Safety-related Events Research Articles

Production supervisor impacts on subordinates' safety outcomes: An investigation of leader-member exchange and safety communication

Problem Supervisors are increasingly important to the functioning of manufacturing operations, in large part due to their role as leaders. While supervisors' relations and communication with their subordinates are known to be important in influencing subordinates' behavior, little is known about how these two factors will impact subordinates' safety. This study investigated how much each factor contributes to safety-related outcomes for blue-collar production employees. Method Production employees at five Pennsylvania wood manufacturers completed a survey during their work shift. Five hundred and ninety eight employees provided data on leader-member exchange (LMX), safety communication, and safety-related events. Archival data on OSHA recordables were also obtained from the producers' human resources database. Results Analyses found that the influence of LMX was greater than that of safety communication in predicting safety-related events. Neither LMX nor safety communication was significantly related to OSHA recordables. Results also demonstrated that employee job satisfaction and demographic variables such as gender and age have safety implications. Impact on Industry Results from this study further emphasize the importance of production supervisors and illustrate the potential role of leader-member exchange in enhancing workplace safety. Specifically, organizations should foster positive social exchange between their employees and supervisors and enhance the leadership qualities of supervisors to help reduce workplace injuries.

05/02345 Monte Carlo modeling of KAMINI

The purpose of this study is to provide a detailed safety analysis of overall system and components in terms of their ability to provide optimum output from the irradiation of TeO2 in the central thimble of the 3 MW TRIGA MARK II research reactor at Atomic Energy Research Establishment (AERE), Savar, Dhaka, Bangladesh. It identifies safety issues relevant to 131I radioisotope production and ensures that safety analysis and design are consistent. It evaluates threats developed within the facility during the irradiation process and ultimately ensures establishment of in-core safety limits and conditions at all stages of 131I production. In-core irradiation safety not only ensures the safe operation of the reactor but also strengthens the production of radioisotopes (RI). This study attempts to review and modify all safety related events and aspects relating to RI production. The three-dimensional continuous energy Monte Carlo code MCNP is used to develop a versatile and accurate full-core model of the TRIGA core. The cross-section library and fission product inventory are generated by using NJOY and ORIGEN computer codes. The methodology to evaluate heat generation and other relevant parameters necessary to provide enough information for thermal hydraulic analysis are discussed. The neutron flux distribution inside the dry and water filled central thimble is determined in order to locate the highest neutron flux trapping position. The thermal hydraulic and safety analysis are performed by elaborate numerical analysis as well as by using GENGTC computer code. A mock-up facility has also been developed to supplement and verify the theoretically predicted results. The total energy generated during irradiation of 50 gm TeO2 sample in dry condition is found to be 113.84 w of which 75% energy is due to neutron heating and rest of the amount is from gamma heating. Around 11.28 w of heat energy is also generated in the quartz vial. When the total generated-heat transfer is considered through conduction and radiation mechanisms, the calculated temperature of 50 g of TeO2 reaches at 970 °C. Considering simultaneous heat transfer mechanisms, (conduction, radiation and convection) the calculated maximum temperature of the 50 g of TeO2 powder comes down at 680 °C. It may be pointed out that very high amount of heat is generated during the irradiation of TeO2 at 3 MW reactor power in dry condition which is nearly the melting point of TeO2 and may be termed as unsafe mode of irradiation.

Management commitment to safety as organizational support: Relationships with non-safety outcomes in wood manufacturing employees

Introduction: Employee perceptions of management commitment to safety are known to influence important safety-related outcomes. However, little work has been conducted to explore nonsafety-related outcomes resulting from a commitment to safety. Method: Employee-level outcomes critical to the effective functioning of an organization, including attitudes such as job satisfaction and commitment to the organization, were included on surveys given to 641 hourly production employees at three wood products manufacturing facilities. Participants' were asked about perceptions of management commitment to safety and job-related variables such as perceived dangerousness of their position, organizational commitment, and withdrawal behaviors. Supervisors also rated the performance of each of their hourly subordinates. Results: Results suggest that employee outcomes differ based on perceptions of management's commitment to safety. Specifically, management commitment to safety was positively related to job satisfaction, organizational commitment, and job-related performance. We also found a negative relationship between commitment to safety and employee withdrawal behaviors. Conclusions: Our results suggest that increasing employee perceptions of management’s personal concern for employee well-being through a dedication to safety will result in positive outcomes beyond improved safety performance. These results also imply that there is a type of social exchange between employees and management that may affect employees similarly to perceived organizational support. Impact on Industry: Results further reinforce the value of a commitment to safety by a firm's management. Organizations with a strong commitment to safety may enjoy not only a reduction in safety-related events but also increases in desirable employee attitudes and behaviors.

