Safety Division Research Articles

Is patient safety sufficient in Japan? Differences in patient safety between Japan and the United States – Learning from the United States

In Japan, patient safety has been promoted at all levels since the 1999 landmark adverse medical event at Yokohama City University Hospital (YCUH). However, patients do not believe that health care is becoming safer. Furthermore, two university hospitals (UHs) that were designated as “advanced treatment hospitals” had their status revoked by the Health Ministry as of June 1, 2015 due to patient safety problems. The history of patient safety in Japan can be roughly divided into two terms: 1999-2009 and since 2010. In the first term, a basic patient safety system was established that included the creation of a patient safety division and an incident-reporting system from the perspective of systems error rather than individual responsibility. Additionally, many companies have promoted the improvement and development of drugs and medical devices in collaboration with health care providers. The two recent serious medical errors at UHs seemed to occur partially due to a lack of medical ethics. Unlike in the United States (US), in Japan, there is no medical license renewal system, the organizations that govern physicians are weak, and the framework of lifelong education is inadequate. Therefore, the second term involves a mindset of quality-driven patient safety. It requires health care providers and policy makers to change their mindset toward medical ethics and patient safety by learning from the US and demands a strong organization and framework to govern physicians in Japan.

Design and implementation of wireless dose logger network for radiological emergency decision support system.

A decision support system (DSS) is implemented in Radiological Safety Division, Indira Gandhi Centre for Atomic Research for providing guidance for emergency decision making in case of an inadvertent nuclear accident. Real time gamma dose rate measurement around the stack is used for estimating the radioactive release rate (source term) by using inverse calculation. Wireless gamma dose logging network is designed, implemented, and installed around the Madras Atomic Power Station reactor stack to continuously acquire the environmental gamma dose rate and the details are presented in the paper. The network uses XBee-Pro wireless modules and PSoC controller for wireless interfacing, and the data are logged at the base station. A LabView based program is developed to receive the data, display it on the Google Map, plot the data over the time scale, and register the data in a file to share with DSS software. The DSS at the base station evaluates the real time source term to assess radiation impact.

Fall 2016 safety & health news

Process Safety ProgressVolume 35, Issue 3 p. 301-302 Safety and Health Division Newsletter Fall 2016 safety & health news John F. Murphy PE, Corresponding Author John F. Murphy PE Editorhamjfm@embarqmail.comSearch for more papers by this author John F. Murphy PE, Corresponding Author John F. Murphy PE Editorhamjfm@embarqmail.comSearch for more papers by this author First published: 19 July 2016 https://doi.org/10.1002/prs.11836Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume35, Issue3September 2016Pages 301-302 RelatedInformation

Development of an aphasia-friendly warfarin consultation tool for patients after stroke

The medicines use and safety division of the NHS Specialist Pharmacy Service in England has created a variety of tools for use in primary and secondary care, including those developed during learning events and in clinical practice. The work is enhanced through collaboration with other professional groups and multidisciplinary colleagues to consider the different ways in which a tool might be developed. The following paper describes the development of a clinical tool, which improves the safety and quality of medications-related care and was co-created by pharmacists, speech and language therapists and patients.

June 2016 Safety and Health News Summer 2016

June 2016 Safety and Health News Summer 2016

Severe accident research activities at Helmholtz-Zentrum Dresden-Rossendorf (HZDR)

Abstract In the frame of the nuclear safety research program of the Helmholtz Association HZDR performs fundamental and applied research to assess and to reduce the risks related to the nuclear fuel cycle and the production of electricity in nuclear power plants. One of the research topics focuses on the safety aspects of current and future reactor designs. This includes the development and application of methods for analyses of transients and postulated accidents, covering the whole spectrum from normal operation till severe accident sequences including core degradation. This paper gives an overview of the severe accident research activities at the Reactor Safety Division at the Institute of Resource Ecology.

Create a firm process safety foundation for your new facilities

Documented here is the acceptance speech of the 2015 Norton H. Walton‐Russell L. Miller Award of the Safety and Health Division of AIChE. The award was presented to Dr. Victor H. Edwards at the annual division banquet at the Global Congress on Process Safety in Austin, TX on April 28, 2015. The speech emphasizes the crucial role that process safety should play in the concept, siting, and design of process plants. © 2016 American Institute of Chemical Engineers Process Saf Prog 35: 258–259, 2016

Safety in long term radioactive waste management: Insight and oversight

High-level, long-lived radioactive waste remains hazardous for periods that go well beyond our human conception of time (many thousands of years). Because active safety measures are considered unreliable, unjustifiable and simply impossible over such long time spans, experts worldwide recommend geological disposal as the preferred strategy for long-term radioactive waste management, to a large extent due to its promise of delivering ‘passive safety’. Passive safety refers to the repository being safe ‘by itself’, i.e. unmediated by human actors and actions. Safety is thus approached technically and delineated as an intrinsic property of the disposal system. As such, the notion of ‘passive safety’ entails a system simplification that allows for approaching safety in a more calculable and predictable manner than would be the case for ‘active safety’. In this article, we describe and analyze the ambiguity of this seemingly straightforward approach to safety. Drawing on constructivist insights from safety science and science and technology studies, we propose a more integrated sociotechnical vision that transcends the active versus passive safety division. The notion of ‘oversight’, as it is currently starting to surface in international radioactive waste management discourses, will be used as a sensitizing concept, offering potential to elaborate such an integrated vision.

