure commonly used to restore the sinus rhythm in patients with supraventricular and ventricular arrhythmias. Its safety, regarding the use of electric current, is still a matter of controversy and debate. The patients with atrial fibrillation/flutter, supraventricular or ventricular tachycardia represent a broad spectrum of clinical conditions and it is difficult to draw the conclusions. The high success rate of DCC in restoring the sinus rhythm, may be partly responsible for enhancing and revealing proarrhythmic properties of antiarrhythmic drugs. The deaths described as a complications of DCC were mainly due to the proarrhythmia and less common to the progression of the pathologic process. The embolic, arrhythmic and anesthetic complications of DCC can be prevented if the known recommendations of performing the DCC are followed. The authors review critically the literature data about the complications of the procedure and come to the conclusion of safety of DCC.

Enhancing the NASA Expendable Launch Vehicle Payload Safety Review Process Through Program Activities

NASA Technical Reports Server (NTRS)

Palo, Thomas E.

2007-01-01

The safety review process for NASA spacecraft flown on Expendable Launch Vehicles (ELVs) has been guided by NASA-STD 8719.8, Expendable Launch Vehicle Payload Safety Review Process Standard. The standard focused primarily on the safety approval required to begin pre-launch processing at the launch site. Subsequent changes in the contractual, technical, and operational aspects of payload processing, combined with lessons-learned supported a need for the reassessment of the standard. This has resulted in the formation of a NASA ELV Payload Safety Program. This program has been working to address the programmatic issues that will enhance and supplement the existing process, while continuing to ensure the safety of ELV payload activities.

Marine safety manual, volume 4 : technical

DOT National Transportation Integrated Search

2005-01-01

A comprehensive manual which provides guidance on the application of Coast Guard regulations and explains the rationale behind their development is vital to the successful execution of the marine safety program. This volume is intended to serve that ...

Patient safety: lessons learned.

PubMed

Bagian, James P

2006-04-01

The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System." However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence "shame and blame") to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.

Implications of case managers' perceptions and attitude on safety of home-delivered care.

PubMed

Jones, Sarahjane

2015-12-01

Perceptions on safety in community care have been relatively unexplored. A project that sought to understand the multiple perspectives on safety in the NHS case-management programme was carried out in relation to the structure, process, and outcome of care. This article presents a component of the nursing perspective that highlights an important element in the structure of nursing care that could potentially impede the nurses' ability to be fully effective and safe. A single case study of the case-management programme was undertaken. Three primary care organisations from three strategic health authorities participated, and three focus groups were conducted (one within each organisation). In total, 17 case management nurses participated. Data were audiotaped and transcribed verbatim and subjected to framework analysis. Nursing staff attitudes were identified as a structure of care that influence safety outcomes, particularly their perceptions of the care setting and the implications it has on their role and patient behaviour. Greater understanding of the expected role of the community nurse is necessary, and relevant training is required for nurses to be successful in empowering patients to perform more safely. In addition, efforts need to be made to improve patients' trust in the health-care system to prevent harm and promote more effective utilisation of resources.

Online Adaptive Radiation Therapy: Implementation of a New Process of Care

PubMed Central

Cao, Minsong; Kishan, Amar; Agazaryan, Nzhde; Thomas, David H; Shaverdian, Narek; Yang, Yingli; Ray, Suzette; Low, Daniel A; Raldow, Ann; Steinberg, Michael L.; Lee, Percy

2017-01-01

Onboard magnetic resonance imaging (MRI) guided radiotherapy is now clinically available in nine centers in the world. This technology has facilitated the clinical implementation of online adaptive radiotherapy (OART), or the ability to alter the daily treatment plan based on tumor and anatomical changes in real-time while the patient is on the treatment table. However, due to the time sensitive nature of OART, implementation in a large and busy clinic has many potential obstacles as well as patient-related safety considerations. In this work, we have described the implementation of this new process of care in the Department of Radiation Oncology at the University of California, Los Angeles (UCLA). We describe the rationale, the initial challenges such as treatment time considerations, technical issues during the process of re-contouring, re-optimization, quality assurance, as well as our current solutions to overcome these challenges. In addition, we describe the implementation of a coverage system with a physician of the day as well as online planners (physicists or dosimetrists) to oversee each OART treatment with patient-specific ‘hand-off’ directives from the patient’s treating physician. The purpose of this effort is to streamline the process without compromising treatment quality and patient safety. As more MRI-guided radiotherapy programs come online, we hope that our experience can facilitate successful adoption of OART in a way that maximally benefits the patient. PMID:29104835

Modelling of Safety Instrumented Systems by using Bernoulli trials: towards the notion of odds on for SIS failures analysis

NASA Astrophysics Data System (ADS)

Cauffriez, Laurent

2017-01-01

This paper deals with the modeling of a random failures process of a Safety Instrumented System (SIS). It aims to identify the expected number of failures for a SIS during its lifecycle. Indeed, the fact that the SIS is a system being tested periodically gives the idea to apply Bernoulli trials to characterize the random failure process of a SIS and thus to verify if the PFD (Probability of Failing Dangerously) experimentally obtained agrees with the theoretical one. Moreover, the notion of "odds on" found in Bernoulli theory allows engineers and scientists determining easily the ratio between “outcomes with success: failure of SIS” and “outcomes with unsuccess: no failure of SIS” and to confirm that SIS failures occur sporadically. A Stochastic P-temporised Petri net is proposed and serves as a reference model for describing the failure process of a 1oo1 SIS architecture. Simulations of this stochastic Petri net demonstrate that, during its lifecycle, the SIS is rarely in a state in which it cannot perform its mission. Experimental results are compared to Bernoulli trials in order to validate the powerfulness of Bernoulli trials for the modeling of the failures process of a SIS. The determination of the expected number of failures for a SIS during its lifecycle opens interesting research perspectives for engineers and scientists by completing the notion of PFD.

A Pharmacy Blueprint for Electronic Medical Record Implementation Success

PubMed Central

Bach, David S.; Risko, Kenneth R.; Farber, Margo S.; Polk, Gregory J.

2015-01-01

Objective: Implementation of an integrated, electronic medical record (EMR) has been promoted as a means of improving patient safety and quality. While there are a few reports of such processes that incorporate computerized prescriber order entry, pharmacy verification, an electronic medication administration record (eMAR), point-of-care barcode scanning, and clinical decision support, there are no published reports on how a pharmacy department can best participate in implementing such a process across a multihospital health care system. Method: This article relates the experience of the design, build, deployment, and maintenance of an integrated EMR solution from the pharmacy perspective. It describes a 9-month planning and build phase and the subsequent rollout at 8 hospitals over the following 13 months. Results: Key components to success are identified, as well as a set of guiding principles that proved invaluable in decision making and dispute resolution. Labor/personnel requirements for the various stages of the process are discussed, as are issues involving medication workflow analysis, drug database considerations, the development of clinical order sets, and incorporation of bar-code scanning of medications. Recommended implementation and maintenance strategies are presented, and the impact of EMR implementation on the pharmacy practice model and revenue analysis are examined. Conclusion: Adherence to the principles and practices outlined in this article can assist pharmacy administrators and clinicians during all medication-related phases of the development, implementation, and maintenance of an EMR solution. Furthermore, review and incorporation of some or all of practices presented may help ease the process and ensure its success. PMID:26405340

National Security Technology Incubator Evaluation Process

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

None, None

This report describes the process by which the National Security Technology Incubator (NSTI) will be evaluated. The technology incubator is being developed as part of the National Security Preparedness Project (NSPP), funded by a Department of Energy (DOE)/National Nuclear Security Administration (NNSA) grant. This report includes a brief description of the components, steps, and measures of the proposed evaluation process. The purpose of the NSPP is to promote national security technologies through business incubation, technology demonstration and validation, and workforce development. The NSTI will focus on serving businesses with national security technology applications by nurturing them through critical stages ofmore » early development. An effective evaluation process of the NSTI is an important step as it can provide qualitative and quantitative information on incubator performance over a given period. The vision of the NSTI is to be a successful incubator of technologies and private enterprise that assist the NNSA in meeting new challenges in national safety and security. The mission of the NSTI is to identify, incubate, and accelerate technologies with national security applications at various stages of development by providing hands-on mentoring and business assistance to small businesses and emerging or growing companies. To achieve success for both incubator businesses and the NSTI program, an evaluation process is essential to effectively measure results and implement corrective processes in the incubation design if needed. The evaluation process design will collect and analyze qualitative and quantitative data through performance evaluation system.« less

When paradigms collide at the road rail interface: evaluation of a sociotechnical systems theory design toolkit for cognitive work analysis.

PubMed

Read, Gemma J M; Salmon, Paul M; Lenné, Michael G

2016-09-01

The Cognitive Work Analysis Design Toolkit (CWA-DT) is a recently developed approach that provides guidance and tools to assist in applying the outputs of CWA to design processes to incorporate the values and principles of sociotechnical systems theory. In this paper, the CWA-DT is evaluated based on an application to improve safety at rail level crossings. The evaluation considered the extent to which the CWA-DT met pre-defined methodological criteria and aligned with sociotechnical values and principles. Both process and outcome measures were taken based on the ratings of workshop participants and human factors experts. Overall, workshop participants were positive about the process and indicated that it met the methodological criteria and sociotechnical values. However, expert ratings suggested that the CWA-DT achieved only limited success in producing RLX designs that fully aligned with the sociotechnical approach. Discussion about the appropriateness of the sociotechnical approach in a public safety context is provided. Practitioner Summary: Human factors and ergonomics practitioners need evidence of the effectiveness of methods. A design toolkit for cognitive work analysis, incorporating values and principles from sociotechnical systems theory, was applied to create innovative designs for rail level crossings. Evaluation results based on the application are provided and discussed.

Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome?

PubMed

Hagerman, Nancy S; Varughese, Anna M; Kurth, C Dean

2014-06-01

Cognitive aids are tangible or intangible instruments that guide users in decision-making and in the completion of a complex series of tasks. Common examples include mnemonics, checklists, and algorithms. Cognitive aids constitute very effective approaches to achieve well tolerated, high quality healthcare because they promote highly reliable processes that reduce the likelihood of failure. This review describes recent advances in quality improvement for pediatric anesthesiology with emphasis on application of cognitive aids to impact patient safety and outcomes. Quality improvement encourages the examination of systems to create stable processes and ultimately high-value care. Quality improvement initiatives in pediatric anesthesiology have been shown to improve outcomes and the delivery of efficient and effective care at many institutions. The use of checklists, in particular, improves adherence to evidence-based care in crisis situations, decreases catheter-associated bloodstream infections, reduces blood product utilization, and improves communication during the patient handoff process. Use of this simple tool has been associated with decreased morbidity, fewer medical errors, improved provider satisfaction, and decreased mortality in nonanesthesia disciplines as well. Successful quality improvement initiatives utilize cognitive aids such as checklists and have been shown to optimize pediatric patient experience and anesthesia outcomes and reduce perioperative complications.

Assessing the Depth of Cognitive Processing as the Basis for Potential User-State Adaptation

PubMed Central

Nicolae, Irina-Emilia; Acqualagna, Laura; Blankertz, Benjamin

2017-01-01

Objective: Decoding neurocognitive processes on a single-trial basis with Brain-Computer Interface (BCI) techniques can reveal the user's internal interpretation of the current situation. Such information can potentially be exploited to make devices and interfaces more user aware. In this line of research, we took a further step by studying neural correlates of different levels of cognitive processes and developing a method that allows to quantify how deeply presented information is processed in the brain. Methods/Approach: Seventeen participants took part in an EEG study in which we evaluated different levels of cognitive processing (no processing, shallow, and deep processing) within three distinct domains (memory, language, and visual imagination). Our investigations showed gradual differences in the amplitudes of event-related potentials (ERPs) and in the extend and duration of event-related desynchronization (ERD) which both correlate with task difficulty. We performed multi-modal classification to map the measured correlates of neurocognitive processing to the corresponding level of processing. Results: Successful classification of the neural components was achieved, which reflects the level of cognitive processing performed by the participants. The results show performances above chance level for each participant and a mean performance of 70–90% for all conditions and classification pairs. Significance: The successful estimation of the level of cognition on a single-trial basis supports the feasibility of user-state adaptation based on ongoing neural activity. There is a variety of potential use cases such as: a user-friendly adaptive design of an interface or the development of assistance systems in safety critical workplaces. PMID:29046625

Assessing the Depth of Cognitive Processing as the Basis for Potential User-State Adaptation.

PubMed

Nicolae, Irina-Emilia; Acqualagna, Laura; Blankertz, Benjamin

2017-01-01

Objective: Decoding neurocognitive processes on a single-trial basis with Brain-Computer Interface (BCI) techniques can reveal the user's internal interpretation of the current situation. Such information can potentially be exploited to make devices and interfaces more user aware. In this line of research, we took a further step by studying neural correlates of different levels of cognitive processes and developing a method that allows to quantify how deeply presented information is processed in the brain. Methods/Approach: Seventeen participants took part in an EEG study in which we evaluated different levels of cognitive processing (no processing, shallow, and deep processing) within three distinct domains (memory, language, and visual imagination). Our investigations showed gradual differences in the amplitudes of event-related potentials (ERPs) and in the extend and duration of event-related desynchronization (ERD) which both correlate with task difficulty. We performed multi-modal classification to map the measured correlates of neurocognitive processing to the corresponding level of processing. Results: Successful classification of the neural components was achieved, which reflects the level of cognitive processing performed by the participants. The results show performances above chance level for each participant and a mean performance of 70-90% for all conditions and classification pairs. Significance: The successful estimation of the level of cognition on a single-trial basis supports the feasibility of user-state adaptation based on ongoing neural activity. There is a variety of potential use cases such as: a user-friendly adaptive design of an interface or the development of assistance systems in safety critical workplaces.

Managing the three 'P's to improve patient safety: nursing administration's role in managing information technology.

PubMed

Simpson, Roy L

2004-08-01

The Institute of Medicine's landmark report asserted that medical error is seldom the fault of individuals, but the result of faulty healthcare policy/procedure systems. Numerous studies have shown that information technology (IT) can shore up weak systems. For nursing, IT plays a key role in eliminating nursing mistakes. However, managing IT is a function of managing the people who use it. For nursing administrators, successful IT implementations depend on adroit management of the three 'P's: People, processes and (computer) programs. This paper examines critical issues for managing each entity. It discusses the importance of developing trusting organizations, the requirements of process change, how to implement technology in harmony with the organization and the significance of vision.

Autonomous system for launch vehicle range safety

NASA Astrophysics Data System (ADS)

Ferrell, Bob; Haley, Sam

2001-02-01

The Autonomous Flight Safety System (AFSS) is a launch vehicle subsystem whose ultimate goal is an autonomous capability to assure range safety (people and valuable resources), flight personnel safety, flight assets safety (recovery of valuable vehicles and cargo), and global coverage with a dramatic simplification of range infrastructure. The AFSS is capable of determining current vehicle position and predicting the impact point with respect to flight restriction zones. Additionally, it is able to discern whether or not the launch vehicle is an immediate threat to public safety, and initiate the appropriate range safety response. These features provide for a dramatic cost reduction in range operations and improved reliability of mission success. .

Integrated Risk Management Within NASA Programs/Projects

NASA Technical Reports Server (NTRS)

Connley, Warren; Rad, Adrian; Botzum, Stephen

2004-01-01

As NASA Project Risk Management activities continue to evolve, the need to successfully integrate risk management processes across the life cycle, between functional disciplines, stakeholders, various management policies, and within cost, schedule and performance requirements/constraints become more evident and important. Today's programs and projects are complex undertakings that include a myriad of processes, tools, techniques, management arrangements and other variables all of which must function together in order to achieve mission success. The perception and impact of risk may vary significantly among stakeholders and may influence decisions that may have unintended consequences on the project during a future phase of the life cycle. In these cases, risks may be unintentionally and/or arbitrarily transferred to others without the benefit of a comprehensive systemic risk assessment. Integrating risk across people, processes, and project requirements/constraints serves to enhance decisions, strengthen communication pathways, and reinforce the ability of the project team to identify and manage risks across the broad spectrum of project management responsibilities. The ability to identify risks in all areas of project management increases the likelihood a project will identify significant issues before they become problems and allows projects to make effective and efficient use of shrinking resources. By getting a total team integrated risk effort, applying a disciplined and rigorous process, along with understanding project requirements/constraints provides the opportunity for more effective risk management. Applying an integrated approach to risk management makes it possible to do a better job at balancing safety, cost, schedule, operational performance and other elements of risk. This paper will examine how people, processes, and project requirements/constraints can be integrated across the project lifecycle for better risk management and ultimately improve the chances for mission success.

Reducing health care hazards: lessons from the commercial aviation safety team.

PubMed

Pronovost, Peter J; Goeschel, Christine A; Olsen, Kyle L; Pham, Julius C; Miller, Marlene R; Berenholtz, Sean M; Sexton, J Bryan; Marsteller, Jill A; Morlock, Laura L; Wu, Albert W; Loeb, Jerod M; Clancy, Carolyn M

2009-01-01

The movement to improve quality of care and patient safety has grown, but examples of measurable and sustained progress are rare. The slow progress made in health care contrasts with the success of aviation safety. After a tragic 1995 plane crash, the aviation industry and government created the Commercial Aviation Safety Team to reduce fatal accidents. This public-private partnership of safety officials and technical experts is responsible for the decreased average rate of fatal aviation accidents. We propose a similar partnership in the health care community to coordinate national efforts and move patient safety and quality forward.

Information systems in food safety management.

PubMed

McMeekin, T A; Baranyi, J; Bowman, J; Dalgaard, P; Kirk, M; Ross, T; Schmid, S; Zwietering, M H

2006-12-01

Information systems are concerned with data capture, storage, analysis and retrieval. In the context of food safety management they are vital to assist decision making in a short time frame, potentially allowing decisions to be made and practices to be actioned in real time. Databases with information on microorganisms pertinent to the identification of foodborne pathogens, response of microbial populations to the environment and characteristics of foods and processing conditions are the cornerstone of food safety management systems. Such databases find application in: Identifying pathogens in food at the genus or species level using applied systematics in automated ways. Identifying pathogens below the species level by molecular subtyping, an approach successfully applied in epidemiological investigations of foodborne disease and the basis for national surveillance programs. Predictive modelling software, such as the Pathogen Modeling Program and Growth Predictor (that took over the main functions of Food Micromodel) the raw data of which were combined as the genesis of an international web based searchable database (ComBase). Expert systems combining databases on microbial characteristics, food composition and processing information with the resulting "pattern match" indicating problems that may arise from changes in product formulation or processing conditions. Computer software packages to aid the practical application of HACCP and risk assessment and decision trees to bring logical sequences to establishing and modifying food safety management practices. In addition there are many other uses of information systems that benefit food safety more globally, including: Rapid dissemination of information on foodborne disease outbreaks via websites or list servers carrying commentary from many sources, including the press and interest groups, on the reasons for and consequences of foodborne disease incidents. Active surveillance networks allowing rapid dissemination of molecular subtyping information between public health agencies to detect foodborne outbreaks and limit the spread of human disease. Traceability of individual animals or crops from (or before) conception or germination to the consumer as an integral part of food supply chain management. Provision of high quality, online educational packages to food industry personnel otherwise precluded from access to such courses.

Evaluation of pedestrian safety campaigns : final report.

DOT National Transportation Integrated Search

2004-02-01

The objective of the study was to determine the efficacy and success of SHAs public service campaign : regarding pedestrian safety. Data collection issues forced a change in this focus as the project progressed. : The study contains two issues tha...

Safety Awareness & Communications Internship

NASA Technical Reports Server (NTRS)

Jefferson, Zanani

2015-01-01

The projects that I have worked on during my internships were updating the JSC Safety & Health Action Team JSAT Employee Guidebook, conducting a JSC mishap case study, preparing for JSC Today Close Call success stories, and assisting with event planning and awareness.