Developing a multi‐professionally agreed list of adverse events for clinical incident reporting in trauma and orthopaedics

The aim of this study was to develop a multi‐professionally agreed list of adverse events, which may act as a prompt for clinical incident reporting in trauma and orthopaedics and to determine what healthcare professionals understand by the term adverse event. A modified Delphi process with healthcare professionals working in trauma and orthopaedics (242) in three NHS trusts was performed. The process involved initial brainstorming sessions, a two‐round Likert‐style postal questionnaire and final focus group discussion. The initial brainstorming sessions generated a list of 224 adverse events to be included in the first round of the postal questionnaire. They included 83 causes of adverse events, 36 health and safety related adverse events and 105 clinical adverse events. Following the second round questionnaire and focus group discussion, a final list of 20 adverse events was produced. There were variations between professional groups in terms of validity scoring of individual adverse events. Overall, medical staff gave a lower rating to the adverse events than the other two professional groups. There were also variations between professional groups in terms of response rates. The modified Delphi process proved to be a successful tool for generating a multi‐professionally agreed list of adverse events and for understanding what healthcare professionals understand by the term adverse event.

Defining and classifying medical error: lessons for patient safety reporting systems

<b>Background:</b> It is important for healthcare providers to report safety related events, but little attention has been paid to how the definition and classification of events affects a hospital’s ability to learn from its experience. <b>Objectives:</b> To examine how the definition and classification of safety related events influences key organizational routines for gathering information, allocating incentives, and analyzing event reporting data. <b>Methods:</b> In semi-structured interviews, professional staff and administrators in a tertiary care teaching hospital and its pharmacy were asked to describe the existing programs designed to monitor medication safety, including the reporting systems. With a focus primarily on the pharmacy staff, interviews were audio recorded, transcribed, and analyzed using qualitative research methods. <b>Results:</b> Eighty six interviews were conducted, including 36 in the hospital pharmacy. Examples are presented which show that: (1) the definition of an event could lead to under-reporting; (2) the classification of a medication error into alternative categories can influence the perceived incentives and disincentives for incident reporting; (3) event classification can enhance or impede organizational routines for data analysis and learning; and (4) routines that promote organizational learning within the pharmacy can reduce the flow of medication error data to the hospital. <b>Discussion:</b> These findings from one hospital raise important practical and research questions about how reporting systems are influenced by the definition and classification of safety related events. By understanding more clearly how hospitals define and classify their experience, we may improve our capacity to learn and ultimately improve patient safety.

Selection of a steam generator pressure control program for a 500 MWe pressurized heavy water reactor power plant through transient analysis

A personal computer based 500 MWe pressurized heavy water reactor (PHWR) power plant transient analysis code has been developed for analysing plant operational transients, for sorting out design issues and for taking decisions on new operating procedures and safety-related transient events. This code is based on the coupled solution of the conservation equations of mass, momentum and energy and the equation of the fluid state for simulation of process transients/dynamics. It includes mathematical models for all the major equipment/subsystems, i.e. the reactor core heat transfer, steam generators (SGs), surge tank (pressurizer), bleed condenser, etc., of the 500 MWe PHWR power plant. All the associated control systems on the primary and secondary sides are also incorporated. These codes are also validated against the available plant data. This code was also used to resolve the issues related to SG pressure control program selection. Two fundamental types of SG pressure control program are available for nuclear power plants, i.e. the constant boiler pressure program (CBPP) and the variable boiler pressure program (VBPP) for power manoeuvring from zero to 100 per cent of full power (FP), and vice versa. With CBPP the secondary steam cycle design and operation are simplified, at the cost of more load on the primary heat transport (PHT) pressure control system, whereas VBPP reduces the load on the PHT pressure controller. Parametric studies were carried out by taking into account the reactor trip, turbine trip and the IRV sizing design basis transient for comparison of these SG pressure control programs, i.e. (1) the earlier old design VBPP with constant PHT temperature 25 per cent of FP onwards, (2) CBPP and (3) VBPP similar to the 220 MWe PHWR SGPC program. After examining the two extremes in cases 1 and 2, the third scheme similar to the 220 MWe boiler pressure control (BPC) program was found to be most suitable. Schemes 2 and 3 put more load on the PHT pressure control and make use of the capacities enhanced by the pressurizer. The dip in the pressurizer level is acceptable in the CBPP, i.e. in the second case also. All the pros and cons of the selection of a BPC program were clearly quantified and resolved by considering a wide range of transients. All the related transient studies are discussed in this paper.

Development and test of a model linking safety-specific transformational leadership and occupational safety.

