Incident analysis purposes

The purpose of this chapter is to show that improvements in safety, quality, and productivity are possible by applying some of the ideas and techniques described in this book. The fact that error reduction approaches have not yet been widely adopted in the CPI, together with questions of confidentiality, has meant that it has not been possible to provide examples of all the techniques described in the book. However, the examples provided in this chapter illustrate some of the most generally useful qualitative techniques. Case studies of quantitative techniques are provided separately in the quantification section (Chapter 5). The first two case studies illustrate the use of incident analysis techniques (Chapter 6). 

When 1 provided counsel to clients in the early stages of development of computer-based incident analysis systems, insurance claims reports and supervisors investigation reports were examined as possible sources of data. Having found those sources to be inadequate as respects causal factors, and not having found other reliable sources, I advised clients not to include causal data in their computer-based analytical systems. For analytical purposes, such systems were reasonably accurate for injury and illness types, for parts of body injured, and for identification data such as location, time of occurrence, department, and so on. 

Five of the 15 forms received require entry of codes for causal factors, incident types, and injury t)q)es. When computer analysis programs first became available, I had been an aggressive promoter of the entiy of causal factor codes for later analysis. That proved to be inappropriate because accurate causal data are often not included in supervisors investigation reports or in insurance claims reports. Now, I recommend that computer-based analysis systems not include provision for causal data entry. They serve analysis purposes quite well for types of accidents, injury types, parts of body injured, and identification data (location, age, job title, etc.). 

A clinical scenario can be examined from a number of different perspectives, each of which may illuminate facets of the case. Cases have, from time immemorial, been used to educate and reflect on the nature of disease. They can also be used to illustrate the process of clinical decision making, the weighing of treatment options and sometimes, particularly when errors are discussed, the personal impact of incidents and mishaps. Incident analysis, for the purposes of improving the safety of healthcare, may encompass all of these perspectives but critically also includes reflection on the broader healthcare system. 

The second problem is description errors included in reports. Reasoning of the causes of incidents or proposal of preventive measures is the crucial part of incident reports. Since non-experts of incident investigation sometimes make incident reports, however, mistakes in analyzing incident causes can occur. Though incident analysis is a complicated task, precise and correct analysis is an essential prerequisite for achieving the purpose of incident reporting. 

Safety analysis uses logic structure representative of possible incidents. Such work methods as fault tree, incident analysis, and decision table are suitable for this purpose. Computation rules for determination of expected frequency of incidents must be formulated accordingly. In a broad sense all mathematical simulation methods which are suited for determination of stress states in technical installations and their parts become aids in safety analysis. These will be described in partial detail later. Here characteristic work methods which are of direct significance with respect to system-related and prognostic consideration of safety analysis will be discussed first,... 

VCE models have been applied for incident analysis [e.g., Sadee ct al. (1977) for the Flixborough explosion] and in risk analysis predictions (Rijnmond Public Authority, 1982). A flash fire model has been developed for risk analysis purposes by Eisenberg ct al. (1975). 

When gathering facts, care should be given so blame is not placed or perceived. The supervisor should explain the purpose of incident analysis. It is important that everyone feels relaxed and a good relationship exists between the supervisor, the employee, and any witnesses. 

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying causes of occupational accidents or incidents. The purpose of investigating and reporting the causes of occurrences is to enable the identification of corrective actions adequate to prevent recurrence and thereby protect the health and safety of the public, the workers, and the environment. Every root cause investigation and reporting process should include five phases. While there may be some overlap between phases, every effort should be made to keep them separate and distinct. The phases of a root cause analysis are... 

This section provides information on the personnel who should be involved in data collection and the design of reporting forms. The specific data needs for major incident analyses are discussed, together with the storage and retrieval of data for the purpose of analysis. 

This report is by Battelle Columbus Division to the Line Pipe Research Supervisory Committee of the American Gas Association. It presents an analysis of statistical data obtained from reports of lea)c or rupture (service) incidents and test failures in natural gas transmission and gathering lines over the 14.5 year period from 1970 through June, 1984. All gas transmission companies were required to notify the Office of Pipeline Safety Operations in the event of a "reportable" incident, as defined by the Code of Federal Regulations. The purpose of the study is to organize the reportable incident data into a meaningful format from which the safety record of the industry can be assessed. 