Pilot Construction Project for Granular Shoulder Stabilization

DOT National Transportation Integrated Search

2013-09-30

Granular shoulders need to be maintained on a regular basis because edge ruts and potholes develop, posing a safety hazard to motorists. The successful mitigation of edge-rut issues for granular shoulders would increase safety and reduce the number o...

Flight State Information Inference with Application to Helicopter Cockpit Video Data Analysis Using Data Mining Techniques

NASA Astrophysics Data System (ADS)

Shin, Sanghyun

The National Transportation Safety Board (NTSB) has recently emphasized the importance of analyzing flight data as one of the most effective methods to improve eciency and safety of helicopter operations. By analyzing flight data with Flight Data Monitoring (FDM) programs, the safety and performance of helicopter operations can be evaluated and improved. In spite of the NTSB's effort, the safety of helicopter operations has not improved at the same rate as the safety of worldwide airlines, and the accident rate of helicopters continues to be much higher than that of fixed-wing aircraft. One of the main reasons is that the participation rates of the rotorcraft industry in the FDM programs are low due to the high costs of the Flight Data Recorder (FDR), the need of a special readout device to decode the FDR, anxiety of punitive action, etc. Since a video camera is easily installed, accessible, and inexpensively maintained, cockpit video data could complement the FDR in the presence of the FDR or possibly replace the role of the FDR in the absence of the FDR. Cockpit video data is composed of image and audio data: image data contains outside views through cockpit windows and activities on the flight instrument panels, whereas audio data contains sounds of the alarms within the cockpit. The goal of this research is to develop, test, and demonstrate a cockpit video data analysis algorithm based on data mining and signal processing techniques that can help better understand situations in the cockpit and the state of a helicopter by efficiently and accurately inferring the useful flight information from cockpit video data. Image processing algorithms based on data mining techniques are proposed to estimate a helicopter's attitude such as the bank and pitch angles, identify indicators from a flight instrument panel, and read the gauges and the numbers in the analogue gauge indicators and digital displays from cockpit image data. In addition, an audio processing algorithm based on signal processing and abrupt change detection techniques is proposed to identify types of warning alarms and to detect the occurrence times of individual alarms from cockpit audio data. Those proposed algorithms are then successfully applied to simulated and real helicopter cockpit video data to demonstrate and validate their performance.

Performance and Safety to NAVSEA Instruction 9310.1A of Lithium-thionyl Chloride Reserve Batteries

NASA Technical Reports Server (NTRS)

Hall, J. C.

1984-01-01

The design, performance and safety of a fully engineered, selfcontained Li/SOCl2 battery as the power source for underwater applications. In addition to meeting the performance standards of the end user this battery is successfully tested under the rigorous safety conditions of NAVSEA Instruction 9310.1A for use on land, aircraft and surface ships.

Nuclear Warheads: The Reliable Replacement Warhead Program and the Life Extension Program

DTIC Science & Technology

2007-07-16

The Defense Nuclear Facilities Safety Board was created by Congress 1988 “as an independent oversight organization within the Executive Branch charged... nuclear facilities .” U.S. Defense Nuclear Facilities Safety Board. “Who We Are,” at [http://www.dnfsb.gov/about/index.html]. beginning, addressed safety...approach, if successful, would “reduce or eliminate the need for ESD controls.”55 Kent Fortenberry, Technical Director of the Defense Nuclear Facilities Safety

The Application of Software Safety to the Constellation Program Launch Control System

NASA Technical Reports Server (NTRS)

Kania, James; Hill, Janice

2011-01-01

The application of software safety practices on the LCS project resulted in the successful implementation of the NASA Software Safety Standard NASA-STD-8719.138 and CxP software safety requirements. The GOP-GEN-GSW-011 Hazard Report was the first report developed at KSC to identify software hazard causes and their controls. This approach can be applied to similar large software - intensive systems where loss of control can lead to a hazard.

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.

Software Safety Risk in Legacy Safety-Critical Computer Systems

NASA Technical Reports Server (NTRS)

Hill, Janice L.; Baggs, Rhoda

2007-01-01

Safety Standards contain technical and process-oriented safety requirements. Technical requirements are those such as "must work" and "must not work" functions in the system. Process-Oriented requirements are software engineering and safety management process requirements. Address the system perspective and some cover just software in the system > NASA-STD-8719.13B Software Safety Standard is the current standard of interest. NASA programs/projects will have their own set of safety requirements derived from the standard. Safety Cases: a) Documented demonstration that a system complies with the specified safety requirements. b) Evidence is gathered on the integrity of the system and put forward as an argued case. [Gardener (ed.)] c) Problems occur when trying to meet safety standards, and thus make retrospective safety cases, in legacy safety-critical computer systems.

Exploring how ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process evaluation.

PubMed

Sheard, Laura; Marsh, Claire; O'Hara, Jane; Armitage, Gerry; Wright, John; Lawton, Rebecca

2017-07-13

A patient safety intervention was tested in a 33-ward randomised controlled trial. No statistically significant difference between intervention and control wards was found. We conducted a process evaluation of the trial and our aim in this paper is to understand staff engagement across the 17 intervention wards. Large qualitative process evaluation of the implementation of a patient safety intervention. National Health Service staff based on 17 acute hospital wards located at five hospital sites in the North of England. We concentrate on three sources here: (1) analysis of taped discussion between ward staff during action planning meetings; (2) facilitators' field notes and (3) follow-up telephone interviews with staff focusing on whether action plans had been achieved. The analysis involved the use of pen portraits and adaptive theory. First, there were palpable differences in the ways that the 17 ward teams engaged with the key components of the intervention. Five main engagement typologies were evident across the life course of the study: consistent, partial, increasing, decreasing and disengaged. Second, the intensity of support for the intervention at the level of the organisation does not predict the strength of engagement at the level of the individual ward team. Third, the standardisation of facilitative processes provided by the research team does not ensure that implementation standardisation of the intervention occurs by ward staff. A dilution of the intervention occurred during the trial because wards engaged with Patient Reporting and Action for a Safe Environment (PRASE) in divergent ways, despite the standardisation of key components. Facilitative processes were not sufficiently adequate to enable intervention wards to successfully engage with PRASE components. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Experience and lessons from surveillance and studies of the 2009 pandemic in Europe.

PubMed

Nicoll, A; Ammon, A; Amato Gauci, A; Amato, A; Ciancio, B; Zucs, P; Devaux, I; Plata, F; Mazick, A; Mølbak, K; Asikainen, T; Kramarz, P

2010-01-01

Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the 'known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring (Component 3) for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) (Component 4) is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of Component 4) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2-4, resourcing them realistically and devising new ways of sharing analyses. Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.

Variable dynamic testbed vehicle : safety plan

DOT National Transportation Integrated Search

1997-02-01

This safety document covers the entire safety process from inception to delivery of the Variable Dynamic Testbed Vehicle. In addition to addressing the process of safety on the vehicle , it should provide a basis on which to build future safety proce...

Corridor-wide Safety Data Analysis and Identification of Existing Successful Safety Programs

DOT National Transportation Integrated Search

2010-06-01

Many diverse factors contribute to motor vehicle crashes. States have multiple competing priorities and limited resources to address these priorities, so there is a need, particularly in our current economic climate, to prioritize interventions and s...

Keys to Successful Diabetes Self-Management for Uninsured Patients: Social Support, Observational Learning, and Turning Points A Safety Net Providers’ Strategic Alliance Study

PubMed Central

Hanahan, Melissa A.; Werner, James J.; Tomsik, Phillip; Weirich, Stephen A.; Reichsman, Ann; Navracruz, Lisa; Clemons-Clark, Terri; Cella, Peggi; Terchek, Joshua; Munson, Michelle R.

2015-01-01

Objective To determine how medically uninsured patients with limited material resources successfully manage diabetes. Methods Clinicians at 5 safety net practices enrolled uninsured adult patients (N=26) with prior diagnosis of diabetes for 6 months or longer. Patients were interviewed about enabling factors, motivations, resources, and barriers. Chart reviews and clinician surveys supplemented interview data. Interview, survey, and chart review data were analyzed and findings were summarized. Results Two distinct groups of patients were investigated: 1) “successful,” defined as those with an HbA1c of ≤7% or a recent improvement of at least 2% (n=17); and 2) “unsuccessful,” defined as patients with HbA1c of ≥9% (n=9) without recent improvement. In comparison to unsuccessful patients, successful patients more often reported having friends or family with diabetes, sought information about the disease, used evidence-based self-management strategies, held an accurate perception of their own disease control, and experienced “turning point” events that motivated increased efforts in disease management. Conclusions Uninsured safety net patients who successfully managed diabetes learned from friends and family with diabetes and leveraged disease-related events into motivational turning points. It may be beneficial for clinicians to incorporate social learning and motivational enhancement into diabetes interventions to increase patients’ motivation for improved levels of self-management. PMID:21671529

Donor motivations, associated risks and ethical considerations of oocyte donation.

PubMed

Boutelle, Amy L

2014-01-01

Three decades after the first reported successful cases, oocyte donation continues to grow in popularity and regard as an established method to aid women in achieving their reproductive goals. As a result of the increased demand for donated oocytes, many young women in the U.S. volunteer to undergo complex medical procedures to donate their oocytes in return for financial compensation. To best care for these women before, during and after donation, it is important to explore donor characteristics and motivations, discuss the safety of the donation procedure and examine the ethical issues related to this process. © 2014 AWHONN.

Successful reentry: the perspective of private correctional health care providers.

PubMed

Mellow, Jeff; Greifinger, Robert B

2007-01-01

Due to public health and safety concerns, discharge planning is increasingly prioritized by correctional systems when preparing prisoners for their reintegration into the community. Annually, private correctional health care vendors provide $3 billion of health care services to inmates in correctional facilities throughout the U.S., but rarely are contracted to provide transitional health care. A discussion with 12 people representing five private nationwide correctional health care providers highlighted the barriers they face when implementing transitional health care and what templates of services health care companies could provide to state and counties to enhance the reentry process.

A Test Generation Framework for Distributed Fault-Tolerant Algorithms

NASA Technical Reports Server (NTRS)

Goodloe, Alwyn; Bushnell, David; Miner, Paul; Pasareanu, Corina S.

2009-01-01

Heavyweight formal methods such as theorem proving have been successfully applied to the analysis of safety critical fault-tolerant systems. Typically, the models and proofs performed during such analysis do not inform the testing process of actual implementations. We propose a framework for generating test vectors from specifications written in the Prototype Verification System (PVS). The methodology uses a translator to produce a Java prototype from a PVS specification. Symbolic (Java) PathFinder is then employed to generate a collection of test cases. A small example is employed to illustrate how the framework can be used in practice.

Preventing home health nursing assistant back and shoulder injuries.

PubMed

Leff, E W; Hagenbach, G L; Marn, K K

2000-10-01

Franklin County Home Health Agency (St Albans, Vermont) undertook a performance improvement project in 1996 to reduce employee injuries. A review of recent injuries led to the prevention of licensed nursing assistants' (LNAs') back and shoulder injuries as the first priority. Root causes of injuries were agency communication, employee training, patient home environment, nursing assistant body mechanics, and failure to use safety measures. Given that injury causality is complex and multifactorial, a variety of improvement strategies were implemented over the following two to three years. IMPLEMENTATION OF POTENTIAL SOLUTIONS: Short-term (a few months), mid-term (six months), and long-term (one year) potential solutions to the LNA back and shoulder injury problem were charted. Safety and health training was the major focus of the team's short-term plan. Risk management forms were to be used to identify and follow up on hazardous situations. Project plans that were successfully implemented included revision of LNA plans of care, standardization of the return-to-work process after injury, development of guidelines for identifying unsafe patient lifts and transfers, improved follow-up of employee reports of injury-risk situations in patient homes, improved body mechanics screening of new employees, and a stronger injury-prevention training program for current employees. A less successful initiative was aimed at collecting more data about injuries and causal factors. Employee injuries were gradually reduced from 4-10 per quarter to 0-3 per quarter. Injury prevention requires commitment, persistence, and patience--but not expensive improvements. Multiple interventions increase the chances of success when there are many root causes and lack of evidence regarding the effectiveness of various approaches.

49 CFR 1106.4 - The Safety Integration Plan process.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 8 2011-10-01 2011-10-01 false The Safety Integration Plan process. 1106.4... CONSIDERATION OF SAFETY INTEGRATION PLANS IN CASES INVOLVING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS OF CONTROL § 1106.4 The Safety Integration Plan process. (a) Each applicant in a transaction subject...

49 CFR 1106.4 - The Safety Integration Plan process.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 8 2013-10-01 2013-10-01 false The Safety Integration Plan process. 1106.4... CONSIDERATION OF SAFETY INTEGRATION PLANS IN CASES INVOLVING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS OF CONTROL § 1106.4 The Safety Integration Plan process. (a) Each applicant in a transaction subject...

49 CFR 1106.4 - The Safety Integration Plan process.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 8 2014-10-01 2014-10-01 false The Safety Integration Plan process. 1106.4... CONSIDERATION OF SAFETY INTEGRATION PLANS IN CASES INVOLVING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS OF CONTROL § 1106.4 The Safety Integration Plan process. (a) Each applicant in a transaction subject...

49 CFR 1106.4 - The Safety Integration Plan process.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 8 2012-10-01 2012-10-01 false The Safety Integration Plan process. 1106.4... CONSIDERATION OF SAFETY INTEGRATION PLANS IN CASES INVOLVING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS OF CONTROL § 1106.4 The Safety Integration Plan process. (a) Each applicant in a transaction subject...

49 CFR 1106.4 - The Safety Integration Plan process.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 8 2010-10-01 2010-10-01 false The Safety Integration Plan process. 1106.4... CONSIDERATION OF SAFETY INTEGRATION PLANS IN CASES INVOLVING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS OF CONTROL § 1106.4 The Safety Integration Plan process. (a) Each applicant in a transaction subject...

Software Development Standard Processes (SDSP)

NASA Technical Reports Server (NTRS)

Lavin, Milton L.; Wang, James J.; Morillo, Ronald; Mayer, John T.; Jamshidian, Barzia; Shimizu, Kenneth J.; Wilkinson, Belinda M.; Hihn, Jairus M.; Borgen, Rosana B.; Meyer, Kenneth N.;

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 2A: Accident model document, appendix

NASA Technical Reports Server (NTRS)

1972-01-01

The detailed abort sequence trees for the reference zirconium hydride (ZrH) reactor power module that have been generated for each phase of the reference Space Base program mission are presented. The trees are graphical representations of causal sequences. Each tree begins with the phase identification and the dichotomy between success and failure. The success branch shows the mission phase objective as being achieved. The failure branch is subdivided, as conditions require, into various primary initiating abort conditions.

The advocacy in action study a cluster randomized controlled trial to reduce pedestrian injuries in deprived communities.

PubMed

Lyons, R A; Towner, E; Christie, N; Kendrick, D; Jones, S J; Hayes, M; Kimberlee, R; Sarvotham, T; Macey, S; Brussoni, M; Sleney, J; Coupland, C; Phillips, C

2008-04-01

Road traffic-related injury is a major global public health problem. In most countries, pedestrian injuries occur predominantly to the poorest in society. A number of evaluated interventions are effective in reducing these injuries. Very little research has been carried out into the distribution and determinants of the uptake of these interventions. Previous research has shown an association between local political influence and the distribution of traffic calming after adjustment for historical crash patterns. This led to the hypothesis that advocacy could be used to increase local politicians knowledge of pedestrian injury risk and effective interventions, ultimately resulting in improved pedestrian safety. To design an intervention to improve the uptake of pedestrian safety measures in deprived communities. Electoral wards in deprived areas of England and Wales with a poor record of pedestrian safety for children and older adults. Design mixedmethods study, incorporating a cluster randomized controlled trial. Data mixture of Geographical Information Systems data collision locations, road safety interventions, telephone interviews, and questionnaires. Randomization 239 electoral wards clustered within 57 local authorities. Participants 615 politicians representing intervention and control wards. Intervention a package of tailored information including maps of pedestrian injuries was designed for intervention politicians, and a general information pack for controls. Primary outcome number of road safety interventions 25 months after randomization. Secondary outcomes politicians interest and involvement in injury prevention cost of interventions. Process evaluation use of advocacy pack, facilitators and barriers to involvement, and success.

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

PubMed

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

2013-04-01

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

Everolimus-eluting stents in interventional cardiology

PubMed Central

Townsend, Jacob C; Rideout, Phillip; Steinberg, Daniel H

2012-01-01

Bare metal stents have a proven safety record, but limited long-term efficacy due to in-stent restenosis. First-generation drug-eluting stents successfully countered the restenosis rate, but were hampered by concerns about their long-term safety. Second generation drug-eluting stents have combined the low restenosis rate of the first generation with improved long-term safety. We review the evolution of drug-eluting stents with a focus on the safety, efficacy, and unique characteristics of everolimus-eluting stents. PMID:22910420

Combining System Safety and Reliability to Ensure NASA CoNNeCT's Success

NASA Technical Reports Server (NTRS)

Havenhill, Maria; Fernandez, Rene; Zampino, Edward

2012-01-01

Hazard Analysis, Failure Modes and Effects Analysis (FMEA), the Limited-Life Items List (LLIL), and the Single Point Failure (SPF) List were applied by System Safety and Reliability engineers on NASA's Communications, Navigation, and Networking reConfigurable Testbed (CoNNeCT) Project. The integrated approach involving cross reviews of these reports by System Safety, Reliability, and Design engineers resulted in the mitigation of all identified hazards. The outcome was that the system met all the safety requirements it was required to meet.

VPP Star recognition

NASA Image and Video Library

2011-06-09

Stennis Space Center Deputy Director Rick Gilbrech (right) accepts a plaque designating the test facility as a Voluntary Protection Program Star site. Presenting the plaque is Clyde Payne, area director for the Occupational Safety and Health Administration in Jackson, Miss. OSHA established VPP in 1982 as a proactive safety management model to recognize excellence in safety and health. Since then, more than 2,000 organizations have been designated VPP Star sites. To reach that goal, an organization must demonstrate comprehensive and successful safety and health management programs in the workplace.

[Sustainable process improvement with application of 'lean philosophy'].

PubMed

Rouppe van der Voort, Marc B V; van Merode, G G Frits; Veraart, Henricus G N

2013-01-01

Process improvement is increasingly being implemented, particularly with the aid of 'lean philosophy'. This management philosophy aims to improve quality by reducing 'wastage'. Local improvements can produce negative effects elsewhere due to interdependence of processes. An 'integrated system approach' is required to prevent this. Some hospitals claim that this has been successful. Research into process improvement with the application of lean philosophy has reported many positive effects, defined as improved safety, quality and efficiency. Due to methodological shortcomings and lack of rigorous evaluations it is, however, not yet possible to determine the impact of this approach. It is, however, obvious that the investigated applications are fragmentary, with a dominant focus on the instrumental aspect of the philosophy and a lack of integration in a total system, and with insufficient attention to human aspects. Process improvement is required to achieve better and more goal-oriented healthcare. To achieve this, hospitals must develop integrated system approaches that combine methods for process design with continuous improvement of processes and with personnel management. It is crucial that doctors take the initiative to guide and improve processes in an integral manner.

