Safety Lapses Research Articles

Food safety, voluntary recall and firm reputation

AbstractProduct recalls are direct remedies for producers in case of food safety problems. Unlike in the United States or other developed countries, in China, voluntary recalls are rarely documented in the food sector. The purpose of this paper is to address two questions: (1) why do firms adopt different recall strategies in different countries; (2) under what circumstances can voluntary recall help firms build up their food safety reputation? Based on the theory of collective reputation, we develop a dynamic model to incorporate firms' recall strategy and investigate the impact of such a strategy on industry collective reputation. The model takes into account production hazards: producers' lapses in food safety despite good‐faith efforts. Our results show that voluntary recall helps a firm to maintain a good historical record. Hence, firms are likely to achieve a high level of collective reputation under voluntary recall. However, a firm is willing to initiate voluntary recall only if the collective reputation is high enough. This explains the current situation in China: as consumers show little trust (belief in collective reputation is low), firms cannot recover the recall loss and thus have no incentive to initiate a voluntary recall.

Social responsibility, information technology, and high-quality development of mining enterprise using structural equation modeling (SEM)

In the post-epidemic era, the geopolitical landscape is poised to impact global dynamics, with mineral supply emerging as a potential bottleneck for China's economic growth. Addressing this challenge requires Chinese mining enterprises to align mineral resources with domestic demand while bolstering their global influence. Despite this imperative, outdated technology, safety lapses, and inadequate measures have led to frequent mining accidents. This study explores the intricate relationship between corporate social responsibility (CSR) and information technology (IT) in the mining industry's high-quality development. Employing literature analysis, qualitative and quantitative methods, and structural equation modeling (SEM), we analyze data from 6334 mining companies listed on the Shenzhen Stock Exchange (2011–2018). Findings emphasize the substantial impact of both CSR and IT on high-quality development. While CSR fosters industry development, IT integration enhances social responsibility fulfillment, propelling high-quality development. As China shifts to high-quality development, this research highlights the pivotal role of CSR, surpassing IT, in driving the mining sector's evolution. These insights contribute to understanding the intricate dynamics between social responsibility and high-quality development, offering innovative perspectives for governance and technological advancement in the mining sector.

Beyond the Hospital: Redefining the Role of Pharmacists in Transitions of Care

Unjustifiable medication discrepancies or inconsistency are responsible for more than half of medication errors occurring at transitions in care and up to one-third could have the potential to cause harm. Studies have shown that pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. In Singapore, the Hospital-to-Home (H2H) programme in Changi General Hospital (CGH) focuses on providing care to vulnerable patients transitioning from different settings, who are exposed to gaps in care and lapses in quality and safety. The Home Medical Service by Pharmacists was pioneered in CGH and Singapore in October 2020 to enhance provision of pharmacy-related services by certified collaborative prescribing pharmacists in the home setting. The purpose of this quality improvement project is to identify provider and patient characteristics that are predictive of the response towards this new pharmacy service, which in turn influences the referrals to the service.
 A fishbone diagram was used to analyse and categorise the problems into different factors – pharmacist-, nursing-, physician-, patient-, and process-related. Pharmacist-, nursing- and physician-related factors include poor awareness of the potential value-added roles of pharmacists due to the lack of prescribing experience in the home setting. Patient-related factors include difficulty in establishing the appropriate criteria to identify patients who need pharmacist’s intervention. Process-related factors include potential additional cost to patients.
 Based on the Model of Improvement, several changes were implemented in two Plan-Do-Study-Act (PDSA) cycles. The first cycle was to perform roadshows to the H2H team comprising of physicians and nurses, to raise awareness of the new pharmacy service and pharmacist's roles (more in-depth medication reconciliation, drug information, and prescribing). After three months, the second cycle was initiated by conducting regular monthly case audits with the H2H team to monitor progress, identify lapses, and receive feedback to further improve processes and explore potential areas that pharmacists can contribute.
 After implementing PDSA cycle 1, the average number of unique home visits by pharmacists per month increased from 1 visit to 4 visits, and subsequently increased to 8 visits after implementing PDSA cycle 2. A survey was also conducted to determine if the changes implemented were satisfactory to the team. Overall, 80% of responses were satisfied with the Home Medical Service by Pharmacists in managing patients under the H2H programme.
 This project had enabled us to achieve improvements in several processes which facilitated the refinement of pharmacist’s roles in the H2H programme to complement the team’s current roles and increased awareness of these roles within the team. Lastly, we will continue to further improve other problem areas yet be addressed and together with the H2H team, close the gaps in care for patients undergoing transitions of care.