The purpose of this analysis was to assess the risk of operating Limerick Station, specifically with regard to its location near a high population density area. These risks were evaluated to determine whether they represent a disproportionately high segment of the total societal risk from postulated nuclear reactor incidents. 

Although conventional electron-probe microanalysis appears to be unsuitable for analysis of the exposed surface layer of atoms in an alloy catalyst, recent developments have shown that X-ray emission analysis can still be used for this purpose (89, 90). By bombarding the surface with high energy electrons at grazing incidence, characteristic Ka radiation from monolayer quantities of both carbon and oxygen on an iron surface was observed. Simultaneously, information about the structure of the surface layer was obtained from the electron diffraction pattern. 

Category C (possible human carcinogen) was evidenced by a dose-related increase in the incidence of leiomyosarcomas in the urinary bladder, a significant dose-related trend for combined hepatocellular adenomas and carcinomas in males, and a significantly higher incidence of combined lung adenomas and carcinomas in females. For the purpose of risk characterization, the RfD approach should be used for quantification of human cancer risk. The chronic exposure analysis revealed <100% RfD, and it is assumed that the chronic dietary endpoint is protective for cancer dietary exposure [64]. 

The purpose of the CSB data search and analysis was to better understand the impact of reactive incidents by evaluating their number, severity, and causes. Five recent reactive incidents-which illustrate the diversity of reactive hazards-are highlighted throughout this section. 

An amount of energy I a2 is removed from a beam with irradiance /, as a result of reflection, refraction, and absorption of the rays that are incident on the sphere that is, every ray is either absorbed or changes its direction and is therefore counted as having been removed from the incident beam. An opaque disk of radius a also removes an amount of energy I a2, and to the extent that scalar diffraction theory is valid, a sphere and an opaque disk have the same diffraction pattern. Therefore, for purposes of this analysis, we may replace the sphere by an opaque disk. 

Our analysis has been restricted to the response of a sphere to an applied uniform static electric field. But we are interested in scattering problems where the applied (incident) field is a plane wave that varies in space and time. We showed that a sphere in an electrostatic field is equivalent to an ideal dipole therefore, let us assume that for purposes of calculations we may replace the sphere by an ideal dipole with dipole moment emaE0 even when the applied field is a plane wave. However, the permittivities in (5.15) are those appropriate to the frequency of the incident wave rather than the static field values. 

Several methods are available in the literature for the measurement of aliphatic amines in biological samples [28]. Problems with specificity and separation and cumbersome derivatisation and/or extraction procedures have limited the use of these techniques on a larger scale in clinical practice. The lack of a simple analytical method may have led to an underestimation of the incidence of the fish odour syndrome. For diagnosing the syndrome, an analytical technique should be used that is able to simultaneously and quantitatively measure TMA and its N-oxide in the complex matrix of human urine. Two such methods are currently available for this purpose proton nuclear magnetic resonance (NMR) spectroscopy and head-space gas analysis with gas chromatography or direct mass spectrometry (see below). 

For food safety purposes the overriding aim is that food contamination should be reduced to the lowest practicable level, bearing in mind the potential costs and benefits involved. Since it is difficult to establish cause and effect relationships following long-term (chronic) exposure at low concentrations, it may be necessary to base action on prudence rather than on proven harm to health. However, if this approach is to maintain the confidence of both consumers and producers of food, a rational evaluation of all relevant information is required so that the balance between the risks and benefits of veterinary drugs can be assessed. Information on the incidence of potentially harmful drug residues is fundamental to this cost-benefit analysis so too is the consumption of the commodities involved (particularly for susceptible consumers or those consumers who eat more). Account must also be taken of the potential fall in food production if a drug is controlled or prohibited, and also the animal health and welfare implications that may result from the restriction of an animal medicine for which there may be no effective alternative. 

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