Analyzing the national fire incident reporting system to identify carbon monoxide incidents in the U.S. lodging industry.
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SUBMITTER: Smith PK
PROVIDER: S-EPMC8683956 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe study objectives were to describe the incidence and the nature of patient safety incidents (PSIs) in primary care general practice settings, and to explore the association between these incidents and practice or organizational characteristics.MethodsGPs, randomly selected from a national influenza surveillance network (n = 800) across France, prospectively reported any incidents observed each day over a one-week period between May and July 2013. An incident was an event or circumstance that could have resulted, or did result, in harm to a patient, which the GP would not wish to recur. Primary outcome was the incidence of PSIs which was determined by counting reports per total number of patient encounters. Reports were categorized using existing taxonomies. The association with practice and organizational characteristics was calculated using a negative binomial regression model.Results127 GPs (participation rate 79%) reported 317 incidents of which 270 were deemed to be a posteriori judged preventable, among 12,348 encounters. 77% had no consequences for the patient. The incidence of reported PSIs was 26 per 1000 patient encounters per week (95% CI [23‰ -28‰]). Incidents were three times more frequently related to the organization of healthcare than to knowledge and skills of health professionals, and especially to the workflow in the GPs' offices and to the communication between providers and with patients. Among GP characteristics, three were related with an increased incidence in the final multivariable model: length of consultation higher than 15 minutes, method of receiving radiological results (by fax compared to paper or email), and being in a multidisciplinary clinic compared with sole practitioners.ConclusionsPatient safety incidents (PSIs) occurred in mean once every two days in the sampled GPs and 2% of them were associated with a definite possibility for harm. Studying the association between organizational features of general practices and PSIs remains a major challenge and one of the most important issues for safety in primary care.
| S-EPMC5308773 | biostudies-literature
Project description:The performance of a fire resistant coating for tunnel passive fire protection under successive severe thermal loading is presented. The material falls under the class of potassium based geopolymers (K-geopolymer) and was prepared by mixing ferronickel (FeNi) slag, doped with pure alumina, with a highly alkaline potassium hydroxide aqueous phase. Its performance was assessed by subjecting a concrete slab with a five cm thick K-geopolymer coating layer into successive RijksWaterStaat (RWS) fire incidents. During the first test, the maximum measured temperature in the K-geopolymer/concrete interface was 250 °C, which is 130 °C lower than the RWS test requirement, while, during the second fire test, the maximum temperature was almost 370 °C, which is still lower than the RWS requirement proving the effectiveness of the material as a thermal barrier. In addition, the material retained its structural integrity, during and after the two tests, without showing any mechanical or thermal damages.
| S-EPMC5512901 | biostudies-other
Project description:ObjectiveWe aimed to explain the operational mechanism of China National Patient Safety Incidents Reporting System, analyze patterns and trends of incidents reporting, and discuss the implication of the incidents reporting to improve hospital patient safety.DesignA nationwide, registry-based, observational study design.Data sourceThe database of China National Patient Safety Incidents Reporting System.Outcome measuresOutcome measures of this study included the temporal, regional, and hospital distribution of the reports, as well as the incident type, location, parties, and possible reasons for frequently occurring incidents.ResultsDuring 2012-2017, 36,498 patient safety incidents were reported. By analyzing the time trends, we found that there was a significant upward trend on incidents reporting in China. The most common type of incidents was drug-related incidents, followed by nursing-related incidents and surgery-related incidents. The three most frequent locations of incident occurrence were Patient's Room (65.4%), Ambulatory Care Unit (8.4%), and Intensive Care Unit (7.4%). The majority of the incidents involved nurses (40.7%), followed by physicians (29.5%) and medical technologist (13.6%). About 44.4% of the incidents were attributed to the junior staff (work experience ≤5 years). In addition, incidents triggered by the senior staff (work experience >5 years) were more often associated with severe patient harm.ConclusionTo strengthen the incidents reporting system and generate useful evidence through learning from incidents reporting will be important to China's success in improving the nation's patient safety status.
