Incident Reporting System Research Articles

Prediction of aviation safety incident risk level based on ECSDNN

Prediction of aviation safety incident risk level is an important means of active risk management. Considering the high-dimensional complexity and class imbalance of massive aviation safety incident data, a prediction method for aviation safety incident risk level based on integrated cost-sensitive deep neural network (ECSDNN) is proposed. The feature representation of aviation safety incident data is realized by using the method of embedded coding of categorical attributes and splicing of numerical attributes; the cost-sensitive matrix and cost-sensitive loss function are designed by comprehensively considering the misclassification ratio and fixed cost, and the base classifier model based on cost-sensitive deep neural network (CSDNN) is constructed; the hard voting method is used to integrate multiple base classifiers with different parameters and performances to construct the integrated prediction model ECSDNN for aviation safety incident risk level. The experimental results on the Aviation Safety Incident Reporting System (ASRS) dataset show that compared with the optimal prediction ability of the baseline algorithm, the prediction accuracy of the ECSDNN model is improved 4.51%; compared with the single CSDNN base classifier, the prediction accuracy is improved 3.17%.

Decentralized Incident Reporting: Mobilizing Urban Communities with Blockchain

This paper introduces an innovative response to the pressing challenge of rapid and effective incident detection and management in urban settings. The proposed solution is a decentralized incident reporting system (IRS) harnessing blockchain technology and decentralized data storage systems. By empowering residents to report incidents, the proposed IRS enables seamless real-time monitoring and intervention by relevant departments. Built on a blockchain foundation, the proposed solution ensures immutability, transparency, security, and auditability, enhancing data resilience and comprehensive applicability. The proposed system leverages the InterPlanetary File System (IPFS) for the storage of incident proofs to manage the blockchain size effectively. Through the proposed IRS, transparency is upheld, enabling complete auditability of incident details and required interventions by citizens, societal bodies, and governmental bodies. Moreover, an incentive model is introduced to encourage active participation in incident reporting, thereby enhancing the system’s overall effectiveness and long-term sustainability. The proposed IRS integrates mobile technology to facilitate user engagement and data submission, essential for urban emergency management. Empirical validation using the Quorum–Raft blockchain demonstrates the feasibility of the proposed approach in terms of system throughput, incident reporting delay, blockchain size, and deployment cost. Specifically, the system maintains a latency of under 15 s even at high transaction rates, can handle up to 200 incidents per second, and is cost-effective, with deployment estimates for 16 organizations over five years being under 1.99 million USD. The method involves extensive testing with simulated incidents and user interactions to ensure robustness and scalability, showcasing the system’s potential for effective emergency management in urban environments.

Improving the safety of radiotherapy treatment processes via incident-driven FMEA feedback loops.

Failure mode and effects analysis (FMEA) is a valuable tool for radiotherapy risk assessment, yet its outputs might be unreliable due to failures not being identified or due to a lack of accurate error rates. A novel incident reporting system (IRS) linked to an FMEA database was tested and evaluated. The study investigated whether the system was suitable for validating a previously performed analysis and whether it could provide accurate error rates to support the expert occurrence ratings of previously identified failure modes. Twenty-three pre-identified failure modes of our external beam radiotherapy process, covering the process steps from patient admission to treatment delivery, were proffered on dedicated FMEA feedback and incident reporting terminals generated by the IRS. The clinical setting involved a computed tomography scanner, dosimetry, and five linacs. Incoming reports were used as basis to identify additional failure modes or confirm initial ones. The Kruskal-Wallis H test was applied to compare the risk priorities of the retrospective and prospective failure modes. Wald's sequential probability ratio test was used to investigate the correctness of the experts' occurrence ratings by means of the number of incoming reports. Over a 15-month period, 304 reports were submitted. There were 0.005 (confidence interval [CI], 0.0014-0.0082) reported incidents per imaging study and 0.0006 (CI, 0.0003-0.0009) reported incidents per treatment fraction. Sixteen additional failure modes could be identified, and their risk priorities did not differ from those of the initial failure modes (p=0.954). One failure mode occurrence rating could be increased, whereas the other 22 occurrence ratings could not be disproved. Our approach is suitable for validating FMEAs and deducing additional failure modes on a continual basis. Accurate error rates can only be provided if a sufficient number of reports is available.