Improving operating room safety

PubMed Central

2009-01-01

Despite the introduction of the Universal Protocol, patient safety in surgery remains a daily challenge in the operating room. This present study describes one community health system's efforts to improve operating room safety through human factors training and ultimately the development of a surgical checklist. Using a combination of formal training, local studies documenting operating room safety issues and peer to peer mentoring we were able to substantially change the culture of our operating room. Our efforts have prepared us for successfully implementing a standardized checklist to improve operating room safety throughout our entire system. Based on these findings we recommend a multimodal approach to improving operating room safety. PMID:19930577

Impacts of Health and Safety Education: Comparison of Worker Activities Before and After Training

PubMed Central

Becker, Paul; Morawetz, John

2014-01-01

Background The International Chemical Workers Union Council (ICWUC) Center for Worker Health and Safety Education in Cincinnati, Ohio, trains workers to protect themselves from hazards due to chemical spills and other chemical exposures. We evaluated whether the ICWUC Hazardous Waste Worker Training Program affects the attitudes and post-training activities, of trained union workers. Methods Detailed survey questionnaires were administered to 55 workers prior to and 14–18 months following training. Surveys queried trainees’ interest and involvement in safety and health, use of information resources, training activities at their worksite, and their attempts and successes at making worksite improvements. Results Post-training, the study population showed an increase in training of other workers, use of resources, attempts at improvements, success rates for those attempting change, and overall success at making improvements. Self-reported interest decreased, and self reported involvement in health and safety did not significantly change. Conclusion The study demonstrates that workers are more willing to attempt to change worksite conditions following training, and that their efficacy at making changes is substantially greater than before they were trained. The study confirms earlier work and strengthens these conclusions by using statistically tested comparisons of impact measures pre- and post-training. PMID:15202126

Using Modified-ISS Model to Evaluate Medication Administration Safety During Bar Code Medication Administration Implementation in Taiwan Regional Teaching Hospital.

PubMed

Ma, Pei-Luen; Jheng, Yan-Wun; Jheng, Bi-Wei; Hou, I-Ching

2017-01-01

Bar code medication administration (BCMA) could reduce medical errors and promote patient safety. This research uses modified information systems success model (M-ISS model) to evaluate nurses' acceptance to BCMA. The result showed moderate correlation between medication administration safety (MAS) to system quality, information quality, service quality, user satisfaction, and limited satisfaction.

[Skin and tissue bank: Operational model for the recovery and preservation of tissues and skin allografts].

PubMed

Martínez-Flores, Francisco; Sandoval-Zamora, Hugo; Machuca-Rodriguez, Catalina; Barrera-López, Araceli; García-Cavazos, Ricardo; Madinaveitia-Villanueva, Juan Antonio

2016-01-01

Tissue storage is a medical process that is in the regulation and homogenisation phase in the scientific world. The international standards require the need to ensure safety and efficacy of human allografts such as skin and other tissues. The activities of skin and tissues banks currently involve their recovery, processing, storage and distribution, which are positively correlated with technological and scientific advances present in current biomedical sciences. A description is presented of the operational model of Skin and Tissue Bank at INR as successful case for procurement, recovery and preservation of skin and tissues for therapeutic uses, with high safety and biological quality. The essential and standard guidelines are presented as keystones for a tissue recovery program based on scientific evidence, and within an ethical and legal framework, as well as to propose a model for complete overview of the donation of tissues and organ programs in Mexico. Finally, it concludes with essential proposals for improving the efficacy of transplantation of organs and tissue programs. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Effect of cuprous oxide with different sizes on thermal and combustion behaviors of unsaturated polyester resin.

PubMed

Hou, Yanbei; Hu, Weizhao; Gui, Zhou; Hu, Yuan

2017-07-15

Cuprous oxide (Cu 2 O) as an effective catalyst has been applied to enhance the fire safety of unsaturated polyester resin (UPR), but the particle size influence on combustion behaviors has not been previously reported. Herein, the UPR/Cu 2 O composites (metal oxide particles with average particle-size of 10, 100, and 200nm) were successfully synthesized by thermosetting process. The effects of Cu 2 O with different sizes on thermostability and combustion behaviors of UPR were characterized by TGA, MCC, TG-IR, FTIR, and SSTF. The results revel that the addition of Cu 2 O contributes to sufficient decomposition of oxygen-containing compounds, which is beneficial to the release of nontoxic compounds. The smallest-sized Cu 2 O performs the excellent catalytic decomposition effect and promotes the complete combustion of UPR, which benefits the enhancement of fire safety. While the other additives retard pyrolysis process and yield more char residue, and thus the flame retardancy of UPR composites was improved. Therefore, catalysis plays a major role for smaller-sized particles during thermal decomposition of matrix, while flame retarded effect became gradual distinctly for the larger-sized additives. Copyright © 2017 Elsevier B.V. All rights reserved.

Modeling and applications in microbial food safety

USDA-ARS?s Scientific Manuscript database

Mathematical modeling is a scientific and systematic approach to study and describe the recurrent events or phenomena with successful application track for decades. When models are properly developed and validated, their applications may save costs and time. For the microbial food safety concerns, ...

SLUDGE TREATMENT PROJECT KOP DISPOSITION - THERMAL AND GAS ANALYSIS FOR THE COLD VACUUM DRYING FACILITY

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

SWENSON JA; CROWE RD; APTHORPE R

2010-03-09

The purpose of this document is to present conceptual design phase thermal process calculations that support the process design and process safety basis for the cold vacuum drying of K Basin KOP material. This document is intended to demonstrate that the conceptual approach: (1) Represents a workable process design that is suitable for development in preliminary design; and (2) Will support formal safety documentation to be prepared during the definitive design phase to establish an acceptable safety basis. The Sludge Treatment Project (STP) is responsible for the disposition of Knock Out Pot (KOP) sludge within the 105-K West (KW) Basin.more » KOP sludge consists of size segregated material (primarily canister particulate) from the fuel and scrap cleaning process used in the Spent Nuclear Fuel process at K Basin. The KOP sludge will be pre-treated to remove fines and some of the constituents containing chemically bound water, after which it is referred to as KOP material. The KOP material will then be loaded into a Multi-Canister Overpack (MCO), dried at the Cold Vacuum Drying Facility (CVDF) and stored in the Canister Storage Building (CSB). This process is patterned after the successful drying of 2100 metric tons of spent fuel, and uses the same facilities and much of the same equipment that was used for drying fuel and scrap. Table ES-l present similarities and differences between KOP material and fuel and between MCOs loaded with these materials. The potential content of bound water bearing constituents limits the mass ofKOP material in an MCO load to a fraction of that in an MCO containing fuel and scrap; however, the small particle size of the KOP material causes the surface area to be significantly higher. This relatively large reactive surface area represents an input to the KOP thermal calculations that is significantly different from the calculations for fuel MCOs. The conceptual design provides for a copper insert block that limits the volume available to receive KOP material, enhances heat conduction, and functions as a heat source and sink during drying operations. This use of the copper insert represents a significant change to the thermal model compared to that used for the fuel calculations. A number of cases were run representing a spectrum of normal and upset conditions for the drying process. Dozens of cases have been run on cold vacuum drying of fuel MCOs. Analysis of these previous calculations identified four cases that provide a solid basis for judgments on the behavior of MCO in drying operations. These four cases are: (1) Normal Process; (2) Degraded vacuum pumping; (3) Open MCO with loss of annulus water; and (4) Cool down after vacuum drying. The four cases were run for two sets of input parameters for KOP MCOs: (1) a set of parameters drawn from safety basis values from the technical data book and (2) a sensitivity set using parameters selected to evaluate the impact of lower void volume and smaller particle size on MCO behavior. Results of the calculations for the drying phase cases are shown in Table ES-2. Cases using data book safety basis values showed dry out in 9.7 hours and heat rejection sufficient to hold temperature rise to less than 25 C. Sensitivity cases which included unrealistically small particle sizes and corresponding high reactive surface area showed higher temperature increases that were limited by water consumption. In this document and in the attachment (Apthorpe, R. and M.G. Plys, 2010) cases using Technical Databook safety basis values are referred to as nominal cases. In future calculations such cases will be called safety basis cases. Also in these documents cases using parameters that are less favorable to acceptable performance than databook safety values are referred to as safety cases. In future calculations such cases will be called sensitivity cases or sensitivity evaluations Calculations to be performed in support of the detailed design and formal safety basis documentation will expand the calculations presented in this document to include: additional features of the drying cycle, more realistic treatment of uranium metal consumption during oxidation, larger water inventory, longer time scales, and graphing of results of hydrogen gas concentration.« less

Validating the Outcome of Partnering on Major Capital Projects

DOT National Transportation Integrated Search

2017-01-27

Research on the mechanics of successful collaborative partnering in roadway construction is relatively scarce; however, there is general agreement that successful partnering can result in better budget and schedule control as well as increase safety ...

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...

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...

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...

Promoting patient safety through prospective risk identification: example from peri-operative care.

PubMed

Smith, A; Boult, M; Woods, I; Johnson, S

2010-02-01

Investigation of patient safety incidents has focused on retrospective analyses once incidents have occurred. Prospective risk analysis techniques complement this but have not been widely used in healthcare. Prospective risk identification of non-operative risks associated with adult elective surgery under general anaesthesia using a customised structured "what if" checklist and development of risk matrix. Prioritisation of recommendations arising by cost, ease and likely speed of implementation. Groups totalling 20 clinical and administrative healthcare staff involved in peri-operative care and risk experts convened by the UK National Patient Safety Agency. 102 risks were identified and 95 recommendations made. The top 20 recommendations together were judged to encompass about 75% of the total estimated risk attributable to the processes considered. Staffing and organisational issues (21% of total estimated risk) included recommendations for removing distractions from the operating theatre, ensuring the availability of senior anaesthetists and promoting standards and flexible working among theatre staff. Devices and equipment (19% of total estimated risk) could be improved by training and standardisation; airway control and temperature monitoring were identified as two specific areas. Pre-assessment of patients before admission to hospital (12% of estimated risk) could be improved by defining a data set for adequate pre-assessment and making this available throughout the NHS. This technique can be successfully applied by healthcare staff but expert facilitation of groups is advisable. Such wider-ranging processes can potentially lead to more comprehensive risk reduction than "single-issue" risk alerts.

A successful model of Road Traffic Injury surveillance in a developing country: process and lessons learnt.

PubMed

Razzak, Junaid Abdul; Shamim, Muhammad Shahzad; Mehmood, Amber; Hussain, Syed Ameer; Ali, Mir Shabbar; Jooma, Rashid

2012-05-16

Road Traffic Injuries (RTIs) are one of the leading causes of death and disability worldwide with 90% of global mortality concentrated in the low and middle income countries. RTI surveillance is recommended to define the burden, identify high risk groups, plan intervention and monitor their impact. Despite its stated importance in the literature, very few examples of sustained surveillance systems are reported from low income countries. This paper shares the experience of setting up an urban RTI surveillance program in the emergency departments of five major hospitals in Karachi, Pakistan. We describe the process of establishing a surveillance system including assembling a multi-institution research group, developing a data collection methodology, carrying out data collection and analysis and dissemination of information to the relevant stakeholders. In the absence of a road safety agency, the surveillance system required developing individual partnerships with industry, police, city government, media and many other stakeholders. Impact of the surveillance is demonstrated by some initiatives in the local trauma system and improvements in road design to effect hazard reduction. We demonstrated that a functional RTI surveillance program can be established, and effectively managed in a developing country, despite lack of infrastructure and limitation of resources. Data utilization in the absence of well defined road safety infrastructure within the government is a challenge. More effective actions are hampered by the limited capacity in the transport and health sectors to do in-depth analysis through road safety audits and trauma registries.

Development of an Integrated Human Factors Toolkit

NASA Technical Reports Server (NTRS)

Resnick, Marc L.

2003-01-01

An effective integration of human abilities and limitations is crucial to the success of all NASA missions. The Integrated Human Factors Toolkit facilitates this integration by assisting system designers and analysts to select the human factors tools that are most appropriate for the needs of each project. The HF Toolkit contains information about a broad variety of human factors tools addressing human requirements in the physical, information processing and human reliability domains. Analysis of each tool includes consideration of the most appropriate design stage, the amount of expertise in human factors that is required, the amount of experience with the tool and the target job tasks that are needed, and other factors that are critical for successful use of the tool. The benefits of the Toolkit include improved safety, reliability and effectiveness of NASA systems throughout the agency. This report outlines the initial stages of development for the Integrated Human Factors Toolkit.

NIRS in Space?

NASA Technical Reports Server (NTRS)

Peterson, David L.; Condon, Estelle (Technical Monitor)

2000-01-01

Proponents of near infrared reflectance spectroscopy (NIRS) have been exceptionally successful in applying NIRS techniques to many instances of organic material analyses. While this research and development began in the 1950s, in recent years, stimulation of advancements in instrumentation is allowing NIRS to begin to find its way into the food processing systems, into food quality and safety, textiles and much more. And, imaging high spectral resolution spectrometers are now being evaluated for the rapid scanning of foodstuffs, such as the inspection of whole chicken carcasses for fecal contamination. The imaging methods are also finding their way into medical applications, such as the non-intrusive monitoring of blood oxygenation in newborns. Can these scientific insights also be taken into space and successfully used to measure the Earth's condition? Is there an analog between the organic analyses in the laboratory and clinical settings and the study of Earth's living biosphere? How are the methods comparable and how do they differ?

The American Organization of Nurse Executives System CNE task force: a work in progress.

PubMed

Rudisill, Pamela T; Thompson, Pamela A

2012-01-01

Health care is a complex industry, consequently requiring a diverse group of health care executives leading initiatives for efficiency and effectiveness in patient care delivery. Value-based purchasing and pay for performance are at the top of the list for indicators of success, and many hospitals are merging into health care systems. The role of the system chief nurse executive is an evolving role to lead health care systems in clinical, operational, patient safety, and patient satisfaction processes and outcomes. The American Organization of Nurse Executives, being the voice for nursing leadership, convened a group of system chief nurse executives to address the role, function, and competencies needed for this significant and emerging role in health care. This article describes the role statement and system chief nurse executive competencies needed for success in the role. In addition, the next steps for addressing the needs of this group will be outlined in this article.

Influence Map Methodology for Evaluating Systemic Safety Issues

NASA Technical Reports Server (NTRS)

2008-01-01

"Raising the bar" in safety performance is a critical challenge for many organizations, including Kennedy Space Center. Contributing-factor taxonomies organize information about the reasons accidents occur and therefore are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This project successfully addressed the following two problems: (1) methods and metrics to support the design of effective taxonomies are limited and (2) influence relationships among contributing factors are not explicitly modeled within a taxonomy.

Sounding rocket and balloon flight safety philosophy and methodologies

NASA Technical Reports Server (NTRS)

Beyma, R. J.

1986-01-01

NASA's sounding rocket and balloon goal is to successfully and safely perform scientific research. This is reflected in the design, planning, and conduct of sounding rocket and balloon operations. The purpose of this paper is to acquaint the sounding rocket and balloon scientific community with flight safety philosophy and methodologies, and how range safety affects their programs. This paper presents the flight safety philosophy for protecting the public against the risk created by the conduct of sounding rocket and balloon operations. The flight safety criteria used to implement this philosophy are defined and the methodologies used to calculate mission risk are described.

Radial line method for rear-view mirror distortion detection

NASA Astrophysics Data System (ADS)

Rahmah, Fitri; Kusumawardhani, Apriani; Setijono, Heru; Hatta, Agus M.; Irwansyah, .

2015-01-01

An image of the object can be distorted due to a defect in a mirror. A rear-view mirror is an important component for the vehicle safety. One of standard parameters of the rear-view mirror is a distortion factor. This paper presents a radial line method for distortion detection of the rear-view mirror. The rear-view mirror was tested for the distortion detection by using a system consisting of a webcam sensor and an image-processing unit. In the image-processing unit, the captured image from the webcam were pre-processed by using smoothing and sharpening techniques and then a radial line method was used to define the distortion factor. It was demonstrated successfully that the radial line method could be used to define the distortion factor. This detection system is useful to be implemented such as in Indonesian's automotive component industry while the manual inspection still be used.

Verification and Validation Methodology of Real-Time Adaptive Neural Networks for Aerospace Applications

NASA Technical Reports Server (NTRS)

Gupta, Pramod; Loparo, Kenneth; Mackall, Dale; Schumann, Johann; Soares, Fola

2004-01-01

Recent research has shown that adaptive neural based control systems are very effective in restoring stability and control of an aircraft in the presence of damage or failures. The application of an adaptive neural network with a flight critical control system requires a thorough and proven process to ensure safe and proper flight operation. Unique testing tools have been developed as part of a process to perform verification and validation (V&V) of real time adaptive neural networks used in recent adaptive flight control system, to evaluate the performance of the on line trained neural networks. The tools will help in certification from FAA and will help in the successful deployment of neural network based adaptive controllers in safety-critical applications. The process to perform verification and validation is evaluated against a typical neural adaptive controller and the results are discussed.

Field tests of a participatory ergonomics toolkit for Total Worker Health

PubMed Central

Kernan, Laura; Plaku-Alakbarova, Bora; Robertson, Michelle; Warren, Nicholas; Henning, Robert

2018-01-01

Growing interest in Total Worker Health® (TWH) programs to advance worker safety, health and well-being motivated development of a toolkit to guide their implementation. Iterative design of a program toolkit occurred in which participatory ergonomics (PE) served as the primary basis to plan integrated TWH interventions in four diverse organizations. The toolkit provided start-up guides for committee formation and training, and a structured PE process for generating integrated TWH interventions. Process data from program facilitators and participants throughout program implementation were used for iterative toolkit design. Program success depended on organizational commitment to regular design team meetings with a trained facilitator, the availability of subject matter experts on ergonomics and health to support the design process, and retraining whenever committee turnover occurred. A two committee structure (employee Design Team, management Steering Committee) provided advantages over a single, multilevel committee structure, and enhanced the planning, communication, and team-work skills of participants. PMID:28166897

Potential difficulties in applying the Pay for Safety Scheme (PFSS) in construction projects.

PubMed

Choi, Tracy N Y; Chan, Daniel W M; Chan, Albert P C

2012-09-01

Since 1996, the Government of the Hong Kong Special Administrative Region (HKSAR) has introduced the Pay for Safety Scheme (PFSS) to the public works construction contracts to uplift their safety performance. However, the adoption of PFSS has also encountered some difficulties that merit considerable attention. This paper purports to provide a concise review of the prevailing application of PFSS in Hong Kong in general, and to explore the potential difficulties associated with PFSS in particular. By means of an empirical questionnaire survey geared towards industrial practitioners with extensive direct hands-on PFSS experience, their opinions were solicited, analyzed and compared between the client group and contractor group of respondents. The three most significant difficulties in implementing PFSS were found to be: (1) "Plenty of paperwork required for certifying payment to contractor"; (2) "Complicated contract documents and lengthy assessment process"; and (3) "Over-tight project schedule requiring rush jobs". The output of this research study is particularly essential in assisting the contracting parties to mitigate the avoidable hindrances when embarking on PFSS. It has also generated valuable insights into developing effective recommendations for alleviating the barriers to PFSS success for future construction projects. Copyright © 2011 Elsevier Ltd. All rights reserved.

Certification Processes for Safety-Critical and Mission-Critical Aerospace Software

NASA Technical Reports Server (NTRS)

Nelson, Stacy

2003-01-01

This document is a quick reference guide with an overview of the processes required to certify safety-critical and mission-critical flight software at selected NASA centers and the FAA. Researchers and software developers can use this guide to jumpstart their understanding of how to get new or enhanced software onboard an aircraft or spacecraft. The introduction contains aerospace industry definitions of safety and safety-critical software, as well as, the current rationale for certification of safety-critical software. The Standards for Safety-Critical Aerospace Software section lists and describes current standards including NASA standards and RTCA DO-178B. The Mission-Critical versus Safety-Critical software section explains the difference between two important classes of software: safety-critical software involving the potential for loss of life due to software failure and mission-critical software involving the potential for aborting a mission due to software failure. The DO-178B Safety-critical Certification Requirements section describes special processes and methods required to obtain a safety-critical certification for aerospace software flying on vehicles under auspices of the FAA. The final two sections give an overview of the certification process used at Dryden Flight Research Center and the approval process at the Jet Propulsion Lab (JPL).

