Safety indicators defining

In this sub-Section a concise overview will be presented of safety indicators commonly used in current chemical process industry. Safety Indicators in this Chapter are restricted to the safety related risk indicators present in an organization. The Sis defined here are present in the chemical process industry in the form of operational data, and in the form of results from (safety) tools. In both cases the Sis aim to indicate the safety status, or risks, Marono (Marono et al., 1998). To retrieve the risk coverage area of commonly used Sis, both the tools, as well as the data they are based on have to be known. The relations between data, tools, and indicators are depicted graphically in Figure 10. 

From this analysis it appears that a huge discrepancy exists between deviations prior to accidents, that can be found in normal operation and the pro-active safety indicators and methods in current use. The re-occurring indirect safety related deviations that are the dominant class of events causing accidents are therefore defined as the precursors for accidents, as stated in Chapter 1. Furthermore, from Table 5 it can be concluded that a clear link between risk reduction and the normal way of working is not explicitly present in one of the three methods. Finally, the feasibility of methods (except PRISMA) needs some attention additional expert knowledge is often necessary to apply the method. The focus of the method indicating safety risks developed in this thesis will lie especially on these three criteria. 

In the previous Chapter it was shown that most accidents are preceded by deviations in the operational process, e.g. Heinrich (Heinrich, 1959), Turner (Turner, 1978), Leplat (Leplat, 1987), Reason (Reason, 1997), etc. Additionally, it was shown that a specific class of deviations is present which is not covered by current pro-active safety indicators. These deviations are characterised by a high likelihood and low perceived safety related consequences and were defined as precursors and re-occur in the operational process of the organization prior to an accident. In order to find these deviations in a real life operation and to eventually find their underlying causes, the concepts of re-occurring deviation and operational process have to be explained in more detail. The various definitions and concepts derived in this Chapter are necessary to understand the next Chapters, which shows how they are applied in practice. 

As the scientific literature has focused increasingly on the importance ofnear misses, even the potential for errors, a basic reconsideration of the initial distinction between quality and safety indicators seems in order. Seminal works on errors resulting from the provision of a service in any industry, have well established that errors can occur during any process. Therefore, it appears of much greater importance to understand the environment, structures, processes, as well as the attitudes of the people themselves rather than the outcomes defined as either quantifiable or qualifiable events. 

Only accident performance indicators were accounted, as more advanced safety indicators are available just for major facilities. Accident based indicators are always available, as defined by a major Italian standard code (UNI 2007). Accident rates were converted in performances, considering average national rates as reference values. 

The assessment and analysis of the inherent safety performance in the hydrogen system requires sound and appropriate metrics. Several valuable proposals for inherent safety metrics (Cozzani et al. 2007, Tugnoli et al. 2007) as well as the main issues needed for such assessment are well summarized in the literature (Roller ef a/. 2001, Khan eta/. 2003). Recently, a novel consequence-based approach for inherent safety key performance indicators (KPI) assessment was proposed (Tugnoli et al. 2007). The approach bases the calculation of safety indicators on the evaluation of the expected outcomes of the hazard present in the system, by runs of specific physical consequence models. The KPI method was preferred in the current assessment framework, since, unlike other approaches, it allows easily fitting the peculiarities of the analysed systems and does not require subjective judgment. Furthermore, the KPI method was newly reviewed to describe some particular features of the hydrogen chain. In particular the assessment of transport units was added and new index aggregation rules were defined. 

Define at least five patient safety indicators. 

The second view is macroscopic. In case more than one event is evaluated, an aggregation of the single events is possible in order to assess the overall effects. If the sample under investigation happens to contain accident and non-accident events, an accident rate or prevention rate can be calculated as ratio of frequency of accidents (or one minus accidents) with a measure by frequency of accidents without the measure. Summary statistics can also be computed in non-accident events by statistically evaluating the indicators defined on the physical level. In comparison to a baseline without measure the change due to a specific safety measure can be evaluated at the desired level of detail. Within the accident group, rates for specific injury severities as well as a fatality rate can be estimated. 