Age-specific colorectal cancer incidence trends in Canada, 1971–2021

IntroductionColorectal cancer (CRC) incidence among adults younger than 50 years has increased in recent decades, leading to some advocating for lowering the age to start CRC screening. Here, we estimate age-specific trends in CRC incidence in Canada and changes in risk by birth cohort. MethodsCRC incidence data from 1971 to 2021 by province, sex, and five-year age group (35−64) were obtained from the National Cancer Incidence Reporting System and the Canadian Cancer Registry. Annual percent changes in age-specific or age-adjusted incidence rates were analyzed with joinpoint regression. Birth cohort effect was estimated with age-period-cohort models and reported as cohort incidence rate ratios (IRRs) with respect to the 1947–51 cohort. ResultsCRC incidence has increased among all age groups under 50 years, with the largest relative increases occurring in the youngest age group (35–39 years). Males and females had similar incidence trends, though males under age 50 had larger increases than females. The birth cohort analysis showed that males born since 1966 have a significantly higher risk than those born at any other time. ConclusionsThese results up to 2021 confirm and update reports that CRC incidence is increasing among adults under age 50 in Canada and that the youngest birth cohorts carry the highest risk. Future studies should assess the effectiveness of CRC screening in younger populations.

The burden of natural gas leaks on public sector emergency response in the United States

Fire departments play a critical role in responding to potential hazards generated by natural gas and propane leaks, yet the costs of providing these services is unknown. Here, we analyzed 15 years of gas leak-coded incidents from the National Fire Incident Reporting System (NFIRS) and estimated associated costs using fire department operating budgets. From 2003 to 2018, a total of 2.4 million gas leak-coded incidents required fire department responses, accounting for ∼0.8% of all nationwide incidents. Reported gas leak incidents have steadily increased nationwide, nearly quadrupling from 2003 to 2018. In 2018, New York City (NYC) experienced 22,090 gas leak incidents—more than the next 25 cities combined—conservatively costing NYC $70 million annually. With a median national response cost of $2609 (S.D. $1734), uncombusted gas leaks conservatively cost U.S. fire departments $564 million in 2018—at least 10x greater than for gas leak-caused fires. City-level natural gas systems entail an underappreciated and increasing public cost burden on emergency response services. Findings herein raise the salience of gas leak-associated emergency response costs and support improved gas leak response coordination between emergency services and gas utility providers. Decision-makers are encouraged to incorporate these costs into cost-benefit analyses and consider the intended and unintended effects on emergency response systems in managing energy transitions.

Development and Implementation of a Safety Incident Report System for Health Care Discipline Students During Clinical Internships: Observational Study.

Patient safety is a fundamental aspect of health care practice across global health systems. Safe practices, which include incident reporting systems, have proven valuable in preventing the recurrence of safety incidents. However, the accessibility of this tool for health care discipline students is not consistent, limiting their acquisition of competencies. In addition, there is no tools to familiarize students with analyzing safety incidents. Gamification has emerged as an effective strategy in health care education. This study aims to develop an incident reporting system tailored to the specific needs of health care discipline students, named Safety Incident Report System for Students. Secondary objectives included studying the performance of different groups of students in the use of the platform and training them on the correct procedures for reporting. This was an observational study carried out in 3 phases. Phase 1 consisted of the development of the web-based platform and the incident registration form. For this purpose, systems already developed and in use in Spain were taken as a basis. During phase 2, a total of 223 students in medicine and nursing with clinical internships from universities in Argentina, Brazil, Colombia, Ecuador, and Spain received an introductory seminar and were given access to the platform. Phase 3 ran in parallel and involved evaluation and feedback of the reports received as well as the opportunity to submit the students' opinion on the process. Descriptive statistics were obtained to gain information about the incidents, and mean comparisons by groups were performed to analyze the scores obtained. The final form was divided into 9 sections and consisted of 48 questions that allowed for introducing data about the incident, its causes, and proposals for an improvement plan. The platform included a personal dashboard displaying submitted reports, average scores, progression, and score rankings. A total of 105 students participated, submitting 147 reports. Incidents were mainly reported in the hospital setting, with complications of care (87/346, 25.1%) and effects of medication or medical products (82/346, 23.7%) being predominant. The most repeated causes were related confusion, oversight, or distractions (49/147, 33.3%) and absence of process verification (44/147, 29.9%). Statistically significant differences were observed between the mean final scores received by country (P<.001) and sex (P=.006) but not by studies (P=.47). Overall, participants rated the experience of using the Safety Incident Report System for Students positively. This study presents an initial adaptation of reporting systems to suit the needs of students, introducing a guided and inspiring framework that has garnered positive acceptance among students. Through this endeavor, a pathway toward a safety culture within the faculty is established. A long-term follow-up would be desirable to check the real benefits of using the tool during education. Trial Registration: ClinicalTrials.gov NCT05350345; https://clinicaltrials.gov/study/NCT05350345.

