Safety Lessons Research Articles

Domestic Violence and Safe Storage of Firearms in the COVID-19 Era.

Domestic Violence and Safe Storage of Firearms in the COVID-19 Era.

Exploring children’s participation in commercial swimming lessons through the social determinants of health

Drowning is a public health challenge, disproportionately impacting children. Social determinants of health (SDH) such as socio-economic disadvantage and geographic isolation increase drowning risk. Swimming and water safety lessons, in part, have reduced drowning in children, while also enabling healthy aquatic participation. Research suggests that some Australian children receive insufficient swimming and water safety education and are not achieving essential skills. A cross-sectional retrospective analysis of swimming and water safety skills achieved by a cohort of children (5-12years) attending commercial swimming lessons in three Australian states was undertaken. Variables included participant demographics (age, gender, and the SDH of socio-economic status [SES], and geographical remoteness) and skills being taught and achieved. Skills achieved were analysed against the National Swimming & Water Safety Framework and the National Benchmark. Swim schools were more likely to teach freestyle (87%) and backstroke (83%); and less likely to teach water safety skills like treading water (53%), and survival backstroke (46%). Overall, 40% of 12-year-old children failed to achieve the National Benchmark of 50 metres freestyle, fewer were achieving minimum water safety skills. Children from low socio-economic areas and regional locations were less likely to be achieving 50 metres freestyle. Children in this study were commonly from major cities (94%) and of high socio-economic areas (53%). Swimming lessons must incorporate a broad range of swimming and water safety competencies to ensure children have the skills required to reduce drowning, especially for those deemed at increased risk. Stakeholders must prioritise holistic drowning prevention education strategies, ensuring all children can access swimming and water safety programs regardless of their socio-economic status or geographical location.

The Piper Alpha Disaster: A Personal Perspective with Transferrable Lessons on the Long-Term Moral Impact of Safety Failures

The 1988 Piper Alpha disaster remains one of the worst safety-related accidents of its kind in the Oil & Gas sector. However, whereas the myriad lessons learned from this disaster are common knowledge among chemical and process engineers, the valuable safety lessons from this harrowing story are arguably not so obvious to laboratory chemists. Herein, a breakdown of and personally lived long-term perspective on the Piper Alpha accident is provided to show the transferrable lessons available for improving chemical laboratory safety culture.

Memories and safety lessons learned of an Apollo Electrical Engineer

This article documents lessons learned from experiences in NASA's Apollo and Skylab Programs. These lessons are valuable for future missions, NASA exploration, and commercial flights. The article describes the author's experiences as an electrical engineer supporting design, testing, and mission operations during various Apollo, Skylab, and Apollo Soyuz Test Project missions. Incidents include the Apollo 13 oxygen tank explosion, the Apollo 14 docking close call, the Apollo 15 propulsion system electrical short, the Apollo 10 inadvertent lunar module abort, the Skylab 4 loss of control for entry, the Apollo Soyuz Test Project crew ingestion of toxic propellant, the Apollo 7 AC bus short, and the Apollo 16 Lunar Rover Vehicle anomalies. Lessons from two incidents on uncrewed flights, the Apollo 4 launch pad instrumentation electrical noise and the Mars Viking test stand electrical noise problem, are also included because of their direct relevance to human spaceflight.

Learning Outcomes: Safety Education for Comprehensive School Pupils

This paper investigates the learning outcomes of comprehensive school pupils in the context of safety based on a quantitative research design. We considered learning and safety competence here as a combination of knowledge, skills and attitudes. We collected the data using two questionnaires, TUKO I (n=375) and TUKO II (n=272). Teachers and the third sector (NGO´s, non-governmental organizations) external experts carried out safety lessons and drills in four comprehensive schools in between two data collection periods.The results of this study show that about one third of the pupils had the good to excellent level of safety knowledge. A novel finding of this study is that during the intervention, the primary school pupils developed their safety attitude whereas the secondary school pupils improved their safety skills. Based on this pilot study, we can conclude that experiential learning and safety drills in schools might have an effect especially on safety attitudes and skills. However, there is a need for more research to understand the relations of cause and effect.

Twenty four years of oral and maxillofacial surgery malpractice claims in Spain: patient safety lessons to learn.

