Promoting Systemic Incident Analysis in Healthcare – Key Challenges and Ways Forward

AbstractThe safety of personnel and resources is considered to be a cornerstone of prehospital Emergency Medical Services (EMS) operations and practice. However, barriers exist that limit the comprehensive reporting of EMS safety data. To overcome these barriers, many high risk industries utilize a technique called Human Factors Analysis (HFA) as a means of error reduction. The goal of this approach is to analyze processes for the purposes of making an environment safer for patients and providers. This report describes an application of this approach to safety incident analysis following a situation during which a paramedic ambulance crew was exposed to high levels of carbon monoxide.Levy MJ, Seaman KG, Levy JL. A human factors analysis of an EMS crew's exposure to carbon monoxide. Prehosp Disaster Med. 2012;27(3):1-2.

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Working relationships between obstetric care staff and their managers: a critical incident analysis

BMC Health Services Research ◽

10.1186/s12913-016-1694-x ◽

2016 ◽

Vol 16 (1) ◽

Cited By ~ 3

Author(s):

Effie Chipeta ◽

Susan Bradley ◽

Wanangwa Chimwaza-Manda ◽

Eilish McAuliffe

Keyword(s):

Critical Incident ◽

Obstetric Care ◽

Care Staff ◽

Working Relationships ◽

Incident Analysis

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An Incident Analysis System NICTER and Its Analysis Engines Based on Data Mining Techniques

Advances in Neuro-Information Processing - Lecture Notes in Computer Science ◽

10.1007/978-3-642-02490-0_71 ◽

2009 ◽

pp. 579-586 ◽

Cited By ~ 11

Author(s):

Daisuke Inoue ◽

Katsunari Yoshioka ◽

Masashi Eto ◽

Masaya Yamagata ◽

Eisuke Nishino ◽

...

Keyword(s):

Data Mining ◽

Data Mining Techniques ◽

Its Analysis ◽

Analysis System ◽

Incident Analysis

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An Operating PSA Application at EDF: the Probabilistic Incident Analysis

Probabilistic Safety Assessment and Management ’96 ◽

10.1007/978-1-4471-3409-1_45 ◽

1996 ◽

pp. 279-284

Author(s):

A. Dubreuil-Chambardel ◽

P. François ◽

H. Pesme ◽

B. Maliverney

Keyword(s):

Incident Analysis

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Chemical Incident Analysis Involving Storage of Fertilizer Product

Journal of the National Academy of Forensic Engineers ◽

10.51501/jotnafe.v38i1.104 ◽

2021 ◽

Vol 38 (1) ◽

Author(s):

Rogerio De Medeiros Tocantins ◽

Bettina Tomio Heckert ◽

Rafael Salum de Oliveira ◽

Hélio João Coelho ◽

Gisele Chibinski Parabocz ◽

...

Keyword(s):

Chemical Reaction ◽

Water Bodies ◽

Reaction Products ◽

Future Studies ◽

Adjacent Water ◽

Forensic Engineering ◽

Fertilizer Material ◽

The City ◽

Incident Analysis

A forensic engineering analyses of a chemical incident is presented that was classified as a self-sustaining decomposition (SSD) event, which occurred in a load of 10,000 tons of NK 21-00-21 fertilizer bulk stored inside a warehouse in the city of São Francisco do Sul in Brazil. The chemical reaction developed within the fertilizer mass and took several days to be controlled, resulting in the evacuation of thousands of residents. The water used to fight against the reaction, after having contact with the load of fertilizer material, promoted changes in adjacent water bodies, causing the death of animals (fish, crustaceans, and amphibians). The smoke from the chemical reaction products damaged the incident’s surrounding vegetation. Large SSD events are rare, with an average worldwide frequency of one every three years. Therefore, in addition to presenting a case study of this type of phenomenon, the main objective of this work is to discuss the causes that led to SSD reaction at this event, evaluate its consequences, and motivate future studies.

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