The authors developed, tested, and replicated a model in which safety-specific transformational leadership predicted occupational injuries in 2 separate studies. Data from 174 restaurant workers (M age = 26.75 years, range = 15-64) were analyzed using structural equation modeling (LISREL 8; K. G. Jöreskog & D. Sörbom, 1993) and provided strong support for a model whereby safety-specific transformational leadership predicted occupational injuries through the effects of perceived safety climate, safety consciousness, and safety-related events. Study 2 replicated and extended this model with data from 164 young workers from diverse jobs (M age = 19.54 years, range = 14-24). Safety-specific transformational leadership and role overload were related to occupational injuries through the effects of perceived safety climate, safety consciousness, and safety-related events.

Safety-related plasma events for ITER-FEAT

Safety-related plasma events were investigated to assess the effects on the design of ITER-FEAT. Overpower transients were calculated to estimate the maximum possible fusion power due to loss of plasma control, and the consequent damage to in-vessel components. A passive plasma shutdown during an ex-vessel loss of coolant was investigated to estimate the maximum first wall temperature and consequent hydrogen production by the beryllium/steam reaction. Scenarios of a bounding vertical displacement event were analysed to clarify the maximum in-vessel damage due to the plasma event.

Two randomized controlled trials comparing the Hulka and Filshie Clips for tubal sterilization

To compare the effectiveness and safety of the Filshie Clip System™ and Hulka Clip System when applied via minilaparotomy and laparoscopy, we conducted 2 multicenter randomized controlled trials of 2126 women (878 in the minilaparotomy study and 1248 in the laparoscopy study) who received either the Filshie or Hulka Clip. A physician other than the operator evaluated patients postoperatively and again at 1, 6, and 12 months after surgery. We compared the cumulative incidence of pregnancy and the frequency of safety related events for the device groups. Twenty-four month follow-up was planned for a subset of 599 women in the laparoscopy study. One woman who received the Filshie Clip and 6 women who received the Hulka Clip became pregnant within one year. The 12-month life-table pregnancy probability was 1.1 per 1000 women in the Filshie Clip group and 6.9 per 1000 women in the Hulka Clip group. The difference in the risk of pregnancy through 12 months between device groups neared statistical significance (p = 0.06). Among the extended follow-up subset, the 12- and 24-month cumulative pregnancy probabilities were 3.9 and 9.7 per 1000 women for the Filshie Clip group and 11.7 and 28.1 per 1000 women for the Hulka Clip group (p = 0.16 for comparison through 24 months). Both the Filshie and Hulka Clips are effective and safe for use in tubal occlusion.

Two randomized controlled trials comparing the Tubal Ring and Filshie Clip for tubal sterilization

Objective: To compare the effectiveness and safety of the Filshie Clip and Tubal Ring systems when applied via minilaparotomy and laparoscopy. Design: Prospective, multicenter randomized controlled clinical trial, with postoperative evaluation by a physician who was masked to the operative technique. Setting: Healthy volunteers in a variety of hospital settings. Patient(s): 2746 women (915 in the minilaparotomy study and 1831 in the laparoscopy study) who had requested permanent surgical sterilization. Intervention(s): Surgical tubal ligation, using either Filshie Clips or Tubal Rings. A physician other than the surgeon evaluated the patients after the operation and again at 1, 6, and 12 months after surgery. Main Outcome Measure(s): Pregnancy rates and safety-related events. Result(s): During the 12 months after surgery, two women who received the Filshie Clip and two women who received the Tubal Ring became pregnant, giving a 12-month life-table pregnancy probability of 1.7 per 1000 women in both groups. The Tubal Ring was more difficult to apply and had higher rates of tubal or mesosalpingeal injuries at surgery. The Filshie Clip group had three cases of spontaneous clip expulsion during the follow-up period. Conclusion(s): Both the Filshie Clip and Tubal Ring are effective and safe for use in tubal occlusion.

Safety and effect of transforming growth factor‐β2 for treatment of venous stasis ulcers