Emotional intelligence as a conduit for improved occupational health safety environment in the oil and gas sector

To address the issue of promoting occupational health and safety at the workplace, this study aimed to evaluate the mediating effect of four different dimensional constructs of Emotional Intelligence (EI) on the influence Occupational Health and Safety Management Practices (OHSMP) hold on safety performance and workplace accidents among oil and gas workers. The study is explanatory research that adopted a cross-sectional survey design. Convenience and stratified sampling techniques were used to select 699 respondents from the three major government-owned oil and gas organizations. The multiple standard regression and bootstrapping mediation methods were used for data analysis after subjecting the data to exploratory and confirmatory factor assessments. Results indicated that OHSMP significantly predicts EI, safety performance, and workplace accidents. Again, EI was found to predict safety performance and workplace accidents significantly. Results also indicated that all the construct dimensions for measuring EI significantly explain the relationship between OHSMP and safety performance, as well as the influence of OHSMP on workplace accidents. The theoretical basis for these findings is that workers with high-level EI are likely to cope with occupational health and safety lapses or safety-related challenges at the workplace by participating and complying with the organization’s safety management practices or procedures. Such employees are likely to exhibit safe working behaviors and contribute to improving safety performance in the organization.

Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement.

Promoting and maintaining patient safety in primary care requires different strategies and monitoring than utilized in large healthcare delivery systems. Maintenance of a culture of safety is key to providing patient safety but has been difficult to measure in primary care. This is particularly true in rural settings where practice size is a major barrier to measurement reliability. Primary care evaluates a wide range of patients, including those who are immunocompromised and others who have infectious diseases. Providing a safe environment with proper wearing of N95 masks, clean examination rooms, and adequate ventilation is important. Patients with infectious diseases should be separated from other patient populations. Primary care is often less bureaucratic than hospitals, but also has fewer resources to implement patient safety initiatives, along with detecting safety lapses and adverse events. However, monitoring the practice's safety practices and the culture of safety is of utmost importance and should be performed using both outcome and process measures. Because of the small size of many rural practices, effective monitoring of adverse events and maintenance of safety protocols should include patients. Patients are an important resource for reporting of adverse events and medical treatment outcomes. The aim of this manuscript is to underscore the importance of patient safety in primary care and to stimulate future research in developing a metric for the culture of safety in primary care, which also incorporates the patient perspective. Patients should be viewed not only as beneficiaries of patient safety but also as a critical component of its maintenance.

Health profile of workers from different industries in Singapore.

Workplace safety and health are interrelated - a worker who is not healthy may cause safety lapses at the workplace; conversely, safety lapses could affect the health of the workers. This study was part of a larger Total Workplace Safety and Health (WSH) programme run by the Workplace Safety and Health Council, Singapore. The objectives were to obtain a baseline health profile of workers across four major industries and identify important health risks for targeted workplace interventions. Five service providers (SPs) were appointed to run the Total WSH programme. As part of the programme, SPs conducted an anonymous basic health survey among workers of participating companies. The responses of 6,373 respondents from the cleaning, construction, manufacturing, and transport and storage industries were studied. The overall response rate was 62%. Key health issues identified were high rates of obesity (22%) and smoking (24%) and low prevalence of regular exercise and healthy dietary habits. Chronic disease rates were similar to population self-reported rates (hypertension 15%, high lipid 12% and diabetes mellitus 6%). The workers reported high work stress (13%). Health issues are prevalent in the workforce and may affect work and employee safety. It is increasingly important for employees' health to be considered in risk assessments and prioritised in workplace safety and health management systems and strategies. Health promotion interventions should be targeted, and multilevel and multicomponent initiatives should be integrated with pre-existing occupational safety programmes.

Autonomous Vehicles: Sophisticated Attacks, Safety Issues, Challenges, Open Topics, Blockchain, and Future Directions