Perancangan Sistem Pelaporan Incident Hack Di Kominfo Lombok Tengah Menggunakan Agile Pendekatan Scrum

The Scrum method is a methodology included in agile software development. Scrum is considered to be able to produce good quality software according to user wishes, can be used in large and small projects, and is easy to adopt changes. The scrum activity stages include product backlog, sprint backlog, daily scrum, sprint review, and sprint retrospective. Roles in Scrum include product owner, scrum master, and development team. Scrum has structured and iterative stages, so that if the product in the first sprint is not sufficient to meet needs, then in the next sprint a system can be developed that is in accordance with user evaluation. The results obtained from Designing a Hack Incident Reporting System at Kominfo Central Lombok Using the Agile Scrum Approach were proven to be able to overcome changes in requirements during the system development phase, producing products that met the wishes of users because they received repeated reviews.

A novel historical data-based method for predicting firefighters demand in urban fires

Urban fires are a prevalent type of fire that requires prompt and effective responses. Determining the appropriate number of firefighters at the alarm time is crucial, but it mostly relies on the experience of decision-makers. Due to the fuzziness and limitations of human knowledge, there is often a deviation between the number of firefighters dispatched relying on personal subjective experience and the realistic demand. This paper proposed a historical data-based method for predicting the demand number of firefighters in urban fire. Initially, the National Fire Incident Reporting System (NFIRS) data and Global Historical Climatology Network Daily (GHCN-D) weather data were combined to create a fused dataset. The dataset was subjected to anomaly detection and feature selection, then the processed data was used to predict the number of firefighters using artificial neural network (ANN). In this process, the Genetic Algorithm (GA) was applied to optimize ANN structure. Finally, comparative experiments were conducted to evaluate the performance of the proposed method, which demonstrated superior accuracy in comparison to common regression models and traditional ANN. This advancement brings the number of dispatched firefighters closer to the actual demand and contributes to ensuring an adequate allocation of firefighters for urban fires. Consequently, decision-makers can make more informed decisions regarding the number of firefighters to dispatch, leading to more effective responses to urban fires.

Perceptions of U.S. and U.K. Incident Reporting Systems: A Scoping Review.

The aim of the study is to evaluate the extent, range, and nature of the literature that concerns healthcare providers' perceptions following the use of incident reporting systems (IRSs) in the United States (U.S.) and the United Kingdom (U.K.). Literature was compared describing providers' perceptions of reporting patient safety incidents using IRSs from healthcare systems built on public, private, for-profit, or nonprofit insurers in the U.S., with providers' perceptions using an IRS within a universal government supported healthcare system in the U.K. This scoping review searched literature from 4 electronic databases, producing 4863 articles between January 2010 to March 2023. Eleven U.S. and 8 U.K. articles met the inclusion criteria. Providers described system and individual barriers when using IRSs. The U.S. providers described more concerns regarding individual barriers (fear of punitive response or retaliation, feel incapable or shamed, unsure of what constitutes a patient safety incident, and concerned about litigation) than providers in the U.K. Both countries had similar responses regarding system barriers, except for U.K. providers who were more concerned than the U.S. about damage to professional culture. Providers in both countries believed incident reporting was ineffective and time consuming with hospital leaders seldom acknowledging or integrating improvement measures based on reported incidents. Sustainable improvements in patient care must be driven by hospital leadership who create just cultures where reporting of safety concerns is encouraged and respected within nonpunitive milieus.

Incidence of Breast Cancer in Younger Women: A Canadian Trend Analysis.