The Laboratory Safety Standard at 25: Implementation of the Standard through the Chemical Hygiene Plan and the Chemical Hygiene Officer – Is it trickling down?

The Occupational Exposure to Hazardous Chemicals in Laboratories Standard requires that the employer designate a Chemical Hygiene Officer, have a Chemical Hygiene Plan, and actively verify that it remains effective. 29 CFR1910.1450 defines the Chemical Hygiene Plan (CHP) as a written program developed and implemented by the employer which sets forth procedures, equipment, personal protective equipment and work practices that protect employees from health hazards presented by hazardous chemicals used in that work place. The CHP must include provisions for worker training, chemical exposure monitoring where appropriate, medical consultation when exposure occurs, criteria for the use of personal protective equipment (PPE) and engineering controls, special precautions for particularly hazardous substances, and a requirement for a Chemical Hygiene Officer (CHO) responsible for implementation of the CHP. The CHP must be tailored to reflect specific chemical hazards present in the institution laboratory. Laboratory personnel must receive training regarding the Laboratory standard, the CHP, and other laboratory safety practices, including exposure detection, physical and health hazards associated with chemicals, and protective measures. All of these elements of laboratory safety practice are critical for maintaining a safe laboratory workplace. However, relevant to the effectiveness of the laboratory standard are the questions as to how important, how relevant and how usable is the typical Chemical Hygiene Plan? Are Chemical Hygiene Plans currently used and managed in the manner conceived by OSHA when the standard was issued? How do leading institutions use them today and how could they be improved? We present results of a survey of institutional academic and industrial laboratory EHS professionals accessed through the Division of Chemical Health and Safety (DCHAS). We also present the results of a survey about PPE use at a research institution as a test of how to implement lab safety programs on the ground with engaged lab personnel, rather than issuing toothless policies. The survey was carried out among laboratory personnel at a research institution. The surveys are anonymous but the results but include responses from safety personnel in industry and academic research institutions and from researchers in medical research laboratories and employees in clinical laboratories.

Abstract TP333: Independent Variables Contributing to Stroke Mortality in a Tertiary Medical Center With a Large Rural Referral Base

Background: Inpatient mortality rates have been used as a quality measure in stroke. Some factors are within the control of healthcare providers and others, such as age or severity of illness are by nature non-modifiable. Various risk adjustment models (UHC, GWTG) attempt to account for severity of illness based on patient characteristics with the presumption that remaining differences in mortality are accounted by differences in health care quality. In this study we examine how patient mortality can be effected by a number of independent variables, including care provided prior to admission, involvement of palliative care team, and patient and family preference Methods: We initially reviewed our mortality reports from GWTG-Stroke and UHC for 2014 at Dartmouth-Hitchcock Medical Center (DHMC), and identified a cohort of 49 patients deceased from stroke using the appropriate ICD-9 codes and the discharge status of “expired”. We compared cases reviewed by The Division of Quality, Safety, and Value (DQSV) at DHMC with independent chart review performed by neurologists from our stroke program, who focused on factors such as route of hospitalization, management prior to admission and end of life care. Deaths were categorized into three categories: 1. Non-preventable. 2. Possible iatrogenic mortality 3. Non-iatrogenic, but possibly preventable based on specific circumstances of the case. Results: A significant number of preventable cases were found on clinician’s review compared to the case reviews based on the DQSV. Notably at least 7 cases were found to have complications prior to transfer to our facility. None of these preventable deaths were due to premature withdrawal of care. Conclusions: These results suggest that institutions similar to ours would benefit from improving quality of care of stroke patients at the referral hospitals prior to transfer. This work also implies that as health care moves towards an incentivized and outcome-based system, using mortality scores alone to label hospitals as excellent or poor may have the unintended consequences of compromising patient care in order to reach benchmarks that do not take into account the unique variables of different hospital settings.