Transforming growth factor-beta(2) promotes healing in a variety of animal models and exhibits clinical effects thought to be mediated by connective tissue formation. Two clinical trials were conducted to evaluate the safety and effect of transforming growth factor-beta(2) purified from bovine bone and delivered topically to venous stasis ulcers three times per week for up to 6 weeks by means of a lyophilized collagen vehicle. The first was an open-label trial comparing transforming growth factor-beta(2) purified from bovine bone (0.5 microg/cm(2)) with a placebo consisting of lyophilized collagen vehicle-without active drug. After no safety issues arose in that trial, a prospectively randomized, closed-label, observer-blinded, three-armed trial was conducted to compare bovine transforming growth factor-beta(2) (2.5 microg/cm(2)) with the collagen matrix placebo vehicle and with a standard dressing. Standardized elastic compression was applied to all test extremities. The rate of reduction of ulcer area as measured by planimetry was the primary measure of effect. No serious safety-related events occurred in either trial. Clinical evaluation suggested that improvement in the quality and quantity of granulation tissue appeared to precede epithelialization of ulcers treated with bovine transforming growth factor-beta(2). In both studies, treatment with bovine transforming growth factor-beta(2) appeared to have a positive effect on the rate of ulcer closure, whereas ulcers in the control groups continued to exhibit impaired healing. In the open-label study, the mean rate of closure of ulcers treated with bovine transforming growth factor-beta(2) was significantly greater than that of ulcers treated with placebo. There was likewise enhanced reduction in ulcer area in the ulcers treated with bovine transforming growth factor-beta(2) in the second trial. However, because of a higher variability in patient response and a greater placebo effect, the difference was not significant. The placebo was not worse than the standard care arm, thereby showing that the vehicle is not injurious to healing. The combined results of the two trials suggest that, at doses of 0.5 to 2.5 microg/cm(2), bovine transforming growth factor-beta(2) is safe as a topically applied agent in a collagen matrix vehicle and can have a positive effect on closure of venous stasis ulcers. Large multicenter trials appear to be indicated to evaluate fully the potential utility of transforming growth factor-beta(2) in accelerating closure of chronic dermal ulcers.

Safety Investments and Operating Conditions: Determinants of Accident Passenger-Vessel Damage Cost

Econometric transportation research heretofore has focused on the likelihood of the occurrence of safety related events (event probability), e.g., investigating determinants of accident rates.' However, the risk of travel to the passenger (i.e., the probability of sustaining injury or death) not only has the aspect of probability but also the aspect of severity conditional probability-the severity of the given that it has occurred.2 Hence, an alternative (to probability) for investigating the risk of travel is to focus on the severity of safety related events. Since the severity of a safety related event is conditioned upon the occurrence of the event, the and severity conditional probabilities of safety related events are expected to have common determinants.

The Use of Abnormal Event Data in Nuclear Power Reactor System Analysis Using the Sequence Combining Method

The Abnormal Occurrences Reporting System (AORS) of the Commission of the European Communities is a data bank that contains homogenized information on safety-related events that have occurred in nuclear power plants in Europe and the United States, covering -- 780 yr of total reactor operation from 1969 to 1985. The use and analysis potential of this information system are illustrated, particularly with respect to the support it gives to incident analysts and probabilistic safety assessment (PSA) practitioners. As an example, attention is focused on a particular methodology for using the incident data during the modeling stage of a PSA study, or more generally, in the course of any type of incident analysis.

Valve testing and development in the laboratories of the kwu group of siemens ag

In nuclear power plants, valves make up the largest number of active components. Valve failures contribute to safety-related events and to nuclear power plant downtime. KWU together with plant operators and valve manufacturers have therefore made increasing efforts to improve valve performance, particularly through experimental qualification at valve test facilities. Newly-developed valves are qualified by type tests. Hypothetical accidents such as ATWS and main steam pipe breaks have been modeled at full-scale test facilities, and the as-specified performance of safety valves and main steam isolation valves has been demonstrated experimentally. In-service testing and maintenance using a valve service system developed by KWU, which is conducted in close cooperation with the power plant operators and the valve manufacturers during plant operation and scheduled outages, further improve valve reliability and safety over the entire service life of the plant.

事象シーケンス抽出システムＣＥＳＡＳの開発 システム設計と解析手法

For the purpose of efficient utilization of safety-related event information on nuclear power plants, a new computer software package CESAS has been developed. CESAS is to extract systematically the event sequence, that is sequential and causal relationship between occurrences, from the event description written in natural language of English.This system is designed to be based on knowledge engineering technique utilized in the field of natural language treatment. The analytical process in this system consists of following three steps:(1) To analyze each sentence syntactically and semantically(2) To identify sentences, clauses or phrases representing occurrences(3) To deduce the mutual relationship between occurrences.An existing syntactic analysis approach is applied to the above (1) step. As for (2) and (3) steps, a new analytical approach has been developed.In this paper, the outlines of CESAS and the newly developed approach are described and the analytical result is shown in comparison with a manually-extracted event sequence.

Public attitudes toward food safety

This article presents the results of a national opinion poll of grocery shoppers on their attitudes toward food safety. Specific issues examined include nutrition and food safety, attitudes toward specific substances, product tampering, product recalls, sources of information, and responsibility for food safety. Results indicate that in spite of a series of food safety related events over the last three years, public confidence in the basic wholesomeness and safety of our food supply has remained intact.