Oral and maxillofacial surgery (OMS) malpractice risk is of special interest due to both the aesthetic component of some procedures and the complexity of the pathologies involved. This study aims to identify relevant factors involved in OMS professional liability (PL) claims to help achive better management of risks and improve patient safety. We performed a retrospective analysis of 315 OMS claims opened between 1990 and 2014 from the database of the PL Department of the Catalonian Council of Medical Colleges, and identified their clinical, economical and juridical characteristics. OMS showed a high rate of compensation (33.8%). Dental implant surgery, third molar surgery and rhinoplasty presented the greatest exposure to claims, and in these cases, lack of osteointegration of dental implants, neurologic injury of inferior dentoalveolar/lingual nerves and a poor aesthetic result were the most frequently compensated sequelae. Statistically, significant association was found between this perioperative complications group and the presence of PL. Poorly documented patient information (informed consent document) was also significantly related with PL outcome. OMS is a specialty of medium risk for claims, especially oral surgery cases. Surgical complications, such as neurologic damage after oral/head and neck procedures and poor aesthetic results, do occur and deserve special attention to improve patient safety, as well as patient-information procedure.

Preliminary environmental radiation considerations for CFETR

Since Chinese fusion engineering test reactor (CFETR) stepped into the engineering design phase, it was significant to discuss the environmental radiation issues considering both Chinese radiation safety regulations and lessons learned from international thermonuclear experimental reactor (ITER) being constructed in France. In this study, firstly, the legal and regulatory framework of nuclear safety in China and ITER licensing process lessons were reviewed. Secondly, public dose limit was proposed for CFETR. Thirdly, safety limit and radioactive source terms were discussed and proposed for CFETR. Fourthly, public radiation dose was estimated, tritium emission limit was proposed under normal operation from the perspectives of tritium emission limit for nuclear power plants (NPPs) in China and reverse value based on public dose limit. Finally, potential consequences of environmental radiation were discussed under accidental conditions. Nuclear emergency countermeasures including no evacuation criteria needed or not were proposed. The preliminary environmental radiation considerations were proposed for CFETR: 1) It had better invite the experts from Chinese national nuclear safety administration (NNSA) to participate in the engineering design, which can make the related persons understand the fusion safety characteristics as early as possible, so as to further speed the licensing process; 2) 0.1 mSv/a was proposed as the public dose limit of CFETR under normal operation; 3) The same ITER safety limit was proposed to be set for CFETR from the consideration of both comparable size of vacuum vessel (VV) and hydrogen/dust explosion; 4) A tritium emission limit of 5–33 g/a was proposed for CFETR; 5) The “no off-site emergency response” was suggested as one of the safety goals during the design of CFETR, however, “off-site emergency measures” were still proposed to be deployed during the operation of CFETR. It was expected the environmental radiation considerations could provide a reference to speed the construction of CFETR on the premise of environment friendly and public safety.

МЕТОДИКА ОРГАНИЗАЦИИ И ПРОВЕДЕНИЯ УРОКА ОБЖ (8 КЛАСС) ПО ФОРМИРОВАНИЮ СИСТЕМЫ ПОНЯТИЙ О ЧРЕЗВЫЧАЙНЫХ СИТУАЦИЯХ ТЕХНОГЕННОГО ХАРАКТЕРА СРЕДСТВАМИ НАГЛЯДНОГО МОДЕЛИРОВАНИЯ

The paper deals with the topical issue of formation of the system of concepts of the man-caused emergency situations during the classes when learning the course “Life Safety”. Within the current school education in the area of life safety, the concepts are more often presented to the students ready prepared that is reflected in the low level of subject knowledge of schoolchildren as the verbatim learning of the concepts does not promote the development of active thinking processes. At the same time, in the practice of subject training, the methodological recommendations on the application of active (interactive) methods and means of teaching when teaching the course “Life Safety” allowing updating and intensifying the educational process and thus involving schoolchildren in the active cognitive activity are underrepresented. The main goal of the paper is to develop the technique of organizing and conducting a Life Safety lesson in the 8th grade using visual modeling means, the application of which is aimed at the formation of the high level of subject knowledge of schoolchildren due to the use of various graphical objects (signs, pictures, symbols, legend keys, etc.), color palettes, associations, threads, etc. Mental maps displaying the structure of the system of concepts, the interrelation of concepts and their genesis form the basis of visual modeling means in the proposed experimental technique. The paper presents the example of the developed experimental technique of a lesson with the application of visual modeling means (mental maps) when teaching the course “Life Safety” (the 8th grade). The author considers the Life Safety lesson plan-notes where he describes in detail the course of the Life Safety lesson as well as demonstrates the examples of formed mental maps visually displaying the system of concepts of man-caused emergency situations, in particular, the accidents with the release of accidentally chemically hazardous substances.

