Chain of events analysis in diving accidents treated by the Royal Netherlands Navy 1966-2023

Introduction

Diving injuries are influenced by a multitude of factors. Literature analysing the full chain of events in diving accidents influencing the occurrence of diving injuries is limited. A previously published 'chain of events analysis' (CEA) framework consists of five steps that may sequentially lead to a diving fatality. This study applied four of these steps to predominately non-lethal diving injuries and aims to determine the causes of diving injuries sustained by divers treated by the Diving Medical Centre of the Royal Netherlands Navy.

Methods

This retrospective cohort study was performed on diving injuries treated by the Diving Medical Centre between 1966 and 2023. Baseline characteristics and information pertinent to all four steps of the reduced CEA model were extracted and recorded in a database.

Results

A total of 288 cases met the inclusion criteria. In 111 cases, all four steps of the CEA model could be applied. Predisposing factors were identified in 261 (90%) cases, triggers in 142 (49%), disabling agents in 195 (68%), and 228 (79%) contained a (possible-) disabling condition. The sustained diving injury led to a fatality in seven cases (2%). The most frequent predisposing factor was health conditions (58%). Exertion (19%), primary diver errors (18%), and faulty equipment (17%) were the most frequently identified triggers. The ascent was the most frequent disabling agent (52%).

Conclusions

The CEA framework was found to be a valuable tool in this analysis. Health factors present before diving were identified as the most frequent predisposing factors. Arterial gas emboli were the most lethal injury mechanism.

The use of driver screening tools to predict self-reported crashes and incidents in older drivers

There is a clear need to identify older drivers at increased crash risk, without additional burden on the individual or licensing system. Brief off-road screening tools have been used to identify unsafe drivers and drivers at risk of losing their license. The aim of the current study was to evaluate and compare driver screening tools in predicting prospective self-reported crashes and incidents over 24 months in drivers aged 60 years and older. 525 drivers aged 63-96 years participated in the prospective Driving Aging Safety and Health (DASH) study, completing an on-road driving assessment and seven off-road screening tools (Multi-D battery, Useful Field of View, 14-Item Road Law, Drive Safe, Drive Safe Intersection, Maze Test, Hazard Perception Test (HPT)), along with monthly self-report diaries on crashes and incidents over a 24-month period. Over the 24 months, 22% of older drivers reported at least one crash, while 42% reported at least one significant incident (e.g., near miss). As expected, passing the on-road driving assessment was associated with a 55% [IRR 0.45, 95% CI 0.29-0.71] reduction in self-reported crashes adjusting for exposure (crash rate), but was not associated with reduced rate of a significant incident. For the off-road screening tools, poorer performance on the Multi-D test battery was associated with a 22% [IRR 1.22, 95% CI 1.08-1.37] increase in crash rate over 24 months. Meanwhile, all other off-road screening tools were not predictive of rates of crashes or incidents reported prospectively. The finding that only the Multi-D battery was predictive of increased crash rate, highlights the importance of accounting for age-related changes in vision, sensorimotor skills and cognition, as well as driving exposure, in older drivers when using off-road screening tools to assess future crash risk.

Powered mobility device use in residential aged care: a retrospective audit of incidents and injuries

BACKGROUND

Powered wheelchairs and motorised mobility scooters, collectively called powered mobility devices (PMD), are highly valued by older Australians, including those living in residential care, to facilitate personal and community mobility. The number of PMDs in residential aged care is expected to grow proportionally with that of the wider community, however, there is very little literature on supporting residents to use PMDs safely. Prior to developing such supports, it is important to understand the frequency and nature of any incidents experienced by residents whilst using a PMD. The aim of this study was to determine the number and characteristics of PMD use related incidents occurring in a group of residential aged care facilities in a single year in one state in Australia including incident type, severity, assessment, or training received and outcomes on follow-up for PMD users living in residential aged care.

METHODS

Analysis of secondary data, including documentation of PMD incidents and injuries for one aged care provider group over 12 months retrospectively. Follow-up data were gathered 9-12 months post incident to review and record the outcome for each PMD user.

RESULTS

No fatalities were recorded as a direct result of PMD use and 55 incidents, including collisions, tips, and falls, were attributed to 30 residents. Examination of demographics and incident characteristics found that 67% of residents who had incurred incidents were male, 67% were over 80 years of age, 97% had multiple diagnoses and 53% had not received training to use a PMD. Results from this study were extrapolated to project that 4,453 PMD use related incidents occur every year within Australian residential aged care facilities, with the potential for outcomes such as extended recovery, fatality, litigation, or loss of income.

CONCLUSION

This is the first time that detailed incident data on PMD use in residential aged care has been reviewed in an Australian context. Illuminating both the benefits and the potential risks of PMD use emphasizes the need to develop and improve support structures to promote safe PMD use in residential aged care.

Incidents related to safety in mental health facilities in Kenya

BACKGROUND

Both patients and health care providers working in mental health facilities witness high rates of incidents that have the potential to jeopardize their safety. Despite this, there are few studies that have documented the kind of incidents that are experienced, or explored the potential contributors to these incidents, and solutions that would result in better safety. This study explored various types of safety related incidents occurring in mental facilities in Kenya, perceived contributing factors, and recommendations for improve.

METHODS

This qualitative descriptive study was carried out between December 2019 - February 2020. It included 28 mental health staff across 14 mental health unit spread across the country.