Autonomous vehicles (AVs), defined as vehicles capable of navigation and decision-making independent of human intervention, represent a revolutionary advancement in transportation technology. These vehicles operate by synthesizing an array of sophisticated technologies, including sensors, cameras, GPS, radar, light imaging detection and ranging (LiDAR), and advanced computing systems. These components work in concert to accurately perceive the vehicle’s environment, ensuring the capacity to make optimal decisions in real-time. At the heart of AV functionality lies the ability to facilitate intercommunication between vehicles and with critical road infrastructure—a characteristic that, while central to their efficacy, also renders them susceptible to cyber threats. The potential infiltration of these communication channels poses a severe threat, enabling the possibility of personal information theft or the introduction of malicious software that could compromise vehicle safety. This paper offers a comprehensive exploration of the current state of AV technology, particularly examining the intersection of autonomous vehicles and emotional intelligence. We delve into an extensive analysis of recent research on safety lapses and security vulnerabilities in autonomous vehicles, placing specific emphasis on the different types of cyber attacks to which they are susceptible. We further explore the various security solutions that have been proposed and implemented to address these threats. The discussion not only provides an overview of the existing challenges but also presents a pathway toward future research directions. This includes potential advancements in the AV field, the continued refinement of safety measures, and the development of more robust, resilient security mechanisms. Ultimately, this paper seeks to contribute to a deeper understanding of the safety and security landscape of autonomous vehicles, fostering discourse on the intricate balance between technological advancement and security in this rapidly evolving field.

Crucial safety performance indicators in high rise buildings- case study of Bengaluru

The construction industry is accountable for a significant number of safety lapses, making it one of the sectors with the highest occurrence of accidents within our country. While there has been a noticeable shift towards prioritizing safety in the construction field, the mortality rate at work sites has not shown a substantial decrease. Notably, the urban regions have experienced a higher mortality rate due to the surge in infrastructure development, rapid population growth, and limited land availability. These factors have led to an increased demand for constructing high-rise buildings to address these challenges. This research paper presents a comprehensive study accomplished through statistical analysis, data collection, and interviews with various stakeholders at diverse construction sites in Bengaluru, particularly those involving high-rise buildings. Additionally, on-site observation surveys were conducted to evaluate the safety performance of these projects. The study's findings encapsulate critical factors contributing to the lack of safety performance. These insights hold the potential to assist construction stakeholders in enhancing health and safety measures at work sites, thereby facilitating a safer environment for all involved.

Coal mine explosions in India: Management failure, safety lapses and mitigative measures

This paper critically analyzes data on major explosions that have occurred at Indian coal mines over the past 120 years (1900-2020). An estimated 71.79% of mine explosions and 90.68% of associated casualties in India have occurred in Jharkhand and West Bengal states. However, the number of mine-related accidents and casualties attributable to explosions have significantly reduced overall in the last few decades, most noticeably since nationalization of the coal industry. Approximately 92.31% of explosions at Indian coal mines during this period were triggered by methane gas. The use of defective safety lamps and naked lights are identified as the most prominent sources of ignition accounting for 28.21% of total explosions and 53.09% of casualties. Recommendations for improved mine safety are presented which, if adopted, could go a long way toward minimizing even further the possibility for explosions at coal mines in India.

Managing the disabling environment in the South African Secondary Schooling to Promote Safety and Security

The objective of this paper is to critique lack of safety and security in public secondary schools. The paper is both conceptual and empirical in nature within the qualitative research paradigm. The question guiding this paper is: what shall it take to have public secondary school learners stopping to compromise the safety and security measures in their institutions? Interviewing technique and documents review, were employed to generate data. Out of the population of 17 secondary schools in one of the circuits in Vhembe district, in Limpopo Province, South Africa, three were conveniently sampled. Those were the secondary schools that had safety and security lapses that resulted in disabling or unpleasant schooling environment in their institutions. In each of the three sampled secondary school, a School Principal, a School Governing Body Chairperson and a Chairperson for the Representative Council of Learners became research participants. The total number of research participants amounted to nine. Findings revealed that firstly, secondary schools need to create school safety and security officers. Secondly, secondary schools need to embrace a restorative approach to safety and security. Thirdly, secondary schools need to emphasise reduction and eradication of safety and security threats. Fourthly, secondary schools need to regularly conduct safety and security audits. Fifthly, secondary schools need to avoid learner maltreatment and harassment. Lastly, secondary schools need to perfect their safety and security reporting systems. The researcher recommends for the public secondary schooling environments to be free from fear, intimidation and victimisation. This implies secondary schooling needs to prioritise the achievement of safer and secured schooling environment for the sustainable performance of learners.

Self-Assessed Driving Skills and Risky Driver Behaviour Among Young Drivers: A Cross-Sectional Study.