HbA1c screening in the community: Lessons for safety and quality management of a point of care programme

AimTo describe quality management processes and appropriate interpretation with respect to HbA1c point-of-care (POC) testing in a national diabetes and cardiovascular risk screening programme. MethodsWe compared HbA1c results from capillary blood, measured by the cobas b 101 (Roche Diagnostics) POC testing system, with results from venous blood measured by accredited laboratory analysers to inform national screening practice and a (separately-reported) randomised controlled trial. Difference plots and regressions were used to aid interpretation around 40 and 50mmol/mol, the cut-offs used to identify “pre-diabetes” and diabetes in New Zealand. ResultsAfter initial acceptable tests, subsequent batches delivered POC results that varied from laboratory HbA1c by +6 to −14mmol/mol around the clinical cut-offs. Ten faulty batches of discs were recalled worldwide. POC testing was suspended in one region, as was the planned trial. The manufacturing defect was rectified, accuracy of the new batches was confirmed, and testing resumed. ConclusionPOC testing must be conducted within stringent quality assurance processes prior to and while in use. Within such a system, POC testing for HbA1c can be sufficiently accurate for screening and diagnosis of diabetes.

Mitigating risk of preventable medical errors across a network through event sharing.

234 Background: Medical errors are the 4th leading cause of death in the US. Oncology providers are not immune to preventable medical errors occurring in the treatment of their patients. As a national network of five hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer, clinicians and quality professionals recognized an opportunity to encourage and formalize the process of sharing safety events, lessons learned, and action plans to mitigate the risk of repeat occurrence. Methods: An Alert Notification process was established consisting of an algorithm depicting two avenues for action when an event occurs. If the event is considered urgent, characterized by immediate high-risk of repeat occurrence or high-risk of severe harm, an alert is called. The hospital nursing officers and quality directors along with the corporate director of pharmacy and vice president of quality/safety convene within 24 hours of the event to: 1) resolve or “halt” the process; 2) escalate if needed; and 3) formulate a communication plan regarding any change in process. If the event does not meet urgent criteria, the hospital conducts a root cause analysis (RCA) or common cause analysis, depending upon the algorithm. A summary of RCAs conducted for events resulting in temporary or permanent severe harm or worse are presented at the network’s monthly safety meeting, with action plans implemented across sites. Results: The notification algorithm was implemented in September 2017. Since its inception, three events have been communicated using the Urgent Alert Notification, including a syringe recall that halted use at all sites until all lot numbers could be checked, and affected syringes pulled. Several events and near misses have been communicated using the non-urgent process, including for example, discussion of a retained foreign object which resulted in review of processes for orienting staff to new products. Conclusions: The process has promoted communication across the five centers as an error prevention strategy. The sharing allows all sites to cross-fertilize resolutions to minimize rework, reduce the risk of repeat events, and build collective knowledge ensuring patient safety is our first commitment.

Ten Principles for More Conservative, Care-Full Diagnosis.

Physicians must navigate a balance between under- and overdiagnosis, both of which may harm patients. The authors discuss core principles to help find this balance and foster a thoughtful, patient-...

High-Reliability Uncaged: Safety Lessons From Army Aviation.

High-Reliability Uncaged: Safety Lessons From Army Aviation.

U.S. Compounding Pharmacy-Related Outbreaks, 2001-2013: Public Health and Patient Safety Lessons Learned.