RESULTS

All the participants reported having personally experienced an incident that threatened their safety or that of the patients. Most of the respondents (24/26. 91.67%) admitted to have experienced verbal aggression while 54.17%, (n = 24) had experienced physical assault. Participating health care workers attributed the safety incidents to poor infrastructure, limited human resources, and inadequate medication to calm down agitated patients. Suggested solutions to improve patient safety included; improving surveillance systems, hiring more specialized healthcare workers, and provision of adequate supplies such as short-acting injectable psychotropic.

CONCLUSION

Incidents that threaten patient and staff safety are common in mental health facilities in Kenya. There is need to strengthen staff capacity and reporting mechanisms, as well as invest in infrastructural improvements, to safeguard patient and staff safety in mental health facilities in Kenya.

The relationship between safety climate and safety performance: A review

INTRODUCTION

Since its inception more than four decades ago, research on safety climate has been conducted in many industries. Subsequently, a plethora of systematic literature reviews on safety climate in various work environments has focused on research trends and measurement scales. Yet, despite these reviews, the overall picture of how safety climate influences performance is still not well understood. The current study reviews existing literature on safety climate, specifically how it affects safety performance.

METHOD

Literature searches were conducted using EBSCOhost and Web of Science databases in March 2021. We included English-language, peer-reviewed studies that reported the results of research done on safety climate and safety performance. We extracted data (contextual, theoretical, methodological and definition of safety performance) from these studies and were deductively analyzed and categorized into common themes.

RESULTS

One hundred and sixty-two safety climate studies were identified. We found that studies on safety climate-performance were conducted in 16 types of industries while 23 different theories explained the safety climate-performance relationship. The quantity and quality of variables and methods used varied considerably across the surveys. Safety climate is predominantly used as a predictor while safety-related behavior is the most common definition of safety performance among the articles we reviewed. Few papers from the current review were methodologically strong, suggesting that current evidence on the link between safety climate and safety performance still suffers from common method bias.

CONCLUSIONS

Although literature has provided evidence for the positive effect on safety performance via a strong safety climate, strong and convincing methods are still lacking and the causality of an improved safety climate still needs to be demonstrated.

PRACTICAL APPLICATIONS

The findings of the current review offer a better understanding of how employers can improve safety climate in the workplace in various settings.

Audit of the functional preparedness of the selected military hospital in response to incidents and disasters: participatory action research

Introduction

Since hospitals play an important role in dealing with disaster victims, this study was conducted to audit the functional preparedness of the selected military hospital in response to incidents and disasters.

Materials and methods

This applied action research was conducted in all wards of a military hospital from September 2020 to September 2021. The functional preparedness of the hospital was assessed using a functional preparedness checklist containing 17 domains and the weaknesses of the hospital were identified. Then, during the hospital audit cycle, a plan was developed to improve work processes and the functional preparedness of different wards of the hospital in response to incidents and disasters using the FOCUS-PDCA model. The functional preparedness of the hospital was compared before and after the intervention and analyzed using SPSS22.

Results

The relative mean score of hospital preparedness in response to disasters was 508 out of 900 (56.44%) before the intervention, which was moderate. The relative mean score of the hospital preparedness in response to disasters was 561 (63.63%) after the intervention, which was good. The highest preparedness was related to risk assessment (85%) and the lowest preparedness was related to victims’ dead bodies (44%).

Conclusion

Considering the effect of action research on improving the hospital’s functional preparedness in response to disasters, other healthcare facilities are encouraged to incorporate auditing into their work plans.

Systematic review and meta-analysis of environmental Vibrio species - antibiotic resistance

Adequate comprehension of the genomics of microbial resistance to an antimicrobial agent will advance knowledge on the management of associated pathologies and public health safety. However, continued emergences and reemergence of pathogens, including Vibrio species, hallmarks a potential knowledge gap. A clear understanding of the process and forecast of the next trend should be in place to nip in the bud, microbial acquisition of resistance to antibiotics. Therefore, this two-decade (1 January 2000 to 31 December 2019) systematic review and meta-analytical study articulated the prevalence and incidence of antibiotics resistance genes in Vibrio species isolated from environmental samples. Articles from the Web of Science and PubMed electronic databases was engaged. Heterogeneity of the data and bias were analyzed with random effect model meta-analysis and funnel plot. A total of 1920 Vibrio sp. were reported by the ten selected articles included in this study; out of which 32.39% of identified isolates displayed antimicrobial resistance and associated genes. The distribution of antibiotics resistance genes in Vibrio sp., reported within six countries was 21% tetracycline (tet), and 20% sulphonamide (sul) and β-lactamase (bla) respectively. The quinolone, tetracycline and sulfonamide resistance genes showed 32.97% (95% CI 0.18–0.53) prevalence while chloramphenicol, macrolides and aminoglycoside resistance genes are expressed in percentages as 28.67% (95% CI 0.15–0.47) and β-lactamase resistance genes 27.93% (95% CI 0.11–0.56) respectively. The Vibrio antibiotics resistance genes (V-ARG) distribution depicts no regular trend or pattern from the analyzed data. Consequently, more studies would be required to articulate the structure of cohesion in the distribution of the resistance determinants in microbes.

Development of a mechanism for the rapid risk assessment of cross-border chemical health threats

BACKGROUND

Chemical incidents can result in harm to public health and the environment. Although most are localised and have little impact, some affect wide areas, a range of sectors and may lead to many casualties. A public health response to assess the risks and provide advice to authorities and the public is usually required. In some cases, incidents may affect more than one country and require effective cross-border communication and coordination.

OBJECTIVE

We describe tools and mechanisms to improve health security from cross-border chemical health threats and to support the implementation of the Decision of the European Parliament and the Council of the European Union (EU) on serious cross-border threats to health (Decision 1082/2013/EU).