Purpose: Breast cancer (BC) incidence is increasing globally. Age-specific BC incidence trend analyses are lacking for women under age 50 in Canada. In this study, we evaluate the incidence trends in breast cancer in women under age 50 in Canada and compare them with corresponding trends among women 50 to 54. Methods: BC case counts were obtained from the National Cancer Incidence Reporting System (1984-1991) and the Canadian Cancer Registry (1992-2019) both housed at Statistics Canada. Population data were also obtained from Statistics Canada. Annual female BC age-specific incidence rates from 1984 to 2019 were derived for the following age groups: 20 to 29, 30 to 39, 40 to 49, 40 to 44, 45 to 49, and 50 to 54. Changes in trends in age-specific BC incidence rates, if any, and annual percent changes (APCs) for each identified trend, were determined using JoinPoint. Results: Statistically significant increasing trends in BC incidence rates were noted for almost all age groups: since 2001 for 20 to 29 (APC = 3.06%, P < .001); since 2009 for 30 to 39 (APC = 1.25%, P = .007); since 1984 for both 40 to 49 (APC = 0.26%, P < .001) and 40 to 44 (APC = 0.19%, P = .011), increased since 2015 for 40 to 49 (APC = 0.77%, P = .047); and since 2005 for 50 to 54 (APC = 0.38%, P = .022). Among women 45 to 49 there was a non-significant increase since 2005 (APC = 0.24, P = .058). Statistically significant average annualized increases in BC incidence rates were observed for each age group studied. Conclusions: Examining age-specific incidence rates formed a more complete picture of BC time trends with significant increasing trends in the incidence of BC among women in their 20s, 30s, 40s, and early 50s. A greater awareness regarding the increasing number of cases of BC in women younger than 50 is critical to allow for earlier diagnosis with its resultant reduced mortality and morbidity.

Examining Exposure Fires from the United States National Fire Incident Reporting System between 2002 and 2020

Fires resulting from antecedent fires, known as exposure fires, can manifest across diverse environments, including suburban, urban, and rural areas. Notably, exposure fires represented by structure-destroying fires within the wildland–urban interface (WUI) can extend into non-WUI suburban and urban regions, presenting significant challenges. Leveraging data from the United States National Fire Incident Reporting System (NFIRS) spanning 2002 to 2020, this study investigates 131,739 exposure fire incidents impacting 348,089 features (incidents). We analyze reported economic costs, affected feature types, and property utilization patterns for these exposure fires. We also compare these exposure fires to information documented in other databases. Finally, we examine structure separation distance at residential dwellings and describe ignition pathways for selected fires. Reported property losses for some fire incidents amounted to USD 5,647,121,172, with content losses totaling USD 1,777,345,793. Prominent fire incident categories include buildings, vehicles, and natural vegetation fires, predominantly occurring in residential, outdoor, and storage areas. While the NFIRS lacked information on most major structure-destroying WUI fires, highlighting this analysis’s lack of statistical representation, it did provide insights into less extensive exposure fires, both WUI and non-WUI, unrecorded elsewhere. Our study reveals significant distinctions in the distribution of separation distances between damaged-to-damaged structures (average separation of 6.5 m) and damaged-to-not-damaged structures (average separation of 18.1 m). Notably, 84% of the incidents in exposure fires involved fire suppression defensive actions. These defensive actions contributed to the differences in structure separation distance distributions, highlighting the often-neglected role of these measures in assessing structure responses during WUI fires. We examined ignition pathways at select exposure fires, highlighting some common features involved in fire spread and challenges in documenting these pathways. Finally, we propose a set of idealized attributes for documenting exposure fires, accentuating the inherent difficulties in collecting such data across expansive geographical areas, particularly when striving for statistical representation. Our findings yield valuable insights into the multifaceted nature of exposure fires, informing future research and database development to aid in mitigating their impact on vulnerable communities.

Using Incident Reporting Systems to Improve Patient Safety and Quality of Care.

Using Incident Reporting Systems to Improve Patient Safety and Quality of Care.