Pharmacy-compounded sterile preparations (P-CSPs) are frequently relied upon in U.S. health care but are increasingly being linked to outbreaks of infections. We provide an updated overview of outbreak burden and characteristics, identify drivers of P-CSP demand, and discuss public health and patient safety lessons learned to help inform prevention. Outbreaks of infections linked to contaminated P-CSPs that occurred between January 1, 2001, and December 31, 2013, were identified from internal Centers for Disease Control and Prevention reports, Food and Drug Administration drug safety communications, and published literature. We identified 19 outbreaks linked to P-CSPs, resulting in at least 1000 cases, including deaths. Outbreaks were reported across two-thirds of states, with almost one-half (8/19) involving cases in more than 1 state. Almost one-half of outbreaks were linked to injectable steroids (5/19) and intraocular bevacizumab (3/19). Non-patient-specific compounding originating from nonsterile ingredients and repackaging of already sterile products were the most common practices associated with P-CSP contamination. Breaches in aseptic processing and deficiencies in sterilization procedures or in sterility/endotoxin testing were consistent findings. Hospital outsourcing, preference for variations of commercially available products, commercial drug shortages, and lower prices were drivers of P-CSP demand. Recognized outbreaks linked to P-CSPs have been most commonly associated with non-patient-specific repackaging and nonsterile to sterile compounding and linked to lack of adherence to sterile compounding standards. Recently enhanced regulatory oversight of compounding may improve adherence to such standards. Additional measures to limit and control these outbreaks include vigilance when outsourcing P-CSPs, scrutiny of drivers for P-CSP demand, as well as early recognition and notification of possible outbreaks.

Food Crises and Food Safety Incidents in European Union, United States, and Maghreb Area: Current Risk Communication Strategies and New Approaches

Globalization has created a dynamic market, which has dramatically intensified interchanges of goods and information as well as the flow of people among nations. This international phenomenon offers the consumer a choice between a wide variety of foods from diverse locations. However, there are challenges to improving food security and safety on a global scale; the major question is how food safety can be guaranteed while increasing the complexity of food supply chains. A food produced in a certain location usually contains ingredients, additives, and preservatives from different and distant origins. Although countries take several food control measures, their institutional and regulatory frameworks diverge widely, as do the definitions of food crisis, food incidents, and risk management approaches. The present review discusses some past food safety issues and lessons learned. Convergences and differences in the regulatory framework of food control agencies in different regions of the world are herein revealed. Emerging risks are also discussed, particularly the spread of antibiotic resistance in the food chain and the environment, as well as the rise of new antibiotic-resistant pathogenic strains with broader tolerance to environmental factors.

How Do Specialist Teachers Practice Safety Lessons Exploring the Aspects of Physical Education Safety Lessons in Elementary Schools

The purpose of this study was to examine perceptions and practice of safety classes within elementary PE curriculum with PE specialist teachers. Five elementary PE specialist teachers who had at least five years of teaching experience participated in this study. Data were collected from non-participant class observations, in-depth interviews, and documents. Data were analyzed through the inductive categorical analysis. The results of this study are as follows: First, PE specialist teachers perceived that safe PE classes can be achieved by dealing with risks embedded within PE classes such as subject-innate, facility, environmental, and managerial components. Second, PE specialist teachers implemented safety classes by: (a) intentional class activities with detailed lesson plans, (b) reconstructing curriculum, and (c) making safety as a habit not as information acquisition. Third, participants had difficulty in teaching safety in PE classes due to: (a) outcome-oriented safety-first policy, (b) breach of safety codes between teacher and administrator, (c) limited contact with students, and (d) different level of sensitivity to safety issues. The findings suggest that teaching safety in PE classes are complex pedagogical activities that goes beyond teaching CPR or first aids and teacher education program should conceptualize safety issues from a pedagogical perspective.