METHODS

Experts were recruited to a network and their suitability was assessed by using a skills framework. Input by relevant stakeholders such as the World Health Organisation and the European Centre for Disease Prevention and Control, followed by EU-wide exercises, ensured that tools developed were fit for purpose.

RESULTS

A network of public health risk assessors and a methodology for providing rapid independent expert public health advice during a chemical emergency have been developed.

SIGNIFICANCE

We discuss the legacy of these mechanisms including their incorporation into the working arrangements for the EU Scientific Committee for Health, Environment and Emerging Risks and future developments in the field.

Decision-making by medical officer in charge during major incidents: a qualitative study

BACKGROUND

An incident command structure is commonly used to manage responses to major incidents. In the hospital incident command structure, the medical officer in charge (MOC) is in a key position. The decision-making process is essential to effective management, but little is known about which factors influence the process. Therefore, the current study aimed to describe factors influencing decision-making of MOCs.

METHODS

A conventional content analysis was conducted based on 16 individual interviews with medical doctors who had been deployed as MOCs at Swedish hospitals during major incidents.

RESULTS

The results showed that the decision-making and re-evaluation process was a comprehensive analysis influenced by three categories of factors: event factors, including consequences from the type of event, levels of uncertainty and the circumstances; organizational factors, including the doctor's role, information management and the response to the event; and personal factors, such as competence, personality and mental preparedness.

CONCLUSIONS

Reliable and timely information management structure enabling the gathering and analysis of essential information, a clear command structure and appropriate personal qualities were essential and contributed to successful MOCs decision making in major incidents.

The global distribution of acute unintentional pesticide poisoning: estimations based on a systematic review

BACKGROUND

Human poisoning by pesticides has long been seen as a severe public health problem. As early as 1990, a task force of the World Health Organization (WHO) estimated that about one million unintentional pesticide poisonings occur annually, leading to approximately 20,000 deaths. Thirty years on there is no up-to-date picture of global pesticide poisoning despite an increase in global pesticide use. Our aim was to systematically review the prevalence of unintentional, acute pesticide poisoning (UAPP), and to estimate the annual global number of UAPP.

METHODS

We carried out a systematic review of the scientific literature published between 2006 and 2018, supplemented by mortality data from WHO. We extracted data from 157 publications and the WHO cause-of-death database, then performed country-wise synopses, and arrived at annual numbers of national UAPP. World-wide UAPP was estimated based on national figures and population data for regions defined by the Food and Agriculture Organization (FAO).

RESULTS

In total 141 countries were covered, including 58 by the 157 articles and an additional 83 by data from the WHO Mortality Database. Approximately 740,000 annual cases of UAPP were reported by the extracted publications resulting from 7446 fatalities and 733,921 non-fatal cases. On this basis, we estimate that about 385 million cases of UAPP occur annually world-wide including around 11,000 fatalities. Based on a worldwide farming population of approximately 860 million this means that about 44% of farmers are poisoned by pesticides every year. The greatest estimated number of UAPP cases is in southern Asia, followed by south-eastern Asia and east Africa with regards to non-fatal UAPP.

CONCLUSIONS

Our study updates outdated figures on world-wide UAPP. Along with other estimates, robust evidence is presented that acute pesticide poisoning is an ongoing major global public health challenge. There is a need to recognize the high burden of non-fatal UAPP, particularly on farmers and farmworkers, and that the current focus solely on fatalities hampers international efforts in risk assessment and prevention of poisoning. Implementation of the international recommendations to phase out highly hazardous pesticides by the FAO Council could significantly reduce the burden of UAPP.

Congener patterns of polychlorinated dibenzo-p-dioxins, dibenzofurans and biphenyls as a useful aid to source identification during a contamination incident in the food chain

Polychlorinated dibenzo-p-dioxins (PCDDs), dibenzofurans (PCDFs) and biphenyls (PCBs) are still considered among the most important groups of contaminants in the food chain. Self-control by food producers and official control by authorities are important activities that allow contaminant sources to be traced and promote further reduction in food and feed levels. Strict but feasible maximum levels were set by the EU Commission for food and feed to support this strategy, as well as action levels and thresholds. When products exceed these levels, it is important to trace the source of contamination and take measures to remove it. Congener patterns of PCDD/Fs and PCBs differ between sources and are important tools for source identification. Therefore, patterns associated with different sources and incidents relating to various feed matrices and certain agricultural chemicals were collated from published scientific papers, with additional ones available from some laboratories. The collection was evaluated for completeness by presentations at workshops and conferences. Primary sources appear to derive from 5 categories, i) by-products from production of organochlorine chemicals (e.g. PCBs, chlorophenols, chlorinated pesticides, polyvinyl chloride (PVC)), ii) the result of combustion of certain materials and accidental fires, iii) the use of inorganic chlorine, iv) recycling/production of certain minerals, and v) certain naturally occurring clays (ball clay, kaolinite). A decision tree was developed to assist in the identification of the source.

Incident reports involving hospital administrative staff: analysis of data from the Japan Council for Quality Health care nationwide database

Background

Task shifting and task sharing in health care are rapidly becoming more common as the shortage of physicians increases. However, research has not yet examined the changing roles of hospital administrative staff. This study clarified: (1) the adverse incidents caused by hospital administrative staff, and the direct and indirect impact of these incidents on patient care; and (2) the incidents that directly involved hospital administrative staff.