The first few years of driving is a critical period when driving skills develop and the driving style is established. While the actual driving skills improve during the first few years of driving, a novice driver’s view of himself/herself as a safe and/or skilful driver also develops rapidly. The aim of this study was to investigate self-evaluated driver safety and perceptual-motor skills among different age groups of young drivers, along with the relationships between self-evaluated skills and driving behaviour. The sample consisted of a stratified random sample of 18–25-year-old drivers from the Finnish driving licence register. The questionnaires, which included the Driver Skill Inventory (DSI), Driver Behaviour Questionnaire (DBQ) and background information, were completed and returned by a total of 1,058 participants. While female drivers assessed their safety skills to be higher than their perceptual-motor skills, the opposite was true for males. In both sexes, perceptual-motor skills increased, and safety skills decreased with experience. Perceptual-motor skills correlated negatively with safety skills, lapses and errors, but positively with aggressive and ordinary violations. Safety skills correlated negatively with all DBQ variables. Safety orientation seems to be most clearly reflected in deliberate aberrant driving behaviours. Sex differences were observed in the development of behaviours and skills, perceptual-motor skills only increased with age among males, while safety skills decreased through experience among both men and women. Results showed that driving experience was strongly related to both driving style (violations, errors) and the drivers’ view of their skills (safety orientation), highlighting the importance of the first few years of driving.

The blame game- experiences of female residents in obstetrics & gynecology regarding lapses in patient safety.

Objectives:Primary objective was to explore experiences of female residents of Obstetrics and Gynecology (OB/GYN) regarding lapses in patient safety (PS) while secondary objective was to explore factors hampering or favouring improvement of PS in OB/GYN.Methods:In this qualitative narrative study carried out in OB/GYN department of Combined Military Hospital (CMH) Lahore for six months from 1st April to 30th September 2021, six fourth-year residents were asked to write narratives of their personal experiences of medical error (witnessed or committed) in detail and reflect on those experiences, which were then transcribed. Code labels and themes were assigned manually. Interpretation of these themes was done after thematic content analysis.Results:Six, fourth-year female residents with a mean age of 28.6±1.8 participated in the study. Two main themes with sub-themes were identified: 1) Challenges in patient safety (Personal challenges, Workplace challenges, Barriers to PS), 2) Lessons learnt from experiences (Self-improvement and; Promotion of patient safety culture). Heavy workload with long working hours, lack of communication and teamwork, lack of experience and inadequate supervision were major factors involved in PS lapses experienced by residents.Conclusion:Incidents of Patient Safety (PS) lapses had a strong impact on the emotional and professional life of residents. Formal PS training with improvement of working conditions may help promote PS culture.

792. Outbreak of Multidrug-resistant Pseudomonas aeruginosa in a Tertiary Healthcare System in Detroit

Background Pseudomonas aeruginosa is one of the most common causes of healthcare-associated infections in critically ill patients and those with suboptimal immunity. However, the development of multidrug resistant Pseudomonas aeruginosa (MDR Pa) creates an even great disease burden and threat to both the hospital and local community health. The purpose of this study is to illustrate a descriptive analysis of a cluster of MDR Pseudomonas, during a local surge of SARS-CoV-2 (COVID 19) pandemic. The goal is to shed more light on the troublesome parallel during outbreaks, such as COVID-19 and consequential secondary outcomes. MethodsFrom November 2020 through February 2021, 16 patients exposed to the intensive care units of a tertiary healthcare system were infected or colonized with a multidrug-resistant strain of P. aeruginosa (Figure 1). Outbreak investigation was conducted via retrospective chart review of the first eight cases and prospective analysis of the latter eight cases. The isolates collected prospectively were analyzed for taxonomic identification, antimicrobial resistance profile, and phylogenetic analysis. Clinical characteristics of all patients were collected, and epidemiological investigation was carried out. MDR is defined as resistance to at least four classes of antibiotics: third-generation cephalosporins, fluoroquinolones, aminoglycosides, and carbapenems. Figure 1. Epidemiological Curve of Cases of Multidrug-resistant Pseudomonas aeruginosa in the Detroit Medical Center from November 2020-February 2021 ResultsOf the 16 cases of MDR Pa infections, seven died within five months (Table 1). Antimicrobial resistance gene profiling detected blaOXA and blaPAO betalactamase genes in all the samples. One sample contained an additional blaVIM resistance gene, although this patient was colonized and not actively infected. The analysis suggests existence of two clusters demonstrating relatedness and possible horizontal transmission. Timing of this cluster of cases coincides with surge of COVID-19 cases. This highlights the importance of infection control measures and antimicrobial stewardship. Table 1. Characteristics of patients infected with multidrug-resistant Pseudomonas aeruginosa (MDR-Pa) at Detroit Medical Center, November 2020 to February 2021 ConclusionSince early 2017 studies show there is a growing prevalence worldwide in transferable resistance, particularly for β-lactamases and carbapenemases, MDR Pseudomonas. This study emphasizes an irony paralleled during a pandemic, the needed efforts to prevent unintentional lapses in patient safety.Disclosures All Authors: No reported disclosures