| S-EPMC6371930 | biostudies-literature
Project description:ObjectiveMany Dutch hospitals have established internal systems for reporting incidents. However, such internal systems do not allow learning from incidents that occur in other hospitals. Therefore a multicenter, information technology (IT) supported reporting system named central medication incidents registration (CMR) was developed. This article describes the architecture, implementation and current status of the CMR in The Netherlands and compare it with similar systems in other countries.System descriptionAdequate IT is required to sufficiently support a multicenter reporting system. The CMR system consists of a website, a database, a web-based reporting form, an application to import reports generated in other reporting systems, an application to generate an overview of reported medication incidents, and a national warning system for healthcare providers.Current statusFrom the start of CMR 90 of all 93 (96.8%) hospitals and 872 of 1948 (44.8%) community pharmacies participated. Between March 2006 and March 2010 the CMR comprised 15,694 reports of incidents. In the period from March 2010 to March 2011, 1642 reports were submitted by community pharmacies in CMR and the hospitals submitted 2517 reports. CMR is similar to various systems in other countries, but it seems to use more IT applications.DiscussionThe CMR is developing into a nationwide reporting system of medication incidents in The Netherlands, in which hospitals, community pharmacies, mental healthcare organizations and general practitioners participate.ConclusionThe architecture of the system met the requirements of a nationwide reporting system across different healthcare providers.
| S-EPMC3197996 | biostudies-literature
Project description:Critical incident reporting involves highlighting events and near-misses which have a potential impact on patient care and patient safety. Reporting of critical incidents is a recognised tool in improving patient safety. Within the community paediatric setting in the Belfast Health & Social Care Trust (BHSCT) there is a paucity of incident report forms. The purpose of this quality improvement project was to establish the barriers to reporting critical incidents and to implement plan-do-study-act (PDSA) cycles to create a climate for change. The methodology for this project was to firstly perform a baseline audit to review all submitted critical incident reports for the Community Paediatric team in the BHSCT for a six month period. A questionnaire was distributed to staff within the multidisciplinary team to establish examples of barriers to reporting. Interventions performed included introducing an agreed definition of a critical incident, distributing/presenting questionnaire findings to senior members of the various management teams and providing feedback to healthcare workers after presentation of a critical incident presentation. A review of incident reports was performed over the subsequent six month period to assess how the interventions impacted on incident reporting. Over 12 questionnaires 28 barriers to reporting critical incidents were reported which fell into five separate categories. Staff members were twice as likely to report negativity after reporting a critical incident. Overall critical incident reporting within the BHSCT Community Paediatric team improved from 11 incident reports (1.8 per month) to 22 incident reports (3.7 per month) after completion of the quality improvement project. This represents an increase of 100%.
| S-EPMC4693063 | biostudies-literature
Project description:To ensure systems in hospitals improve to make patient care safer, learning must occur when things go wrong. Incident reporting is one of the commonest mechanisms used to learn from harm events and near misses. Only a relatively small number of incidents that occur are actually reported and different groups of staff have different rates of reporting. Nationally, junior doctors are low reporters of incidents, a finding supported by our local data. We set out to explore the culture and awareness around incident reporting among our junior doctors, and to improve the incident reporting rate within this important staff group. In order to achieve this we undertook a number of work programmes focused on junior doctors, including: assessment of their knowledge, confidence and understanding of incident reporting, education on how and why to report incidents with a focus on reporting on clinical themes during a specific time period, and evaluation of the experience of those doctors who reported incidents. Junior doctors were asked to focus on incident reporting during a one week period. Before and after this focussed week, they were invited to complete a questionnaire exploring their confidence about what an incident was and how to report. Prior to "Incident Reporting Week", on average only two reports were submitted a month by junior doctors compared with an average of 15 per month following the education and awareness week. This project highlights the fact that using a focussed reporting period and/or specific clinical themes as an education tool can benefit a hospital by promoting awareness of incidents and by increasing incident reporting rates. This can only assist in improving hospital systems, and ultimately increase patient safety.
