The Analysis of Safety Recommendation and Human Error Prevention Strategies in Flight Operations

Author(s):  
Jeng-Chung Chen ◽  
Chia-Fen Chi ◽  
Wen-Chin Li
2012 ◽  
Vol 1 (2) ◽  
pp. 54 ◽  
Author(s):  
Luigi Brunetti ◽  
Dong-Churl Suh

Background: Medication errors are a significant public health concern.  Although significant advances have been made, errors are still relatively common and represent an opportunity for healthcare improvement.Methodology/Principal Findings: Since the publication of To Err is Human, medication errors have been under tremendous scrutiny.  Organizations have moved towards a non-punitive approach to evaluating errors.  This approach to medication errors has aided in identifying common pathways to medication errors and improving understanding regarding the anatomy of a medication error.  As a result, prevention strategies have been developed to target common themes contributing to errors.  Error prevention strategies may target common contributors of medication errors, broadly grouped as performance lapses, lack of knowledge, and lack or failure of safety systems.  Strategies to thwart medication errors range from process improvement to integration of technology in the health care environment.Conclusions/Significance:  Organizations should devote resources to address medication error prevention strategies in an effort to improve patient outcomes and decrease morbidity and mortality associated with medication errors.


Author(s):  
Mario Pohl ◽  
Uwe Bielke ◽  
Rainer Börret ◽  
Rolf Rascher ◽  
Olga Kukso

1997 ◽  
Vol 1997 (1) ◽  
pp. 539-543 ◽  
Author(s):  
Gary L. Gregory ◽  
Richard W. Holly ◽  
Megan Thomas

ABSTRACT This paper details the process used by two states, California and Washington, to develop common reporting of oil spill causes. Many different agencies use databases to store oil spill information, but there is a general lack of standardization in reporting requirements, making it difficult to share information. Many of these databases only reflect initial spill reports, and few contain information on spill causes that could be used to prevent oil spills from occurring. Washington State's Office of Marine Safety (OMS) has developed an extensive database that includes spill and casualty information from vessels transiting Washington state waters. California State Lands Commission, Marine Facilities Division (MFD), has similarly developed an oil spill database for marine terminals in the state of California. What makes these systems unique is that they attempt to integrate reliable, accurate information on incident causes, paying particular attention to human error. Both agencies have joined together in a pilot program to share oil spill causal information using common terms. This paper addresses the approach used to establish common data dictionaries, oil spill report formats, and a methodology to determine causal information. California and Washington are currently working with other states and British Columbia to develop common reporting throughout the West Coast. The information collected and shared can be used by each jurisdiction to develop appropriate prevention strategies.


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