Using State Agency Reports to Augment Ohio’s Agricultural Injury Surveillance Efforts

ABSTRACT Background Agriculture is a hazardous industry with undocumented injury events. Credible surveillance measures are critical for this industry, especially to guide injury prevention programs with targeted recommendations for specific commodity groups and populations. This multi-phase study explored the feasibility for two state agency databases, the Ohio Bureau of Workers’ Compensation (BWC) Program and the Emergency Medical Services Incident Reporting System (EMSIRS), to augment the state’s Bureau of Labor Statistics (BLS) annual reports. Methods BWC data described injury claims in agricultural workplaces from 1999 to 2008. State EMSIRS data described the types of medical emergencies for which EMS services were requested to Ohio farms in 2013–2014. Descriptive analyses were performed on each distinctive source. Results Over 14,000 BWC claims were analyzed, with primary nature of injury identified as sprains and strains of bodily extremities; falls were the most common cause of injury. The EMSIRS data provided 1,376 cases, where EMS services were requested to Ohio farms at injury onset. Some cases had possibility to be excluded in CFOI or employment claims data, with 24% patients 65 years and older and 6% children 13 years and younger. The primary cause of injury was falls, and the highest reported injury type was blunt trauma. Conclusions Both BWC and EMSIRS databases showed the potential to enhance Ohio’s agricultural surveillance data with viable information not found in previously used systems. Each agency database had its own merits to further clarify and quantify morbidity. When used together, these sources enrich surveillance statistics to describe Ohio’s agricultural injury incidents.

Psychological Safety and Use of Incident Reporting Systems

Psychological Safety and Use of Incident Reporting Systems

Adverse events in the global healthcare practice of an Occupational Mutual Insurance Company in Spain.

Patient safety is currently a main issue in healthcare practice. Adverse events (AEs) management is a key instrument for the application of strategies to prevent harm to patients. To analyze the type, severity and preventability, according to validated scales, of AEs occurring annually in the healthcare practice of an Occupational Mutual Insurance Company in order to implement action plans to improve patient safety. We analyzed the reported AEs in an Incident Reporting System and AEs detected in the Audit program of clinical records as a result of treating injured or ill workers in our 88 ambulatory care centers. We detected 28 AEs in the clinical records (CR), representing 0.05 AE/CR, with maximum values in the COM sample (26 AEs, 0.11) and much lower in INT (1 AEs, 0.02) and MIN (1 AE, 0.02). The most frequent AE type was procedure-related, followed by infection and care. AEs of severity level D (11 cases) and E (9 cases) predominated, while level F was also detected (6 cases). Intermediate values in preventability (3 and 4) predominated, 61.5% were preventable. With the Incident Reporting System, 27 AEs were identified, predominated by procedural type. Most reported AE severities was in levels E (10 cases) and C (8 cases), 89% were preventable. Our company detects AEs via the Incident Reporting System and annual Audit program of clinical records, both of which are complementary, and may result in the implementation of more effective Patient Safety measures.

A RETROSPECTIVE ANALYSIS OF SURGICAL POSITIONING INJURY USING INCIDENT REPORTING SYSTEM

(Purpose) Surgical positioning injury (SPI) is a cutaneous, musculoskeletal, neurological, or vascular injury resulting from the position of the patient during surgery. We performed a retrospective study using incident reporting system to examine the incidence of SPI at our hospital. (Materials and methods) Among anesthesiology managed surgical cases, SPI cases reported in the incident reporting system between 2012 and 2017 were examined. The primary endpoint was the incidence of SPI. (Results) Of 35,400 anesthesiology managed cases, 59 (0.2%) had SPI reported in the incident reporting system. Forty-four (75%) were male patients. Median age and BMI were 60 and 23.6 years, respectively. Forty-four (75%) were not supine position. Median operative time and blood loss were 419 minutes and 220 ml, respectively. Nurses reported incident reports in 52 (88%) cases, and only 7 (12%) by physicians. Skin injuries were reported in 42 cases (71%) and neurovascular injuries in 17 cases (29%). Of the neurovascular injuries, 4 (7%) were lower extremity compartment syndrome. Three cases of the 4 received the fasciotomy. (Conclusions) The incidence of SPI reported in the incident report system was 0.2%. Four cases had compartment syndrome. This result suggested the importance of intraoperative and postoperative observation in addition to proper correct positioning.