Safety and efficacy of herbal tea for patients with diabetes mellitus

Purpose: The aim of this report is to review (i) safety and efficacy and (ii) medical marketing and regulation of Glucos Cut (GC) Tea. Methodology: The electronic databases such as PubMed, ScienceDirect, Google Scholar, and MEDLINE via EBSCOhost were searched with no limit to year of publication. Additional information was obtained from the Micromedex, “Medicines (Advertisement and Sales) Act 1956” and the “Guideline on Advertising of Medicines and Medicinal Products to General Public 2006.” Results: Of total 28 articles reviewed, only 20 relevant full-text articles were obtained and reviewed. GC Tea consists of five different herbs, i.e. green tea, Gymnema sylvestre, mulberry leaf, rooibos tea, and stevia. Green tea, mulberry leaf, and rooibos tea were reported to be effective at improving lipid profile and also exhibit a good antioxidant property. Review also found that G. sylvestre has a sweet suppression activity while stevia showed a significant reduction in postprandial glucose. All these five herbs were reported to have minimal adverse effect, which make it safe for human consumption. GC Tea is categorized as a drinking supplement, which is controlled by the Food Safety and Quality Division, Ministry of Health. Hence, it does not need to be registered with the National Pharmaceutical Control Bureau. Conclusion: GC Tea has benefits in reducing risk of diabetes, cardiovascular diseases, and obesity. GC Tea also has antioxidant properties that help reduce risk of cancer. Only mild adverse effects were reported when consuming these herbs in recommended dose.

Application of R6 failure assessment method to obtain fracture toughness

Determination of fracture toughness, J–R curve from experimental test results requires certain geometry factors. These expressions of geometry factors are available for standard geometries and loading configurations. However, these expressions are not available in open literature for complex geometries and loading configurations. R6 Failure Assessment Diagram (FAD) methodology is used for assessment of failure in the failure regime of cleavage fracture, ductile crack initiation and plastic collapse. In this paper, the use of this method is extended to estimate the entire J–R curve from the fracture test results. Under comprehensive test programme initiated at RSD (Reactor Safety Division), BARC (Bhabha Atomic Research Centre), large numbers of straight pipes with circumferential cracks have been tested. These experimental results have been used to calculate material J–R curves using R6 FAD, which are subsequently compared with conventionally calculated J–R curves using η factor approach. It can be observed that the J–R curves calculated using both approaches are in good agreements for three out of total six pipes studied. Further, the segregation of J–R curves based on the size of pipes has been studied in the light of prevalent crack tip constraints. Here, crack tip constraints are calculated in terms of stress triaxiality parameters ‘Q’ for all pipes. It can be noted that the J–R curves for 8in. pipes are ‘toughened’ because they have lower constraints than 16in. pipes. This establishes the theory that high/low crack tip constraint causes low/high material fracture toughness.

Supporting and activating clinical governance development in Ireland: sharing our learning.

The purpose of this paper is to present a description of the Irish national clinical governance development initiative and an evaluation of the initiative with the purpose of sharing the learning and proposing actions to activate structures and processes for quality and safety. The Quality and Patient Safety Division of the Health Service Executive established the initiative to counterbalance a possible focus on finances during the economic crisis in Ireland and bring attention to the quality of clinical care. A clinical governance framework for quality in healthcare in Ireland was developed to clearly articulate the fundamentals of clinical governance. The project plan involved three overlapping phases. The first was designing resources for practice; the second testing the implementation of the national resources in practice; and the third phase focused on gathering feedback and learning. Staff responded positively to the clinical governance framework. At a time when there are a lot of demands (measurement and scrutiny) the health services leads and responds well to focused support as they improve the quality and safety of services. Promoting the use of the term "governance for quality and safety" assisted in gaining an understanding of the more traditional term "clinical governance". The experience and outcome of the initiative informed the identification of 12 key learning points and a series of recommendations The initial evaluation was conducted at 24 months so at this stage it is not possible to assess the broader impact of the clinical governance framework beyond the action project hospitals. The single most important obligation for any health system is patient safety and improving the quality of care. The easily accessible, practical resources assisted project teams to lead changes in structures and processes within their services. This paper describes the fundamentals of the clinical governance framework which might serve as a guide for more integrative research endeavours on governance for quality and safety. Experience was gained in both the development of national guidance and their practical use in targeted action projects activating structures and processes that are a prerequisite to delivering safe quality services.