Methods

This study used case report data from the Japan Council for Quality Health care collected from April 1, 2010 to March 31, 2019, including a total of 30,823 reports. In April 2020, only the 88 self-reported incidents by hospital administrative staff were downloaded, excluding incidents reported by those in medical and co-medical occupations. Data from three reports implicating pharmacists were rejected and the quantitative and textual data from the remaining 85 case reports were analyzed in terms of whether they impacted patient care directly or indirectly.

Results

Thirty-nine reports (45.9%) involved direct impact on patient care, while 46 (54.1%) involved indirect impact on patient care. Most incidents that directly impacted patient care involved administrative staff writing prescriptions on behalf of a doctor (n = 24, 61.5%); followed by errors related to system administration, information, and documentation (n = 7, 17.9%). Most reported errors that indirectly affected patient care were related to system administration, information, and documentation used by administrative staff (n = 22, 47.8%), or to reception (n = 9, 19.6%). Almost all errors occurred during weekdays. Most frequent incidents involved outpatients (n = 23, 27.1%), or occurred next to examination/operation rooms (n = 12, 14.1%). Further, a total of 14 cases (16.5%) involved patient misidentification.

Conclusions

Incidents involving hospital administrative staff, the most common of which are medication errors from incorrect prescriptions, can lead to severe consequences for patients. Given that administrative staff now form a part of medical treatment teams, improvements in patient care may require further submission and review of incident reports involving administrative staff.

[The new radiation protection legislation-part 1 : Modifications in radiology for the workflow in clinical routine]

BACKGROUND

On 31 December 2018, the new Radiation Protection Regulation came into effect in Germany and made the new Radiation Protection Act more concrete. The old Radiation Protection Regulation and X‑ray Regulation have thereby been replaced.

OBJECTIVES

The substantial modifications regarding the practical daily routine in radiology are summarized.

METHODS

Modifications and innovations of the New Radiation Protection Act and Regulation compared to the old Radiation Protection Regulation and X‑ray Regulation and accordances were evaluated. Thereby the main focus was in the relevance for workflow in clinical routine.

RESULTS AND CONCLUSION

The new legislation contains a number of regulations that provide crucial tools for implementation of radiation protection, quality assurance, and dose optimization. However, this also requires additional time and personnel.

Threats and Interventions During the Treatment of Tuberculosis in an Inner-city District

BACKGROUND

Since there are active drugs against tuberculosis (TB), the most effective control measures are to assure treatment adherence and to perform contact tracing. Given the long treatment duration and characteristics of some TB patients, threats that put at risk treatment adherence may appear. Identify and address them is essential to achieve the objectives of disease control.

OBJECTIVES

To identify the epidemiological characteristics of TB patients and the incidents and threats occurring during treatment, to describe the interventions performed to enhance treatment adherence and to determine if there are differences among native and foreign-born patients in the TB clinical unit of a referral hospital in the inner city of Barcelona.

METHODS

A descriptive, observational, cross-sectional study was performed. We recorded information on sociodemographic and clinical characteristics, incidents and interventions during treatment in all patients with TB diagnosed between September 2013 and August 2016.

RESULTS

172 patients were included, 62.2% were foreign-born. The most common incidents and threats were medication-related complications (43.0%), missed follow-up visits (34.3%), communication problems (25.6%), comorbidities complications (23.8%), trips (19.2%), fear of social rejection (16.9%) and change of address (14.5%). The adherence-promoting interventions were: follow-up calls, directly observed treatment, medical and humanitarian reports, extra visits and cultural mediation. Incidents and interventions were more frequent in foreign-born patients, however there were no differences in treatment success among Spanish and foreign-born.

CONCLUSION

In this inner city several incidents occurred during TB treatment that can threaten adherence and are more common among foreign-born patients. Coordination among professionals from different healthcare settings was able to overcome obstacles in most cases and achieve TB treatment completion.

Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database

Background Transdermal opioids are widely used among elderly adults with chronic pain. However, transdermal patches may be involved in a significant proportion of opioid-related patient safety incidents, as the application process includes several subprocesses, each associated with an individual risk of error. Objective The aim was to obtain specific knowledge on patient safety incidents related to transdermal opioid treatment within both the primary care sector and the hospital sector in Denmark. Setting The study is descriptive with data provided by the Danish Patient Safety Database. Methods We manually retrieved all patient safety incidents concerning transdermal opioids reported for 2018 from (1) the hospital sector and (2) the primary care sector. Study data were collected and managed using REDCap electronic data capture tools. Main outcome measure The available information for each incident was sorted into the following categories: location, medication process, type of problem, outcome at time of reporting, and outcome classification. Results A total of 866 patient safety incidents involving transdermal opioids were reported to the Danish Patient Safety Database in 2018. No fatal incidents were present in the database. In 386 cases, the incidents were reported as harmful, and these 386 cases were analysed. Most reports came from the primary care sector (nursing home, home care or social housing). The majority of incidents were related to the administration of the patch in the medication process, and the most prevalent problem was the omission of doses. Conclusion This study has demonstrated that the administration of transdermal opioids is challenging and may cause harm, particularly in the primary care sector. To improve patient safety, optimized systems, including guidelines on drug management and the continuing education of healthcare personnel in transdermal opioid management, are necessary. These guidelines should preferably incorporate reminders and checklists, since the omission of doses was the most reported problem.

Differences in Perspectives of Medical Device Adverse Events: Observational Results in Training Program Using Virtual Cases

BACKGROUND

Medical device adverse event reporting is an essential activity for mitigating device-related risks. Reporting of adverse events can be done by anyone like healthcare workers, patients, and others. However, for an individual to determine the reporting, he or she should recognize the current situation as an adverse event. The objective of this report is to share observed individual differences in the perception of a medical device adverse event, which may affect the judgment and the reporting of adverse events.