Senior executive transportation & public safety summit : national traffic incident management leadership & innovation roadmap for success

DOT National Transportation Integrated Search

2012-09-05

This report summarizes the proceedings, findings, and recommendations from a two-day Senior Executive Summit on Transportation and Public Safety, held June 26 and 27, 2012 at the United States Department of Transportation (USDOT) in Washington, D.C. ...

23 CFR 650.309 - Qualifications of personnel.

Code of Federal Regulations, 2011 CFR

2011-04-01

... Safety Inspector under the National Society of Professional Engineer's program for National Certification in Engineering Technologies (NICET) and have successfully completed an FHWA approved comprehensive... Accreditation Board for Engineering and Technology; (ii) Successfully passed the National Council of Examiners...

23 CFR 650.309 - Qualifications of personnel.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Safety Inspector under the National Society of Professional Engineer's program for National Certification in Engineering Technologies (NICET) and have successfully completed an FHWA approved comprehensive... Accreditation Board for Engineering and Technology; (ii) Successfully passed the National Council of Examiners...

Creating a Viable Climate for Change When Working With Community Organizations

DOT National Transportation Integrated Search

1995-01-01

Building a successful traffic safety program starts with the recognition that : to be successful, the community-wide effort requires the support of many : individuals and organizations. If everyone is to work collectively toward the : overall plannin...

Evaluation of Bleb Morphology and Reduction in IOP and Glaucoma Medication following Implantation of a Novel Gel Stent

PubMed Central

Spinetta, Roberta; Cannizzo, Paola Maria Loredana; Consolandi, Giulia; Lavia, Carlo; Germinetti, Francesco; Rolle, Teresa

2017-01-01

Objective To evaluate the efficacy and safety of the Xen Gel Stent and provide a macro- and microscopic analyses of bleb morphology. Methods A prospective 12-month study on patients with primary open-angle glaucoma. Patients underwent implantation of the XEN Gel Stent (Allergan INC, Dublin, Ireland) either alone or combined with a cataract surgery. Biomicroscopy, in vivo confocal microscopy (IVCM), and anterior segment-optical coherence tomography (AS-OCT) were used to assess bleb morphology. Safety parameters were adverse events, best corrected visual acuity, visual field, and corneal endothelial cell loss. A postoperative IOP ≤ 18 mmHg without or on medications was respectively defined as complete and qualified success while an IOP ≥ 18 mmHg was defined as failure. Results Twelve eyes of 11 patients were evaluated. At one year, 5 out of 10 patients available achieved a complete success while five were qualified success. AS-OCT showed that bleb wall reflectivity was significantly higher in the failure group; IVCM revealed that stromal density was significantly lower in the success group. No safety issues were recorded. Conclusion Implantation of the XEN Gel Stent appears to be a safe and effective procedure. AS-OCT and IVCM may be helpful in bleb assessment. PMID:28751986

The efficacy and safety of external cephalic version after a previous caesarean delivery.

PubMed

Weill, Yishay; Pollack, Raphael N

2017-06-01

External cephalic version (ECV) in the presence of a uterine scar is still considered a relative contraindication despite encouraging studies of the efficacy and safety of this procedure. We present our experience with this patient population, which is the largest cohort published to date. To evaluate the efficacy and safety of ECV in the setting of a prior caesarean delivery. A total of 158 patients with a fetus presenting as breech, who had an unscarred uterus, had an ECV performed. Similarly, 158 patients with a fetus presenting as breech, and who had undergone a prior caesarean delivery also underwent an ECV. Outcomes were compared. ECV was successfully performed in 136/158 (86.1%) patients in the control group. Of these patients, 6/136 (4.4%) delivered by caesarean delivery. In the study group, 117/158 (74.1%) patients had a successful ECV performed. Of these patients, 12/117 (10.3%) delivered by caesarean delivery. There were no significant complications in either of the groups. ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Operational Performance Risk Assessment in Support of A Supervisory Control System

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

Denning, Richard S.; Muhlheim, Michael David; Cetiner, Sacit M.

Supervisory control system (SCS) is developed for multi-unit advanced small modular reactors to minimize human interventions in both normal and abnormal operations. In SCS, control action decisions made based on probabilistic risk assessment approach via Event Trees/Fault Trees. Although traditional PRA tools are implemented, their scope is extended to normal operations and application is reversed; success of non-safety related system instead failure of safety systems this extended PRA approach called as operational performance risk assessment (OPRA). OPRA helps to identify success paths, combination of control actions for transients and to quantify these success paths to provide possible actions without activatingmore » plant protection system. In this paper, a case study of the OPRA in supervisory control system is demonstrated within the context of the ALMR PRISM design, specifically power conversion system. The scenario investigated involved a condition that the feed water control valve is observed to be drifting to the closed position. Alternative plant configurations were identified via OPRA that would allow the plant to continue to operate at full or reduced power. Dynamic analyses were performed with a thermal-hydraulic model of the ALMR PRISM system using Modelica to evaluate remained safety margins. Successful recovery paths for the selected scenario are identified and quantified via SCS.« less

Institutionalizing Lessons Learned

NASA Technical Reports Server (NTRS)

McBrayer, Robert O.; Thomas, Dale

2001-01-01

The NASA Integrated Action Team (NIAT) was formed by the NASA Administrator in March 2000. The purpose of this team was to identify the actions that NASA must take to address systemic findings reported in 4 different anomaly investigations. Team membership represented senior managers from all the field centers and NASA Headquarters. NIAT report addressed 165 findings and developed 17 action plans that are described in five themes: people and teams, technology, risk, formulation rigor, and communications. The NIAT actions present a systems solution for strengthening formulation and implementation of programs and improving the environment for their support. NIAT results included: enhancing success by avoiding failures that could have been prevented through good planning and sound practice; ensuring that prudent risks do not compromise safety; and ensuring that mission risks are objectively assessed, appropriately mitigated and consciously accepted by the program team and customers. Definitions of Faster, Better, Cheaper and Success Criteria were also developed and included as part of the NIAT report. As a result of the NIAT report, program and project management process changes were incorporated into NASA's quality system documentation, including NPG 7120.513, "NASA Program and Project Management Processes and Requirements. This paper describes the NIAT results and the resulting updates to NPG 7120.5 that keep this program and project management description a living process.

Quantification of the impact of multifaceted initiatives intended to improve operational efficiency and the safety culture: a case study from an academic medical center radiation oncology department.

PubMed

Chera, Bhishamjit S; Mazur, Lukasz; Jackson, Marianne; Taylor, Kinely; Mosaly, Prithima; Chang, Sha; Deschesne, Kathy; LaChapelle, Dana; Hoyle, Lesley; Saponaro, Patricia; Rockwell, John; Adams, Robert; Marks, Lawrence B

2014-01-01

We have systematically been incorporating several operational efficiency and safety initiatives into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful, metrics. The data from 5 quality improvement initiatives, each focused on a specific safety/process concern in our clinic, are presented. Data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using statistical analysis. Results from the Agency for Health Care Research and Quality (AHRQ) patient safety culture surveys administered during and after many of these initiatives were similarly compared. (1) Workload levels for nurses assisting with brachytherapy were high (National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores >55-60, suggesting, "overwork"). Changes in work flow and procedure room layout reduced workload to more acceptable levels (NASA-TLX <55; P < .01). (2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range, 1-11) times per patient treatment to a mean <1 (range, 0-3; P < .001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (ie, delayed, on time). (3) The rates of replans by dosimetrists was reduced from 11% to 6% (P < .01) through a more systematic pretreatment peer review process. (4) Standardizing nursing and resident functions reduced patient wait times by ≈ 45% (14 min; P < .01). (5) Standardizing presimulation instructions from the physician reduced the number of patients experiencing delays on the simulator (>50% to <10%; P < .01). To assess the overall changes in "patient safety culture," we conducted a pre- and postanalysis using the AHRQ survey. Improvements in all measured dimensions were noted. Quality improvement initiatives can be successfully implemented in an academic radiation oncology department to yield measurable improvements in operations resulting in improvement in patient safety culture. Copyright © 2014 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Water Safety Plan on cruise ships: a promising tool to prevent waterborne diseases.

PubMed

Mouchtouri, Varvara A; Bartlett, Christopher L R; Diskin, Arthur; Hadjichristodoulou, Christos

2012-07-01

Legionella spp. and other waterborne pathogens have been isolated from various water systems on land based premises as well as on ships and cases of Legionnaires' disease have been associated with both sites. Peculiarities of cruise ships water systems make the risk management a challenging process. The World Health Organization suggests a Water Safety Plan (WSP) as the best approach to mitigate risks and hazards such as Legionella spp. and others. To develop WSP on a cruise ship and discuss challenges, perspectives and key issues to success. Hazards and hazardous events were identified and risk assessment was conducted of the ship water system. Ship company management, policies and procedures were reviewed, site visits were conducted, findings and observations were recorded and discussed with engineers and key crew members were interviewed. A total of 53 hazards and hazardous events were taken into consideration for the risk assessment and additional essential barriers were established when needed. Most of them concerned control measures for biofilm development and Legionella spp. contamination. A total of 29 operational limits were defined. Supplementary verification and supportive programs were established. Application of the WSP to ship water systems, including potable water, recreational water facilities and decorative water features and fountains, is expected to improve water management on ships. The success of a WSP depends on support from senior management, commitment of the Captain and crew members, correct execution of all steps of a risk assessment and practicality and applicability in routine operation. The WSP provides to shipping industry a new approach and a move toward evidence based water safety policy. Copyright © 2012 Elsevier B.V. All rights reserved.

A Recipe for Success OSHA VPP and Wellness

NASA Technical Reports Server (NTRS)

Keprta, Sean

2010-01-01

This slide presentation reviews the Voluntary Protection Program (VPP) which is a program to promote effective worksite-based safety and health. In the VPP, management, labor, and OSHA establish cooperative relationships at workplaces that have implemented a comprehensive safety and health management system. The history of JSC's Total Health program and the movement from the Safety and Total Health program and the efforts to become certified by OSHA is reviewed.

Purification of Houttuynia cordata Thunb. Essential Oil Using Macroporous Resin Followed by Microemulsion Encapsulation to Improve Its Safety and Antiviral Activity.

PubMed

Pang, Jianmei; Dong, Wujun; Li, Yuhuan; Xia, Xuejun; Liu, Zhihua; Hao, Huazhen; Jiang, Lingmin; Liu, Yuling

2017-02-15

Essential oil extracted from Houttuynia cordata Thunb. ( H. cordata ) is widely used in traditional Chinese medicine due to its excellent biological activities. However, impurities and deficient preparations of the essential oil limit its safety and effectiveness. Herein, we proposed a strategy to prepare H. cordata essential oil (HEO) safely and effectively by combining the solvent extraction and the macroporous resin purification flexibly, and then encapsulating it using microemulsion. The extraction and purification process were optimized by orthogonal experimental design and adsorption-desorption tests, respectively. The average houttuynin content in pure HEO was then validated at 44.3% ± 2.01%, which presented a great potential for industrial application. Subsequently, pure HEO-loaded microemulsion was prepared by high-pressure homogenization and was then fully characterized. Results showed that the pure HEO-loaded microemulsion was successfully prepared with an average particle size of 179.1 nm and a high encapsulation rate of 94.7%. Furthermore, safety evaluation tests and in vitro antiviral testing indicated that the safety and activity of HEO were significantly improved after purification using D101 resin and were further improved by microemulsion encapsulation. These results demonstrated that the purification of HEO by macroporous resin followed by microemulsion encapsulation would be a promising approach for industrial application of HEO for the antiviral therapies.

Organizing safety: conditions for successful information assurance programs.

PubMed

Collmann, Jeff; Coleman, Johnathan; Sostrom, Kristen; Wright, Willie

2004-01-01

Organizations must continuously seek safety. When considering computerized health information systems, "safety" includes protecting the integrity, confidentiality, and availability of information assets such as patient information, key components of the technical information system, and critical personnel. "High Reliability Theory" (HRT) argues that organizations with strong leadership support, continuous training, redundant safety mechanisms, and "cultures of high reliability" can deploy and safely manage complex, risky technologies such as nuclear weapons systems or computerized health information systems. In preparation for the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Office of the Assistant Secretary of Defense (Health Affairs), the Offices of the Surgeons General of the United States Army, Navy and Air Force, and the Telemedicine and Advanced Technology Research Center (TATRC), US Army Medical Research and Materiel Command sponsored organizational, doctrinal, and technical projects that individually and collectively promote conditions for a "culture of information assurance." These efforts include sponsoring the "P3 Working Group" (P3WG), an interdisciplinary, tri-service taskforce that reviewed all relevant Department of Defense (DoD), Miliary Health System (MHS), Army, Navy and Air Force policies for compliance with the HIPAA medical privacy and data security regulations; supporting development, training, and deployment of OCTAVE(sm), a self-directed information security risk assessment process; and sponsoring development of the Risk Information Management Resource (RIMR), a Web-enabled enterprise portal about health information assurance.

Visual field defects may not affect safe driving.

PubMed

Dow, Jamie

2011-10-01

In Quebec a driver whose acquired visual field defect renders them ineligible for a driver's permit renewal may request an exemption from the visual field standard by demonstrating safe driving despite the defect. For safety reasons it was decided to attempt to identify predictors of failure on the road test in order to avoid placing driving evaluators in potentially dangerous situations when evaluating drivers with visual field defects. During a 4-month period in 2009 all requests for exemptions from the visual field standard were collected and analyzed. All available medical and visual field data were collated for 103 individuals, of whom 91 successfully completed the evaluation process and obtained a waiver. The collated data included age, sex, type of visual field defect, visual field characteristics, and concomitant medical problems. No single factor, or combination of factors, could predict failure of the road test. All 5 failures of the road test had cognitive problems but 6 of the successful drivers also had known cognitive problems. Thus, cognitive problems influence the risk of failure but do not predict certain failure. Most of the applicants for an exemption were able to complete the evaluation process successfully, thereby demonstrating safe driving despite their handicap. Consequently, jurisdictions that have visual field standards for their driving permit should implement procedures to evaluate drivers with visual field defects that render them unable to meet the standard but who wish to continue driving.

Collaborative vaccine development: partnering pays.

PubMed

Ramachandra, Rangappa

2008-01-01

Vaccine development, supported by infusions of public and private venture capital, is re-entering a golden age as one of the fastest growing sectors in the life-sciences industry. Demand is driven by great unmet need in underdeveloped countries, increased resistance to current treatments, bioterrorism, and for prevention indications in travelers, pediatric, and adult diseases. Production systems are becoming less reliant on processes such as egg-based manufacturing, while new processes can help to optimize vaccines. Expeditious development hinges on efficient study conduct, which is greatly enhanced through research partnerships with specialized contract research organizations (CROs) that are licensed and knowledgeable in the intricacies of immunology and with the technologic and scientific foundation to support changing timelines and strategies inherent to vaccine development. The CRO often brings a more objective assessment for probability of success and may offer alternative development pathways. Vaccine developers are afforded more flexibility and are free to focus on innovation and internal core competencies. Functions readily outsourced to a competent partner include animal model development, safety and efficacy studies, immunotoxicity and immunogenicity, dose response studies, and stability and potency testing. These functions capitalize on the CRO partner's regulatory and scientific talent and expertise, and reduce infrastructure expenses for the vaccine developer. Successful partnerships result in development efficiencies, elimination or reduced redundancies, and improved time to market. Keys to success include honest communications, transparency, and flexibility.

Improving Our Odds: Success through Continuous Risk Management

NASA Technical Reports Server (NTRS)

Greenhalgh, Phillip O.

2009-01-01

Launching a rocket, running a business, driving to work and even day-to-day living all involve some degree of risk. Risk is ever present yet not always recognized, adequately assessed and appropriately mitigated. Identification, assessment and mitigation of risk are elements of the risk management component of the "continuous improvement" way of life that has become a hallmark of successful and progressive enterprises. While the application of risk management techniques to provide continuous improvement may be detailed and extensive, the philosophy, ideals and tools can be beneficially applied to all situations. Experiences with the use of risk identification, assessment and mitigation techniques for complex systems and processes are described. System safety efforts and tools used to examine potential risks of the Ares I First Stage of NASA s new Constellation Crew Launch Vehicle (CLV) presently being designed are noted as examples. Recommendations from lessons learned are provided for the application of risk management during the development of new systems as well as for the improvement of existing systems. Lessons learned and suggestions given are also examined for applicability to simple systems, uncomplicated processes and routine personal daily tasks. This paper informs the reader of varied uses of risk management efforts and techniques to identify, assess and mitigate risk for improvement of products, success of business, protection of people and enhancement of personal life.

Research product transfer for local calibration factors of the Highway Safety Manual (HSM) and integrated surrogate safety assessment framework : final report.

DOT National Transportation Integrated Search

2015-12-01

This technology transfer workshop presented transportation planners in the public and private sectors with two successful and closely related studies, conducted respectively by Morgan State University and the University of Virginia. The first module ...

48 CFR 1816.405-274 - Award fee evaluation factors.

Code of Federal Regulations, 2010 CFR

2010-10-01

... factor, if used, must include consideration of risk management (including mission success, safety... above the contracting officer, with the concurrence of the project manager. The rationale for any waiver shall be documented in the contract file. When safety, export control, or security are considered under...

Implementation and implication of total quality management on client- contractor relationship in residential projects

NASA Astrophysics Data System (ADS)

Murali, Swetha; Ponmalar, V.

2017-07-01

To make innovation and continuous improvement as a norm, some traditional practices must become unlearnt. Change for growth and competitiveness are required for sustainability for any profitable business such as the construction industry. The leading companies are willing to implement Total Quality Management (TQM) principles, to realise potential advantages and improve growth and efficiency. Ironically, researches recollected quality as the most significant provider for competitive advantage in industrial leadership. The two objectives of this paper are 1) Identify TQM effectiveness in residential projects and 2) Identify the client satisfaction/dissatisfaction areas using Analytical Hierarchy Process (AHP) and suggest effective mitigate measures. Using statistical survey techniques like set of questionnaire survey, it is observed that total quality management was applied in some leading successful organization to an extent. The main attributes for quality achievement can be defined as teamwork and better communication with single agreed goal between client and contractor. Onsite safety is a paramount attribute in the identifying quality within the residential projects. It was noticed that the process based quality methods such as onsite safe working condition; safe management system and modern engineering process safety controls etc. as interlinked functions. Training and effective communication with all stakeholders on quality management principles is essential for effective quality work. Late Only through effective TQM principles companies can avoid some contract litigations with an increased client satisfaction Index.

Quality and Safety Implications of Emergency Department Information Systems

PubMed Central

Farley, Heather L.; Baumlin, Kevin M.; Hamedani, Azita G.; Cheung, Dickson S.; Edwards, Michael R.; Fuller, Drew C.; Genes, Nicholas; Griffey, Richard T.; Kelly, John J.; McClay, James C.; Nielson, Jeff; Phelan, Michael P.; Shapiro, Jason S.; Stone-Griffith, Suzanne; Pines, Jesse M.

2013-01-01

The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services “meaningful use” incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals’ electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital’s or physician group’s approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order–wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system’s ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or enterprise systems. PMID:23796627

Exploiting Science: Enhancing the Safety Training of Pilots to Reduce the Risk of Bird Strikes

NASA Astrophysics Data System (ADS)

Mendonca, Flavio A. C.