Quality plan. This document describes die objectives, structure, schedule, organisation, resources and costs of delivering the service, together with the approach, processes, controls and procedures that will be applied by team members to then-work, in order to accomplish the objectives. The only change was to highlight that safety indicators should be included in the regular status reporting and the required escalation of safety-related issues must be defined. 

The safety policy statement is different from the formal overall safety policy. The safety policy provides in-depth details about the who, what, and where of safety administration, defines responsibilities, and describes the approach to be taken with regard to safety. The safety policy can be considered an artifact that points to the espoused values of the organization. How well the policy is implemented and followed will give an indication as to the true values held by the organization. The safety policy statement is a brief, concise sentence that conveys the essence of the safety policy and drives immediate action and behavior. 

As with the treatment of metabolic acidosis, the role of NaHC03 therapy is not well defined for respiratory acidosis. Realize that administration of NaHC03 can paradoxically result in increased C02 generation (HC03 + H+ —> H2C03 —> H20 + C02) and worsened acidemia. Careful monitoring of the pH is required if NaHC03 therapy is started for this indication. The use of THAM in respiratory acidosis (see metabolic acidosis, above) has unproven safety and benefit. 

The exact role of rituximab in RA is not clearly defined, but it is indicated for patients with moderate to severe RA with a history of inadequate response to DMARDs and other BRMs. Rituximab carries a black-box warning of fatal infusion reactions and severe mucocutaneous reactions even though these events did not occur during the RA clinical trials. The benefits of rituximab must be tempered against the safety concerns reported with use of rituximab in the oncology setting. 

This Chapter starts with an example of an actual accident, that occurred in spite of all the measures and indicators implemented to prevent it from happening. Subsequently, some important safety concepts are defined to prevent confusion and misinterpretations. Then it is discussed why in spite of the developments in safety scope and environment since the industrial revolution measuring safety is still a problem. The Chapter ends by presenting the research scope and the derived research questions. 

On the use of metrics for indicating safety, likelihood and consequence have a principal role and they form the two basic dimensions. When indicating risks, from historical facts and figures, simulations and knowledge, the likelihood and consequences can be established. The actual likelihood and consequence can never be derived exactly and they will always be based on perceptions of risks as discussed in Chapter 1. This perception of risks will in this Chapter be referred to as the perceived risks , which is the defined as the (perceived) likelihood and the perceived consequences of an event. The Sis attempt to indicate this perceived safety related risk in terms of the perceived likelihood and the perceived safety-related consequence of an event. For reasons of clarity the term risk will refer to the perceived safety related risk and consequences will refer to the perceived safety related consequences in the remainder of this Chapter. The consequences are always based on people s perception of how great the damage to people, environment, or assets might be. The likelihood of an event will sometimes be estimated (perceived). 

In order to reflect these lead times, the concept of a timestamp is introduced. Timestamp is used in computer science documenting the system time when a certain event or transaction occurs e.g. for logging events (N.N. 2007). In the context of future inventory value planning, the time-stamp marks the period, when the first raw material has reached a certain stage in the value chain network included into a specific product. In the example illustrated in fig. 57, the raw material is processed in the same period to be converted into product 1. Therefore, all four value chain steps indexed from one to four occur in the same period and have the same time-stamp one. Conversion into product 2, however, requires additional time caused by production lead times, safety inventory and/or transportation time, that the steps indexed with five and six have a time stamp of two. The timestamp reflects that the inventory value of product 2 is not based on the raw material costs from the same period but based on the raw material costs from the previous period in order to reflect the lead time. Consequently, value chain indices and timestamps are defined for all steps and can cover multiple periods reflecting that raw materials in a global complex multi-stage value chain network can take several months, until they are sold as part of a finished product to the market. 

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