Gestão Ambiental Portuária: fragilidades, desafios e potencialidades no porto do Rio Grande, RS, Brasil

Port Environmental Management: weaknesses, challenges and opportunities in the Port of Rio Grande, RS, Brazil Lately established when compared to the international scenario, the port environmental management in Brazil is mainly based on the processes of environmental licensing. The conditions of these license processes reflect how management is not related to environmental planning, but instead in mitigating existing impacts. In addition, environmental management occurs in a fragmented way and not in phase with port development, arising the need of national policies that allow connections between port processes with environmental sustainability. This article describes the results of a detailed diagnosis of the processes of environmental planning and management of the Port of Rio Grande, RS - Brazil, as a representative of the Brazilian port sub- sector, whose model of environmental management is still fragmented and barely implemented. The work also reflects the experience of the first author who acted for some time under the Division of Environment, Health and Safety in the Port of Rio Grande (DMASS). It was developed based on a qualitative research methodology applied to document analyses and semi- structured interviews with key actors involved in the actions of port planning and management environmental at national and local levels. The institutional experiences at DMASS was shown as a positive methodological tool for conducting the qualita- tive assessment of the critical processes related to port environmental management. The interviews, in turn, permitted a better basis on issues of public policy and environmental governance within the port environment, becoming a key part to corrobo

Suggested safe harbor limit for titanium dioxide: an exposure level which protects consumers from cancer incidence.

Suggested safe harbor limit for titanium dioxide: an exposure level which protects consumers from cancer incidence.

What Professionalism Skills Should Be Taught In Community College Health Fields?

The United States Department of Labor predicts the demand in healthcare sector careers to soar as patient demographics continue to change with the aging population of adults (Henderson, 2012). To meet this demand, community colleges will continue to play a vital role in the education of healthcare occupations, as nearly 60% of all healthcare workers are educated in these institutions. Furthermore, student demographics within community colleges are becoming more ethnically diverse. The dramatic changes in population and labor force composition suggest a more robust approach be taken when teaching professionalism skills. In order to promote student completion rates and recognize the evolving changes within the healthcare system, a health and public safety division within a large community college surveyed its faculty members and their clinical affiliates to determine what professional skills should be taught within an entry-level healthcare course. This brief paper describes the survey findings and implications for the development of a future healthcare professionalism course.

Safety and health news

Process Safety ProgressVolume 34, Issue 1 p. 100-102 Safety and Health Division News Letter Safety and health news John F. Murphy PE, Corresponding Author John F. Murphy PE Editorhamjfm@embarqmail.comSearch for more papers by this author John F. Murphy PE, Corresponding Author John F. Murphy PE Editorhamjfm@embarqmail.comSearch for more papers by this author First published: 11 February 2015 https://doi.org/10.1002/prs.11733Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume34, Issue1March 2015Pages 100-102 RelatedInformation

Size Evolution of Sodium Combustion Aerosol with Various RH%

ABSTRACTStudies on sodium aerosol characteristics are very important for fast reactor safety. Physical and chemical changes that occur at various times at various atmospheric conditions to sodium aerosols would results particles in various diameters. In this context, a study has been conducted in Aerosol Test Facility, Radiological Safety Division, in which sodium combustion aerosols were generated in a controlled manner and made to hover in a confined volume. The particle diameter (Mass Median Diameter - MMD) is measured on-line with progress of time by using Mastersizer. The experiments are conducted by generating aerosols in two different mass concentrations viz. 3.0 g m–3 and 0.5 g m–3 and in three different relative humidity conditions viz. 20%, 50% and 90% to show the influence of relative humidity on the particle diameter. A theoretical simulation of particle growth due to coagulation is drawn and compared with the experimental value. It is observed that sodium combustion aerosols size grow due to absorption of moisture (hygroscopic growth) in the initial period of times say in first 20 minutes followed by Brownian coagulation. An empirical relation is determined based on the difference between coagulation growth and experimental observation and applied to match experimental observation of particle diameter. A detailed experimental procedure, theoretical simulation and comparison of results of particle growth between experimental observation and theoretical simulation are presented in this paper.

유류저장시설 인근 농경지 중 Benzene, Toluene, Ethylbenzene 및 Xylene (BTEX) 잔류량 모니터링

Monitoring of Benzene, Toluene, Ethylbenzene and Xylene (BTEX) Residues in Arable Lands around Oil Reservoir Sung‐Jin Lim, Jin‐Hyo Kim, Geun‐Hyoung Choi, Nam‐Jun Cho, Jin‐Hwan Hong and Byung‐Jun Park (Chemical Safety Division, Agro‐Food Safety & Crop Protection Department, National Academy of Agricultural Science, Rural Development Administration, Wanju, 565‐851, Korea, 2Agro‐Food Safety & Crop Protection Department National Academy of Agricultural Science, Rural Development Administration, Wanju, 565‐851, Korea)

Safety & Health News

Process Safety ProgressVolume 33, Issue 1 p. 104-108 Safety and Health Division Newsletter Safety & Health News John F. Murphy PE, Editor, John F. Murphy PE, EditorSearch for more papers by this author John F. Murphy PE, Editor, John F. Murphy PE, EditorSearch for more papers by this author First published: 14 February 2014 https://doi.org/10.1002/prs.11665Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume33, Issue1March 2014Pages 104-108 RelatedInformation