Analysis of bird strikes to aviation in the U.S. from 1990 to 2015 indicate that the successful mitigation efforts at airports, which must be sustained, have reduced incidents with damage and a negative effect-on-flight since 2000. However, such efforts have done little to reduce strikes outside the airport jurisdiction, such as occurred with US Airways Flight 1549 in 2009. There are basically three strategies to mitigate the risk of bird strikes: standards set by aviation authorities, technology, and actions by crewmembers. Pilots play an important role as stakeholders in the prevention of bird strikes, especially outside the airport environment. Thus, safety efforts require enhanced risk management and aeronautical decision-making training for flight crews. The purpose of this study was to determine if a safety training protocol could effectively enhance CFR Part 141 general aviation pilots' knowledge and skills to reduce the risk of bird strikes to aviation. Participants were recruited from the Purdue University professional flight program and from Purdue Aviation. The researcher of this study used a pretest posttest experimental design. Additionally, qualitative data were collected through open-ended questions in the pretest, posttest, and a follow-up survey questionnaire. The participants' pretest and posttest scores were analyzed using parametric and nonparametric tests. Results indicated a significant increase in the posttest scores of the experimental group. An investigation of qualitative data showed that the topic "safety management of bird hazards by pilots" is barely covered during the ground and flight training of pilots. Furthermore, qualitative data suggest a misperception of the safety culture tenets and a poor familiarity with the safety risk management process regarding bird hazards. Finally, the researcher presented recommendations for practice and future research.

Clinical performance of a new blood control peripheral intravenous catheter: A prospective, randomized, controlled study.

PubMed

Seiberlich, Laura E; Keay, Vanessa; Kallos, Stephane; Junghans, Tiffany; Lang, Eddy; McRae, Andrew D

2016-03-01

The performance of a new safety peripheral intravenous catheter (PIVC) that contains a blood control feature in the hub (blood control) was compared against the current hospital standard without blood control (standard). In this prospective, non-blinded trial, patients were randomized 1:1 to receive either device. Insertions were performed and rated by emergency room nurses. Primary endpoints included clinical acceptability, incidence of blood leakage, and risk of blood exposure. Secondary endpoints were digital compression, insertion success, and usability. 15 clinicians performed 152 PIVC insertions (73 blood control, 79 standard). Clinical acceptability of the blood control device (100%) was non-inferior to the standard (98.7%) (p < 0.0001). The blood control device had a lower incidence of blood leakage (14.1% vs 68.4%), was superior in eliminating the risk of blood exposure (93.9% vs 19.1%) and the need for digital compression (95.3% vs 19.1%), while maintaining non-inferior insertion success rates (95.9% vs 93.7%) and usability ratings (p < 0.0001). In comparison with the hospital-standard, the new safety PIVC with integrated blood control valve had similar clinical acceptability ratings yet demonstrated superior advantages to both clinicians and patients to decrease blood leakage and the clinician's risk of blood exposure, during the insertion process. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Integrating weather and geotechnical monitoring data for assessing the stability of large scale surface mining operations

NASA Astrophysics Data System (ADS)

Steiakakis, Chrysanthos; Agioutantis, Zacharias; Apostolou, Evangelia; Papavgeri, Georgia; Tripolitsiotis, Achilles

2016-01-01

The geotechnical challenges for safe slope design in large scale surface mining operations are enormous. Sometimes one degree of slope inclination can significantly reduce the overburden to ore ratio and therefore dramatically improve the economics of the operation, while large scale slope failures may have a significant impact on human lives. Furthermore, adverse weather conditions, such as high precipitation rates, may unfavorably affect the already delicate balance between operations and safety. Geotechnical, weather and production parameters should be systematically monitored and evaluated in order to safely operate such pits. Appropriate data management, processing and storage are critical to ensure timely and informed decisions. This paper presents an integrated data management system which was developed over a number of years as well as the advantages through a specific application. The presented case study illustrates how the high production slopes of a mine that exceed depths of 100-120 m were successfully mined with an average displacement rate of 10- 20 mm/day, approaching an almost slow to moderate landslide velocity. Monitoring data of the past four years are included in the database and can be analyzed to produce valuable results. Time-series data correlations of movements, precipitation records, etc. are evaluated and presented in this case study. The results can be used to successfully manage mine operations and ensure the safety of the mine and the workforce.

Practicing safe cell culture: applied process designs for minimizing virus contamination risk.

PubMed

Kiss, Robert D

2011-01-01

CONFERENCE PROCEEDING Proceedings of the PDA/FDA Adventitious Viruses in Biologics: Detection and Mitigation Strategies Workshop in Bethesda, MD, USA; December 1-3, 2010 Guest Editors: Arifa Khan (Bethesda, MD), Patricia Hughes (Bethesda, MD) and Michael Wiebe (San Francisco, CA) Genentech responded to a virus contamination in its biologics manufacturing facility by developing and implementing a series of barriers specifically designed to prevent recurrence of this significant and impactful event. The barriers included steps to inactivate or remove potential virus particles from the many raw materials used in cell culture processing. Additionally, analytical testing barriers provided protection of the downstream processing areas should a culture contamination occur, and robust virus clearance capability provided further assurance of virus safety should a low level contamination go undetected. This conference proceeding will review Genentech's approach, and lessons learned, in minimizing virus contamination risk in cell culture processes through multiple layers of targeted barriers designed to deliver biologics products with high success rates.

Office-based anesthesia: new frontiers, better outcomes, and emphasis on safety.

PubMed

Desai, Meena S

2008-12-01

Office-based anesthesia has grown and continues to grow very rapidly in the ever-changing medical environment. The demand of patients, surgeons and the evolving economic environment has set off a dynamic growth explosion. This explosion has created aggressive and tumultuous enhancements, some of which have been adapted well and some of which have led to disastrous results. As we institute rules and regulations to govern this 'wild west' of anesthesia, the landscape is set with some new guidelines that continue to evolve.Practice recommendations have been outlined for fire safety especially on patient fires. Closed claim studies offer valuable recommendations for MAC claims in the office based setting. Anesthesia Patient Safety Foundation and the ASA have outlined valuable information regarding the nonsilencing of equipment alarms.New equipment enhancements have generated successful mobile general anesthesia platforms. Finally, as we forge ahead we must construct measurements of our safety and success as outcome parameters are developed. The review of recent literature and technological advances has provided some valuable lessons in the evolution of patient safety and office based technology for the surgical office-based environment. As this specialty grows, measures of its outcome parameters will allow a gauge of performance.

An Autonomous Flight Safety System

NASA Technical Reports Server (NTRS)

Bull, James B.; Lanzi, Raymond J.

2007-01-01

The Autonomous Flight Safety System (AFSS) being developed by NASA s Goddard Space Flight Center s Wallops Flight Facility and Kennedy Space Center has completed two successful developmental flights and is preparing for a third. AFSS has been demonstrated to be a viable architecture for implementation of a completely vehicle based system capable of protecting life and property in event of an errant vehicle by terminating the flight or initiating other actions. It is capable of replacing current human-in-the-loop systems or acting in parallel with them. AFSS is configured prior to flight in accordance with a specific rule set agreed upon by the range safety authority and the user to protect the public and assure mission success. This paper discusses the motivation for the project, describes the method of development, and presents an overview of the evolving architecture and the current status.

The Evolution of Process Safety: Current Status and Future Direction.

PubMed

Mannan, M Sam; Reyes-Valdes, Olga; Jain, Prerna; Tamim, Nafiz; Ahammad, Monir

2016-06-07

The advent of the industrial revolution in the nineteenth century increased the volume and variety of manufactured goods and enriched the quality of life for society as a whole. However, industrialization was also accompanied by new manufacturing and complex processes that brought about the use of hazardous chemicals and difficult-to-control operating conditions. Moreover, human-process-equipment interaction plus on-the-job learning resulted in further undesirable outcomes and associated consequences. These problems gave rise to many catastrophic process safety incidents that resulted in thousands of fatalities and injuries, losses of property, and environmental damages. These events led eventually to the necessity for a gradual development of a new multidisciplinary field, referred to as process safety. From its inception in the early 1970s to the current state of the art, process safety has come to represent a wide array of issues, including safety culture, process safety management systems, process safety engineering, loss prevention, risk assessment, risk management, and inherently safer technology. Governments and academic/research organizations have kept pace with regulatory programs and research initiatives, respectively. Understanding how major incidents impact regulations and contribute to industrial and academic technology development provides a firm foundation to address new challenges, and to continue applying science and engineering to develop and implement programs to keep hazardous materials within containment. Here the most significant incidents in terms of their impact on regulations and the overall development of the field of process safety are described.

WE-G-BRA-07: Analyzing the Safety Implications of a Brachytherapy Process Improvement Project Utilizing a Novel System-Theory-Based Hazard-Analysis Technique

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

Tang, A; Samost, A; Viswanathan, A

Purpose: To investigate the hazards in cervical-cancer HDR brachytherapy using a novel hazard-analysis technique, System Theoretic Process Analysis (STPA). The applicability and benefit of STPA to the field of radiation oncology is demonstrated. Methods: We analyzed the tandem and ring HDR procedure through observations, discussions with physicists and physicians, and the use of a previously developed process map. Controllers and their respective control actions were identified and arranged into a hierarchical control model of the system, modeling the workflow from applicator insertion through initiating treatment delivery. We then used the STPA process to identify potentially unsafe control actions. Scenarios weremore » then generated from the identified unsafe control actions and used to develop recommendations for system safety constraints. Results: 10 controllers were identified and included in the final model. From these controllers 32 potentially unsafe control actions were identified, leading to more than 120 potential accident scenarios, including both clinical errors (e.g., using outdated imaging studies for planning), and managerial-based incidents (e.g., unsafe equipment, budget, or staffing decisions). Constraints identified from those scenarios include common themes, such as the need for appropriate feedback to give the controllers an adequate mental model to maintain safe boundaries of operations. As an example, one finding was that the likelihood of the potential accident scenario of the applicator breaking during insertion might be reduced by establishing a feedback loop of equipment-usage metrics and equipment-failure reports to the management controller. Conclusion: The utility of STPA in analyzing system hazards in a clinical brachytherapy system was demonstrated. This technique, rooted in system theory, identified scenarios both technical/clinical and managerial in nature. These results suggest that STPA can be successfully used to analyze safety in brachytherapy and may prove to be an alternative to other hazard analysis techniques.« less

HSE auditing

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

Herwaarden, A.J.F. van; Sykes, R.M.

1996-12-31

Shell International Exploration and Production (SIEP) commenced a programme of Health Safety and Environmental (HSE) auditing in its Operating Companies (Opcos) in the late 1970s. Audits in the initial years focused on safety aspects with environmental and occupational aspects being introduced as the process matured. Part of the audit programme is performed by SIEP auditors, external to the Opcos. The level of SIEP-led audit activity increased linearly until the late 1980s, since when a level of around 40 Audits per year has been maintained in roughly as many companies. For the last 15 years each annual programme has included structuredmore » audits of all facets of EP operations. The frequency and duration of these audits have the principle objective of auditing all HSE critical processes of each Opco`s activity, within each five-year cycle. Durations vary from 8-10 days with a 4 person team to 18-20 days with a 6-8 person team. Each audit returns a satisfactory or unsatisfactory rating based on analysis of the effectiveness of the so-called eleven principles of Enhanced Safety Management (ESM) required to be applied throughout the Group. Independence is maintained by the SIEP audit leader, who carries ultimate responsibility for the content and wording of each report, where necessary backed-up by senior management in SIEP. These SIEP-led audits have been successful in the following areas: (1) Provision of early warning in areas where facilities integrity or HSE management was likely to be compromised. (2) Aiding the establishment of an internal HSE auditing process in many Opcos. (3) Training, through participation in audits, not only auditors, but also prospective line managers in the effective management of HSE. With the recent introduction of HSE Management Systems (HSE-MS) in many Opcos, auditing is now in the process of controlled evolution from ESM to HSE-MS based.« less

Distilling the Verification Process for Prognostics Algorithms

NASA Technical Reports Server (NTRS)

Roychoudhury, Indranil; Saxena, Abhinav; Celaya, Jose R.; Goebel, Kai

2013-01-01

The goal of prognostics and health management (PHM) systems is to ensure system safety, and reduce downtime and maintenance costs. It is important that a PHM system is verified and validated before it can be successfully deployed. Prognostics algorithms are integral parts of PHM systems. This paper investigates a systematic process of verification of such prognostics algorithms. To this end, first, this paper distinguishes between technology maturation and product development. Then, the paper describes the verification process for a prognostics algorithm as it moves up to higher maturity levels. This process is shown to be an iterative process where verification activities are interleaved with validation activities at each maturation level. In this work, we adopt the concept of technology readiness levels (TRLs) to represent the different maturity levels of a prognostics algorithm. It is shown that at each TRL, the verification of a prognostics algorithm depends on verifying the different components of the algorithm according to the requirements laid out by the PHM system that adopts this prognostics algorithm. Finally, using simplified examples, the systematic process for verifying a prognostics algorithm is demonstrated as the prognostics algorithm moves up TRLs.

Management of return-to-work programs for workers with musculoskeletal disorders: a qualitative study in three Canadian provinces.

PubMed

Baril, R; Clarke, J; Friesen, M; Stock, S; Cole, D

2003-12-01

In this qualitative research project, researchers in three Canadian provinces explored the perceptions of many different actors involved in return-to-work (RTW) programs for injured workers, studying their views on successful RTW strategies and barriers to/facilitators of the RTW process, then analyzing the underlying dynamics driving their different experiences. Each research team recruited actors in a variety of different workplaces and key informants in the RTW system, and used a combination of in-depth, semi-structured interviews and focus groups to collect data, which were coded using an open coding system. Analysis took a social constructionist perspective. The roles and mandates of the different groups of actors (injured workers; other workplace actors; actors outside the workplace), while sometimes complementary, could also differ, leading to tension and conflict. Characteristics of injured workers described as influencing RTW success included personal and sociodemographic factors, beliefs and attitudes, and motivation. Human resources managers and health care professionals tended to attribute workers' motivation to their individual characteristics, whereas injured workers, worker representatives and health and safety managers described workplace culture and the degree to which workers' well-being was considered as having a strong influence on workers' motivation. Some supervisors experienced role conflict when responsible for both production quotas and RTW programs, but difficulties were alleviated by innovations such as consideration of RTW program responsibilities in the determination of production quotas and in performance evaluations. RTW program success seemed related to labor-management relations and top management commitment to Health and Safety. Non-workplace issues included confusion stemming from the compensation system itself, communication difficulties with some treating physicians, and role conflict on the part of physicians wishing to advocate for patients whose problems were non-compensable. Several common themes emerged from the experiences related by the wide range of actors including the importance of trust, respect, communication and labor relations in the failure or success of RTW programs for injured workers.

Managing pedestrian safety II : A case-control study of collision locations on state routes in King County and Seattle, Washington

DOT National Transportation Integrated Search

2008-01-01

The safety of non-motorized transportation systems is essential to the public acceptance and overall success of Washington State's and local jurisdictions' efforts to reduce congestion. The State's and the jurisdictions' goals to increase non-SOV (si...

Fire and Life Safety Training Needs of Rail Rapid Transit System and Fire Service Personnel

DOT National Transportation Integrated Search

1983-05-01

This report presents a summary and the results of the successful workshop "On Track to Fire and Life Safety in Rail Rapid Transit," held on August 2-4, 1982, at Crystal City, Virginia. Sponsored by the Urban Mass Transportation Administration (UMTA) ...

Program activities associated with safety belt use. Volume 2, Research report

DOT National Transportation Integrated Search

1987-11-13

By the end of 1986, 26 states and the District of Columbia had active safety belt use laws, each supported by a variety of state and community activities. They were not equally successful, as belt-use rates ranged from 23 to 74%. To investigate these...

78 FR 71715 - Amendments to Highway Safety Program Guidelines

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-29

... promulgate uniform guidelines for State highway safety programs. This notice revises five of the existing... successful and are based on sound science and program administration. The revised guidelines are Guideline No... become effective as of the date of publication of this document in the Federal Register. FOR FURTHER...

Program activities associated with safety belt use. Volume 1, User's summary

DOT National Transportation Integrated Search

1987-11-13

By the end of 1986, 26 states and the District of Columbia had active safety belt use laws, each supported by a variety of state and community activities. They were not equally successful, as belt-use rates ranged from 23 to 74%. To investigate these...

Aerospace Safety Advisory Panel

NASA Technical Reports Server (NTRS)

1992-01-01

The results of the Panel's activities are presented in a set of findings and recommendations. Highlighted here are both improvements in NASA's safety and reliability activities and specific areas where additional gains might be realized. One area of particular concern involves the curtailment or elimination of Space Shuttle safety and reliability enhancements. Several findings and recommendations address this area of concern, reflecting the opinion that safety and reliability enhancements are essential to the continued successful operation of the Space Shuttle. It is recommended that a comprehensive and continuing program of safety and reliability improvements in all areas of Space Shuttle hardware/software be considered an inherent component of ongoing Space Shuttle operations.

Cultural transformation toward patient safety: one conversation at a time.

PubMed

Moore, Martie L; Putman, Patrice A

2008-01-01

Patient safety has become a critical objective for nursing leaders within the healthcare setting. Changing the culture to ensure the highest level of communication and safety is a daunting task. Many of the contributing factors that lead to patient harm are rooted in conflict and ineffective conversations. This article shares the story of how 1 organization agreed to make a cultural transformation and the success it realized one conversation at a time.

Evaluating the Effectiveness of Traditional Training Methods in Non-Traditional Training Programs for Adult Learners through a Pre-Test/Post-Test Comparison of Food Safety Knowledge

ERIC Educational Resources Information Center

Dodd, Caleb D.; Burris, Scott; Fraze, Steve; Doerfert, David; McCulloch, Abigail

2013-01-01

The incorporation of hot and cold food bars into grocery stores in an effort to capture a portion of the home meal replacement industry is presenting new challenges for retail food establishments. To ensure retail success and customer safety, employees need to be educated in food safety practices. Traditional methods of training are not meeting…

Integrating system safety into the basic systems engineering process

NASA Technical Reports Server (NTRS)

Griswold, J. W.

1971-01-01

The basic elements of a systems engineering process are given along with a detailed description of what the safety system requires from the systems engineering process. Also discussed is the safety that the system provides to other subfunctions of systems engineering.

NASA Expendable Launch Vehicle (ELV) Payload Safety Review Process

NASA Technical Reports Server (NTRS)

Starbus, Calvert S.; Donovan, Shawn; Dook, Mike; Palo, Tom

2007-01-01

Issues addressed by this program: (1) Complicated roles and responsibilities associated with multi-partner projects (2) Working relationships and communications between all organizations involved in the payload safety process (3) Consistent interpretation and implementation of safety requirements from one project to the rest (4) Consistent implementation of the Tailoring Process (5) Clearly defined NASA decision-making-authority (6) Bring Agency-wide perspective to each ElV payload project. Current process requires a Payload Safety Working Group (PSWG) for eac payload with representatives from all involved organizations.

High reliability and implications for nursing leaders.

PubMed

Riley, William

2009-03-01

To review high reliability theory and discuss its implications for the nursing leader. A high reliability organization (HRO) is considered that which has measurable near perfect performance for quality and safety. The author has reviewed the literature, discussed research findings that contribute to improving reliability in health care organizations, and makes five recommendations for how nursing leaders can create high reliability organizations. Health care is not a safe industry and unintended patient harm occurs at epidemic levels. Health care can learn from high reliability theory and practice developed in other high-risk industries. Viewed by HRO standards, unintended patient injury in health care is excessively high and quality is distressingly low. HRO theory and practice can be successfully applied in health care using advanced interdisciplinary teamwork training and deliberate process design techniques. Nursing has a primary leadership function for ensuring patient safety and achieving high quality in health care organizations. Learning HRO theory and methods for achieving high reliability is a foremost opportunity for nursing leaders.

Managing Risk in Safety Critical Operations - Lessons Learned from Space Operations

NASA Technical Reports Server (NTRS)

Gonzalez, Steven A.