| S-EPMC4645800 | biostudies-literature
Project description:Smoking materials are a common ignition source for residential fires. In Australia, reduced fire risk (RFR) cigarettes regulation was implemented in 2010. However, the impact of this regulation on residential fires is unknown. This paper examines the impact of the RFR cigarettes regulation on the severity and health outcomes of fire incidents in New South Wales (NSW), Australia, from 2005 to 2014. Fire department data from 2005 to 2014 were linked with ambulance, emergency department, hospital, outpatient burns clinic and mortality datasets for NSW. Negative binomial regression analysis was performed to assess the changes to fire incidents' severity pre- and post-RFR cigarettes regulation. There was an 8% reduction in total fire incidents caused by smokers' materials post-RFR cigarettes regulation. Smokers' materials fire incidents that damaged both contents and structure of the building, where fire flames extended beyond the room of fire origin, with over AUD 1000 monetary damage loss, decreased by 18, 22 and 12%, respectively. RFR cigarettes regulation as a fire risk mitigation has positively impacted the residential fire incident outcomes. This provides support for regulation of fire risk protective measures and bestows some direction for other fire safety policies and regulations.
| S-EPMC9566670 | biostudies-literature
Project description:Background: Understanding the causes of patient safety incidents is essential for improving patient safety; therefore, reporting and analysis of these incidents is a key imperative. Despite its implemention more than 15 years ago, the institutionalization of incident reporting in Indonesian hospitals is far from satisfactory. The aim of this study was to analyze the factors responsible for under-reporting of patient safety incidents in Indonesian public hospitals from the perspectives of leaders of hospitals, government departments, and independent institutions.MethodsA qualitative research methodology was adopted for this study using semi-structured interviews of key informants. 25 participants working at nine organizations (government departments, independent institutions, and public hospitals) were interviewed. The interview transcripts were analyzed using a deductive analytic approach. Nvivo 10 was used to for data processing prior to thematic analysis.ResultsThe key factors contributing to the under-reporting of patient safety incidents were categorized as hospital related and nonhospital related (government or independent agency). The hospital-related factors were: lack of understanding, knowledge, and responsibility for reporting; lack of leadership and institutional culture of reporting incidents; perception of reporting as an additional burden. The nonhospital-related factors were: lack of feedback and training; lack of confidentiality mechanisms in the system; absence of policy safeguards to prevent any punitive measures against the reporting hospital; lack of leadership.ConclusionOur study identified factors contributing to the under-reporting of patient safety incidents in Indonesia. The lack of government support and absence of political will to improve patient safety incident reporting appear to be the root causes of under-reporting. Our findings call for concerted efforts involving government, independent agencies, hospitals, and other stakeholders for instituting reforms in the patient safety incident reporting system.
| S-EPMC9243549 | biostudies-literature
Project description:Resilience has become an important concept in urban governance, yet, the policies that cities actually adopt and implement to build resilience remain largely unknown. The lack of empirical studies on resilience policies hinders our ability to develop theory, ask new questions, and test hypotheses. The goal of this paper is to quantify and compare policies and programs of the 101 largest cities in the U.S. that tangibly affect resilience. We develop a set of resilience policies and then search government websites for evidence of adoption of those policies. To explore patterns of policy adoption, we conduct factor analysis and correlation. We find that resilience does not coalesce around any particular sets of programs. Instead, resilience is a flexible concept, modified to address local context. Substantive groupings of policies do not explain policy adoption. Different dimensions such as funding and level of needed commitment may better explain empirical patterns of policy adoption. Across cities, greater attention must be dedicated to addressing drivers of social vulnerability and climate change impacts. By examining what cities are doing and whether there are underlying patterns to the policies they pursue, we tackle basic empirical questions of how to make sense of the evolving resilience landscape.
| S-EPMC8605798 | biostudies-literature
Project description:AimTo examine (a) when medication incidents occur and which type is most frequent; (b) consequences for patients; (c) incident reporters' perceptions of causes; and (d) professional categories reporting the incidents.DesignA descriptive multicentre register study.MethodsThis study included 775 medication incident reports from 19 Swedish hospitals during 2016-2017. From the 775 reports, 128 were chosen to establish the third aim. Incidents were classified and analysed statistically. Perceived causes of incidents were analysed using content analysis.ResultsIncidents occurred as often in prescribing as in administering. Wrong dose was the most common error, followed by missed dose and lack of prescription. Most incidents did not harm the patients. Errors in administering reached the patients more often than errors in prescribing. The most frequently perceived causes were shortcomings in knowledge, skills and abilities, followed by workload. Most medication incidents were reported by nurses.
| S-EPMC7424444 | biostudies-literature