METHODS

We trained twenty-three participants from twelve Asia-Pacific Economic Cooperation (APEC) member economies about international guidelines for medical device vigilance. We developed and used six virtual cases and six questions. We divided participants into six groups and compared their opinions. We also surveyed the country's opinion to investigate the beginning point of 'patient use'. The phases of 'patient use' are divided into: 1) inspecting, 2) preparing, and 3) applying medical device.

RESULTS

As for the question on the beginning point of 'patient use,' 28.6%, 35.7%, and 35.7% of participants provided answers regarding the first, second, and third phases, respectively. In training for applying international guidelines to virtual cases, only one of the six questions reached a consensus between the two groups in all six virtual cases. For the other five questions, different judgments were given in at least two groups.

CONCLUSION

From training courses using virtual cases, we found that there was no consensus on 'patient use' point of view of medical devices. There was a significant difference in applying definitions of adverse events written in guidelines regarding the medical device associated incidents. Our results point out that international harmonization effort is needed not only to harmonize differences in regulations between countries but also to overcome diversity in perspectives existing at the site of medical device use.

A 20-year analysis of compressed gas diving-related deaths in Tasmania, Australia

INTRODUCTION

This study reviews diving deaths that occurred in Tasmanian waters over a 20-year period.

METHODS

Detailed analysis was undertaken of deaths that occurred from 01 January 1995 to 31 December 2014. The cases were collated from numerous sources. Utilising a chain of events analysis, factors were identified and assigned to predisposing factors, triggers, disabling agents, disabling injuries and cause of death. These were then scrutinised to ascertain regional variables, remediable factors and linkages which may benefit from targeted risk mitigation strategies.

RESULTS

Seventeen deaths were identified across this 20-year period, which included one additional case not previously recorded. All were recreational divers and 15 were male. Five were hookah divers, 12 were scuba divers. Important predisposing factors identified included equipment (condition and maintenance), pre-existing health conditions, diver experience and training. These factors can now be used to promote public health messages for divers.

CONCLUSIONS

This 20-year study highlighted regional variations for Tasmanian deaths and presents opportunities for strategies to prevent diving deaths in the future. Of particular concern was the diving practice of 'hookah' diving, which has no governing regulations. The study highlighted the importance of applying a structured methodology such as chain of events analysis to scrutinise diving deaths.

What went right? An analysis of the protective factors in aviation near misses

Learning from successful safety outcomes, or what went right, is an important emerging component of maintaining safe systems. Accordingly, there are increasing calls to study normal performance in near misses as a part of safety management activities. Despite this, there is limited guidance on how to accomplish this in practice. This article presents a study in which using Rasmussen's risk management framework to analyse 16 serious incidents from the aviation domain. The findings show that a network of protective factors prevents accidents with factors identified across the sociotechnical system. These protective networks share many properties with those identified in accidents. The article demonstrates that is possible to identify these networks of protective factors from incident investigation reports. The theoretical implications of these results and future research opportunities are discussed. Practitioner Statement: The analysis of near misses is an important part of safety management activities. This article demonstrates that Rasmussen?s risk management framework can be used to identify networks of protective factors which prevent accidents. Safety practitioners can use the framework described to discover and support the system-wide networks of protective factors.

Radiation Emergencies: Dogs and Cats

Exposure of dogs and cats to clinically significant amounts of ionizing radiation is unlikely. However, accidental release of radiation has occurred and nuclear terrorism is possible. If an incident occurs, early reaction will be by first responders, followed by state and federal emergency personnel. It is possible that veterinarians will be called upon to assist to evaluate animals for contamination and/or exposure, perform initial lifesaving tasks, and decontaminate people's pets. Therefore, veterinary professionals should understand radiation exposure, what is happening, the possible effects on animals, and how to provide veterinary care and assistance in a radiation emergency.

Comparing population and incident data for optimal air ambulance base locations in Norway

Background

Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data.

Methods

We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5–95 percentile) of 4675 (940–36,264) inhabitants and 10 (2–38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure.

Results

The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was −0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts.

Conclusion

Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data.

Risk factors for near-miss events and safety incidents in pediatric radiation therapy

BACKGROUND AND PURPOSE

Factors contributing to safety- or quality-related incidents (e.g. variances) in children are unknown. We identified clinical and RT treatment variables associated with risk for variances in a pediatric cohort.

MATERIALS AND METHODS

Using our institution's incident learning system, 81 patients age ≤21 years old who experienced variances were compared to 191 pediatric patients without variances. Clinical and RT treatment variables were evaluated as potential predictors for variances using univariate and multivariate analyses.

RESULTS

Variances were primarily documentation errors (n = 46, 57%) and were most commonly detected during treatment planning (n = 14, 21%). Treatment planning errors constituted the majority (n = 16 out of 29, 55%) of near-misses and safety incidents (NMSI), which excludes workflow incidents. Therapists reported the majority of variances (n = 50, 62%). Physician cross-coverage (OR = 2.1, 95% CI = 1.04-4.38) and 3D conformal RT (OR = 2.3, 95% CI = 1.11-4.69) increased variance risk. Conversely, age >14 years (OR = 0.5, 95% CI = 0.28-0.88) and diagnosis of abdominal tumor (OR = 0.2, 95% CI = 0.04-0.59) decreased variance risk.