2002-01-01

The Mission Control Center (MCC) at Johnson Space Center (JSC) has a rich legacy of supporting Human Space Flight operations throughout the Apollo, Shuttle and International Space Station eras. Through the evolution of ground operations and the Mission Control Center facility, NASA has gained a wealth of experience of what it takes to manage the risk in Safety Critical Operations, especially when human life is at risk. The focus of the presentation will be on the processes (training, operational rigor, team dynamics) that enable the JSC/MCC team to be so successful. The presentation will also share the evolution of the Mission Control Center architecture and how the evolution was introduced while managing the risk to the programs supported by the team. The details of the MCC architecture (e.g., the specific software, hardware or tools used in the facility) will not be shared at the conference since it would not give any additional insight as to how risk is managed in Space Operations.

Situation analysis for automotive pre-crash systems

NASA Astrophysics Data System (ADS)

Böhning, Marcus A.; Ritter, Henning; Rohling, Herrman

2008-01-01

According to the "World Report on Road Traffic Injury Prevention" jointly issued by the World Health Organization and the World Bank about 1.2 million people are killed and up to 50 million people are injured in road traffic accidents worldwide each year. While passive safety systems like the airbag are already deployed successfully to reduce fatalities and injuries, active safety systems assist the driver by issuing a warning or by taking corrective actions to either avoid a collision completely or, if impossible, to mitigate collision consequences. Today's radar sensors have the ability to detect and track objects with a high accuracy in range and velocity, therefore a collision warning system may consist of a radar sensor, a data processing unit and a model to describe possible evasion maneuvers. This allows to analyze the probability of a collision and to calculate the danger potential of the current situation. In this paper, such a system is proposed and it is verified with synthetic as well as real sensor data.

Implementing an Integrated Commitment Management System at the Savannah River Site Tank Farms

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

Blanchard, A.

1999-06-16

Recently, the Savannah River Site Tank Farms have been transitioning from pre-1990 Authorization Basis requirements to new 5480.22/.23 requirements. Implementation of the new Authorization Basis has resulted in more detailed requirements, a completely new set of implementing procedures, and the expectation of even more disciplined operations. Key to the success of this implementation has been the development of an Integrated Commitment Management System (ICMS) by Westinghouse Safety Management Solutions. The ICMS has two elements: the Authorization Commitment Matrix (ACM), and a Procedure Consistency Review methodology. The Authorization Commitment Matrix is a linking database, which ties requirements and implementing documents together.more » The associated Procedure Consistency Review process ensures that the procedures to be credited in the ACM do in fact correctly and completely meet all intended commitments. This Integrated Commitment Management System helps Westinghouse Safety Management Solutions and the facility operations and engineering organizations take ownership in the implementation of the requirements that have been developed.« less

Ontology-Based Architecture for Intelligent Transportation Systems Using a Traffic Sensor Network.

PubMed

Fernandez, Susel; Hadfi, Rafik; Ito, Takayuki; Marsa-Maestre, Ivan; Velasco, Juan R

2016-08-15

Intelligent transportation systems are a set of technological solutions used to improve the performance and safety of road transportation. A crucial element for the success of these systems is the exchange of information, not only between vehicles, but also among other components in the road infrastructure through different applications. One of the most important information sources in this kind of systems is sensors. Sensors can be within vehicles or as part of the infrastructure, such as bridges, roads or traffic signs. Sensors can provide information related to weather conditions and traffic situation, which is useful to improve the driving process. To facilitate the exchange of information between the different applications that use sensor data, a common framework of knowledge is needed to allow interoperability. In this paper an ontology-driven architecture to improve the driving environment through a traffic sensor network is proposed. The system performs different tasks automatically to increase driver safety and comfort using the information provided by the sensors.

Participatory approach to identify interventions to improve the health, safety, and work productivity of smallholder women vegetable farmers in the Gambia.

PubMed

Vanderwal, Londa; Rautiainen, Risto; Ramirez, Marizen; Kuye, Rex; Peek-Asa, Corinne; Cook, Thomas; Culp, Kennith; Donham, Kelley

2011-03-01

This paper describes the qualitative, community-based participatory approach used to identify culturally-acceptable and sustainable interventions to improve the occupational health, safety, and productivity of smallholder women vegetable farmers in The Gambia (West Africa). This approach was used to conduct: 1) analysis of the tasks and methods traditionally used in vegetable production, and 2) selection of interventions. The most arduous garden tasks that were amenable to interventions were identified, and the interventions were selected through a participatory process for further evaluation. Factors contributing to the successful implementation of the participatory approach used in this study included the following: 1) ensuring that cultural norms were respected and observed; 2) working closely with the existing garden leadership structure; and 3) research team members working with the subjects for an extended period of time to gain first-hand understanding of the selected tasks and to build credibility with the subjects.

Factors Associated with the Adoption of Food Safety Controls by the Mexican Meat Industry

NASA Astrophysics Data System (ADS)

Maldonado-Simán, Ema; Martínez-Hernández, Pedro Arturo; García-Muñiz, José G.; Cadena-Meneses, José

Food marketing at international and domestic markets has focused on processing systems that improve food safety. The objective of this research is to determine the factors influencing the implementation of the HACCP system in the Mexican meat industry, and to identify the main marketing destination of their products. Only 18.5% of enterprises reports fully operational HACCP in their plants. The main destination of their production in the domestic market is supermarkets, suppliers and distributors and specific niches of the domestic market. Exports are to USA, Japan, Korea and Central America and some niches of the domestic market with requirements of higher quality. The four principal factors that motivate enterprises to adopt HACCP are associated with improvement of plant efficiency and profitability, adoption of good practices, improvement of product quality and waste reduction. It is concluded that Mexican enterprises adopt HACCP to successfully remain and face competition by foreign enterprises in the domestic market and to a lesser extent to compete in the international market.

Effects of a Brief Team Training Program on Surgical Teams' Nontechnical Skills: An Interrupted Time-Series Study.

PubMed

Gillespie, Brigid M; Harbeck, Emma; Kang, Evelyn; Steel, Catherine; Fairweather, Nicole; Panuwatwanich, Kriengsak; Chaboyer, Wendy

2017-04-27

Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS. Pretest-posttest interrupted time-series design with statistical process control analysis was used to detect longitudinal changes in teams' NOTSS. We evaluated NOTSS using the revised NOTECHS weekly for 20 to 25 weeks before and after implementation of a team training program. We observed 179 surgical procedures with cardiac, vascular, upper gastrointestinal, and hepatobiliary teams. Mean posttest NOTECHS scores increased across teams, showing special cause variation. There were also significant before and after improvements in NOTECHS scores in respect to professional role and in the use of the Surgical Safety Checklist. Our results suggest associated improvements in teams' NOTSS after implementation of the team training program.

Systematic and progressive implementation of the centers of excellence for rheumatoid arthritis: a methodological proposal.

PubMed

Santos-Moreno, Pedro; Caballero-Uribe, Carlo V; Massardo, Maria Loreto; Maldonado, Claudio Galarza; Soriano, Enrique R; Pineda, Carlos; Cardiel, Mario; Benavides, Juan Alberto; Beltrán, Paula Andrea

2017-12-01

The implementation of excellence centers in specific diseases has been gaining recognition in the field of health; specifically in rheumatoid arthritis, where the prognosis of the disease is related to an early diagnosis and a timely intervention, it is necessary that the provision of health services is developed in an environment of quality, opportunity, and safety with the highest standards of care. A methodology that allows this implementation in such a way that is achievable by the most of the care centers is a priority to achieve a better attention to populations with this disease. In this paper, we propose a systematic and progressive methodology that will help all the institutions to develop successful models without faltering in the process. The expected impact on public health is defined by a better effective coverage of high-quality treatments, obtaining better health outcomes with safety and accessibility that reduces the budgetary impact for the health systems of our countries.

Collectors, Producers, and Circulators of Tibetan and Chinese Medicines in Sichuan Province

PubMed Central

Springer, Lena

2016-01-01

The act of prescribing pharmaceutical drugs to patients is normally the site of judgements about the drug’s efficacy and safety. The success of treatments and the licences for commodities depend on the biochemical identity of the drugs and of their path and transformations inside the body. However, the ‘supply chain’ outside the body is eschewed by such discourse, and its importance for both pharmaceutical brands and physician-centred historiographies is ignored. As this ethnographic fieldwork on Tibetan and Chinese medicines in Sichuan shows, overlooked social actors ensure reliable knowledge about medicinal things and materials long before patients take their medicine. This paper takes a step back from the final products―clearly defined as ‘Tibetan’ or ‘Chinese’―and introduces those who produce and distribute them. Via observations of particular regimes of circulation and processing, the actions of collecting, manufacturing, transporting, and educating appear as the first and foremost acts of efficacy and safety. PMID:28239310

Ontology-Based Architecture for Intelligent Transportation Systems Using a Traffic Sensor Network

PubMed Central

Fernandez, Susel; Hadfi, Rafik; Ito, Takayuki; Marsa-Maestre, Ivan; Velasco, Juan R.

2016-01-01

Intelligent transportation systems are a set of technological solutions used to improve the performance and safety of road transportation. A crucial element for the success of these systems is the exchange of information, not only between vehicles, but also among other components in the road infrastructure through different applications. One of the most important information sources in this kind of systems is sensors. Sensors can be within vehicles or as part of the infrastructure, such as bridges, roads or traffic signs. Sensors can provide information related to weather conditions and traffic situation, which is useful to improve the driving process. To facilitate the exchange of information between the different applications that use sensor data, a common framework of knowledge is needed to allow interoperability. In this paper an ontology-driven architecture to improve the driving environment through a traffic sensor network is proposed. The system performs different tasks automatically to increase driver safety and comfort using the information provided by the sensors. PMID:27537878

Improving Patient Safety in Public Hospitals: Developing Standard Measures to Track Medical Errors and Process Breakdowns.

PubMed

Ackerman, Sara L; Gourley, Gato; Le, Gem; Williams, Pamela; Yazdany, Jinoos; Sarkar, Urmimala

2018-03-14

The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized. Surveys and transcripts from the meetings were analyzed to understand the decision-making process. The Delphi process included eight panelists. Consensus was reached to adopt 9 of 13 proposed measures. All 9 measures were unanimously considered valid, but concern was expressed about the feasibility of implementing several of the measures. Although safety net health systems face high barriers to standardized measurement, our study demonstrates that consensus can be reached on acceptable and feasible methods for tracking patient safety gaps in safety net health systems. If accompanied by the active participation key stakeholder groups, including patients, clinicians, staff, data system professionals, and health system leaders, the consensus measures reported here represent one step toward improving ambulatory patient safety in safety net health systems.

Odon device for instrumental vaginal deliveries: results of a medical device pilot clinical study.

PubMed

Schvartzman, Javier A; Krupitzki, Hugo; Merialdi, Mario; Betrán, Ana Pilar; Requejo, Jennifer; Nguyen, My Huong; Vayena, Effy; Fiorillo, Angel E; Gadow, Enrique C; Vizcaino, Francisco M; von Petery, Felicitas; Marroquin, Victoria; Cafferata, María Luisa; Mazzoni, Agustina; Vannevel, Valerie; Pattinson, Robert C; Gülmezoglu, A Metin; Althabe, Fernando; Bonet, Mercedes

2018-03-12

A prolonged and complicated second stage of labour is associated with serious perinatal complications. The Odon device is an innovation intended to perform instrumental vaginal delivery presently under development. We present an evaluation of the feasibility and safety of delivery with early prototypes of this device from an early terminated clinical study. Hospital-based, multi-phased, open-label, pilot clinical study with no control group in tertiary hospitals in Argentina and South Africa. Multiparous and nulliparous women, with uncomplicated singleton pregnancies, were enrolled during the third trimester of pregnancy. Delivery with Odon device was attempted under non-emergency conditions during the second stage of labour. The feasibility outcome was delivery with the Odon device defined as successful expulsion of the fetal head after one-time application of the device. Of the 49 women enrolled, the Odon device was inserted successfully in 46 (93%), and successful Odon device delivery as defined above was achieved in 35 (71%) women. Vaginal, first and second degree perineal tears occurred in 29 (59%) women. Four women had cervical tears. No third or fourth degree perineal tears were observed. All neonates were born alive and vigorous. No adverse maternal or infant outcomes were observed at 6-weeks follow-up for all dyads, and at 1 year for the first 30 dyads. Delivery using the Odon device is feasible. Observed genital tears could be due to the device or the process of delivery and assessment bias. Evaluating the effectiveness and safety of the further developed prototype of the BD Odon Device™ will require a randomized-controlled trial. ANZCTR ACTRN12613000141741 Registered 06 February 2013. Retrospectively registered.

Safety management in multiemployer worksites in the manufacturing industry: opinions on co-operation and problems encountered.

PubMed

Nenonen, Sanna; Vasara, Juha

2013-01-01

Co-operation between different parties and effective safety management play an important role in ensuring safety in multiemployer worksites. This article reviews safety co-operation and factors complicating safety management in Finnish multiemployer manufacturing worksites. The paper focuses on the service providers' opinions; however, a comparison of the customers' views is also presented. The results show that safety-related co-operation between providers and customers is generally considered as successful but strongly dependent on the partner. Safety co-operation is provided through, e.g., training, orientation and risk analysis. Problems encountered include ensuring adequate communication, identifying hazards, co-ordinating work tasks and determining responsibilities. The providers and the customers encounter similar safety management problems. The results presented in this article can help companies to focus their efforts on the most problematic points of safety management and to avoid common pitfalls.

[Operating Room Nurses' Experiences of Securing for Patient Safety].

PubMed

Park, Kwang Ok; Kim, Jong Kyung; Kim, Myoung Sook

2015-10-01

This study was done to evaluate the experience of securing patient safety in hospital operating rooms. Experiential data were collected from 15 operating room nurses through in-depth interviews. The main question was "Could you describe your experience with patient safety in the operating room?". Qualitative data from the field and transcribed notes were analyzed using Strauss and Corbin's grounded theory methodology. The core category of experience with patient safety in the operating room was 'trying to maintain principles of patient safety during high-risk surgical procedures'. The participants used two interactional strategies: 'attempt continuous improvement', 'immersion in operation with sharing issues of patient safety'. The results indicate that the important factors for ensuring the safety of patients in the operating room are manpower, education, and a system for patient safety. Successful and safe surgery requires communication, teamwork and recognition of the importance of patient safety by the surgical team.

Launch Services Safety Overview

NASA Technical Reports Server (NTRS)

Loftin, Charles E.

2008-01-01

NASA/KSC Launch Services Division Safety (SA-D) services include: (1) Assessing the safety of the launch vehicle (2) Assessing the safety of NASA ELV spacecraft (S/C) / launch vehicle (LV) interfaces (3) Assessing the safety of spacecraft processing to ensure resource protection of: - KSC facilities - KSC VAFB facilities - KSC controlled property - Other NASA assets (4) NASA personnel safety (5) Interfacing with payload organizations to review spacecraft for adequate safety implementation and compliance for integrated activities (6) Assisting in the integration of safety activities between the payload, launch vehicle, and processing facilities

Towards a Fuzzy Bayesian Network Based Approach for Safety Risk Analysis of Tunnel-Induced Pipeline Damage.

PubMed

Zhang, Limao; Wu, Xianguo; Qin, Yawei; Skibniewski, Miroslaw J; Liu, Wenli

2016-02-01

Tunneling excavation is bound to produce significant disturbances to surrounding environments, and the tunnel-induced damage to adjacent underground buried pipelines is of considerable importance for geotechnical practice. A fuzzy Bayesian networks (FBNs) based approach for safety risk analysis is developed in this article with detailed step-by-step procedures, consisting of risk mechanism analysis, the FBN model establishment, fuzzification, FBN-based inference, defuzzification, and decision making. In accordance with the failure mechanism analysis, a tunnel-induced pipeline damage model is proposed to reveal the cause-effect relationships between the pipeline damage and its influential variables. In terms of the fuzzification process, an expert confidence indicator is proposed to reveal the reliability of the data when determining the fuzzy probability of occurrence of basic events, with both the judgment ability level and the subjectivity reliability level taken into account. By means of the fuzzy Bayesian inference, the approach proposed in this article is capable of calculating the probability distribution of potential safety risks and identifying the most likely potential causes of accidents under both prior knowledge and given evidence circumstances. A case concerning the safety analysis of underground buried pipelines adjacent to the construction of the Wuhan Yangtze River Tunnel is presented. The results demonstrate the feasibility of the proposed FBN approach and its application potential. The proposed approach can be used as a decision tool to provide support for safety assurance and management in tunnel construction, and thus increase the likelihood of a successful project in a complex project environment. © 2015 Society for Risk Analysis.

Experiments To Demonstrate Chemical Process Safety Principles.

ERIC Educational Resources Information Center

Dorathy, Brian D.; Mooers, Jamisue A.; Warren, Matthew M.; Mich, Jennifer L.; Murhammer, David W.

2001-01-01

Points out the need to educate undergraduate chemical engineering students on chemical process safety and introduces the content of a chemical process safety course offered at the University of Iowa. Presents laboratory experiments demonstrating flammability limits, flash points, electrostatic, runaway reactions, explosions, and relief design.…

Analysis of vehicle's safety envelope under car-following model

NASA Astrophysics Data System (ADS)

Tang, Tie-Qiao; Zhang, Jian; Chen, Liang; Shang, Hua-Yan

2017-05-01

In this paper, we propose an improved car-following model to explore the impacts of vehicle's two safety distances (i.e., the front safety distance and back safety distance) on the traffic safety during the starting process. The numerical results show that our model is prominently safer than the FVD (full velocity difference) model, i.e., our model is better than the FVD model from the perspective of the traffic safety, which shows that each driver should consider his two safety distances during his driving process.

A Model-Based Product Evaluation Protocol for Comparison of Safety-Engineered Protection Mechanisms of Winged Blood Collection Needles.

PubMed

Haupt, C; Spaeth, J; Ahne, T; Goebel, U; Steinmann, D

2016-05-01

To evaluate differences in product characteristics and user preferences of safety-engineered protection mechanisms of winged blood collection needles. Randomized model-based simulation study. University medical center. A total of 33 third-year medical students. Venipuncture was performed using winged blood collection needles with 4 different safety mechanisms: (a) Venofix Safety, (b) BD Vacutainer Push Button, (c) Safety-Multifly, and (d) Surshield Surflo. Each needle type was used in 3 consecutive tries: there was an uninstructed first handling, then instructions were given according to the operating manual; subsequently, a first trial and second trial were conducted. Study end points included successful activation, activation time, single-handed activation, correct activation, possible risk of needlestick injury, possibility of deactivation, and preferred safety mechanism. The overall successful activation rate during the second trial was equal for all 4 devices (94%-100%). Median activation time was (a) 7 s, (b) 2 s, (c) 9 s, and (d) 7 s. Single-handed activation during the second trial was (a) 18%, (b) 82%, (c) 15%, and (d) 45%. Correct activation during the second trial was (a) 3%, (b) 64%, (c) 15%, and (d) 39%. Possible risk of needlestick injury during the second trial was highest with (d). Possibility of deactivation was (a) 0%, (b) 12%, (c) 9%, and (d) 18%. Individual preferences for each system were (a) 11, (b) 17, (c) 5, and (d) 0. The main reason for preference was the comprehensive safety mechanism. Significant differences exist between safety mechanisms of winged blood collection needles.

Efficacy and safety of mepivacaine compared with lidocaine in local anaesthesia in dentistry: a meta-analysis of randomised controlled trials.