EVALUATION OF THE OCCUPATIONAL HEALTH AND SAFETY LESSONS IN ASSOCIATE DEGREE PROGRAMS (THE CASE OF BLACK SEA REGION)

Aim: This study was aimed to determine whether occupational health and safety lessons and Labor Law lessons were included in departments of Vocational High Schools (VHS) and Health Vocational High Schools (HVHS) in Black Sea region and to develop recommendations on occupational health and safety (OHS) consciousness among students. Method: The cross-sectional, descriptive study involves 111 programs in HVHS and 1067 programs in VHS in the Black Sea region. In context, it has been investigated whether the lessons of OHS and Labor Law were taken into the curriculum with the information obtained from the Bologna Information System and the lesson programs of universities in Black Sea region and these lessons were elective or compulsory in curriculum. Results: 18% of programs in HVHS in Black Sea region had compulsory OHS lessons and 40% of them had elective OHS lessons and 2% of them had compulsory Labor Law lessons and 5% of them had elective Labor Law lessons. 36% of programs didn’t include these lessons in the curriculum. 15% of programs in VHS had compulsory occupational health and safety lessons and 24% of them had elective OHS lessons and 15% of them had compulsory Labor Law lessons and 7% of them had elective Labor Law lessons. 39% of programs didn’t include these lessons in the curriculum. Conclusion: It has been determined that majority of programs in Black Sea did not have OHS lessons or had elective lessons. It is imperative OHS training be included in training curriculum to create OHS awareness among the students.

EUS-guided portal pressure measurement (with videos).

A growing number of studies have explored EUS-guided vascular catheterization due to the relative proximity of the gastrointestinal tract to the major blood vessels of the mediastinum and abdomen. In particular, EUS-guided access of the portal vein (PV) may be favorable given the relative difficulty of PV access through standard percutaneous routes. Two major diagnostic applications of EUS-guided vascular access include angiography and assessment of intravascular pressure. This review will outline the different devices and techniques employed to obtain angiographic visualization and/or direct pressure measurements of the portal circulation. Ease of access, safety, and important lessons learned from each approach will be highlighted.

Biases Can Get in the Way of Important Shared Safety Lessons

Most professionals have read many tragic tales about medication errors published in various media sources, including in this column and in the Institute for Safe Medication Practice’s (ISMP’s) Medication Safety Alert! and Nurse Advise-ERR publications. These examples have included events from acute care locations and emergency departments across the United States. As with most serious events, these errors were the result of the intersection between faulty organizational systems and risky human behaviors, as demonstrated by the following examples: Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP ⁎ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA.

The elements of a commercial human spaceflight safety reporting system

In its report on the SpaceShipTwo accident the National Transportation Safety Board (NTSB) included in its recommendations that the Federal Aviation Administration (FAA) “in collaboration with the commercial spaceflight industry, continue work to implement a database of lessons learned from commercial space mishap investigations and encourage commercial space industry members to voluntarily submit lessons learned.” In its official response to the NTSB the FAA supported this recommendation and indicated it has initiated an iterative process to put into place a framework for a cooperative safety data sharing process including the sharing of lessons learned, and trends analysis. Such a framework is an important element of an overall commercial human spaceflight safety system.As the industry matures and approaches a time of regular operational flights carrying paying commercial passengers, the time is right to consider the development of an industry-wide safety reporting system focused on operational hazards, incidents, and close calls. Mature safety reporting systems of this nature exist, both in the aerospace sector and in other industries. For example:•The Aviation Safety Reporting System (ASRS) in the United States•The Federal Railroad Authority Confidential Close Call Reporting System•The NASA Safety Reporting System (NSRS)•Aviation Safety Reporting Systems operated by several civil aviation authorities around the globeThese successful systems offer a number of lessons learned and operational best practices that might be applied to a prospective commercial human spaceflight safety reporting system. Through a review of these programs, focusing on systems in the U.S., this paper will describe elements of a safety reporting system that might be developed in support of the commercial human spaceflight industry. Factors to be addressed include:•Origins and motivations for the system•Organizational and operational approaches•Treatment of confidentiality, both for reporters' personally identifiable information, and for proprietary or commercially sensitive information•Relationship to lessons learned and safety data exchange programs•Authority to act upon information receivedOne element that these systems often have in common is that they were established following a tragic incident involving the loss of multiple lives. The FAA's efforts to analyze and implement a commercial spaceflight; safety lessons learned database offers a window to develop a safety reporting system, in consultation with; industry, prior to similar tragic incidents involving commercial spaceflight participants;

Poor reporting and documentation in drug-associated Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis - Lessons for medication safety.

Poor reporting and documentation in drug-associated Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis - Lessons for medication safety.