CONCLUSIONS

Variances in children occurred in early treatment phases, but were detected at later workflow stages. Quality measures should be implemented during early treatment phases with a focus on younger children and those cared for by cross-covering physicians.

An analysis of environmental incidents for a national Antarctic program

Research stations in Antarctica are concentrated on scarce ice-free habitats. Operating these stations in the harsh Antarctic climate provides many challenges, including the need to handle bulk fuel and cargo increasing the risk of environmental incidents. We examined 195 reports of environmental incidents from the Australian Antarctic Program, spanning six years, to investigate the impacts and pathways of contemporary environmental incidents. Fuel and chemical spills were most common, followed by biosecurity incursions. The majority of reports were assessed as having insignificant actual impacts. Either the incidents were small, or active, rapid response and mitigation procedures minimised impact. During the period only one spill report (4000 l) was assessed as a 'high' impact. This is despite over 13 million litres of diesel utilised. The majority of incidents occurred within the existing station footprints. The pathways leading to the incidents varied, with technical causes predominately leading to spills, and procedural failures leading to biosecurity incursions. The large number of reports with inconsequential impacts suggest an effective environmental management system with a good culture of reporting environmental incidents. Our findings suggest that the key to continual improvement in an ongoing environmental management system is to learn from incidences and take action to prevent them occurring again, with an end-goal of minimising the residual risk as much as possible.

Chain of events analysis for a scuba diving fatality

INTRODUCTION

A scuba diving fatality usually involves a series of related events culminating in death. Several studies have utilised a chain of events-type analysis (CEA) to isolate and better understand the accident sequence in order to facilitate the creation of relevant countermeasures. The aim of this research was to further develop and better define a process for performing a CEA to reduce potential subjectivity and increase consistency between analysts.

METHODOLOGY

To develop more comprehensive and better-defined criteria, existing criteria were modified and a template was created and tested using a CEA. Modifications comprised addition of a category for pre-disposing factors, expansion of criteria for the triggers and disabling agents present during the incident, and more specific inclusion criteria to better encompass a dataset of 56 fatalities. Four investigators (raters) used both the previous criteria and this template, in randomly assigned order, to examine a sample of 13 scuba diver deaths. Individual results were scored against the group consensus for the CEA. Raters' agreement consistency was compared using the Index of Concordance and intra-class correlation coefficients (ICC).

RESULTS

The template is presented. The index of concordance between the raters increased from 62% (194⁄312) using the previous criteria to 82% (257⁄312) with use of this template indicating a substantially higher inter-rater agreement when allocating criteria. The agreement in scoring with and without template use was also quantified by ICC which were generally graded as low, illustrating a substantial change in consistency of scoring before and after template use.

CONCLUSION

The template for a CEA for a scuba diving fatality improves consistency of interpretation between users and may improve comparability of diving fatality reports.

Rasmussen's legacy and the long arm of rational choice

Rational choice theory says that operators and others make decisions by systematically and consciously weighing all possible outcomes along all relevant criteria. This paper first traces the long historical arm of rational choice thinking in the West to Judeo-Christian thinking, Calvin and Weber. It then presents a case study that illustrates the consequences of the ethic of rational choice and individual responsibility. It subsequently examines and contextualizes Rasmussen's legacy of pushing back against the long historical arm of rational choice, showing that bad outcomes are not the result of human immoral choice, but the product of normal interactions between people and systems. If we don't understand why people did what they did, Rasmussen suggested, it is not because people behaved inexplicably, but because we took the wrong perspective.

Failing to Fix What is Found: Risk Accommodation in the Oil and Gas Industry

The present program of research synthesizes the findings from three studies in line with two goals. First, the present research explores how the oil and gas industry is performing at risk mitigation in terms of finding and fixing errors when they occur. Second, the present research explores what factors in the work environment relate to a risk-accommodating environment. Study 1 presents a descriptive evaluation of high-consequence incidents at 34 oil and gas companies over a 12-month period (N = 873), especially in terms of those companies' effectiveness at investigating and fixing errors. The analysis found that most investigations were fair in terms of quality (mean = 75.50%), with a smaller proportion that were weak (mean = 11.40%) or strong (mean = 13.24%). Furthermore, most companies took at least one corrective action for high-consequence incidents, but few of these corrective actions were confirmed as having been completed (mean = 13.77%). In fact, most corrective actions were secondary interim administrative controls (e.g., having a safety meeting) rather than fair or strong controls (e.g., training, engineering elimination). Study 2a found that several environmental factors explain the 56.41% variance in safety, including management's disengagement from safety concerns, finding and fixing errors, safety management system effectiveness, training, employee safety, procedures, and a production-over-safety culture. Qualitative results from Study 2b suggest that a compliance-based culture of adhering to liability concerns, out-group blame, and a production-over-safety orientation may all impede safety effectiveness.

[Prioperative adverse events: critical reading of the data registry used in the surgery department of military hospital Moulay Ismail, Meknes]

Introduction

Malgré les importants progrès qui ont été faits dans le domaine de la sécurité en anesthésie, la morbidité (grave ou non, liée complètement ou partiellement à l’anesthésie) reste cependant fréquente, et aucun praticien n’est aujourd’hui à l’abri d’un accident. Dans le contexte actuel où la priorité est donnée à la formation, à l’amélioration de la qualité et de la sécurité des soins, la survenue d’un accident d’anesthésie au bloc opératoire est un événement extrêmement traumatisant. La crainte de poursuite, le contexte émotionnel rendent cette gestion parfois très difficile. Pour cette raison, elle doit faire l’objet d’une codification, à la manière des protocoles de bloc, avec trois grands axes de gestion: le patient victime, le personnel médical et paramédical impliqué et l’analyse de l’incident pour éviter une récidive.