PubMed

Su, Naichuan; Liu, Yan; Yang, Xianrui; Shi, Zongdao; Huang, Yi

2014-04-01

The objective of the study was to assess the efficacy and safety of mepivacaine compared with lidocaine used in local anaesthesia in dentistry. Medline, Cochrane Central Register of Controlled Trials, EMBASE, Chinese BioMedical Literature Database, China National Knowledge Infrastructure and WHO International Clinical Trials Registry Platform were searched electronically. Relevant journals and references of studies included were hand-searched for randomised controlled trials comparing mepivacaine with lidocaine in terms of efficacy and safety. Twenty-eight studies were included, of which 15 had low risk of bias and 13 had moderate risk of bias. In comparison with 2% lidocaine with 1:100,000 adrenaline, 3% mepivacaine showed a lower success rate (P = 0.05), a shorter onset time of pulpal anaesthesia (P = 0.0005), inferior pain control during injection phase and superior inhibition of heart rate increase (P < 0.0001). In contrast, 2% mepivacaine with 1:100,000 adrenaline gave a higher success rate (P < 0.00001), a similar onset time of pulpal anaesthesia (P = 0.34) and superior pain control during injection phase (P < 0.0001); 2% mepivacaine with 1:20,000 levonordefrin had the same success rate (P = 0.69) and similar onset time of pulpal anaesthesia (P = 0.90). In addition, 3% mepivacaine had shorter onset time (P = 0.004), same level of success rate (P = 0.28) and similar pain control during injection and postinjection compared with 2% lidocaine with 1:50,000 adrenaline. Given the efficacy and safety of the two solutions, 2% mepivacaine with vasoconstrictors is better than 2% lidocaine with vasoconstrictors in dental treatment. Meanwhile, 3% plain mepivacaine is better for patients with cardiac diseases. © 2014 FDI World Dental Federation.

Efficacy and safety of bupivacaine versus lidocaine in dental treatments: a meta-analysis of randomised controlled trials.

PubMed

Su, Naichuan; Wang, Hang; Zhang, Shu; Liao, Shuang; Yang, Shuying; Huang, Yi

2014-02-01

The objective of this study was to assess the efficacy and safety of bupivacaine compared with lidocaine in local anaesthesia in dental treatment. Medline, Cochrane Central Register of Controlled Trials, EMBASE, Chinese BioMedical Literature Database, China National Knowledge Infrastructure, and the World Health Organisation (WHO) International Clinical Trials Registry Platform were searched electronically. Relevant journals and references of studies included were hand-searched for randomised controlled trials comparing bupivacaine with lidocaine in terms of efficacy and safety. Sixteen studies were included, of which nine had low, six had moderate and one had high risk of bias. In comparison with 2% lidocaine plus 1:100,000 adrenaline, 0.5% bupivacaine plus 1:200,000 adrenaline showed a higher success rate in inflamed pulp (P = 0.03) but a lower success rate in vital pulp (P < 0.00001), a lower percentage of patients using postoperative analgesics (P < 0.00001), a longer onset times of pulpal anaesthesia and a longer duration of pulpal anaesthesia (P < 0.00001). In comparison with 2% lidocaine plus 1:80,000 adrenaline, 0.75% bupivacaine plus 1:200,000 adrenaline had same level of success rate (P = 0.29), and was better in postoperative pain control (P = 0.001) while 0.75% levobupivacaine had same level of postoperative pain control (P = 0.16); 0.5% levobupivacaine had higher success rate (P = 0.04) and was better in postoperative pain control (P = 0.001) than 2% lidocaine. There was no statistically significance in adverse events between two groups. Given the efficacy and safety, the bupivacaine group is better than the lidocaine group in dental operations that take a relatively long time, especially in endodontic treatments or where there is a need for postoperative pain management. © 2013 FDI World Dental Federation.

Shift work, safety, and aging.

PubMed

Folkard, Simon

2008-04-01

It has long been recognized that older shift workers may have shorter and more disturbed day sleeps between successive night shifts than their younger colleagues. This has given rise to considerable concern over the safety of aging shift workers because of the increasing age of the work force and increases in retirement age. Because there have been no direct studies of the combined effects of shift work and age on safety, the present paper begins by reviewing the literature relating safety to features of shift systems. It then considers the general effect of age on occupational injury rates before examining existing evidence of the combined effects of shift work and age on performance capabilities. The results of the literature review indicate that when the a priori risk is constant, there is reasonably clear evidence that injury rates are higher at night, and that they increase over successive night shifts more rapidly than over successive day shifts. Further, although occupational injuries are less frequent in older workers, those that do occur tend to be more serious. Finally, there is some suggestive evidence from studies of objectively measured performance capabilities that older workers may be less able to both maintain their performance over the course of a night shift and cope with longer spans of successive night shifts. It is concluded that it seems possible, even though unproven as yet, that older workers may be at greater risk both to injury and accident on the night shift. There is a strong need for future epidemiological studies of the combined effects of shift work and age on injuries and accidents, and that these should attempt to separate the effects of age per se from those of generation.

Public-Private Partnerships in Lead Discovery: Overview and Case Studies.

PubMed

Gottwald, Matthias; Becker, Andreas; Bahr, Inke; Mueller-Fahrnow, Anke

2016-09-01

The pharmaceutical industry is faced with significant challenges in its efforts to discover new drugs that address unmet medical needs. Safety concerns and lack of efficacy are the two main technical reasons for attrition. Improved early research tools including predictive in silico, in vitro, and in vivo models, as well as a deeper understanding of the disease biology, therefore have the potential to improve success rates. The combination of internal activities with external collaborations in line with the interests and needs of all partners is a successful approach to foster innovation and to meet the challenges. Collaboration can take place in different ways, depending on the requirements of the participants. In this review, the value of public-private partnership approaches will be discussed, using examples from the Innovative Medicines Initiative (IMI). These examples describe consortia approaches to develop tools and processes for improving target identification and validation, as well as lead identification and optimization. The project "Kinetics for Drug Discovery" (K4DD), focusing on the adoption of drug-target binding kinetics analysis in the drug discovery decision-making process, is described in more detail. © 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

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

Dorr, Kent A.; Ostrom, Michael J.; Freeman-Pollard, Jhivaun R.

CH2M Hill Plateau Remediation Company (CHPRC) designed, constructed, commissioned, and began operation of the largest groundwater pump and treatment facility in the U.S. Department of Energy’s (DOE) nationwide complex. This one-of-a-kind groundwater pump and treatment facility, located at the Hanford Nuclear Reservation Site (Hanford Site) in Washington State, was built to an accelerated schedule with American Recovery and Reinvestment Act (ARRA) funds. There were many contractual, technical, configuration management, quality, safety, and Leadership in Energy and Environmental Design (LEED) challenges associated with the design, procurement, construction, and commissioning of this $95 million, 52,000 ft groundwater pump and treatment facility tomore » meet DOE’s mission objective of treating contaminated groundwater at the Hanford Site with a new facility by June 28, 2012. The project team’s successful integration of the project’s core values and green energy technology throughout design, procurement, construction, and start-up of this complex, first-of-its-kind Bio Process facility resulted in successful achievement of DOE’s mission objective, as well as attainment of LEED GOLD certification, which makes this Bio Process facility the first non-administrative building in the DOE Office of Environmental Management complex to earn such an award.« less

Combustion Module-2 Achieved Scientific Success on Shuttle Mission STS-107

NASA Technical Reports Server (NTRS)

Over, Ann P.

2004-01-01

The familiar teardrop shape of a candle is caused by hot, spent air rising and cool fresh air flowing behind it. This type of airflow obscures many of the fundamental processes of combustion and is an impediment to our understanding and modeling of key combustion controls used for manufacturing, transportation, fire safety, and pollution. Conducting experiments in the microgravity environment onboard the space shuttles eliminates these impediments. NASA Glenn Research Center's Combustion Module-2 (CM-2) and its three experiments successfully flew on STS-107/Columbia in the SPACEHAB module and provided the answers for many research questions. However, this research also opened up new questions. The CM-2 facility was the largest and most complex pressurized system ever flown by NASA and was a precursor to the Glenn Fluids and Combustion Facility planned to fly on the International Space Station. CM-2 operated three combustion experiments: Laminar Soot Processes (LSP), Structure of Flame Balls at Low Lewis-Number (SOFBALL), and Water Mist Fire Suppression Experiment (Mist). Although Columbia's mission ended in tragedy with the loss of her crew and much data, most of the CM-2 results were sent to the ground team during the mission.

DISPELLING MYTHS AND MISCONCEPTIONS TO IMPLEMENT A SAFETY CULTURE

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

Potts, T. Todd; Smith, Ken; Hylko, James M.

2003-02-27

Industrial accidents are typically reported in terms of technological malfunctions, ignoring the human element in accident causation. However, over two-thirds of all accidents are attributable to human and organizational factors (e.g., planning, written procedures, job factors, training, communication, and teamwork), thereby affecting risk perception, behavior and attitudes. This paper reviews the development of WESKEM, LLC's Environmental, Safety, and Health (ES&H) Program that addresses human and organizational factors from a top-down, bottom-up approach. This approach is derived from the Department of Energy's Integrated Safety Management System. As a result, dispelling common myths and misconceptions about safety, while empowering employees to ''STOPmore » work'' if necessary, have contributed to reducing an unusually high number of vehicle, ergonomic and slip/trip/fall incidents successfully. Furthermore, the safety culture that has developed within WESKEM, LLC's workforce consists of three common characteristics: (1) all employees hold safety as a value; (2) each individual feels responsible for the safety of their co-workers as well as themselves; and (3) each individual is willing and able to ''go beyond the call of duty'' on behalf of the safety of others. WESKEM, LLC as a company, upholds the safety culture and continues to enhance its existing ES&H program by incorporating employee feedback and lessons learned collected from other high-stress industries, thereby protecting its most vital resource - the employees. The success of this program is evident by reduced accident and injury rates, as well as the number of safe work hours accrued while performing hands-on field activities. WESKEM, LLC (Paducah + Oak Ridge) achieved over 800,000 safe work hours through August 2002. WESKEM-Paducah has achieved over 665,000 safe work hours without a recordable injury or lost workday case since it started operations on February 28, 2000.« less

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.

78 FR 17233 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; Process...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-20

... ACTION: Notice. SUMMARY: The Department of Labor (DOL) is submitting the Occupational Safety and Health Administration (OSHA) sponsored information collection request (ICR) titled, ``Process Safety Management of...., permitting electronic submission of responses. Agency: DOL-OSHA. Title of Collection: Process Safety...

75 FR 5167 - Office of Hazardous Materials Safety; Notice of Delays In Processing of Special Permits Applications

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-01

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration Office of Hazardous Materials Safety; Notice of Delays In Processing of Special Permits Applications AGENCY: Pipeline..., Office of Hazardous Materials Special Permits and Approvals, Pipeline and Hazardous Materials Safety...

75 FR 78800 - Office of Hazardous Materials Safety; Notice of Delays in Processing of Special Permits Applications

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-16

... DEPARTMENT OF TRANSPORTATION Pipeline and Hazardous Materials Safety Administration Office of Hazardous Materials Safety; Notice of Delays in Processing of Special Permits Applications AGENCY: Pipeline..., Office of Hazardous Materials Special Permits and Approvals, Pipeline and Hazardous Materials Safety...

Plant hydraulics and photosynthesis of 34 woody species from different successional stages of subtropical forests.

PubMed

Zhu, Shi-Dan; Song, Juan-Juan; Li, Rong-Hua; Ye, Qing

2013-04-01

It is important to understand the ecophysiological characters of plants when exploring mechanisms underlying species substitution in the process of plant succession. In the present study, we selected 34 woody species from different stages of secondary succession in subtropical forests of southern China, and measured their hydraulic conductivity, gas exchange rates, leaf nutrients and drought-tolerance traits such as xylem resistance to cavitation, turgor loss point and carbon isotope ratio. Principal component analysis revealed that early-, mid- and late-successional species were significantly separated along axis 1, which was strongly associated with hydraulic-photosynthetic coordination. In contrast to species distributed in late-successional forest, early-successional species had the highest hydraulic conductivity, net photosynthetic rates, photosynthetic nitrogen and phosphorus use efficiencies, but had the lowest photosynthetic water-use efficiency. However, changes of the measured drought-tolerance traits of the 34 species along the succession did not demonstrate a clear trend - no significant correlations between these traits and plant successional stages were found. Moreover, the trade-off between hydraulic efficiency and safety was not identified. Taken together, our results suggested that hydraulic efficiency and photosynthetic function, rather than drought tolerance, play an important role in species distributions along plant succession in subtropical forests. © 2012 Blackwell Publishing Ltd.

General RMP Guidance - Appendix D: OSHA Guidance on PSM

EPA Pesticide Factsheets

OSHA's Process Safety Management (PSM) Guidance on providing complete and accurate written information concerning process chemicals, process technology, and process equipment; including process hazard analysis and material safety data sheets.

A system to improve medication safety in the setting of acute kidney injury: initial provider response.

PubMed

McCoy, Allison B; McCoy, Allison Beck; Peterson, Josh F; Gadd, Cynthia S; Gadd, Cindy; Danciu, Ioana; Waitman, Lemuel R

2008-11-06

Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for nephrotoxic or renally cleared drugs. We developed a comprehensive medication safety intervention with varying levels of workflow intrusiveness within computerized provider order entry to continuously monitor for and alert providers about early-onset acute kidney injury. Initial provider response to the interventions shows potential success in improving medication safety and suggests future enhancements to increase effectiveness.

Outcomes studies of the gastrointestinal safety of cyclooxygenase-2 inhibitors.

PubMed

Scheiman, James M

2002-01-01

Short-term endoscopic studies of the highly selective cyclooxygenase-2 (COX-2) inhibitors (coxibs) rofecoxib and celecoxib have shown that these agents are well tolerated and have efficacy equivalent to nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) with fewer adverse effects on the upper gastrointestinal (GI) tract. These studies are limited, however, as the detection of endoscopic lesions is not well correlated with symptomatic ulcers and ulcer complications. Outcomes studies of the GI safety are, therefore, essential to understanding how coxibs are likely to perform in a clinical practice setting. Four large outcomes studies (Vioxx Gastrointestinal Outcomes Research, VIGOR; Assessment of Difference Between Vioxx and Naproxen to Ascertain Gastrointestinal Tolerability and Effectiveness trial, ADVANTAGE; Celecoxib Long-term Arthritis Safety Study, CLASS; and the Successive Celecoxib Efficacy and Safety Studies, SUCCESS) examined the GI safety of rofecoxib and celecoxib in over 39,000 patients with osteoarthritis or rheumatoid arthritis. Results of these studies showed that patients taking a supratherapeutic dose of rofecoxib or celecoxib had significantly lower rates of GI-related adverse events than those taking a nonselective NSAID (naproxen, ibuprofen, or diclofenac). Reduced risk of upper GI events was seen in patients with multiple risk factors and in patients using low-dose aspirin and corticosteroids concomitantly with a coxib. Results of large outcomes studies provide support for the COX-2 hypothesis and demonstrate the long-term safety and tolerability of coxibs.

Object-Oriented MDAO Tool with Aeroservoelastic Model Tuning Capability

NASA Technical Reports Server (NTRS)

Pak, Chan-gi; Li, Wesley; Lung, Shun-fat

2008-01-01

An object-oriented multi-disciplinary analysis and optimization (MDAO) tool has been developed at the NASA Dryden Flight Research Center to automate the design and analysis process and leverage existing commercial as well as in-house codes to enable true multidisciplinary optimization in the preliminary design stage of subsonic, transonic, supersonic and hypersonic aircraft. Once the structural analysis discipline is finalized and integrated completely into the MDAO process, other disciplines such as aerodynamics and flight controls will be integrated as well. Simple and efficient model tuning capabilities based on optimization problem are successfully integrated with the MDAO tool. More synchronized all phases of experimental testing (ground and flight), analytical model updating, high-fidelity simulations for model validation, and integrated design may result in reduction of uncertainties in the aeroservoelastic model and increase the flight safety.

Equipment Standards: History, Litigation, and Advice

PubMed Central

Hedley-Whyte, John; Milamed, Debra R.

1999-01-01

Summary The authors present a concise history of the development of national and international standards for surgical equipment. Standards-writing organizations, surgical and other specialty societies, universities, test houses, and the U.S. government have influenced this process, which is now manifested in complex interactions between national and international standards-writing organizations, and in CE (Conformité Europeene) marks being placed on surgical equipment in the United States and elsewhere. The history of litigation in standards development is also reviewed. Recommendations to maximize patient safety and to help ensure successful, cost-effective defense in litigation for surgeons who use equipment and may suffer its malfunctions are given. Overall, the complicated oversight of surgical equipment standards and the approval process appears to be contributing to the improving and outstanding results of U.S. surgery reported by the U.S. government. PMID:10400045

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

Johnson, W.A.

The Food Safety and Inspection Service (FSIS) is responsible for the wholesomeness, safety, and adulteration-free status of meat and poultry. The agency developed the National Residue Program (NRP) to monitor these products for residue of drugs, pesticides, and environmental contaminants. Today, few chemical residues are detected in meat and poultry because of the success of the NRP. 3 figs.

Use of COTS Batteries on ISS and Shuttle: Payload Safety and Mission Success

NASA Technical Reports Server (NTRS)

Jeevarajan, Judith A.

2004-01-01

Contents: Current program requirements; Challenges with COTS batteries; manned vehicle COTS methodology in use; List of typical flight COTS batteries; Energy content and toxicity; Hazards, failure modes and controls for different battery chemistries; JSC test details; List of incidents from Consumer Protection Safety Commission; Conclusions ans recommendations.

Building the vision, a series of AZTech ITS model deployment success stories for the Phoenix metropolitan area : number eight : rapid response, improving communications between traffic management and emergency SVCS

DOT National Transportation Integrated Search

1998-01-01

Improving safety is an essential element of AZTech's mission. By extending the use of advanced communications technology and integrating individual traffic management systems, AZTech facilitates : safety on the roadways. To improve the management of ...

THE SCHOOL HEALTH AND SAFETY PROGRAM.

ERIC Educational Resources Information Center

1963

INVOLVING INDIVIDUALS AS WELL AS ORGANIZATIONS, THE PROGRAM AIMED AT THE OPTIMUM HEALTH OF ALL CHILDREN, AND IMPROVEMENT OF HEALTH AND SAFETY STANDARDS WITHIN THE COMMUNITY. EACH OF THE CHILDREN WAS URGED TO HAVE A SUCCESSFUL VACCINATION FOR SMALL POX, THE DPT SERIES AND BOOSTER, THE POLIO SERIES, AND CORRECTIONS OF ALL DENTAL DEFECTS AND…

Application of a rotation system to oilseed rape and rice fields in Cd-contaminated agricultural land to ensure food safety.

PubMed

Yu, Lingling; Zhu, Junyan; Huang, Qingqing; Su, Dechun; Jiang, Rongfeng; Li, Huafen

2014-10-01

This field experiment analyzed the phytoremediation effects of oilseed rape in moderately cadmium (Cd)-contaminated farmland and the food safety of successive rice in an oilseed rape-rice rotation system. Two oilseed rape cultivars accumulated Cd at different rates. The rapeseed cultivar Zhucang Huazi exhibited high Cd accumulation rates, higher than the legal limit for human consumption (0.2mgkg(-1)); Cd concentrations in the cultivar Chuanyou II-93 were all below the maximum allowed level. Planting oilseed rape increased the uptake of Cd by the successive rice crop compared with a previous fallow treatment. Most Cd concentrations of brown rice were below the maximum allowed level. The phytoextraction efficiency was lower in the moderately Cd-contaminated soil in field experiments. The results suggest screening rice cultivars with lower Cd accumulation can assure the food safety; the mobilization of heavy metals by roots of different plant species should be considered during crop rotation to assure food safety. Copyright © 2014 Elsevier Inc. All rights reserved.

Requirements for significant problem reporting and trend analysis

NASA Technical Reports Server (NTRS)

1988-01-01

This handbook supplements policies, requirements, and procedures of NMI 8070.3 to ensure that NASA management at each organizational level is: fully aware of trends affecting both the level of safety and the potential for mission success established for both NASA manned space programs and its supporting institutions; fully and independently informed of problems that represent significant risk to the safety of all personnel (including the general populace) and to the success of a mission or operation through a program mechanism herein defined as Significant Problem Reporting; and in full agreement with the level of elimination of these problems through the closed-loop accounting of corrective actions. The requirements of this handbook are supportive of the agency's safety, reliability, maintainability, and quality assurance (SRM&QA) program objectives and are applicable to all organizational elements of NASA connected with or supporting developmental or operational manned space program/projects (including associated payloads) and the related institutional facilities.