Practice without prospect: The imaginary response to the recording and investigations of sexual assault in prison

This article draws on Incident Reporting System data from the National Offender Management Service over a ten-year period (2004–2014) and limited, small-scale interviews with four custodial managers. Pat Carlen's work (2008) on imaginary penalities provides the theoretical framework for an assessment of the reporting, recording and initial response to sexual assaults in prisons in England and Wales. The article argues that the recording of sexual assaults became part of a response to new management systems that emphasised compliance, process and audit rather than realising safety in custody. Although the data shows substantial levels of initial activity among staff it is, in essence, practice without prospect. The article suggests that outcomes generally for sexual assaults in prisons in England and Wales are uncertain. Incident reporting has become a bureaucratic process ‘or paper shadow’, which Goffman described as showing ‘what has been done by whom, what is to be done, and who last had responsibility for it’ (Goffman 1961: 73).

Identifying Type II workplace violence from clinical notes using natural language processing.

Type II workplace violence in health care, perpetrated by patients/clients toward home healthcare nurses, is a serious health and safety issue. A significant portion of violent incidents are not officially reported. Natural language processing can detect these "hidden cases" from clinical notes. In this study, we computed the 12-month prevalence of Type II workplace violence from home healthcare nurses' clinical notes by developing and utilizing a natural language processing system. Nearly 600,000 clinical visit notes from two large U.S.-based home healthcare agencies were analyzed. The notes were recorded from January 1, 2019 to December 31, 2019. Rule- and machine-learning-based natural language processing algorithms were applied to identify clinical notes containing workplace violence descriptions. The natural language processing algorithms identified 236 clinical notes that included Type II workplace violence toward home healthcare nurses. The prevalence of physical violence was 0.067 incidents per 10,000 home visits. The prevalence of nonphysical violence was 3.76 incidents per 10,000 home visits. The prevalence of any violence was four incidents per 10,000 home visits. In comparison, no Type II workplace violence incidents were recorded in the official incident report systems of the two agencies in this same time period. Natural language processing can be an effective tool to augment formal reporting by capturing violence incidents from daily, ongoing, large volumes of clinical notes. It can enable managers and clinicians to stay informed of potential violence risks and keep their practice environment safe.

Student Breakout Session

The 2022 students-only session is a unique opportunity for perfusionists-in-training to connect with one another and to create a space in which they feel confident to speak up. The session will comprise three parts. First, there will be an introduction to the structure and function of the Australian and New Zealand College of Perfusionists (ANZCP), including the roles of the Executive and Board, requirements for recertification, opportunities to participate in the College, and the invaluable resource that Perfusion Incident Reporting System (PIRS) is. The presentation will then cover preparation for the Certification Exam VIVA. Expectations for this exam will be clearly explained, effective study techniques will be explored, and the group will step through a practice question together integrating the strategies discussed. The final topic of the session will be “life beyond traineeship” focusing on how to continue acquiring skills once formal training is complete. Students will be encouraged to see attaining a Certified Clinical Perfusionist (CCP) as the beginning of a lifelong learning pathway and the group will discuss how to identify gaps in their perfusion experience and work on strategies to fill them, to become a confident and well-rounded clinician.

Analysis Dimension of Healty Work Environment for Successful Patient Safety Incident Reporting: A Cross Sectional Study

Incident reporting of patient safety is the first step in improving patient safety through learning from previous incidents. However, barriers to incident reporting caused by work environment factors make the patient safety incident system not run well in various countries. This study analyzes nurses’ dimensions of a healthy work environment toward reporting patient safety incidents. This study used an observational analytic design with a cross-sectional approach. This study was conducted in a regional hospital in West Nusa Tenggara province in October - November 2022 with a total sample of 151 nurses working in the inpatient room. Sample determination used a quota sampling technique. Measurement of a healthy work environment was adopted from the HWE Tools and Measurement of incident reporting. The questionnaire was adopted from the Patient Safety Incident Reporting and Learning Systems. Data collection techniques implemented primary data questionnaires and multiple linear regression tests. The results showed a relationship between communication, collaboration, decision-making, staff suitability, recognition, and leadership to patient safety incident reporting with a p-value of 0.001 each (p &lt;0.05). The most dominant relationship is Recognition (B=0.39, p=0.001). Recognition means stimulating a person’s psychological growth and a positive mindset to complete tasks, solve problems, overcome obstacles, and bounce back from difficult situations. Therefore, individual attitudes alone are not enough to make individuals behave to report or not report incidents but must be supported by the wishes of those who have great influence in the environment and want individuals to report if an incident occurs.