Méthodes

Dans un but d’améliorer les soins prodigués au bloc opératoire nous avons établi un registre où sont consignés continuellement les différents incidents et accidents survenu soit en salle opératoire ou en salle de surveillance post interventionnelle. Une première lecture a été faite à l’occasion des Journées d'Enseignement Post Universitaire (JEPU) de Fès (Maroc) organisées en partenariat avec les JEPU de la Pitié salpêtrière de Paris à la faculté de Médecine et de Pharmacie de Fès sous le thème: «Les Situations Critiques Au Bloc Opératoire» les 17 et 18 Avril 2015.

Résultats

1761 patients ont été admis aux différentes salles du bloc opératoire dont 96 en salle d’endoscopie et 17 sédations en radiologie. 29 patients (1.64%) ont présentés un incident et/ou un accident en péri opératoire. La plupart des effets indésirables sont survenus en per opératoire (58,6%). Dans 28,6% des cas en postopératoire immédiat ou en salle de surveillance post interventionnelle (SSPI). La plupart des complications survenues sont d’ordre respiratoire (34%) ou cardio vasculaire (31%). On a colligé 5 décès en périopératoire soit une mortalité de 0,28%. La détermination de la cause n’est pas toujours évidente. Le facteur humain serait responsable de 24% des incidents.

Conclusion

Cette observation illustre les différents événements indésirables survenus depuis la création de ce registre il y a 6 mois. Nous proposons une lecture critique de ce registre dans le seul souci est d’améliorer nos pratiques dans une perspective de renforcer la sécurité anesthésique.

Relationship between incident types and impact on patients in drug name errors: a correlational study

Background

There are many reports regarding various medical institutions’ attempts at incident prevention, but the relationship between incident types and impact on patients in drug name errors has not been studied. Therefore, we analyzed the relationship between them, while also assessing the relationship between preparation and inspection errors. Furthermore, the present study aimed to clarify the incident types that lead to severe patient damage.

Methods

The investigation object in this study was restricted to “drug name errors”, preparation and inspection errors in them were classified into three categories (similarity of drug efficacy, similarity of drug name, similarity of drug appearance) or two groups (drug efficacy similarity (+) group, drug efficacy similarity (−) group). Then, the relationship between preparation and inspection errors was investigated in three categories, the relationship between incident types and impact on patients was examined in two groups.

Results

The frequency of preparation errors was liable to be caused by the following order: similarity of drug efficacy > similarity of drug name > similarity of drug appearance. In contrast, the rate of inspection errors was liable to be caused by the following order: similarity of drug efficacy < similarity of drug name < similarity of drug appearance. In addition, the number of preparation errors in the drug efficacy similarity (−) group was fewer than that in the drug efficacy similarity (+) group. However, the rate of inspection errors in the drug efficacy similarity (−) group was significantly higher than that in the drug efficacy similarity (+) group. Furthermore, the occupancy rate of preparation errors, incidents more than Level 0, 1, and 2 in the drug efficacy similarity (−) group increased gradually according to the rise of patient damage.

Conclusions

Our results suggest that preparation errors caused by the similarity of drug appearance and/or drug name are likely to lead to the incidents (inspection errors), and these incidents are likely to cause severe damage to patients subsequently.

Electronic supplementary material

The online version of this article (doi:10.1186/s40780-015-0011-x) contains supplementary material, which is available to authorized users.

Metro passenger behaviors and their relations to metro incident involvement

The frequent incidents caused by metro passengers in China suggest that it is necessary to explore the classification and effects of passenger behaviors and their relations to incident involvement. A metro passenger behavior questionnaire (MPBQ) and a metro station staff questionnaire (MSSQ), both comprising 32 behavior items, were developed and surveyed on a sample of metro passengers (N=579) and metro staff (N=99). Using the MPBQ, the self-reported frequency of each aberrant behavior was measured and subjected to explanatory factor analysis, which revealed a three-factor solution on the 28 retained behavior items: transgressions, self-willed inattentions and abrupt violations. ANOVA was used to examine the effects of demographic and riding profile variables on different types of behaviors. The MSSQ was used to collect metro staff opinions on behavior frequency, severity and entities that might be affected, given that a specific behavior occurred. An importance hierarchy was established over the 32 identified behaviors to determine the most important riding behaviors. Finally, logistic regression showed that riding time, number of stops experienced by a passenger and, more importantly, transgressions and abrupt violations, were significant predictors of incident involvement. The possible explanations and implications of the findings might help in understanding passenger behaviors and targeting metro safety interventions in ways that promote safer operations.

Effects of extraordinary snowfall on traffic safety

Snowfall affects traffic safety by causing changes in roadway surface and visibility that result in crashes, spinouts, and breakdowns. Using data collected at a site that regularly receives nearly 1000 cm of snow during the snow season, this study examines the impact of snowfall quantity, gap between snow events, and weather conditions on crash and incident frequencies. Estimation results from regression analysis show that snowfall severity significantly impacts crashes and incidents but the impact diminishes marginally with each additional centimeter of snow. Gap has a significant fixed effect on crashes but its impact on incidents varies significantly across observations. The effect of the mixed precipitation condition is smaller in comparison to an all-snow condition. These results will help inform policy for snow removal and traffic enforcement in areas of high snowfall.