Isolation and Purification of Biotechnological Products

NASA Astrophysics Data System (ADS)

Hubbuch, Jürgen; Kula, Maria-Regina

2007-05-01

The production of modern pharma proteins is one of the most rapid growing fields in biotechnology. The overall development and production is a complex task ranging from strain development and cultivation to the purification and formulation of the drug. Downstream processing, however, still accounts for the major part of production costs. This is mainly due to the high demands on purity and thus safety of the final product and results in processes with a sequence of typically more than 10 unit operations. Consequently, even if each process step would operate at near optimal yield, a very significant amount of product would be lost. The majority of unit operations applied in downstream processing have a long history in the field of chemical and process engineering; nevertheless, mathematical descriptions of the respective processes and the economical large-scale production of modern pharmaceutical products are hampered by the complexity of the biological feedstock, especially the high molecular weight and limited stability of proteins. In order to develop new operational steps as well as a successful overall process, it is thus a necessary prerequisite to develop a deeper understanding of the thermodynamics and physics behind the applied processes as well as the implications for the product.

Best practices from WisDOT mega and ARRA projects--request for information : benchmarks and metrics.

DOT National Transportation Integrated Search

2012-03-01

Successful highway construction is measured by cost, time, safety, and quality. One further measure of success is the quantity of Request for Information's (RFI) submitted and their impact. An RFI is a formal written procedure initiated by the contra...

Changing the S and MA [Safety and Mission Assurance] Paradigm

NASA Technical Reports Server (NTRS)

Malone, Roy W., Jr.

2010-01-01

Objectives: 1) Optimize S&MA organization to best facilitate Shuttle transition in 2010, successfully support Ares developmental responsibilities, and minimize the impacts of the gap between last Shuttle flight and start of Ares V Project. 2) Improve leveraging of critical skills and experience between Shuttle and Ares. 3) Split technical and supervisory functions to facilitate technical penetration. 4) Create Chief Safety and Mission Assurance Officer (CSO) stand-alone position for successfully implementation of S&MA Technical Authority. 5) Minimize disruption to customers. 6) Provide early involvement of S&MA leadership team and frequent/open communications with S&MA team members and steak-holders.

Evaluating the implementation of health and safety innovations under a regulatory context: a collective case study of Ontario's safer needle regulation.

PubMed

Chambers, Andrea; Mustard, Cameron A; Breslin, Curtis; Holness, Linn; Nichol, Kathryn

2013-01-22

Implementation effectiveness models have identified important factors that can promote the successful implementation of an innovation; however, these models have been examined within contexts where innovations are adopted voluntarily and often ignore the socio-political and environmental context. In the field of occupational health and safety, there are circumstances where organizations must adopt innovations to comply with a regulatory standard. Examining how the external environment can facilitate or challenge an organization's change process may add to our understanding of implementation effectiveness. The objective of this study is to describe implementation facilitators and barriers in the context of a regulation designed to promote the uptake of safer engineered medical devices in healthcare. The proposed study will focus on Ontario's safer needle regulation (2007) which requires healthcare organizations to transition to the use of safer engineered medical devices for the prevention of needlestick injuries. A collective case study design will be used to learn from the experiences of three acute care hospitals in the province of Ontario, Canada. Interviews with management and front-line healthcare workers and analysis of supporting documents will be used to describe the implementation experience and examine issues associated with the integration of these devices. The data collection and analysis process will be influenced by a conceptual framework that draws from implementation science and the occupational health and safety literature. The focus of this study in addition to the methodology creates a unique opportunity to contribute to the field of implementation science. First, the study will explore implementation experiences under circumstances where regulatory pressures are influencing the organization's change process. Second, the timing of this study provides an opportunity to focus on issues that arise during later stages of implementation, a phase during the implementation cycle that has been understudied. This study also provides the opportunity to examine the relevance and utility of current implementation science models in the field of occupational health where the adoption of an innovation is meant to enhance the health and safety of workers. Previous work has tended to focus almost exclusively on innovations that are designed to enhance an organization's productivity or competitive advantage.

Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents

PubMed Central

Mira, José Joaquín; Vicente, Maria Asuncion; Fernandez, Cesar; Guilabert, Mercedes; Ferrús, Lena; Zavala, Elena; Silvestre, Carmen; Pérez-Pérez, Pastora

2016-01-01

Background Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. Objective The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. Methods The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA’s design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. Results BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). Conclusions BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use. PMID:27678308

Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents.

PubMed

Carrillo, Irene; Mira, José Joaquín; Vicente, Maria Asuncion; Fernandez, Cesar; Guilabert, Mercedes; Ferrús, Lena; Zavala, Elena; Silvestre, Carmen; Pérez-Pérez, Pastora

2016-09-27

Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA's design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.

Industry Initiated Core Safety Attributes for Human Spaceflight for the 7th IAASS Conference

NASA Technical Reports Server (NTRS)

Mango, Edward J.

2014-01-01

Now that the NASA Commercial Crew Program (CCP) is beginning its full certification contract for crew transportation to the International Space Station (ISS), is it time for industry to embrace a minimum set of core safety attributes? Those attributes can then be evolved into an industry-led set of basic safety standards and requirements. After 50 years of human space travel sponsored by governments, there are two basic conditions that now exist within the international space industry. The first, there is enough of a space-faring history to encourage the space industry to design, develop and operate human spaceflight systems without government contracts for anything other than services. Second, industry is capable of defining and enforcing a set of industry-based safety attributes and standards for human spaceflight to low-Earth orbit (LEO). This paper will explore both of these basic conditions with a focus on the safety attributes and standards. In the United States, the Federal Aviation Administration (FAA) is now starting to dialogue with industry about the basic safety principles and attributes needed for potential future regulatory oversight. This process is not yet formalized and will take a number of years once approval is given to move forward. Therefore, throughout the next few years, it is an excellent time and opportunity for industry to collaborate together and develop the core set of attributes and standards. As industry engages and embraces a common set of safety attributes, then government agencies, like the FAA and NASA can use that industry-based product to strengthen their efforts on a safe commercial spaceflight foundation for the future. As the commercial space industry takes the lead role in establishing core safety attributes, and then enforcing those attributes, the entire planet can move away from governmental control of design and development and let industry expand safe and successful space operations in LEO. At that point the governmental agencies can focus on oversight of the industries' defined standards and enforcement for common welfare of the space-faring populous and overall public safety.

Effective Safety Management in Construction Project

NASA Astrophysics Data System (ADS)

Othman, I.; Shafiq, Nasir; Nuruddin, M. F.

2017-12-01

Effective safety management is one of the serious problems in the construction industry worldwide, especially in large-scale construction projects. There have been significant reductions in the number and the rate of injury over the last 20 years. Nevertheless, construction remains as one of the high risk industry. The purpose of this study is to examine safety management in the Malaysian construction industry, as well as to highlight the importance of construction safety management. The industry has contributed significantly to the economic growth of the country. However, when construction safety management is not implemented systematically, accidents will happen and this can affect the economic growth of the country. This study put the safety management in construction project as one of the important elements to project performance and success. The study emphasize on awareness and the factors that lead to the safety cases in construction project.

Emotion regulation during threat: Parsing the time course and consequences of safety signal processing

PubMed Central

HEFNER, KATHRYN R.; VERONA, EDELYN; CURTIN, JOHN. J.

2017-01-01

Improved understanding of fear inhibition processes can inform the etiology and treatment of anxiety disorders. Safety signals can reduce fear to threat, but precise mechanisms remain unclear. Safety signals may acquire attentional salience and affective properties (e.g., relief) independent of the threat; alternatively, safety signals may only hold affective value in the presence of simultaneous threat. To clarify such mechanisms, an experimental paradigm assessed independent processing of threat and safety cues. Participants viewed a series of red and green words from two semantic categories. Shocks were administered following red words (cue+). No shocks followed green words (cue−). Words from one category were defined as safety signals (SS); no shocks were administered on cue+ trials. Words from the other (control) category did not provide information regarding shock administration. Threat (cue+ vs. cue−) and safety (SS+ vs. SS−) were fully crossed. Startle response and ERPs were recorded. Startle response was increased during cue+ versus cue−. Safety signals reduced startle response during cue+, but had no effect on startle response during cue−. ERP analyses (PD130 and P3) suggested that participants parsed threat and safety signal information in parallel. Motivated attention was not associated with safety signals in the absence of threat. Overall, these results confirm that fear can be reduced by safety signals. Furthermore, safety signals do not appear to hold inherent hedonic salience independent of their effect during threat. Instead, safety signals appear to enable participants to engage in effective top-down emotion regulatory processes. PMID:27088643

Unproven (questionable) dietary and nutritional methods in cancer prevention and treatment.

PubMed

Herbert, V

1986-10-15

"Unproven" is a euphemism for questionable. The definition of a questionable method is that it has not successfully answered the two basic consumer protection questions of efficacy and safety, to wit: Has it been responsibly, objectively, reproducibly, and reliably demonstrated in humans in the responsible (peer-reviewed) literature accepted for the shelves of the National Library of Medicine in Bethesda, Maryland, to be: More effective than suggestion or doing nothing? and in addition, either As safe as doing nothing? or, in the alternative, If there is any question with respect to safety, to have a reasonably and objectively clear potential for benefit which exceeds its potential for harm? Any proposed cancer prevention or treatment modality which has not successfully answered the above efficacy question plus one of the two safety questions is by definition questionable. It is experimental if it is new, and very probably quackery if it is old. Experimental therapy may be either ethical and responsible or unethical and irresponsible. It is unethical and irresponsible to not tell the patient experiments are being conducted on him, to charge the patient to perform research on him, or to ask the patient to sign an informed consent aimed at exculpating the doctor rather than protecting the patient. Ethical and responsible informed consents clearly delineate that what is being done is experimental, and that efficacy and safety have not been determined. Products promoted for profit to the public without passing peer process are almost without exception ineffective, often harmful, and sometimes lethal. This includes Laetrile, immunoaugmentative therapy, chelation therapy, macrobiotic diets, and other alternative therapies. Anecdotal and testimonial claims of cure, on investigation, almost invariably prove due to coincidence, suggestibility, and/or the natural history of the disorder, and fall into one of the five categories of "cures that are not": The patient never had cancer. The cancer was cured or put in remission by responsible therapy, but the promoted therapy was irrelevantly also given, and is erroneously credited for the cure. The cancer is progressing silently, but erroneously represented as cured. The patient is dead, but represented as cured. The patient had a spontaneous remission, which is publicized as a "cure," while failing to publicize the hundred or more deaths per "success" which followed the same "cure." Quackery involves the consumer fraud of taking money under false pretenses. The false pretense is the promotion and selling of questionable diagnostic tests and therapies advertising them to be safe and effective.(ABSTRACT TRUNCATED AT 400 WORDS)

Implementation of safety checklists in surgery: a realist synthesis of evidence.

PubMed

Gillespie, Brigid M; Marshall, Andrea

2015-09-28

The aim of this review is to present a realist synthesis of the evidence of implementation interventions to improve adherence to the use of safety checklists in surgery. Surgical safety checklists have been shown to improve teamwork and patient safety in the operating room. Yet, despite the benefits associated with their use, universal implementation of and compliance with these checklists has been inconsistent. An overview of the literature from 2008 is examined in relation to checklist implementation, compliance, and sustainability. Pawson's and Rycroft-Malone's realist synthesis methodology was used to explain the interaction between context, mechanism, and outcome. This approach incorporated the following: defining the scope of the review, searching and appraising the evidence, extracting and synthesising the findings, and disseminating, implementing, and evaluating the evidence. We identified two theories a priori that explained contextual nuances associated with implementation and evaluation of checklists in surgery: the Normalisation Process Theory and Responsive Regulation Theory. We identified four a priori propositions: (1) Checklist protocols that are prospectively tailored to the context are more likely to be used and sustained in practice, (2) Fidelity and sustainability is increased when checklist protocols can be seamlessly integrated into daily professional practice, (3) Routine embedding of checklist protocols in practice is influenced by factors that promote or inhibit clinicians' participation, and (4) Regulation reinforcement mechanisms that are more contextually responsive should lead to greater compliance in using checklist protocols. The final explanatory model suggests that the sustained use of surgical checklists is discipline-specific and is more likely to occur when medical staff are actively engaged and leading the process of implementation. Involving clinicians in tailoring the checklist to better fit their context of practice and giving them the opportunity to reflect and evaluate the implementation intervention enables greater participation and ownership of the process. A major limitation in the surgical checklist literature is the lack of robust descriptions of intervention methods and implementation strategies. Despite this, two consequential findings have emerged through this realist synthesis: First, the sustained use of surgical checklists is discipline-specific and is more successful when physicians are actively engaged and leading implementation. Second, involving clinicians in tailoring the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership.

Prevention, The Beginning of the Rehabilitation Process: A View from New Zealand. Monograph #46.

ERIC Educational Resources Information Center

Campbell, Ian B.

The monograph argues that prevention should be considered the first step in the rehabilitation process, and examines preventive efforts in the areas of occupational safety, road safety, home safety, and sporting and recreational safety. Following an introductory chapter, other chapters discuss: (1) the close relationship between compensation,…

Improved safety culture and labor-management relations attributed to changing at-risk behavior process at Union Pacific.

DOT National Transportation Integrated Search

2009-09-01

Changing At-Risk Behavior (CAB) is a safety process that is being conducted at Union Pacifics San Antonio Service Unit (SASU) with the aim of improving road and yard safety. CAB is an example of a proactive safety risk-reduction method called Clea...

Overcoming dysfunctional momentum: Organizational safety as a social achievement

Treesearch

Michelle A. Barton; Kathleen M. Sutcliffe

2009-01-01

Research on organizational safety and reliability largely has emphasized system-level structures and processes neglecting the more micro-level, social processes necessary to enact organizational safety. In this qualitative study we remedy this gap by exploring these processes in the context of wildland fire management. In particular, using interview data gathered from...

Engineering Hematopoietic Cells for Cancer Immunotherapy: Strategies to Address Safety and Toxicity Concerns.

PubMed

Resetca, Diana; Neschadim, Anton; Medin, Jeffrey A

2016-09-01

Advances in cancer immunotherapies utilizing engineered hematopoietic cells have recently generated significant clinical successes. Of great promise are immunotherapies based on chimeric antigen receptor-engineered T (CAR-T) cells that are targeted toward malignant cells expressing defined tumor-associated antigens. CAR-T cells harness the effector function of the adaptive arm of the immune system and redirect it against cancer cells, overcoming the major challenges of immunotherapy, such as breaking tolerance to self-antigens and beating cancer immune system-evasion mechanisms. In early clinical trials, CAR-T cell-based therapies achieved complete and durable responses in a significant proportion of patients. Despite clinical successes and given the side effect profiles of immunotherapies based on engineered cells, potential concerns with the safety and toxicity of various therapeutic modalities remain. We discuss the concerns associated with the safety and stability of the gene delivery vehicles for cell engineering and with toxicities due to off-target and on-target, off-tumor effector functions of the engineered cells. We then overview the various strategies aimed at improving the safety of and resolving toxicities associated with cell-based immunotherapies. Integrating failsafe switches based on different suicide gene therapy systems into engineered cells engenders promising strategies toward ensuring the safety of cancer immunotherapies in the clinic.

Some Challenges in the Design of Human-Automation Interaction for Safety-Critical Systems

NASA Technical Reports Server (NTRS)

Feary, Michael S.; Roth, Emilie

2014-01-01

Increasing amounts of automation are being introduced to safety-critical domains. While the introduction of automation has led to an overall increase in reliability and improved safety, it has also introduced a class of failure modes, and new challenges in risk assessment for the new systems, particularly in the assessment of rare events resulting from complex inter-related factors. Designing successful human-automation systems is challenging, and the challenges go beyond good interface development (e.g., Roth, Malin, & Schreckenghost 1997; Christoffersen & Woods, 2002). Human-automation design is particularly challenging when the underlying automation technology generates behavior that is difficult for the user to anticipate or understand. These challenges have been recognized in several safety-critical domains, and have resulted in increased efforts to develop training, procedures, regulations and guidance material (CAST, 2008, IAEA, 2001, FAA, 2013, ICAO, 2012). This paper points to the continuing need for new methods to describe and characterize the operational environment within which new automation concepts are being presented. We will describe challenges to the successful development and evaluation of human-automation systems in safety-critical domains, and describe some approaches that could be used to address these challenges. We will draw from experience with the aviation, spaceflight and nuclear power domains.

Development of a safety decision-making scenario to measure worker safety in agriculture.

PubMed

Mosher, G A; Keren, N; Freeman, S A; Hurburgh, C R

2014-04-01

Human factors play an important role in the management of occupational safety, especially in high-hazard workplaces such as commercial grain-handling facilities. Employee decision-making patterns represent an essential component of the safety system within a work environment. This research describes the process used to create a safety decision-making scenario to measure the process that grain-handling employees used to make choices in a safety-related work task. A sample of 160 employees completed safety decision-making simulations based on a hypothetical but realistic scenario in a grain-handling environment. Their choices and the information they used to make their choices were recorded. Although the employees emphasized safety information in their decision-making process, not all of their choices were safe choices. Factors influencing their choices are discussed, and implications for industry, management, and workers are shared.

Adoptable Interventions, Human Health, and Food Safety Considerations for Reducing Sodium Content of Processed Food Products

PubMed Central

Allison, Abimbola; Fouladkhah, Aliyar

2018-01-01

Although vital for maintaining health when consumed in moderation, various epidemiological studies in recent years have shown a strong association between excess dietary sodium with an array of health complications. These associations are robust and clinically significant for development of hypertension and prehypertension, two of the leading causes of preventable mortality worldwide, in adults with a high-sodium diet. Data from developed nations and transition economies show worldwide sodium intake of higher than recommended amounts in various nations. While natural foods typically contain a moderate amount of sodium, manufactured food products are the main contributor to dietary sodium intake, up to 75% of sodium in diet of American adults, as an example. Lower cost in formulation, positive effects on organoleptic properties of food products, effects on food quality during shelf-life, and microbiological food safety, make sodium chloride a notable candidate and an indispensable part of formulation of various products. Although low-sodium formulation of each product possesses a unique set of challenges, review of literature shows an abundance of successful experiences for products of many categories. The current study discusses adoptable interventions for product development and reformulation of products to achieve a modest amount of final sodium content while maintaining taste, quality, shelf-stability, and microbiological food safety. PMID:29389843

Adoptable Interventions, Human Health, and Food Safety Considerations for Reducing Sodium Content of Processed Food Products.

PubMed

Allison, Abimbola; Fouladkhah, Aliyar

2018-02-01

Although vital for maintaining health when consumed in moderation, various epidemiological studies in recent years have shown a strong association between excess dietary sodium with an array of health complications. These associations are robust and clinically significant for development of hypertension and prehypertension, two of the leading causes of preventable mortality worldwide, in adults with a high-sodium diet. Data from developed nations and transition economies show worldwide sodium intake of higher than recommended amounts in various nations. While natural foods typically contain a moderate amount of sodium, manufactured food products are the main contributor to dietary sodium intake, up to 75% of sodium in diet of American adults, as an example. Lower cost in formulation, positive effects on organoleptic properties of food products, effects on food quality during shelf-life, and microbiological food safety, make sodium chloride a notable candidate and an indispensable part of formulation of various products. Although low-sodium formulation of each product possesses a unique set of challenges, review of literature shows an abundance of successful experiences for products of many categories. The current study discusses adoptable interventions for product development and reformulation of products to achieve a modest amount of final sodium content while maintaining taste, quality, shelf-stability, and microbiological food safety.