Retrospective Study on Personal Protective Equipment During Pandemic Link to Outbreak of Carbpenem-Resistant Enterobacteriace

Background: In 2019, according to the Centers for Disease Control and Prevention, carbapenem-resistant Enterobacteriaceae (CRE), had cost the lives of >35,000 patients, particularly the most virulent plasmid-mediated New Delhi metallo-β-lactamase (NDM). Although healthcare systems normally have strict surveillance and infection control measures for CRE, the rapid emergence of novel SAR-CoV-2 and COVID-19 led to a shortage of personal protective equipment (PPE) and medical supplies. As a result, routine infection practices, such as contact precautions, were violated. Studies have shown this depletion and shift in resources compromised the control of infections such CRE leading to rising horizontal transmission. Method: A retrospective study was conducted at a tertiary healthcare system in Detroit, Michigan, to determine the impact of PPE shortages during the COVID-19 pandemic on NDM infection rates. The following periods were established during 2020 based on PPE availability: (1) pre-PPE shortage (January–June), (2) PPE shortage (July–October), and (3) post-PPE shortage (November–December). Rates of NDM per 10,000 patient days were compared between periods using the Wilcoxon signed rank-sum test. Isolates were confirmed resistant by NDM by molecular typing performed by the Michigan State Health Department. Patient characteristics were gathered by medical chart review and patient interviews by telephone. Results: Overall, the average rate of NDM infections was 1.82 ±1.5 per 10,000 patient days. Rates during the PPE shortage were significantly higher, averaging 3.6 ±1.1 cases per 10,000 patient days (P = .02). During this time, several infections occurred within patients on the same unit and/or patients with same treating team, suggesting possible horizontal transmission. Once PPE stock was replenished and isolation practices were reinstated, NDM infection rates decreased to 0.77 ±1.1 per 10,000 patient days. Conclusion: Control of CRE requires strategic planning with active surveillance, antimicrobial constructs, and infection control measures. The study illustrates that in times of crisis, such as the COVID-19 pandemic, the burden of effective infection control requires much more multidisciplinary efforts to prevent unintentional lapses in patient safety. A swift response by the state and local health departments at a tertiary-care healthcare center conveyed a positive mitigation of the highest clinical threats and decreased horizontal transmission of disease.Funding: NoDisclosures: None

A care escalation framework to address lapses in donning and doffing of personal protective equipment during the COVID-19 pandemic

A care escalation framework to address lapses in donning and doffing of personal protective equipment during the COVID-19 pandemic

Pushing boundaries of video review in trauma: using comprehensive data to improve the safety of trauma care

Adverse events and lapses in safety are identified after the fact and often discussed through postevent review. These rounds rely on personal recollection, information from patient charts and incident reports...

How To Maximize Trainee Education During the Coronavirus Disease-2019 Pandemic: Perspectives From Around the World

How To Maximize Trainee Education During the Coronavirus Disease-2019 Pandemic: Perspectives From Around the World

COVID-19 Response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team.

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

Outbreak of Clostridium perfringens food poisoning linked to leeks in cheese sauce: an unusual source.

Between 11-13 December 2018, local public health authorities in the West Midlands, England were alerted to 34 reports of diarrhoea with abdominal cramps. Symptom onset was ~10 h after diners ate Christmas meals at a restaurant between 7-9 December 2018. A retrospective case-control study, environmental and microbiological investigations were undertaken to determine the source and control the outbreak. An analytical study was undertaken with odds ratios (OR) and 95% confidence intervals (CI). Forty persons were recruited to the analytical study (28/40 cases). Multivariable analysis found that leeks in cheese sauce was the only item associated with illness (aOR 51.1; 95% CI 4.13-2492.1). Environmental investigations identified significant lapses in food safety, including lapses in temperature control during cooking and hot holding, likely cross-contamination between raw and cooked foods and the reuse of leftover cheese sauce for the next day's service. No food samples were taken during the exposure period. Two faecal samples were positive for Clostridium perfringens with one confirming the enterotoxigenic gene. Cheese sauce is an unusual vehicle for the organism and the first time this has been reported in England.

Top U.S. biodefense lab pauses work after safety lapses

Top U.S. biodefense lab pauses work after safety lapses