Differences in recognition of similar medication names between pharmacists and nurses: a retrospective study

Background

Differences in error rates between pharmacists and nurses in terms of drug confirmation have not been studied. The purpose of this study was to analyze differences in error rates between pharmacists and nurses from the viewpoint of error categories, and to clarify differences in recognition regarding drug name similarity.

Methods

In this study, preparation errors and incidents were classified into three categories (drug strength errors, drug name errors, and drug count errors) to investigate the influence of error categories on pharmacists and nurses. In addition, errors in two categories (drug strength errors and drug name errors) were reclassified into another two error groups, to investigate the influence of drug name similarity on pharmacists and nurses: a “drug name similarity (−) group” and a “drug name similarity (+) group”. Then, differences in error rates of pharmacists and those of nurses were analyzed respectively within three categories and two groups. Furthermore, differences in error rates between pharmacists and nurses were analyzed in each of the three categories and two groups.

Results

Error rates of pharmacists for both drug strength errors and drug name errors were significantly higher than that for drug count errors, and similar results were obtained for nurses (P < 0.05). However, there were no significant differences in error rates between pharmacists and nurses in each of the three categories. Furthermore, error rate of nurses was significantly higher than that of pharmacists in the drug name similarity (+) group (P < 0.05), while there was no significant difference in error rates between pharmacists and nurses in the drug name similarity (−) group.

Conclusions

These results suggest that in contrast to pharmacists, nurses are easily affected by similarities in drug names. Therefore, pharmacists should offer information on medications having plural strengths or similar names to nurses, in order to minimize damage to patients resulting from errors.

Electronic supplementary material

The online version of this article (doi:10.1186/s40780-015-0017-4) contains supplementary material, which is available to authorized users.

[Impact on the improvement of paediatric emergency services using a standardised model for the declaration and analysis of incidents]

INTRODUCTION

The aim of this study is to analyse changes in the incidents reported after the implementation of a new model, and study its results on patient safety.

PATIENTS AND METHODS

In 2012 an observational study with prospective collection of incidents reported between 2007 and 2011 was conducted. In May 2012 a model change was made in order to increase the number of reports, analyse their causes, and improve the feedback to the service. Professional safety representatives were assigned to every department, information and diffusion sessions were held, and a new incident reporting system was implemented. With the new model, a new observational study with prospective collection of the reports during one year was initiated, and the results compared between models.

RESULTS

In 2011, only 19 incidents were reported in the Emergency Department, and between June 1, 2012 to June 1, 2013, 106 incidents (5.6 times more). The incidents reported were medication incidents (57%), identification (26%), and procedures (7%). The most frequent causes were human (70.7%), lack of training (22.6%), and working conditions (15.1%). Some measures were implemented as a result of these incidents: a surgical checklist, unit doses of salbutamol, tables of weight-standardised doses of drugs for cardiopulmonary resuscitation.

CONCLUSIONS

The new model of reporting incidents has enhanced the reports and has allowed improvements and the implementation of preventive measures, increasing the patient safety in the Emergency Department.

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

OBJECTIVE

To explore contributing factors (CF) associated to related critical patients safety incidents.

DESIGN

SYREC study pos hoc analysis.

SETTING

A total of 79 Intensive Care Departments were involved.

PATIENTS

The study sample consisted of 1.017 patients; 591 were affected by one or more incidents.

MAIN VARIABLES

The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed.

RESULTS

A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable.

CONCLUSIONS

The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss.

Incidents and complications of permanent venous central access systems: a series of 1,460 cases

BACKGROUND

Implanted venous access devices or permanent central venous access systems (PCVASs) are routinely used in oncologic patients. Complications can occur during the implantation or use of such devices. We describe such complications of the PCVAS and their management.

METHODS

Our retrospective study included 1,460 cases in which PCVAS was implanted in the 11 years between January 2002 and January 2013, including 810 women and 650 men with an average age of 45.2 years. We used polyurethane or silicone catheters. The site of insertion and the surgical or percutaneous procedure were selected on the basis of clinical data and disease information. The subclavian and cephalic veins were our most common sites of insertion.

RESULTS

About 1,100 cases (75%) underwent surgery by training surgeons and 360 patients by expert surgeons. Perioperative incidents occurred in 33% and 12% of these patients, respectively. Incidents (28%) included technical difficulties (n=64), a subcutaneous hematoma (n=37), pneumothoraces (n=15), and an intrapleural catheter (n=1). Complications in the short and medium term were present in 14.2% of the cases. Distortion and rupture of the catheter (n=5) were noted in the costoclavicular area (pinch-off syndrome). There were 5 cases of catheter migration into the jugular vein (n=1), superior vena cava (n=1), and heart cavities (n=3). No patient died of PCVAS insertion or complication.

CONCLUSION

PCVAS complications should be diagnosed early and treated with probable removal of this material for preventing any life-threatening outcome associated with complicated PVCAS.

Effective drinking water collaborations are not accidental: interagency relationships in the international water utility sector

The role that deficient institutional relationships have played in aggravating drinking water incidents over the last 30 years has been identified in several inquiries of high profile drinking water safety events, peer-reviewed articles and media reports. These indicate that collaboration between water utilities and public health agencies (PHAs) during normal operations, and in emergencies, needs improvement. Here, critical elements of these interagency collaborations, that can be integrated within the corporate risk management structures of water utilities and PHAs alike, were identified using a grounded theory approach and 51 semi-structured interviews with utility and PHA staff. Core determinants of effective interagency relationships are discussed. Intentionally maintained functional relationships represent a key ingredient in assuring the delivery of safe, high quality drinking water.